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Santa Clara County
Social Services Agency
Department of Family and Children’s Services
SOC 815- 817-818 COMBINED FOR TEMPORARY PLACEMENT
PROCEDURAL CHECKLIST
Most forms necessary for a “temporary placement” are combined in this document. The “Important Information for
Caregivers” booklet (SCZ 200J) and the Ombuds’ “You Have Rights Too” materials, which must be given to the
caregiver as a part of training and orientation, are not included in this combined document. The following forms are
forwarded to the Placement Tracking Team (PTT): SOC 815-temp place, SOC 817- temp place, SOC 818- temp place,
Caregiver Information Sheet” (SCZ 200), any necessary Alternative Plans (SCZ 200K) and/or Corrective Action Plan
(SCZ 200L), and the SCZ 17.
For full approval, Live Scan results and other information, as indicated below, should be added to the SOC-temp
placement forms that were completed for the temporary placement and copies should be submitted to the PTT.
This temporary, emergency placement assessment is made pursuant to the following Welfare and Institutions Code §:
309(d) for a child who is: 361.45 for a child who is:
in temporary custody (pre-detention hearing) or in court-ordered placement, and
ordered into a temporary placement (pre- the caregiver suddenly becomes unavailable, and
dispositional hearing The child requires a change in placement on an
emergency basis
Date of caregiver’s initial request to be assessed for placement:
Primary Care Provider Secondary Care Provider
Procedural Steps: Steps 1-10 must be accomplished prior to proceeding with a temporary placement, except
for the dates required in the shaded boxes. The dates required for the shaded boxes are entered either the
next business day after the temporary placement or prior to full approval, as indicated below.
1. Completed the “Caregiver Information Sheet” form (SCZ 200A).
2. All adults in the home completed and signed the “Criminal Record Statement” form (LIC 508D).
LIC 508D(s) did did not report criminal conviction(s).
3. CLETS results requested and reviewed for all adults in the home (choose a or b).
a. CLETS results did not report criminal conviction(s).
b. CLETS results did report criminal conviction(s) [choose (1) or (2)]
(1) “Director’s Exemption Regarding WIC 361.4(d)(3)” (SCZ 49) was approved prior
to the temporary placement.
(2) “Request for Relative/Non-Relative Extended Family Member Criminal Record
Exemption” (SCZ 572) was approved prior to the temporary placement.
Full Approval Reminder: The Social Worker must confirm by reviewing all Live Scan results that the
exemption request based on CLETS contained all convictions.
4. Provided each adult in the home with a completed “Live Scan Referral” form (SCZ 152).
Note: The caregiver and all adults in the home should be fingerprinted within 2 business days following the
temporary placement and prior to the Detention hearing. If the caregiver and adults in the home are not
fingerprinted within ten (10) days of the CLETS check, either the child or the person(s) who has not been
fingerprinted must leave the home.
5. Requested CACI results for all adults in the home via the “CACI Facsimile Inquiry Form,” which is faxed to the
Department of Justice. (If the CACI shows a child abuse history, the child may not be placed temporarily prior
to an approved Child Abuse Review.
6. Reviewed the Out of State Disclosure and Criminal History Statement (LIC508d) to determine if a child abuse
record check in another state must be requested. (The child may be placed temporarily, pending the receipt of
child abuse record results or the completion of the assessment of the child abuse record in the other state.)
7. CWS/CMS record checked for substantiated child abuse and/or neglect records conducted for all adults
in the home.
8. CACI and CWS/CMS child abuse/neglect record checks reviewed, and results indicated (choose a or b):
a. No substantiated child abuse and/or neglect allegations for any adult in the home.
b. Substantiated child abuse and/or neglect allegation(s) found for an adult(s) in the home.
(1.) “Child Abuse and/or Neglect Record Review” (SCZ 200M) was approved prior
to the temporary placement.
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9. Conducted a home site inspection and completed the “Checklist of Health and Safety Standards for Approval
of Family Caregiver Home” [SOC 817-temp place]
10. Reviewed results of site inspection to determine if either an Alternative Plan (SCZ 200K) or Corrective Action
Plan (SCZ 200L) is needed.
Note: A Social Worker conducting an assessment in the field can obtain supervisory approval for an
Alternative or Corrective Action Plan via telephone, followed by signed supervisory approval on the
SCZ 200K and/or SCZ 200L the next business day.
a. Neither an Alternative or Corrective Action Plan was needed, and the caregiver’s home
is certified as meeting the building and grounds standards for approval.
b An Alternative Plan was needed and approved by the Supervisor, and the caregiver’s home
is certified as meeting the building and grounds standards for approval [choose (1.) or (2.)].
(1.) Supervisor signed the Plan prior to the temporary placement.
(2.) Supervisor approved Plan by telephone on followed by signing
the Plan the next business day on .
1
c. A Corrective Action Plan for a potential impact deficiency was approved by the Supervisor and is
pending completion. The caregiver’s home is not yet certified as meeting the building and grounds
standards for approval. The temporary placement proceeded with this Corrective Action Plan.
pending [Choose (1) or (2) below.]
(1) Supervisor signed the Plan prior to the temporary placement.
(2) Supervisor approved Plan by telephone on followed by signing
the Plan the next business day on .
Full Approval Reminder: The Social Worker (or a Social Worker acting on behalf of the assigned
Social Worker) must confirm by in-person inspection that the potential impact deficiency was
corrected. Then, the Social Worker (or a Social Worker acting on behalf of the assigned Social
Worker) signs the SOC 817 to certify that the home meets the standards.
11. Gave the caregiver(s) a copy of the “Important Information for Caregivers” booklet (SCZ 200J) and the State
Ombuds’ “You Have Rights Too” child’s personal rights flyer and poster, and either:
a Went over the SCZ 200J and “You Ave Rights Too” materials with the caregiver(s) and completed the
SOC 818-temp placement form, OR
b. Made an appointment within 5 business days to go over the SCZ 200J and “You Ave Rights Too”
materials with the caregiver(s) and complete the SOC 818-temp placement form.
12. Completed the information required in the shaded areas of the SOC 815-temp place on pages 1-3.
Note: At the time of the temporary placement, the following sections of the SOC 815 will be or might be
incomplete, and will need to be completed prior to full approval:
The “Criminal Record/Prior Abuse,” section on page 1, because Live Scan results are pending
at the time of the temporary placement.
The “Safety of Home and Grounds” section on page 2 when a Corrective Action Plan for a
potential impact deficiency is pending.
The approval certification and Social Worker/Supervisor signature section on page 2, because
approval assessment is not complete.
The matrix on page 4.
