Form 5605, Life Safety Code Overview Worksheet

Instructions

Updated: 4/2014

Purpose

Form 5605 is completed by Waiver Survey & Certification (WS&C) residential reviewers when a Home and Community-based Services (HCS) four-bed home does not have evidence of a fire safety authority inspection having been conducted in the last 12 months.

Procedure

A WS&C residential reviewer completes and submits Form 5605 to the Architectural Unit when an HSC four-bed home does not have an inspection by a local fire safety authority, the State Fire Marshal’s Office, or Texas Health and Human Services Commission (HHSC) Office of Maintenance and Construction within the last 12 months.

Detailed Instructions

Reviewer — Enter the name of the residential reviewer

Date of Inspection — Enter the date of the residential reviewer’s inspection.

Provider Information

Name — Enter the name of the program provider.

Area Code and Telephone — Enter the area code and telephone number of the program provider.

Address of Home — Enter the street address for the four-bed home.

City, State, ZIP Code — Enter the city, state, and ZIP code for the four-bed home.

Contact — Enter the name of the person who acted as the contact for the program provider at the time of the inspection.

Date Home Certified as Four-Bed — Enter the date, if known, when the home was first certified as a four-bed home.

Location Description — Enter, at least, the program provider-assigned location code for the home. Since this form only applies to four-bed homes, it is not necessary to indicate that the home is a four-bed home.

Comments

Provider Determined Evacuation Capability (E-Score) — Enter the evacuation capability and the numerical E-score, if known. Homes that are inspected by local fire authorities under the International Fire Code might not have E-scores, which is okay.

Date of Last Fire Inspection — Enter the date of the last fire marshal or HHSC fire inspection.

Notes — Enter information about wall and ceiling finishes in this area. In homes that were last inspected by a local fire authority, include the fire prevention code and edition used by the local fire safety authority, if possible.

Inspecting Authority — Enter the name of the agency or political subdivision that performed the fire inspection noted above.

Fire Sprinkler Type — If the home is equipped with a fire sprinkler system, determine the type of system from documentation provided by the program provider, if possible.

NFPA 13 — This type of fire sprinkler system includes full sprinkler protection in the attic and at covered outdoor areas. This system type would require a fire department connection on the outside of the home.

NFPA 13R — Homes protected by this type of fire sprinkler system would not, generally, have sprinklers in the closets.

NFPA 13D — If the sprinkler system is connected to large tanks of water in the garage or a utility room, the sprinkler system is probably of this type.

None — Mark if the home does not have a fire sprinkler system.

Date of Last Fire Sprinkler Inspection, if Applicable — If the home is equipped with a fire sprinkler system, enter the date of the last inspection by an independent service company; the provider should have documentation.

Minimum Construction — For each item, mark Yes, No or N/A (Not Applicable).

1. Is the home fully sheathed?

• Mark Yes if all walls and ceilings are covered in gypsum board (sheetrock). Take special care when the finished surface of a wall or ceiling is wood paneling. You may be able to determine through staff interview or by knocking on the wall whether there is gypsum board.
• Mark No if all walls and ceiling are not covered in gypsum board (if you see holes in walls or ceilings) or if it is not possible to determine whether all walls and ceilings are covered in gypsum board.
• Mark N/A if the walls are not gypsum board. This is not typical of any home setting. In general, this box will not be marked.

Means of Escape — For each item, mark Yes, No or N/A.

1. Are all escape pathways in the home continuously maintained free of obstructions or impediments?
2. Does each story of the home have two remotely located means of escape (such as exterior doors or stairways) that do not require using windows? — Generally, homes will have, at least, a front and back door.
3. Do all individuals have a primary means of escape from their bedrooms that does not require using windows and the means of escape from the bedroom is totally separate from a kitchen or common living area? (If the home has a sprinkler system, mark as N/A.) — Mark Yes, if an individual is able to escape from their bedroom without climbing out a window and the path does not pass through a room or space that is open to a kitchen, living room, or other common living area. If the home is equipped with a fire sprinkler system, mark N/A.
4. Do all individuals' bedrooms have an outside window that is operable, a door opening directly to the outside, or passage into an adjacent unlocked space that provides a mean of escape separate from the primary means of escape? (If the home has a sprinkler system, mark as N/A.) — An acceptable secondary means of escape may be an operable window, a door from the bedroom directly to the outside, or a path through an adjacent room to one of these. If any of these options are available, mark Yes. If the home is equipped with a fire sprinkler system, mark N/A.
5. If the individual's bedroom has an outside window and no other secondary means of escape, is the clear opening of all bedroom windows not less than 5.7 square feet, with a width of not less than 20 inches and the height not less than 24 inches? (If the home has a sprinkler system, mark as N/A.) — Mark Yes if the window meets this requirement. If the home is equipped with a fire sprinkler system, mark N/A.

• This is a measurement of the clear opening of a window. If the window is opened fully, what is the size of the opening you could climb through?
• A window 20 inches by 24 inches is not large enough to meet the 5.7 square foot area.
• A window 20 inches wide must be at least 41 inches tall.
• A window 24 inches tall must be at least 34 inches wide.

