SOC 815, SOC 817 and SOC 818-COMBINED
FOR CALIFORNIA RELATIVE AND NREFM APPROVALS
This Cover Page is submitted to the Placement Tracking Team (PTT) with the appropriate SOC form(s). It summarizes which SOC form(s) is necessary for various relative and non-relative extended family member assessments and communicates which type of data input is necessary to the Placement Tracking Team. This document combines all three approval forms and can be word processed and/or printed out and completed by pen.
Note: For temporary placements, use the “SOC 815 817-818 Combined for 309(d) or 361.45 Temp Placement.”Date of caregiver’s initial request to be assessed for approval:
Primary Care Provider / Secondary Care Provider
1. Completion of Full Approval after Temporary § 309(d) or 361.45 Approval.
2. Full Initial Assessment for Approval (complete forms SOC 815, 817, and 818)
3. Full Annual Reassessment for Approval (complete forms SOC 815, 817, and 818)
Prior approval date:4. Early Full Reassessment for Approval because the family moved or a new Dependent Child of the Court is placed in the caregiver’s home (complete forms SOC 815, 817, and 818).
Prior approval date:SUBMIT THIS COVER PAGE TO THE PLACEMENT TRACKING TEAM WITH THE SOC FORMS
correcting or updating a SOC approval form BeTween Regular AssessmenTs
· To correct a previously submitted SOC form between the initial assessment and the annual reassessment, or between annual reassessments:
Ø Copy the form requiring correction.
Ø Write correct information on the copy. Initial and date the correction(s).
Ø The social worker (and supervisor, if applicable) re-sign and re-date above the original signature(s) and signature dates, noting “corrected” above the social worker’s signature
Ø File the copy of the corrected form in the child’s file. Do not send the copy of the corrected SOC form(s) to the PTT.
· When a non-child welfare child or adult joins the household between the initial assessment and annual reassessment, or between annual reassessments:
Ø Copy the last completed “Checklist of Health and Safety Standards” (SOC 817).
Ø Reassess the caregiver’s building and grounds, noting any changes on the copy of the form. (Complete Alternative Plans and/or Corrective Action Plans, if necessary.)
Ø Initial and date any changes.
Ø The social worker re-signs and re-dates his/her signature on page 2 above the original signature and signature dates, noting “update” above the new signature.
Ø File the copy of the updated SOC 817 in the child’s file. Do not send a copy of the updated SOC 817 to the PTT.
· Additionally, when a new adult joins the household or a member of the household turns age 18, or the social worker becomes aware that a minor over the age of 14 years may have a criminal record:
Ø Copy the last completed ”Approval of Family Caregiver Home” (SOC 815.)
Ø Add criminal and child abuse record check and “DOJ RAP Backs Requested” dates (also “Exemption Requested” and “Exemption Granted/Denied” dates, if applicable) on page 3 of the copy. Initial and date next to the name of the new adult.
Ø Initial and date next to either “All Adults Cleared” or “Not Cleared” under #1, “Criminal Record/Prior Abuse Clearance” on page 1 of the copy.
Ø The social worker and supervisor re-sign and re-date their signatures on page 2 of the copy above their signatures/date, noting “update” above the social worker’s signature.
Ø File the copy of the SOC 815 in the child’s file. Do not send a copy of the updated SOC 815 to the PTT.
SOC815-817-818 Combined – Rev. 1/12
/ Approval of Family Caregiver Home / Page 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
/CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent Name : / List child(ren) or NMD belowCase #: / Social Security #: / List # below / Birth Date: / List DOB below
Caregiver Name: / List caregiver(s) below
Approval of Family Caregiver Home
Pursuant to the provisions of WIC Section 319 319 or 361.45(d)(1), I certify that I assessed
Full Name(s) of Caregiver(s) If a couple or 2 people (e.g., grandmother and aunt) are providing care, list both people.Address
the / / Relative / / NREFM
Relationship
of / ; and
Minor Dependent/NMD Name / Social Security Number / DOB
the / / Relative / / NREFM
Relationship
of / ; and
Minor Dependent/NMD Name / Social Security Number / DOB
the / / Relative / / NREFM
Relationship
of / ; and
Minor Dependent/NMD Name / Social Security Number / DOB
the / / Relative / / NREFM
Relationship
of / ; and
Minor Dependent/NMD Name / Social Security Number / DOB
1. Criminal Record/ Prior Abuse Clearances
This section cannot be completed until record check results from Live Scan fingerprinting are reviewed.Criminal Record and Child Abuse records have been checked and cleared or exempted for the caregiver(s), all adults and other non-exempt person(s) living in the home or on the premises, or who have routine/significant contact with a minor dependent child(ren).
ALL ADULTS CLEAREDNOT CLEARED
2. Caregiver Qualifications
The above named (prospective) caregiver has been assessed as able to care for and supervise the above named minor dependent child(ren) and provide for the child(ren)’s special needs; Caregiver Assessment completed and attached.The above name (prospective) caregiver has been assessed as able to care for and supervise the above named nonminor dependent. Caregiver Assessment (SOC818 NMD) completed and attached.
