STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent Name:
Case Number: _____
Caregiver Name: __________________________________________________________________________________
Relative or Nonrelative Extended Family Member
Caregiver Assessment - Nonminor Dependent
All statements below must be answered Yesto approve the (prospective) caregiver. When
there is a No answer, the worker should assess whether the provision of reasonable
assistance or additional services to the (prospective) caregiver would enable the (prospective)
caregiver to properly respond to the nonminor dependent’s needs, health and safety. If the
worker later reassesses the (prospective) caregiver and determines that conditions supporting
the Noanswer 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 (prospective) caregiver has been provided a summary of State home approval
regulations and is capable, having sufficient physical and mental health, to meet the statutory
and regulatory requirements for care and supervision appropriate to the nonminor dependent.
[MPP §31-445.141]
[ ] Yes [ ] No
Comments:
2. The (prospective) caregiver agrees to report to the approval agency by telephone, e-mail, or
fax the occurrence of any event listed in Section 893161(b)(1)-(b)(9) within 24 hours after the
event occurs to the approval agency and within 7 calendar days provide a written report to the
approval agency containing the information in §893161(d). [§893161(b), (c), (d)]
[ ] Yes [ ] No
Comments:
3. The (prospective) caregiver understands and agrees to maintain records regarding the
nonminor dependent, including, but not limited to, name, date of birth, date of placement in the
home, discharge information, health and educational records, the written needs and services
plan (if provided), and the Transitional Independent Living Plan (TILP). The (prospective)
caregiver agrees to allow the nonminor dependent access to these records. [§89370(a)(1), (2)
and (4)/893170(a) and (b)]
[ ] Yes [ ] No
Comments:
SOC 818NMD (1/12) Relative or Nonrelative Extended Family Member
Required-No Substitute Permitted Caregiver Assessment - Nonminor Dependent Page 1 of 6
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent Name:
Case Number: _____
Caregiver Name: __________________________________________________________________________________
4. The (prospective) caregiver agrees to assist the nonminor dependent in obtaining and
keeping his or her own records, and will give any original or photocopy of those records to the
nonminor dependent (or responsible placing agency) when the nonminor dependent
permanently leaves the home. 893170(c) and (d)]
[ ] Yes [ ] No
Comments:
5. The (prospective) caregiver has been provided with a copy of the nonminor dependent's
personal rights contained in Section 893172, understands them, and agrees to ensure that the
nonminor dependent is accorded those rights. [§893712(b)]
[ ] Yes [ ] No
Comments:
6. The (prospective) caregiver agrees to tell and provide a written copy of the personal rights
contained in Section 893172 to the nonminor dependent, and to give the nonminor dependent
information regarding agencies which the nonminor dependent may contact concerning
violations of these rights. 893172(d)]
[ ] Yes [ ] No
Comments:
7. The (prospective) caregiver agrees to develop, implement and maintain written expectations,
alternatives and consequences for the nonminor dependent residing in the home. The
caregiver agrees to give the nonminor dependent an opportunity to review the expectations,
alternatives and consequences. [§893172.1(a)(1)]
[ ] Yes [ ] No
Comments:
8. The (prospective) caregiver agrees to discuss and come to a mutual agreement with the
nonminor dependent about reasonable and temporary alternatives or consequences when the
nonminor dependent does not meet the expectations for living in the home. [§893172.1(b)]
[ ] Yes [ ] No
Comments:
SOC 818NMD (1/12) Relative or Nonrelative Extended Family Member
Required-No Substitute Permitted Caregiver Assessment - Nonminor Dependent Page 2 of 6
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent Name:
Case Number: _____
Caregiver Name: __________________________________________________________________________________
9. When a nonminor dependent is subject to reasonable/temporary alternatives/consequences,
the (prospective) caregiver agrees to inform the nonminor dependent about imposition of
alternatives/consequences, discuss the reason(s) for alternatives/consequences, develop a plan
for compliance, set a time limit, and document the decision to impose
alternatives/consequences. [§893172.1(c)(1)-(c)(5)]
[ ] Yes [ ] No
Comments:
10. The (prospective) caregiver understands that a nonminor dependent may have a personal
landline or cellular telephone, and/or a personal computer for Internet access in the home, upon
arrangement with the caregiver. If the caregiver subscribes to an Internet service, the caregiver
agrees to make that service accessible to the nonminor dependent. [§893173]
[ ] Yes [ ] No
Comments:
11. When the nonminor dependent requests the caregiver to provide transportation, the
(prospective) caregiver agrees to utilize a vehicle that is in safe operating condition.
