Form Soc 157b - Silp Inspection - Checklist Of Facility Health And Safety Standards

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SILP Inspection: Checklist of Facility Health and Safety Standards
Name:
SLIP Address:
City:
State:
Zip Code:
Section A: SILP Placement Type
EXEMPT Housing - university/college housing, Job Corps., AmeriCorps, California Conservation Corps, (w/onsite housing);
adult residential treatment facility; sober living facility.
Tribal SILPS - SILPs on or near a reservation approved by the tribal placing agency. For areas that are exempted for tribal
housing, circle “Tribal waiver” in the waiver column.
Apartment, House, Condo, Single Room Occupancy (SRO), room rental, room & board situation.
(CONTINUE to Section B).
Does NMD have a child(ren) living with them?
Yes
No
MAINTENANCE
Section B: SAFETY CHECKLIST
YES
NO
WAIVER
NEEDED
1.
Bedroom/sleeping area: Bedroom/sleeping area used by the young
adult has at least one exit that ensures safe, direct emergency exit to
the outside. If security bars are installed on a window, the window is
considered operable only if equipped with a safety release device. Only
one window has to have a release.
2.
Sleeping arrangements for child(ren) are safe (free from obstructions and
other hazards, crib side locks in place and bottom of crib is at correct
height for child’s age and size).
3.
Sleeping room is not a kitchen or bathroom. There are no more than four
adults sleeping in the room and there is a clear and direct path for each
adult to exit the room in case of emergency and adequate storage for
each adult’s clothing and personal items.
4.
Home has functioning, commercially manufactured carbon monoxide
TRIBAL
detectors and smoke detectors (or functioning, commercially
WAIVER
manufactured indoor sprinkling system) installed in all hallways in the
ONLY
NMD’s sleeping area.
TRIBAL
5.
Bathroom: NMD has access to a bathroom that contains a toilet, sink and
WAIVER
tub or shower maintained in a safe, operating condition free from health
ONLY
hazards (e.g. mold, sewage back-ups).
6.
Kitchen: the NMD has an area to prepare meals; appliances are safe and
TRIBAL
operational; there is adequate storage for food; and there are no apparent
WAIVER
OR SRO
health hazards. NOTE: SROs are not required to have kitchens.
7.
Indoor and outdoor halls, stairs, ramps, porches and decks are free from
obstructions and no structural damage that poses a safety hazard is
observed.
8.
Lighting and outlets are provided in rooms used by the NMD and no
TRIBAL
WAIVER
observable electrical hazards are present.
ONLY
9.
Waste is stored, located and disposed of in a manner that will not
permit the transmission of communicable disease, strong odors, create
a nuisance or provide a breeding place or food source for insects or
rodents.
10.
Home has adequate ventilation.
11.
Home has a safe and functioning heat source that can be used to keep
the home at a safe and comfortable temperature. The heating source
TRIBAL
can be a space heater if it has proper safety features (automatic shut-off
WAIVER
if tipped over, screen fully covering the heating element), is used in a
ONLY
safe manner (nothing draped over it and or sticking into it, etc.) and can
provide enough heat to maintain a comfortable temperature in the room.
12.
Other.
SOC 157B (7/17)
PAGE 1 OF 2

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