MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILD PLACING AGENCY SUPERVISORY REVIEW
DATE	NAME OF AGENCY/SITE	ADDRESS
LICENSURE PERIOD	NAME OF PERSON(S) ATTENDING CONFERENCE
PRESIDENT NAME/ADDRESS	CHAIR OF BOARD NAME/ADDRESS
LICENCED FOR RECOMMENDATION OF FOSTER HOME LICENSURE PLACEMENT OF CHILDREN IN FOSTER FAMILY HOMES FOSTER CARE SERVICES ADOPTION SERVICES
A survey of your facility has been conducted, and you are hereby notified of the standard findings as stated below.
= Compliance X = Noncompliance
x	ITEM	x	ITEM	x	ITEM
Organization and Administration (Section 40-73.020)	Operational Requirements (Section 40-73.040)	Foster Family Services
Governing Body	Office Space/Equipment	Foster Family Assessment/Renewal
License Posted Conspicuous Place	Fees/fiscal Practices	Foster Homes Licensing Violations
Financial Management	Records Extraordinary Events	Placement of Children and Foster Family Homes (Section 40-73.070)
Personnel Practices (Section 40-73.030)	Protection and Care of the Child (Section 40-73.050)	Placement Policy
Personnel Manual	Unusual Incident	Foster Care Services (Section 40-73.075)
Personnel Records	Confidentiality	Records/Supervision
Staff Qualification and Requirements (Section 40-73.035)	Discipline	Adoption Services (Section 40-73.080)
Administrative Staff/Supervisor	Health Care (Section 40-73.055)	Program Requirements
Professional Staff	Health Procedures	Birth Parent Services
Contracted Staff	Recommendation of Foster Homes for Licensure (Section 40-73.060)	Services to Child
Students/Volunteers	Initial Procedures	Services to Adoptive Family
Caseload Size	Other
COMMENTS:
A CORRECTIVE ACTION PLAN TO ADDRESS THE ABOVE CITED NON-COMPLIANCE ISSUES MUST BE PROVIDED TO THE RESIDENTIAL PROGRAM UNIT (RPU) WITHIN THIRTY (30) DAYS OF RECEIPT OF THIS FORM. A COPY OF THIS FORM WILL BE FORWARDED TO THE CHAIRMAN OF THE BOARD OF DIRECTORS.
AGENCY REPRESENTATIVE	LICENSING CONSULTANT