Form Lcr-1023a Forpd - Life-Safety Inspection Report Page 2
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3LCR-1023B FORPD (10-13) – PAGE 2
RECORD NO.:
Plumbing (R6-18-707):
YES NO
Inspector’s Comments
Date Corrected
1.
The setting has a continuous source of safe drinking water ..................................
2.
Hot water temperature in areas for bathing does not exceed 120°F ......................
Hot water temperature:
ºF
3.
Sewage disposal is functioning with no visible signs of leakage ..........................
4.
Setting has at least 1 working toilet, sink, and tub/shower per 10 residents .........
Number of working toilets:
shower/tubs:
bathroom sinks:
Fire Safety (R6-18-708):
1.
Flammables/combustibles are stored more than 3 feet from the hot water heater
and other heat sources ...........................................................................................
2.
Working fireplaces/wood stoves are protected by fire screens .................
NA
3.
Setting has at least one functioning fire extinguisher with a minimum rating of
2A: 10BC on each level ........................................................................................
4.
Setting has at least one working smoke detector on each level .............................
5.
Setting has at least one working smoke detector in each bedroom .......................
6.
Setting has an emergency evac. plan which meets the following standards .........
YES
NO
Identifies two routes to evacuate from bedrooms used for care
Identifies the location of fire extinguishers & fire evacuation equipment
Designates a safe meeting place outside the setting
Is maintained in the setting
7.
Exits from the setting are unobstructed.................................................................
8.
Bedrooms used for care must have an exit that opens directly to the outside .......
9.
Locks/bars on windows in bedrooms used for care and on doors leading to the
outside have a quick release mechanism...............................................................
10. Settings providing care to 6 or more individuals practice and document an
evacuation drill at least once every 3 months ..........................................
NA
11. The address for the setting is posted and visible from the street ..............
NA
Pools and Spas (R6-18-709):
1.
Pools are maintained, not stagnant, & are clear enough to see through the water
to the bottom surface of the pool ..........................................................................
2.
If water is deeper than 4 ft., a shepherds crook & ring buoy with attached rope
are available in the pool area ...................................................................
NA
3.
The enclosure/fence meets the following standards: ................................
NA
YES
NO
The exterior side of the fence is at least 5 ft. high with no foot/handholds
If chain link, the mesh measures less than 1 ¾” horizontally ...............
NA
Openings measure less than 4 inches
Gates are self –closing, self-latching and open away from the pool
The gate latch is at least 54” above the ground
The gate to the enclosure is locked
4. If the setting constitutes part of the enclosure, the following standards are met
NA - No part of the setting is inside or connected to the pool fence
YES
NO
The fence does not interfere with safe egress from the setting
A door from the setting does not open within the pool enclosure
A window in a bedroom designated for an individual receiving care is not
positioned within the pool enclosure
Other windows within the pool enclosure are permanently secured to open
no more than 4 inches
This inspection represents the condition of the setting only on the date and time of the inspection.
The setting was in full compliance with all safety measures evaluated by the OLCR Life-Safety Inspector.
The setting was not in full compliance with all safety measures and corrections are required.
Licensing agency must verify corrections
OLCR must verify corrections
Date full compliance verified by OLCR
Inspector’s comments:
Inspector’s Name (print)
Inspector’s signature
I acknowledge that the findings of this inspection have been reviewed with me and I have been provided with a copy.
Provider’s Name (print)
Provider’s signature
Distribution : ORIGINAL – OLCR Inspector; COPY – Licensing/Certification agency; COPY – Care Provider
See reverse for ADA/EOE/LEP/GINA statements
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