CONFIDENTIAL INFORMATION

07/25/2022
EARLY START IFSP IFSP Meeting Date ____________
07/25/2022
(Initial IFSP________ͺ____) ✔ Initial † Annual
†
07/25/2022
Individualized Family Service Plan Transition process discussed ____ͺ________
1/31/2023
____ͺ________
Projected 6 month Review
✔ Inland Regional Center (IRC)
† 07/31/2023
Projected Annual Review ____ͺ____ͺ___
† Local Ed. Agency (LEA):_____________________________ Projected Transition Plan 07/31/2023
____ͺ________
Corona-Norco Unified School District
District of Residence:__________________________________ Projected 3 yr. Placement 3/7/2024
____ͺ________

Hernandez-Perez, Uriel
Child’s Name:________________________________________ ✔ ELIGIBLE
† † NOT ELIGIBLE

8416399
UCI #_______________________ ✔ 03/07/2021
† Male † Female DOB___________________Chron. 16m 18d
Age.___________Adj. 15m 17d
Age____________
Elsa Douville, M.A.
Service Coordinator_________________________________________________________ † Received School academic calendar
† Established Risk____________________________________________ † Solely Low Incidence_________________________________________
† High Risk (factors)______________________________________________________________________________________________________
CA Developmental Delay: † Cognitive † Communication † Fine Motor † Gross Motor † Social/Emotional † Adaptive/Self-Help
AA Developmental Delay: † Cognitive ✔
† Communication ✔
† Fine Motor † Gross Motor ✔
† Social/Emotional † Adaptive/Self-Help

Guadalupe Perez Alfonso Hernandez

Parent(s) or Guardian_________________________________________________________________________________________
923 W. 5th St. Apt. 17 Corona, CA 92882 0DLOLQJ
Address____________________________________________________________________________________________________
(List both Street & Mailing Address if different)

951-254-6411
Phone_______________________ guadalupeperez_85@hotmail.com
/_______________________ /_____________________________________________________
(Primary) (Secondary) (E-Mail)
Latino
Ethnicity: _______________________________________ Home Language: † English ✔ † Spanish † Other_______________________
Interpreter Requested: † Yes ✔ † No Written Translation Requested: † Yes ✔ † No

FAMILY APPROVAL / IFSP PARTICIPANTS

† I/We consent to the evaluation & assessment, and ✔
✔ † the development of this Individualized Family Service Plan (IFSP).
07/25/2022
_________________________________________________________________________________________________________
Parent/Guardian Signature(s) Date
*****************************************************************************************************************************************************************************************************
✔
† _____ I/We have had an opportunity to participate in the development of this IFSP
✔
† _____ I/We have received/will receive* a copy of this IFSP at no charge. *IFSP will be sent († mail ✔
† e-mail) within 15 days.
✔
† _____ I/We DO agree to implement the attached outcomes and Consent to the services in this IFSP.
✔
† _____
_ I/We have been informed of our rights and received a copy of the Parent’s Rights and Procedural Safeguards.
✔
† _____ Early Start Family Resource Network services discussed. Consent for referral † Yes ✔ † Not at this time.
† _____ I/We DO NOT agree with this entire plan and withhold my/our consent for:______________________________________
07/25/2022
_________________________________________________________________________________________________________
Parent/Guardian Signature(s) Date
****************************************************************************************************************************************************************************************************
† _____ I/We understand that my child Does Not Qualify for † IRC ES services † School/LEA ES services at this time.
† _____ I/We have received a copy of the Early Start Complaint process, Mediation conference request and Due Process Hearing request.
_________________________________________________________________________________________________________
Parent/Guardian Signature(s) Date

Summary of Services (see IFSP for service details)

Service Type Frequency/Duration/Intensity Provider Start Date
Specialized Instruction 60 0LQKU[
1 week 1 Young Interventions 07/25/2022
0LQKU[ 
0LQKU[ 
0LQKU[ 

OTHER IFSP TEAM PARTICIPANTS

NAME / SIGNATURE AGENCY / PHONE Present Phone Consult Report
Elsa Douville, M.A. IRC ISC 909-890-4744 † ✔
† † †
Diana Gallegos, B.A. Stars Therapy † † ✔
† ✔
†
Melissa Cruz, OTR/L, SICP Stars Therapy † † ✔
† ✔
†
IFSP-01 (2015)
 CHILD’S FAMILY AND MEDICAL INFORMATION
Hernandez-Perez, Uriel 8416399 07/25/2022
CHILD’S NAME_________________________________________UCI#___________________________DATE_________________
✔ I/We have provided the following information voluntarily
†
CHILD’S STRENGTHS
FAMILY CONCERNS AND PRIORITIES
Concerns: Nothing at the moment. Eating, sleeping, and playing.

Priorities: Communicate more.

CHILD’S WEEKLY ROUTINE NEEDS / RECOMMENDATIONS

Wakes up, play, breakfast, play, bath, nap, lunch, play,
Specialized Instruction for parent training to facilitate his
walk outside, dinner, bedtime.
development and to acquire new skills in all developmental
areas.

