STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Case #:____________________ Social Security Number:___________________ Birth Date:___________________
Caregiver Name: ________________________________________________________________________________
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SOC 815 (1/12) Approval of Family Caregiver Home
Assessment Approval Worker's Signature
Assessment Approval County
Minor Dependent Nonminor Dependent
3. SAFETY OF THE HOME AND GROUNDS
An on-site inspection of the home's building and grounds was conducted on
The home is clean, safe, sanitary and in good repair, meeting required licensing/approval standards set forth in
MPP 31-445 and Title 22, Division 6, Chapter 9.5, Article 3 of the California Code of Regulations; Checklist of Health
and Safety Standards (SOC 817 or SOC 817 NMD as applicable) completed and attached.
HOME DOES NOT MEET APPROVAL STANDARDS.
4. PERSONAL RIGHTS
Information regarding the personal rights of the minor dependent child(ren) or nonminor dependent has been
ided to the (prospective) caregiver who has agreed to provide a copy of that information to any dependent minor
child(ren) or nonminor dependent (or the authorized representative where applicable) placed in the home.
5. COMPLETION OF ORIENTATION/TRAINING
The (prospective) caregiver has received a summary of State approval regulations and completed the orientation
ided by the county.
I certify that the above-named (prospective) caregiver meets the standards for relative or nonrelative
ended family member home approval as of .
I certify that as of , the above-named (prospective) caregiver meets the
standards for relative or nonrelative extended family member home approval pending completion of a Plan of
I certify that the above-named (prospective) caregiver DOES NOT meet the standards for relative or
nonrelative extended family member home approval as of .
Plan of Correction completed on .
Plan of Correction not completed by agreed due date.