Fillable Printable Home Inspection Report Forms
Fillable Printable Home Inspection Report Forms
Home Inspection Report Forms
Foster Care – Home Inspection Checklist
Foster Parent: License Address:
Inspection Type:
Probationary
Initial
Renewal
Monitoring
Inspection Date:
Are there currently placements in this home?
Yes
No
Home Safety Inspection Items (Initial and Renewal all license types):
Address visible and home is accessible 501-12-6-16
Interior/Exterior maintained and safe 501-12-6-1
Hazards abated 501-12-6-12 (see licensor reference guide)
Test smoke detector on each level 501-12-6-2
Carbon monoxide detector on each level 501-12-6-3
Check charge on extinguisher (min rated 2A-10BC) accessible on main level 501-12-6-4
Bathrooms have locks 501-12-6-5
Working appliances/plumbing 501-12-6-11
Chemicals locked
501-12-7-8/501-12-3-12 (see licensor reference guide) Where?
chemicals stored in original packaging OR
chemicals stored in compliant containers labeled with manufacturer directions/warnings
Where?
Flammable substances (gas, kerosene etc) locked in ventilated area separate from living areas R-501-12-7-9
Where?
Medications (prescription, over the counter, vitamins, supplements) are locked 501-12-10-7
Where?
Medications remain in original packaging R-501-12-10-8
Alcohol is inaccessible to foster children R-501-12-7-7 N/A OR where kept?
Telephone (recognizable by 9-1-1 system) on-site with foster children at all times 501-12-7-3
If family uses only mobile or internet phones, how will they ensure onsite phone at all
times?
Emergency numbers posted visible to children 501-12-7-3
2 exits on each level adequately sized for emergency personnel 501-12-6-14
Multi-level has automatic fire suppression system OR
Escape ladder OR Stairway OR Other egress to ground level describe:
Outlet covers Safety gates Fireplace gates Other
First aid kit in home (meds locked separately) 501-12-7-4
Pets that are required to be vaccinated by state or tribal law must be vaccinated against diseases that
can transmit to humans, including rabies. N/A Comments:
Parents do not smoke with foster children present. 501-12-7-1 N/A
Smoking plan:
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Foster Bedrooms
List number of bedrooms in home
40 sq. ft. per child; measurements/capacities:
Comparable to other bedroom spaces (access, space, furnishings, location, etc.) 501-12-6-5.h
Source of natural light that opens to outdoors 501-12-6-6.i
Screened window R-501-12-6-6
Closet or dresser 501-12-6-7
Beds adequate to size of children R-501-12-6-6.e
Available bed per child in accordance with 501-12-6-6.e
No more than 4 kids in any bedroom 501-12-6-6.g
Comments:
Firearms
No firearms in this home OR
Stored together with ammo in container commercially manufactured for gun storage R-501-12-7-6.b OR
Unloaded and securely locked R-501-12-7-6.c where? ; AND
Ammo locked separately where? R-501-12-7-6-c.i
Key/combo is not the same for locked gun and ammo storage areas R-501-12-7—c.ii
Describe: OR
Firearms in display cases are disabled and unloaded R-501-12-7-6.d AND
Ammo securely locked in separate location. Where?
Comments:
Transportation
Vehicles used for transporting foster youth are enclosed and registered 501-12-11-2
Functional seatbelts R-501-12-11-2
Emergency contact information posted 501-12-11-3
First aid kit in each vehicle 501-12-11-4
Comments:
Verify these items when providers have placements (Review with new families also)
No more than 2 children under age 2 (including biological/adopted etc). 501-12-5-6
Rooms not shared by opposite genders (over age 2) 501-12-6-6.a
No children over age 2 in the parent’s room 501-12-6-6.b
No more than 2 non-ambulatory 501-12-5-7
No more than 3 foster children (unless siblings) 62A-2-101-16.a and b (see licensor reference guide)
No more than 4 in any bedroom 501-12-6-6.g
Parents provided life safety/emergency/evacuation training to current foster children R501-12-7-2
Parents don’t provide child care (see statutory definition on licensor reference guide) or DHS licensed services in
home 501-12-4-7.f
Respite care maximum 10 days per 30 day period R-5-1-12-5-9 N/A Comments:
No more than 6 in the home for respite (unless all but two are siblings) N/A R501-12-5-9.c
Comments:
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Beds adequate to size of children R-501-12-6-6.e
Safety devices (outlet covers, safety gates, fireplace gates etc) appropriate to age 501-12-7-12:
Caseworker consulted re: locking common household items R-501-12-7-10
Physical restraint used? Yes No; certification submitted 501-12-12-9
Protective gear is accessible/utilized (helmets, life vests, safety certification training, body padding 501-
12-7-12-b
N/A OR Describe:
Age/size appropriate car seat, booster seat R-501-12-11-2 N/A
Agency/caseworker contact information posted in vehicle 501-12-11-3
Adherence to previous safety plan N/A OR
Adherence to specific restrictions (age, gender, capacity) R-r01-12-4-8
Disclosure of major changes in situation (may require new medical reference, income statement
application if moved, investigations etc) N/A
Comments:
Safety plan initiated Yes No
Overall comments/safety plan details/hazards observed/items to monitor:
RECOMMENDATIONS
1. Type:
LFC
LSC
2. Capacity:
One
Two
Three
3. Maximum capacity for siblings:
3.
