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

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PROBATION QUARTERLY REPORT FORMAT EXHIBIT W
Los Angeles County Probation Department Placement Quarterly Report Minor’s Name: DPO Name: D.O.B: / AGE: Area Office: P.O.B (Place of Birth): Phone: SSN#: Reporting Period: Legal Status: Adm. Date: Current Residence: Case Goal: Family Reunification Presenting Problems: Areas of Strength: Family Support Intelligence Adjustment to Placement (please summarize the last 3 months) Month - Month - Month - Relative Placement Rev. 02/26/2004 Page 1 of 7 Long-Term Foster Care Emancipation Good Peer Relationship Other
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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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EXHIBIT A specified in the Needs an
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EXHIBIT A The CONTRACTOR shall Moni
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FOSTER YOUTH BILL OF RIGHTS EXHIBIT
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EXHIBIT A-I 19. Residents have the
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EXHIBIT A-I Reprise 25. Residents s
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INTENTIONALLY LEFT BLANK EXHIBIT A-
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EXHIBIT A-IVa STATE OF CALIFORNIA
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FOSTER CHILD’S NEEDS AND CASE PLA
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AGENCY - GROUP HOME AGREEMENT Child
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EXHIBIT A-VIII SPECIAL INCIDENT REP
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5. SERIOUS INJURY, ILLNESS OR ACCID
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EXHIBIT A-VIII 10. SIGNIFICANT INCI
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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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(CSW completes top section) Los Ang
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D. Please attach a list of the foll
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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
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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
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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
Page 701 and 702:
distribution base. The result of th
Page 703 and 704:
special cost studies (such as an en
Page 705 and 706:
other activity. The bases must be e
Page 707 and 708:
g. The results of each negotiation
Page 709 and 710:
49. Training costs 50. Transportati
Page 711 and 712:
e. Costs identified in subparagraph
Page 713 and 714:
compensation for employees on feder
Page 715 and 716:
(3) Excise taxes on accumulated fun
Page 717 and 718:
with certainty as to time, intensit
Page 719 and 720:
appeals, antitrust suits, or the pr
Page 721 and 722:
(1) Donated or volunteer services m
Page 723 and 724:
(1) Capital expenditures for genera
Page 725 and 726:
(2) "Idle facilities" means complet
Page 727 and 728:
enovations, alterations, equipment,
Page 729 and 730:
. For non-profit organizations subj
Page 731 and 732:
already required or maintained. Als
Page 733 and 734:
see paragraphs 37., Professional se
Page 735 and 736:
41. Recruiting costs. a. Subject to
Page 737 and 738:
continued to own the property. This
Page 739 and 740:
48. Termination costs applicable to
Page 741 and 742:
(3) Fees charges by the educational
Page 743 and 744:
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
Page 749 and 750:
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 -
Page 755 and 756:
A-C Handbook Page 9 CONTRACTOR shal
Page 757 and 758:
A-C Handbook Page 11 2.3 Petty Cash
