Form Soc 815 - Approval Of Family Caregiver Home
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5STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent
Nonminor Dependent Name___________________________________________________
Case #:____________________ Social Security Number:___________________ Birth Date:___________________
Caregiver Name: ________________________________________________________________________________
Approval of Family Caregiver Home
Pursuant to the provisions of W&IC Section 319 or 361.45(d)(1), as applicable, I certify that I assessed
__________________________________________________________________________________________
Name
___________________________________________________________________________
Address
the
Relative
NREFM______________________________________________________________________
l
Re
ationship
_____________________________________________
of
_________________________________; and
Minor Dependent /NMD Name
Social Security Number
DOB
the
Relative
NREFM
________________________________________________________________________________________
Relationship
of _______________________________________________________________________________________; and
Minor Dependent /NMD Name
Social Security Number
DOB
the
Relative
NREFM______________________________________________________________________
Relationship
of ___________________________________________________________________________________________.
Minor Dependent /NMD Name
Social Security Number
DOB
1. CRIMINAL RECORD/ PRIOR ABUSE CLEARANCES
Criminal Record and Child Abuse records have been checked and cleared or exempted for the caregiver(s), all adults
and other non-exempt person(s) living in the home or on the premises, or who have routine/significant contact with a
minor dependent child(ren).
ALL ADULTS CLEARED/EXEMPTED
NOT CLEARED
2. CAREGIVER QUALIFICATIONS
The above named (prospective) caregiver has been assessed as able to care for and supervise the above named
minor dependent child(ren) and provide for the child(ren)'s special needs; Caregiver Assessment (SOC 818)
completed and attached.
The above named (prospective) caregiver has been assessed as able to care for and supervise the above named
nonminor dependent; Caregiver Assessment (SOC 818 NMD) completed and attached.
CAREGIVER NOT QUALIFIED.
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SOC 815 (1/12)
Approval of Family Caregiver Home
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Parent category: Legal