CURRENT FAMILY RESOURCES REFERRALS

† Insurance_______________ † Dental__________________ † SSI † IHSS † SART † IRC Psych
† Medi-Cal ✔
✔ † IEHP † Molina ✔
† WIC † CCS † WIC † CHDP † Dental Hygienist † IRC OT/PT Cl.
✔
† Family Support † DCFS † IRC † LEA † CPS † CCS Medical † Dentist † IRC Nutr.
† SSI______ † TANF____ † Food Stamps____________ † TANF † CCS Therapy † Tots and Toys † (6)51
Other______
Young Interventions
† Infant program_______________________________________ † EPSDT † Early Head Start † Genetic † Other______
† Other______________________________________________

CHILD’S PRESENT HEALTH AND MEDICAL INFORMATION

VISION Pass
Results:_______________________
07/05/2022 Dr. Rosalie De Guzman
Date evaluated______________By:______________________________________________ Informal screeing
______________________________
Name of Evaluator & Discipline ______________________________
Tool (s) Used: † First Look † Vision Exam † Other____________________________ ✔ See attached † Records to be requested
†

HEARING Pass
Results:_______________________
07/05/2022. Dr. Rosalie De Guzman
Date evaluated______________By:______________________________________________ Informal Screeing.
______________________________
Name of Evaluator & Discipline ______________________________
Tool (s) Used: † Music to My Ears † BAER/ABR † Sound field † Other_____________________ ✔
† See attached † Records to be requested

CURRENT MEDICAL CONDITION / DIAGNOSIS / HEALTH HISTORY / PHYSICIANS

(Medical records: † reviewed † to be requested) +W 30" :W 25.5 lbs +&
Parent reports during her pregnancy the medical concerns were diabetes and being hospitalized for one month due to
COVID. Parent reports her labor was induced due to water breaking and no contractions. Uriel was born via induced
vaginal delivery. He was born 35 weeks premature, he weighed 5 lbs 10.3 oz. He was in NICU for 2 weeks prematurity,
hypoglycemia, feeding (ng tube) and jaundice (photo therapy). At 9 months of age he developed anemia which was
treated with over the counter iron. There are no current concerns with anemia. Parent reports he had 1 month of
coughing and sneezing, the pediatrician prescribe medication and inhaler/nebulizer. He drinks from a baby bottle,
sipper cup and he uses a spoon and finger to self feed. Parent reports no feeding difficulties.

3HGLDWULFLDQ Rosalie A. De Guzman 3KRQH 951-270-0067 /9 )8

'LHW Table Food and Milk. $OOHUJLHV Unknown Allergy

DENTAL: Parent brushes his teeth.
✔ ✔ Oral hygiene discussed † Dental handout/pamphlet given
† Parent cleans/brushes child’s teeth †
CURRENT MEDICATIONS / PROCEDURES / ADAPTIVE DEVICES
Medications: Albuterol HFA 90 mcg inhaler every 4-6 hours.
Adaptive Devices: Nebulizer
No Procedures.

IMMUNIZATIONS: † Current † Not Current __________________ † Record reviewed † Record to be requested

IFSP-02 (2013)
 CHILD’S PRESENT LEVELS OF DEVELOPMENT
Hernandez-Perez, Uriel 8416399 07/25/2022
CHILD’S NAME_________________________________________UCI#___________________________DATE_________________

16m 18d
C.A.____________A.A.____________15m 17d Location: † Home † Regional Center † School † Telehealth
✔ Other_________________
COVID Precaution 11
GHOD\DWPR
Location Justification (if not natural environment)______________________________________________________________
07/08/2022 07/08/2022 Diana Gallegos, B.A. Melissa Cruz, OTR/L, SICP
Date(s) evaluated/assessed___________________Evaluators_____________________________________________
Tool(s) Used: † Michigan † Bayley _______________________ † REEL † PLS † ✔ ✔ DAY-C † Hawaii
✔ M-CHAT
† † Denver II † ✔ Peabody Dev. Motor Scales † ELAP † DRDP † ✔ Teacher observation
✔ Parent report
† ✔ Review of records
† † Informed Clinical Opinion † Other_____________________________

SOCIAL / EMOTIONAL Age Level 9 months

Shows preference for certain toys, activities, or places
Expresses affection

Plays simple games

RS 18, SS 78

ADAPTIVE / SELF-HELP Age Level 13 months

Sleeps through the night; may take one nap during the day
Drinks from open cup or glass held by adult
Sips liquid from glass or cup using a straw

RS 20, SS 87

FINE MOTOR Age Level 9 months

Picks up a small object using thumb and forefinger
Pokes with index finger
Turns pages in book; may be thick pages

RS 14, SS 87

COGNITIVE Age Level 13 months

Hands an object to an adult to have that person repeat or start a desired action
Attempts to start toy if he or she has seen someone else make it work
Places a small object into small container
RS 25, SS 89

COMMUNICATION Age Level

(E) laughs out loud 5((/,,,
23
 ([SUHVVLYH5DZ$JH 7 PR
(E) uses word for parent or caregiver discriminately  5HFHSWLYH5DZ$JH
28 8 PR

(R) briefly stops activity when name is called RS 7, SS 71, 6 months

Expressive_______________

(R) responds with appropriate gestures to "up", "bye-bye", or other routines RS 8, SS 67, 8 months
Receptive________________

GROSS MOTOR Age Level 16 months

Climbs low play equipment

Runs at least 10 ft without falling

Throws a ball overhand with relative accuracy
RS 35, SS 97

IFSP-03 (2013)
 CHILD’S OUTCOMES
Hernandez-Perez, Uriel 8416399 07/25/2022
CHILD’S NAME_________________________________________UCI#___________________________DATE_________________

1
# _______ OUTCOME: Timeline for achieving outcome:
Uriel will use three or more two-word phrases when asking for food, toys or 07/25/2022
Begin Date:______________________
other objects 3-4 times a day with his family.