13. The Social Worker signs below and submits these “Procedural Checklist” pages, all SOC-temp forms and any
necessary SCZ 200K or SCZ 200L forms to the Supervisor for review and approval the next business day
following the temporary placement.
14. Within one business day of the temporary placement, submit the following copies to the PTT:
These two “Procedural Checklist” pages with the Social Worker’s and Social Work Supervisor’s
signatures below.
The “Caregiver Information Sheet” (SCZ 200).
Either a signed SOC 817-temp place with any Alternative Plan, or an unsigned SOC 817-temp place
form with a copy of any pending Corrective Action Plan for a potential impact deficiency, if applicable.
The SOC 818-temp placement form, if training/orientation was completed before temporary placement.
The partially completed SOC 815-temp placement form
The “Placement/Address Change Form” (SCZ 17).
The caregiver meets the requirements for a temporary placement per WIC § 309(d) or 361.45.
Social Worker Signature Date Supervisor Signature Date
1
A “potential impact deficiency” does not pose an immediate threat to the health or safety of children (e.g., a household maintenance problem that is readily correctable. A
temporary placement can proceed with a Corrective Action Plan for a potential impact deficiency pending. A temporary placement cannot proceed with an “immediate
impact deficiency” pending (e.g., unlocked guns, swimming pools, accessible poisons, etc.).
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Facsimile Inquiry for Child Abuse Central Index Check (CACI)
To print-out the current version of the “Facsimile Inquiry for child Abuse Central Index Check
(CACI)” form, open Acrobat Reader, go to the G drive, go to template, go to forms, and open
“CACI Facsimile Inquiry Form.”
The form appears on the G: drive and DFCS Intranet Forms List as:
CACI (Child Abuse Central Index) Records Request
Santa Clara County
Social Services Agency
Department of Family and Children’s Services
CAREGIVER INFORMATION SHEET
CHILD(REN) FOR WHOM PLACEMENT IS REQUESTED
Child(ren)’s Name(s) Date of Birth Sex Relationship to Caregiver
INFORMATION ABOUT CAREGIVER(S)
Caregiver’s Name Partner/Spouse
Last Name First Name Middle Name Last Name First Name Middle Name
Other Names For This Person, e.g., Maiden Name, Aliases Other Names For This Person, e.g., Maiden Name, Aliases
Date of Birth Social Security Number Date of Birth Social Security Number
Driver’s License Number Telephone Numbers Driver’s License Number Telephone Numbers
Home: Home:
Work: Work:
State Number State Number
Address
Street City State Zip Code
INFORMATION ABOUT ADULTS AND CHILDREN IN HOME
Name(s)
Date Of Social Security Driver’s License Relationship To
(List Other Names By Which The Sex
Birth Number (State And Number) Child(ren)
Person Has Been Known)
INFORMATION ABOUT ADULTS WHO HAVE SIGNIFICANT CONTACT WITH CAREGIVER(S) OR OTHER
HOUSEHOLD MEMBERS, AND ADULTS WHO WILL HAVE SIGNIFICANT CONTACT WITH THE CHILD(REN)
Name(s)
Social Security Driver’s License Relationship To
(List Other Names By Which The Date Of Birth Sex
Number (State And Number) Child(ren)
Person Has Been Known)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Minor Dependent Nonminor Dependent Name : List child(ren) or NMD below
Case #: 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 I certify that I assessed
Full Name(s) of Caregiver(s)
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 CLEARED Complete this section after
NOT CLEARED all after Live Scan results
are received.
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.
SOC 815-817-818-temp place Rev. 1/12 Approval of Family Caregiver Home Page 1 of 5
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. Note: Do not complete this section until home meets
HOME DOES NOT MEET APPROVAL STANDARDS. building and grounds standards, including approval of
any necessary Alternative Plan and/or completion of
any necessary Corrective Action Plan.
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. Note: Do not complete this section until after you have
gone over the SCZ 200J and “Your Have Rights Too”
5. COMPLETION OF ORIENTATION/TRAINING materials with the caregiver(s) and completed the
SOC 818.
The (prospective) caregiver has received a summary of State approval regulations and completed the
orientation 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. Complete this certification section after all
approval steps are accomplished.
Date of home visit at which SW
Plan of Correction completed on 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)
SOC 815-817-818-temp place 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
Live Scan Submitted Live Scan Received
Temporary Placement
(W&I 309(d)(2)&(d)(3); (W&I 309(d)(2)&(d)(3); Rapback ICT Exemptions
(W&I 309(d)(1); 361.45)
361.4; 361.45) 361.4; 361.45)
Approved 14
Effective Date
Requested by
Applicant 13
CACI (faxed)
Megan’s Law Check/Date
Approved by
Presence in
Established
Established
Denied 15
CWS/CMS
Exemption
Exemption
Exemption
CACI 10
(309d) 2
(309d) 3
(309d) 4
Home 1
DOJ 12
CACI 7
DOJ 5
DOJ 8
CLETS
Search
FBI 6
FBI 9
11
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.
SOC 815-817-818-temp place Rev. 1/12 Approval of Family Caregiver Home Page 3 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:
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.
If Yes, Date Date
Resided Outside If Yes, Name Is Registry Not
Requested Received Cleared
CA Within Last 5 of Other Maintained by Cleared
Other Other (Date)
Years State(s) Other State(s)? (Date)
State(s) Info State(s) Info
Caregiver YES NO YES NO
Other Adult
Out-of-state inquiries are not applicable for adults with
significant contact.
SOC 815-817-818-temp place Rev. 1/12 Approval of Family Caregiver Home Page 4 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:
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.
DAP* CAP**
Section STANDARD YES NO APPROVED
COMPLETE
D
89318 APPLICANT QUALIFICATIONS
89319 CRIMINAL RECORD CLEARANCE REQUIREMENT
89323 EMERGENCY PROCEDURE
89361/893161 REPORTING REQUIREMENTS
89370/893170 CHILDREN’S RECORDS/NONMINOR DEPENDENTS’ RECORDS
89372/893172 PERSONAL RIGHTS
893172.1 EXPECTATIONS, ALTERNATIVES, AND CONSEQUENCES
89373/893173 TELEPHONES
Complete this page prior to full
89374/893174 TRANSPORTATION
89376/893176 FOOD SERVICE approval of the caregiver.
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.
SOC 815-817-818-temp place Rev. 1/12 Approval of Family Caregiver Home Page 5 of 5
Child’s Name: Case Number:
Caregiver Name:
STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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
*Alternative
The following statements must be answered YES, unless not applicable or Yes No N/A Approved
an exception is granted to approve the home for placement.
[§ 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.
