MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Large Family Resource Home Assessment Checklist

Licensed Vendor Name(s)	Parent 1	DVN
Parent 2
Resource Development Worker	Assessment Date
Completion of this form is part of a mutual assessment process between the resource development worker and both licensed resource parents desiring to be approved as a large family resource home.
Qualifications
1. All household members age 17 and older Attach additional paper if necessary for homes with more than 7 household members 17 & older	Date of clear results received(must be within past 90 days)
MSHP Fingerprints	FCSR	Case. Net	CA/N
(Resource Parent)
(Resource Parent)
(Other household resident)
(Other household resident)
(Other household resident)
(Other household resident)
(Other household resident)
2. Initial Foster Home license, FH, begin date
3. Current Foster Home, FH begin date
4. Three written recommendations (attached)
Name	Title/occupation/relationship to applicant(s)
5. Large Family Resource Home Training Completed ( enter name and dates completed for each adult residing in the home)
Name	Date
6. Attach written plan for daily one-on-one time with each foster youth in the home
Physical Standards
7. Compliance with licensing rule 13 CSR 35-60.040	Date
8. Approved Fire and Safety Assessment Form, CD-30
9. Approval for one of the resource providers to be employed, no yes If yes, attach Plan for Employment per policy 4.14 attachment B
10. Two Toilets for foster youth use * there must be 2 toilets for every 5 children in the home
11. Shower/Tub for foster youth use * there must be 1 shower/tub for every 5 children in the home
12. Household telephone for emergencies	phone number
13. Locations of all surveillance cameras (if applicable)
14. Attached list of items prohibited for foster youth to have in the home
15. Resource Home Safety Checklist completed within 2 weeks of approval begin date	Date Completed
Capacity
16. Number of Adults residing in home ( age 18 & older)
17. Number of Biological/Adopted and other children 17 years of age and younger residing in the home
18. Maximum number of foster youth approved for placement ( not to exceed 10 total children 17 years of age and younger including children listed in field #17)
Supports
19. Attach the list of services the home has access to and will use for medical, physical and social treatment as identified in the foster youth’s case plan
20. Attach the list of social, recreational, educational and vocation activities in the community the resource home uses to encourage social and community integration through the development of life skills
21. Attach Supervision Backup Plans A B	Supervision plan includes names and contact information of qualified and screened adults to provide supervision (not respite) to household if necessary for both parents not to be available to provide supervision. There shall be a plan “A” and a plan “B”. Include dates when a clear Family Care Safety Registry result was received on all adults included in the plan.
22. Attach Transportation Plan	Transportation plan includes all resources used to transport all and any household member collectively and individually to court, visits, medical appointments, therapy appointments, school functions, Family Support Team Functions, family outings, etc.
Care of Children ( use additional pages if needed)
23. Describe how each resource parent recognizes and responds appropriately to a child’s verbal and physical expressions of needs and wants.	Parent 1	Parent 2
24. What does the family do to make new foster youth placed in the home feel comfortable?	Parent 1	Parent 2
25. In what ways are the foster youth made to feel like a member of the family?	Parent 1	Parent 2
26. List each resource parent’s strengths regarding foster youth behaviors.	Parent 1	Parent 2
27. List each resource parent’s challenges regarding foster youth behaviors.	Parent 1	Parent 2
28. Consider and document each resource parent’s identified strengths regarding their Relationship with Birth Parents.	Parent 1	Parent 2
29. Consider and document each resource parent’s identified challenges regarding their Relationship with Birth Parents.	Parent 1	Parent 2
30. Provide examples of how each resource parent guides foster youth towards independence.	Parent 1	Parent 2
31. What is the strategic plan to prevent children from raising children?	Parent 1	Parent 2
31. All the required forms for providing foster care are understood, agreed to by way of signature, and located in the resource provider case file. Including, CD101, CD117, CD119, CD128, and CD194. Check if parent understands and form is signed. For additional adults in the home include name.
Parent 1	Other adult(s) in home
Parent 2

Signatures:

Resource Parent	Date	Resource Parent	Date
Resource Development Worker	Date	Supervisor	Date

Attach this document to the amended Home Assessment for the approved Large Family Resource Home