Form Soc 815 - Approval Of Family Caregiver Home Page 5
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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:___________________________________________________________________________________________
Checklist of Standards for Approval of Family Caregiver Home
Pursuant to Division 31, MPP 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.
Section
STANDARD
YES
NO
DAP*
CAP**
89318
APPLICANT QUALIFICATIONS
89319
CRIMINAL RECORD CLEARANCE REQUIREMENT
89323
EMERGENCY PROCEDURES
89361/893161
REPORTING REQUIREMENTS
89370/893170
CHILDREN’S RECORDS/NONMINOR DEPENDENTS’ RECORDS
89372/893172
PERSONAL RIGHTS
893172.1
EXPECTATIONS, ALTERNATIVES, AND CONSEQUENCES
89373/893173
TELEPHONES
89374/893174
TRANSPORTATION
89376/893176
FOOD SERVICE
89377
REASONABLE AND PRUDENT PARENT STANDARD
89378/893178
RESPONSIBILITY FOR PROVIDING CARE & SUPERVISION
89379/893179
ACTIVITIES
89387/893187
BUILDINGS AND GROUNDS
89387.2
STORAGE SPACE
89388
COOPERATION & COMPLIANCE
*DAP: DOCUMENTED ALTERNATIVE PLAN MADE
**CAP:
CORRECTIVE ACTION PLAN MADE
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SOC 815 (1/12)
Approval of Family Caregiver Home
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