[§89373] Telephone service shall be readily accessible in the home at all
times, unless alternative telephone access is approved and documented.
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for Approval of Family Caregiver Home
Child’s Name: Case Number:
Caregiver Name:
STANDARDS NOT PERMITTING ALTERNATIVE PLANS
The following statements must be answered YES, unless not applicable or a Yes No N/A
»CAP
corrective action plan has been agreed upon. # indicates a standard for Completed
which “not applicable” is an unacceptable response.
[89387(a)(6)] Each bedroom has at least one operable window or door that
ensures safe, direct, emergency exit to the outside. If security window
#
bars are used, the window is considered operable only if equipped with
safety release devices.
(a)(8) Bunk beds of more than two tiers must not be used.
#
(a)(8)(B) Children under six years of age or those who are unable to climb
into or out of the upper tier of a bunk bed unassisted shall not be permitted to
use the upper tier.
(b) The home appears to be clean, safe, sanitary and in good repair.
(c ) Indoor and outdoor halls, stairs, ramps, and porches are free of
obstructions and hazards.
(d) Swimming pools, spas, and other bodies of water are inaccessible to
children under 10 years of age and to disabled children.
(h) Yard or outdoor activity space shall be provided free from hazards that
endanger the health and safety of a child.
(j) Home contains at least 1 toilet, sink, tub or shower maintained in safe,
clean operating condition. #
(k) Home is maintained at a safe and comfortable temperature at all times.
#
(l) Child’s safety is ensured in homes with fireplaces, open forced heaters
and woodstoves.
(m) Necessary lighting is provided in all rooms and other areas to ensure
comfort and safety in the home. #
(n) Hot water from faucets is delivered at a safe temperature.
(o) Waste is stored, located and disposed of in a manner that will
not permit the transmission of communicable disease or of odors, create a
(p) Home or provide sprinkling place or functioning smoke detector
nuisance, has indoor a breedingsystemor food source for insects or rodents.
installed in the hallway(s) of each sleeping area audible in each #
bedroom or sleeping room.
[§89387.2(a)(1).(2).(2)(A), and (3)] Storage areas of firearms and other
dangerous weapons are locked. In lieu of locked storage, the caregiver
utilizes trigger locks or has removed and locked the firing pin/s separately
from the firearm/s. Ammunition is stored and locked separately from
firearms.
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for Approval of Family Caregiver Home
Child’s Name(s): Enter name(s) on each page Case Number:
Caregiver Name: Enter name(s) on each page
STANDARDS NOT PERMITTING ALTERNATIVE PLANS
The following statements must be answered YES, unless not applicable or Yes No N/A
»CAP
a corrective action plan has been agreed upon. # indicates a standard for Completed
which “not applicable” is an unacceptable response.
[89387.2(b)(1),(2), and (3)] Medicines, disinfectants, cleaning solutions,
poisons, firearms, and other dangerous items are stored where
inaccessible to child, except where the caregiver may apply the
reasonable and prudent standard and allow a child to have access to #
household knives and appliances, medications, disinfectants and
cleaning solutions, if age and developmentally appropriate and safety
is assured.
* Alternative: Documented Alternative Plan must be attached.
» Correctable Deficiencies: Corrective Action Plan must be attached. NOTE
I certify that the home of meets the standards
(Caregiver’s Name)
for approval as described in this form.
IF MORE THAN ONE SW DID A SITE INSPECTION, THE SW WHO VERIFIED THAT THE CAP WAS COMPLETED
SIGNS ABOVE AND ENTERS THE DATE OF THE INSPECTION WHERE THE CAP WAS VERIFIED AS COMPLETED.
ALL DAPS MUST BE APPROVED AND CAPS COMPLETED PRIOR TO SIGNING THE CERTIFICATION.
Signature (County CWS or Probation Worker) Date
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for Approval of Family Caregiver Home
DEFICIENCIES AND PLANS OF CORRECTION
When a violation of health and safety standards is observed, the county worker has the
responsibility to determine the length of time by which a correction must be made and to
provide the relative with reasonable assistance in meeting that standard. The basic
factors to be considered in making this assessment are the potential consequences to
the child(ren) placed in the home and the immediacy of the need to correct.
The types of deficiencies are as follows:
1. Immediate Impact: Deficiencies that, if not corrected, would have a direct and
immediate risk to the health, safety or personal rights of the foster child. If
placement is imminent, correction MUST BE MADE prior to placement of the
child.
2. Potential Impact: Deficiencies that without correction could become a risk to the
health, safety or personal rights of the child(ren).
Examples of Immediate Impact Deficiencies:
For initial approval:
1. Health Related: unlocked poisons, inappropriate storage of medications.
2. Food Service: food contaminated with mold, fungus or bacteria; bloated or
ruptured canned foods; infestation of insects or vermin; unsanitary conditions in
food preparation areas that present immediate health hazard; storing of food next
to or with toxic substances.
3. Building and Grounds: no fence or approved cover for bodies of water; broken
stair or stair railings; poisons, toxic substances, firearms in areas accessible to the
child(ren); unlit stairwells used by the child(ren).
4. Fixtures, Furniture, Equipment and Supplies: toilet not in working condition,
garbage accessible to children, unsafe fireplace or heaters that are in use, unsafe
water temperature, condition of bedding or towels is unsanitary, furniture is broken
and could cause injury if used.
5. Criminal Record Clearance and Child Abuse Index Check: failure to obtain a
CLETS clearance and submit a fingerprint or Criminal Record Clearance and Child
Abuse Index Check for those individuals whom have frequent and routine contact
with the child(ren) in care.
For re-assessment, all of the above, and:
1. Personal Rights: abuse, neglect, inappropriate use of restraints, the use of
corporal punishment, and similar violations having a direct negative impact on
either the physical or emotional wellbeing of the child(ren) in care.
SOC 815-817-818-temp place Rev. Checklist of Health and Safety Standards Page 4 of 6
12/29/10 for Approval of Family Caregiver Home
2. Health Related Services: storing mislabeled, unlabeled, outdated or discontinued
medications; failure to ensure that needed medical care is provided to those in
care.
3. Food Service: failure to maintain enough food to meet the needs of the child(ren)
for the next 24 hours.
4. Care and Supervision: child requires a level of care that cannot be met by the
caregiver without the provision of additional supports or services.
5. Supplies: failure to maintain enough basic hygiene items to meet the needs of the
child(ren).
Examples of Potential Impact Deficiencies:
For initial approval:
1. Food Service: failure to clean dishes and utensils.
2. Buildings and Grounds: conditions that may have a negative impact on the
child(ren) in care if not corrected, such as multiple conditions that indicate an
overall deterioration of the home; widespread neglect of maintenance; unsanitary
living and food preparation areas.
