State of California—Health and Human Services Agency Department of Developmental Services
Supported Living Services Standardized Assessment Questionnaire
Per WIC § 4689(p)(1), this questionnaire is designed to ensure that individuals in or entering supported living
arrangements receive the appropriate amount and type of supports to meet the person’s choice and needs as determined
by the IPP team.
The IPP team is to complete the questionnaire at the time of development, review, or modification of an individual’s IPP.
The questionnaire, in conjunction with the service provider’s comprehensive assessment, will assist the team in
determining if the services recommended or provided are necessary, that generic resources are utilized to the fullest
extent possible, and the most cost effective methods of service provision are utilized. If this process results in a reduction
of services, the regional center is to inform the individual of the reason for the reduction and provide the individual a
written notice of fair hearing rights pursuant to WIC § 4701.
1. Are medical considerations/supports
necessary and sufficient?
Yes
No
2. Are considerations/supports for
medications or treatments necessary
and sufficient?
Yes
No
3. Are behavioral considerations/
supports necessary and sufficient?
Yes
No
4. Does the individual require the
personal care, transfers, toileting,
and/or feeding as detailed in the
support plan?
Yes
No
5. Are safety and emergency
procedures necessary and sufficient?
Yes
No
6. Have all the possible support
alternatives been considered (e.g.
med. planners, telephone check-in
systems, self-checklist programs,
etc.)?
Yes
No
7. Are IHSS hours maximized?
Yes
No
8. Are generic services/supports
maximized?
Yes
No
9. Are natural supports maximized and
are there sufficient opportunities to
maintain and expand them (e.g.
Circle of Support, friends, family,
etc.)?
Yes
No