7/31/2023
Target Date:______________________

CRITERIA FOR PROGRESS: PROCEDURE FOR MEASUREMENT

- has a word, sound, or sign for "drink." ✔ Developmental Testing
†
- says one word that conveys entire thought; meaning depends context (e.g † Clinical Opinion
"cookie" may mean "wants more" or "the cookie fell"). ✔ Parent Observation/report
†
- uses 10- 15 words spontaneously. ✔ Teacher Observation/report
†
- points to three body parts when asked. ✔ Data Collection/Review of records
†
- carries out two-step directions that are related (e.g. "Go to the table and bring
✔ IFSP team will review outcomes &
†
me the toy.")
- points to six body parts when asked. progress, eligibility & service needs
at least semi-annually

# _______ OUTCOME: Timeline for achieving outcome:

Begin Date:______________________

Target Date:______________________

CRITERIA FOR PROGRESS: PROCEDURE FOR MEASUREMENT

† Developmental Testing
† Clinical Opinion
† Parent Observation/report
† Teacher Observation/report
† Data Collection/Review of records
† IFSP team will review outcomes &
progress, eligibility & service needs
at least semi-annually

# _______ OUTCOME: Timeline for achieving outcome:

Begin Date:______________________

Target Date:______________________

CRITERIA FOR PROGRESS: PROCEDURE FOR MEASUREMENT

† Developmental Testing
† Clinical Opinion
† Parent Observation/report
† Teacher Observation/report
† Data Collection/Review of records
† IFSP team will review outcomes &
progress, eligibility & service needs
at least semi-annually

IFSP-04 (2015)
 IFSP SERVICES
Hernandez-Perez, Uriel 8416399 07/25/2022
CHILD’S NAME_________________________________________UCI#___________________________DATE_________________

SERVICE Specialized Instruction

MEETS OUTCOMES 1
SERVICE TYPE ✔
† Required † Non-Required
FUNDING AGENCY ✔
† IRC † Private Insurance
† LEA † Generic:_________________________________________
SERVICE LOCATION ✔
† Home † Center-based
† Community † Other___________________________________________
LOCATION JUSTIFICATION
(if not natural environment)
FREQUENCY/INTENSITY/DURATION 60
As part of __________ 1
minutes / hour session(s) / __________ week
time(s) per ______________
† Per School Program Calendar 1
1:______ 07/25/2022
Begin Date:_________________ 7/31/2023
End Date:__________________
PROVIDER Young Interventions

SERVICE
MEETS OUTCOMES
SERVICE TYPE † Required † Non-Required
FUNDING AGENCY † IRC (Co-payments) † Private Insurance
† LEA † Generic:_________________________________________
SERVICE LOCATION † Home † Center-based
† Community † Other___________________________________________
LOCATION JUSTIFICATION
(if not natural environment)
FREQUENCY/INTENSITY/DURATION As part of __________ minutes / hour session(s) / __________ time(s) per ______________
† Per School Program Calendar 1:______ Begin Date:_________________ End Date:__________________
PROVIDER

SERVICE
MEETS OUTCOMES
SERVICE TYPE † Required † Non-Required
FUNDING AGENCY † IRC † Private Insurance
† LEA † Generic:_________________________________________
SERVICE LOCATION † Home † Center-based
† Community † Other___________________________________________
LOCATION JUSTIFICATION
(if not natural environment)
FREQUENCY/INTENSITY/DURATION As part of __________ minutes / hour session(s) / __________ time(s) per ______________
† Per School Program Calendar 1:______ Begin Date:_________________ End Date:__________________
PROVIDER

SERVICE
MEETS OUTCOMES
SERVICE TYPE † Required † Non-Required
FUNDING AGENCY † IRC † Private Insurance
† LEA † Generic:_________________________________________
SERVICE LOCATION † Home † Center-based
† Community † Other___________________________________________
LOCATION JUSTIFICATION
(if not natural environment)
FREQUENCY/INTENSITY/DURATION As part of __________ minutes / hour session(s) / __________ time(s) per ______________
† Per School Program Calendar 1:______ Begin Date:_________________ End Date:__________________
PROVIDER
IFSP-04a (2015)
 CONFIDENTIAL CONSUMER INFORMATION
Inland Counties Regional Center
See California Welfare & Institutions
Code, Section 4514

NAME: Hernandez-Perez, Uriel

UCI#: 8416399

DOB: 03/07/2021

REEL-3
Receptive-Expressive Emergent Language Test-Third Edition

Date of Test: 07/08/2022

Chronological Age: 16 m 1 d Adjusted Age: 15m 0d

Raw Age Ability %ile

Score Equivalent Score Rank
Receptive Language
28 8 70 2%

Expressive Language
23 7 68 1%

Sum of Receptive and Expressive Ability Scores

138

Language Ability Score 63

Descriptive Rating: REEL-3 Ability Score

Very Superior >130
Superior 121-130
Above Average 111-120
Average 90-110
Below Average 80-89
Poor 70-79
✔ Very Poor <70

Comments: __________________________________________________________________________
RECEPTIVE: Guadalupe shared that Uriel listens to conversations around him, enjoys
____________________________________________________________________________________
hearing words that name objects, sometimes obeys simple commands, and responds to
____________________________________________________________________________________
"Where" questions by looking for the person or object named.
____________________________________________________________________________________
EXPRESSIVE: Guadalupe shared that Uriel makes sounds as if singing along with
____________________________________________________________________________________
songs. He playfully babbles a limited number of vowels and consonants. Except when he
becomes upset, he more often makes contented sounds and expressions.

