CMS-07-021/023 - Los Angeles County Department of Children and ...

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EMANCIPATION PREPARATION GOAL CONTRACT (To be completed by youth ages 14 and older) EXHIBIT A-XI (CSW completes top section) This is a 6 month contract and represents the period of and ending YOUTH’S AGE: DATE: CASE CASE # POTENTIAL EMANCIPATION NEXT COURT INSTRUCTIONS TO YOUTH: The purpose of this contract is to capture the goals you are agreeing to achieve over the next 6 months. It is a good organizing tool to help you stay focused and keep track of your progress toward accomplishing each goal. Your CSW and Caregiver will also have copies of this contract and will help you monitor your success. My goal for the next 6 months is: ACTIVITY What will I do? DEADLINE When will I get it done? RESOURCES What people, places, and things are available to help me? COMMENTS Signing this contract means we will all work to complete the steps necessary to help me meet my goals. My Signature: Date Caregiver Signature: Date: CSW Signature: Date:
(CSW completes top section) Los Angeles County Department of Children and Family Services EMANCIPATION PREPARATION GOAL CONTRACT (To be completed by youth ages 14 and older) This is a 6 month contract and represents the period of time beginning___________ and ending_____________ YOUTH’S NAME____________________________________________ AGE_______ DATE_______________ CASE NAME_________________________________________________ CASE #_______________________ POTENTIAL EMANCIPATION DATE___________________________ NEXT COURT DATE_______________ EXHIBIT A-XI INSTRUCTIONS TO YOUTH: The purpose of this contract is to capture the goals you are agreeing to achieve over the next 6 months. It is a good organizing tool to help you stay focused and keep track of your progress toward accomplishing each goal. Your CSW and Caregiver will also have copies of this contract and will help you monitor your success. My goal for the next 6 months is: _____________________________________________ ______________________________________________________________________ ___ ACTIVITY DEADLINE RESOURCES COMMENTS What will I do? When will I What people, places, and things get it done? are available to help me? Signing this contract means we will all work to complete the steps necessary to help me meet my goals. My Signature: Date____________________________ Caregiver Signature: Date____________________________ CSW Signature: Date_______________________
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DEPARTMENT OF CHILDREN AND FAMILY S
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REQUEST FOR STATEMENT OF QUALIFICAT
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1.0 INTRODUCTION 1.1 Preamble For o
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COUNTY agencies and their partners
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1.3 DCFS Mission Statement DCFS wil
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2.0 GENERAL INFORMATION 2.0 Scope o
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2.4.1.2 Prospective Contractor must
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old for 30 days or less; (3) provid
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Contractor protest. In all cases, t
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2.19 Conflict of Interest No County
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submit evidence at that hearing. Af
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solicitation may result in the pros
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County’s contracting process by c
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2.33 Contractor’s Charitable Cont
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3.0 Instructions to Prospective Con
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The request for a Solicitation Requ
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3.7.1 Language The SOQ and all docu
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coverage should the prospective Con
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3.8.6 Please refer to Section 3.0 I
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4.0 SOQ REVIEW/SELECTION/QUALIFICAT
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The Department will execute Board o
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19 20 21 22 List of Required Forms
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CONTRACTOR’S ORGANIZATION QUESTIO
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CONTRACTOR’S ORGANIZATION QUESTIO
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VENDOR’S EEO CERTIFICATION REQUIR
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REQUIRED FORMS - FORM 5 FAMILIARITY
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PROSPECTIVE CONTRACTOR LIST OF TERM
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REQUIRED FORMS - FORM 9 COUNTY OF L
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REQUIRED FORMS - FORM 11 OFFER TO P
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CERTIFICATION OF FISCAL COMPLIANCE
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LIST OF COMMITMENTS Legal Name of A
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REQUIRED FORMS - FORM 17 CONTRACTOR
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CERTIFIED FOSTER PARENT CONFIDENTIA
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CONTRACTOR’S EMPLOYEE ACKNOWLEDGE
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Type of program: Foster Family Agen
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CONTRACTOR’S NAME: CONTRACT NO. N
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REQUEST FOR STATEMENT OF QUALIFICAT
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TRANSMITTAL FORM TO REQUEST A RFSQ
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APPENDIX E LISTING OF CONTRACTORS D
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SAMPLE CONTRACT COUNTY OF LOS ANGEL
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LIST OF EXHIBITS SAMPLE CONTRACT Ex
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SAMPLE CONTRACT Exhibit A-IX Requir
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as a single process. SAMPLE CONTRAC
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SAMPLE CONTRACT 2.27 “Foster Care
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SAMPLE CONTRACT written in accordan
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SAMPLE CONTRACT Such insurance shal
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SAMPLE CONTRACT 6.0 INSURANCE COVER
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SAMPLE CONTRACT partial, and supple
