Fillable Supplemental Residential/Adult Daycare FACILITY QUESTIONNAIRE (Risk Placement Services, Inc.)

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Supplemental Residential/Adult Daycare FACILITY QUESTIONNAIRE (Risk Placement Services, Inc.)

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Supplemental Residential/Adult Daycare FACILITY QUESTIONNAIRE
PLEASE ATTACH A COPY OF FACILITY LICENSE AND MOST RECENT STATE INSPECTION
1. Location Number Name of the Agency
Name of the Facility
2. Which of the following best describes this facility?
Substance Abuse Mental Health Other
Group Homes Domestic Violence Homeless Shelter
Residential Halfway House Res. Treatment/Halfway House Adult daycare
Sober Living Supervised Living Arrangements Other
3. Licensed bed capacity or Total bed capacity (if not licensed facility) Current occupancy ____________
# Daycare clients _______
4. Is this facility for: Mentally Ill? % of total Developmentally disabled? ___% of total
Non- Ambulatory? _____________% of total Alzheimer/Memory Care? ___________% of total
5. Are residents required to have physical exams prior to enrolling in the facility/program? Yes No
Do staff members administer medications?
Yes No
Are medicines kept locked when not in use?
Yes No
6. Advise number of residents in each age group at this facility:
___ Less than 18 _____ 18 to 30 ____31 to 59 _____ 60 and over
7. Do you transport clients? Yes No
Are there off premises activities and/or field trips?
Yes No. If yes, please describe:
_________________________________________________________________________________________________
________________
_
________________________________________________________________________________
8. Does the facility have the following life safety practices?
Fire Alarms?
Yes No Central____ Local____
Emergency Lighting? Yes No
Sprinkler system?
Yes No
Are evacuation plans posted and practiced?
Yes No How often are the drills held? _______
Are Exit doors equipped with Panic Hardware?
Yes No
Any non-ambulatory patients residing above the first floor?
Yes No
If “yes” please explain___________________________________________________________________
9. Does this facility have 24 hour on-site staff?
Yes No.
10. Are clients adjudicated or here in lieu of incarceration?
Yes No If yes, please explain________________________
_________________________________________________________________________________________________
11. At what temperature is the water set?
12. Any swimming pool or hot tub on premises? Yes No If yes, please provide the following:
Depth (pool) ____
Secured by locked fence?
Yes No
Please describe procedures for use by clients/residents________________________________________________
____________________________________________________________________________________________
MP 4004ce 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 2 of 2
13. Is the insured responsible for obtaining medical treatment for residents? Yes No
Do staff members administer medications?
Yes No
Are medicines kept locked when not in use?
Yes No
Are written records kept on all clients?
Yes No
14. Do you have sign out procedures?
Yes No Alarms on doors? Yes No
15. Are there animals on premises?
Yes No If yes, please describe size and breed:
__________________________________________________________________________________
Are they restrained or do they interact with clients?
_______________________________
Date Signed Signature of Applicant
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Supplemental ResidentialAdult Daycare FACILITY QUESTIONNAIRE (Risk Placement Services, Inc.)

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Completed 30 July 2020

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