Melissa Cruz, OTR/L, SICP

_______________________________________
Infant Services Coordinator, Early Start Program
Stars Therapy

ICRC 583 (9-26-13)

 INLAND REGIONAL CENTER
EARLY START PROGRAM
…Promoting Developmental Progress



 





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u Parents’ Rights: An Early Start Guide for Families u
Confidentiality & Access to Records
E arly Start records are an important source of information about your child. The
information you provide to the regional center or local education agency (LEA) about your
child and your family is confidential. Such information will only be shared with authorized
persons involved in your child’s services.
As a parent,* you have the right to
1. access records, including the right to have you or your representative examine and obtain
copies of records relating to your child; You may request that any regional center or LEA
amend or remove information relating to your child from the records. [CFR 303.402, CCR
52164, CCR 52168]
Evaluation & Assessment
T he determination of eligibility for Early Start in California includes a timely,
comprehensive, multidisciplinary evaluation and assessment of every child under age
three years who is suspected to be in need of early intervention services. If no parent or guard-
ian is available or the child is a ward of the court, a knowledgeable surrogate parent who has no
conflicting interest will be appointed. Procedural safeguards ensure that families are provided
their rights under the law. [CFR 303.322, CFR 303.406, CCR 52082]
As a parent, you have the right to
1. be fully informed of your rights under Early Start;
[CFR 303.403, GC 95020(c), CCR 52160, CCR 52161]
2. refer your child for evaluation and assessment, provide information throughout the pro-
cess, make decisions, and give informed consent for your child’s early intervention services;
[CFR 303.401, CFR 303.404, CCR 52040(d)]
3. understand and provide voluntary written permission or refusal before the initial evalua-
tion and assessments are administered; [CFR 303.405, CCR 52162]
4. participate in the initial evaluation and assessment process including eligibility determina-
tion; [CFR 303.322, GC 95020, CCR 52082, CCR 52084]
5. receive a completed initial evaluation and assessment within 45 days after the referral of
your child to a regional center or an LEA; [CFR 303.321, CFR 303.322, CCR 52086]
6. participate in a meeting to share the results of evaluations and assessments; and
[GC 95020(b)]
7. participate in all decisions regarding eligibility and services.
[CFR 303.343, GC 95014(a), GC 95020(b), CCR 52082(a), CCR 52104]
Individualized Family Service Plan
A n individualized family service plan (IFSP) is a written plan for providing early
intervention services to an eligible child and the child’s family. For an infant or toddler
who has been evaluated for the first time, a meeting must take place within 45 days of the refer-
ral to the regional center or LEA to share the results of the evaluation, to determine eligibility,
and, for children who are eligible, to develop the initial IFSP. Evaluation results and determina-
tion of eligibility may be shared with families prior to the first IFSP meeting. [CFR 303.340, CFR
303.342, GC 95020(b), CCR 52100, CCR 52102]
A periodic review of your child’s IFSP must take place at least every six months. A review may
occur more frequently if there are any changes to the IFSP or if you request a periodic review
with the regional center or LEA. The IFSP must also be reviewed annually to evaluate how your
child is doing and to make any needed changes to the IFSP. [CFR 303.342, CCR 52102]
During the development and implementation of an IFSP, you have the right as the parent
2. receive, within five days of your request, copies of records relating to your child and/or
explanations that you request; [CCR 52164]
3. request a meeting with the director of the regional center or the superintendent
of the LEA about information contained in the record; and [CCR 52168]
4. have personally identifiable information about your child maintained in a confidential
manner and have its sources, access, uses, and policies for location, storage, disclosure,
retention, and destruction explained to you per the Family Education Rights and Privacy
Act. [CFR 303.401, CFR 303.460, CCR 52160, CCR 52162, CCR 52165, CCR 52169]
* Refer to CCR 52000(b)(36) for definition of parent.
The Individuals with Disabilities Education Act (IDEA) requires
the following:
1. Evaluation and assessment materials are administered in the language of the parents’
choice or other mode of communication, unless it is clearly not feasible
to do so. [CFR 303.323, CCR 52084]
2. Evaluation and assessment procedures and materials are selected and administered so as
not to be racially or culturally discriminatory. [CFR 303.323, CCR 52082]
3. Evaluation and assessment materials are appropriate to assess the specific areas of devel-
opmental need and are used for the specific purposes for which they were designed. [CFR
303.322, CCR 52082]
4. Evaluations and assessments are conducted by qualified personnel. [CFR 303.322,
CCR 52082, CCR 52084]
5. Evaluations and assessments administered to children with known vision, hearing,
orthopedic, or communication impairments are selected to accurately reflect the child’s
developmental level. [CFR 303.322, CCR 52082]
6. Evaluations and assessments are administered in the five developmental areas, which
include physical development (motor abilities, vision, hearing, and health status); com-
munication development; cognitive development; adaptive development; and social or
emotional development. Assessments and evaluations are ongoing while your child is in
Early Start. [CFR 303.322, CCR 52082, CCR 52084, CCR 52102]
7. Evaluations and assessments shall be conducted in natural environments whenever pos-
sible. [CCR 52082(i), CCR 52084(e)]
8. Pertinent records relating to your child’s health status and medical history are reviewed.
[CFR 303.322, CCR 52082]
9. No single procedure is used as the sole criterion for determining your child’s eligibility for
early intervention services. [CFR 303.323, CCR 52082]
10. Interviews to identify family resources, priorities, and concerns regarding the development
of your child and your family’s needs are voluntary. [CFR 303.322,
CCR 52084, CCR 52106]
6. give consent to services listed on the IFSP. If you do not give consent to a service, it
will not be provided. You may withdraw consent after initially accepting or receiving a
service; [CFR 303.342, CFR 303.404, CFR 303.405, CCR 52102]
7. have services provided in the natural environment or an explanation of why that
is not possible; [CFR 303.12, CFR 303.344, CCR 52106]
8. exchange information about your child among other agencies; [CFR 303.460, CCR 52112, CCR
52169]
9. be notified in writing before any agency or service provider proposes or refuses
to initiate or change your child’s identification, evaluation, assessment, placement, or the
provision of appropriate early intervention services to your child or your family.
[CFR 303.403, CCR 52161]
The notice must contain:
to s THEACTIONTHATISPROPOSEDORREFUSED
s REASONSFORTHEACTIONAND
1. attend the IFSP meetings and participate in developing the IFSP; [CFR 303.343, CCR 52104] s ALLAVAILABLEPROCEDURALSAFEGUARDS
2. invite other family members to attend IFSP meetings; [CFR 303.343, CCR 52104]
The notice must be presented in the language of your choice, unless it is clearly not feasible to
3. invite an advocate or persons other than family members to attend and do so, and may be translated so that you understand its contents.
participate in the IFSP meetings; [CFR 303.343, CCR 52104] [CFR 303.400 to 303.460, CCR 52161]
4. have a copy of the complete IFSP; [CFR 303.402, CCR 52102]
5. have the contents of the IFSP fully explained in the language of your choice; [CFR 303.342,
CFR 303.403, CCR 52102]

