Licensing Standards Checklist for 24 Hour Family Care 65C 13 by HyDfVm


									                            State of Florida, Department of Children and Families, Family Safety
                            LICENSING STANDARDS CHECKLIST FOR
                            24-HOUR FAMILY CARE (65C-13)

Check One:              Initial Licensing Standards Checklist                      Relicensing Standards Checklist

Check One:              Foster           Shelter               Therapeutic            Dual             Respite           Therapeutic/IRT

 Name of Substitute Parent(s)                                                            Home Phone Number        Work Phone Number

 Address of Substitute Parent(s)                                                                City             State    Zip Code

 Licensing Counselor                                        Date

Place a checkmark in the appropriate column to indicate Compliance (C), Non -Compliance (N/C) or Not Applicable
(N/A). Any N/A entry requires an explanation. Use the back of the sheet if necessary. Items marked N/C require
a written request for a waiver. Requests for waivers of licensing standards must be in writing and
submitted to the approving authority with a copy attached. "IN" indicates that the standard applies to initial
licensing only. " RL" indicates that the standard applies to relicensing only. Items not marked with " IN" or "RL"
apply to initial licensing and relicensing.

                     STANDARD                                  C    N/C      N/A              COMMENTS (disclose results)
*1.   Application for License. 13.009(5)(c) and            X                       Date applicant(s) signed.
 2. 30 days to request additional information, 90                         X        Not applicable unless additional information is
    days for approval/denial in accordance with                                    requested. For example, the license expires 4-1 but
    120.60, F.S.                                                                   something comes up 3-1, you have 90 days to revoke
                                                                                   starting from 3-1.
 3. Background Screening:                          X                               Date applicant(s) signed.
    *a. Release of information form (CF-FSP 5090)
        signed by applicant(s) and adult household
        members. 13.009(6)(a)5a
     b. Local criminal records check completed on X                                The local criminal records checks is completed yearly
        all persons 12 and older who live in the                                   through the sheriff located in the community in which
        home. 13.009(6)(c)                                                         the applicant resides. Were the local criminal records
                                                                                   checks completed (yes/no)?
      *c. Results of local criminal records check     X                            Indicate what agency conducted the local criminal
          indicate no conviction, no plea of nolo                                  records check, the date of the check and who the
          contendere, and no plea of guilty to crimes                              check was conducted on. If there were any arrests,
          specified in 409.175(4)(a)6, F.S. and
                                                                                   please note here. If the arrest involves great detail,
                                                                                   please advise to see assessment.
      *d. Fingerprinting has been completed on all X                               Have fingerprints been completed on all adults in the
          persons age 18 or older who reside in the                                home (yes/no)?
          home. 13.009(6)(d)1
      *e. Fingerprint clearance has been received for X                            Name each adult and the date of the clearance letter.
          all persons 18 and over. 13.009(6)(b)
       f. Abuse Registry form (CF 1651) submitted X                                Has the Central Abuse Hotline form been submitted
          which includes all members of the family.                                (yes/no)?
          13.009(6)(a)6 and 13.009(6)(a)7(e)
      *g. FAHIS clearance received (on all adults in X                             Date of FAHIS results. What is the outcome of the
          the household). 13.006(3)                                                FAHIS check. If there are abuse reports, please
                                                                                   indicate the number. Explanation of the report needs
                                                                                   to be in assessment. Must state if any licensing
                                                                                   concerns arose as result of investigation.
      *h. FDLE clearance obtained on all persons           X                       Have FDLE’s been received (yes, no or n/a)? Please
          age 12 and older who live in the home.                                   list name and date received if yes.

