State of Vermont Department of Disabilities, Aging and

Agency: Please complete and upload into the Housing Portal prior to scheduling the inspection

Date of Inspection

Name of Participant

Guardian (s)

Physical or Mobility Impairments (Brief Description)

Expected Date of Occupancy

Type of Home AFC DS TBI Total Number of Bedrooms in Home

Home Provider Name

911 Address

City, State, Zip Code

Home Provider Phone Number

Agency

Service Coordinator

Independent LivingPre-Inspection Housing Standards and Checklist

TO BE COMPLETED BY THE AGENCY

v_01/10/22

☐ If a water test is required, it has been requested and the results have been received.Any home that is not on a public water system is required to have a water test completed. It is up to thehome owner to request this test. The test needs to be requested, submitted, and the results receivedand uploaded into the DAIL Housing Portal prior to requesting an assessment with the HousingContractor. The Shared Living Provider will need a copy of the results to show the Housing Contractorduring the assessment.

☐ If a chimney cleaning verification is required, it has been obtained from the Shared LivingProvider. Any home that burns wood or wood pellets as a heating source needs to verify the chimneyhas been cleaned and inspected by a professional chimney cleaner. This certification needs to beuploaded into the DAIL Housing Portal prior to the assessment being requested, and the Shared LivingProvider will need a copy to show the Housing Contractor during the assessment.

The agency is required to do an in-person pre-inspection of any shared living provider home, work with the shared living provider to correct any known deficiencies, obtain any required documentation, and create an Assessment and upload the documentation into the DAIL Housing Portal prior to requesting a home safety inspection.

Kitchen

YES NO N/A

1 Fire Extinguisher is a minimum 3 pounds 2 Fire Extinguisher is charged 3 Fire Extinguisher is mounted between heat source & exit path

4 GFCI at all electrical duplex 6’ from sink 5 Other Findings

Bedroom 1: (Please circle) Floor: 1 2 3 Looking from Street: Left Center Right Front Center Rear

YES NO N/A 6 7 Minimum Size 6.5’ (height) x 8’ (length) x 8’ (width) 8 Room has a smoke detector 9 Room has a solid surface door to block smoke 10 Exit door or egress window is operable to the outside and in good repair

11 Egress window has the right square foot area 12 Egress window meets the min. height (24”) / width (20”) 13 Egress window sill at or less than 44” from the floor 14 Other Findings

Bedroom 2: (Please circle) Floor: 1 2 3 Looking from Street: Left Center Right Front Center Rear

YES NO N/A 15 Location – looking from street to home: 16 Minimum Size 6.5’ (height) x 8’ (length) x 8’ (width) 17 Room has a smoke detector 18 Room has a solid surface door to block smoke 19 Exit door or egress window is operable to the outside and in good repair 20 Egress window has the right square foot area

21 Egress window meets the min. height (24”) / width (20”) 22 Egress window sill at or less than 44” from the floor 23 Other Findings

Bedroom 3: (Please circle) Floor: 1 2 3 Looking from Street: Left Center Right Front Center Rear

YES NO N/A 24 Location – looking from street to home: 25 Minimum Size 6.5’ (height) x 8’ (length) x 8’ (width) 26 Room has a smoke detector 27 Room has a solid surface door to block smoke 28 Exit door or egress window is operable to the outside and in good repair 29 Egress window has the right square foot area 30 Egress window meets the min. height (24”) / width (20”) 31 Egress window sill at or less than 44” from the floor 32 Other Findings

Bath

YES NO N/A 33 Duplex installations in the bathroom w/in 6’ of sink are GFCI 34 Other Findings

CONVENTIONAL HEATING SYSTEMS

YES NO N/A 35 Heating system can ensure 70 degree temperature during the winter 36 There is a smoke detector in the basement OR at the heat source area 37 The heating system is vented to prevent CO blowback or other hazards 38 Oil / Kerosene: There is a clearly marked emergency switch at or before the

entrance to the boiler / furnace room 39 Oil / Kerosene: Is there a thermal switch over the furnace 40 Gas Systems: There is a thermal switch over the furnace (or built into the

furnace controls, if possible, to ascertain)

41 Boilers: There is a pressure relief valve [PRV] in good condition 42 The PRV discharge pipe is within 6” of the floor or other lower level 43 Electric: If electric heaters are used, there is 6” of clearance from

combustibles 44 Other Findings

WOOD OR WOOD-RELATED HEATING SYSTEMS

YES NO N/A 45 There is a 3 lb minimum Fire Extinguisher for rooms with wood heat 46 The Fire Extinguisher is charged 47 Fire Extinguisher is mounted between heat source & exit path

48 There is a smoke detector in the room with wood heat 49 Installation: The stove is 36” or more from combustible surfaces OR

are there heat shields installed per instruction that would decrease the clearances to 18"

50 Installation: There is a non-combustible hearth of at least 18” in front of the loading door

51 Installation: The flue pipe is 18” from combustibles or are heat shields installed per Instruction that would decrease the clearances to 9”

52 Installation: There is proof of annual chimney cleaning 53 Installation: All interior wood stoves have their own flue / chimney 54 Installation: The vent piping is in good condition (no gaps, not loose, etc) 55 Installation: Pellet stoves are installed per manufacturers specifications –

(Note: in order to show this, the inspector must be able to review the installation guide that came with the stove.)

56 Other Findings

SAFETY HAZARDS

Electricity YES NO N/A 57 Electricity: Exterior duplex plugs are protected by GFCI

58 Electricity: Washing machine duplex plugs are protected by GFCI (Note: the GFCI may be located at the breaker box which extends coverage to the entire circuit.

