Child’s Name: Case Number:
Child’s Name: Case Number:
Caregiver Name: __________________________________________________________________________________
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Relative or Non-Relative Extended Family Member
Caregiver Assessment
All statements below must be answered Yesto approve the caregiver. When there is a No
answer, 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’s needs,
health and safety. If the worker later reassesses the caregiver and determines that conditions
supporting the No answer have changed sufficiently to answer Yes, caregiver 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 specific needs of the child to be served. 89318]
[ ] Yes [ ] No
Comments:
2. The caregiver is aware of the childs immediate emotional, behavioral, physical, medical, and
educational needs and is able to meet the health, safety, and well-being needs of the child.
89378/WIC 361.2]
[ ] Yes [ ] No
Comments:
3. The caregiver understands State child abuse and neglect laws and shall report by telephone,
e-mail, or fax any circumstances indicating the child has been abused or neglected within 24
hours after the event occurs to the approval agency. [§89361]
[ ] Yes [ ] No
Comments:
4. The caregiver understands the child shall be entitled to participate in age and
developmentally appropriate extracurricular, enrichment, and social activities. [§89379(a)]
[ ] Yes [ ] No
Comments:
SOC 818 (12/10) Relative or Non-Relative Extended Family Member
Caregiver Assessment Page 1 of 6
Child’s Name: Case Number:
Child’s Name: Case Number:
Caregiver Name: __________________________________________________________________________________
5. The caregiver shall be responsible for applying the Reasonable and Prudent Parent
Standard, which is characterized by careful and sensible parental decisions that shall take in
consideration the age, maturity and developmental level, behavioral tendencies, mental and
physical health, medications, abilities and limitations, the nature and inherent risks of harm, in
order to maintain the child’s health, safety, and best interest. [§89377]
[ ] Yes [ ] No
Comments:
6. The caregiver will ensure that only positive discipline practices which promote the health and
well being of the child are used in the home, and will not use corporal punishment or allow any
form of discipline that violates the child's personal rights. [§89372(a)(1)]
[ ] 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 any accidents, injuries or incidents that threaten to harm the
physical or emotional health or safety of the child within 24 hours after the event occurs by
telephone, e-mail, or fax and submit a written report within 7 calendar days to the approval
agency. [§89361(a) and (b)]
[ ] Yes [ ] No
Comments:
9. The caregiver agrees to report any change in household composition within 24 hours, and a
change in the residence or mailing address within 10 working days, by telephone, e-mail, or fax
to the approval agency. [§89361]
[ ] Yes [ ] No
Comments:
SOC 818 (12/10) Relative or Non-Relative Extended Family Member
Caregiver Assessment Page 2 of 6
Child’s Name: Case Number:
Child’s Name: Case Number:
Caregiver Name: __________________________________________________________________________________
10. The caregiver agrees to report any change in the location of the home to the approval
agency by telephone, e-mail, or fax 30 days prior to the move or as soon as the information is
available. [§89361(d)]
[ ] Yes [ ] No
Comments:
11. The caregiver has been provided with a copy of the child's personal rights, 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 post emergency telephone numbers in a prominent location,
discuss emergency procedures with the child, and practice emergency procedures every
6 months. [§89323(a) and (a)(1)]
[ ] Yes [ ] No
Comments:
13. The caregiver understands that they are permitted to arrange for occasional short-term
babysitters, alternative caregivers, respite care, leaving children alone without adult supervision,
licensed child care, and participation in extracurricular, enrichment, and social activities.
[§89378(a)(1)(A) through (F)]
[ ] Yes [ ] No
Comments:
14. The caregiver shall provide at least three nutritious meals daily, provide between meal
snacks, meet any special dietary needs of the child, afford the same quantity and quality of food
available to all household members, and invite the child to participate in all household meals.
[§89376]
[ ] Yes [ ] No
Comments:
SOC 818 (12/10) Relative or Non-Relative Extended Family Member
Caregiver Assessment Page 3 of 6
Child’s Name: Case Number:
Child’s Name: Case Number:
Caregiver Name: __________________________________________________________________________________
15. The caregiver understands and agrees that an infant who is not able to hold a bottle, shall
be held during bottle-feeding using an unbreakable bottle and at no time shall a bottle be
propped for an infant. [§89376]
[ ] Yes [ ] No
Comments:
16. Caregivers are permitted to encourage, but not require, a child as age and developmentally
appropriate, to learn meal preparation, which may include the use of kitchen knives and
appliances [§89376]
[ ] Yes [ ] No
Comments:
17. The caregiver shall ensure the child’s transportation to medical appointments, school, and
extracurricular, enrichment, or social activities in vehicles that are in safe operating condition,
unless other arrangements for transportation are stated in the written plan or placement
agreement. [§89374(a) and (c)]
[ ] Yes [ ] No
Comments:
18. The caregiver understands and will ensure that the child is permitted to have age and
developmentally appropriate access to personal hygiene products, kitchen knives and
appliances, medications, disinfectants, and cleaning solutions.
[§89372(a)(2)(B)] and 89387.2(b)(1) through (3)]
[ ] Yes [ ] No
Comments:
19. Caregiver shall provide adequate care and supervision for the number of children in care.
Capacity issues do not apply to relative/NREFM homes [§89378], unless the relative or NREFM
home is a licensed home. [§89228]
[ ] Yes [ ] No
Comments:
SOC 818 (12/10) Relative or Non-Relative Extended Family Member
Caregiver Assessment Page 4 of 6
Child’s Name: Case Number:
Child’s Name: Case Number:
Caregiver Name: __________________________________________________________________________________
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. (Caregiver Initial)
2. I/We agree to cooperate with the county in the maintenance of caregiver standards.
(Caregiver Initial)
3. I/We have been provided with a copy of the child(ren)'s personal rights and understand them
and agree to ensure that all members of the household will abide by them. (Caregiver
Initial)
4. I/We agree to provide for the special needs of any child placed in my/our care, including but
not limited to:
To provide the services identified in the child’s placement agreement and, if applicable,
Transitional Independent Living Plan. [§89378(a)] (Caregiver 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(c)(1)] (Caregiver 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] (Caregiver
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
[§89387(d)] (Caregiver 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 Signature Date
Caregiver Name (Print)
Caregiver Signature Date
SOC 818 (12/10)
Caregiver Name (Print)
Relative or Non-Relative Extended Family Member
Caregiver Assessment Page 5 of 6
Child’s Name: Case Number:
Child’s Name: Case Number:
Caregiver Name: __________________________________________________________________________________
Assessment Summary:
The relative/non-relative extended family member has the ability and capacity to provide
care and supervision to meet the child(ren)'s needs.
[ ] Yes [ ] No
Signature of County CWS or Probation Worker Phone Number Date
SOC 818 (12/10) Relative or Non-Relative Extended Family Member
Caregiver Assessment Page 6 of 6
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