© 2009 Department of Developmental Services www.dds.ca.gov/earlystart Ϯ

 PA R E N T S ’ R I G H T S : A N E A R LY S T A R T G U I D E F O R FA M I L I E S
Mediation Conferences, Due Process Hearings, and State Complaints
I n Early Start, parents have rights and protections to assure that early intervention
services are provided to their children in a manner appropriate to their needs, in consid-
eration of family concerns, and in compliance with applicable federal and State statutes and
regulations. The following procedures are only for children under the age of three years. [CFR
303.422, CCR 52170, CCR 52172, CCR 52173, CCR 52174]
As a parent, you have the right to
1. request a mediation conference and/or a due process hearing any time a regional center
or LEA proposes or refuses to initiate or change the identification, evaluation, assessment,
placement, and/or provision of appropriate early intervention service(s); [CFR 303.419, CFR
303.420, CCR 52172]
2. be informed of your right to file a complaint or a request for mediation or due process; [CFR
303.510, CCR 52170]
3. file a complaint if you believe there has been a violation of any federal or state statute or
regulation governing early intervention services under Early Start including eligibility and
services; and [CFR 303.511, CCR 52170]
4. request a mediation conference immediately, prior to a complaint or due process hearing
request, or at any time during the complaint/due process hearing processes to resolve a
dispute related to any matter concerning federal or state statute or regulation governing early
intervention services under Early Start [CCR 52170(b)]; and
5. file a complaint if a due process decision fails to be implemented. [CCR 52170(b)]
MEDIATION CONFERENCES
Mediation is a flexible, non-binding, confidential process in which a neutral mediator facilitates
settlement negotiations between you and another party. Voluntary impartial mediation confer-
ences are a more informal way to resolve disagreements with early intervention service agencies
or to address alleged violations of any state and federal statutes or regulations. Mediation is
voluntary [CFR 303.419, CCR 52173].
As a parent you have the right to
1. file a request for mediation as the initial option for resolving a dispute or any time during the
due process hearing or complaint process [CFR 303.419, CCR 52173];
2. request a due process hearing or file a state complaint if the disagreement is not resolved
[CCR 52173];
3. refuse to participate in mediation [CFR 303.419, CCR 52173];
4. have an impartial person facilitate the mediation conference [CFR 303.419, CCR 52173(c)];
5. require that the mediation conference is carried out at a time and in a location that is reason-
ably convenient for you [CFR 303.419, CCR 52173];
6. have all personally identifiable information maintained in a confidential manner [CFR
303.419(b), CCR 52173(g)]; and
7. receive a written document outlining the agreements reached as a result of the mediation
conference [CFR 303.419, CCR 52173(i)].
Requests for mediation are filed with the:
Office of Administrative Hearings
Attention: Early Start Intervention Section
2349 Gateway Oaks Drive, Suite 2000, Sacramento, CA 95833
(916) 263-0654 Fax: (916) 376-6318
[CCR 52173]
DUE PROCESS HEARINGS
All parents are encouraged to resolve differences at the lowest administrative level possible.
When differences between you and a regional center or LEA cannot be resolved, due process
hearings are available. You, as a parent, are encouraged to seek assistance from your child’s
service coordinator, the regional center, or the Special Education Local Plan Area (SELPA) office.
[CFR 303.420, CCR 52172]
Circumstances leading to a due process hearing may be disagreements related to a proposal or
refusal for identification, evaluation, assessment, placement, or services. [CCR 52172(a)]
Your child will continue to receive the early intervention services identified on the IFSP that
he/she is currently receiving unless you and the regional center or LEA otherwise agree to a
change. If your disagreement involves a new service that has not started, your child will receive
all services identified on the IFSP that are not in dispute. This does not include your regional
center providing early intervention services after your child has reached 36 months of age, as
federal law and regulations do not allow states to pay for early intervention services under any
circumstances once your child transitions from Early Start. The program or programs your
child enrolls in subsequent to transition from Early Start is responsible for providing you and
your child services for which he or she is eligible to receive. [CCR 52172(g)]
Requests for a due process hearing are filed with the Office of Administrative Hearings at the
following address:* [CFR 303.420, CCR 52172]
Office of Administrative Hearings
Attention: Early Start Intervention Section
2349 Gateway Oaks Drive, Suite 200, Sacramento, CA 95833
