Form Rfa 809c - Resource Family Visit - Corrective Action Plan
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2STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
County/Agency:
FOR COUNTY/AGENCY USE ONLY
Address/Contact Information:
Amended: _____________________
(Date Of Original Report)
RESOURCE FAMILY VISIT – CORRECTIVE ACTION PLAN
Purpose of Form: Use this form to document all deficiencies that require a Corrective Action Plan (CAP).
It is the intent of the RFA worker to conduct all interactions and communications with the Resource Family with courtesy and respect and to be minimally
disruptive to the Resource Family and the children in their care while also ensuring that the home is a safe and nurturing placement.
Resource Family Name: ____________________________________ Resource Family ID Number: ________________________________
DESCRIBE HOW THE
DESCRIBE EACH DEFICIENCY
DUE DATE
DEFICIENCY WILL BE CORRECTED
I acknowledge receipt of this report and understand my appeal rights as explained on the following page of this form.*
RF PRINTED NAME:
RF SIGNATURE:
DATE:
TELEPHONE NUMBER:
RF WORKER PRINTED NAME:
RF WORKER SIGNATURE:
DATE:
TELEPHONE NUMBER:
RF WORKER SUPERVISOR PRINTED NAME:
TELEPHONE NUMBER:
*
RFA Worker: Check this box if a Resource Family parent was not available to sign the report. Immediately mail the report by
certified mail to the Resource Family address of record.
RFA 809C (9/17) (Mandatory)
(Confidential/Public: Depending on type of information)
Copy: Resource Family
Distribution: Original: County
Page ______ of _____
_
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