Exhibit XIV Provider Census Report.xlsm

XLSM spreadsheet 142 KB Posted Jun 1, 2024

Attached to: Master Agreement AZ|CTR071431
Contract number: CTR071431
Issued by: Arizona

About this file

Written by GovTribe AI · Sep 19, 2025

This document is an Excel spreadsheet titled "Exhibit XIV Provider Census Report" from the Arizona Department of Child Safety (DCS), focusing on congregate care provider tracking and reporting. The document is a comprehensive template for providers and subcontractors who offer congregate care services for children, designed to capture detailed facility, placement, and census information for children in state care. It appears to be an administrative tool used by the Arizona DCS to monitor and manage child placement across various facilities and providers.

The census report template requires providers to document specific details including facility locations, licensed and contracted bed counts, contact information, and daily placement tracking. Providers must submit the census report daily by 5 PM to OpenBeds@azdcs.gov, with mandatory fields covering child placement information such as length of stay, child's age, full name, placement and exit dates, gender, facility name, placement source, school information, and additional contextual details. The document includes dropdown menus for destination details, placement sources, and other categorical information, suggesting a standardized approach to tracking child placements across Arizona's congregate care system.

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Agency Face Sheet

	Arizona Department of Child Safety
Congregate Face Sheet		V5

Provider
Provider Name	License Information
Quick Connect #	Contracted Population
Admin. Office Address	Contracted Age Range

Daily Placement (7 days a week 8am-5pm)
Name (Main Contact)	Name (Backup Contact)
Email Address (Main Contact)	Email Address (Backup Contact)
Phone # (Main Contact)	Phone Number (Backup Contact)

After Hour Placement (7 days a week 5pm-8am)
Name (Main Contact)	Name (Backup Contact)
After Hours Placement Phone #	After Hours Placement Phone # (Backup)

Facility Locations
Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort and Speciality	Cohort and Speciality
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds	Licensed Beds
DCS Contracted Beds	DCS Contracted Beds
DCS Contracted Vacant Beds	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

DCS Census Report

	Due:Daily No later than 5pm.
Send to: OpenBeds@azdcs.gov		Arizona Department of Child Safety

Congregate Care Census Report

	This roster shall contain only ADCS Congregate Care, ADJC and Tribal Placements											Current Date:
	Length of Stay (Days)	Child's Age	Child's Full Name
(Last, First)	Placement Date
xx/xx/xxxx	Exit Date xx/xx/xxxx	Bed Hold End Date	Destination Detail
(drop down)	Child's Gender	DOB
xx/xx/xxxx	Person ID #	Facility Name	Cottage/Casita	Placement Source	School Name	County for Dually Adjudicated	Probation	Probation Officer Contact Information	Comments
		child age	child name	placement date	exit date		details	children	childdob	facility	source
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DCS Exit Dates

	Length of Stay (Days)	Child's Age	Child's Full Name
(Last, First)	Placement Date
xx/xx/xxxx	Exit Date xx/xx/xxxx	Bed Hold End Date	Destination Detail
(drop down)	Child's Gender	DOB
xx/xx/xxxx	Person ID #	Facility Name	Cottage/Casita
		child age	child name	placement date	exit date	details	children	childdob	facility

Subcontractor Agency Face Sheet Arizona Department of Child Safety Congregate Care Subcontractor Face Sheet

Provider
Provider Name	License Information	Group Home/Shelter or both
Quick Connect #	Contracted Population
Admin. Office Address	Contracted Age Range

Census Report
Name (Main Contact)	Name (Backup Contact)
Email Address (Main Contact)	Email Address (Backup Contact)
Phone # (Main Contact)	Phone Number (Backup Contact)

After Hour Placement
Name (Main Contact)	Name (Backup Contact)
After Hours Placement Phone #	After Hours Placement Phone # (Backup)

Facility Locations
Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group

Villarreal, Myriam: Include Contracted Cohort and specialty Separate by coma.

	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

	DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)		Facility E-Mail Address
Facility Phone Number		Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for specific facility.

Licensed Beds Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

Villarreal, Myriam: This number must match the # identified in your license or operating certificate for this particular location.

DCS Contracted Beds

DCS Contracted Vacant Beds Villarreal, Myriam: This number is the number of beds contracted with DCS.

Villarreal, Myriam: This number is the number of beds contracted with DCS.

DCS Contracted Vacant Beds
Facility E-Mail Address (If applicable)	Facility E-Mail Address
Facility Phone Number	Facility Phone Number

Facility Name	Facility Name
Cottage/ Casita (If Applicable)	Cottage/ Casita (If Applicable)
Cohort Group	Cohort Group
Licensed Beds