San Luis Obispo County Department of Social Services

San Luis Obispo County Department of Social Services Resource Family Approval Permanency Assessment Report PART B – SOCIAL SERVICES

This section to be completed by Social Services.

Name of Social Worker Completing: Name of Family: OTHERS RESIDING OR FREQUENTLY IN THE HOME? Yes No DSS CWS 833 attached?

APPLICANT DISPOSITION This home is Matched Unmatched

Child Specific Placement Child Resides in home now? Yes No The applicant(s) have applied to become a Resource Family for: Future Placement The applicant applied to accept Foster/Adopt of a Male Female Male or Female Child/children between the ages of and . The applicants are are not Open to placement of a sibling group. If open to a sibling group, how many? If Matched, describe any specific needs this child has that should be considered as part of the permanency assessment:

APPLICANT #1 APPLICANT #2 Health Screening Completed: Health Screening Completed: Yes No Yes No Concerns noted: Concerns noted: Parenting Training Completed:

BACKGROUND CLEARANCE INFORMATION APPLICANT #1 Department of Date: The Department has reviewed the criminal, child Justice Cleared NOT Cleared welfare and DMV history for this applicant and makes the following determination: Child Abuse Date: Index Cleared NOT Cleared Approved FBI Records Date: Check Cleared NOT Cleared Not Approved DMV Records Date: Check Cleared NOT Cleared

Applicant completes Part A, DSS Completes Part B, Cooperative Agency SW completes Part C

DSS CWS 153-B (Rev: 11/07/14) RFA DSS Permanency Assessment Report Page 1 of 4 San Luis Obispo County Department of Social Services Resource Family Approval Permanency Assessment Report PART B – SOCIAL SERVICES

CWS Records Date: Check Cleared NOT Cleared

BACKGROUND CLEARANCE INFORMATION – continued APPLICANT #2 Department of Date: The Department has reviewed the criminal, child Justice Cleared NOT Cleared welfare and DMV history for this applicant and makes the following determination: Child Abuse Date: Index Cleared NOT Cleared Approved FBI Records Date: Check Cleared NOT Cleared Not Approved DMV Records Date: Check Cleared NOT Cleared CWS Records Date: Check Cleared NOT Cleared

OTHER ADULTS IN THE HOME Name: Department of Justice: The Department has reviewed the criminal, CWS and DMV history Cleared Not Cleared for this adult and makes the following determination: Child Abuse Index: Approved Cleared Not Cleared Not Approved FBI Records Check:

Cleared Not Cleared

DMV Records Check:

Cleared Not Cleared

CWS Records Check:

Cleared Not Cleared

Name: Department of Justice: The Department has reviewed the criminal, CWS and DMV history Applicant completes Part A, DSS Completes Part B, Cooperative Agency SW completes Part C

Cleared Not Cleared for this adult and makes the following determination: Child Abuse Index: Approved Cleared Not Cleared Not Approved FBI Records Check:

Cleared Not Cleared

DMV Records Check:

Cleared Not Cleared

CWS Records Check:

Cleared Not Cleared

REFERENCES - See DSS CWS 151 attached Date Person(s) Interviewed Location

LEGAL & FINANCIAL NOTIFICATIONS AND ADVISEMENTS The Applicant(s) have been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative caregivers, foster parents, and adoptive parents. The Applicant(s) have also been advised of their duty of honest disclosure and have agreed to openly discuss any historical concerns, along with their ongoing duty of disclosure of new events or information which may require an updated or amended home study. The agency’s grievance review hearing procedures have have not been explained to the Applicant(s).

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