Form Soc 817nmd - Checklist Of Health And Safety Standards For Approval Of Family Caregiver Home - Nonminor Dependent
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5STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Nonminor Dependent Name:
Case Number:
Caregiver Name: ___________________________________________________
Checklist of Health and Safety Standards
for Approval of Family Caregiver Home – Nonminor Dependent
Pursuant to Manual of Policies and Procedures Division 31, 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.
STANDARDS PERMITTING ALTERNATIVE PLANS
The following statements must be answered YES, unless not applicable or
Yes
No
N/A
*Alternative
exception is granted, to approve the home for placement.
§89373 Telephone service shall be readily accessible in the home at all
times, unless alternative telephone access is approved and documented.
§89387(a)(4)-(5) No room commonly used for other purposes or as a
public or general passageway to another room is used as a bedroom.
§89387(a)(10) Each bedroom has sufficient portable or permanent closet
and drawer space to accommodate the nonminor dependent’s clothing
and personal belongings.
§893187(c)(1) No more than 2 people, including a nonminor dependent
and a child, or another nonminor dependent, share a bedroom.
§893187(c)(3), (A) Each nonminor dependent has an individual bed
equipped with a clean mattress and pillow(s) in good repair, and clean
linens (blankets, bedspread, sheets, pillow cases and mattress pad).
§893187(c)(4) A bassinet, crib, or bed that meets the requirements of
§89387(a)(9)(A)-(a)(9)(E) is provided for the nonminor dependent’s child.
STANDARDS NOT PERMITTING ALTERNATIVE PLANS
The following statements must be answered YES, unless not applicable or
»
Yes
No
N/A
CAP
a corrective action plan has been agreed upon. # indicates a standard for
which “not applicable” is an unacceptable response.
§89387(a)(6) Each bedroom has at least one operable window or door
that ensures safe, direct, emergency exit to the outside. If security
#
window bars are used, the window is considered operable only if
equipped with safety release devices.
§89387(b) The home appears to be clean, safe, sanitary and in good
repair.
§89387(c) Indoor and outdoor halls, stairs, ramps, and porches are free of
obstructions.
§89387(h) Yard or outdoor activity space shall be provided free from
hazards that endanger the health and safety of a nonminor dependent.
§89387(j) Home contains at least 1 toilet, 1 sink, and 1 tub or shower
#
maintained in safe, clean operating condition.
§89387(k) Home is maintained at a safe and comfortable temperature at
#
all times.
SOC 817NMD (1/12)
Checklist of Health and Safety Standards for
Page 1 of 5
Required-No Substitution Permitted
Approval of Family Caregiver Home-Nonminor Dependent
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