Free Community Based Residential Facility (CBRF) Fire Inspection-F-60795 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-60795 (Rev. 04/09)

STATE OF WISCONSIN

COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) FIRE INSPECTION
DHS 83.47(3), Wisconsin Administrative Code, requires that Community Based Residential Facilities arrange for an annual inspection by the local fire authority or a certified fire inspector using this Department form or other forms or correspondence used by the local fire authority or certified fire inspector.
Name ­ Facility

Address

City

State

Zip Code

Licensee Name

County

FIRE SAFETY Yes No
1. 2. 3. 4. Does the facility have a written and readily available emergency plan that specifies actions and procedures for meeting emergency situations? Do all means of exiting (including all corridors leading to exits) provide unobstructed travel to the outside? Are storage areas maintained in a safe, dry and orderly condition? Are attics and basements free of accumulations of garbage, refuse, soiled laundry, discarded furniture, old newspapers, boxes, discarded equipment, and similar combustible items? Are combustible materials kept a minimum of 3 feet away from any furnace, boiler, water heater, fireplace or other similar equipment? Are there any exposed polystyrene surfaces or insulation? NOTE: A common example of polystyrene is rigid foam insulation board. These exposed surfaces are prohibited. 6. 7. 8. 9. 10. 11. 12. 13. 14. Is the emergency number for the fire department posted near all telephones? If the kitchen has an exhaust vent, is it kept clean and properly maintained? Does staff have knowledge of fire safety plan and have they received training? DHS 83.20(2)(b) Are any flammable liquids, such as gasoline, turpentine or paint thinner, stored in the basement or near ignition sources? If any electric space heaters are present, do they have automatic thermostatic control and are they physically attached to a wall? Are there any oil-fired, kerosene, gas, or alcohol space heaters in the facility? NOTE: The use of such heaters is PROHIBITED in a CBRF. From documentation provided by the facility, has each oil furnace been serviced at least annually OR has each gas furnace or boiler been serviced at least once every 3 years, by a heating contractor or local utility company? Does each wood-burning stove or fireplace have a flue separate from the one used by a gas or oil fired furnace or boiler? From a visual inspection, or documentation, does it appear that the flue of a wood-burning stove or fireplace is cleaned as often as necessary and is unobstructed?

5.

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FIRE EXTINGUISHERS
Yes No 15. 16. 17. 18. 19. 20. 21. 22. 23. Is at least one fire extinguisher, with a minimum 2A, 10 b-C rating, provided on each floor? Are fire extinguishers located at the head of each stairway? Are extinguishers located so that the maximum travel distance does not exceed 75 feet? Is an extinguisher mounted in or near the kitchen? Are extinguishers mounted where they are clearly visible? Are extinguishers mounted so the top is not over 5 feet above the floor and the bottom of the extinguisher is not less than 4 inches above the floor? Are extinguishers accessible at all times? Are all fire extinguishers serviced at least annually? Are all employees of the facility familiar with the operation of the fire extinguishers?

FIRE PROTECTION SYSTEMS Smoke Detection System Yes No
24. 25. 26. 27. 28. 29. 30. Is there an interconnected or radio frequency smoke detection system installed and operable? Is a smoke detector located at the head of every open stairway? Is a smoke detector located on the hallway side of the door to every enclosed stairway on each floor level? Are smoke detectors in corridors and rooms spaced not more than 30 feet apart and no further than 15 feet from any wall? Is there at least one smoke detector in each common use room including living rooms, dining rooms, family rooms, lounges and recreation rooms, but not including kitchens or bathrooms? If house rules permit smoking in sleeping rooms, do rooms in which smoking is allowed have a smoke detector integrated into the rest of the detection system? Does the interconnected or radio frequency detection system include smoke detectors in each resident bedroom, each room of staff living quarters (excluding kitchen and bathrooms) and each basement room (excluding the furnace room)? Have heat detectors, which are integrated with the smoke detection system, been installed in each kitchen, in each attached garage, in the attic (or each enclosed compartment of the attic), in enclosed furnace rooms, and in enclosed laundry rooms? From documentation provided by the facility, does it appear that all interconnected smoke detectors have been tested not less than once every other month? From documentation provided by the facility, does it appear that the smoke detectors are installed and maintained in accordance with the manufacturer's recommendations? Are all smoke detectors currently working? Are all smoke and heat detectors tested by a service company annually? Check this box if the facility is NOT SPRINKLERED and proceed to the next section.

31.

32. 33. 34. 35.

Sprinkler System Yes No
36. 37. 38. 39. 40.

From a visual inspection, does it appear that all sprinkler heads are free of paint, cob webs, or other debris and any kind of covering? Is there at least 18 inches of clearance below sprinkler heads, especially in closets? From a visual inspection, does it appear that all light fixtures and other ceiling mounted obstructions would not obstruct the flow of water form any sprinkler head? From a visual inspection, does it appear that any shelving or any items obstruct the flow of water from any sprinkler head? Is there a report of the annual sprinkler system inspection, done by a licensed sprinkler contractor, in documentation at the facility?

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SMOKE SEPARATION Yes No
41. Is there a door, which has a latch and an automatic closing device, at all interior stairs between the basement and first floor? NOTE: The closing device may be a spring of sufficient strength to close the door and activate the latch. 42. 43. Do all shafts (clothes chutes, dumbwaiter, etc.) leading to the basement have a door, latch, and automatic closing device (See preceding note.) on each level above the lowest floor? Are all doors described in the preceding two questions normally kept closed? NOTE: Any devices on or near a door used to prop the door open must be removed.

ELECTRICAL SAFETY Yes No
44. From a visual inspection, does it appear that clothes dryers are properly installed and vented with rigid metal vent pipe? NOTE: No type of rigid or flexible plastic ducting OR flexible metallic ducting may be used. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. Is the electrical system protected by safety fuses or circuit breakers? From a visual inspection, is there any temporary wiring, exposed wiring or abandoned wiring? Are there any missing or broken outlets or switch plates in the facility? For junction boxes that are visible, are there any open junction boxes or missing cover plates? From a visual inspection, does it appear that extension cords are in good repair? Are extension cords appropriately rated for the amperage of the appliances they are being used with? When extension cords are used, do they extend beyond the room of origin? Are any extension cords located beneath rugs or carpets? Do extension cords extend across any doorway or pathway? Does each refrigerator have its own outlet, with no other appliance plugged into that outlet?

EXIT LIGHTS Yes No
55. 56. Are all required exit signs lighted? Is there a standby power source for emergency egress lighting in exit passageways and stairways?

SIGNATURE - Fire Inspection Officer

Name (Print or type.) ­ Fire Inspection Officer

Name - Fire Department

Date CBRF Inspected