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DEPARTMENT OF HEALTH AND FAMILY SERVICES Office of Quality Assurance OQA-953 (Rev. 10-06)

WISCONSIN

ADULT FAMILY HOME FIRE SAFETY GUIDE
This guide can be used to assist the applicant, licensee and licensing specialist to determine compliance with the fire safety requirements of HFS 88. This form is not mandatory.

Name Adult Family Home

Address

City-State-Zip Code

Licensee Name

County

Name - Person Completing This Form

Date Completed

Yes

No 1. 2. 3.

4. 5. 6. 7.

8. 9. 10. 11.

12. 13.

14. 15. 16. 17. 18.

FIRE SAFETY Is the home free from hazards and kept uncluttered and free of dangerous substances? [HFS 88.05(3)(b)] Does the home have at least two (2) means of exiting that provide unobstructed travel to the outside? [HFS 88.05(4)(c)1.] Does the home have exits ramped to grade, with a hard surfaced pathway with handrails, if a resident is not able to walk at all, or able to walk only with difficulty, or only with the assistance of crutches, a cane, or walker, or is unable to easily negotiate stairs without assistance? [HFS 88.05(2)(a) and (a)1.]. Does the licensee have a written plan for the immediate and safe evacuation of all occupants of the home in the event of a fire? [HFS 88.05(4)(d)1.] Does the fire evacuation plan identify an external meeting place? [HFS 88.05(4)(d)1] Does the licensee review the fire safety evacuation plan with each new resident immediately following placement? [HFS 88.05(4)(d)2a.] Does the licensee conduct semi-annual fire drills with all household members with written documentation of the date and evacuation time for each drill maintained by the home? [HFS 88.05(4)(d)2c.] Is the licensee or service provider in the home at all times when a resident who is incapable of self evacuation is present in the home? [HFS 88.05(4)(f)] Does the home have the telephone number for the fire department located on or near each telephone? [HFS 88.05(5)] Are the residents able to easily enter and exit the home? [HFS 88.05(2)] Does any resident who is unable to easily negotiate stairs without assistance have his or her bedroom, toilet and bathing facilities and all common living areas on the first floor? [HFS 88.05(2)(d)] If any resident is not able to walk at all, do exit and interior doors have a clear opening of at least 32 inches? [HFS 88.05(2)(a)2.] If there is any resident in the home who has either manual strength or dexterity limitations, does the home have levered handles on all doors normally used by that resident if these can be replaced and if replacement is readily achievable? [HFS 88.05(2)(c)] Does the home electrical system meet the local building codes? [HFS 88.05(3)(c)] Is there a condition or occurrence relating to the operation of the home that directly threatens the safety of a resident? [HFS 88.03(6)] Has the oil furnace been inspected and serviced every 2 years by a heating contractor? [HFS 88.05(3)(e)2a.] Has the gas furnace been inspected and serviced every 3 years by a heating contractor? [HFS 88.05(3)(e)2b.] Has the chimney been visually inspected by the inspector who inspected the gas or oil furnace? [HFS 88.05(3)e)2c.]

OQA-953 (Rev. 10-06) Page 2

Yes

No

Yes

No

Yes

No

FIRE SAFETY (continued) 19. If the home has a wood burning stove or fireplace, is there a flue separate from the one used by a gas or oil furnace? [HFS 88.05(3)(e)2d.] 20. If "yes" to number 19, has the flue been cleaned as often as necessary, but not less than 2 times during each heating season? If this wood burning stove or fireplace is used no more than four days each month of the heating season, has the flue been cleaned at least during each heating season? [HFS 88.05(3)(e)2d.] 21. Has the licensee evaluated the new resident using the form produced by the department, OQA-2372 Resident Evacuation Assessment, to determine whether the resident is able to evacuate the home without any help within 2 minutes? [HFS 88.05(4)(d)2a.] 22 Has the licensee evaluated each resident annually for evacuation time using the department's form, OQA-2373 Resident Evacuation Assessment? [HFS 88.05(4)(d)2b.] 23. Has the licensee made all service providers who work on the premises aware of each resident having an evacuation time of more than 2 minutes? [HFS 88.05(4)9c)2b.] 24. If there was a fire in the home, which required the assistance of the fire department, did the licensee inform the licensing agency within 72 hours of the occurrence? [HFS 88.05(4)(e)] 25. Has the clothes dryer(s) in the home been properly vented in accordance with manufacturers' recommendations? SMOKE DETECTION SYSTEM 26. Does the home have one or more single station, battery operated, electrically interconnected or radio signal emitting smoke detectors on each floor level? [HFS 88.05(4)(b)1.] 27. Is there a smoke detector located in each habitable room, except the kitchen and bathroom? [HFS 88.05(4)(b)1.] 28. Is there a smoke detector at the head of each open stairway? [HFS 88.05(4)(b)1.] 29. Is there a smoke detector at the door leading to every enclosed stairway? [HFS 88.05(4)(b)1.] 30. Is there a smoke detector on the ceiling of the living room or family room? [HFS 88.05(4)(b)1.] 31. Is there a smoke detector on the ceiling of every sleeping room? [HFS 88.05(4)(b)1.] 32. Is there a smoke detector in the basement? {HFS 88.05(4)(b)1.] 33. Has the licensee maintained each required smoke detector in working condition? [HFS 88.05(4)(b)2.] 34. Has the licensee documented that each smoke detector was tested monthly to make sure it is operating? If a unit is found to be not operating, the licensee is to immediately replace the battery or have the unit repaired or replaced. [HFS 88.05(4)(b)2.] FIRE EXTINGUISHER 35. Is there a fire extinguisher on each floor? [HFS 88.05(4)(a)] 36. Does each fire extinguisher have a minimum 2A, 10B C rating? [HFS 88.05(4)(a)] 37. Is each fire extinguisher mounted? [HFS 88.05(4)(a)] 38. Is there a fire extinguisher at the head of each stairway? [HFS 88.05(4)(a)] 39. Is there a fire extinguisher located in or near the kitchen? A single fire extinguisher in close proximity to the kitchen and the head of a stairway may be used to meet the requirement for an extinguisher at each location. [HFS 88.05(4)(a)] 40. Is the fire extinguisher maintained in readily usable condition? [HFS 88.05(4)(a)] 41. Is the fire extinguisher inspected annually be an authorized dealer or the local fire department with an attached tag showing the date of the last dealer or fire department inspection? [HFS 88.05(f)(a)]