Form Lic 03 - Resource Family Home Health And Safety Assessment Checklist Page 2
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4CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING
FFA: _________________________________________________
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
Document for Agency Use Only
Resource Family/Applicant Name: ___________________________________ Family ID Number: _________________
NOT
OUTDOOR ACTIVITY SPACE
MET
MET DAP
N/A
Are yards and outdoor activity spaces free from hazards that endanger the health and safety of a child
or NMD?
Are all swimming pools, spas, and other bodies of water inaccessible to: Dependent children under 10
years of age; minor and NMDs who are developmentally, mentally or physically disabled; a minor or NMD
parent’s child who is under ten years of age or developmentally, mentally, or physically disabled?
Safety Features in Use:
I
I
I
Enclosure
Pool Cover
Alarms
NOT
STORAGE AREA
MET
MET DAP
N/A
Are all household knives, medicines, disinfectants, and cleaning solutions appropriately stored?
Exceptions: The caregiver may allow a child to have access to the above, and household knives and
appliances while applying the Reasonable and Prudent Parent Standard.
Are all firearms, poisons and dangerous items or weapons stored in a locked area?
Exception: Firearms that have the firing pin removed or a trigger lock.
Are ammunition and firing pins stored in a separate locked area?
Is waste located, stored, and disposed of in a manner that will not permit the transmission of diseases or
odors, create a nuisance, or provide a breeding place or food source for insects and rodents?
NOT
MET
MET DAP
N/A
EMERGENCY PROCEDURES
Are emergency numbers placed in a prominent location?
NOT
MET DAP
N/A
TELEPHONES
MET
Is cellular, internet, or landline telephone service accessible at all times?
NOT
SMOKING
MET
MET DAP
N/A
Does the Resource Family/applicant refrain from smoking and prohibit anyone else to smoke in the home
or vehicle used to transport a child/NMD or, when a child/NMD is present, on the outdoor grounds of
the home?
NOT
NO
REPORTING REQUIREMENTS
MET
PLACEMENT(S)
MET
Have any and all reportable incidents been properly reported to the approval and
placement agencies?
NOT
NO
RECORDS FOR CHILDREN AND NONMINOR DEPENDENTS
MET
MET
PLACEMENT(S)
Are all the records of the child or NMD maintained and appropriately stored in a confidential manner?
NOT
NO
PERSONAL RIGHTS
MET
MET
PLACEMENT(S)
Is each child and NMD accorded the personal rights as specified in Welfare and Institutions Code section
16001.9 and FFA Interim Licensing Standards section 88487.8?
RESOURCE FAMILY HOME HEALTH AND SAFETY ASSESSMENT CHECKLIST
PAGE 2 OF 4
LIC 03 (6/17) (MANDATORY)
Distribution: Original Foster Family Agency
Copy: Resource Family/Applicant
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