DSS-1515 (Rev. 04/14)
Child Welfare Section
FOSTER HOME FIRE INSPECTION REPORT
NORTH CAROLINA DIVISION OF SOCIAL SERVICES
NAME OF FOSTER HOME_________________________________ PERSON IN CHARGE____________________
STREET ADDRESS_______________________________________ PHONE #______________________________
Foster Parent’s signature on this form indicates that he/she understands that any item marked NO on this form will result in non-
approval of the home until the items in question are brought into compliance with licensing regulations.
DOCUMENT THE APPROPRIATE ANSWERS AS TO THE
CONDITIONS IN THE HOME RELATING TO THE INSPECTION
YES
NO
N/A
Are Underwriters Laboratory (UL) extension cords used only for portable appliances and not
substituted for permanent wiring?
(Check N/A if the occupant does not use extension cords for permanent wiring.)
Is a Carbon Monoxide (CO) detector installed in homes that use fuel oil products, coal, wood
or gas to heat, cool, cook, operate a hot water heater or gas logs?
Is a working, mounted “ABC” fire extinguisher(s), with a rating not less than 1-A installed and
readily available in the residence?
Do emergency telephone numbers and a fire evacuation plan remain posted continually
in a prominent location, and are they visible to all residents and guests?
Does the home have a working telephone?
Are there working smoke alarms in the residence that comply with the appropriate rule?
CHECK ONE OF THE FOLLOWING
• Houses built prior to 1976: must have a battery or electric smoke alarm installed outside
• Houses built 1976 – June 30, 1999: electric smoke alarms shall be placed outside sleeping
areas as required by the code in effect at construction time.
• Houses built after June 30, 1999: must have smoke alarms in every sleeping room, outside
bedrooms and other areas, interconnected as required in the N.C. Building code.
• Manufactured homes are in compliance with HUD requirements Subpart C – 3280.208 at the
time the foster home was initially licensed. HUD requirements can be found at:
(http://www.ecfr.gov/cgi-bin/text-idx?tpl=/ecfrbrowse/Title24/24cfr3280_main_02.tpl) or by
contacting the NC Office of State Fire Marshal at (919) 661-5880 and requesting to speak to
someone in the Manufactured Building Section.
Are all hallways, doorways, entrances, ramps, steps, and corridors unobstructed, free of
storage, and readily accessible?
Do doors and windows in rooms used for sleeping open properly with little effort?
Are all designated egress (exit) doors free of double key dead bolt locks?
Designate Primary heat source:______________________________________________
Designate Secondary heat source (if applicable):________________________________
List any substandard components or hazards found which are not addressed above or which
require additional inspections.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
INSPECTOR’S SIGNATURE / TITLE__________________________________ DATE OF INSPECTION__________________
PRINT NAME OF INSPECTOR_____________________________________ INSPECTOR’S PHONE#____________________
FOSTER PARENT’S SIGNATURE__________________________________________________DATE_____________________
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