Riverside County Department of Public Social Services-Children’s Services
Initial Placement Checklist-for FFA Homes-DPSS 4068B
Date:
Placing Social Worker Name:
Phone Number:
Identification
FFA Name: Kamali'i Foster Family Agency
FFA Address: 31772 Casino Dr., Ste. B, Lake Elsinore CA 92530
Person Contacted:
Foster Parent Name:
Foster Parent Address:
Foster Parent Phone Number: (
)
-
FFH Number: (951) 674-9400
Child’s Name:
Child’s DOB:
Emergency Phone Number: (
)
-
Facility and Environment:
(Common living areas are well maintained Title 22, Division 6, Chapter 1, 80087, 80088)
Interior Observations:
A
Walls and ceilings are clean and in good repair?
Comments:
B
Floors and floor coverings are clean and in good repair?
Comments:
C
Furniture and fixtures are in good repair?
Comments:
D
Facility sinks, bathroom tubs, toilets, and showers are clean and operable?
Comments:
E
Does the home have an appropriate quantity and quality of books, supplies, and other materials
(including a computer) readily available to the resident?
Comments:
Exterior Observations:
A
The front/back yard lawns are healthy and trimmed (green grass, trimmed and raked)?
Comments:
B
Back/front yard areas are free from litter and debris?
Comments:
DPSS 4068B (03.11) Initial Placement Checklist for FFA Homes
Meets County
Expectation
Yes
No
Meets County
Expectation
Yes
No
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Initial Placement Checklist-for FFA Homes, continued
Client Rooms:
(Title 22, Division 6, Chapter 9, 89387)
A
All bed sheets, pillow cases, mattress pads, blankets, bedspreads, bath and wash towels are in
good condition and sufficient in number?
Comments:
B
Mattresses, box springs and pillow(s) are in good condition?
Comments:
C
There is adequate dresser and closet space for client’s clothing and personal belongings. (A
minimum of two drawers or eight cubic feet of drawer space is provided for each child)?
Comments:
Food Service:
(Title 22, Division 6, Chapter 1, 80076; Chapter 9, 89376)
A
The caregiver will ensure at least three nutritious meals per day, and meet any special dietary
needs of the child as documented?
Comments:
B
Snacks and beverages are available in the home (powdered milk is not used as a beverage)?
Comments:
C
Food storage and preparation areas (i.e. pantries, cupboards, freezers, stoves, microwaves,
refrigerators and counters) are clean?
Comments:
Emergency Contact Numbers:
A
Meets County
Expectation
Yes
No
Meets County
Expectation
Yes
No
Meets County
Expectation
Yes
No
Are emergency medical providers posted? (Hospital, emergency room, urgent care psychiatric
services/ETS, Loma Linda etc).
Comments:
Personal Rights:
(Title 22, Division 6, Chapter 9, 89372; Foster Youth Bill of Rights)
A
Child’s rights are posted in a prominent, publicly accessible location in the FFA home?
Comments:
B
Are minors allowed to call their social workers, probation officers, DMH case manager, CASA, and
attorneys in a reasonable time frame?
Comments:
DPSS 4068B (03.11) Initial Placement Checklist for FFA Homes
Meets County
Expectation
Yes
No
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Initial Placement Checklist-for FFA Homes, continued
Meets County
Expectation
Yes
No
Personal Rights, continued:
C
Are minors allowed to make and receive private telephone calls and mail according to their
personal rights?
Comments:
Meets County
Expectation
Yes
No
Clothing/Hygiene/Personal Belongings:
A
Are minors provided with personal care items appropriate to their ethnic needs and are these
items readily accessible?
Comments:
Meets County
Expectation
Yes
No
Allowances:
A
Are residents provided with monetary allowances proportionate to daily chores?
Comments:
B
Are residents free to spend their allowances as they choose?
Comments:
Meets County
Expectation
Yes
No
Transportation:
(Title 22, Division 6, Chapter 9, #89374
A
Is transportation provided to meet the minors’ needs (To include but not limited to medical
appointments, recreational activities, school, visits, court, etc.)?
Comments:
Placing/Assigned Social Worker Signature:
Date:
FFA/Foster Parent Signature:
Date:
Instructions: Within 48 hours of placement, FFA must fax to the Placement Region at Fax: 951/358-7360.
DPSS 4068B (03.11) Initial Placement Checklist for FFA Homes
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