Form Lcr-1018a Forpd - Supplemental Life-Safety Inspection Report
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2LCR-1018A FORPD (7-09)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Office of Licensing, Certification & Regulation
SUPPLEMENTAL LIFE-SAFETY INSPECTION REPORT
NAME (Last, First, M.I.)
DATE
TIME
ADDRESS (No., Street, City, State, ZIP)
PHONE NO.
E-MAIL ADDRESS
LICENSING AGENCY
(
)
SAFETY MEASURES
COMMENTS
Check () box circle “N/A” if not-applicable (guidelines are on the reverse)
General Safety:
In Compliance: Yes
No
Description of Correction Needed
Date Corrected
1. Home appears clean and free of damage that poses a hazard .............
2. Home is agreeable in temperature, lighting, smell, etc. ......................
3. Appliances for food storage and cooking are working .......................
4. Home has at least 1 working toilet, sink, and
shower/tub per 10 residents ................................................................
5. Ramps, tubs, and showers have slip resistant flooring........................
6. Home has an operable telephone ........................................................
7. Medications (prescription and over-the-counter) are locked up,
medications requiring ready access are safeguarded ..........................
8. Cleaning supplies are safeguarded......................................................
9. Highly toxic substances are kept in locked storage ............................
10. Alcoholic beverages are safeguarded ...............................................
11. Firearms and ammunition are separately locked
and inaccessible. ........................................................................ N/A
12. Firearms have trigger locks or are inoperable............................ N/A
13. Dogs obtained since last inspection have rabies vaccination ..... N/A
14. Animals do not appear to pose a hazard (behavior/disease) ...... N/A
15. Home is free of insect or vermin infestation.......................................
16. A working carbon monoxide detector is in place on each level
that has a fuel-burning appliance ................................................ N/A
Additional Requirements within the Home:
17. Furnishings and equipment in the home appear in good repair ..........
18. Bedrooms for individuals receiving care are finished rooms with
lighting, ventilation, a door with a working doorknob,
floor to ceiling walls, and a usable exit to the outside. .......................
19. Mattress, pillow and bedding are clean and appropriate to weather ...
Exterior of the Home:
20. Yard/outside appears clean, in good repair and free of damage
that poses a hazard ..............................................................................
21. Outside play areas appear free of insect or vermin infestation ...........
22. Pools/spas appear clean ............................................................. N/A
23. Shepherds crook & ring buoy are maintained in the pool area .. N/A
24. Pools/spas are fenced and gates are locked................................ N/A
Vehicle used to transport individuals receiving care:
25. Is equipped with a seat belt for each passenger ......................... N/A
26. Has an appropriate car seat for children under 5 years of age ... N/A
27. Has floor mounted seat belts and wheelchair
lock-downs for individuals transported in wheelchairs.............. N/A
Fire Safety:
28. Portable heaters appear safe/not the primary source of heat ...... N/A
29. Flammables/combustibles are stored >3 ft. from heat sources ...........
30. Each working fireplace is protected by a fire screen ................. N/A
31. Each level of home has a fire extinguisher with a minimum
rating of 2A:10BC ..............................................................................
32. Working smoke detectors are in each bedroom and on each level .....
The emergency evacuation plan is available in the setting .................
33.
Individuals receiving care are familiar with the emergency
34.
evacuation plan ........................................................................... N/A
This inspection represents the condition of the home and premises only at the time of the inspection.
Licensing Worker’s Comments:
LICENSING WORKER’S NAME (Please Print)
LICENSING WORKER’S SIGNATURE
I acknowledge that the findings of this inspection have been reviewed with me.
FOSTER PARENT’S NAME (Please Print)
PROVIDER’S SIGNATURE
Routing: The licensing worker shall maintain the original inspection report and shall provide the care-giver with a copy of the inspection report
within 10 days of the inspection and OLCR with a copy of the inspection report as required by OLCR.
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