CHILD CARE CERTIFICATE

001602021
042612204

Start Date: 06/07/2021 End Date: 11/05/2021

Family: ROGER C WONG Family ID #: 317230
Child: MAKAIO WONG DOB: 10/02/2013
Specialist: Vanessa Ramirez Program: SA-CAPP

Provider: TRABUCO MESA ELEMENTARY Provider ID #: 29433

21400 LINDSAY DRIVE
Trabuco Canyon, CA 92679-3213
Provider Type: Licensed Family Child Care Center-Based License-Exempt
The following information lists the approved days and hours that Children’s Home Society of California (CHS) will pay for child care services. The parent
must contact CHS in advance to request a change in the approved schedule. The Regional Market Rate (RMR) Ceiling listed below has been selected based
on the child’s certified need for care. This RMR Ceiling is the maximum amount that may be reimbursed. If the Provider’s Requested Rate is higher than
the maximum amount that CHS can reimburse, or if care is used outside of the approved schedule, the parent is responsible for any additional payment
that is due to the provider.

CARE AUTHORIZED
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Vacation 10:00AM - 4:00PM 10:00AM - 4:00PM 10:00AM - 4:00PM 10:00AM - 4:00PM 10:00AM - 3:59PM
School 2:15PM - 4:00PM 2:15PM - 4:00PM 2:00PM - 4:00PM 2:15PM - 4:00PM 2:15PM - 3:59PM

Provider Requested Rate Rate Type Child Category Rate Category Amount
Effective Date: 06/07/2021 Weekly ENTERING 1ST-6TH GRADE WEEKLY $195.00
Effective Date: 07/05/2021 Weekly ENTERING 1ST-6TH GRADE WEEK OF JULY 5-9 $156.00

Effective Date Category Age Category Amount

RMR Ceiling(Maximum payment):
06/07/2021 PTW 6+ $143.78

Comments:
PAYMENT:
PE-Child care will be paid based on the certified schedule above.
The maximum amount that CHS will reimburse for the school schedule is $143.78 per week. The maximum amount that CHS will
reimburse for the vacation schedule is $143.78 per week.

Si desea asistencia para revisar la información en este formulario, por favor póngase en contacto con nuestra oficina.
[CDE_0006_CHS] Children's Home Society of California  333 South Anita Drive Suite 350  Orange, CA 92868 