Form SOC154B "Agency - Group Home Agreement Nonminor Dependent Placed by Agency in Group Home" - California

What Is Form SOC154B?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form SOC154B by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form SOC154B "Agency - Group Home Agreement Nonminor Dependent Placed by Agency in Group Home" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AGENCY - GROUP HOME AGREEMENT
Nonminor Dependent Placed by Agency in Group Home
NAME OF YOUNG ADULT
GROUP HOME NAME
BIRTHDATE
DATE PLACED
CASE NUMBER
■ ■
■ ■
Anticipated duration of placement is ________
up to age 19
post-19 medical condition
The Agency will pay $ __________ per month in return for the above-named young adult’s care and supervision as defined in Welfare and Institutions
Code 11460 and other applicable law and regulations. First payment to be within 45 days after placement with subsequent payments to be made monthly.
If additional amounts are to be paid, the reason, amount and conditions shall be set forth here:
■ ■
■ ■
Special problems:
Yes
No
If yes, explain.
AGENCY AGREES TO
GROUP HOME AGREES TO
1.
Provide this young adult the nurture, care, clothing, supervision,
1.
The placing agency will obtain from the young adult all appropriate
treatment arrangements and assistance to other life skills and
releases of Information relevant to this placement so that it can
experience suited to his/her needs.
provide the group home with knowledge of the background and needs
2.
Follow admission requirements related to medical screening, physical
of the young adult necessary for effective care. This shall include with
examination, medical testing and immunization.
the NMD’s consent, a social work assessment, medical reports,
3.
Develop an understanding of the responsibilities, objectives and
educational assessment, psychological/psychiatric evaluations
requirements of the agency in regard to the care of this young adult
identification of special needs and the TILP. This shall be made
and work with the agency in planning for this young adult.
available to group home within 14 days from date of placement.
4.
Notify the placing agency within 24 hours of the provider having
2.
Inform the provider, before placement, of this young adult’s behaviors
knowledge (unless there is a separate written agreement with the
and proclivities that might be harmful to others (including pets) in the
placing agency) by phone followed in writing of significant changes in
home, school or neighborhood.
the young adult’s health, behavior or location as well as significant
3.
Work with the group home staff on discharge planning toward a lower
issues including suspected physical or psychological abuse, death,
level of care or transition to the appropriate adult system of care.
injury, unusual incidents, unusual absence, of young adult, placement
4.
Work with the provider in the development and progress of a transition
issues, changes to work or school participation and all items required
plan. The county placing agency will notify and invite the provider to
by Title 22, Division 6 regulations.
participate in any young adult family team meetings to discuss the
5.
Work together with the placing agency to encourage the maintenance
young adult’s transition plan.
of permanent connections with the young adult’s siblings and other
family members and significant adults, as indicated in the transition
5.
Work together with the provider to develop and maintain positive
plan, and/or young adult and family team meetings whenever possible.
relationships with the young adult’s siblings and other family
6.
Use constructive alternative methods of harm reduction; not use
members, as appropriate.
corporal punishment, punishment before the group, deprivation of
6.
Maintain monthly contact with the young adult.
meals, monetary allowances, visit from family, home visits, threat of
7.
Provide a Medi-Cal card or other medical coverage to the young adult
removal or any other type of degrading or humiliating punishment.
at time of placement.
7.
Respect and keep confidential information given about the young adult.
8.
Continue paying for the young adult’s care as long as the young adult
8.
Work toward discharge to a lower level of care by the 19th birthday or,
remains in placement or, in the temporary absence of the young adult,
if over age 19 with a medical condition, transition to the appropriate
when the placing agency asks the provider to retain an open
adult system of care on a planned basis with maximum involvement of
placement.
the young adult, and the agency.
9.
Inform the provider of the county clothing allowance policy and
9.
Conduct a staffing or review on this young adult at least quarterly.
provide the funding consistent with those policies.
10. Work with the placing agency and the young adult to develop and
10. Verify and remit/reconcile any underpayments within 45 days of
submit to them a transition plan that develops an understanding of the
provider notification of such underpayments.
responsibilities, objectives and requirements of the agency in regard to
11. Notify the provider within 12 months of suspected overpayments, in
the care of this young adult, including the information listed on the next
accordance with applicable laws and regulations.
page of this form, within 30 days of placement of the young adult. The
12. Provide assistance with emergencies. Telephone number for
transition plan shall be updated with the young adult and placing
after-hours or weekends is:
agency at least every six months.