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SAMPLE CONTRACT 7.15 Provided that
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10.0 COUNTY’S RESPONSIBILITY SAMP
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SAMPLE CONTRACT 10.13 The CSWs shal
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SAMPLE CONTRACT and/or Certified Fo
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SAMPLE CONTRACT Investigation/Monit
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SAMPLE CONTRACT will also invite CO
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SAMPLE CONTRACT 18.4 The CONTRACTOR
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SAMPLE CONTRACT management review,
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SAMPLE CONTRACT 20.2 CONTRACTOR and
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SAMPLE CONTRACT 22.2 CONTRACTOR her
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SAMPLE CONTRACT notice by the CONTR
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SAMPLE CONTRACT COUNTY’s prior wr
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SAMPLE CONTRACT FOSTER FAMILY AGENC
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SAMPLE CONTRACT to the Contract, wh
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SAMPLE CONTRACT governing or impact
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8.0 GRIEVANCES SAMPLE CONTRACT term
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SAMPLE CONTRACT 11.1.2 For purposes
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SAMPLE CONTRACT CONTRACTOR will int
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SAMPLE CONTRACT conduct a hearing w
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SAMPLE CONTRACT CONTRACTOR warrants
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SAMPLE CONTRACT solely of CONTRACTO
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1015, attached hereto as Exhibit L.
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SAMPLE CONTRACT 30.1.3 CONTRACTOR m
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SAMPLE CONTRACT not limited to, the
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SAMPLE CONTRACT amounts COUNTY clai
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COUNTY OF LOS ANGELES DEPARMENTS OF
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PART A: INTRODUCTION 1.0 PREAMBLE E
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EXHIBIT A COUNTY agencies and thei
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EXHIBIT A (Health and Safety Code),
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PART B: TARGET DEMOGRAPHICS 1.0 TAR
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1.0 SAFETY EXHIBIT A PERFORMANCE OU
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1.1.7 Required Services by CONTRACT
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EXHIBIT A The CONTRACTOR shall Moni
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PROGRAM TARGET GROUP: Placed Childr
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EXHIBIT A the fullest extent possib
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EXHIBIT A Monitor for Compliance th
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3.0 WELL-BEING EXHIBIT A PERFORMANC
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EXHIBIT A participation in treatmen
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EXHIBIT A individuals to the extent
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EXHIBIT A 88068.2, 88068.3, and 880
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EXHIBIT A objectives appropriate to
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EXHIBIT A The CONTRACTOR shall prov
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3.7.4 Monetary Consequences EXHIBIT
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EXHIBIT A Days. After 14 Days, the
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EXHIBIT A The CONTRACTOR shall have
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EXHIBIT A for the Placed Child to r
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Page 195 and 196: EXHIBIT A The CONTRACTOR shall Moni
Page 197 and 198: FOSTER YOUTH BILL OF RIGHTS EXHIBIT
Page 199 and 200: EXHIBIT A-I 19. Residents have the
Page 201 and 202: EXHIBIT A-I Reprise 25. Residents s
Page 203 and 204: INTENTIONALLY LEFT BLANK EXHIBIT A-
Page 205 and 206: EXHIBIT A-IVa STATE OF CALIFORNIA
Page 207: FOSTER CHILD’S NEEDS AND CASE PLA
Page 225 and 226: AGENCY - GROUP HOME AGREEMENT Child
Page 227 and 228: EXHIBIT A-VIII SPECIAL INCIDENT REP
Page 229 and 230: 5. SERIOUS INJURY, ILLNESS OR ACCID
Page 231 and 232: EXHIBIT A-VIII 10. SIGNIFICANT INCI
Page 233 and 234: SCREENING REQUIREMENT PERIODICITY S
Page 235 and 236: Anticonvulsant medications, when pr
Page 237 and 238: Dr. faxes pages 1 & 2 of PMAF to th
Page 239 and 240: EXHIBIT A-X 2. Contact the physicia
Page 241 and 242: EXHIBIT A-X 1. Instruct the caregiv
Page 243: APPROVAL LEVELS Section Level Appro
Page 247 and 248: D. Please attach a list of the foll
Page 249 and 250: TO THE HEADS OF EXECUTIVE DEPARTMEN
Page 251 and 252: implementation of individual provis
Page 253 and 254: E. Negotiation and Approval of Indi
Page 255 and 256: . The restraints or requirements im
Page 257 and 258: objectives of the organization are
Page 259 and 260: distribution base. The result of th
Page 261 and 262: special cost studies (such as an en
Page 263 and 264: other activity. The bases must be e
Page 265 and 266: g. The results of each negotiation
Page 267 and 268: 49. Training costs 50. Transportati
Page 269 and 270: e. Costs identified in subparagraph
Page 271 and 272: compensation for employees on feder
Page 273 and 274: (3) Excise taxes on accumulated fun
Page 275 and 276: with certainty as to time, intensit
Page 277 and 278: appeals, antitrust suits, or the pr
Page 279 and 280: (1) Donated or volunteer services m
Page 281 and 282: (1) Capital expenditures for genera
Page 283 and 284: (2) "Idle facilities" means complet
Page 285 and 286: enovations, alterations, equipment,
Page 287 and 288: . For non-profit organizations subj
Page 289 and 290: already required or maintained. Als
Page 291 and 292: see paragraphs 37., Professional se
Page 293 and 294: 41. Recruiting costs. a. Subject to
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continued to own the property. This
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48. Termination costs applicable to
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(3) Fees charges by the educational
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e. Foreign travel. Direct charges f
