Form Lic 03 - Resource Family Home Health And Safety Assessment Checklist Page 4
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4CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING
FFA: ________________________________________________
Resource Family/Applicant Name: ___________________________________ Family ID Number: _________________
Notes/Comments Continued:
I certify the home of
as of
DATE
I
meets
I
does not meet
the home environment assessment standards required for Resource Family Approval,
excluding the background check.
DATE
AUTHORIZED FOSTER FAMILY AGENCY ADMINISTRATOR OR DESIGNEE REPRESENTATIVE
By signing below I/we acknowledge that I/we have received a copy of this report.
RESOURCE FAMILY/APPLICANT 1
DATE
RESOURCE FAMILY/APPLICANT 2
DATE
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
PAGE 4 OF 4
LIC 03 (6/17) (MANDATORY)
Distribution: Original Foster Family Agency
Copy: Resource Family/Applicant
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