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1 F Review and Comment Purposes Only t f Implementation Attachment 4 Lifesharing Home Study Physical Site Review Home Study Professional Infmation Name Address Phone Date of Physical Site Review Date of Physical Site Review Lifesharer Home: Address: Phone #: Address: DESCRIPTION OF RESIDENCE Type of Structure and Construction (please check): Apartment Brick Row Home Stucco Duplex Concrete Block Other Wood Frame Do you have a yard? Is your yard fenced? Do you have any pets? If yes what pets? If no, what pets would you consider if the individual wanted one? How many flos (sties) does your home have? Does your home have a basement? Does anyone sleep in the basement? Does your home have an attic? _ 1

2 F Review and Comment Purposes Only t f Implementation Attachment 4 How long have you occupied your present home? Type of Heating (please check all that apply): Gas Oil Coal Electric Other Do you use supplemental space heaters? If yes, what type (electrical, kerosene)? How many full bathrooms do you have? Half baths? How many bedrooms do you have? Square footage of bedroom f an individual living in your home? feet by feet On what flo of the home is this bedroom located? How many smoke detects do you have in your home? Is there a smoke detect on each flo? Do you have fire extinguishers in your home? How many? What type of electrical service do you have (please check)? Circuit breaker Fuse Do you permit smoking in your home? If apartment, is there a Certificate of Occupancy available to the entire building? Neighbhood Location Urban (City) Rural Suburbs Neighbhood Characteristics Quiet isy Congested Heavy Traffic Many Children Safe to be outside? (Circle one) Daytime Nighttime Comments: 2

3 F Review and Comment Purposes Only t f Implementation Attachment 4 Living Areas Kitchen has refrigerat, sink, stove, oven, and cabinet f stage Utensils used f eating, drinking and preparation of food drink are washed and rinsed after each use Crective Action Living room/recreation space in addition to bedrooms Bathroom At least one toilet, shower tub Privacy provided f toilet, shower tub by partitions dos Sink, wall mirr, soap, towels, & toilet paper (individual paper/cloth towels & trash receptacle) Individual washcloth, bath towel & toothbrush f each individual If physically handicapped, one bathroom constructed as accessible Crective Action Bedroom Bedroom is not in basement attic. If a shared room, minimum of 50 sq. ft. per person 60 sq. ft f a single person Room has direct access to a crid Bedroom has one window Bedroom is ventilated. Crective Action 3

4 F Review and Comment Purposes Only t f Implementation Attachment 4 Bed linens laundered weekly Room is not sole means of egress to others rooms entrance to stairway basement Bedroom has a mirr, chest of drawers & closet wardrobe space accessible Bed appropriate size with clean comftable bed pillow, mattress & foundation Laundry Provisions f regular laundry Clean & dirty laundries separate Towels, washcloths, and clothing kept clean Crective Action Stairs Well-secured handrails on stairways with me than two steps (including outside) All stairways, hallways & exits from rooms & home free from obstruction Interi stairs have non-skid surface Landings at interi & exteri stairway dos Crective Action Fire Extinguishers Ptable fire extinguishers with 2A rating on each flo accessible to resident & kitchen with 2A- 10BC Fire extinguishers inspected & approved within 12 months by local fire department lab & industry Fire extinguisher f each sq ft. of space Crective Action Smoke Detects At least one smoke detect on each flo (including attic & basement) Smoke detection devices located in common areas & hallways (& approved by PA Dept. of Lab & Industry, Underwriters Lab. LS) Crective Action 4

5 F Review and Comment Purposes Only t f Implementation Attachment 4 Electricity and Heat Electric lighting in all rooms & hallways, stairways, outside steps, pches & ramps All accessible 120- degree hot pipes, heaters, etc., have protective devices, etc. All operative fireplaces screened with protective devices while in use Crective Action Other obstructed doways locks on dos used as exits, which require keys, padlocks skeleton key locks interi dos with keyed locks to exit rooms (includes skeleton keyed locks) Flos, walls, ceilings, surfaces clean, free of hazards and in good repair All furniture and equipment in good repair Operable phone with emergency numbers posted nearby All cleaning supplies locked Flammable & caustic materials are sted in a locked area away from heat & flame First Aid kit (antiseptic, assted adhesive bandages, sterile gauze, tweezers, tape & scisss) All medications locked visible sign of insect rodent infestation All open windows screened Windows & screens in good repair All weapons sted in a locked case with ammunition sted away from weapons & secured under lock Safety restraints are operable in all vehicles, which may be used to transpt a client All in-ground swimming pools fenced with a gate that is locked when the pool is not in use All aboveground pools that are under 4 ft. in height made inaccessible by a fence with a gate that is locked, with a pool cover other options Crective Action 5

6 F Review and Comment Purposes Only t f Implementation Attachment 4 6