Gender:
Male Female Both
4.
Ages:
Comments on current capacity/maximum capacity/gender groupings etc:
Printed name of person completing inspection:
Date:
Agency: Office of Licensing DCFS Kinship Other:
Note: This checklist is a tool for licensor convenience and does not modify R501-12 or represent the rule in its entirety. It represents
observations specific to the date above. Licensee remains responsible for full compliance with R501-12
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Foster Care – Child Placing Agency Checklist
Parent Requirements
Over age 21 501-12-5-1-c
Legal residents of US 501-12-5-1-d
Legally married or single applicants 501-12-4-1
Agency owners/directors/governing body are not certified to provide proctor or respite care services
501-12-5-3
Parents do not provide child care or other DHS licensed services in the certified home 501-12-4-8.f
Parents provide safety training to children initially and annually thereafter 501-12-7-13
Parent File Requirements
Signed copies of code of conduct, confidentiality agreement and R-501-12 compliance agreement for
each parent in the parent files 501-12-4i, ii, iii
Updated annually 501-12-4-6.a
Signed initial and renewal applications 501-12-4-1 and 501-12-4-6
Current background clearance forms approved by OL for each household member over age 18 in all
certified foster homes. 501-12-4.b (screenings cannot be transferred from other agencies 501-12-4-4)
Written statement of financial viability for each household with supporting documentation 501-12-4-c
Income statement updated annually 501-126.d
Training:
CPR/First Aid training
Pre Service Training
R501-12 Rules
Policy and procedure training and
Annual training
All training is completed PRIOR to making any placements in the home 501-12-14-4&5 [NOTES]
Medical reference for each parent completed by licensed physician, physician’s assistant or nurse
practitioner 501-12-4-2
Medical reference annually or personal health statement if unchanged since last certification 501-12-4-6b
3 acceptable letters of reference 501-12-4-3
Investigations, allegations, criminal activity (OL notified) 501-12-4-4.d
Homestudy and annual updates are signed by a licensed social worker 501-12-4-5.b and 501-12-4-6-e (see licensor
guide for homestudy content requirements)
Original contractual agreement with each parent 501-12-14-8
Written notification of parent’s rights and responsibilities with signed copy located in parent file 501-12-
14-11
If previously licensed/certified in past 3 years: written reference letter from each agency 501-12-4-7
Written emergency plan 501-12-8
Current vehicle Insurance
Current Driver’s licenses
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Agency Requirements
Recruits, trains and supervises parents 501-12-14-3
Provides DHS with identifying information on all of their certified homes via DHS/DCFS website 501-12-14-
6
Maintains documentation of initial written homestudy (see licensor reference guide page for contents)
and annual updates. 501-12-14-7
Monitoring visits documented re: each parent’s adherence to R501-12 (in addition to initial and annual
visits) 501-12-14-9
Investigates and takes action according to their own policies and procedures (approved by the Office of
Licensing) regarding parent violations of 501-12-14-10
Provides OL with written documentation of any denial, revocation, or suspension within 2 weeks of the
action 501-12-14-13
Agencies don’t issue variances without OL director approval 501-12-14-14
Agency adheres to CORE rules
Physical Facilities of Certified Homes
Use Foster Care-Home Visit Checklist to verify agency/parent compliance in individual residences.
Note: This checklist is a tool for licensor convenience and does not modify Licensing Rules or represent the rule in its entirety. It
represents observations specific to the date above. Licensee remains responsible for full compliance with Licensing Rules
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