Form Lcr-1023a Forpd - Life-Safety Inspection Report
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3LCR-1023A FORPD (7-15)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
RSU ID.:
QC ID:
Office of Licensing, Certification, & Regulation (OLCR), 077F • P.O. Box 6123, Phoenix, AZ 85005 • (602) 771-4861
LIFE-SAFETY INSPECTION REPORT
Name:
Date:
Time:
Address:
New Application
Address Change
City:
Zip:
Renewal
Special Request
Telephone:
Licensing/Certification Agency:
Developmental Setting:
HCBS Certified
Respite
Day Program
Therapy
General Conditions & Cleanliness (R6-18-702):
YES NO
Inspector’s Comments
Date Corrected
1.
Interior & exterior in good repair and free of damage that poses a hazard. ................
2.
Play areas and therapy equipment are in good repair. ................................................
3.
Setting is clean to the degree that the condition does not constitute a hazard
4.
Garbage is removed from the setting & premises at least once each week .................
5.
The setting and outside play areas are free of insect and rodent infestation ...............
Safeguarding Hazards (R6-18-703)
1.
Setting has a system to lock highly toxic substances. .................................................
Setting has a system to safeguard cleaning supplies..................................................
2.
Specify system for safeguarding:
3.
Weapons are safeguarded ............................................
No weapons on premises
4.
Firearms are locked in an unbreakable container
No firearms on premises
5.
Firearms are trigger-locked or rendered inoperable
No firearms on premises
Number of firearms identified on the premises: ......................
6.
Ammunition is locked separate from firearms ........
No ammunition on premises
7.
Bathtubs/showers and ramps have slip resistant surfaces .........................................
8.
Handrails and grab-bars are securely attached and stationary .......................
NA
9.
Skirting is intact around the base of the setting, if a mobile home ................
NA
10. Animals do not pose a hazard due to behavior, disease, etc ..........................
NA
11. Evidence is available in the setting for each dog’s current rabies ..................
NA
Vaccinations:
Storage of Medication (R6-18-704):
1.
Prescription and over-the-counter medications in the setting are locked in a securely
fastened storage container ..........................................................................................
2.
Medications that must be readily available or may be accessed per an individual’s
case plan are safeguarded ................................................................................
NA
3.
Medications that must be refrigerated are locked, without preventing access to
refrigerated food ..............................................................................................
NA
Safe Appliances (R6-18-705):
1.
Appliances for refrigerating & cooking food are functioning and safe .......................
Refrigerator temperature:
°F
2.
Setting has sufficient lighting to perform normal activities in bedrooms and
living/program areas. ..................................................................................................
3.
Setting has adequate heating, cooling, & ventilation in bedrooms and
living/program areas ...................................................................................................
Interior temperature:
°F
4.
Setting has an operable telephone. ..............................................................................
5.
The clothes dryer is safely vented with a non-flammable vent hose ................
NA
6.
Each portable heater meets the following standards ........................................
NA
YES NO
Electric, UL Approved, and equipped with a tip-over shut-off switch
Has a protective covering for the heating element
Is placed at least 3 ft. from flammable object when in use
Is not used in bedrooms or as the primary source for heat in the setting
7.
A carbon monoxide detector is installed on each level that has a fuel-burning
appliance or heating device .............................................................................
NA
Electrical Safety (R6-18-706):
1.
Electricity/wiring appears safe. ..................................................................................
2.
Light sockets have light bulbs/are safely covered to prevent electrical shock ............
3.
Interior and exterior electrical panels and outlets are covered and have no exposed
wiring .........................................................................................................................
4.
Electrical outlets are not overloaded ...........................................................................
5.
Electrical cords are in good condition; no broken or frayed cords are in use .............
6.
Extension cords are not used on a permanent basis ....................................................
7.
Mid-sized appliances are plugged into grounded outlets/power strips .......................
8.
Major appliances are plugged directly into grounded outlets .....................................
Distribution : ORIGINAL – OLCR Inspector; COPY – Licensing/Certification agency; COPY – Care Provider
See Page 3 for ADA/EOE/LEP/GINA statements
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