Form DCF-F-CFS0357 "Fire Safety Inspection - Residential Care Centers" - Wisconsin

What Is Form DCF-F-CFS0357?

This is a legal form that was released by the Wisconsin Department of Children and Families - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2016;
  • The latest edition provided by the Wisconsin Department of Children and Families;
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Download Form DCF-F-CFS0357 "Fire Safety Inspection - Residential Care Centers" - Wisconsin

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DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
Fire Safety Inspection – Residential Care Centers
Use of form: Use of this form is voluntary; however, completion of this form by the inspector will meet the requirements of DCF 52.55(3).
Residential care centers for children and youth are required to have a fire safety inspection prior to licensure and annually thereafter. A copy
of the initial inspection report shall be submitted to the department with the initial license application, and a copy of the subsequent annual
inspection reports shall be kept on file at the center for 5 years.
Instructions: The fire inspector completing this form must meet at least one of the following three criteria: be appointed by the municipalities
Fire Chief, have Fire Inspector I Certification, or have NFPA Certification. The inspector shall visually observe the physical plant to determine
compliance with each item, note whether the center is in compliance by checking either “Yes” or “No” and indicate any comments on the last
page in the Comments Section. The fire inspector is encouraged to call or write the licensing specialist if they have any questions or observe
any condition which requires immediate attention. If any items are indicated as not being in compliance at the time of the initial inspection, the
required modifications must be made and a final inspection completed to document compliance.
Note: Department of Commerce has been retitled to Department of Safety and Professional Services. All “Comm” codes became “SPS”
codes effective January 2012.
Name – Facility
Name – Licensee
Facility ID Number
Address – Facility (Street, City, State, Zip Code)
County
FIRE SAFETY
Yes
No
1.
Is a detailed flow-chart type evacuation plan that clearly indicates the direction of each exit for emergency
evacuation posted in a conspicuous place in each building? [52.55(1)(a)]
2.
Does the evacuation plan provide for safe conveyance of all residents promptly from the center by staff in
one trip? [52.55(1)(b)1.]
3.
Does the evacuation plan designate places away from the center to which all residents are evacuated or at
which all are to meet so that it can be determined if all residents are out of danger? [52.55(1)(b)2.]
4.
Does the center comply with chs. SPS 361 to 365, the Wisconsin Commercial Building Code and
applicable local ordinances for number and location of exits, type of exits, exit passageways, and
illumination of exits and exit signs? [52.56(5)(a)]
5.
Are halls, stairs, the attic, closets, basement, furnace room, laundry room, yard and garage free of rubbish
or waste accumulation? [52.51(1)(e)]
6.
Are all bedrooms for residents who are not able to walk, or who can walk only with a means of support
such as crutches, located on a floor level that has an exit discharging at grade level? [52.54(10)]
7.
Are all habitable rooms with floors below grade level in compliance with chs. SPS 361 to 365, the
Wisconsin Commercial Building Code and applicable local ordinances? [52.56(7)]
8.
Do all interior doors (except for locked rooms or units under s. DCF 52.42), including those for closets,
have fastenings or hardware that will allow opening from the inside with one hand without the use of a key?
[52.51(3)(a)]
9.
Are all doors equipped with a lock or latch designed to permit opening the door from either side in case of
emergency? [52.51(3)(b)]
10.
Does an employee on each work shift have a key or other means of opening doors with locks or closing
devices in each building housing residents? [52.51(3)(c)]
11.
Is the smoke detection system installed according to the manufacturer’s instructions and in accordance
with ch. SPS 316 and chs. SPS 361 to 365, the Wisconsin Commercial Building Code and applicable local
ordinances? [52.55(4)(a)]
DCF-F-CFS0357 (R. 02/2016)
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Safety and Permanence
Fire Safety Inspection – Residential Care Centers
Use of form: Use of this form is voluntary; however, completion of this form by the inspector will meet the requirements of DCF 52.55(3).
Residential care centers for children and youth are required to have a fire safety inspection prior to licensure and annually thereafter. A copy
of the initial inspection report shall be submitted to the department with the initial license application, and a copy of the subsequent annual
inspection reports shall be kept on file at the center for 5 years.
Instructions: The fire inspector completing this form must meet at least one of the following three criteria: be appointed by the municipalities
Fire Chief, have Fire Inspector I Certification, or have NFPA Certification. The inspector shall visually observe the physical plant to determine
compliance with each item, note whether the center is in compliance by checking either “Yes” or “No” and indicate any comments on the last
page in the Comments Section. The fire inspector is encouraged to call or write the licensing specialist if they have any questions or observe
any condition which requires immediate attention. If any items are indicated as not being in compliance at the time of the initial inspection, the
required modifications must be made and a final inspection completed to document compliance.