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Southern Research Institute, Birmin
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A-C Handbook Page 1 AUDITOR-CONTROL
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A-C Handbook Page 3 2.2 Cash Receip
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A-C Handbook Page 5 If a Payroll Re
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A-C Handbook Page 7 Outside Meals -
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A-C Handbook Page 9 CONTRACTOR shal
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A-C Handbook Page 11 2.3 Petty Cash
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A-C Handbook Page 13 Salaried emplo
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A-C Handbook Page 15 Indirect Cost
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A-C Handbook Page 17 2.3 Acceptable
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A-C Handbook Page 19 D. UNALLOWABLE
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EXHIBIT C-II AUDITOR-CONTROLLER/DEP
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• California Code of Regulations,
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If CONTRACTOR and A-C/DCFS hold a p
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XIV. Final Report to the Board of S
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EXHIBIT D Cont. I understand that I
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EXHIBIT D-I Cont. I understand that
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24. Equipment Leases 25. Depreciati
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Report all costs related to telepho
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EXHIBIT E D. Total Un-Expended AFDC
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EXHIBIT F (D) If the State Departme
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EXHIBIT F (C) Individuals who are e
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EXHIBIT F subdivision (g). The Stat
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EXHIBIT F processing. (B) Upon requ
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EXHIBIT F self-addressed envelope f
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EXHIBIT F shall disclose that clien
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EXHIBIT F state, would have been pu
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statement, fingerprints and photogr
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Name, Address and Telephone Number
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EXHIBIT G If a CSW or SCSW has any
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EXHIBIT G 10) minute orders and cou
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0500-501.20 (Rev 12/02) EXHIBIT G 4
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EXHIBIT G See Procedural Guide 0200
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EXHIBIT G that the research will no
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EXHIBIT G detrimental to the safety
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EXHIBIT G Procedural Guide 0500-504
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EXHIBIT H of changes to the plan. (
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EXHIBIT I (e) The child's caretaker
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EXHIBIT I CSW in Concurrent Plannin
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Procedures A. WHEN: A CHILD IS DETA
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B. WHEN: A CHILD IS IN OUT-OF-HOME
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Dependency Investigator CSW Respons
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EXHIBIT I For offices who have impl
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EXHIBIT I FB1 Addendum, Family Back
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CHILD WELFARE SERVICES PROGRAM 31-4
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Department of the Treasury Internal
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DCFS FOSTER FAMILY AGENCY CONTRACT
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EXHIBIT N medication authorizations
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EXHIBIT N 5. The DCFS Division Chie
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EXHIBIT O 1. The lesser number is a
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EXHIBIT O COUNTY OF LOS ANGELES CON
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CONTRACTOR’S CERTIFICATION OF COM
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F I F I F I F I EXHIBIT R F O R Y O
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8. Does the child receive the sport
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EXHIBIT R 33. Is the child given th
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Every baby deserves a chance for a
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Es mejor que las mujeres busquen ay
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• Llámenos para recibir informac
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A. WHEN: A FAD INDICATES A POTENTIA
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EXHIBIT T O/P Collection EW 4. INVA
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EXHIBIT T NOTE: Overpayment recover
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Reconciliation EW 3. Receive the Ba
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Overpayment Recovery Unit ES WHO HO
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CHARITABLE CONTRIBUTIONS CERTIFICAT
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SERVICE DELIVERY SITES Foster Famil
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TABLE OF CONTENTS INTRODUCTION/SUMM
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PURPOSE/PHILOSOPHY STATEMENT These
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TEAMING PROCESS Family-Centered Tea
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COURT ORDERS Oftentimes, the judici
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First 24 Hours Child removed from p
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FAMILY VISITATION PLAN Prior to the
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• Whether or not the parent is a
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• Maintain objectivity, and remai
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Judicial Officers Judicial Officers
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Unless the FVP specifically states
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the visitation objectives. In addit
