| 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} |
| No records |
|