Note: Department of Commerce has been retitled to Department of Safety and Professional Services. All “Comm” codes became “SPS”
codes effective January 2012.
Name – Facility
Name – Licensee
Facility ID Number
Address – Facility (Street, City, State, Zip Code)
County
FIRE SAFETY
Yes
No
1.
Is a detailed flow-chart type evacuation plan that clearly indicates the direction of each exit for emergency
evacuation posted in a conspicuous place in each building? [52.55(1)(a)]
2.
Does the evacuation plan provide for safe conveyance of all residents promptly from the center by staff in
one trip? [52.55(1)(b)1.]
3.
Does the evacuation plan designate places away from the center to which all residents are evacuated or at
which all are to meet so that it can be determined if all residents are out of danger? [52.55(1)(b)2.]
4.
Does the center comply with chs. SPS 361 to 365, the Wisconsin Commercial Building Code and
applicable local ordinances for number and location of exits, type of exits, exit passageways, and
illumination of exits and exit signs? [52.56(5)(a)]
5.
Are halls, stairs, the attic, closets, basement, furnace room, laundry room, yard and garage free of rubbish
or waste accumulation? [52.51(1)(e)]
6.
Are all bedrooms for residents who are not able to walk, or who can walk only with a means of support
such as crutches, located on a floor level that has an exit discharging at grade level? [52.54(10)]
7.
Are all habitable rooms with floors below grade level in compliance with chs. SPS 361 to 365, the
Wisconsin Commercial Building Code and applicable local ordinances? [52.56(7)]
8.
Do all interior doors (except for locked rooms or units under s. DCF 52.42), including those for closets,
have fastenings or hardware that will allow opening from the inside with one hand without the use of a key?
[52.51(3)(a)]
9.
Are all doors equipped with a lock or latch designed to permit opening the door from either side in case of
emergency? [52.51(3)(b)]
10.
Does an employee on each work shift have a key or other means of opening doors with locks or closing
devices in each building housing residents? [52.51(3)(c)]
11.
Is the smoke detection system installed according to the manufacturer’s instructions and in accordance
with ch. SPS 316 and chs. SPS 361 to 365, the Wisconsin Commercial Building Code and applicable local
ordinances? [52.55(4)(a)]
DCF-F-CFS0357 (R. 02/2016)
SMOKE DETECTION SYSTEM
Yes
No
12.
Is the equipment listed by a nationally recognized laboratory as meeting nationally recognized standards?
[52.55(13)]
13.
If the center was built or initially licensed before 1982, does the center have, at a minimum, a battery
operated smoke detection system? [52.55(4)(b)]
14.
Was the center built in 1982 or later or has the licensee moved the center to a different building after
September 1, 2000? If “Yes” the center must comply with 14.1, 14.2 and 14.3.
14.1
Does the center have an interconnected smoke detection system that protects the entire building?
[52.55(4)(c)1.] Note: A building that has no more than 8 beds may have a radio-transmitting smoke
detection system.
14.2 Whether the system triggers alarms throughout the building or triggers a centrally located alarm, is
the alarm audible throughout the building when the detector activates? [52.55(4)(c)2.]
14.3
Was the smoke detection system installed on or after September 1, 2000? If “Yes”, does the
system have a secondary power source? [52.55(4)(c)4.]
15.
Is a smoke detector located in the basement? [52.55(4)(c)5.a.]
16.
Is a smoke detector located at the head of every open stairway? [52.55(4)(c)5.b.]
17.
Is a smoke detector located at the door on each floor level leading to every enclosed stairway?
[52.55(4)(c)5.c.]
18.
Is a smoke detector located in every corridor, spaced in accordance with the manufacturer’s separation
specifications? [52.55(4)(c)5.d.]
19.
Is a smoke detector located in each common use room, including every living room, dining room, family
room, lounge and recreation area? [52.55(4)(c)5.e.]
20.
Is a smoke detector located in each sleeping area of each living unit or within 6 feet from the doorway of
each sleeping area? [52.55(4)(c)5.f.]
21.
Does the center have a heat-sensing device in the kitchen? Note: It is recommended that a fixed
temperature heat detector be used in the kitchen. [52.55(6)]
22.
Does the center have a heat-sensing device in the attic? Note: It is recommended that a rate-of-rise heat
detector be used in an attic.
23.