Page 759 and 760:
A-C Handbook Page 13 Salaried emplo
Page 761 and 762:
A-C Handbook Page 15 Indirect Cost
Page 763 and 764:
A-C Handbook Page 17 2.3 Acceptable
Page 765 and 766:
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
Page 803 and 804:
EXHIBIT G See Procedural Guide 0200
Page 805 and 806:
EXHIBIT G that the research will no
Page 807 and 808:
EXHIBIT G detrimental to the safety
Page 809 and 810:
EXHIBIT G Procedural Guide 0500-504
Page 811 and 812:
EXHIBIT H of changes to the plan. (
Page 813 and 814:
EXHIBIT I (e) The child's caretaker
Page 815 and 816:
EXHIBIT I CSW in Concurrent Plannin
Page 817 and 818:
Procedures A. WHEN: A CHILD IS DETA
Page 819 and 820:
B. WHEN: A CHILD IS IN OUT-OF-HOME
Page 821 and 822:
Dependency Investigator CSW Respons
Page 823 and 824:
EXHIBIT I For offices who have impl
Page 825 and 826:
EXHIBIT I FB1 Addendum, Family Back
Page 827 and 828: CHILD WELFARE SERVICES PROGRAM 31-4
Page 829 and 830: CHILD WELFARE SERVICES PROGRAM 31-4
Page 831 and 832: Department of the Treasury Internal
Page 833 and 834: DCFS GROUP HOME CONTRACT INVESTIGAT
Page 835 and 836: EXHIBIT N c) insufficient or poor f
Page 837 and 838: EXHIBIT N 5. The Division Chief or
Page 839 and 840: EXHIBIT O 1. The lesser number is a
Page 841 and 842: EXHIBIT O COUNTY OF LOS ANGELES CON
Page 843 and 844: CONTRACTOR’S CERTIFICATION OF COM
Page 845 and 846: F I F I F I F I EXHIBIT R F O R Y O
Page 847 and 848: 8. Does the child receive the sport
Page 849 and 850: EXHIBIT R 33. Is the child given th
Page 851 and 852: It is best that women seek help to
Page 853 and 854: Safely Surrendered Baby Hotline (87
Page 855 and 856: Cada recién nacido merece una opor
Page 857 and 858: DATE OF ISSUE: APPLICABLE TO: LEGAL
Page 859 and 860: TA/EW b) INVALID OVERPAYMENT EXHIBI
Page 861 and 862: WHO HOW following conditions exist:
Page 863 and 864: EXHIBIT T Deposit EW 3. Reconcile t
Page 865 and 866: O/P Collection EW b) Enter the stat
Page 867: c) FAD Exception Distribution d) Ov
Page 872 and 873: s mobility and independent function
Page 874 and 875: 1180.3. (a) This section shall appl
Page 876 and 877: (A) Obesity. (B) Pregnancy. (C) Agi
Page 880 and 881: Name of School: Address of School:
Page 882 and 883: Date Type Los Angeles County Probat
Page 884 and 885: Are there any SIRS to report? Yes N
Page 886 and 887: TARGET POPULATIONS WITH CORRESPONDI
Page 888 and 889: EXHIBIT Y THE TARGET POPULATION FOR
Page 890 and 891: CONTRACT NO. COUNTY PROGRAM DIRECTO
Page 892 and 893: EXHIBIT CC LOS ANGELES COUNTY SUPER
Page 894 and 895: INTRODUCTION/SUMMARY In June, 2005,
Page 896 and 897: elatives) should reflect the unique
Page 898 and 899: Additionally, every effort should b
Page 900 and 901: DEPENDENCY CASE STAGES Stage 1: Pre
Page 902 and 903: The Pre-Disposition Family Visitati
Page 904 and 905: PRELIMINARY CONSIDERATIONS/FACTORS
Page 906 and 907: • Provide a drug/weapon/violence
Page 908 and 909: • Give parents suggestions for wh
Page 910 and 911: Visitation Objectives (reason for e
Page 912 and 913: issues specific to teen parents. Th
Page 914 and 915: Circumstance Team Response in FVP
Page 916 and 917: BIBLIOGRAPHY Casey Family Programs.
Page 918 and 919: Reporting Runaways A Guide for Care
Page 920 and 921: CONTRACTOR’S OBLIGATIONS UNDER HI
Page 922 and 923: 213-974-2166 EXHIBIT EE The initial
Page 924 and 925: 5.0 MISCELLANEOUS EXHIBIT EE agents
Page 926 and 927: CONTRACTOR’S NAME: CONTRACT NO. C
Page 928 and 929:
BACKGROUND AND RESOURCES: CALIFORNI
Page 930 and 931:
It is best that women seek help to
Page 932 and 933:
Safely Surrendered Baby Hotline (87
Page 934 and 935:
Cada recién nacido merece una opor
Page 936 and 937:
2.203.010 Findings. Chapter 2.203,
Page 938:
APPENDIX M following: 1. Has ten or
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