Community Care Facility Inspection Checklist

COUNTY OF LOS ANGELES PROBATION DEPARTMENT Community Care Facility Inspection Checklist ROBERT B. TAYLOR ANNUAL INSPECTION Chief Probation Officer

GENERAL INFORMATION DATE: AGENCY NAME: SITE NAME:

CORPORATE/MAIN SITE ADDRESS & PHONE: SITE ADDRESS & PHONE:

ADMINISTRATOR: FACILITY MANAGER: Name, Title Name, Title Phone: Phone:

GENERAL RESIDENT POPULATION (CHECK ALL THAT APPLY):

LA Co Probation Other Probation Counties DCFS Private Pay Other RCL RANGE: AGE RANGE: CAPACITY SIZE: # OF PROB MINORS: SEX RANGE: M F SPECIAL SERVICES/TREATMENT RENDERED BY THE GROUP HOME PROGRAM (CHECK ALL THAT APPLY):

Drug Counseling Drug Treatment (ADPA Approved) Sex-Offender Treatment Sexual Identity Program

Mental Health Services (Level 12) Mental Health Services (Level 14) Transitional Living Program

Anger Management Counseling Pregnancy/Maternity Program Other SCHOOL ON GROUNDS?: Yes No (If No, provide a list of ALL schools used)

Name, School District

NECESSARY DOCUMENTATION & POSTINGS: Personal Rights Ombudsman’s # LOCATION WHERE POSTED LOCATION WHERE POSTED Evacuation Plan Facility License LOCATION WHERE POSTED LOCATION WHERE POSTED License #: Updated Program Statement obtained Exp. Date: NOTES:

PROBATION: PROTECTION, CORRECTION, SERVICE Community Care Facility Inspection Checklist Los Angeles County Probation Department

INTERIOR INSPECTION T A E E R M T

A A E T N O M SECTION N NOTES (If expectations not met, explain) / ) 1. Walls/Ceiling S ( 2. Floor/Carpet M

O 3. Doors/Windows

O 4. Furniture R

Y 5. Outlets/Lights A

D 6. Fans/Heaters ) S

( 7. Electronic Equipment

A 8. Smoke Detectors E

R 9. Exits/Fire Escapes A

E Walls/Ceiling R ) Floor/Carpet S ( Doors/Windows M

O Furniture O Outlets/Lights R

G Fans/Heaters N I Electronic Equipment V I

L Smoke Detectors Exits/Fire Escapes

Walls/Ceiling Floor/Carpet Doors/Windows Furniture/Cabinets ) Appliances S (

N Outlets/Lights E Fans/Heaters H

C Electronic Equipment T I Smoke Detectors K Exits/Fire Escapes Food Supply Utensil Supply Fire Extinguisher

of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department T A E E R M T

A A E T N O M SECTION N NOTES (If expectations not met, explain) / Walls/Ceiling M

O Floor/Carpet O Doors/Windows R

G Furniture N

I Outlets/Lights N I Fans/Heaters D

L Smoke Detectors L

A Exits/Fire Escapes H

N Walls/Ceiling I S ( N

I Floor/Carpet M D O Doors/Windows O Furniture/Closet R

D Clothes Supply E

B Appropriate Clothing S

E Outlets/Lights I

R Fans/Heaters O

T Smoke Detectors I

M Exits/Fire Escapes R O

D Walls/Ceiling Floor/Carpet

S Doors/Windows

M Shower O

O Sink

R Toilet H

T Furniture/Cabinets A

B Outlets/Lights Fans/Heaters Toiletries

Walls/Ceiling A

E Floor/Carpet

R Doors/Windows A

Y Cabinets R Outlets/Lights D

N Washer U

A Dryer L Soap/Chemicals

of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department T A E E R M T

A A E T N O M SECTION N NOTES (If expectations not met, explain) Walls/Ceiling Floor/Carpet

N Doors/Windows O

I Furniture/Cabinets T

A Outlets/Lights T

S Medication PMA’s

E Medical Supplies S

R Biohazard Disposal U Smoke Detectors N Exits/Fire Escapes Medical Files

H Walls/Ceiling S

Y Floor/Carpet/Steps A Furniture W R

I Outlets/Lights A

T Fans/Heaters

S Smoke Detectors S Y A E

W Walls/Ceiling G L L A Floor/Carpet A R Doors/Windows O

T Outlets/Lights S ) Equipment/Storage S ( Cabinets M O O E R R

I Pull Station present? YES NO F

R Where are fire extinguishers located? In proper working condition? E H

T O S R E H S I U G N I T

ADDITIONALX COMMENTS: E

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EXTERIOR INSPECTION T A E E R M T

A A E T N O M SECTION N NOTES (If expectations not met, explain) / Y

A Driveway(s) W

E Parking Lot(s) V I Proper Lighting R

D Visible Address T O L

G N I / ) K S ( R

Y Walkway(s) A A P Lawn(s) W

K Pool Area(s) L

A Proper Lighting W ) S ( N W ) A

S Patio(s)/Rails ( L E

I Patio Lighting

N Patio Furniture O

C Balconies/Rails L

A Balcony Lighting B

/ Balcony Furniture ) S

( Porch/Rails O

I Porch Lighting T

A Porch Furniture P

S Decks/Rails K Deck Lighting C

E Deck Furniture D / S E E Walls/Ceiling H G C

A Floor/Steps/Carpet R R Doors/Windows O A P G Furniture/Cabinets & Outlets/Lights Page 5 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department

Storage T A E E R M T

A A E T N O M NOTES (If expectations not met, SECTION N explain) &

S Fences W Gates O

D Walls N I Windows & Bars W

S Other Property Dividers R E D I V I D N Overall Condition O I

T Locked A

T Insurance R

O Registration

P Maintenance Log S

N DL’s on File A

R # of Vehicles T

ADDITIONAL COMMENTS:

ADMINISTRATIVE INFORMATION T A E E R M T

A A E T N O M NOTES (If expectations not met, SECTION N explain)

N Walls/Ceiling O I Floor/Carpet T

A Doors/Windows R

T Furniture/Closet S I Outlets/Lights N I Fans/Heaters M

D Smoke Detectors A

E Exits/Fire Escapes C

I Telephone Access F F

O Periodic Reviews Completed LARRC Completed Case Plans Signed & Current NSPs Signed & Current TILP Completed

of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department C

G STAFF TRAINING INCLUDES: N I Training Schedules T

R Training Manuals w/Sign Off Log O

P PROBATION POLICIES & PROCEDURES MANUAL (w/sign off log) INCLUDES:

E Group Home Investigation R Guidelines

& Bed Hold Policy Guidelines

L On-Ste PO Program Protocol G N N O I L N I A U A N R N T A S E R U D E C O R P

Y T A C E I E L R M T O A A T E P N O M

N NOTES (If expectations not met, SECTION explain) POP SHEETS ACCURATE ACCOUNTING LOGS INCLUDE: S

G Petty Cash Y L O

N Weekly Allowances L

L Clothing Allowances L O A Payment Resolution System R U N T THERAPUTIC SERVICES INCLUDE: N N A

O Services Received Logs C On-Site Therapists or Agency StaffUsed Credentials on File

ADDITIONAL COMMENTS (Include agency strengths & special services provided by group home):

Inspection Completed By:

Name, Title DATE

Exit Interview Completed By:

Name, Title DATE

Exit Interview Reviewed By:

(FACILITY STAFF SIGNATURE) DATE Page 9 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department

(PRINT NAME) (TITLE)