* = Required Information
HOME SAFETY CHECKLIST

A. Emergency Procedures:

1. The number of the local fire department is posted near the phone.
Yes No N/A
NOTE: A 911 sticker should be visible on the phone. Check to be sure the phone number is actually posted and is not missing or taken down for some reason.
2. All smoke detectors are maintained in proper operating condition.
Yes No N/A
NOTE: Check to make sure all smoke detectors are working – replace batteries as needed. Make sure there are always extra batteries on hand.
3. A written emergency escape plan has been developed for each resident.
Yes No N/A
NOTE: Check to be sure that an evacuation plan is posted in each client’s bedroom as well as on each level of the house. These go missing from the client’s rooms frequently, so it makes sense to have some extras on hand in case you need to replace one.
4. Fire drill are conducted quarterly and documented in a log.
Yes No N/A
NOTE: Check the fire drill book to ensure they have been completed and filed correctly.
5. At least one operable flashlight is available and maintained.
Yes No N/A
NOTE: Check the flashlight(s) and replace batteries as necessary. There should be extra batteries available for the flashlight and for the battery powered radio mentioned below (#9).
6. Approved first aid supplies are available and maintained including bandages, sterile compresses, scissors, Ice bag or cold pack, oral or thermal thermometer, Mild liquid soap, adhesive tape and first aid manual.
Yes No N/A
NOTE: Check to be sure all items are present when you check for the thermometer, also check for the plastic thermometer sleeves/covers.
7. A non-coin operated telephone is located within in the residence.
Yes No N/A
8. Residents have been informed of a designated area within the residence where they must go for cover during severe storms or tornadoes.
Yes No N/A
9. A battery powered radio / TV is available and in good operating condition.
Yes No N/A

B. Means of Escape:

1. Exit doors and other means of escape are unobstructed by ice, snow or debris.
Yes No N/A
NOTE: Check all exit doors to ensure they are not even partially blocked inside or outside.
2. Bedroom escape windows are easily openable from the inside and unobstructed by screens that are nailed on, plastic, or by any other barriers to a quick exit.
Yes No N/A
NOTE: Check all exit doors to ensure they are not even partially blocked inside or outside.
3. All locks are openable from the inside without the use of a key.
Yes No N/A
NOTE: Check all locks – outside doors, bathroom doors, and any bedroom doors to be sure they are functioning correctly. In addition, there must be a key on the staff keys for all client bedrooms, and there must be a mechanism of some kind (key, paperclip, etc) available to open the bathroom door if it has been locked from the inside.

C. Electrical:

1. All fuses are properly sized for the circuits they are designed to protect.
Yes No N/A
2. Extension cords are not used in place of permanent wiring.
Yes No N/A
NOTE: No extension cords or multi plug adapters are allowed. Surge strips are permitted, but one surge strip cannot be plugged into another surge strip. Check client bedrooms thoroughly for extension cords and remove any immediately if found.
3. Extension cords are not run under rugs, through walls, door or window openings; nor are they damaged in any way.
Yes No N/A
NOTE: No extension cords or multi plug adapters are allowed. Surge strips are permitted, but one surge strip cannot be plugged into another surge strip. Check client bedrooms thoroughly for extension cords and remove any immediately if found.
4. Multiple plug adapters are not used.
Yes No N/A
5. The main electrical switch is easily accessible.
Yes No N/A
6. The wiring appears safe; no known hazards exist.
Yes No N/A
NOTE: Make sure all outlets have covers on them and that the covers are not broken. Check to be sure they hold the plugs in tightly; in addition there cannot be bare light bulbs. All lights must have some sort of cover.