(916) 263-0654 Fax: (916) 376-6318
[CCR 52172]
*The due process hearing request form may be obtained from your service coordinator, the
regional center, the LEA, and DDS website: www.dds.ca.gov/Forms/pdf/DS1802.pdf
© 2009 Department of Developmental Services
The due process hearing must be completed within 30 days of receipt of the request by the Of-
fice of Administrative Hearings. The timely issuance of the written decision may not be delayed
by any concurrent voluntary local efforts to resolve the matter. The decision will be final unless
appealed. [CFR 303.425, CCR 52172(e)]
STATE COMPLAINTS
Any individual or organization may file a signed, written complaint against the Department of
Developmental Services (DDS), the California Department of Education (CDE), or any regional
center, LEA, or private service provider that receives Part C funds alleging violations of State or
federal early intervention statute or regulation. The complaint process can also address rem-
edies for denial of eligibility or appropriate services. However, even though DDS is mandated
to investigate any complaint it receives, state law does not allow disclosure of the Early Start
recipient’s personally identifiable information without written parental consent, other than
authorized employees specified by the regional center or LEA [CFR 303.510, CCR 52170(a)].
Information or assistance in filing complaints is available from your child’s service coordinator,
the regional center office, or the special education local plan area (SELPA). DDS and CDE are
available for consultation regarding the filing of a complaint. Additional assistance is available
from advocacy organizations such as the State Council on Developmental Disabilities or Dis-
abilities Rights California. As efforts to resolve the matter at the local level are undertaken, a
complaint may be filed concurrently with a request for a mediation conference or due process
hearing. [CFR 303.423, CCR 52170]
Complaints are filed directly with the
Department of Developmental Services
Office of Human Rights and Advocacy Services
Attention: Early Start Complaint Unit
1600 9th Street, Room 240, MS 2-15
Sacramento, CA 95814
(916) 654-1888 Fax (916) 651-8210
[CCR 52170(e)]
Any individual or organization who files a complaint has the right to
[CCR 52170]
1. receive assistance in filing the complaint from the service coordinator, regional center, or
LEA; [CCR 52170]
2. not be compelled to use any other procedures under the Education Code or the Lanterman
Developmental Disabilities Services Act to resolve the complaint; [GC 95007, CCR 52170]
3. submit additional information to DDS that may be helpful to the investigation;
[CCR 52170]
4. receive a final written decision within 60 days of the date DDS receives the complaint; [CCR
52170]
5. receive appropriate remedies that may include monetary reimbursement or other corrective
action, and assurance that services will be provided appropriately in the future if the deci-
sion of DDS includes remedies for denial of appropriate services; [CCR 52170]
6. have any issue in a complaint that is not part of a due process hearing be resolved by DDS
within 60 days of the receipt of the complaint; [CFR 303.512(c), CCR 52171(c)]
7. be notified by DDS that the hearing decision is binding if an issue is being raised in a com-
plaint that had previously been decided in a due process hearing involving the same parties;
and [CCR 52170]
8. have any complaint resolved that alleges the failure of a public agency or private service
provider to implement a due process decision. [CCR 52170]
The complaint must
1. be in writing and contain a signed statement alleging that DDS, CDE, the regional center,
LEA, or other service provider involved with Early Start has violated a federal or State law or
regulation; [CCR 52170(a)]
2. provide the name, address, and phone number of the complainant; [CCR 52170(f)]
3. contain a statement of facts upon which the violation is based; [CCR 52170(f)]
4. include the name of the party responsible against whom the complaint is being filed; [CCR
52170(f)]
5. have occured not more than one year before the date the complaint is received by DDS
unless a longer period is reasonable because the alleged violation continues for the child or
other children, or [CCR 52170(c)]
6. have occured not more than three years before the date on which the complaint is received
by DDS if the complainant is requesting reimbursement or corrective action as remediation
of the complaint [CCR 52170(c)]; and
7. the complaint may also include, if applicable, a description of the voluntary steps taken at
the local level to resolve the complaint. [CCR 52170]
8. be withdrawn if the complainant elects to participate in mediation within the 60-day
complaint investigation.
www.dds.ca.gov/earlystart
ϯ
 







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 FAQ’s – Copays, Coinsurance, Deductibles

Why am I being asked to utilize my child’s health insurance?