Caregiver not qualified.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
/CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent Name :Case #: / Social Security #: / See page 1 / Birth Date: / See page 1
Caregiver Name:
3. Safety of the Home and Grounds
If at reassessment a CAP was necessary, put the date of the last site inspection and SW who confirmed CAP completed.. / An on site inspection of the home's building and grounds was conducted on
by
Date
The home is clean, safe, sanitary and in good repair, meeting licensing/approval standards set forth in MPP 31-445 and Title 22, Division 6, Chapter 9.5, Article 3 of the California Code of Regulations; Checklist of Health and Safety Standards (SOC817 or SOC 817NMD as applicable) completed and attached.
HOME DOES NOT MEET APPROVAL STANDARDS.
4. Personal Rights
/ Information regarding the personal rights of the minor dependent child(ren) or nonminor dependent has been provided to the (prospective) caregiver who has agreed to provide a copy of that information to any dependent minor child(ren) or nonminor dependent (or the authorized representative where applicable) placed in the home.5. COMPLETION OF ORIENTATION/TRAINING
The (prospective) caregiver has received a summary of State approval regulations and completed theorientation provided by the county.
For initial assessments when there is no CAP or after CAP is complete, and reassessments that do not require a CAP:
I certify that the above named (prospective) caregiver meets the standards for relative or
non-relative extended family member home approval as of / .
(Date)
For reassessments when a CAP is necessary:
I certify that as of / the above named (prospective) caregiver meets the
(Date)
/ standards for relative or non-relative extended family member home approval pending completion of the Plan of Correction.
Plan of Correction completed on / Date of home visit at which SW confirmed CAP completed
(Date)
Plan of Correction not completed by agreed to due date.
For initial assessments and reassessments
I certify that the above named (prospective) caregiver DOES NOT meet the standards for relative
Or non-relative extended family member home approval as of / .
(Date)
Assessment Approval Worker's Signature / (Date)
Santa Clara
Assessment Approval County
Supervisor's Signature / (Date)
SOC815-817-818 Combined – Rev. 1/12
/ Approval of Family Caregiver Home / Page 2 of 5
STATE OF CALIFORNI – HEALTH AND HUMAN SERVICES AGENCY / CALIFONRIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent Name :
Case #: / Social Security #: / See page 1 / Birth Date: / See page 1
Caregiver Name:
CRIMINAL BACKGROUND CHECKS
Temporary Placement (W&I 309(d)(1); 361.45) / Live Scan Submitted (W&I 309(d)(2)&(d)(3); 361.4; 361.45) / Live Scan Received (W&I 309(d)(2)&(d)(3); 361.4; 361.45) / Rapback / ICT / ExemptionsMegan’s Law Check/Date / Established Presence in Home 1 / CLETS
(309d) 2 / CACI (faxed)
(309d) 3 / CWS/CMS Search
(309d) 4 / DOJ 5 / FBI 6 / CACI 7 / DOJ 8 / FBI 9 / CACI 10 / Established 11 / Effective Date Approved by DOJ 12 / Exemption Requested by Applicant 13 / Exemption Approved 14 / Exemption Denied 15
Caregiver: / Date / Date / Date / Date / Date / Date / Date / Date / Date / Date / Date / Date / Date / Date / Date
Other Adult
Adult w/Significant Contact
1. Date person know to be in home or with significant contact w/ child (i.e., / 8. Date at top of DOJ criminal record check results.
date social worker became aware of person’s presence or sign. Contact) / 9. Date at top of FBI criminal record results.
2. Date Sheriff’s Record Division signs the bottom of the SCZ 686A. / 10. Date at top of CACI results.
3. Date DOJ responded to faxed CACI request. / 11. Date at top of DOJ criminal record check results (same as # 8).
4. Date of CWS/CMS search. Record results in Contact Notebook. / 12 Date of DOJ’s approval of Inter-County Transfer of Rapback to Santa Clara Co.
5. “Date Submitted” from DOJ criminal record check results. / 13. Date person request criminal record exemption (i.e., date of SCZ 200N or letter).
6. “Date Submitted” from FBI criminal record check results. / 14. Date of authorizing signature on SCZ 49 memo SCZ 572 approving exemption.
7. “Date Submitted” from CACI results. / 15. Date of authorizing signature on SCZ 49 memo SCZ 572 denying exemption.
STATE OF CALIFORNI A– HEALTH AND HUMAN SERVICES AGENCY / CALIFONRIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent Name :
Case #: / Social Security #: / See page 1 / Birth Date: / See page 1
Caregiver Name:
OUT-OF-STATE REGISTRY CHECKLIST
Child abuse registry checks apply to people who had resided in other states, Guam, Puerto Rico and the District of Columbia. There are no provisions for doing checks in other countries.