3. Furniture, Fixtures, Equipment and Supplies: furnishings should be considered as
deficient only when they are clearly damaged to the extent they are not functional,
(e.g., a tear in the seat of a chair vs. exposed springs); no operable sink or shower;
inadequate linens.
For re-assessment, all of the above, and:
1. Reporting Requirements: Failure to notify the Department regarding incidents of
abuse, neglect, death, injury, etc. as required by §89361.
2.
2. Record Keeping: Failure to maintain the child(ren)’s records as required by
§89370.
Plan of Correction
When a child welfare worker has determined that a deficiency exists, the proposed
caregiver and the worker will discuss each deficiency and develop a plan for correcting
each deficiency. If the deficiency is not corrected during the visit, then the plan of
correction must be in writing, with a copy provided to the caregiver, and shall include at
least the following information:
1. Citation of the regulation section that is violated.
2. Description of the nature of the deficiency.
SOC 815-817-818-temp place Rev. Checklist of Health and Safety Standards Page 5 of 6
12/29/10 for Approval of Family Caregiver Home
3. The actions to be taken by the applicant and the assistance to be provided by
the County.
4. The date by which each deficiency shall be corrected.
5. The phone number of the county office responsible for approval of the home.
WHEN THERE ARE CHILDREN IN THE HOME, THE WORKER MUST REQUIRE
IMMEDIATE CORRECTION OF A DEFICIENCY IF THE DEFICIENCY WOULD POSE
AN IMMEDIATE THREAT TO THE HEALTH AND SAFETY OF CHILDREN. UNDER
THESE SAME CIRCUMSTANCES, IF THERE ARE NO CHILDREN IN CARE, AND
PLACEMENT IS IMMINENT, CORRECTION SHOULD BE WITHIN 24 HOURS OR
LESS, AND BEFORE PLACEMENT IS MADE. OTHERWISE, THE DATE FOR
CORRECTING A DEFICIENCY SHALL NOT BE MORE THAN 30 CALENDAR DAYS
FOLLOWING THE DATE OF THE VISIT, UNLESS THE WORKER DETERMINES THAT
THE DEFICIENCY CANNOT BE CORRECTED IN 30 CALENDAR DAYS. IN THIS
CASE, THE WORKER MUST DETERMINE AN APPROPRIATE COMPLETION DATE.
TITLE IV-E IS NOT AVAILABLE UNTIL THE MONTH IN WHICH THE CORRECTIONS
ARE COMPLETED AND THE HOME FULLY MEETS THE STANDARDS.
THE CORRECTIVE ACTION PLAN SHALL SPECIFY CORRECTIVE ACTIONS WHICH
MUST BE TAKEN WITHIN 30 DAYS AND THE DATE ON WHICH THE CORRECTIONS
WILL BE COMPLETED.
In determining the date for correcting a deficiency, the worker should consider the
following:
1. Whether there are children in care.
2. The potential hazard presented by the deficiency.
3. The availability of equipment or personnel necessary to correct the deficiency.
4. The estimated time necessary for delivery and installation of any necessary
equipment.
If a written plan of correction is used, the worker is responsible for ensuring corrections have
been completed within the required timeframes.
SOC 815-817-818-temp place Rev. Checklist of Health and Safety Standards Page 6 of 6
12/29/10 for Approval of Family Caregiver Home
Child’s Name(s): Enter name(s) on each page
Caregiver Name: Enter name(s) on each page
Relative or Non-Relative Extended Family Member
Caregiver Assessment
All statements below must be answered “Yes” to approve the caregiver. When there is a “No” answer, the worker
should assess whether the provision of reasonable assistance or additional services to the caregiver would
enable the caregiver to properly respond to the child’s needs, health and safety. If the worker later reassesses the
caregiver and determines that conditions supporting the No answer have changed sufficiently to answer Yes,
caregiver approval may be given at that time.
Responses to the following statements have been assessed by the undersigned.
NOTE: COMMENT SHOULD NOT QUALIFY A “YES” TO MEAN STANDARD WAS NOT FULLY MET
OR REFER TO AN ITEM BEING COMPLTED IN THE FUTURE.
1. The caregiver has been provided a summary of State home approval regulations and is capable, having
sufficient physical and mental health, to meet these requirements for the care and supervision appropriate to
the type of child(ren) to be served. [§89318]
Yes No
Comments:
2. The caregiver is aware of the child’s immediate emotional, behavioral, physical, medical, and
educational needs and is able to meet the health, safety, and well-being needs of the child.
[§89378/WIC 361.2]
Yes No
Comments:
3. The caregiver understands State child abuse and neglect laws and shall report by telephone,
e-mail, or fax any circumstances indicating the child has been abused or neglected within 24
hours after the event occurs to the approval agency. [§89361]
Yes No
Comments:
4. The caregiver understands the child shall be entitled to participate in age and
developmentally appropriate extracurricular, enrichment, and social activities. [§89379(a)]
Yes No
Comments:
SOC 815-817-818-temp place Rev. 12/29/10 Relative or Non-Relative Extended Family Member Page 1 of 6
Caregiver Assessment
Child’s Name(s): Enter name(s) on each page
Caregiver Name: Enter name(s) on each page
5. The caregiver shall be responsible for applying the Reasonable and Prudent Parent Standard, which is
characterized by careful and sensible parental decisions that shall take in consideration the age, maturity and
developmental level, behavioral tendencies, mental and physical health, medications, abilities and limitations,
the nature and inherent risks of harm, in order to maintain the child’s health, safety, and best interest.
[§89377]
Yes No
Comments:
6. The caregiver will ensure that only positive discipline practices which promote the health and
well being of the child are used in the home, and will not use corporal punishment or allow any
form of discipline that violates the child's personal rights. [§89372(a)(1)]
Yes No
Comments:
7. The caregiver understands and agrees to maintain the child's records, including the placement agreement,
health and educational records, and written consent for medical/dental treatment. [§89370]
Yes No
Comments:
8. The caregiver agrees to report any accidents, injuries or incidents that threaten to harm the physical or
emotional health or safety of the child within 24 hours after the event occurs by telephone, e-mail, or fax and
submit a written report within 7 calendar days to the approval agency. [§89361(a) and (b)]
Yes No
Comments:
9. The caregiver agrees to report any change in household composition within 24 hours, and a
change in the residence or mailing address within 10 working days, by telephone, e-mail, or fax
to the approval agency. [§89361]
Yes No
Comments:
SOC 815-817-818-temp place Rev. 12/29/10 Relative or Non-Relative Extended Family Member Page 2 of 6
Caregiver Assessment
Child’s Name(s): Enter name(s) on each page Case Number:
Caregiver Name: Enter name(s) on each page
10. The caregiver agrees to report any change in the location of the home to the approval agency by telephone,
e-mail, or fax 30 days prior to the move or as soon as the information is
available. [§89361(d)]
Yes No
Comments:
11. The caregiver has been provided with a copy of the child's personal rights, understandsthem, and agrees to
ensure that all members of the household will abide by them. [§89372]
Yes No
Comments:
12. The caregiver agrees to post emergency telephone numbers in a prominent location, discuss emergency
procedures with the child, and practice emergency procedures every 6 months. [§89323(a) and (a)(1)]
Yes No
Comments:
13. The caregiver understands that they are permitted to arrange for occasional short-term
babysitters, alternative caregivers, respite care, leaving children alone without adult supervision,
licensed child care, and participation in extracurricular, enrichment, and social activities.