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Sexual Abuse Permanency Transportat
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SUBCOMMITTEE MEMBERS The Drafting S
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EXHIBIT Y of information, including
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EXHIBIT Y accounting of Disclosures
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DISCHARGE SUMMARY FOR DCFS: FOSTER
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INTENTIONALLY LEFT BLANK EXHIBIT BB
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10.0 COMPLIANCE WITH CIVIL RIGHTS L
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Exhibit T Overpayments Exhibit U Gr
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WHEREAS, CONTRACTOR warrants that i
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2.0 DEFINITIONS Exhibit T Overpayme
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2.16 “Do Not Refer Status” or
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2.31 “Pool Rate” - means the ra
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notify COUNTY of such change. COUNT
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equivalent providing the CONTRACTOR
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a bed open for a Placed Child, CONT
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7.14 CONTRACTOR may appeal the fina
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9.2 If CONTRACTOR’s staff qualify
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10.11 COUNTY Workers shall provide
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13.0 FEES 12.1 CONTRACTOR shall mai
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Exhibit N, DCFS/Probation Group Hom
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16.0 FINANCIAL REPORTING 16.1 CONTR
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closing summary of CONTRACTOR's rec
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including but not limited to, the U
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19.6 Nothing herein precludes COUNT
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entirety; or (2) reduced in accorda
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accounted for and that unspent fund
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omissions, resulting from its perfo
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County of Los Angeles - Department
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4.0 BUDGET REDUCTIONS In the event
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6.2.3 The assurance that all employ
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CONTRACTOR hereby assures that it w
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12.3 CONTRACTOR shall comply with a
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modify, deny or adopt the proposed
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minimum waiting time for clearance.
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County of Los Angeles Department of
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eject children for placement consis
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30.0 DISCLOSURE OF INFORMATION 30.1
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33.7 CONTRACTOR shall obtain the fo
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35.0 TERMINATION FOR CONVENIENCE 35
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CONTRACTOR receives, has access to,
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COUNTY OF LOS ANGELES DEPARTMENT OF
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COUNTY OF LOS ANGELES DEPARTMENTS O
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• Safety and Survival; • Emotio
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Service Access Service providers wi
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The CONTRACTOR shall request approv
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Plan/Quarterly Reports in cooperati
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6.4 The CONTRACTOR’S Treatment Te
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PART C: SERVICE TASKS TO ACHIEVE PE
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1.0: SAFETY PERFORMANCE OUTCOME GOA
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Placed Children; and (2) abide by a
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(b) The CONTRACTOR shall use seclus
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PERFORMANCE OUTCOME SUMMARY 2.0 PER
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2.0: REUNIFICATION/PERMANENCY PERFO
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2.2 Visitation Plan: modification i
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(a) For infants from birth to 6 mon
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PERFORMANCE OUTCOME SUMMARY 3.0 WEL
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3.0 WELL-BEING PERFORMANCE OUTCOME
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(b) Two children’s rights recentl
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their responsibilities to pupils in
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3.2.8 Educational Assessments by th
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information such as immunizations g
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The CONTRACTOR shall have an emerge
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assistance with homework; (5) daily
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3.11.5 Clothing Fit, Appropriatenes
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placed with a minor parent if the C
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PART D - PERFORMANCE REQUIREMENT SU
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FOSTER YOUTH BILL OF RIGHTS EXHIBIT
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19. Residents have the right to con
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not prohibited by the resident's ne
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TABLE OF CONTENTS ii EXHIBIT A-II I
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OUT-OF-HOME CARE EXHIBIT A-II What
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EXHIBIT A-II What is a juvenile cou
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EXHIBIT A-II care still exist, if y
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EXHIBIT A-II Can I have an attorney
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TYPES OF PLACEMENTS EXHIBIT A-II Wh
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GUARDIANSHIP EXHIBIT A-II What is t
