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Effective Date: 
9/2004

Documents

Instructions

Updated: 4/2002

Purpose

  • To provide a documentation that the adult foster home has been inspected for safe and sanitary conditions.

    Note: Form 2329 is used only when local health authorities are unable to inspect the foster home.
  • To provide documentation that the adult foster home complies with the health inspection requirement in the "Minimum Standards for Adult Foster Care."

When to Prepare

The caseworker or person designated to conduct the inspection completes Form 2329 before the foster home is certified and yearly thereafter.

Number of Copies

Complete an original and one copy of Form 2329.

Transmittal

File the original Form 2329 in the adult foster care provider's case folder and send the copy to the provider.

Form Retention

The caseworker keeps the form for three years and 90 days.

Detailed Instructions

Provider Name— Enter the applicant/provider's name.

Address— Enter the address of the adult foster home.

Items 1-32— Check YES or NO to indicate compliance or noncompliance with health and safety standards. If the item is not applicable, check NA and give a brief explanation in the comments section.

Person Conducting Inspection Signature— The caseworker or person designated to conduct the inspection signs and dates the form.

Title— The person conducting the inspection prints his job title.