Form Dss-1515 - Foster Home Fire Inspection Report North Carolina Division Of Social Services
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1FOSTER HOME FIRE INSPECTION REPORT
NORTH CAROLINA DIVISION OF SOCIAL SERVICES
NAME OF FOSTER HOME_________________________________
PERSON IN CHARGE____________________
STREET ADDRESS_______________________________________ PHONE #______________________________
Foster Parent’s signature on this form indicates that he/she understands that any item marked NO on this form will result in non-
approval of the home until the items in question are brought into compliance with licensing regulations.
DOCUMENT THE APPROPRIATE ANSWERS AS TO THE
YES
NO
N/A
CONDITIONS IN THE HOME RELATING TO THE INSPECTION
1
Are Underwriters Laboratory (UL) extension cords used only for portable appliances and not
substituted for permanent wiring?
(Check N/A if the occupant does not use extension cords for permanent wiring.)
2
Is a Carbon Monoxide (CO) detector installed in homes that use fuel oil products, coal, wood
or gas to heat, cool, cook, operate a hot water heater or gas logs?
3
Is a working, mounted “ABC” fire extinguisher(s), with a rating not less than 1-A installed and
readily available in the residence?
4
Do emergency telephone numbers and a fire evacuation plan remain posted continually
in a prominent location, and are they visible to all residents and guests?
5
Does the home have a working telephone?
6
Are there working smoke alarms in the residence that comply with the appropriate rule?
CHECK ONE OF THE FOLLOWING
• Houses built prior to 1976: must have a battery or electric smoke alarm installed outside
every sleeping area.
• Houses built 1976 – June 30, 1999: electric smoke alarms shall be placed outside sleeping
areas as required by the code in effect at construction time.
• Houses built after June 30, 1999: must have smoke alarms in every sleeping room, outside
bedrooms and other areas, interconnected as required in the N.C. Building code.
• Manufactured homes are in compliance with HUD requirements Subpart C – 3280.208 at the
time the foster home was initially licensed. HUD requirements can be found at:
( ) or by
contacting the NC Office of State Fire Marshal at (919) 661-5880 and requesting to speak to
someone in the Manufactured Building Section.
7
Are all hallways, doorways, entrances, ramps, steps, and corridors unobstructed, free of
storage, and readily accessible?
8
Do doors and windows in rooms used for sleeping open properly with little effort?
9
Are all designated egress (exit) doors free of double key dead bolt locks?
10
Designate Primary heat source:______________________________________________
Designate Secondary heat source (if applicable):________________________________
11
List any substandard components or hazards found which are not addressed above or which
require additional inspections.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
INSPECTOR’S SIGNATURE / TITLE__________________________________ DATE OF INSPECTION__________________
PRINT NAME OF INSPECTOR_____________________________________ INSPECTOR’S PHONE#____________________
FOSTER PARENT’S SIGNATURE__________________________________________________DATE_____________________
DSS-1515 (Rev. 04/14)
Child Welfare Section
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