[§89378(a)(1)(A) through (F)]
Yes No
Comments:
14. The caregiver shall provide at least three nutritious meals daily, provide between meal
snacks, meet any special dietary needs of the child, afford the same quantity and quality of food
available to all household members, and invite the child to participate in all household meals.
[§89376]
Yes No
Comments:
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for Approval of Family Caregiver Home
Child’s Name(s): Enter name(s) on each page Case Number:
Caregiver Name: Enter name(s) on each page
15. The caregiver understands and agrees that an infant who is not able to hold a bottle, shall be held during
bottle-feeding using an unbreakable bottle and at no time shall a bottle be propped for an infant. [§89376]
Yes No
Comments:
16. Caregivers are permitted to encourage, but not require, a child as age and developmentally
appropriate, to learn meal preparation, which may include the use of kitchen knives and appliances [§89376]
Yes No
Comments:
17. The caregiver shall ensure transportation to medical appointments, school, and
extracurricular, enrichment, or social activities in vehicles that are in safe operating condition,
unless other arrangements for transportation are stated in the written plan or placement
agreement. [§89374(a) and (c)]
Yes No
Comments:
18. The caregiver understands and will ensure that the child is permitted to have age and
developmentally appropriate access to personal hygiene products, kitchen knives and
appliances, medications, disinfectants, and cleaning solutions.
[§89372(a)(2)(B)] and [§89387.2(b)(1) through (3)]
Yes No
Comments:
19. Caregiver shall provide adequate care and supervision for the number of children in care.
Capacity issues do not apply to relative/NREFM homes [§89378], unless the relative or NREFM
home is a licensed home. [§89228]
Yes No
Comments:
SOC 815-817-818-temp place Rev. 12/29/10 Checklist of Health and Safety Standards Page 4 of 6
for Approval of Family Caregiver Home
Child’s Name(s): Enter name(s) on each page Case Number:
Caregiver Name: Enter name(s) on each page
RELATIVE or NREFM
CAREGIVER DECLARATION AND AGREEMENT
I/We declare that:
1. I/We have been provided with a summary of the state regulations regarding the approval and
operation of a relative foster home and agree to abide by them. (Caregiver Initial)
2. I/We agree to cooperate with the county in the maintenance of caregiver standards.
(Caregiver Initial)
3. I/We have been provided with a copy of the child(ren)’s personal rights and understand them and
agree to ensure that all members of the household will abide by them. (Caregiver Initial)
4. I/We agree to provide for the special needs of any child placed in my/our care, including but not
limited to:
To provide the services identified in the child’s placement agreement and, if applicable,
Transitional Independent Living Plan. [§89378(a)] (Caregiver Initial)
Caregiver(s) may put “N/A” rather than initial(s) if the standard is not applicable for the following (only):
If the child is a minor parent, to provide direct care and supervision of the child of the minor
parent whenever the minor parent is at school or otherwise unavailable/unable to care for the
child. [§89378(c)(1)] (Caregiver Initial)
If the child has a disability, to make necessary specific provisions as required to protect and
assist the child and maximize the child’s potential for self-help. [§89387]
(Caregiver Initial)
If the child is under age 10 or is developmentally disabled, mentally handicapped, or needs
special care and supervision, any pools or open body of water will be secured as required by
[§89387(d)]. (Caregiver Initial)
I/We have not and will not make any false or misleading statements associated with application for
approval, including information regarding the caregiver, family members, family home, or any of the
services to be provided in the home.
Caregiver Signature DATE
Caregiver Name (Print)
Caregiver Signature DATE
Caregiver Name (Print)
NOTE: IF A COUPLE OR TWO PEOPLE (e.g., GRANDMOTHER AND AUNT) SERVE AS CARE PROVIDERS, BOTH MUST SIGN AND INITIAL THIS FORM.
SOC 815-817-818-temp place Rev. 12/29/10 Checklist of Health and Safety Standards Page 5 of 6
for Approval of Family Caregiver Home
Child’s Name(s): Enter name(s) on each page
Caregiver Name: Enter name(s) on each page
Assessment Summary:
The relative/non-relative extended family member has the ability and capacity to provide care
and supervision to meet the child(ren)’s needs.
Yes No
Signature of County CWS or Probation Worker Phone Number Date
SOC 815-817-818-temp place Rev. 12/29/10 Relative or Non-Relative Extended Family Member Page 6 of 6
Caregiver Assessment
LIC 508D
From the CDSS Website (unprotect this document to access these links):
English: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC508D.PDF
Spanish: http://www.dss.cahwnet.gov/cdssweb/entres/forms/Spanish/LIC508DSP.pdf
Vietnamese: http://www.dss.cahwnet.gov/cdssweb/entres/forms/Vietnamese/LIC508DVN.pdf
OR
To print-out the current version of the “Out-of-Home Disclosure & Criminal Record Statement”
form (LIC 508D), open Acrobat Reader, go to the G drive, go to template, go to forms, and open
LIC 508D (the English version) or the LIC 508D-Spanish or the LIC 508D-Vietnamese.
Santa Clara County
Social Services Agency
Department of Family and Children’s Services
ALTERNATIVE PLAN
Name of Caregiver(s):
Address:
Date of Inspection: by
Refer to standard for which alternative plan is recommended:
Alternative Plan:
This alternative plan is recommended for approval, subject to review by the social worker and
supervisor at least annually.
