Form Lic 03 - Resource Family Home Health And Safety Assessment Checklist
Download a blank fillable Form Lic 03 - Resource Family Home Health And Safety Assessment Checklist in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Lic 03 - Resource Family Home Health And Safety Assessment Checklist with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
FFA: _________________________________________________
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
Document for Agency Use Only
Resource Family/Applicant Name: ___________________________________ Family ID Number: _________________
Date: _________
Effective Date: _________ - _________ (not to exceed one year).
Address: _______________________________________________________________
A Resource Family or applicant must meet the required home health and safety assessment standards in the FFA Interim
Licensing Standards. (Health and Safety Code section 1517(a)(2).)
I
I
I
I
Application
Annual Update
Address Change
Other: _________________
HOME HEALTH AND SAFETY ASSESSMENT REQUIREMENTS
Instructions: In order to successfully complete the home health and safety assessment, all of the requirements below
must be answered “MET,” unless not applicable (N/A), a documented alternative plan (DAP) is granted, or a child/NMD is
not placed with the Resource Family or applicant. If the family has been approved for a DAP as indicated on this form,
please attach a copy of the approved DAP to this form and provide a copy of it to the family.
MET NOT
HOME AND GROUNDS
DAP
N/A
MET
Is the home of the Resource Family/applicant(s) clean, safe, sanitary and in good repair?
Are smoke detector(s) and carbon monoxide detectors or sprinklers approved, commercially
manufactured, functioning and installed in hallway(s) in each sleeping area?
Are outdoor and indoor passageways, stairways, inclines, ramps, and open porches free
of obstruction?
Is the bathroom located indoors, have individual privacy and an operational toilet, sink, tub/shower?
Do the faucets for personal care have hot water that is at a safe temperature?
Are fireplaces, open-faced heaters or woodstoves safely maintained and operated?
Is the temperature of the home safe and comfortable?
Is lighting in each room and other areas of the home adequate to ensure comfort and safety?
Do windows with security bars have safety release devices that meet all state and local requirements?
Is the Resource Family/applicant approved to use delayed egress devices pursuant to Welfare and
Institutions Code 16519.52?
Are there first aid supplies appropriate to meet the needs of a child/NMD?
MET NOT
NO
BEDROOMS
DAP
PLACE
MET
MENT(S)
There are no more than 4 children or 4 NMDs of the same gender or gender identity sharing a bedroom.
Exceptions: Up to 4 children under 8 years old may share a room, regardless of their birth sex.
A DAP is needed for more than 4 children or NMDs to a room.
There are no more than one child and one NMD of the same gender or gender identity sharing a bedroom
as permitted in FFA Interim Licensing Standards section 88487.1.
Exceptions: A minor parent and his/her child may share a room, regardless of their birth sex.
There are no more than 2 infants sharing a bedroom with the Resource Family/applicant (Only infants may
share a bedroom with a Resource Family).
MET NOT
BEDROOMS (continued)
DAP
N/A
MET
Are there any bedrooms commonly used for any other purpose, such as a passageway?
Exceptions: A DAP is needed for an adult living in the home who sleeps in a common area.
Does each bedroom have a safe, direct emergency exit to outside?
Does each child and/or NMD have an individual bed?
Does each child’s and/or NMD’s bed have clean linens and is it in good repair?
Are bunk beds not more than 2 tiers high, have railings on upper tier, and not used for children under 6
years old?
Does each bedroom have sufficient closet and drawer storage?
Are all infants supplied with an age and size appropriate, safe and sturdy bassinet or crib, with a clean
comfortable mattress and clean linen? (The crib or bassinet may not have a drop-side, not be tiered or
stacked, and not have slats that could pose a risk of trapping an infant.)
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
PAGE 1 OF 4
LIC 03 (6/17) (MANDATORY)
Distribution: Original Foster Family Agency
Copy: Resource Family/Applicant
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal