TX HHS Form 4004. Residential Child Care Licensing Environment Health Checklist

The Residential Child Care Licensing Environmental Health Checklist for Foster Homes (Form 4004) is designed to ensure that foster family homes in Texas meet the environmental health and safety standards set by the Texas Health and Human Services Commission (HHSC). This form is primarily used by local health authorities or agency staff to assess whether homes are safe, clean, and properly maintained for children in care.

Purpose and Overview

The checklist provides a structured evaluation of a foster home’s environment, covering cleanliness, food storage, plumbing, ventilation, safety measures, and outdoor conditions. The goal is to prevent hazards and maintain a safe and healthy living space for children.

Section-by-Section Explanation

1–3. Home and Grounds, Kitchen, Food Storage

This section verifies that the home and kitchen are clean, and that food is stored safely. Applicants often overlook proper refrigeration and storage of perishable items.

• Common mistakes: leaving food at room temperature, cluttered kitchens, or improperly stored cleaning supplies.
• Tip: Keep perishable items refrigerated and label all containers clearly.

4–7. Water Supply and Plumbing

Ensures access to safe drinking water and proper sewage disposal. Private wells require consulting DSHS if issues arise.

• Typical errors: not checking water heater temperature, neglecting maintenance of plumbing.
• Tip: Maintain water heater below 120°F (49°C) and schedule routine plumbing inspections.

8–11. Bathrooms and Hygiene

Bathrooms must be equipped and sanitary, with soap, toilet paper, and clean towels available.

• Tip: Provide separate clean towels for each child or disposable paper towels.

12–16. Garbage, Yard, and Pest Control

Regular garbage disposal, well-drained yards, and pest control are mandatory.

• Common oversight: garbage cans left uncovered or standing water in the yard.

17–18. Ventilation and Windows

Proper ventilation and screened windows help maintain air quality and prevent insect entry.

19–21. Dangerous Substances and Electrical Safety

Cleaning supplies, medicines, and accessible electric outlets must be secured. TVs and fans should be mounted or guarded to prevent accidents.

22–24. Floor, Steps, and Glass Safety

Ensure all indoor and outdoor surfaces are non-slippery, free of splinters, and glass doors are marked at a child’s eye level.

25. Weapons and Hazardous Materials

Weapons, firearms, and explosives must be stored according to Texas Administrative Code §749.2961.

26–28. Stairways, Beds, and Recreation Equipment

Stairways must be well lit with secure railings, beds must have mattress protectors, and outdoor play equipment should be safe and maintained.

Practical Tips for Completion

• Complete the checklist thoroughly for every foster home inspection.
• Document any hazards immediately and maintain records of corrective actions.
• Double-check all contact information and dates.

Examples of Real-Life Use

• A new foster parent preparing their home for inspection uses this checklist to ensure compliance with state regulations.
• Local health authority staff conducting a routine inspection uses Form 4004 to verify sanitation, safety, and environmental standards.
• An agency responding to a complaint about unsafe conditions uses the checklist to identify hazards and recommend corrective measures.

Required Documents

• Completed Form 4004 checklist
• Comments or notes documenting hazards and corrective actions
• Facility and staff contact information

Frequently Asked Questions

Who must complete this form?

Local health authority or agency staff performing environmental inspections of foster homes.

When is this checklist required?

During licensing inspections, renewal evaluations, or when complaints are filed regarding foster home conditions.

What are common mistakes?

• Failing to secure hazardous materials or electrical outlets.
• Overlooking cleanliness of bathrooms and kitchens.
• Improper storage of perishable foods or garbage.

What happens if violations are found?

Non-compliance may result in corrective action plans, temporary suspension, or revocation of foster home licensing.

Can this form be submitted electronically?

Check with the local HHSC office; usually, physical inspections are required.

Micro-FAQ

• Purpose: Ensures foster homes meet environmental health standards.
• Who files: Local health or agency staff.
• Deadline: During licensing or inspection schedules.
• Attachments: Checklist, notes, and facility contact info.
• Submitted to: Texas Health and Human Services Commission.

Related Forms and Resources

• Residential Child Care Licensing Application Forms
• Texas Foster Home Safety Guidelines
• Other Texas HHSC Licensing Checklists

Form Details

Name: Residential Child Care Licensing Environmental Health Checklist – Foster Homes

Form Number: 4004

Region: Texas

Date of Revision: August 2025