Form Soc 818nmd - Relative Or Nonrelative Extended Family Member Caregiver Assessment - Nonminor Dependent

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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 “Yes” to 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 “No” answer 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
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