CF-FSP 5205, Sep 2000 (Replaces Jul 99 edition which may be used)
(Stock Number: 3CF-00206)
                    STANDARD                                C   N/C           N/A                        COMMENTS
IN *i. Affidavit of Good Moral Character                X                           Date applicant(s) signed.
          (CF 1649) signed and notarized by all
          persons age 18 or older. 13.009(6)(f)
IN *j.    Employment history check obtained.            X                           Indicate where the applicant(s) currently work(s) and
          13.009(6)(a)5b and 13.009(6)(h)                                           the date when employment was verified. Please also
                                                                                    include the two year employment history check.
IN *k. Three satisfactory personal references           X                           Indicate who references are (name and relationship to
          obtained. 13.009(6)(a)3                                                   applicant) and the date received. Personal character
                                                                                    references must include at least one reference from
                                                                                    school personnel (if applicable). These references
                                                                                    cannot be related to the applicant(s).
IN *l. School reference obtained on all school          X                           Name of school(s) and date received.
       age children in foster home. 13.009(6)(a)3
RL *m. Background screening has been completed X                                    Have fingerprints been done and clearance letters
       on all persons who have become 18 years                                      received for all children who have turned 18 (yes/no)?
       of age or new adults residing in the                                         If yes, please indicate who, date of local laws and
       household. 13.006(a)5                                                        date of clearance letter.
RL     n. FDLE arrest records clearance obtained        X                 X         Mark “C” if applicant(s) were re-screened. Mark “N/A”
          every 5 years. 13.009(6)(d)                                               if applicant(s) are not due for 5-year screening and
                                                                                    indicate the date the applicant(s) are due to be re-
IN *4. Documentation if previously licensed by          X                 X         This is either “C” or “N/A”. If the applicant(s) was
      another agency or state. 13.009(s)(a)4                                        previously licensed with another agency who was the
                                                                                    agency the applicant was licensed with and where?
                                                                                    When was the written reference from that agency

      *a. EPSDT Form (CF-FSP 5021) signed by            X                           Date applicant(s) signed.
           applicants. 13.012(12)
      *b. Confidentiality Statement (CF-FSP 5087)       X                           Date applicant(s) signed.
           signed by applicants. 13.009(5)(d)
      *c. Affidavit of Civil Rights Compliance signed   X                           Date applicant(s) signed.
           by all shelter and group home parents, and
           medical foster home parents who are
           Medicaid certified. 13.001(3)(b)
RL    *d. Foster Care Counselor’s Review of Foster      X                           Please contact case mangers/counselors with
           Parents Performance as listed in the                                     comments regarding applicant(s) and children in the
           Bilateral Service Agreement (CF-FSP                                      home.
           5223). 13.006(2)
RL    *e. Section A of Relicensing Summary (CF-         X                           Who completed section A and when?
           FSP 5027) completed by licensing
           counselor. 13.006(4)
RL    *f. Section B of Relicensing Summary (CF-         X                           Did the applicant(s) complete section B and when?
           FSP 5027) completed by substitute care
           parents. 13.006(5)
RL     g. Emergency shelter home log is maintained                                  Is the log maintained and up to date?
           up-to-date. 13.001(3)(d)
       h. Bilateral Service Agreement between the       X                           Date applicant(s) signed the agreement.
             Department of Children and Families and
             Foster Parents licensed by the Dept.,
             signed (CF-FSP 5226). 13.012(20)
        i. Signed Authorization for Release of Health   X                 X         This release of information is required for all adoption
           and Medical Information for Prospective                                  applicants. As needed for foster parents. If it is
           Foster and Adoptive Parents                                              required, please indicate the date applicant(s) signed.
           (CF-FSP 5230).
 6.   HOME SAFETY                                       X                 X         Firearm Affidavit Signed:___________________
       a. Guns and ammunition must be kept                                          Mark N/A if there are no guns in the home. If there
            separately and in a locked cabinet.                                     are guns/ammo in the home, please indicate the
            13.011(14)(c)                                                           locations of each and what kind of lock is used.
      b. All medications, poisonous chemicals, and X                                Where are medications, poisonous chemicals, and
         cleaning materials must be in a locked                                     cleaning materials locked. What kind of lock is used
         place, inaccessible to children.                                           to makes these items inaccessible to children?

