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					                                                                                                                     Santa Clara County
                                                                                                                  Social Services Agency
                                                                                             Department of Family and Children’s Services




                                 REQUEST FOR ADMINISTRATIVE REVIEW OF
                                 A FOSTER FAMILY HOME PLACEMENT HOLD

      Initial Review             Subsequent Review Number:                    (Attach all prior Reviews and their attachments)

 Date of Hold


 Foster Family Home Name:                                                                       License #:
                                                                  Removal due
                      Children                         Age                                      Current Placement
                                                                  to allegation

 1.                                                                Yes         No

 2.                                                                Yes         No

 3.                                                                Yes         No

 4.                                                                Yes         No
 Prior Complaint History?          Yes        No (If yes, explain in attachments)
 Plan of Correction         Yes          No          Licensing SWS:
Section II
      Staffing Date                           Staff involved                                  Staffing Outcome




Section III
 Date Submitted to Service Bureau SSPM for Review:
 Service Bureau SSPM recommendation:                  Lift Hold   Continue Hold
 Comments:




 Date Submitted to Placement Support Bureau SSPM for Review:
 Placement Support Bureau SSPM recommendation:                    Lift Hold         Continue Hold
 Comments:




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Section IV
  Date Submitted to Director for Approval:
  Email, Fax or hand deliver this to:
                                         E-mail                             Phone                  Fax
  Norma Doctor Sparks             Norma.Sparks@ssa.sccgov.org              975-5700             975-5871
  Jaime Lopez                     Jaime.Lopez@ssa.sccgov.org               975-5702             975-5870
  DFCS Director Exec Asst.                                                 975-5700             N/A will receive
                                                                                                Director’s fax
  After sending the worksheet, immediate call Director’s Executive Assistant to inform that the email or fax has
  been sent.


                           To be completed by the DFCS Director or Designee
                   Placement Hold Lifted                               Placement Hold Remains
  Comments/Instructions:




             Director, Department of Family and Children’s Services                            Date




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REQUEST FOR ADMINISTRATIVE REVIEW OF A FOSTER FAMILY HOME PLACEMENT HOLD

Date:                                    Initial Status Report
                                         Status Update

Foster Family Home Name:

1. The reason(s) that the FFH was placed on hold.




2. Prior Complaint History (if applicable):




3. The reasons for recommending or not recommending that the FFH be taken off hold.




4. Plan of Correction (if applicable).




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