[§89374(a)/893174(d)]
[ ] Yes [ ] No
Comments:
12. The (prospective) caregiver agrees to provide the nonminor dependent with access to at
least three nutritious meals daily, between meal snacks, and any special dietary needs of the
nonminor dependent; afford the same quantity and quality of food available to all household
members; and, invite the nonminor dependent to participate in all household meals. [§89376(a),
(a)(1), (b)/893176(b)]
[ ] Yes [ ] No
Comments:
13. The (prospective) caregiver agrees to allow the nonminor dependent access to all meal
preparation areas, appliances, and utensils for meal preparation and provide opportunities for
the nonminor dependent to plan meals, grocery shop, and store and prepare food. 893176(c)]
[ ] Yes [ ] No
Comments:
SOC 818NMD (1/12) Relative or Nonrelative Extended Family Member
Required-No Substitute Permitted Caregiver Assessment - Nonminor Dependent Page 3 of 6
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent Name:
Case Number: _____
Caregiver Name: __________________________________________________________________________________
14. The (prospective) caregiver is aware of the nonminor dependent’s emotional, behavioral,
physical, medical, and educational needs and is able and agrees to provide care and
supervision as necessary to meet the needs of the nonminor dependent. [§893178]
[ ] Yes [ ] No
Comments:
15. The (prospective) caregiver agrees to assist the nonminor dependent with developing skills
needed for self-sufficiency, such as those skills listed in Section 893178(c). [§893178(c)]
[ ] Yes [ ] No
Comments:
16. The (prospective) caregiver understands that the nonminor dependent is not required to
provide care and supervision to minors in the home, but may do so only as an occasional
short-term babysitter when the nonminor dependent is of sufficient maturity, experience and
ability. [§893178(e)]
[ ] Yes [ ] No
Comments:
17. The (prospective) caregiver agrees to encourage the nonminor dependent to seek, select
and maintain permanent connections with family and other caring, committed adults of the
nonminor dependent. [§893178(g)]
[ ] Yes [ ] No
Comments:
18. The (prospective) caregiver understands the nonminor dependent shall be entitled to
participate in activities of his or her own choosing. [§893179(b)]
[ ] Yes [ ] No
Comments:
SOC 818NMD (1/12) Relative or Nonrelative Extended Family Member
Required-No Substitute Permitted Caregiver Assessment - Nonminor Dependent Page 4 of 6
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent Name:
Case Number: _____
Caregiver Name: __________________________________________________________________________________
19. The (prospective) caregiver agrees to allow the nonminor dependent access to information
about vocational and postsecondary educational options and emancipation programs. If
requested by the nonminor dependent, the (prospective) caregiver agrees to assist the
nonminor dependent with information about career requirements and salary; internet career
searches; community sponsored career, volunteer or internship events and opportunities; and,
THP-Plus, THP-Plus Foster Care, and supervised independent living placements (SILPs).
[§893179(c)]
[ ] Yes [ ] No
Comments:
Additional Comments:
SOC 818NMD (1/12) Relative or Nonrelative Extended Family Member
Required-No Substitute Permitted Caregiver Assessment - Nonminor Dependent Page 5 of 6
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent 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 or nonrelative extended family member 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 nonminor dependent's personal rights and
understand them and agree to ensure that all members of the household will abide by them.
________ (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
Caregiver Name (Print)
Assessment Summary:
The relative/non-relative extended family member has the ability and capacity to provide
care and supervision to the nonminor dependent.
[ ] Yes [ ] No
Signature of County CWS or Probation Worker Phone Number Date
SOC 818NMD (1/12) Relative or Nonrelative Extended Family Member
Required-No Substitute Permitted Caregiver Assessment - Nonminor Dependent Page 6 of 6
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