                   STANDARD                              C   N/C           N/A                      COMMENTS
     c. Alcoholic beverages should be stored out of X                            How and where is alcohol stored?
        reach of small children. To avoid access to
        alcoholic beverages by older children, it is
        recommended that these beverages be
        kept in a locked place. 13.011(14)(b)

     d. Pets must be vaccinated and their           X                  X         Please mark N/A if there are no pets in the home. If
        vaccinations must be current.                                            there are pets, please indicate the date of last
        13.011(14)(d)                                                            vaccination and what kind of animal.
     e. Children's access to large pets or          X                            The applicant(s) must have a method to restrict
        potentially dangerous animals must be                                    children’s access to large pets or potentially
        restricted. 13.011(14)(e)                                                dangerous animals.
     f. Transportation must be immediately        X                              Year/Make/Model of each vehicle owned by the family
        available for use in emergencies.                                        or is used to transport children.
     g. Access to a telephone must be immediately X                              Is there access to a telephone in case of an
        available for use in emergencies.                                        emergency? Where?
     h. The home must be free from fire hazards. X                               Are there any fire hazards visible in the home
        13.011(15)(a)                                                            (yes/no)?

    i. All combustible items must be stored away X                               Are combustible items stored away from heat sources
       from sources of heat. 13.011(15)(a)                                       (yes/no)?
    j. The home must not be heated by unvented X                                 Does the home have central heat/air?
       gas heaters. 13.011(15)(b)
   k. An evacuation plan is posted in a              X                           Where is the evacuation plan posted?
       conspicuous place and shared with the
       children. 13.011(15)(c)
IN l. Applicants have been informed that fire        X                           Is the foster parent(s) aware that drills must be done
       drills must be held at least every six                                    every 6 months? Please indicate the date they were
       months. 13.011(15)(c)                                                     instructed.
RL m. Fire drills are held at least every six months X                           Indicate the date of each fire drill for the year.
       and documented by the foster parent.
   n. All fireplaces, space heaters, steam           X                           What precautions are taken to protect children from
       radiators and hot surfaces must be shielded                               any of these hot surfaces?
       against accidental contact. 13.011(15)(d)
   o. All bedrooms must have either a window or X                                Do all rooms have at least one window or alternate
       door with approved means of exit, in                                      door to exit? Bedrooms in basement and above the
       addition to the normal entry/exit door.                                   second floor must have either a window or door with
                                                                                 approved means of exit.
    p. The home is equipped with the following:     X                            List locations of smoke detectors in the home.
       1. An operating smoke detector in each
           sleeping area. 13.011(15)(f)1
       2. Portable chemical fire extinguisher in    X                            Note locations of fire extinguishers and the date of the
           the kitchen, size 2A10BC, annually                                    annual inspection.
           inspected and tagged. 13.011(15)(f)3
       3. Exits, stairways and hallways shall not X                              Are all of these areas clean and easy to walk through
           be used for storage or otherwise                                      or cluttered?
       4. All doors with locks must be capable of X                              Yes/No Please explain if answer is no.
           being opened from inside.
       5. If home is equipped with burglar bars, X                               If home has burglar bars, does it meet these
           the caregiver must demonstrate that:                                  requirements? Does the home have an alarm
           (a) The burglar bars can be released to                               system?
                allow exit, or
           (b) Other means of exit are readily
                available from each sleeping area.
                13.011(15)(f)4a and b
 7. TRANSPORTATION SAFETY                           X                            Are vehicles used to transport children in compliance
    a. All vehicles used to transport children must                              with applicable motor vehicle laws of the State? Are
       be in compliance with applicable motor                                    vehicles equipped with seat belts and/or approved car
       vehicle laws of the state, and equipped with                              seats for children under 4 years of age?
       seat belts and/or approved car seats for
       children under 4 years of age.