• If the individual's bedroom has an outside window and no other secondary means of escape, is the bottom of all bedroom window openings no more than 44 inches above the floor? (If the home has a sprinkler system, mark as N/A.) — Mark Yes, if the only available secondary means of escape from a bedroom is through an outside window and the dimension from the floor to the bottom of the window opening is no more than 44 inches. If the home is equipped with a fire sprinkler system, mark N/A.
• If the individual's bedroom has an outside window and no other secondary means of escape, is the window within 20 feet of the ground level or does the window or door open onto an exterior balcony? (If the home has a sprinkler system, mark as N/A.) — Mark Yes if the only available secondary means of escape from a bedroom is through an outside window and the window is within 20 feet of the ground or opens onto an exterior balcony. If the home is equipped with a fire sprinkler system, mark N/A.
• Is there a primary means of escape other than an interior stair? — Mark Yes if the home is more than one story tall and there are other ways to escape upstairs bedrooms without traversing an interior stair. If the home is only one story, mark N/A.
• Are all doors operable from the egress side without a key, tool or special knowledge?
• Protection — For each item, mark Yes, No or N/A.
  1. Are all interior stairs enclosed at the top or bottom level? — Mark Yes if either the top or the bottom of an interior stair is enclosed with walls and doors. If the home is only one story, mark N/A.
  2. Are quantities of storage similar or below that normally found in a single family residence?
  3. Is the only type of wall and ceiling finish in the home painted gypsum board (sheetrock, i.e., there is no wood paneling, wallpaper or acoustical ceiling tiles)?
  4. If the answer to the above question is no, did the program provider provide documentation regarding flame spread (Class A, B or C)? Provide a detailed description of the finish and flame spread under Notes in the Comments section. — Documentation might include manufacturer’s literature or documentation indicating the provider has applied a commercial treatment to the finish material to achieve an acceptable flame spread rating, in which case the documentation should include what product was applied and when it was applied.
  5. Has the fire alarm system been checked annually and does it appear to be in working order?
  6. Is there at least one manual pull station in the home?
  7. Are there smoke alarms on every floor, including basements? (Smoke alarms are not required in crawl spaces or unfinished attics.)
  8. Are there smoke alarms in all living areas?
  9. Are there smoke alarms in all bedrooms?
  10. Does the home have a sprinkler system? If the answer is yes, provide information above under comments regarding the type of system and when the system was last inspected.
  11. If the home has a sprinkler system, is there a heat detection system in the attic that activates the fire alarm system or are there sprinklers in the attic? (Ask the operator. Do not inspect the attic.) — If the home is not equipped with a fire sprinkler system, mark N/A.
  12. Are all individuals' bedrooms separated from hallways by walls?
  13. Do all doors to the individuals' bedrooms latch?
  14. Are there no obstructions, such as furniture, that would prevent the individual from closing the bedroom door?
  15. If the home does not have a sprinkler system, are doors to the individuals' bedrooms self-closing? — If the home is not equipped with a fire sprinkler system, mark N/A.
  16. Does the home have adequate, fully charged ABC fire extinguishers within 75 feet of any location in the home?
  17. Do labels on the fire extinguishers indicate that staff inspects the extinguishers monthly and an authorized person is inspecting the extinguishers annually?
  Building Services — For each item, mark Yes, No or N/A.
  1. If there are electrical receptacles located within 6 feet of the edge of a sink, do the receptacles have ground-fault circuit interrupter (GFCI) protection? — Mark Yes if electrical receptacles within 6 feet of sinks are protected by a built-in circuit breaker to protect against electrocution.
  2. Are all circuits labeled at the main electrical panel?
  Operating Features — For each item, mark Yes, No or N/A.
  1. Does the home have a written emergency plan for protecting all persons in the event of a fire?
  2. Does the plan include special staff response and can staff explain their duties and responsibilities under the plan?
  3. Does the plan address the fire protection procedures and any assistance needed to ensure the safety of each individual present in the home?
  4. Have individuals in the home received training in the proper actions to be taken in the event of a fire?
  5. Have fire drills been conducted not less than six times over the past year on a bimonthly basis with not less than two drills conducted during the night when individuals are asleep? — Bimonthly means every other month in this context.
  6. Does the home have a smoking policy? — A home should have a policy, even if the policy is that smoking is not permitted.
  7. If smoking is permitted, are noncombustible safety-type ashtrays provided in convenient locations? — Chimney-type or smoker station type cigarette disposal devices are not generally considered safe ashtrays.
  8. Does the home have documents to prove that new drapery, curtains or other similarly loosely hanging furnishings (but not shower curtains) meet the flame propagation performance criteria required in NFPA 701? — Documentation might include labels attached to draperies/curtains, literature from the manufacturer, or records indicating the provider has treated the draperies and curtains with a product to provide this protection. Documentation of treatment should indicate what product was applied (ideally the label or container is available) and the date it was applied.