Relative or Non-Relative Extended Family Member

Caregiver Assessment

If any statements are answered No, the caregiver cannot be approved. The worker should assess whether the provision of reasonable assistance or additional services to the caregiver would enable the caregiver to properly respond to the child(ren)’s needs and the child(ren)’s health and safety. If the worker later reassesses the caregiver and determines that conditions supporting the No answer have changed sufficiently to answer Yes, approval may be given at that time.

Responses to the following statements have been assessed by the undersigned.

1. The caregiver has been provided a summary of State home approval regulations

and is capable, having sufficient physical and mental health, to meet these requirements for the care and supervision appropriate to the type of child(ren) to be served. [89317]

Yes No

Comments:

2. The caregiver is aware of the child(ren)’s immediate medical, psychological, and educational needs and is able to respond to those needs. [89378]

Yes No

Comments:

3. The caregiver understands State child abuse and neglect laws and agrees to report any circumstances indicating the child(ren) has been abused or neglected [§89361].

Yes No

Comments:

CHILD:	PROPOSED CAREGIVER:

4. The caregiver can provide the children opportunities for and encouragement in participation in group sports, leisure time, family, school and daily living activities [89379(a)].

Yes No

Comments:

5. The caregiver is able to care for the child(ren) in a healthy and safe way [§89378].

Yes No

Comments:

6. The caregiver will ensure that only positive discipline practices which promote the health and well being of the child(ren) are used in the home, and will not use nor allow any form of discipline that violates the child's personal rights [§89372].

Yes No

Comments:

7. The caregiver understands and agrees to maintain the child's records, including the

placement agreement, health and educational records and written consent for

medical/dental treatment [§89370].

Yes No

Comments:

8. The caregiver agrees to report all changes in household composition, or change in the residence or mailing address, or absence of the caregiver from the home of more than 48 hours [§89370].

Yes No

Comments:

CHILD:	PROPOSED CAREGIVER:

9. The caregiver agrees to post emergency telephone numbers, discuss emergency situations with children and practice emergency procedures every 6 months [§89323].

Yes No

Comments

10. The caregiver agrees to report any accidents, injuries or incidents that threaten to harm the physical or emotional health or safety of the child [§89361].

Yes No

Comments:

11. The caregiver has been provided with a copy of the child's personal rights and

understands them and agrees to ensure that all members of the household will abide by them [§89372].

Yes No

Comments:

12. The caregiver agrees to ensure direct care and supervision is provided to meet the child's needs during participation in those activities that are sponsored by third parties [§89379(b)].

Yes No

Comments:

CHILD:	PROPOSED CAREGIVER:

13. The caregiver will provide at least three nutritious meals daily to meet the child’s dietary needs. [§89376].

Yes No

Comments:

14. The caregiver will ensure all transportation for children is provided in vehicles in safe operating condition, by a driver complying with all applicable laws [§89374].

Yes No

Comments:

Assessment Summary:

The relative/non-relative extended family member has the ability and capacity to provide care and supervision to meet the child's/children's needs.

Yes No

Signature of County Child Welfare Worker
Phone Number
Date

CHILD:	PROPOSED CAREGIVER:

RELATIVE or NREFM

CAREGIVER DECLARATION AND AGREEMENT

I/We declare that:

1. I/We have been provided with a summary of the state regulations regarding the approval and

operation of a relative foster home and agree to abide by them. __________(Initial)

2. I/We agree to cooperate with the county in the maintenance of caregiver standards.

3. I/We have been provided with a copy of the child's personal rights and understand them and

agree to ensure that all members of the household will abide by them.

4. I/We agree to provide for the special needs of any child placed in our care, including but not

limited to:

• To provide the services identified in the child’s Needs and Services Plan and, if applicable,

Transitional Independent Living Plan (§89378(b) and §89387.2) __________(Initial)

• If the child is a minor parent, to provide direct care and supervision of the child of the minor

parent whenever the minor parent is at school or otherwise unavailable/unable to care for the child

(§89378) ________(initial)

• If the child has a disability, to make necessary specific provisions as required to protect and assist

the child and maximize the child’s potential for self-help (§89387). ________(initial)

• If the child is under age 10 or is developmentally disabled, mentally handicapped, or needs

special care and supervision, any pools or open body of water will be secured as required by

§89387(d). ________(initial)

I/We have not and will not make any false or misleading statements associated with application for

approval, including information regarding the caregiver, family members, family home, or any of the

services to be provided in the home

Caregiver Name	Date

Caregiver Name	Date

Caregiver Assessment

CHILD:

PROPOSED CAREGIVER:

SOC 818 Revised 10-02	Page 4 of 5

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

SOC 818 Revised 10-02 Page 1 of 5

DCS 309B (10/01)

Approval of Relative/non-relative extended family member home

Glenn D. Gibbons

2002-11-06

Dolores Escandon

Form

HSS