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CPS Home Visit Inspection Form

The best welfare of the child is the primary concern of CPS investigators and their agency. When a home visit must be made to parents, many different areas must be checked to properly assess whether the child or children are growing up in a hazard-free and child-friendly environment.


The following digital CPS home visit checklist helps the inspector step by step to take care of all points and to evaluate them according to the requirements of the authority. With Lumiform's digital tool, there is also the possibility to work with parents on inspection issues that need to be improved. To do this, actions are triggered and time-stamped. This allows CPS investigators to track via the dashboard when a next home visit needs to be conducted to check if failed inspection points have been cleaned up.


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  • Cut inspection time by 50%
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CPS Home Visit Inspection Form

General Information

Application/Provider Name
Address
City
ZIP Code
Telephone Number

General

The facility is clean, sanitary, and free of hazards including window blind cord hazards.
Adequate handrails and ramps provided.
Operating emergency lighting available.
Age appropriate furnishings and activities for children.
Bathroom, kitchen floors are washable.
Electrical outlets are tamper-proof if needed.
Premises are free from pests.
Address is clearly visible and location is accessible.
Pets and animals are safe and free from disease.
Light fixtures provide children good visibility and comfort.
Room temperatures at reasonable levels.
Home has adequate ventilation.
Home has adequate laundry facilities and storage.
The children have plenty of clothes.

Home Safety & Health

Knives, tools, matches, and other potentially hazardous materials are not accessible based on age, and identified safety concerns and behaviors specific to each child.
Chemicals, detergents, and other toxic substances are not stored with food products or accessible in any way that poses a risk to children.
Pools and hot tubes are secured and inaccessible to children.
Pools are adequately fenced to discourage climbing.
A supervision plan is in place when the home has a pool or bodies of water.
Combustible items are properly stored at least 36” from any heating sources.
Alcoholic beverages are inaccessible.
Smoking is prohibited in all living spaces and in car with children.
Guns and other weapons are secure and inaccessible to children.
Ammunition is inaccessible and separate from weapons if not in a gun safe.
Family vehicles have seatbelts. All drivers have a current license and insurance.
Family has car seats for the age range as needed.
Wheeled baby walkers will not be used.
Individual clean bed linens, towels, and wash cloths are provided for each foster child.
Home has at least one working telephone for emergencies.
(check name not set)

Fire Safety

Flammable materials and poisons are inaccessible to children.
Stoves, heaters or obstacles do not block exit way.
Any barrier to exiting is easily opened and does not cause delay.
Lock on outside exit doors unlock when knob is turned from inside.
Home has one swinging exit door that is hinged or pivoted on the side.
The house has two exit doors.
Bedroom windows for children are large enough for emergency rescue.
Fireplaces, wood stoves, heatings systems have barriers for under age 6.
Smoke alarms are in good working condition and mounted correctly.
Home has at leats one working 2A10BC-rated 5lb. or lager fire extinguisher.
Multi-level homes must have escape from upper floor.
Family conducts regular fire drills with children.
Family has a written fire evacuation plan for the home.

Bedrooms

Bedrooms have adequate ceiling heights.
Bedrooms have unrestricted direct access to common rooms.
Room has adequate floor space for safety and comfort.
No more than 4 children per bedroom.
80 square meter if mother/father and her/his infant share bedroom.
Only one mother and newborn per bedroom.
Each child has at least a 27 inch wide clean, comfortable bed of their own.
All beds and cribs used for sleeping have waterproof mattress materials if needed.
Toddler beds have standard crib mattresses sufficient in length and width for the comfort of the child under age 6.
Crib meets all safety requirements.
Cribs must have no more tha 2 3/8 inches between slats.
Crip bumpers, stuffed toys, pillows not placed in cribs with infants.
Infants are placed on their backs for sleeping.
Upper bunks not used by anyone who might be endangered.
Sleeping arrangements for the kids are exist and fit to their ages.

Medical Care and Medications

First aid supplies are on hand.
Poison Control number with first aid supplies and posted on or near telephone.
All medications are in locked storage with pet medications separate from human medications and external medications separate from internal.
Prescription medications are given to children recorded.
Medications are given only according to prescription lables.

Food/Diet

Food served to children and infants meets needs of the children.
Enough healthy food is in the house.
Food is readily available to children.
Food is handled and properly stored to prevent contamination, spoilage, or a threat to the health of children.

Confirmation

Supervision plan is in place if hazardous conditions exist.
Applicant's Signature
Parents' Signature
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