Does the building house residents unable to take independent action for self-preservation? Note: If “Yes”,
the building must comply with 23.1, 23.2 or both. [52.51(2)(a)]
23.1
Is the building of fire-resistive construction as defined in chs. SPS 361 to 365, the Wisconsin
Commercial Building Code? [52.51(2)(a)]
23.2
Is the building protected by a complete, automatic fire sprinkler system that has been installed in
accordance with the manufacturer’s instructions, has residential or fast response sprinkler heads,
and meets the requirements of chs. SPS 361 to 365, the Wisconsin Commercial Building Code and
any applicable local ordinances?
2
SMOKE DETECTION SYSTEM (continued)
Yes
No
24.
Are all sprinklered or fire-resistive constructed residential living areas in a building separated from adjacent
non-sprinklered or non-fire proof constructed areas in the same building by at least a 2-hour rated fire wall
separation? [52.51(2)(b)]
25.
Has all psychiatric screening (heavy mesh wire or translucent nonbreakable material placed over window
openings to prevent egress) in use at the center been approved by the local fire department prior to being
installed? [52.56(10)]
26.
Are all steam radiators, electric fans, electrical heating units and hot surfaces such as pipes covered by
screens or guards? [52.56(11)]
27.
Are fire detectors and emergency lights which could be vandalized by residents protected by wire cages or
by other acceptable means? [52.56(11)]
SMOKE / FIRE SEPARATION
28.
Do all open interior stairways have one-hour labeled fire-resistant self-closing doors? [52.55(5)]
29.
Do all enclosed interior stairways have one-hour labeled fire-resistant self-closing doors at each floor level?
30.
Are all residential buildings separated from attached garages by a one hour rated fire wall separation that
either abuts a ceiling in the garage that will withstand fire for one hour or extends up to the underside of the
garage roof? [52.56(8)]
CARBON MONOZIDE DETECTOR
31.
Does the residential care center in a one-unit or two-unit building have a functional carbon monoxide
detector installed in the basement and on each floor level, except the attic, garage, or storage area of each
unit, in accordance with the requirements of s. 101.647 Stats.?
Note: A one-unit building is a single family residence. A two-unit building is a duplex or two-flat.
32.
Does the residential care center in a building with at last 3 units have one or more functional carbon
monoxide detectors installed in accordance with requirements of s. 101.149 Stats.?
FLAMMABLES
33.
Are all flammable liquid fuels stored in separate buildings not attached to buildings housing residents?
Note: A center shall limit total storage to 10 gallons in each of the separate buildings, except for the
contents of the gasoline tanks of motor vehicles. [52.55(9)(a)]
34.
Are flammable liquid fuels inaccessible to residents?
35.
Does the storage and labeling of the flammable liquid fuel containers meet the requirements for portable
tank storage in s. SPS 310.28?
36.
Are other flammables such as paints, varnishes and turpentine stored in locked fire-proof cabinets that
meet the requirements of s. SPS 310.27? [52.55(9)(b)]
3
FIRE EXTINGUISHERS
Yes
No
37.
Does the number, location, mounting, placement and maintenance of fire extinguishers comply with chs.
SPS 314 and 361 to 365? [52.55(10)(c)]
38.
Do all buildings have fire extinguishers with a minimum 2A, 10 BC, rating? [52.55(10)(b)]
39.
Do all buildings in which flammable liquids are stored have a fire extinguisher with a 2A, 40 BC, rating?
40.
Do all kitchen areas have a fire extinguisher with a 2A, 40 BC, rating? [52.55(10)(a)]
41.
Does each floor used for resident activities have at least one fire extinguisher? [52.55(10)(d)]
ELECTRICAL SAFETY
Yes
No
42.
Are portable space heaters or any device which has an open flame in use? Use of these items is
prohibited. [52.55(11)(a)]
43.
Do bedrooms contain cooking devices? Use of these items is prohibited. [52.55(11)(b)]
44.
Are ground fault interrupter (GFI) outlets in use for all electrical outlets within 6 feet of a water source in
bathrooms, kitchens, laundry rooms, and basements and in the garage and on the exterior of the group
home? [52.51(5)(b)3.]
45.
Are extension cords providing regular electrical service inside buildings? Such use of extension cords is
prohibited. [52.51(5)(c)]
46.
Does the center have any temporary wiring or exposed or abandoned wiring? [52.51(5)(d)]
OTHER COMMENTS If additional space is needed, attach separate sheet(s).
This fire inspection was completed by a qualified fire inspector on __________________
(mm/dd/yyyy)
Name – Fire inspector completing fire inspection:
___________________________________________________
Name – Agency:
_______________________________________________________________________________
Telephone Number – Agency:
__________________________
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