Form Dcf F Cfs0909 is one of the most important forms that you will need to complete if you are a Florida resident who is receiving financial assistance from the Department of Children and Families. This form will help the department to determine whether or not you qualify for financial assistance, and how much assistance you should receive. It is important to ensure that all information on this form is accurate and up-to-date, as any mistakes could lead to delays in your receipt of benefits. Make sure to consult with a caseworker if you have any questions about completing this form.
| Question | Answer |
|---|---|
| Form Name | Form Dcf F Cfs0909 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | 2012, GFI, DCF-F-CFS0909, Licensee |
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
Fire Safety Inspection – Group Homes
Use of form: Group homes for children are required to have an annual fire safety inspection and submit the results of the inspection to the department. Use of this form is voluntary; however, completion of this form by the inspector will meet the requirements of DCF 57.13(9), 57.42(4) applicable SPS codes and applicable local building and fire codes. Personally identifiable information gathered on this form will be used only for identification purposes. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
Instructions: The inspector shall visibly observe the physical plant to determine compliance with each item, note whether the group home is in compliance by checking either “Yes” or “No” and indicate any comments on the last page in the Other Comments section. The fire inspector is encouraged to call or write the licensing specialist if they have any questions or observe any condition which requires immediate attention. If any items are indicated as not being in compliance at the time of the initial inspection, the required modifications must be made and a final inspection completed to document compliance. The group home shall provide the department with a copy of the completed final inspection report.
Name – Facility
Name – Licensee
Facility ID Number
Address – Facility (Street, City, State, Zip Code)
County
FIRE SAFETY
Yes No
1. Is a diagrammatic floor plan that clearly indicates the direction of each exit for emergency evacuation posted on each floor level? [57.42(2)(a)]
2. Are all passageways leading to exits clear and unobstructed? Note: At least one exit door shall be at least 3 feet in width. [57.40(2)(a)]
3. Are halls, stairs, the attic, closets, basement, furnace room, laundry room, yard and garage free of rubbish or waste accumulation? [57.40(1)(a)]
4. Do all habitable rooms on the second floor have access to at least 2 exits? Note: At least one of the exits shall be a stairway to the first floor or to grade. [57.40(2)(c)1.]
•A window may be used as a second exit from a second floor room occupied by a child 6 years of age or older if the window can be opened from the inside without the use of tools, is at least 22 inches in the smallest dimension, is at least 5 square feet in area and has a lower sill that is not more than 4 feet from the floor and has a window escape ladder for use in an emergency evacuation. [57.40(2)(c)2.]
•An exit to a balcony may be used as a second exit from a second floor room occupied by a child under 6 years of age if the balcony is not more than 15 feet above grade with a floor that measures at least 3 feet by 3 feet and a rail that is not more than 36 inches high. [57.40(2)(c)3.]
5. Do all habitable rooms above the second floor have at least 2 exits? Note: Both exits shall be stairways to the second floor or to grade or that are to one stairway to the second floor and one stairway to grade. Windows and balconies may not be designated as exits. [57.40(2)(d)]
6. Do all habitable rooms below grade have at least two exits? Note: At least one exit shall be a stairway to grade or a door that is below grade level that leads to grade level by an outdoor stairway. [57.40(2)(e)]
•
•
A stairway leading to a first floor above grade may be used as a second exit from a room below grade.
A window may be used as a second exit from a room below grade if the window can be opened from the inside without the use of tools, is at least 22 inches in the smallest dimension, is at least 5 square feet in area and has a lower sill that is not more than 4 feet from the floor.
FIRE SAFETY (continued)
Yes No
7. Are stairways, halls and aisles maintained in good repair, adequately lighted and free from obstacles? [57.41(9)]
8. Do all stairwells have a handrail?
.
FIRE EXTINGUISHERS
9. Are fire extinguishers present in the size, type and location specified by the local fire department? [57.42(3)(a)]
10. Is there at least one extinguisher with a rating specified by the local fire department mounted in the kitchen? [57.42(3)(a)]
11. Is at least one fire extinguisher with a rating specified by the local fire department provided on each floor level? [57.42(3)(a)]
12. Are all fire extinguishers operable? [57.42(3)(b)]
13. Does each extinguisher have a label indicating its present condition and date of annual inspection? [57.42(3)(b)]
SMOKE DETECTION
14. Is a smoke detection system installed and operable? Note: The minimum requirement is a UL listed electrically interconnected system or a radio
15. Is a smoke detector located at the head of every open stairway? [57.42(1)(b)1.]
16. Is a smoke detector located next to doors leading to every enclosed stairway on each floor level? [57.42(1)(b)2.]
17. Are smoke detectors located in every hall? Note: Smoke detectors located in a hall shall not be spaced more than 30 feet apart nor more than 15 feet from any wall. [57.42(1)(b)3.]
18. Are smoke detectors located in each common use room? Note: This includes living rooms, dining areas, lounges, family rooms and recreation rooms, but does not include kitchens. [57.42(1)(b)4.]
19. Are smoke detectors located in each bedroom? [57.42(1)(b)5.] Note: A smoke detector that is located in a room used as a bedroom may be battery operated, free standing and separate from the interconnected system. [57.42(1)(d)]
20. Are smoke detectors located in the basement? [57.42(1)(b)6.]
21. Are smoke detectors located in the attic if accessible? [57.42(1)(b)7.]
CARBON MONIXIDE DETECTOR
22. Does the group home in a
Note: A
23. Does the group home in a building with at last 3 units have one or more functional carbon monoxide detectors installed, in accordance with the requirements of s. 101.149 Stats.?
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SMOKE SEPARATION
Yes No
24. Do all stairways serving three or more levels have a door at either the bottom or top of the stairway? [57.40(2)(b)]
25. Is that door kept closed at all times? [57.40(2)(b)]
ELECTRICAL SAFETY
26. From a visual inspection, does it appear that clothes dryers are properly vented? [57.40(6)(g)]
27. Are portable space heaters in use? [57.40(4)(e)]
28. Are ground fault interrupter (GFI) outlets in use for all electrical outlets within 6 feet of a water source in bathrooms, kitchens, laundry rooms, and basements and in the garage and on the exterior of the group home? Note: Facilities constructed on or after January 1, 2006, must comply with this rule. [57.41(4)]
OTHER COMMENTS If additional space is needed, attach separate sheet(s).
This fire inspection was completed by a qualified fire inspector on __________________
(mm/dd/yyyy)
Name – Fire inspector completing fire inspection: ___________________________________________________
Name – Agency: _______________________________________________________________________________
Telephone Number – Agency: __________________________
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