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The form collects organization and director information, requires certification of accuracy, and sets obligations to follow MDCPS provisions. It specifies renewal timing, consequences of late submissions, and the required renewal materials, including annual reports, board details, budgets, audits with IRS Form 990, staffing plans, policy revisions, inspections, insurance, and facility-use changes, plus submission to the Licensure Unit and executive director questions.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/renewal-application-for-a-congregate-care-license-12-11-24/638788/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/renewal-application-for-a-congregate-care-license-12-11-24/638788.png","ImageObject",300,407,{"name":92,"@type":93},"RuangKosong","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-10","2026-10-22",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"How does the renewal process work if the agency submits a timely renewal application?","Question",{"text":112,"@type":113},"When the agency submits a timely application, the current license remains in effect until the Department completes review and issues a license or denies the application. Renewal still must be completed before the current license expiration date.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What documents are required for a congregate care license renewal?",{"text":117,"@type":113},"The renewal application must include materials such as the annual report, Board members’ names and terms, current fiscal year budget and 25% operating budget availability proof, the most recent CPA/IRS audit package with IRS Form 990, staffing and organizational details, program review and evaluation, personnel policy revisions, staff development and training plan, program accreditations and certificates, fire and health inspections from the last three months, facility diagram/use changes, insurance coverage, and relevant fee/charge policies for adoption agencies.",{"name":119,"@type":110,"acceptedAnswer":120},"Where must the completed renewal documents be submitted and what is the purpose of the executive director questions?",{"text":121,"@type":113},"All required documents must be submitted to the Licensure Unit along with the Application for Licensure and the Questions for Executive Director. The executive director questions gather facility condition and compliance details related to rooms, resident occupancy, windows, water procedures during supply loss, and bedroom ground-level requirements.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},638788,1792716003,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":24,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},962090883219,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Governor Tate Reeves  \nCommissioner Andrea A. Sanders  \n[www.mdcps.ms.gov](www.mdcps.ms.gov)  \nRenewal Application for a Congregate Care License Please check box for the type of license  \n\n|  | Therapeutic Foster Care (Private Child Placing Home) |  | Therapeutic Group Home |  | Emergency Shelter |\n| --- | --- | --- | --- | --- | --- |\n|  | Regular Group Home |  | Maternity Home |  | Adoption |\n\nApplicant   Name of Organization/Agency  \nName of Director/Administrator Title  \nMailing Address    \nStreet or Box No. City State Zip  \nLocation if different   Street Address City State Zip  \nTelephone No.   \nI/We certify that all information submitted for this application is true and correct to the best of my/our knowledge. I/We understand that any misrepresentation of information shall be grounds for denial of this application.  \nIf granted a License, I/We agree to abide by the provisions therein as set forth by the Mississippi Department of Child Protection Services.  \nSigned    Chairman of Board or Authorized Agent*  \nTitle    \nDate    \nTelephone No.    \nStreet Address City State Zip  \n*Attach statement verifying that Authorized Agent has authority to submit application.  \nGovernor Tate Reeves  \nCommissioner Andrea A. Sanders  \n[www.mdcps.ms.gov](www.mdcps.ms.gov)  \n\n|  | 1. At least two (2) months before the license expires, the Department shall notify the agency and request completion of a license renewal application. (Rule 3.5A At least sixty (60) days before a congregate care license is set to expire, MDCPS should notify the provider and request completion of a license renewal application) |\n| --- | --- |\n|  | 2. When the agency submits a timely application for renewal, the current license shall remain in effect until the review is completed and the Department issues a license or denies the application. However, renewal must be accomplished prior to the expiration date of the current license. If the renewal application and all the required documents have notbeen received prior to the current license expiration date, the renewal license shall be denied. (Rule 3.5B When the provider submits a timely application for renewal, the current license will remain in effect until the review is completed and MDCPS either issues a congregate care license or denies the application. Renewal must be accomplished prior to the expiration date of the current license. If the renewal application and all the required documents have not been received prior to the current license expiration date, the renewal license will be denied.) |\n|  | 3. A renewal application shall be sent with the following materials: Rule 3.5 C |\n|  | a. A copy of the annual report published since the last license was issued; : Rule 3.5 C1 |\n|  | b. A list of names, addresses, occupations, and term expiration of all Board Members; and specify the officers of the Board; Rule 3.5 C2 |\n|  | c. The budget for the current fiscal year, which shows capital necessary for a twelve (12) month period of operation. The agency should provide proof that twenty-five percent (25%) of the current operating budget is available in the name of the agency, which shall not include the Department board payment; Rule 3.5 C3 |\n|  | d. The most recent financial audit review by a Certified Public Accountant (CPA) and IRS Form 990; Rule 3.5 C4 |\n|  | e. The names, classifications and qualifications of current staff and work schedule; Rule 3.5 C5 |\n|  | f. A copy of the current staff organizational table, if changed since the last license was issued; Rule 3.5 C6 |\n|  | g. A description of any program review and evaluation, and changes in program content and purpose which haveoccurred since the last license was issued; Rule 3.5 C7 |\n|  | h. A copy of any revisions in personnel policies that have been made since the last license was issued; Rule 3.5 C8 |\n|  | i. A copy of the current staff development and in-service training plan (see Section III. Personnel: Staff Developmentand In-Service Training); Rule 3.","cbCairZL9jgBS5D8","https://ap.wps.com/l/cbCairZL9jgBS5D8","pdf",300451,"English","# Renewal Application for a Congregate Care License\n## License Type Selection\n## Applicant/Organization Information\n## Certification and Signature\n## Renewal Notice and Submission Rules\n## Required Renewal Materials\n## Submission Address and Executive Director Questions","[{\"question\":\"How does the renewal process work if the agency submits a timely renewal application?\",\"answer\":\"When the agency submits a timely application, the current license remains in effect until the Department completes review and issues a license or denies the application. Renewal still must be completed before the current license expiration date.\"},{\"question\":\"What documents are required for a congregate care license renewal?\",\"answer\":\"The renewal application must include materials such as the annual report, Board members’ names and terms, current fiscal year budget and 25% operating budget availability proof, the most recent CPA/IRS audit package with IRS Form 990, staffing and organizational details, program review and evaluation, personnel policy revisions, staff development and training plan, program accreditations and certificates, fire and health inspections from the last three months, facility diagram/use changes, insurance coverage, and relevant fee/charge policies for adoption agencies.\"},{\"question\":\"Where must the completed renewal documents be submitted and what is the purpose of the executive director questions?\",\"answer\":\"All required documents must be submitted to the Licensure Unit along with the Application for Licensure and the Questions for Executive Director. The executive director questions gather facility condition and compliance details related to rooms, resident occupancy, windows, water procedures during supply loss, and bedroom ground-level requirements.\"}]","Renewal Application for a Congregate Care License - 12-11-24 | PDF",1792699589,13]