Home Safety Checklist Template
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1
2Home Safety Checklist
Adult Foster Care
Child Foster Care
Family Day Care
ADULT FOSTER CARE (AFC) - A Home Safety Checklist, approved by the commissioner, must be
completed by the operator and the commissioner before licensure each year a fi re marshal inspection is not
made. Reference MN Rules, Part 9555.6125, Subp. 2.
FAMILY FOSTER HOME (FFH) - An inspection using the Home Safety Checklist shall be made jointly
by the applicant and the agency before licensure and relicensure. Reference MN Rules, Part 9545.0190,
Subp. 5C.
FAMILY DAY CARE (FDC) - The Home Safety Checklist may be used as part of the licensing study.
Reference MN Rules, Parts 9502.0425-9502.0445.
Emergency Procedures
Yes
No
1. The emergency phone numbers are posted near the phone.
Yes
No
2. Emergency procedures are planned, written, and posted.
Yes
No
3. A battery powered fl ashlight and radio/TV is available and operable.
Yes
No
4. First-aid supplies are readily available.
Yes
No
5. An operable telephone is located within the residence.
Yes
No
6. Exit doors and windows are not obstructed and are easily opened from the inside.
Physical Environment
Yes
No
1. The wiring appears safe; no known hazards exist.
Yes
No
2. Extension cords are appropriately used and are not used in place of permanent
wiring.
Yes
No
3. A fi re extinguisher is maintained in the kitchen cooking area or area approved
by the fi re marshal.
Fire extinguisher rating: _____________
Yes
No
4. All smoke detectors are properly installed, appropriately located, and maintained
in proper operating condition.
Yes
No
5. All interior doors can be unlocked from the outside and the key is easily acces-
sible in the case of an emergency.
Yes
No
6. If there is an attached garage, a proper fi re separation is maintained between the
house and garage. (FDC)
Yes
No
7. The water temperature is set to prevent scalding, as appropriate; in day care
homes the temperature does not exceed 120• F.
Yes
No
8. Fireplaces, wood burning stoves, and other hot surfaces are protected by guards
to prevent burns.
Yes
No
9. Furnaces are checked regularly and maintained in good working condition.
DHS-0644 (10-95)
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Parent category: Life