59 Electricity: There are no obvious electrical hazards such as open junction boxes, visible frayed wires, unsafe connections, switches / duplexes missing plate covers or unsafe use of extension cords

60 Electricity: The circuit breaker box is in good condition (no KO’s missing, etc.) 61 Electricity: Other findings

Water Heaters YES NO N/A

62 Water Heaters: The water heater has a PRV and a ¾” discharge pipe from the valve to within 6” of the floor

63 Water Heaters: The water heater is vented correctly

Doors/Exit Path & Decks/Rals YES NO N/A 64 Doors / Exit Path: Exit doors or paths are free from locking mechanisms

keyed from inside 65 Doors / Exit Path: All stairways have at least one handrail 66 Decks / Rails: For decks floor surfaces 24” to 30” above ground level –the

deck has a sturdy railing at least 30” high 67 Decks / Rails: For deck floor surfaces over 30” above ground level – The

deck has a sturdy railing at least 42” high 68 Doors / Exit Path / Decks / Rails: Other Findings

Firearms YES NO N/A 69 Firearms: All firearms are securely locked in a gun safe, closet or with trigger

or cable locks, with key(s) kept in a separate location 70 Firearms: Guns stored in cabinets with glass / plexiglass fronts have trigger

locks 71 Firearms: Other Findings

HEALTH HAZARDS

Carbon Monoxide YES NO N/A 72 Carbon Monoxide: Home is equipped with carbon monoxide detectors in a

common area 73 Carbon Monoxide: Carbon monoxide detectors are placed in areas

with heating sources 74 Carbon Monoxide: Other Findings

Drilled well, dug well, or spring Water YES NO N/A 75 Drilled well, dug well, or spring Water: Water has been tested for E.

Coli/Coliform within the past year 76 Water Supply / Wastewater: The home has an operating septic system 77 Water Supply / Wastewater: Other Findings

Hazards Material / Other Health Hazard YES NO N/A 78 Hazards Material / Other Health Hazard: Hazardous materials such as

flammables or poisons, are stored away from heat or in such a way that they cannot likely be a hazard to home occupants

79 Hazards Material / Other Health Hazard: Other Findings

80 Hazards Material / Other Health Hazard: The potential for asbestos exposure exists in the home

81 Hazards Material / Other Health Hazard: Other Findings

82 Hazards Material / Other Health Hazard: The potential for lead dust exposure exists in the home (from lead-based paint)

83 Hazards Material / Other Health Hazard: Other Findings

OTHER HOUSING SAFETY / HEALTH ISSUES

Garage Condition YES NO N/A 84 Garage Condition: The wiring system / electrical supply is in good condition

85 Garage Condition: The use of extension cords is minimized 86 Garage Condition: If hazardous materials such as flammables or poisons are

in the garage, they are stored away from heat or in such a way that they cannot likely be a hazard to home occupants

87 Garage Condition: If the garage is heated, the units are installed and vented correctly

88 Garage Condition: Other findings

Fire Escape Plan YES NO N/A 89 Fire Escape Plan: The Shared Living Provider created a Fire Escape Plan

90 Fire Escape Plan: Has a MAP of egress routes 91 Fire Escape Plan: Has written instructions 92 Fire Escape Plan: Is Posted 93 Fire Escape Plan: (Re-Inspections)Plan is practiced at least once every six months

The completed Pre-Inspection Housing and Standards Checklist is required to be uploaded into the Related tab of the Assessment in the DAIL Housing Portal, when the Assessment is created in the DAIL Housing Portal. The fire escape plan, water test (if applicable), chimney cleaning and inspection report (if applicable), also need to be uploaded into the Portal. These need to be completed prior to the Housing Contractor performing the home safety inspection.

Comments/Other Information:

Bedroom 4: (Please circle) Floor: 1 2 3 Looking from Street: Left Center Right Front Center Rear

Bedroom 5: (Please circle) Floor: 1 2 3 Looking from Street: Left Center Right Front Center Rear YES NO N/A

24 Location – looking from street to home:

25 Minimum Size 6.5’ (height) x 8’ (length) x 8’ (width)

26 Room has a smoke detector

27 Room has a solid surface door to block smoke

28 Exit door or egress window is operable to the outside and in good repair

29 Egress window has the right square foot area

30 Egress window meets the min. height (24”) / width (20”)

31 Egress window sill at or less than 44” from the floor

32 Other Findings Bedroom 6: (Please circle) Floor: 1 2 3 Looking from Street: Left Center Right Front Center Rear YES NO N/A

24 Location – looking from street to home:

25 Minimum Size 6.5’ (height) x 8’ (length) x 8’ (width)

26 Room has a smoke detector

27 Room has a solid surface door to block smoke

28 Exit door or egress window is operable to the outside and in good repair

29 Egress window has the right square foot area

30 Egress window meets the min. height (24”) / width (20”)

31 Egress window sill at or less than 44” from the floor

32 Other Findings

YES NO N/A

24 Location – looking from street to home:

25 Minimum Size 6.5’ (height) x 8’ (length) x 8’ (width)

26 Room has a smoke detector

27 Room has a solid surface door to block smoke

28 Exit door or egress window is operable to the outside and in good repair

29 Egress window has the right square foot area

30 Egress window meets the min. height (24”) / width (20”)

31 Egress window sill at or less than 44” from the floor

32 Other Findings