<p> COUNTY OF LOS ANGELES PROBATION DEPARTMENT Community Care Facility Inspection Checklist ROBERT B. TAYLOR ANNUAL INSPECTION Chief Probation Officer</p><p>GENERAL INFORMATION DATE: AGENCY NAME: SITE NAME:</p><p>CORPORATE/MAIN SITE ADDRESS & PHONE: SITE ADDRESS & PHONE:</p><p>ADMINISTRATOR: FACILITY MANAGER: Name, Title Name, Title Phone: Phone: </p><p>GENERAL RESIDENT POPULATION (CHECK ALL THAT APPLY):</p><p>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):</p><p>Drug Counseling Drug Treatment (ADPA Approved) Sex-Offender Treatment Sexual Identity Program</p><p>Mental Health Services (Level 12) Mental Health Services (Level 14) Transitional Living Program</p><p>Anger Management Counseling Pregnancy/Maternity Program Other SCHOOL ON GROUNDS?: Yes No (If No, provide a list of ALL schools used)</p><p>Name, School District</p><p>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:</p><p>PROBATION: PROTECTION, CORRECTION, SERVICE Community Care Facility Inspection Checklist Los Angeles County Probation Department</p><p>INTERIOR INSPECTION T A E E R M T</p><p>A A E T N O M SECTION N NOTES (If expectations not met, explain) / ) 1. Walls/Ceiling S ( 2. Floor/Carpet M</p><p>O 3. Doors/Windows</p><p>O 4. Furniture R</p><p>Y 5. Outlets/Lights A</p><p>D 6. Fans/Heaters ) S</p><p>( 7. Electronic Equipment</p><p>A 8. Smoke Detectors E</p><p>R 9. Exits/Fire Escapes A</p><p>C</p><p>E Walls/Ceiling R ) Floor/Carpet S ( Doors/Windows M</p><p>O Furniture O Outlets/Lights R</p><p>G Fans/Heaters N I Electronic Equipment V I</p><p>L Smoke Detectors Exits/Fire Escapes</p><p>Walls/Ceiling Floor/Carpet Doors/Windows Furniture/Cabinets ) Appliances S (</p><p>N Outlets/Lights E Fans/Heaters H</p><p>C Electronic Equipment T I Smoke Detectors K Exits/Fire Escapes Food Supply Utensil Supply Fire Extinguisher</p><p>Page 2 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department T A E E R M T</p><p>A A E T N O M SECTION N NOTES (If expectations not met, explain) / Walls/Ceiling M</p><p>O Floor/Carpet O Doors/Windows R</p><p>G Furniture N</p><p>I Outlets/Lights N I Fans/Heaters D</p><p>L Smoke Detectors L</p><p>A Exits/Fire Escapes H</p><p>G / )</p><p>N Walls/Ceiling I S ( N</p><p>I Floor/Carpet M D O Doors/Windows O Furniture/Closet R</p><p>D Clothes Supply E</p><p>B Appropriate Clothing S</p><p>E Outlets/Lights I</p><p>R Fans/Heaters O</p><p>T Smoke Detectors I</p><p>M Exits/Fire Escapes R O</p><p>D Walls/Ceiling Floor/Carpet</p><p>S Doors/Windows</p><p>M Shower O</p><p>O Sink</p><p>R Toilet H</p><p>T Furniture/Cabinets A</p><p>B Outlets/Lights Fans/Heaters Toiletries</p><p>Walls/Ceiling A</p><p>E Floor/Carpet</p><p>R Doors/Windows A</p><p>Y Cabinets R Outlets/Lights D</p><p>N Washer U</p><p>A Dryer L Soap/Chemicals</p><p>Page 3 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department T A E E R M T</p><p>A A E T N O M SECTION N NOTES (If expectations not met, explain) Walls/Ceiling Floor/Carpet</p><p>N Doors/Windows O</p><p>I Furniture/Cabinets T</p><p>A Outlets/Lights T</p><p>S Medication PMA’s</p><p>E Medical Supplies S</p><p>R Biohazard Disposal U Smoke Detectors N Exits/Fire Escapes Medical Files</p><p>H Walls/Ceiling S</p><p>Y Floor/Carpet/Steps A Furniture W R</p><p>I Outlets/Lights A</p><p>T Fans/Heaters</p><p>S Smoke Detectors S Y A E</p><p>W Walls/Ceiling