(b) The following
information regarding the child shall be obtained and maintained in the child's
record:
(1) Legal name, preferred name if
different from legal name, and preferred gender pronouns.
(2) Political affiliation with an Indian
tribe or Alaskan village, including membership or citizenship, if
applicable.
(3) The name, address,
and telephone number of all adults with whom the child was living immediately
prior to the current placement.
(4)
The name, address, and telephone number of the child's parent(s), if
known.
(5) The name, address, and
telephone number of the placement worker and placement agency.
(6) Educational records, if available,
describing the child's present academic level, including their grade or
performance level, and any previous school-related problems.
(7) Dental and medical history, if available,
including immunization records; and physician's orders for any medically
necessary diet as specified in Section
80076(a)(6).
(8) The child's court status, if applicable,
including a copy of any custody orders and agreements with parent(s) or
person(s) having legal custody.
(9)
The placement agency's list of persons who should or should not be allowed to
visit.
(A) Notwithstanding (b)(9), the
facility's visitation policy must be in accordance with the child's personal
rights as specified in 84072(d)(8).
(10) Any special dietary needs or
practices.
(11) Medical,
psychiatric and psychological reports that identify special needs of children
diagnosed as mentally disordered or developmentally disabled.
(12) Medical and dental insurance coverage
information, or information regarding the agency or person responsible for
medical and dental costs.
(13)
Consent forms, completed by the child's authorized representative(s), to permit
the facility to authorize medical care.
(14) A copy of the standard appraisal form
specified in Section
84068.1(b)(1)(C),
if used.
(15) A copy of the current
court order, or written authorization of the child's parent or guardian, for
each psychotropic medication, as defined in Section
84001(p)(4).
(A) Written authorization of the child's
parent or guardian may only be documented in lieu of a court order if the child
is not a dependent or ward of the court, or it is documented in the child's
record that the county placing agency has verified a court order is not
required.
(B) This section shall
not apply when the child's record contains documentation from the child's
prescribing physician that the psychotropic medication has been provided in an
emergency situation, as described in California Rules of Court, rule
5.640.
(16) A separate
log for each psychotropic medication prescribed to the child documenting all
the following:
(A) The name of the
medication.
(B) The date of the
prescription.
(C) The quantity of
medication and number of refills initially prescribed.
(D) When applicable, any additional refills
prescribed.
(E) The prescribed
dosage and directions for use as specified in writing by the physician
prescribing the medication, including any changes directed by the
physician.
(F) The date and time of
each dose taken by the child.
(G)
Documentation of each refusal.
1.
Documentation shall include the name of the medication refused, date and time
of the refusal, the reason for the refusal, who was notified of the refusal,
and any observed results of the refusal.
(H) Staff initials for each time a
psychotropic medication is taken by a child, as an indication that they
supervised the child self-administering their psychotropic medication.
1. Initials shall not be pre-filled on the
log.
(17) The
original documentation signed by a child and their authorized representative
acknowledging receipt of information regarding a child's personal rights as
specified in Section
84072(c).
(18) The names and contact information for
the child's social worker(s), probation officer(s), attorney(s), service
providers, foster youth advocates, Court Appointed Special Advocates (CASAs),
and education rights holder if other than the parent or parents, and when
applicable, representatives designated by the child's Indian tribe to
participate in the juvenile court proceeding, information that the child is
entitled to receive from the placing agency pursuant to section
16001.9(a)(11)
of the Welfare and Institutions Code.
(c) If it is determined that the facility can
provide the services necessary to meet the child's needs, the following
additional information shall be maintained in the child's record:
(1) A copy of the child's original needs and
services plan; verification, signed by the child and their authorized
representative(s), that they were offered the opportunity to participate in
plan development; and verification that the authorized representative(s) have
approved the plan.
(2) Signed
copies of the facility's policies and procedures regarding the child's removal
and/or discharge; discipline; and complaints.
(3) Documentation that vaccinations have been
obtained as specified in Section
84069.1, if immunization records
are not available prior to placement.
(4) Records and documentation regarding any
fines levied as specified in Sections
84026(c)(1) through
(4).
(5) Copies of any modifications to the
child's needs and services plan; verification, signed by the child and their
authorized representative(s), that they were offered the opportunity to
participate in any such modifications; and verification that the authorized
representative(s) have approved such modifications.