Resided Outside CA Within Last 5 Years / If Yes, Name of Other State(s) / Is Registry Maintained by Other State(s)? / If Yes, Date Requested Other State(s) Info / Date Received Other State(s) Info / Cleared(Date) / Not Cleared
(Date)
Caregiver / YES / NO / YES / NO
Other Adult
Adult with Significant Contact
SOC815-817-818 Combined – Rev. 1/12 / Approval of Family Caregiver Home / Page 4of 5
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY / CALIFONRIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent Name :
Case #: / Social Security #: / See page 1 / Birth Date: / See page 1
Caregiver Name:
Checklist of Standards
for Approval of Family Caregiver Home
Pursuant to Division 31, MPP 31-445, in order to be approved, all relative and nonrelative extended family member homes must meet the following standards, set forth in Title 22, Division 6, Chapter 9.5, Article 3.
Section / Standard / yes / no / dap*Approved
/ cap**completed
89318 / Applicant QUALIFICATIONS
89319 / criminal record clearance REQUIREMENT
89323 /
emergency PROCEDURES
89361/893161 / reporting requirements89370/893170 / cHILDREN’S RECORDS/nonminor dependents’ records
89372/893172 / personal rights
893172.1 / expectations, alternatives, and consequences
89373/893173 / telephones
89374/893174 / transportation
89376/893176 / food service
89377 / reasonalbe and prudent parent standard
89378/893178 / RESPONSIBILITY FOR PROVIDING care & supervision
89379/893179 / activities
89387/893187 / bUILDINGS AND GROUNDS
89387.2 / storage space
89388 / cooperation & compliance
*dap: DOCUMENTED ALTERNATIVE PLAN made
**Cap: CORRECTIVE ACTION PLAN made
NOTE: ONLY ONE BOX SHOULD BE CHECK FOR EACH STANDARD. CHECK THE “YES” BOX IF THE STANDARD IS MET AND NO DAP OR CAP IS NECESSARY. CHECK THE “DAP” BOX IF THE SUPERVISOR APPROVES AN ALTERNATIVE PLAN. CHECK THE “CAP” BOX IF A CORRECTIVE ACTION PLAN IS COMPLETED. CHECK THE “NO” BOX IF THE STANDARD IS NOT MET BECAUSE THE ALTERNATIVE PLAN IS NOT APPROVED OR THE CORRECTIVE ACTION PLAN IS NOT COMPLETED.SOC815-817-818 Combined – Rev. 1/12 / Approval of Family Caregiver Home / Page 4of 5
Child’s Name(s): No names are necessary on this page / Case Number:
Caregiver Name:
Child’s Name(s): Enter name(s) on each page / Case Number:
Caregiver Name: Enter name(s) on each page
Checklist of Health and Safety Standards
for Approval of Family Caregiver Home
Pursuant to Division 31 MPP 31-445, in order to be approved, all Relative & Non-Relative Extended Family Member Homes must meet the following standards set forth in Title 22, Division 6, Chapter 9.5, Article 3.
Note: Only one box should be checked for each standard. Check the “Yes” box if the standard is met and no alternative plan or corrective action plan is necessary. Check the “DAP” box if the supervisor approves the alternative plan. Check the “CAP” box if a corrective action plan is completed. Check the “No” box if the standard is not met because the alternative plan is not approved or the corrective action plan is not completed.STANDARDS PERMITTING ALTERNATIVE PLANS
The following statements must be answered YES, unless not applicable or an exception is granted to approve the home for placement. /
Yes
/No
/N/A
/*AlternativeApproved
[§ 89387] Adequate bedroom space is provided.
/ / / //
(a)(1) No more than 2 children share a bedroom.
/ / / //
(a)(2) No sharing a bedroom by children of opposite sex unless each child is
under 5 years of age.
/ / / //
(a)(2)(A) A minor parent may share a bedroom with the minor parent’s child of the opposite sex.
/ / / //
(a)(2)(B) A caregiver may request a Documented alternative Plan (LIC 973)
permitting a child to share a bedroom based on the child’s gender identity.
/ / / //
(a)(3) The child does not share a bedroom with an adult unless the child is an infant.
/ / / //
(a)(3)(A) There are no more than 2 infants and no more than 2 adults sharing the same bedroom.
/ / / //
(a)(4)-(5) No room commonly used for other purposes or as a public or general passageway to another room is used as a bedroom.
/ / / //
(a)(7) Each child has individual bed with clean linens, pillow, blankets, and
mattress in good repair.
/ / / //
(a)(7)(B) Easy passage is allowed between beds and room entrance.
/ / / //
(a)(8)(A) Bunk beds shall have reailings on both sides of the upper tier to prevent falling.
/ / / //
(a)(9) Infant has age- and size-appropriate, safe, sturdy bassinet or crib.
/ / / //
(a)(10) Each bedroom has sufficient portable or permanent closet and drawer space for each child.