Supervised Visit And-Or Supervised Exchanges Site Visit-Quality Control {PFC-67}

Family Court Services SUPERVISED VISIT and/or SUPERVISED EXCHANGES SITE VISIT/QUALITY CONTROL Date: Name of Agency: Name of Program (if applicable): SITE VISIT 1. More than one location? Yes No If yes, attach list of locations. No Comment: Evaluator Name: California Superior Court, County of Fresno 2. Hours listed match application? Yes 3. Bus Routes (list) Bus Stop Distance: 4. Parking Adequate? Yes No Night Lighting? Yes No Comments: 5. Disabled Parking: Yes No Insurance (Liability, Professional, Business) on file and verified: Yes No Comments: 6. Premises appear and smell clean? Yes No Comments: 7. Number of Private Supervised Visit Rooms: 1 2 3 4 8. Rate appropriateness for child-friendly parent/child interaction in supervised visit rooms: Excellent Adequate Poor 10. Security or quick access to security, if needed? Yes No Comments: 11. Medical Emergency Plan or medical care if needed? Yes No Comments: 12. Written Policies and Procedures? Yes No Comments: 13. Written information provided to participants for safety procedures provided in advance? Yes No Comments: 14. Written contract provided to participants outlining terms and conditions of visitation signed by both parties? Yes No Comments: 9. Evacuation Emergency Plan? Yes No Comments: PFC-67 E12-14 MANDATORY Supervised Visit and/or Supervised Exchanges Site Visit/ Quality Control Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Family Court Services SUPERVISED VISIT and/or SUPERVISED EXCHANGES SITE VISIT/QUALITY CONTROL 15. Parties advised before supervised visit commenced that no confidential privilege exists? Observed Not Observed Inconsistently applied Comments: 16. Professional Providers Proof of Training available: Yes Comments: 17. Therapeutic Providers Proof of Licenses available: Yes Comments: 18. Cancellation Policy Posted: Yes No Comments: 19. Bilingual Staff? Yes No Languages Spoken on Staff: Access to Language Line or for the Hearing Impaired? Yes No Comments: 20. Waiting Area: Lighting Adequate Yes No Child Friendly? Yes No Separated from visitation area? Yes No N/A Comments: 21. Separate entrance/exit for parents: Yes No 22. Visit observation conducted? Yes No Number of times: 23. Complaint level received by court from Fewer than 3 From 4-8 9 or more Complaint topic concerns: 24. Positive comments received by court from Fewer than 3 From 4-8 9 or more General positive topics: Final Recommendation: Unqualified retention on list. Qualified retention on list, meet with program to relay concerns, possible MOU addendum. Remove from list, meet with program to discuss changes needed to reapply for inclusion. to No No Incomplete Incomplete California Superior Court, County of Fresno to PFC-67 E12-14 MANDATORY Supervised Visit and/or Supervised Exchanges Site Visit/ Quality Control Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com