Form Na 1271 - Notice Of Action - Denial Of Home - Assessment/approval
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3STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
COUNTY OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Notice Date:
NOTICE OF ACTION -- DENIAL OF HOME
Case Name:
ASSESSMENT/APPROVAL
Case No.:
Worker Name:
Telephone:
Address:
ADDRESSEE
Questions? Ask your Worker.
STATE HEARING:
If you think this action is
wrong, you can ask for a hearing. The last page
tells you how.
THE COUNTY HAS DENIED YOUR REQUEST FOR HOME ASSESSMENT. HERE’S WHY:
I
You were determined not to be a relative of the minor or nonminor dependent as defined in Welfare and Institutions Code
section 319(f).
I
You were determined not to be a nonrelative extended family member (NREFM) to the minor or nonminor dependent as defined in
Welfare and Institutions Code section 362.7.
THE COUNTY HAS ASSESSED YOU/YOUR HOME AND HAS DENIED APPROVAL. HERE’S WHY:
I
Your criminal background and/or child abuse history could not be cleared/exempted. See the Additional Details section.
I
The criminal background and/or child abuse history of someone living in your home could not be cleared/exempted. See the Additional
Details section.
I
Your home did not meet health and safety requirements for the reason(s) described in the Additional Details section.
I
You did not meet the qualifications to be a caregiver as described in the Additional Details section.
I
You did not complete the required orientation and training. See the Additional Details section.
I
Other (explain):
THERE ARE UNMET STANDARDS SET FORTH IN TITLE 22, DIVISION 6, CHAPTER 9.5, ARTICLE 3. YOU DID NOT MEET THE
STANDARDS CHECKED BELOW. SEE THE ADDITIONAL DETAILS SECTION.
Standard
I
Applicant Qualifications pursuant to section 89318
I
Criminal Record Clearance Requirement pursuant to section 89319
I
Emergency Procedures pursuant to section 89323
I
Reporting Requirements pursuant to section 89361
I
Nonminor Dependent - Reporting Requirements pursuant to section 893161
I
Children’s Records pursuant to section 89370
I
Nonminor Dependents' Records pursuant to section 893170
I
Personal Rights pursuant to section 89372
I
Nonminor Dependent - Personal Rights pursuant to section 893172
I
Expectations, Alternatives, and Consequences pursuant to section 893172.1
NA 1271 (5/14) REQUIRED FORM - NO SUBSTITUTE PERMITTED
PAGE 1 OF 3
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