Monthly Safety Inspection
Christ Centered Homes, Inc
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Name
Please Select
Adams
Blackstone
Brown
Deyo
Elm I
Elm II
Glengarry
Grace
Herkimer-Hays
Herkimer-Reagan
Herkimer Apt.
Hill Place
Homecrest
Marvin
Madison
Monroe
Napoleon
Pleasant I
Pleasant II
Pontiac Trail
Russell
Second
Six
Spring Arbor
Tipton
West
West Washington
Westhaven
Westwood
Name
First Name
Last Name
Name of Your Quality Improvement Officer
Please Select
Cheryl Howard
Liz Logan
Alicia Williams
Jodi Rodriguez
Erica Parker
Postings
Rows
Compliant
Non Compliant
NA
Emergency Numbers
Evacuation maps
MSDS Sheets
Calculation
Facility Self Check
Rows
Compliant
Non Compliant
NA
Are all Exits and Hallways unobstructed
Are all entrances /Exits and Parking Areas free of trip and fall hazards
Has all plumbing been checked for leaks or defects
Are all combustible items kept 6 feet away from heat sources
Are all Circuit breakers clearly marked and accessible
Was the Hot water temperature checked and found to be between 110-120 degrees
Was the refrigerator checked and found to be 40 degrees for fridge and ) for freezer
Is Salt Supply available during the months of November -March
Emergency Kits
Rows
Compliant
Non Compliant
NA
First
Aid Kit is Fully Stocked
Emergency Bag has all required Items
Bloodborne Pathogens Kits is available
Fire Prevention and Protection
Rows
Compliant
Non Compliant
NA
Smoke Detectors work Upon Testing
Fire Extinguishers have pin intact and current tag
Was a fire drill conducted on each shift this month
Carbon Monoxide Detector work upon testing
Have all electrical cords been inspected
Have Heating vents and registers been cleaned
Has Air conditioner and Furnace Filters been cleaned
Are all flammable liquids and cleaners properly stored and locked
Staff Training
Rows
Compliant
Non Compliant
NA
All All staff members First Aid and CPR Up to Date
Are All Staff Trained on Universal Precautions
Are All Staff Knowledgeable on Emergency Evacuation Plans
Is the Smoking Policy enforced and followed
Equipment Safety
Rows
Compliant
Non Compliant
NA
Emergency Lights all illuminate
All Appliances are in Good Working Order
House Number Clearly marked and Visable
Telephone in working order
Vehicle Safety
Rows
Compliant
Non Compliant
NA
Were you fluid Levels/Belts/ Hoses/ Oil Levels professionally Checked this Month
Did you Inspect your windsheild wipers for wear and breaks
Is Your Radio Operational
Are your Door Locks Operational
Are all windows Operational
Are heating and Cooling systems operational
Do all Low Beam / High Beams and Hazard Lights work
Do You have the necessary amount of tie downs per wheelchair
Is you lift equipment operational
Is your Mileage Log intact and up to date with no discrepancies
Medication Safety Box
Rows
Compliant
Non Compliant
NA
Are Medications Kept Locked at all times
Are all medications Clearly Marked and Labe
Are all outdated Medications destroyed properly
Date of this Monthly Inspection
-
Month
-
Day
Year
Date Picker Icon
Date on Fire Extinguisher Tags
-
Month
-
Day
Year
Date Picker Icon
Date of last Annual Inspection by External Company
-
Month
-
Day
Year
Date Picker Icon
Date of last Annual E-Score
-
Month
-
Day
Year
Date Picker Icon
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