SAFY Surveys:

F-063 Foster Home Environment Evaluation

Base Information

INSTRUCTIONS: An environmental evaluation of the foster home will be completed quarterly. This form will be completed for three quarters and the state specific safety audit form will be completed during the fourth quarter at the anniversary date of the license/certification.

Foster Parent

Date of Evaluation

Fire, Safety, Environmental Checklist

Review fire, safety, and environmental checklist with foster parents. At a minimum check the following: (Only complete this survey for those questions that you answered "No" or "N/A".)

Fire/smoke detectors are working.

Fire extinguisher is charged and available.

Firearms, paint ball guns, or any projectile instrument kept on the grounds of or in the home are stored in an inoperative condition in a locked area inaccessible to children.

Ammunition, arrows or projectiles for weapons are stored in a locked area separate from the weapon.

Medication is stored properly in locked containers per SAFY Medication Policy P-5.

Alcohol is stored so it is inaccessible to children.

The evacuation plan is posted.

Fire drills are practiced on a regular basis.

Every child has an approved bed with clean linen and mattress.

There is appropriate food supply for the number of persons living in the home.

If foster home has pool or pond, there is a safety plan incorporating supervision of children, adequate water safety equipment, emergency numbers, etc.

Outdoor recreational equipment is maintained in safe/working condition.

Safety outlet plugs are present for any unused outlets if children 5 and under are placed in the home.

Water heater temperature is below 120 degrees when read with a metal thermometer.

Client information is kept in a secure location to prevent access by unauthorized persons.

The home has a working telephone in the home at all times.

The home and all structures associated with the home are maintained in a clean, safe, clutter free and sanitary condition and in a reasonable state of repair (intact windows; including window guards where necessary, doors, steps; free from exposed wiring; free from rodent or insect infestation; walls and ceilings are free of holes).

The home and all structures associated with the home are lead free inside and outside (look for peeling paint around windows, wall, ceilings; bubbling paint, and holes). If these conditions exist and the house was built before 1978, then a lead inspection is necessary.

The home has adequate heat, lighting, water, refrigeration, cooking and toilet facilities

Respite Provider packet is present in home with up to date information for each client.

Foster parent policy manual is present in the home and up to date.

Is the emotional climate of the foster home adequate?

Is the relationship between the client and foster parents in the home adequate?

Is the level and quality of supervision by the foster parents adequate?

Is the overall neatness, cleanliness, and orderliness of the foster home adequate?

Was the CAP completed on time?

Each vehicle owned by the foster parent is covered by insurance.

The financial situation of the foster home has stayed the same. (layoff, unemployment, foreclosure, moved/changed landlords, etc.)

Pets and/or additional verification of shot records have stayed the same.

The composition of the home/family (birth, death, adoption, someone moved in or out; this does not include foster children) has stayed the same.

There has been no criminal offense or any conviction sought against the foster parent or any resident 12 years of age or older in the home.

There have been no arrests on anyone in the home.

There has not been any involvement with law enforcement / police.

There are no legal proceedings, such as eviction, or divorce pending.

There are no plans to move.

Each vehicle owned by foster parent has the appropriate passenger restraint systems that are in working order and or age appropriate for the ages of the children in the home.

SAFY Survey Engine

F-063 Foster Home Environment Evaluation