Signature of Caregiver Date
Signature of Caregiver Date
Alternative Plan Recommended for Approval By:
Signature of Social Worker SW # Date
Alternative Plan Approved By:
Signature of Social Work Supervisor Date of Approval
G:\template\forms\SCZ200K.doc
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cc. Caregiver Page 1of 1
Santa Clara County
Social Services Agency
Department of Family and Children’s Services
CORRECTIVE ACTION PLAN
Name of Caregiver(s):
Address:
Date of Inspection: by
Cite regulation section that is violated:
Description of the deficiency:
Actions to be taken by the applicant/caregiver and the assistance to be provided by the county:
The date by which each deficiency shall be corrected:
The telephone number of the social worker or agency responsible for approval of the home is :
I agree to correct the deficiency within the timeframe specified above.
Signature of Caregiver Date
Signature of Caregiver Date
Corrective Action Plan Recommended for Approval By:
Signature of Social Worker SW # Date
Corrective Action Plan Approved By:
Signature of Social Work Supervisor Date of Approval
G:\template\forms\SCZ200L.doc
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cc. Caregiver Page 1 of 1
County of Santa Clara
Social Services Agency
Department of Family and Children’s Services
373 West Julian Street, San Jose, CA 95110
PRE-DETENTION TEMPORARY RELEASE AGREEMENT
Between Agency and Responsible Relative
Child D.O.B. Child D.O.B.
_______________________________ __________ _______________________________ __________
_______________________________ __________ _______________________________ __________
______________________________ __________ _______________________________ __________
On ______________________, at _______________ AM/PM, the above child(ren) was placed into
temporary
custody by ____________________________________________________pursuant to Section 305
(Name/Agency)
and/or Section 306 of the Welfare and Institutions Code. Said child(ren) is alleged to come within the
provisions of Section 300 of the Welfare and Institutions Code of California and will remain in protective
custody pending a judicial hearing on/or before _________________________.
(Detention Hearing Date)
Pursuant to Welfare and Institutions Code Section 361.45, the Social Services Agency hereby authorizes that
said minor(s) be temporarily released to the following responsible relative:
____________________________________________________________ effective _______________
pending the above-scheduled detention hearing. The minor shall remain in the temporary custody of the
Social Services Agency, Department of Family and Children’s Services, in the home of the above-named
responsible relative, pending the above-scheduled detention hearing, on the conditions specified below.
I, ___________________________________________________________, declare that I am the above
(Name of Caretaker)
child(ren)’s _______________________________________________________and I am related to their
(State relationship)
birth/adopted mother/father by blood/marriage. I agree to provide responsible, temporary care for the
child(ren) in my home, and I understand that the child(ren) remains in the temporary custody of the Social
Services Agency, Department of Family and Children’s Services, pending the above-mentioned detention
hearing.
I understand that financial assistance, if required, to care for said child(ren) will not be authorized prior to the
date of an order of the Juvenile Court detaining said child(ren) in my home and/or my application for AFDC
funds on behalf of said child(ren). I further agree to comply fully with the following condition(s). Any violation
of the condition(s) will result in the child(ren)’s immediate removal from my care.
The caretaker will assure that the child(ren) have no contact directly/indirectly with:
[(Parent(s) or Person(s)]
AGENCY / RELATIVE PRE-DETENTION AGREEMENT
PAGE 2
Visitation supervision/unsupervised with ____________________________________________ is
authorized. Visitation is to be supervised by you and to occur _____________________________
(Where)
and _____________________________________________
(How often)
Phone contact monitored / not monitored between
____________________________________________
[(Parent(s) or Person(s)]
and _________________________________ is allowed _____________________________
(Child(ren)’s Name) (How Often/Time Limits)
Known dangerous propensities of the child have been discussed prior to placement.
They include:
The caretaker further agrees that they will:
Submit to fingerprint identification and criminal clearance check within 48 hours.
Permit no discussion with the child regarding this case.
Respect the family’s right to confidentiality. Information regarding this family will not be shared with
others.
Cooperate fully with the Department of Family and Children’s Services.
Immediately contact law enforcement (911) and the Department of Family and Children’s Services
299-2071 (DFCS 24-hour Hotline) if the parent(s) attempts to remove the minor(s) or violate the
visitation arrangement.
Bring the child to Court hearing as requested by the Social Worker.
Take the child to medical appointments as requested by the Social Worker.
Signed by: _________________________________________________ Date: __________________
Signed by: __________________________________ Address: __________________________________
__________________________________
Date: _____________________________________
Parent(s) Notified:
___________________________________________________________________________
(Who/Date/Time)
Others Notified:
___________________________________________________________________________
(Who/Date/Time)
Distribution: Original to relative
Copy to Assessment Center
Copy to Dependent Intake
Santa Clara County
Social Services Agency
Department of Family and Children’s Services
SHERIFF’S DEPARTMENT CRIMINAL RECORD CHECK REQUEST (CLETS)
REQUEST PRIORITY: PLEASE PRINT, TYPE OR WORD-PROCESS ENTRIES. Received
Urgent (same or next day results) Regular (2 day results) Initial Request Update Request Date Time
From: Social Worker Requesting CLETS To: Assessment and Intake Center
Name: SW #: Fax: (408) 558-5570
Phone #: W. Julian Floor #: Phone: (408) 558-5480 or 558-5400
From: Assessment and Intake Center To: Sheriff’s Dept., Records
From: Sheriff’s Department, Records To: Assessment and Intake Center
.
DFCS Case Name: SSA Case Number:
Subject’s Name: Jr. Sr.
Last First Middle
AKA’s:
Date of Birth: Female Male Driver’s Lic. No.:
Soc. Sec No. FBI No. CII No. PFN No.:
Last Known Address:
Number - Street - Apt. City State Zip
Purpose of Record Check:
Legal Basis for Access to CLETS: Welfare and Institutions Code §§ 272, 308, 309, 319, 328, 361.4, WIC 388(e)(4), and 16504.5
To conduct an investigation pursuant to Section 11166.3 of the Penal Code or an investigation involving a child in which the child is
alleged to come within the jurisdiction of the juvenile court under Section 300.
Subject’s Relationship to Child: Parent Guardian Other:
To document that a parent and other adult under investigation or assessment was put on notice of the requirement to submit to
fingerprinting, the person refused to submit to fingerprinting or the whereabouts of the person is unknown, use the SCZ 152A.
To assess the appropriateness and safety of placing a child who has been detained or is a dependent of the court, in the approved home
of a relative pursuant to Section 309 or 361.4, or the approved home of a non-relative extended family member as described in Section
362.7.
Subject’s Relationship to Child: Relative Caregiver Non-Relative Extended Family Member Caregiver (NREFM) OR
Another person involved with the relative’s or NREFM’s home: Another adult in the home A person age 18 years or older
who has significant contact with the child (other than a professional providing the child a service), including any person who has a
familial or intimate relationship with any person living in home A child over the age of 14 years in the home who is believed to
have a criminal record An adult providing temporary care for a child placed in the home.