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INDEPENDENT LIVING EXHIBIT A-II Wha
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CONFIDENTIALITY AND YOUR RECORDS EX
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WHEN RECORDS ARE DESTROYED Juvenile
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MONEY EXHIBIT A-II Do I have a righ
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RELIGION Can my foster parents or N
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EXHIBIT A-II What if I can't get a
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EMANCIPATION EXHIBIT A-II What does
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EXHIBIT A-II What are the disadvant
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KNOW YOUR RIGHTS EXHIBIT A-II With
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DEFINITION INDEX The number refers
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ENDNOTES 1. The following abbreviat
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35. WIC 317(c) 36. WIC 317(d),(e) E
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84. VC 12814.6 85. VC 17701 86. FC
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PROBATION CASE PLAN FORM (PROB 1385
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EXHIBIT A-V 1. Describe Circumstanc
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EXHIBIT A-V Probation Officer’s R
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EXHIBIT A-V _______________________
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SIGNATURES: EXHIBIT A-V MINOR: THIS
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FOSTER CHILD’S NEEDS AND CASE PLA
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cc: to group home, child’s(ren’
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SPECIAL INCIDENT REPORTING GUIDE FO
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4 EXHIBIT A-VIII 5. SERIOUS INJURY,
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6 EXHIBIT A-VIII 10. SIGNIFICANT IN
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SCREENING REQUIREMENT PERIODICITY S
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Anticonvulsant medications, when pr
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Dr. faxes pages 1 & 2 of PMAF to th
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EXHIBIT A-X 2. Contact the physicia
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EXHIBIT A-X 1. Instruct the caregiv
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APPROVAL LEVELS Section Level Appro
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Group Home Organization: FORMAT FOR
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Exhibit A-XIIIa COUNTY OF LOS ANGEL
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Exhibit A-XIIIb COUNTY OF LOS ANGEL
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GROUP HOME PROGRAM STATEMENT EXHIBI
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TO THE HEADS OF EXECUTIVE DEPARTMEN
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implementation of individual provis
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E. Negotiation and Approval of Indi
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. The restraints or requirements im
Page 699 and 700:
objectives of the organization are
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distribution base. The result of th
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special cost studies (such as an en
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other activity. The bases must be e
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g. The results of each negotiation
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49. Training costs 50. Transportati
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e. Costs identified in subparagraph
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compensation for employees on feder
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(3) Excise taxes on accumulated fun
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with certainty as to time, intensit
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appeals, antitrust suits, or the pr
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(1) Donated or volunteer services m
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(1) Capital expenditures for genera
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(2) "Idle facilities" means complet
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enovations, alterations, equipment,
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. For non-profit organizations subj
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already required or maintained. Als
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see paragraphs 37., Professional se
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41. Recruiting costs. a. Subject to
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continued to own the property. This
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48. Termination costs applicable to
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(3) Fees charges by the educational
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e. Foreign travel. Direct charges f
Page 745 and 746:
Southern Research Institute, Birmin
Page 747 and 748:
A-C Handbook Page 1 AUDITOR-CONTROL
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A-C Handbook Page 3 2.2 Cash Receip
Page 751 and 752:
A-C Handbook Page 5 If a Payroll Re
Page 753 and 754:
A-C Handbook Page 7 Outside Meals -
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A-C Handbook Page 9 CONTRACTOR shal
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A-C Handbook Page 11 2.3 Petty Cash
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A-C Handbook Page 13 Salaried emplo
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A-C Handbook Page 15 Indirect Cost
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A-C Handbook Page 17 2.3 Acceptable
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A-C Handbook Page 19 D. UNALLOWABLE
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EXHIBIT C-II AUDITOR-CONTROLLER/DEP
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EXHIBIT C-II circumstances, the ent
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EXHIBIT C-II At the pre-exit meetin
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EXHIBIT C-II will be provided with
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CONTRACTOR EMPLOYEE ACKNOWLEDGEMENT
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Group Home Semi-Annual Expenditure
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EXHIBIT F (D) If the State Departme