                    STANDARD                                C   N/C           N/A                          COMMENTS
     *b. All vehicles owned or leased by the           X                            Applicant(s) must have all vehicles owned by them
         substitute parents used for transporting                                   insured to include liability for transporting children.
         children must have proof of liability                                      Insurance policies should be available for inspection
         insurance. 13.011(16)(b)
                                                                                    at the time of licensure and relicensure. What
                                                                                    insurance company is the applicant(s) listed with and
                                                                                    does the policy include liability for transporting
     *c. Substitute parents who drive must have a      X                            Lists driver’s license numbers for each adult in the
         valid drivers license. (Obtain the license                                 home that will be responsible for transporting
         number.) 13.011(16)(c)                                                     children.
  8. There are no more than two infants under 2         X                 X         How many children under the age of 2?
     years of age in the home. 13.001(1)
  9. Therapeutic foster homes are limited to two        X                 X         Is this a therapeutic home?
     children. 13.001(1)(b)
*10. There are no more than five children in the        X                           How many children, total, are in the home? Specify
     home, including the substitute care parents' own                               how many are biological, adopted, foster care etc.
     children in the home. There must be a waiver
     on file if there are more than 5 total children in
     the home, naming the children the waiver is for.
     13.001(1)(a) and 13.011(2)(b)
*11. A family cannot hold dual licensure to provide X                               A family day care and foster care cannot be provided
     family day care and family foster care to                                      in the same home.
     children simultaneously. 13.011(2)(d)
IN 12. If married, substitute care parents have a X                                 Describe relationships / family composition. If
     stabilized legal marriage. 13.001(2)                                           married/divorced, provide dates and state what
                                                                                    applicable documentation exist in file.
*13. If both parents are employed, there are           X                            What childcare arrangements are in place? What
     adequate child care arrangements. 13.011(6)                                    facilities do/will the children attend? Is the day care
                                                                                    facility licensed?
*14. Verification of income and to include net         X                            Date verified
     income. 13.011(4)
*15. Substitute care parents must have sufficient      X                            The applicant(s) must have sufficient income to
     income to assure their stability and the security                              absorb four to six weeks of a foster child’s care until
     of their own family without relying on board                                   board payment is received. Do foster parents report
     payments. 13.011(4)
                                                                                    any hardships in meeting the needs of the children in
                                                                                    their home? Please indicate the $ amount of expense
                                                                                    and income.
*16. Health history obtained on each household         X                            Applicant(s) are required to share health history on
     member and additional information obtained if                                  each member of the household including physical,
     applicable. 13.011(7)                                                          mental health and other treatments received. Date
                                                                                    health history was obtained. Do the applicant(s) or
                                                                                    household members report any medical problems?
                                                                                    Are they on any medication? What is the medication
17. Substitute parents must be willing to provide the X                             Where does the applicant(s) attend church? Do
    opportunity for a child's participation in the faith                            children attend with them? If child is a different faith,
    of his choice or that requested by the birth                                    do parents have problems with supporting the child in
    family. 13.011(8)
                                                                                    that faith?
18. A parent whose religious preference or other       X                            Does the applicant(s) religious beliefs prevent them
    connections preclude the use of a licensed                                      from seeking medical help as needed?
    medical physician for the department's children
    may not be licensed. 13.011(8)
19. The home must have access to schools,              X                            What schools, hospitals, etc are in the area?
    churches, medical care, recreation and
    community facilities. 13.011(10)(a)
20. PHYSICAL ENVIRONMENT                               X        X                   If the home clean? Is there anything in the home that
     a. The home must be clean and free of                                          could present a risk to the child(ren).
        hazards to the health and physical well-
        being of the family. 13.011(13)(g)
     b. The home and premises must be free from        X        X                   Are there any hazardous conditions in the home?
        objects, materials, and conditions which
        constitute a danger to children.

