CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING
RESOURCE FAMILY APPROVAL CERTIFICATE
In accordance with applicable provisions of the Health and Safety Code of California and Foster Family Agency
Interim Licensing Standards of the California Department of Social Services, the licensed Foster Family Agency
shown below has issued this Resource Family Approval Certificate to:
Resource Family Name: _________________________________________________________________________
Resource Family Address: _______________________________________________________________________
_____________________________________________________________________________________________
To receive and provide care for children and nonminor dependents subsequently placed by the agency.
This Approval:
1.
Does not permit the acceptance of children or nonminor dependents for care from any other agency,
individual, parent or guardian.
2.
Is not transferable; is limited to the terms of the approval and may be rescinded at the discretion of the
foster family agency or the California Department of Social Services.
3.
Is granted upon the following conditions:
Capacity: _____________________________________________________________________________________
Conditions on Approval: _________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Date of Approval: ________________________________
“I hereby certify that the above named Resource Family meets the approval standards in the Foster Family Agency
Interim Licensing Standards.”
_______________________________________
_______________________________________
Foster Family Agency Name
_______________________________________
_______________________________________
License Number
_______________________________________
_______________________________________
Address
Title
_______________________________________
_______________________________________
Date
City, State, Zip Code
PLEASE KEEP ON FILE IN RESOURCE FAMILY HOME
RESOURCE FAMILY APPROVAL CERTIFICATE
LIC 05A (7/17) (OPTIONAL)
Original: Resource Family
Copy: Foster Family Agency