M-9B-UF Unlicensed Facility Foster Home Onsite Monitoring Checkl

Monitoring and Compliance for Office of Refugee Resettlement (ORR) Care Provider Facilities

M-9B-UF Unlicensed Facility Foster Home On Site Monitoring Checklist

OMB: 0970-0564

Document [docx]
Download: docx | pdf

Updated: 12/9/22 OMB 0970-0564 [valid through MM/DD/2026]


Foster Home Monitoring Checklist – Walkthrough (LTFC and TFC) – Unlicensed Facility (UF) Quarterly Health and Safety Visit1


General Home Information

Foster Parent Name(s):



Name of UC:

Foster Home Licensed Capacity:

Foster Home Address:



Date of Home Visit:

# of Children in Foster Home:

Age/Gender:

Program Name:



Type of Foster Home License:

# of Adults in Foster Home:

Relationship to FP/Gender:

*** PLEASE NOTE ANY NEW/UNKNOWN NAMES, AGES, RELATIONSHIPS, and MEDICAL NEEDS of Adults or Children living or working in the home (verify all info with FP case file)***



Compliant?


Compliant?

  1. General Safety and Security

Y

N

n/a


Y

N

n/a

Cleaning chemicals inaccessible to UC




Firearms (if applicable) inaccessible to UC




Medical supplies/prescriptions inaccessible to UC




Other unsafe areas inaccessible to UC




Fire extinguishers and smoke alarms in working order (test)




Pets? (clean/dangerous)




Playground/outdoor equipment (if applicable) appears safe and age appropriate




Outdoor area secure (fences in good repair, pool, supervised access)




Carbon Monoxide detectors (if applicable, gas fuel in home)









  1. General Safety and Security
















Compliant?

  1. Confidentiality

Y

N

n/a

Confidential UC information in a secure location




Only individuals with a need to know basis have access to the case files




Private place for UC to make phone calls (if applicable)






  1. Confidentiality












Compliant?


Compliant?

  1. General Home Structure

Y

N

n/a


Y

N

n/a

Clean and Safe (windows/door locks)




Kitchen




Child-friendly (e.g. no safety/trip hazards)




UC dietary restrictions posted/accessible




Home is properly maintained (including furniture)




Food stored in a sanitary manner




Infants/toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers)




Knives/sharp objects inaccessible to youth




Well-ventilated








Adequately heated/cooled




Bathrooms




Child-to-parent ratio met




Soap








Toilet paper




Bedrooms




Working toilets




Separate by gender (per state licensing)




Hot/cold water




Natural light/dark at night




Appropriate privacy




Private place to store personal items/clothing




Hygiene/grooming items




UC provided appropriate clothing/footwear




Towels




Provision of appropriate linens








Adequately accommodate all UC










  1. General Home Structure











Compliant?


Compliant?

  1. Documents that should be accessible to youth

Y

N

n/a


Y

N

n/a

Phone numbers for UC to report sexual abuse/harassment (best practice)




Grievance procedures posted




Program rules posted




Extra copies of UC grievance forms




Foster home rules




Evacuation procedures posted prominently on each floor





  1. Documents that should be accessible to youth















Foster Home Monitoring Checklist – Other




Observed?


Observed?

Services to Potentially Observe

Y

N

n/a


Y

N

n/a

Recreation – large muscle, outdoors




Chore assignments




Meals















Reviewed?

Logs/Schedules to Potentially Review

Y

N

n/a

UC documents maintained by the foster parent (phone logs, prescription logs, recreation logs/calendar, fire drill logs etc.)






Other Notes











1 Unlicensed Facility Quarterly Health and Safety Visits are performed for long-term group homes. ORR does not operate unlicensed long-term foster care or transitional foster care programs.


THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR contractor monitors staff to document their findings during the walkthrough portion of quarterly site visits. Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact UCPolicy@acf.hhs.gov.

Shape1


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created2023-11-20

© 2024 OMB.report | Privacy Policy