G L L A Floor/Carpet A R Doors/Windows O</p><p>T Outlets/Lights S ) Equipment/Storage S ( Cabinets M O O E R R</p><p>I Pull Station present? YES NO F</p><p>R Where are fire extinguishers located? In proper working condition? E H</p><p>T O S R E H S I U G N I T</p><p>ADDITIONALX COMMENTS: E</p><p>Page 4 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department</p><p>EXTERIOR INSPECTION T A E E R M T</p><p>A A E T N O M SECTION N NOTES (If expectations not met, explain) / Y</p><p>A Driveway(s) W</p><p>E Parking Lot(s) V I Proper Lighting R</p><p>D Visible Address T O L</p><p>G N I / ) K S ( R</p><p>Y Walkway(s) A A P Lawn(s) W</p><p>K Pool Area(s) L</p><p>A Proper Lighting W ) S ( N W ) A</p><p>S Patio(s)/Rails ( L E</p><p>I Patio Lighting</p><p>N Patio Furniture O</p><p>C Balconies/Rails L</p><p>A Balcony Lighting B</p><p>/ Balcony Furniture ) S</p><p>( Porch/Rails O</p><p>I Porch Lighting T</p><p>A Porch Furniture P</p><p>S Decks/Rails K Deck Lighting C</p><p>E Deck Furniture D / S E E Walls/Ceiling H G C</p><p>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</p><p>Storage T A E E R M T</p><p>A A E T N O M NOTES (If expectations not met, SECTION N explain) &</p><p>S Fences W Gates O</p><p>D Walls N I Windows & Bars W</p><p>S Other Property Dividers R E D I V I D N Overall Condition O I</p><p>T Locked A</p><p>T Insurance R</p><p>O Registration</p><p>P Maintenance Log S</p><p>N DL’s on File A</p><p>R # of Vehicles T</p><p>ADDITIONAL COMMENTS:</p><p>Page 6 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department</p><p>ADMINISTRATIVE INFORMATION T A E E R M T</p><p>A A E T N O M NOTES (If expectations not met, SECTION N explain)</p><p>N Walls/Ceiling O I Floor/Carpet T</p><p>A Doors/Windows R</p><p>T Furniture/Closet S I Outlets/Lights N I Fans/Heaters M</p><p>D Smoke Detectors A</p><p>E Exits/Fire Escapes C</p><p>I Telephone Access F F</p><p>O Periodic Reviews Completed LARRC Completed Case Plans Signed & Current NSPs Signed & Current TILP Completed</p><p>Page 7 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department C</p><p>G STAFF TRAINING INCLUDES: N I Training Schedules T</p><p>R Training Manuals w/Sign Off Log O</p><p>P PROBATION POLICIES & PROCEDURES MANUAL (w/sign off log) INCLUDES:</p><p>E Group Home Investigation R Guidelines</p><p>& Bed Hold Policy Guidelines</p><p>Y S</p><p>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</p><p>Y T A C E I E L R M T O A A T E P N O M</p><p>N NOTES (If expectations not met, SECTION explain) POP SHEETS ACCURATE ACCOUNTING LOGS INCLUDE: S</p><p>G Petty Cash Y L O</p><p>N Weekly Allowances L</p><p>O</p><p>L Clothing Allowances L O A Payment Resolution System R U N T THERAPUTIC SERVICES INCLUDE: N N A</p><p>O Services Received Logs C On-Site Therapists or Agency StaffUsed Credentials on File</p><p>ADDITIONAL COMMENTS (Include agency strengths & special services provided by group home):</p><p>Page 8 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department</p><p>Inspection Completed By:</p><p>Name, Title DATE</p><p>Exit Interview Completed By:</p><p>Name, Title DATE</p><p>Exit Interview Reviewed By:</p><p>(FACILITY STAFF SIGNATURE) DATE Page 9 of 10 Community Care Facility Inspection Checklist Los Angeles County Probation Department</p><p>(PRINT NAME) (TITLE)</p><p>Page 10 of 10</p>