11. Written progress reports on the transition plan progress shall be
provided at least every six months or more frequently by mutual
agreement.
12. Give the agency prior notice of at least 7 days of intent to discharge
this young adult unless it is agreed upon with the agency that less
notice is necessary. Discharge should be based on a mutual plan
developed by the agency and group home.
13. Conform to the licensing requirements.
14. Provide state and federal agencies access to documentation when
documentation is maintained on young adults in their care.
15. Follow any requirements associated with the county’s clothing
allowance policy and procedures.
16. Remit any overpayment in full to the county welfare department upon
receipt of a notice of action or following the completion of due process.
17. Inform county upon discovery of any apparent overpayment.
cc: To group home, young adult’s social service record
AGENCY -- GROUP HOME AGREEMENT
Confidential accordance with
Penal Code Section 11167.5 and/or
WIC Section s827 and 10850
SOC 154B (1/12) REQUIRED FORM - NO SUBSTITUTE PERMITTED
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AGENCY - GROUP HOME AGREEMENT
Nonminor Dependent Placed by Agency in Group Home
NAME OF YOUNG ADULT
GROUP HOME NAME
BIRTHDATE
DATE PLACED
CASE NUMBER
■ ■
■ ■
Anticipated duration of placement is ________
up to age 19
post-19 medical condition
The Agency will pay $ __________ per month in return for the above-named young adult’s care and supervision as defined in Welfare and Institutions
Code 11460 and other applicable law and regulations. First payment to be within 45 days after placement with subsequent payments to be made monthly.
If additional amounts are to be paid, the reason, amount and conditions shall be set forth here:
■ ■
■ ■
Special problems:
Yes
No
If yes, explain.
AGENCY AGREES TO
GROUP HOME AGREES TO
1.
Provide this young adult the nurture, care, clothing, supervision,
1.
The placing agency will obtain from the young adult all appropriate
treatment arrangements and assistance to other life skills and
releases of Information relevant to this placement so that it can
experience suited to his/her needs.
provide the group home with knowledge of the background and needs
2.
Follow admission requirements related to medical screening, physical
of the young adult necessary for effective care. This shall include with
examination, medical testing and immunization.
the NMD’s consent, a social work assessment, medical reports,
3.
Develop an understanding of the responsibilities, objectives and
educational assessment, psychological/psychiatric evaluations
requirements of the agency in regard to the care of this young adult
identification of special needs and the TILP. This shall be made
and work with the agency in planning for this young adult.
available to group home within 14 days from date of placement.
4.
Notify the placing agency within 24 hours of the provider having
2.
Inform the provider, before placement, of this young adult’s behaviors
knowledge (unless there is a separate written agreement with the
and proclivities that might be harmful to others (including pets) in the
placing agency) by phone followed in writing of significant changes in
home, school or neighborhood.
the young adult’s health, behavior or location as well as significant
3.
Work with the group home staff on discharge planning toward a lower
issues including suspected physical or psychological abuse, death,
level of care or transition to the appropriate adult system of care.
injury, unusual incidents, unusual absence, of young adult, placement
4.
Work with the provider in the development and progress of a transition
issues, changes to work or school participation and all items required
plan. The county placing agency will notify and invite the provider to
by Title 22, Division 6 regulations.
participate in any young adult family team meetings to discuss the
5.
Work together with the placing agency to encourage the maintenance
young adult’s transition plan.
of permanent connections with the young adult’s siblings and other
family members and significant adults, as indicated in the transition
5.
Work together with the provider to develop and maintain positive
plan, and/or young adult and family team meetings whenever possible.
relationships with the young adult’s siblings and other family
6.
Use constructive alternative methods of harm reduction; not use
members, as appropriate.
corporal punishment, punishment before the group, deprivation of
6.
Maintain monthly contact with the young adult.
meals, monetary allowances, visit from family, home visits, threat of
7.
Provide a Medi-Cal card or other medical coverage to the young adult
removal or any other type of degrading or humiliating punishment.
at time of placement.
7.
Respect and keep confidential information given about the young adult.
8.
Continue paying for the young adult’s care as long as the young adult
8.
