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Department of Human Services Licensing Division - Family Systems April 2018 Child Foster Care Home Safety Checklist Child Foster Care (CFC) – Prior to licensure the foster home must be inspected by a licensing agency employee using the home safety checklist from the Commissioner of human services. Reference Minnesota Rules, part 2960.3050, subpart. 1. Items on this home safety checklist may not be deleted or altered. Name of License Holder/Program: Emergency Procedures The following items must be posted and/or readily accessible in a prominent location in a common area of the home where they can be easily observed by a person responding to an incident. Yes No 1. A list of emergency phone numbers. Yes No 2. A written fire/emergency escape plan Yes No 3. An operable flashlight and radio or television set that does not require electricity. Yes No 4. Accessible first-aid supplies. Yes No 5. An operable telephone. Physical Environment Yes No 1. Exit doors and windows are not obstructed and are easily opened from the inside. Yes No 2. The wiring appears safe; no known hazards exist. Yes No 3. Extension cords are appropriately used and are not used in place of permanent wiring. Yes No 4. A fire extinguisher with a minimum rating of 2A:10BC is maintained in the home. Yes No 5. All smoke detectors work and are properly installed on all levels of the home. Yes No 6. All interior doors can be unlocked from the outside and the opening device is readily accessible in case of emergency. Yes No 7. Home is clean and free from accumulations of dirt, grease, garbage, peeling paint, vermin and insects. Yes No 8. Outside property is free from debris and safety hazards. Exterior stairs and walkways are free of ice and snow. Yes No 9. Fireplaces, wood burning stoves, and hot surfaces are protected by guards in order to prevent burns. Yes No 10. Furnaces are maintained in good working condition. ---PAGE BREAK--- April 2018 Home Safety & Health Yes No 1. Knives, tools, matches, and other potentially hazardous materials are not accessible based on the ages of the children and identified safety concerns and behaviors specific to each child in care. Yes No 2. Chemicals, detergents, and other toxic substances are not stored with food products or accessible in any way that poses a risk to children. Yes No 3. Combustible items are properly stored at least 36” from any heating sources. Yes No 4. Individual clean bed linens, towels, and wash cloths are provided for each foster child. Yes No 5. Food is handled and properly stored to prevent contamination, spoilage, or a threat to the health of children. Yes No 6. Medication is not accessible to children. Schedule II controlled substances are stored in a locked area. N/A (no Schedule II controlled substances in the home) Yes No 7. There is a safe water supply in the home. Yes No 8. The water temperature does not exceed 120 degrees Fahrenheit in order to prevent scalding. Yes No 9. Weapons and ammunition are stored separately in locked areas that are not accessible or visible to children. Weapons include firearms and other instruments or devices designed N/A for and capable of producing bodily harm. (no weapons in the home) Sleeping Space for Foster Children & Reduction of Risk of Sudden Unexpected Infant Death Yes No 1. The sleeping space for foster children has two exits. If the sleeping space for foster children is in an area of the home not normally used for sleeping, describe the alternative sleeping arrangements: Check here if care WILL NOT be provided to infants If checked, do not complete the items below. Yes No 2. A safe crib is available and used for each infant in care. (Before placing an infant in foster care, the agency must verify that there is a safe crib in the home). Yes No 3. Infants younger than one year of age in care are placed to sleep on their back, in a crib, directly on a firm mattress. ---PAGE BREAK--- April 2018 Yes No 4. If an infant is not placed to sleep on their back, there is documentation from the infant’s physician directing an alternative sleeping position for the infant. The physician directive must be on a form approved by the commissioner. Yes No 5. The crib’s firm mattress has a fitted sheet, appropriate to the mattress size that fits on the mattress, and overlaps the underside of the mattress so it cannot be dislodged by pulling on the corner of the sheet with reasonable effort. Yes No 6. Nothing is placed in the crib with the infant except for the infant’s pacifier. Yes No 7. Minnesota Statutes, section 245A.1435 Reduction of Risk of Sudden Unexpected Infant Death in Licensed Programs has been reviewed by all caregivers. All caregivers agree to comply with the requirements of this section. Comments/explanation for obvious safety hazards or concerns: Applicant/License Holder Date Agency Worker Date