Date Visited {date_visited} 
Location {location} 
Coordinator {coordinator} 
Location Phone {loc_phone} 
# Of Ind {no_of_ind} 
# Of Staff {no_of_staff} 

Exterior

Observations

Yes/No

Comments

Steps/Ramp Strips in Good Condition {chk1} {cmt1} 
Ramp Strips in Good Condition {chk2}  {cmt2} 
Hand Rails Secure {ck3}  {cmt3} 
Lawn Moved/Trees and Shrubs Trimmed {chk4}  {cmt4} 
Cracked/Peeling Paint {chk5}  {cmt5} 
Functional Windows with Screens {chk6}  {cmt6} 
Downspouts/Gutters Affixed {chk7}  {cmt7} 
Pavement in Good Condition {chk8}  {cmt8} 
Outside Free of Trash/Debris {chk9}  {cmt9} 

Interior

Wheelchair Accessible (If Applicable) {chk10}  {cmt10} 
Adequate Living/Work Space {chk11}  {cmt11} 
Thermostat set at 72 degrees {chk12}  {cmt12} 
Room Clean and Free from Clutter {chk13}  {cmt13} 
Free for Apparent Hazards {chk14}  {cmt14} 
Home Odor Free {chk15}  {cmt15} 
Proper Trash Storage/Disposal {chk16}  {cmt16} 
Plumbing Working Properly {chk17}  {cmt17} 
Carpet Clean / Floors {chk18}  {cmt18} 
Adequate Cleaning Supplies {chk19}  {cmt19} 
Furniture Reflects Individual's Choice {chk20}  {cmt20} 
Decorations Reflect Individual's Choice {chk21}  {cmt21} 
Adequate Lighting {chk22}  {cmt22} 
Adequate Window Coverings {chk23}  {cmt23} 
Dryer Trap Free From Lint {chk24}  {cmt24} 
Wallls Free From Marks {chk25}  {cmt25} 

Kitchen

Appliances Clean {chk26}  {cmt26} 
Appliances in Working Order {chk27}  {cmt27} 
Adequate Food {chk28}  {cmt28} 
Proper Food Storage (Rotate for Date) {chk29}  {cmt29} 
Food Reflects Diets {chk30}  {cmt30} 
Proper Food Handling {chk31}  {cmt31} 
Adequate Utensils/Dinnerware {chk32}  {cmt32} 
Walls Free From Marks {chk33}  {cmt33} 

Master Bathroom

Allows for Privacy {chk34}  {cmt34} 
Soap/Towels/Paper {chk35}  {cmt35} 
Cleanliness {chk36}  {cmt36} 
Personalized {chk37}  {cmt37} 
Proper Ventilation {chk38}  {cmt38} 
Walls from Marks {chk39}  {cmt39} 

Other Bathroom

Allows for Privacy {chk40}  {cmt40} 
Soap/Towel/Toilet Paper {chk41}  {cmt41} 
Cleanliness {chk42}  {cmt42} 
Personalized {chk43}  {cmt43} 
Proper Ventilation {chk44}  {cmt44} 
Walls free from Marks {chk45}  {cmt45} 

Other Bathroom

Allows for Privacy {chk46}  {cmt46} 
Soal/Towels/Toilet Paper {chk47}  {cmt47} 
Cleanliness {chk48}  {cmt48} 
Personalized {chk49}  {cmt49} 
Proper Ventilation {chk50}  {cmt50} 
Walls Free From Marks {chk51}  {cmt51} 

Bedroom (Residential)

Allows for Privacy {chk52}  {cmt52} 
Adequate Closets/Storage {chk53}  {cmt53} 
Personal Items Kept in Rooms {chk54}  {cmt54} 
Trash Cans Available {chk55}  {cmt55} 
Walls Free From Marks {chk56}  {cmt56} 
Cleanliness {chk57}  {cmt57} 

Bedroom 2 (Residential)

Allows for Privacy {chk58}  {cmt58} 
Adequate Closets/Storage {chk59}  {cmt59} 
Personal Items Kept in Rooms {chk60}  {cmt60} 
Trash Cans Available {chk61}  {cmt61} 
Walls Free from Marks {chk62}  {cmt62} 
Cleanliness {chk63}  {cmt63} 

Bedroom 3 (Residential)

Allows for Privacy {chk64}  {cmt64} 
Adequate Closets/Storage {chk65}  {cmt65} 
Personal Items Kept in Rooms {chk66}  {cmt66} 
Trash Cans Available {chk67}  {cmt67} 
Walls Free From Marks {chk68}  {cmt68} 
Cleanliness {chk69}  {cmt69} 

Medical

45 Days Reviews {chk70}  {cmt70} 
Ensure New Meds are in Place (if Applicable) {chk71}  {cmt71} 
Are New/Existing PMOFs filled? Psych & Non Psych {chk72}  {cmt72} 
Are all MARs filled out Completely? Documentation on reverse {chk73}  {cmt73} 
Check PMOFs to Ensure they are filled out {chk74}  {cmt74} 

Individual's Personal Items

Log Maintained {chk75}  {cmt75} 
Present in the home {chk76}  {cmt76} 
Good Condition {chk77}  {cmt77} 

Activity Logs

Activity Noted Being done at visit {chk78}  {cmt78} 

Vehicle

Mileage Log Completed up to date {chk79}  {cmt79} 
Clean {chk80}  {cmt80}
Damage Present (is it old or new; location of damage) {chk81}  {cmt81} 
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