Form Lic 03 - Resource Family Home Health And Safety Assessment Checklist Page 3
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4CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING
FFA: ________________________________________________
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
Document for Agency Use Only
Resource Family/Applicant Name: ___________________________________ Family ID Number: _________________
MET NOT
NO
TRANSPORTATION
PLACEMENT(S)
MET
Is transportation provided to children/NMDs for health-related services, school, extracurricular,
enrichment, cultural, and social activities?
Are the vehicles that are used (or that will be used) to transport children/NMDs in safe
operating condition?
Are Resource Families transporting children in appropriate child passenger restraint systems?
MET NOT
NO
FOOD AND NUTRITION
PLACEMENT(S)
MET
Are special dietary needs met and nutritious meals and snacks provided to children/NMDs?
MET NOT
NO
REASONABLE AND PRUDENT PARENT STANDARD
PLACEMENT(S)
MET
Is the Reasonable and Prudent Parent Standard applied as required for decisions related to children?
*A Resource Family shall use the Reasonable and Prudent Parent Standard as defined in Welf. & Inst Code section 362.04 and 362.05
and FFA Interim Licensing Standards section 88487.12.
MET NOT
NO
RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION
PLACEMENT(S)
MET
Are the care and supervision meeting the specified needs of the child or NMD?
MET NOT
NO
ACTIVITIES
PLACEMENT(S)
MET
Is the child/NMD permitted and encouraged to participate in extracurricular, enrichment, cultural, and
social activities?
COOPERATION AND COMPLIANCE
Yes
No
Have any false or misleading statements regarding Resource Family Approval or the operation of
I
I
the home been made or disseminated by the applicant or Resource Family?
RESOURCE FAMILY APPROVAL FFA INTERIM LICENSING STANDARDS
DAP’S
Met
Not Met
I
I
I
Instructions: If any of the boxes were checked as “Not Met,” then please describe what must occur for the item to be checked off as
“Met” and include any supportive services an FFA may provide to assist the family in meeting the requirement. Additionally, please
include a description of any matters a placing worker may want to consider prior to making a placement, depending on the needs of
the child. This may include but is not limited to: Are electrical outlets covered? Are safety gates placed on the top and bottom of
interior stairways? Are there any animals in the home that may pose a health or safety risk?
Notes/Comments:
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
PAGE 3 OF 4
LIC 03 (6/17) (MANDATORY)
Distribution: Original Foster Family Agency
Copy: Resource Family/Applicant
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