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EXHIBIT F (C) Individuals who are e
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EXHIBIT F subdivision (g). The Stat
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EXHIBIT F processing. (B) Upon requ
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EXHIBIT F self-addressed envelope f
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EXHIBIT F shall disclose that clien
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EXHIBIT F state, would have been pu
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statement, fingerprints and photogr
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Name, Address and Telephone Number
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EXHIBIT G If a CSW or SCSW has any
Page 799 and 800:
EXHIBIT G 10) minute orders and cou
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0500-501.20 (Rev 12/02) EXHIBIT G 4
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EXHIBIT G See Procedural Guide 0200
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EXHIBIT G that the research will no
Page 807 and 808:
EXHIBIT G detrimental to the safety
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EXHIBIT G Procedural Guide 0500-504
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EXHIBIT H of changes to the plan. (
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EXHIBIT I (e) The child's caretaker
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EXHIBIT I CSW in Concurrent Plannin
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Procedures A. WHEN: A CHILD IS DETA
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B. WHEN: A CHILD IS IN OUT-OF-HOME
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Dependency Investigator CSW Respons
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EXHIBIT I For offices who have impl
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EXHIBIT I FB1 Addendum, Family Back
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Department of the Treasury Internal
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DCFS GROUP HOME CONTRACT INVESTIGAT
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EXHIBIT N c) insufficient or poor f
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EXHIBIT N 5. The Division Chief or
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EXHIBIT O 1. The lesser number is a
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EXHIBIT O COUNTY OF LOS ANGELES CON
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CONTRACTOR’S CERTIFICATION OF COM
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F I F I F I F I EXHIBIT R F O R Y O
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8. Does the child receive the sport
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EXHIBIT R 33. Is the child given th
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It is best that women seek help to
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Safely Surrendered Baby Hotline (87
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Cada recién nacido merece una opor
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DATE OF ISSUE: APPLICABLE TO: LEGAL
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TA/EW b) INVALID OVERPAYMENT EXHIBI
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WHO HOW following conditions exist:
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EXHIBIT T Deposit EW 3. Reconcile t
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O/P Collection EW b) Enter the stat
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c) FAD Exception Distribution d) Ov
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s mobility and independent function
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1180.3. (a) This section shall appl
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(A) Obesity. (B) Pregnancy. (C) Agi
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PROBATION QUARTERLY REPORT FORMAT E
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Name of School: Address of School:
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Date Type Los Angeles County Probat
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Are there any SIRS to report? Yes N
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TARGET POPULATIONS WITH CORRESPONDI
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EXHIBIT Y THE TARGET POPULATION FOR
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CONTRACT NO. COUNTY PROGRAM DIRECTO
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EXHIBIT CC LOS ANGELES COUNTY SUPER
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INTRODUCTION/SUMMARY In June, 2005,
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elatives) should reflect the unique
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Additionally, every effort should b
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DEPENDENCY CASE STAGES Stage 1: Pre
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The Pre-Disposition Family Visitati
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PRELIMINARY CONSIDERATIONS/FACTORS
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• Provide a drug/weapon/violence
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• Give parents suggestions for wh
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Visitation Objectives (reason for e
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issues specific to teen parents. Th
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Circumstance Team Response in FVP
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BIBLIOGRAPHY Casey Family Programs.
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Reporting Runaways A Guide for Care
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CONTRACTOR’S OBLIGATIONS UNDER HI
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213-974-2166 EXHIBIT EE The initial
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5.0 MISCELLANEOUS EXHIBIT EE agents
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CONTRACTOR’S NAME: CONTRACT NO. C
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BACKGROUND AND RESOURCES: CALIFORNI
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It is best that women seek help to
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Safely Surrendered Baby Hotline (87
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Cada recién nacido merece una opor
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2.203.010 Findings. Chapter 2.203,
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APPENDIX M following: 1. Has ten or
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