Texas NIENTOR ANNUAL REVIEW OF MENTOR HOMES MS 749.349 (1 749.2901; 749.2803 The following tool is to be completed for each home on an annual basis. This form. combined with the Recruiter's Health and Safety Assessments (for the year). the Coordinator's Health and Safety Annual Review. and Subchapter Worksheet will ful?ll the standard of reviewing homes on regular basis to justify as the ongoing assessments of the caregiver?s abilities to meet the needs of the children in care and evaluating the foster home for compliance with all rules that apply to the home. Mentor Name: Small, Clemon Sherrill Date: 12.12.12 Risk indicators- History Compliance: Yes No This home has been reviewed for all compliance related issues. Yes No Action Plan such as a letter or developmental plan has been created to bring ?le into 100% compliance with deadlines. Yes No This home has been reviewed for all non-compliances over the past year. See Recruiter Health and Safety Assessment (all four quarters) and Coordinator Annual Review. Investigations: Yes No This home has been reviewed for all investigations both external and internal for the past year. List number and dates of all investigations. Attach extra sheets if needed Date Allegation Ruled out (Y or N) Date Al legation Ruled out (Y or N) Date Allegation Ruled out (Y or N) Non Compliance! Developmental Plans: Yes No This home has been reviewed for all past non-compliance and developmental plans over the past year and all plans have been completed. See Developmental Plans andlor Action Plan to ensure plan is followed up on. Placement History: Yes No This home's placement history has been reviewed. List number of failed placements for the year. Failed placements include requests for removals. program initiated removals and negative discharges. See Placement History Number of failed placements 5 Rev 2/l l. Ip mztexaslrecruitmentlmentor ?le/annual review DA970 Mentor Name: Other Risk indicators: (Staff opinions and information contained in the file) DYes Elva DYes Elves No EYes Yes If yes to any of the above. please address: ll T9524: MEEIIQR mvgeg children to respite and relggagsl to. them to Texgs MEN - 3123 home, Has the mentor been dif?cult to reach at times over the past year? Has the mentor failed to report incidents in a timely manner? During the past year where their any unresolved unexplained bruises or marks on any child that were not addressed through either an investigation. developmental plan or explainable expianation by a doctor? Has the mentor failed to report individuals who visit the home or lived in the home and who are not referenced in the home study? Is there anyone living in the home or visiting the home whom there is no background check listed for them in the ?le? Did the mentor change address more than twice over the past calendar year? Has the mentor family suffered any signi?cant loss of family members or close friends either through divorce, miscarriage. separation or death over the past year? Has the mentor given any notices on a child to be removed due to the family's inability to handle a child's challenging behavior over the past year? Has the mentor reported or documented they are ?stressed out" or ?burned out" to the program staff in the past year? Has there been any negative feedback regarding the mentor family from the referring agency. school or other individuals in: the community? If yes. list the feedback and the resolution with the mentor below. he at l'n like eoldt ir he i M5. Small hg gang fgling swam!? out and will calms that she is unable to gate the ghildren in the home. It a i foot 3; wellI Rha had nve ati w'th a ut' then conc rn about I ECI a statement that the ch'ldre uid not u'c res situati nai msandcallsT MENTO ff mall rec tl bro 2 (1 at! note rtaina twhati in with the Main inth meat hat ti id nti a iti nalsu stem to them and the numm; of children plagd into the home. The for home is gging out to the home on 12, !2 to have a detailed discussion with the familv. Has there been any report concoming improper supervision of any child placed in the home over the past year? If yes. please list incident and out come. Evaluation of speci?c Home study standards: Honsghofd ggmm?ign; 219. 244 7. List current members living in the home: Rev lel.lp mztexasirecruitmentlmentor ?lefannual review . 1 Menlur Namc: Num: 5.1 km Relnlionship Gummy Mstumus) Che 'l mall A Foster um 11 fl Minn]; Yes Nu Hg :g menlgr'; 534ng gram; (Maggi mm; [mm-mi Ms 142.24471Q If yes, describe flung", efiecl on [he Funily's abilin (are for children in Iheir home. a 'va 'in leicare mm 7' 9, a i: 7 41244 lfyu, describe [ha changes, their arm on the family': nhilhy to cm for swam: in Ihcir ham. gm; henna ha mr ma in rumor 1 rm 4 9 1r yes. ascribe Ih: Meir :fi'ecl on the family's abilily u: care for children in mi: llama. Mg. Small brake m; in hceild 9f Hymn: i; IMVenr abn h; fling gnhis by] 'ug Elm szu ritual": < l. I.) fildmluml leview DA972 a Mentor Name: The family has only cared for basig level of care The! havg in tbgir ability [9 cm ?qr the as all glacernents have failed. The following signatures listed below have reviewed all the information pertaining to this foster family and agree that this family should continue to work as foster parents. The reason for this continuation of working with this family is based on: Tx MENTOR asameeti ed wi ii: i nl2l .2 ltwillbed te i tin nex ste Rtakes witht fa ii .We will Here sed to arei efforts ureth rnil remai aMe It is recommended that they continue to work with 2 number of children, ages through 11 and genderts) mag. Type of services: CI Respite care Child-care Services #3 Treatment Services Date Title Degree 5 1M Signature PM Date Title Degree Signature of Child Management Staff Date Title 1 M4 Degree 1' n_ Rev I. rn:texas!recruitmentlmentor file/annual review DA973 ,a