California Early Intervention Services Act (CEISA) Section 95004 indicates that direct services shall be
provided pursuant to the existing regional center system under the Lanterman Developmental Disabilities
Services Act, contained within the Welfare and Institutions Code (WIC) and 95004(b)(1) private health
insurance for medical services identified in the Individual Family Service Plan (IFSP), other than for evaluation
and assessment, shall be used. Many required early intervention services are considered medically necessary
by various private health insurances. Welfare and Institutions Code Section 4659(c) states that regional
centers shall not purchase any service that would otherwise be available from private insurance.

When should I begin to access health services for my child?

Immediately. You will need to inquire and access health services while the regional center is completing
evaluations and assessments to determine eligibility for Early Start. There may be duplication of assessments
between the regional center and your health plan in order to determine your child’s developmental needs. If
your child is eligible for Early Start, your service coordinator will review your health plan benefits and coverage
limitations at your initial Individual Family Service Plan (IFSP). The primary funding agency for each required
service will be determined and included in your IFSP.

Does the regional center assist with co-payments, co-insurance and deductibles?
Yes, as of July 1, 2019, regardless of income, a family is eligible for co-payments, co-insurance and
deductible reimbursement.7KHSURYLGHUPXVWEHYHQGRUHGZLWKWKH5HJLRQDO&HQWHULQRUGHURUGHUWRUHFHLYH
,5&IXQGLQJ ForBehavioral Services after age 3 under the Lanterman Act, income requirements below must
bemet in order to qualify for reimbursement.

Prior to July 1, 2019 for Early Start Service OR for ongoing Behavioral Health Service after age 3 under the
Lanterman Act:, families whose yearly gross income is below 400% of the federal poverty level (FPL) are
eligible to receive reimbursement for co-payments/co-insurance and deductibles when the service is provided
by an in network provider. Families whose yearly income is above 400% of FPL may be eligible for
reimbursement if criteria for exceptional circumstances are met: 1-The existence of an extraordinary event
that impacts the ability of the parent to meet the care and supervision needs of the child to help maintain the
child at home or in the least restrictive setting or impacts the ability of parent with a health care service plan or
health insurance policy, to pay the copay or coinsurance. 2-The existence of catastrophic loss that
temporarily limits the parent ability to pay the health care service plan or health insurance policy and creates
a direct economic impact on the family. Catastrophic loss may include, but not limited to, natural disasters
and accidents involving major injuries to an immediate family member. 3-Significant unreimbursed medical
costs associated with the care of the consumer or another child who is also a regional center consumer.

What information do I need to provide to my service coordinator?

1) Co-Payment/Co-Insurance/Deductible Assistance Request Letter (ICRC 946): This letter serves as a
request for assistance. You will need to indicate the specific copay assistance you are requesting,
including type of therapy, frequency and amount of assistance requested.


  6XPPDU\RI%HQHILWV62%: This is required if your child has private insurance and will be receiving
ongoing Occupational Therapy (OT), Physical Therapy (PT), or Speech Therapy (Speech). You can obtain
this from most insurance companies by calling your insurance company or by downloading it from their
website. AKA: ([SODQDWLRQRI&RYHUDJH(2&, Summary of Plan.

 Authorization of Services: This document will have the type, date and frequency of services that your
insurance has agreed to pay. We can only assist with copays if your insurance has approved the services.

 Signed IFSP Addendum: We will need your written consent in order to provide services.

What if I don’t want to submit my health insurance documentation?

Your health insurance information is required. Regional center may fund for early intervention services (OT, PT
and/or Speech) to offer your family the opportunity to provide the required information and access health
services. A Notice of Action (NOA) will be sent within 30 days of service end date if family chooses to not
pursue insurance coverage.

What is the difference between an 6XPPDU\RI%HQHILWV62% and Explanation of

Benefits (EOB)?

6XPPDU\RI%HQHILWV62% is a summary of all the benefits that are covered by your insurance company. It
documents the deductible amounts, copay/coinsurance, categories of coverage, and what is not covered and
it will show you the limits of coverage. This summary document will also show you what the family vs.
individual deductible is (you only need to meet the individual deductible for the early start eligible child). This
is not related to an actual visit to a doctor.

Explanation of Benefit (EOB) is a summary of the charges that have occurred from a visit to a doctor/health
care provider. It states the cost of the visit and the patient responsibility for the visit. A copy is mailed to you
and a copy to your doctor/health care provider. It may also be referred to as a Schedule of Benefits under
some health plans.

Who can I ask for help if I have questions about co-payments?

You can contact your service coordinator if you have questions about the provision of early start therapy
services or co-payments.

