STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Approval of Family Caregiver Home

Pursuant to the provisions of WIC Section 319 I certify that I assessed
Name:	Address:
the maternal paternal	NREFM Relationship to child
Child:	SS#:	DOB:
1..	Criminal Record/ Prior Abuse Clearances
Criminal Record and Child Abuse records have been checked for the caregiver(s), all adults living in the home or on the premises, and other non-exempt person(s) who have routine contact with the child.
ALL ADULTS CLEARED
NOT CLEARED
2.	Caregiver Qualifications
The above named prospective caregiver has been assessed as able to care for and supervise the above named child(ren) and provide for the child's special needs; Caregiver Assessment completed and attached
Caregiver not qualified
3.	Safety of the Home and Grounds
An on-site inspection of the home's building and grounds was conducted on
Date:	by:
and the home is clean, safe, sanitary and in good repair for the safety and well-being of the child(ren), meeting required licensing/approval standards set forth in MPP 31-445.3; Checklist of Health and Safety Standards completed and attached.
HOME DOES NOT MEET APPROVAL STANDARDS.
4.	Child's Personal Rights
Information regarding the personal rights of foster children has been provided to the prospective caregiver who has agreed to provide a copy of that information to any child (or the child’s authorized representative where applicable) placed in his or her home.

Child’s Name:
SS #:	DOB:
5.	COMPLETION OF ORIENTATION/TRAINING

The caregiver has received a summary of the State approval regulations and completed the orientation provided by the county.
I certify that the above named caregiver meets the standards for relative or non-relative extended family member home approval as of .
I certify that as of the above named caregiver meets the standards for relative or non-relative extended family member home approval pending completion of the Plan of Correction.
Plan of Correction completed on .
Plan of Correction not completed by agreed to due date.
I certify that the above named caregiver DOES NOT meet the standards for relative or non-relative extended family member home approval as of .
Assessment Approval Worker’s Signature
Date
Supervisor’s Signature
Date

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CRIMINAL BACKGROUND CHECKS

CLETS	CWS/CMS

Search	Live Scan

Appoint-ment

LIVE
SCAN

DOC

CACI

FBI

Requested

FBI Received

Exemption

Requested

Exemption Granted

Exemption

Denied	DOJ

RAP-Backs

Requested
Caregiver	(Date)	(Date)	(Date)	(Date)	(Date)	(Date)	(Date)	(Date)	(Date)	(Date)	(Date)

Other Adults

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

Checklist of Standards For Approval of Family Caregiver Home

Pursuant to Division 31 MPP 31-445.3, in order to be approved, all Foster Care Homes must meet the following standards, set forth in

Title 22, Division 6, Chapter 9.5, Article 3.

SECTION

STANDARD

YES

NO

DAP

CAP

89317

APPLICANT QUALIFICATIONS

89319

CRIMINAL RECORD CLEARANCE REQUIREMENT

89323

EMERGENCY PLAN

89361

REPORTING REQUIREMENTS

89370

CHILDREN’S RECORDS

89372

PERSONAL RIGHTS

89373

TELEPHONES

89374

TRANSPORTATION

89376

FOOD SERVICE

89378

RESPONSIBILITY FOR PROVIDING CARE & SUPERVISION

89379

ACTIVITIES

89387

BUILDINGS AND GROUNDS

89387.1

OUTDOOR ACTIVITY SPACE

89387.2

STORAGE SPACE

89388

COOPERATION & COMPLIANCE

SOC 815 (R10/02)

SOC 815 Revised 10-02	PAGE 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES

Glenn D. Gibbons

2002-11-06

Dolores Escandon

CWS/CMS