APD 0342 (4/19)

Adult Foster Home Evacuation/Fire Drill Record

Name of licensee:

Date:

Time: a.m. p.m.

AFH address:

Date of last fire drill conducted when residents were in bed:

• Location of simulated fire: • Exit route:

(Should vary location/route for each evacuation drill.) • Initial point of safety: • Final point of safety:

Type of evacuation drill: Sleeping hours Daytime

Resident’s name (last, first)

Resident evacuation times to initial point of safety Individual evacuation

time Substitute required? Description of assistance needed

Yes No Yes No Yes No Yes No Yes No

Other occupants (children, spouses, etc.)

Individual evacuation

time Substitute required? Description of assistance needed

Yes No Yes No Yes No Yes No Yes No Total evacuation time:

Note: Total evacuation for all occupants to the initial point of safety must be within three (3) minutes or less.

Caregivers present during evacuation drill

Minimum number of staff in the AFH at any given time:

Note: The number of staff assisting residents during an evacuation drill may not exceed the minimum number of staff in the AFH at any time.

Caregiver name Used as a substitute for a resident? Role during drill

Yes No Yes No Yes No Signature of staff conducting drill: