Form Rfa 809 - Resource Family Visit Record
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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:
I
Amended: _____________________
(Date Of Original Report)
RESOURCE FAMILY VISIT RECORD
(Resource Family Name)
(specific address)
(specific address)
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.
Type of Visit:
I
Corrective Action Plan (CAP)
I
Annual Update
I
Case Management
RF NAME:
RF ID:
CAPACITY:
CENSUS:
ADDRESS (STREET, CITY, STATE, ZIP CODE):
TELEPHONE NUMBER:
I
Announced
Met with ______________________________ on ________________ from ________________ to ________________
(Date)
(Start Time)
(End Time)
(Print Name )
I
Unannounced
Provide a brief summary of the visit: ___________________
__________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
I acknowledge receipt of this report.*
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:
*
I
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 809 (9/17) (Mandatory)
(Confidential/Public: Depending on type of information)
Copy: Resource Family
Distribution: Original: County
Page 1 of _____
_
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