To document that a relative or NREFM caregiver or other adults involved with the relative’s or NREFM’s home was put on
notice of the requirement to submit to fingerprinting, use the SCZ 152.
To determine appropriate placement options for a non-minor prior to placing the non-minor in a setting with minor dependents.
To attempt to locate a parent or guardian pursuant to Section 311 of a child who is the subject of dependency court proceedings.
To document that the parent’s or guardian’s whereabouts is unknown, use the SCZ 152A.
CLETS CHECKS FOR RELATIVE AND NREFM CAREGIVERS AND ADULTS ASSOCIATED WITH THEIR HOMES WHO HAVE FREQUENT
CONTACT WITH THE CHILD(REN) MUST BE FOLLOWED BY LIVE SCAN FINGERPRINTING WITHIN 10 JUDICIAL DAYS OF DATE OF
THE SHERIFF’S DEPARTMENT CLETS RESPONSE (SEE DATE OF SHERIFF’S DEPARTMENT STAFF PERSON’S SIGNATURE BELOW).
I hereby certify that the above information is true to the best of my knowledge. The requestor certifies that CLETS information will
not be released to any unauthorized person.
Name of Requestor (print): Worker No.:
Signature of Requestor: Phone No.:
No Criminal Record Found Subject has a Warrant? Yes No
Update (subsequent request) for this same individual: Please see original criminal record check results sent to:
No New Criminal Record Found
New Criminal Record Found and New Record (only) ___________________________________ on ____________
Signature of Sheriff’s Department Records Division Staff Person Date
LIVE SCAN REFERRAL
USE THIS FORM FOR CAREGIVERS, ADDITIONAL ADULTS IN THEIR HOMES OR ADULTS ASSOCIATED WITH A
RELATIVE’S OR NREFM’S HOME, AND OFFICIAL VOLUNTEERS.
Referral Date: USE ONE FORM FOR EACH INDIVIDUAL.
The Social Worker must check this box, if applicable:
Because you are a person in or associated with a relative or NREFM home, fingerprinting must be done by
(date), which is 10 days from the date of the CLETS record check.
If you are not fingerprinted by this date, the Social Worker will conclude that you refuse to be fingerprinted.
Case Information
Check appropriate box(s) next to “Name” in this section. For relatives and NREFMs, enter child(ren)’s name(s) and DFCS case number.
For adoptive home and foster care license applicants, enter name(s) of applicant(s). For volunteers, enter volunteer’s name.
Name Child(ren) License Applicant Adoption Home Study Applicant Volunteer DFCS Case Number
Information about Person to be Fingerprinted
Full Name (last, first, middle) Date of Birth Place of Birth
Other Names Used (e.g., maiden name, alias) Driver’s License No. Social Security No.
Residence Street Address City State Zip Code
Citizenship: U.S. Citizen? Yes No If not, citizen of what country?
Reason for Criminal and/or Child Abuse Record Check
Select the “Reason for Record Check” and place an “x” in the box in that row indicating if the person is a primary applicant* or an
additional adult.**
Primary Additional Return
Reason for Record Check
Applicant Adult Responses to:
SubArrest Relative (For assessment of prospective relative
Undersigned DFCS
and non-relative extended family members [NREFM] for
Social Worker
approval)
Designated
Foster Home License (For foster home license applicants) Resource Homes
Unit Supervisor
Designated
Petition for Adoption (For adoption home study applicants) Resource Homes
Unit Supervisor
Undersigned DFCS
Placement options for a non-minor dependent (NMD)
Staff Person
Undersigned DFCS
Volunteer participating in an Official Volunteer Programs N/A
Staff Person
*A “Primary Applicant” is a prospective relative or NREFM caregiver; an applicant for a foster care license and/or an adoptive home study;
or a prospective DFCS volunteer.
**An “Additional Adult” is a person age 18 years or older residing in the home of an applicant; a person age 18 years or older
residing outside the caregiver’s home (other than a professional providing services to the child) known to the social worker to
have significant contact with the child, including any person who has a familial or intimate relationship with any person living in
the home; any person over the age of 14 years living in the home who the social worker believes may have a criminal record; or
respite care provider.
NOTE: An applicant for a foster care license or relative/NREFM approval and an adoption home study (an “adoptive concurrent
placement” applicant) must be fingerprinted twice: once for each type of caregiver assessments.
Referred by:
( )
DFCS Staff Person’s Name (Please Print) Worker Number Telephone Number
INFORMATION ABOUT LIVE SCAN FINGERPRINTING FACILITIES AND PROCEDURES
The STEPS to be fingerprinted by Live Scan depend upon where you choose to be fingerprinted. Your choices are:
Department of Family and Children’s Services (DFCS) Facilities
DFCS Main Office Assessment and Intake Center
373 W. Julian Street, First Floor 4525 Union Avenue
San Jose, CA 95110 San Jose, CA 95124
For Appointments call (408) 975-5116 For Appointments call (408) 558-5480
Appointments: Appointments:
Mon., Wed. Thurs. & Fri. – 10.00 a.m. to 12:30 p.m. Tues, Wed., Thurs. Sat. & Sun. – 12:30 p.m. to 8:30 p.m.
Tuesday – 11:00 a.m. to 2:30 p.m.
Santa Clara County Sheriff’s Department Facilities
Main Headquarters Office West Valley Substation
55 West Younger Ave. 1601 South De Anza Blvd.
San Jose, CA 95110 Cupertino, CA 95014
For Appointments call (408) 808-4760 For Appointments call (408) 868-6614
Appointments: Appointments:
Mon. through Fri. - 7:00 a.m. to 5:30 p.m. Mon. through Fri. - 8:30 a.m. to 4:30 p.m.
(Closed 12:00 to 1:00 p.m.)
South County Sub-Station Stanford Sub-Station
12431 Monterey Road 711 Sierra St.
San Martin, CA 95046 Stanford, CA 94305
For Appointments call (408) 686-3651 For Appointments call (650) 725-2499
Appointments: Appointments:
Mon. – 8:05 a.m. to 4:30 p.m. Mon. through Thurs. – 8:00 a.m. to 4:00 p.m. (On these
Tues., Wed. & Thurs. – 7:05 a.m. to 3:30 p.m. days, no appointment is needed 9:00 a.m. to 11:00 a.m. and 1:15
Fri. – 8:05 a.m. to 4:30 p.m. to 3:30 p.m.)
Fri. – 10:30 a.m. to 4:00 p.m.