                   STANDARD                                  C   N/C           N/A                      COMMENTS
    *c. The home must be inspected and                   X                           Date home inspection was approved and who
         approved by a representative of the local                                   approved the inspection.
         health department prior to licensing.
         13.006(1), 13.009(6)(a)7 and 13.011(11)(c)
IN *d. Testing for radon gas has been completed          X                 X         Date of test and name of county. N/A if home is
         and report received. 13.009(6)(I)                                           located in Orange County.
RL *e. Testing for radon gas must be completed           X                 X         “C” when re-testing has been completed (every 5
         every five years. 13.009(6)(I)                                              years). “N/A” if testing is not due.
      f. The home must have a safe outdoor play          X                           Describe outdoor area. Is the outdoor play area safe?
         area as part of the property or within                                      Is the play area within reasonable walking distance?
         reasonable walking distance.
     g. The home environment must meet                   X                           Date home inspection was approved.
         sanitation standards contained in 64E-12,
    *h. If local ordinances require fire inspections                       X         Not applicable
         of the foster home, proof the home has
         successfully passed inspection must be
         supplied to the department and maintained
         in the licensing file.
    *i. The home must have a continuous supply           X                           Date home inspection was approved.
         of clean drinking water approved by the
         county health department in the county of
         residence. If the water is not from a
         standard city water supply, the foster
         parents must have the water tested and
         approved. 13.011(13)(h)
      j. The home must have an adequate supply           X                           Date home inspection was approved.
         of hot water for bathing and dishwashing.
     k. Hot water which is accessible to children        X                           Date home inspection was approved.
         must not exceed 120 degree Fahrenheit
         (43 degrees Celsius) at the faucet.
21. SWIMMING POOLS (If no pool, skip this                X       X         X          Water Safety Affidavit : Date Signed _____________
    section.)                                                                        Please indicate N/A if there is no pool. If the home
     a. Swimming pools must have a barrier on all                                    does have a pool, describe the barrier that surrounds
         four sides of at least four feet in height.                                 pool on all sides. The barrier may consist of a house
                                                                                     plus a fence on the remaining three sides or a four-
                                                                                     sided fence.
     b. All access through the barrier must have         X                           Does entryway to pool have lock? What kind of lock
          one of the following safety features:                                      and which of the 3 below do they have.
         1. Alarm
         2. Key lock
         3. Self-locking doors
         4. Bolt Lock
     c. When the swimming pool is not in use, all        X                           Were all entry points locked during visit? Is foster
         entry points must be locked. 13.011(12)(c)                                  parent aware of policy?
     d. Steps or ladders leading to above ground         X                           Where are ladders stored? Where was ladder during
         pools must be secured, locked or removed                                    visit? Please indicate N/A if in-ground pool.
         when the pool is not in use. 13.011(12)(c)
     e. Hot tubs and spas shall be required to           X                           Was cover on and locked?
         have a safety cover that is locked when
         not in use. 13.011(12)(c)
      f. Swimming pools must be equipped with            X                           Note which of the following devices the foster parent
         one of the following life-saving devices                                    has and the location of that item.
         (specify which one): 13.011(12)(d)
         1. Ring buoy