Work toward discharge to a lower level of care by the 19th birthday or,
remains in placement or, in the temporary absence of the young adult,
if over age 19 with a medical condition, transition to the appropriate
when the placing agency asks the provider to retain an open
adult system of care on a planned basis with maximum involvement of
placement.
the young adult, and the agency.
9.
Inform the provider of the county clothing allowance policy and
9.
Conduct a staffing or review on this young adult at least quarterly.
provide the funding consistent with those policies.
10. Work with the placing agency and the young adult to develop and
10. Verify and remit/reconcile any underpayments within 45 days of
submit to them a transition plan that develops an understanding of the
provider notification of such underpayments.
responsibilities, objectives and requirements of the agency in regard to
11. Notify the provider within 12 months of suspected overpayments, in
the care of this young adult, including the information listed on the next
accordance with applicable laws and regulations.
page of this form, within 30 days of placement of the young adult. The
12. Provide assistance with emergencies. Telephone number for
transition plan shall be updated with the young adult and placing
after-hours or weekends is:
agency at least every six months.
11. Written progress reports on the transition plan progress shall be
provided at least every six months or more frequently by mutual
agreement.
12. Give the agency prior notice of at least 7 days of intent to discharge
this young adult unless it is agreed upon with the agency that less
notice is necessary. Discharge should be based on a mutual plan
developed by the agency and group home.
13. Conform to the licensing requirements.
14. Provide state and federal agencies access to documentation when
documentation is maintained on young adults in their care.
15. Follow any requirements associated with the county’s clothing
allowance policy and procedures.
16. Remit any overpayment in full to the county welfare department upon
receipt of a notice of action or following the completion of due process.
17. Inform county upon discovery of any apparent overpayment.
cc: To group home, young adult’s social service record
AGENCY -- GROUP HOME AGREEMENT
Confidential accordance with
Penal Code Section 11167.5 and/or
WIC Section s827 and 10850
SOC 154B (1/12) REQUIRED FORM - NO SUBSTITUTE PERMITTED
PAGE 1 OF 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Initial transition plan summary shall include:
A.
Medical and dental needs, including the medical condition that requires the group home placement after age 19
B.
Psychological/psychiatric issues identified
C. Staffing review summaries
D.
Educational /employment assessment
E.
Peer adjustment
F.
Relationship to staff and other adults identified as potential permanent connections
G. Involvement in recreation programs
H. Behavior problems impacting house rules
I.
Short-term treatment objectives (goals established for next 3 months)
J.
Long-range goals including anticipated length of placement and discharge planning
K.
Tasks planned to reach objectives and goals as defined in the young adult’s TILP and staff who will be performing these
tasks,including agency service activity
L.
Identification of unmet needs
M. Involvement of young adult in the transition program
Periodic update of transition plan:
A.
Current status of young adult’s physical and psychological health. This includes, as applicalbe, the reasons(s) why admission to or
continuation in a group home is the best alternative available to meet the young adult’s special needs
B.
Reassessment of young adult’s adjustment to the group home, program, peers, school and staff
C. Progress toward short-term objectives and long-range goals as defined in the young adult’s TILP including tasks which have been
performed to reach these objectives and goals. This includes as applicable, tasks which have been performed to reach these
objectives and goals and how the placement will contribute to the young adult’s transition to independent living and the treatment
strategies that will be used to prepare the young adult for a less restrictive, more family-like setting.
D.
Reassessment of unmet needs and efforts made to meet these needs
E.
Modification of ttransition plan, tasks to be performed and anticipated length of placement, including the target date for discharge
from the group home placement
F.
Involvement of young adult in transition program
G. Progress of discharge planning
I have read the foregoing and agree to conform to these requirements. The terms of this agreement shall remain in force until
changed by mutual agreement of both parties or when this young adutl is removed from the group home.
SIGNATURE OF PLACEMENT WORKER
SIGNATURE OF AUTHORIZED GROUP HOME REPRESENTATIVE
TITLE
TITLE
NAME OF AGENCY
NAME OF GROUP HOME
ADDRESS
ADDRESS
PHONE
DATE
DATE
PHONE
(
)
(
)
cc: To group home, young adult’s social service record
AGENCY -- GROUP HOME AGREEMENT
Confidential in acordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
PAGE 2 of 2
SOC 154B (1/12) REQUIRED FORM - NO SUBSTITUTES PERMITTED
Page of 2