D. Housekeeping:

1. The basement, closets and attic are free of old rags, papers, mattresses, broken furniture and / or hazardous quantities of other combustible items.
Yes No N/A
NOTE: Keep the clutter cleared out.
2. The space beneath stairways is free of all combustible storage.
Yes No N/A
NOTE: Keep the clutter cleared out.
3. If the answer to item 2 is “no” the underside of the stairway is protected by sheathing materials providing at least one house fire resistance.
Yes No N/A
NOTE: Keep the clutter cleared out.
4. Combustible items are properly stored at least 36” from any heating source.
Yes No N/A
NOTE: Make sure there is nothing sitting within 36” of the furnace or hanging on the wall within 36 inches.
5. All flammable and combustible liquids are properly stored.
Yes No N/A
NOTE: Propane tanks for gas grills cannot be stored in your garage if the garage is attached to the house.
6. Food is obtained, handled, and stored to prevent contamination spoilage, or a threat to health.
Yes No N/A
NOTE: Make sure food is stored properly in the refrigerator covered, and dated. Dry goods such as cereal or rice must be stored in a sealed container or bag so that bugs are unable to get into it.
7. Residence is clean and free from accumulations of dirt, rubbish and peeling paint.
Yes No N/A
NOTE: Check everywhere! Cobwebs, corners, behind doors, under beds, under furniture, in the window sills.
8. Chemicals, detergents, medicines and other toxic substances are stored separately from food products, and are inaccessible to residents, if appropriate.
Yes No N/A
NOTE: Check to be sure that cleaning supplies are stored separately from food and medications. In addition, oral medications must be kept in a separate basket or container and topical, drops, etc.
9. Water from privately owned wells is tested annually by a Minnesota Dept. of Health Certified laboratory.
Yes No N/A
10. Individual clean towels, wash cloths and bed linens are available to each resident.
Yes No N/A
11. Schedule ll controlled substances are stored in a locked storage area.
Yes No N/A
NOTE: Ask your PC or the LPN if you are not sure if you have any Schedule ll medications.
12. Weapons and ammunition are stored separately in locked storage areas.
Yes No N/A

E. Heating / Cooking Equipment:

1. The furnace is checked at least every other year and maintained in good working condition.
Yes No N/A
NOTE: Check the sticker on the furnace. If it is not within the past two years or if the due date is approaching within a couple of months, notify maintenance via e-mail and cc the Program Coordinator.
2. Kitchen cooking areas are clean and free of accumulated grease.
Yes No N/A
NOTE: The stovetop and under the range hood need to be free of grease.
3. The water heating equipment is provided with a proper temperature and / or pressure relief valve.
Yes No N/A
4. The water temperature is set at an appropriate level to prevent scalding.
Yes No N/A
NOTE: Test the water temperature with a thermometer. It should not register above 115 degrees. If it is higher than 115 degrees, contact maintenance immediately.
5. Fire places are equipped with a sturdy metal fire screen or heat tempered glass doors.
Yes No N/A
6. Wood burning appliances are maintained the proper distance from combustibles.
Yes No N/A

F. Physical Plant:

1. At least on 2A-10BC rated and approved portable fire extinguisher is maintained in the kitchen cooking area and is serviced and tagged annually.
Yes No N/A
NOTE: The fire extinguisher must have a tag showing it has been serviced or purchased within the past year. The fire extinguisher should be mounted in the kitchen in an accessible location but not above the stove.
2. All smoke detectors are maintained in proper operating condition.
Yes No N/A
NOTE: Check to make sure all smoke detectors are working – replace batteries as needed. Make sure there are always extra batteries on hand.
3. The bathroom door is openable from the outside in case of emergency and the opening device is maintained at an easily accessible location near the door.
Yes No N/A
NOTE: A paperclip or the key can be taped to the top of the door frame.
4. It there is an attached garage, a proper fire separation is maintained between the house and garage.
Yes No N/A
NOTE: The fire door must be self closing and must latch completely.
5. Any changes or repairs to the residence that require a building permit have been reported to the locale agency.
Yes No N/A
6. Any fire that causes damage to the residence or requires the services of a fire department has been reported within 24 hours to the local agency.
Yes No N/A
7. Each client closet has a covering of some sort – closet doors or curtains.
Yes No N/A

Security code