         2. Rescue tube

         3. Floatation device with a rope attached
            which is sufficient in length to cover the

                     STANDARD                                C   N/C           N/A                     COMMENTS
       *g. Substitute care parents who have              X                           When was water safety class completed?
           swimming pools have completed a basic
           water safety course. 13.011(12)(g)
        h. Substitute care providers have been                                       Yes/No – The following (1-3) also applies to water
           informed that: 13.011(12)(e)                                              activities outside of the home. For example, the
                                                                                     family does not own a pool but regularly visits water
           1. Direct adult supervision is required       X                           What are the rules for the use of the pool? Are foster
              when children are using the swimming                                   parents aware of policy?
              pool, spa or hot tub, or are in the pool
              area; and 13.011(12)(e)2                                               What are the rules when participating in water
                                                                                     activities outside of the home?
           2. Children who are not proficient in         X                           What kind of floating devices are available for the
              swimming must wear a life jacket or                                    children and where are they kept?
              approved floating device when in the
              pool area, and 13.011(12)(e)1                                          Will floating devices be available to children if
            3. All high risk recreation activities, such X                           Does family engage in any of these activities? What
                boating, water sports, or contact sports                             precautions are taken for children’s safety?
                shall have direct adult supervision.
22.    Each child must be provided with adequate         X                           What storage space is available for each child? Does
       storage space for personal belongings and a                                   each child have their own dresser or do they share,
       designated space for hanging clothes in or near                               etc.?
       the bedroom occupied by the child.
23.    Each child must have his/her own bed and each X                               List number of bedrooms, number and type of bed in
       infant his/her own full size crib and his/her own                             each room and who each room belongs to.
       individual, clean and age appropriate bedding.
*24.   Children in substitute care must not share a      X                           Do any children sleep in the master bedroom? What
       bedroom with any adult, except for infants 12                                 is the child’s age? If over 1, explain medical condition
       months or younger or when a child’s medical or                                or situation that makes this necessary.
       psychological needs so indicate (documentation
       placed in licensing file if a child older than 12
       months is in a room with an adult).
25.    Any child over 3 years of age must not share a X                              Specify if there are girls/boys sharing a room.
       bedroom with a child of the opposite sex.
IN     *26. A minimum of 30 hours of pre-service         X                 X         What training requirements were met?
       training completed. 13.009(5)(a)
IN     27. A minimum of two family consultation visits X                   X         Date of visits.
       completed, one visit must be with the entire
       family. 13.009(6)(a)2a
IN     28. Two satisfactory visits with neighbors.       X                 X         A minimum of two visits to neighbors who know the
       13.009(6)(a)2c                                                                substitute parents is required. These visits can
                                                                                     usually be conducted at the time of the home visits.
                                                                                     Who were the neighbors visited and when?
IN 29. Family Profile completed and submitted by X                         X         Date completed
       applicants. 13.009(5)(b)
IN     30. Home study, summary and                       X                 X         Date completed
       recommendations completed. 13.009(4)(d)
IN     31. The study has been reviewed and signed        X                 X         Date reviewed and signed by applicant(s).
       by the prospective foster or adoptive parents.
32.    Emergency shelter care providers are required     X                           Are applicant(s) willing to receive placements at any
       to be available to receive children 24 hours a                                time during the day.
       day. 13.011(1)(a)
*33.   Substitute care parents have received a copy of   X                           Are applicant(s) aware of discipline policy? What
       the department's discipline policy, have                                      types of discipline do they use with the children?
       acknowledged receipt, and have agreed to
       abide by that policy. 13.010(1)(b)5
                                                                                     Date discipline policy was signed?
RL *34. A minimum of 8 hours of inservice training X                       X         Please indicate the total amount of training hours for
       completed. 13.006(8)                                                          each applicant?
                     STANDARD                                 C   N/C       N/A                      COMMENTS
RL 35. Licensing counselor must meet with the             X                       Date counselor met with applicant(s) and any notes
       substitute care family to review the relicensing                           about what was discussed, including foster parent(s)
       summary and to formulate recommendations                                   expectations.
       for relicensing. 13.006(7)

NARRATIVE: (continue on back of sheet if necessary)

List all family members who were present during home visit. Make any notes regarding situations that would change
composition of household (adoptions, births, etc.)

Make notes regarding any concerns in the home. Is the home on a corrective action plan? Note any progress or problems
on plan.


Note how many children and for what ages the home is to be re-licensed for. Is the home therapeutic or traditional.

Signature of Counselor                                    Date                Signature of Counselor's Supervisor              Date

Revised 6/04


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