Name___________________________________________________
Case #:____________________ Social Security Number:___________________ Birth Date:___________________
Caregiver Name: ________________________________________________________________________________
1 of 5
SOC 815 (1/12) Approval of Family Caregiver Home
__________________________________________________________________________________________
Name
___________________________________________________________________________
Address
______________________________________________________________________
Relationship
______________________________________________________________________________
Minor Dependent /NMD Name Social Security Number DOB
________________________________________________________________________________________
Relationship
_______________________________________________________________________________________
Minor Dependent /NMD Name Social Security Number DOB
______________________________________________________________________
Relationship
___________________________________________________________________________________________.
Minor Dependent /NMD Name Social Security Number DOB
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent
Approval of Family Caregiver Home
Pursuant to the provisions of W&IC Section 319 or 361.45(d)(1), as applicable, I certify that I assessed
the Relative NREFM
of
; and
the Relative NREFM
of ; and
t
he Relative NREFM
of
1. CRIMINAL RECORD/ PRIOR ABUSE CLEARANCES
Criminal Record and Child Abuse records have been checked and cleared or exempted for the caregiver(s), all adults
and other non-exempt person(s) living in the home or on the premises, or who have routine/significant contact with a
minor dependent child(ren).
ALL ADULTS CLEARED/EXEMPTED
NOT CLEARED
2. CAREGIVER QUALIFICATIONS
The above named (prospective) caregiver has been assessed as able to care for and supervise the above named
minor dependent child(ren) and provide for the child(ren)'s special needs; Caregiver Assessment (SOC 818)
completed and attached.
The above named (prospective) caregiver has been assessed as able to care for and supervise the above named
nonm
inor dependent; Caregiver Assessment (SOC 818 NMD) completed and attached.
CAREGIVER NOT QUALIFIED.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Name___________________________________________________
Case #:____________________ Social Security Number:___________________ Birth Date:___________________
Caregiver Name: ________________________________________________________________________________
2 of 5
SOC 815 (1/12) Approval of Family Caregiver Home
______________________________________________________
(Date) (Name)
____________________________
(Date)
___________________________
(Date)
_________________________
(Date)
_________________________
(Date)
___________________________
Assessment Approval Worker's Signature
(Date)
_________________________________________________
Assessment Approval County
___________________________
Supervisor's Signature
(Date)
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
by
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
prov
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
prov
ided by the county.
I certify that the above-named (prospective) caregiver meets the standards for relative or nonrelative
ext
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
Correction.
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.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Name: __________________________________________________________
Case #:_______________________ Social Security Number:_______________________ Birth Date:_______________________
Caregiver Name:___________________________________________________________________________________________
3 of 5
SOC 815 (1/12) Approval of Family Caregiver Home
Date Date Date Date Date Date Date Date Date Date Date Date Date Date
Minor Dependent Nonminor Dependent
CRIMINAL BACKGROUND CHECKS
Megan’s Law Check/Date
Date
Temporary Placement
(W&IC 309(d)(1); 361.45)
Live Scan Submitted
(W&IC
309(d)(2)&(d)(3);
W&IC 361.4;
361.45)
Live Scan Received
(W&IC 309(d)(2)&(d)(3);
W&IC 361.4; 361.45)
Rapback
ICT Exemptions
Established
Presence
In
Home
CLETS
(309d)
CACI
(
309d)
CWS/CMS
S
earch
(309d)
DOJ
FBI
CACI
DOJ
FBI
CACI
Established
Effective Date
A
pproved by
DOJ
Exemption
R
equested by
Applicant
Exemption
A
pproved
Exemption
D
enied
Caregiver
Other Adult
Adult w/Significant Contact
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Dependent Name: __________________________________________________________
Case #:_______________________ Social Security Number:_______________________ Birth Date:_______________________
Caregiver Name:___________________________________________________________________________________________
4 of 5
SOC 815 (1/12) Approval of Family Caregiver Home
Minor Dependent Nonminor
OUT-OF-STATE CHILD ABUSE REGISTRY CHECKLIST
Resided Outside
CA Within Last 5
Years
YES NO
If Yes,
Name of
Other
State(s)
Is Registry
Mai
ntained by
Other State(s)?
YES NO
If Yes, Date
Requested
Other State(s)
Info
Date
R
eceived
Other
State(s) Info
Cleared
(
Date)
Not
Cleared
(Date)
Caregiver
Other Adult
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Name: __________________________________________________________
Case #:_______________________ Social Security Number:_______________________ Birth Date:_______________________
Caregiver Name:___________________________________________________________________________________________
5 of 5
Approval of Family Caregiver Home
Minor Dependent Nonminor Dependent
Checklist of Standards for Approval of Family Caregiver Home
Pursuant to Division 31, MPP Section 31-445, in order to be approved, all relative and nonrelative extended family member homes
must meet the following standards set forth in Title 22, Division 6, Chapter 9.5, Article 3.
Section STANDARD YES NO DAP* CAP**
89318 APPLICANT QUALIFICATIONS
89319 CRIMINAL RECORD CLEARANCE REQUIREMENT
89323 EMERGENCY PROCEDURES
89361/893161 REPORTING REQUIREMENTS
89370/893170 CHILDREN’S RECORDS/NONMINOR DEPENDENTS’ RECORDS
89372/893172 PERSONAL RIGHTS
893172.1 EXPECTATIONS, ALTERNATIVES, AND CONSEQUENCES
89373/893173 TELEPHONES
89374/893174 TRANSPORTATION
89376/893176 FOOD SERVICE
89377 REASONABLE AND PRUDENT PARENT STANDARD
89378/893178 RESPONSIBILITY FOR PROVIDING CARE & SUPERVISION
89379/893179 ACTIVITIES
89387/893187 BUILDINGS AND GROUNDS
89387.2
STORAGE SPACE
89388 COOPERATION & COMPLIANCE
*DAP: DOCUMENTED ALTERNATIVE PLAN MADE
**CAP: CORRECTIVE ACTION PLAN MADE
SOC 815 (1/12)
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