()$4VKHHWproduced ZLWKKHOSIURP NLARC ES Program) 

   
 








 


 







 





 

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1

Relationships MATTER!
YOU are the most
important person
in your child’s life!
That is why the
relationship between
you and your child is
an important focus
of early intervention.
Early Start services are
designed to empower
YOU so that you can
better address your
child’s unique needs.
Your service providers
will provide ideas and
support so that you can
help your child learn
the skills that YOU think
are most important!
TAKE A MINUTE...
Social and emotional development describes the ability
to experience and express feelings, form relationships,
and explore the world. Social and emotional development
is the foundation for all other learning and development
throughout life. This is true for all children, including those
with disabilities and delays. All families, with support, can
help their child learn how to make friends, show strong
emotions in healthy ways, and handle conflicts peacefully.
These are examples of social and emotional skills. Your
relationship with your child matters because positive
relationships change your child’s brain for the better.
Every single day, everywhere you are, positive parent/
child interactions help strengthen your bond, giving your
child what they need to learn and grow.
When your child feels
safe, secure, nurtured,
and loved, they grow
and learn!

We understand that parenting

is not always easy! Parents with
young children who have delays or
disabilities may need extra support.
Behavior, communication and physical Take a minute to play,
challenges can make parenting sing, read and laugh
especially difficult. Your Early Start with your child.
Team is here to help you! You can
strengthen the bond and connection
you have with your child every day,
during your daily routines. We will
help you learn how!

For more information on social and emotional development, watch

h this video at:
http://earlystartneighborhood.ning.com/ssip-resources/TaMvideo
TaMvideo
ϭϰ
 You and
Ideas and tips...
your child…

How do you know when Watch your child so that you can start to recognize their cues. They may use
your child is happy, sad, body movements, facial expressions, and sounds to show you how they feel.
frustrated, scared, or mad? Imagine how your child experiences things.

Validate your child’s feelings, and label them with simple words. For example,
How do you respond to your “I can see that you are frustrated because you cannot reach your toy.”
child’s feelings? If your child is happy, keep doing what you’re doing. If your child is upset, take
a moment to comfort them.

How do you help your baby
or young child learn to calm
down?
Remember to stay calm yourself. Try different ways to calm your child, such as
holding them, rocking them, getting them a special toy or blanket, singing, or
playing soothing music.
Think of healthy ways to handle feelings: take deep breaths, count to four,
blow bubbles, sing a song, or do a silly dance with your child. Ask if your child
wants a hug.

How do you show
your child that they are
important and loved?
Take time to connect with your child: smile, talk and listen to them, read, sing,
and play with them, enjoy a meal together.
Turn off electronics more often so that you can focus on your relationship with
your child.

How do you encourage the Keep in mind that if your child is tired, thirsty, hungry, or uncomfortable, they
behavior you want to see will not be on their best behavior. Take care of them before you try to teach
from your child? them a new behavior.

Do you have any concerns

or questions about your Talk to your Early Start Team. We are here to help!
child?

Remember

You are your child’s first teacher! Children learn the most from what other people do… especially you!
Give yourself a break when you are having a hard time remaining calm. Be sure your child is safe and
give yourself a minute to calm down. You might say “I need some time to think about how I can help
you.” Take care of your own emotional wellness. If you have stress, depression, or anxiety, it affects your
child. Get the help and support you need.

Was this resource helpful? Tell us here: www.surveymonkey.com/r/TaMFlyer

Developed with the support of the California Interagency Coordinating Council (ICC) on Early
Intervention and the Early Start Comprehensive System of Personnel Development. Early Start is
implemented by the Department of Developmental Services
ϭϱ
 You and
Ideas and tips...
your child…

How do you know when Watch your child so that you can start to recognize their cues. They may use
your child is happy, sad, body movements, facial expressions, and sounds to show you how they feel.
frustrated, scared, or mad? Imagine how your child experiences things.

Validate your child’s feelings, and label them with simple words. For example,
How do you respond to your “I can see that you are frustrated because you cannot reach your toy.”
child’s feelings? If your child is happy, keep doing what you’re doing. If your child is upset, take
a moment to comfort them.

How do you help your baby
or young child learn to calm
down?
Remember to stay calm yourself. Try different ways to calm your child, such as
holding them, rocking them, getting them a special toy or blanket, singing, or
playing soothing music.
Think of healthy ways to handle feelings: take deep breaths, count to four,
blow bubbles, sing a song, or do a silly dance with your child. Ask if your child
wants a hug.

How do you show
your child that they are
important and loved?
Take time to connect with your child: smile, talk and listen to them, read, sing,
and play with them, enjoy a meal together.
Turn off electronics more often so that you can focus on your relationship with
your child.

How do you encourage the Keep in mind that if your child is tired, thirsty, hungry, or uncomfortable, they
behavior you want to see will not be on their best behavior. Take care of them before you try to teach
from your child? them a new behavior.

Do you have any concerns

or questions about your Talk to your Early Start Team. We are here to help!
child?

Remember

You are your child’s first teacher! Children learn the most from what other people do… especially you!
Give yourself a break when you are having a hard time remaining calm. Be sure your child is safe and
give yourself a minute to calm down. You might say “I need some time to think about how I can help
you.” Take care of your own emotional wellness. If you have stress, depression, or anxiety, it affects your
child. Get the help and support you need.

Was this resource helpful? Tell us here: www.surveymonkey.com/r/TaMFlyer

Developed with the support of the California Interagency Coordinating Council (ICC) on Early
Intervention and the Early Start Comprehensive System of Personnel Development. Early Start is
implemented by the Department of Developmental Services