Sheriff’s Department Facilities in Other California Counties
Contact the Sheriff’s Department in the California county in which you choose to be fingerprinted to learn location of facilities.
STEPS for Department of Family and Children’s Services (DFCS) Facilities:
1. Call to make an appointment to be fingerprinted at the most convenient facility for you.
2. Arrive at least 30 minutes before the appointment time.
3. Bring a government-issued picture identification card or document to the appointment.*
4. Present this “Live Scan Referral” form to the DFCS staff.
STEPS for Santa Clara County Sheriff’s Department Facilities:
1. Call one of the following DFCS facilities to make arrangements to obtain a “Request for Live Scan Services” form:
San Jose DFCS Facilities South County Facilities
Assessment & Intake Center (408) 558-5480 Gilroy Family Center (408) 846-4400
West Julian Street (408) 975-5116 South County Child Welfare Office (408) 758-3440
Tompkins Crt., Gilroy (408) 686-8711
2. Bring a government-issued picture identification card or document to the appointment.*
3. Present this “Live Scan Referral” form and the “Request for Live Scan Services” form to the Sheriff’s Department staff.
Note: If you choose to go to the 55 West Younger facility, check in at the Officers’ station window located to the left in
the lobby, near the public telephones. Do not take a number or wait in line.
STEPS for Sheriff’s Department Facilities in Other California Counties:
1. Call (408) 975-5116 (the main DFCS facility in San Jose) to make arrangements to obtain a “Request for Live Scan
Services” form.
2. When you receive the “Request for Live Scan Services” form, please immediately call the county’s Sheriff’s Department
and follow that department’s procedures for people requesting to be fingerprinted by Live Scan.
3. Bring a government-issued picture identification card or document to the appointment.*
4. Present this “Live Scan Referral” form and the “Request for Live Scan Services” form to the Sheriff’s Department staff.
*Picture Identification: You must present a government issued picture identification card or document (e.g., California
DMV identification card, driver’s license, passport, documentation from another country’s consulate). Credit cards cannot
be used as proof of identity.
Additional Information
Please be on time for the appointment. Please call if you are unable to keep the appointment. Persons arriving late
may need to be rescheduled. Fingerprinting appointments can be rescheduled.
Extremely long or curled fingernails will interfere with fingerprinting.
Cut or otherwise injured fingertips will interfere with fingerprinting. Schedule the Live Scan fingerprinting appointment
after the injury has healed. Notify the social worker that fingerprinting is delayed.
You will not be able to supervise children during the fingerprinting appointment. If you bring children, please make
arrangements for supervision.
CAREGIVER INFORMATION SHEET
EXTRACURRRICULAR, ENRICHMENT AND SOCIAL ACTIVITIES,
AND THE REASONABLE AND PRUDENT PARENT STANDARD
This Information Sheet is intended to give you information regarding current law which
entitles foster children to participate in age-appropriate, extracurricular, enrichment, and
social activities.
Current law contained in Section 362.05 of the Welfare and Institutions Code (W&IC)
provides that:
Every child adjudged a dependent child of the juvenile court (a foster child) shall
be entitled to participate in age-appropriate extracurricular, enrichment, and
social activities.
Caregivers must use a “prudent parent standard” in determining whether to give
permission for a foster child to participate in extracurricular, enrichment, and
social activities.
Caregivers must take reasonable steps to determine the appropriateness of the
activity in consideration of the child’s age, maturity, and developmental level.
Any state or local regulation or policy which prevents or creates barriers to
participation in those activities is prohibited.
Each state and local entity is required to ensure that private agencies providing
services to foster children have policies consistent with this section and that
those agencies promote and protect the ability of foster children to participate in
age-appropriate extracurricular, enrichment, and social activities.
The law refers to a reasonable and prudent parent standard, which caregivers are
required to use. Reasonable and prudent parent standard is defined as follows:
“Reasonable and prudent parent” standard means the standard characterized by
careful and sensible parental decisions that maintain the child’s health, safety,
and best interests.
Every day, parents make important decisions about their children’s activities. Foster parents
are faced with making the same decisions for the foster children in their care. However,
when foster parents make decisions. they also must consider licensing or approval laws and
regulations to ensure the health and safety of foster children in care.
The California Department of Social Services understands that state law and regulations
have previously prohibited youth from participating in extracurricular activities unless certain
requirements were met. Now, however, W&IC Section 362.05 empowers foster parents to
approve or disapprove activities based on their own assessment using a “reasonable and
prudent parent standard” without prior approval of the child’s social worker, the licensing or
approval agency, or the juvenile court.
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In enacting this law, the Legislature recognized the importance of making every effort to
normalize the lives of foster children. Typical childhood activities in which foster children
have been denied participation in the past include, for example, school-sponsored field trips
or sports, sleep-over with friends, scouting, and 4-H activities. Frequently, foster parents are
reluctant to sign permission slips for foster children, when this should not be the case.
Participation in these types of activities is important to the child’s wellbeing, not only
emotionally, but in developing valuable life-coping skills.
In applying the “reasonable and prudent parent standard,” foster parents are required to
take “reasonable steps” to determine the appropriateness of the activity in consideration of
the child’s age, maturity, and developmental level. It is recognized that there are many
different ways to determine whether an activity is appropriate for a foster child in your care.
Therefore, the following examples of “reasonable steps” that a foster parent may take in
making this determination are provided as a guide to assist you in your decision-making
process.
Have adequate information about the foster child in your care so you can make
informed decisions. For example, make an effort to be aware of anything in the
foster child’s history or case plan, and of any orders issued by the juvenile court
that may suggest that a particular activity would not be appropriate for the foster
child. If you are not aware of the child’s history or if the case plan is silent on
whether the proposed activity would be appropriate, you are encouraged to
consult with the child’s social worker.
Take into account the type of activity and consider the foster child’s mental and
physical health, and behavioral propensities.
Consider where the activity will be held, with whom the foster child will be going,
and when they will return.
Consider all the information you have gathered and ask the question: is this an
age-appropriate extracurricular, enrichment or social activity?
Take into account the reasonably foreseeable risks of an activity and what safety
factors and direct supervision may be involved in the activity in order to prevent
potential harm to the foster child. (i.e., hunting, paint ball, archery or similar
activities that may pose a higher risk).
This law only applies to participation in age-appropriate extracurricular, enrichment, and
social activities. This law does not apply, for example, to unsupervised time at home. Any
person having contact with a foster child for purposes other than those associated with a
foster child’s participation in age-appropriate, extracurricular, enrichment and social
activities must comply with existing criminal background check requirements specified in
Health and Safety Code Section 1522 and W&IC Sections 39(d) and 361.4, as applicable.
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