ICF Physical Environment Inspection
Inspector Name:
*
First Name
Last Name
Apartment
*
JT
A1
A2
A3
B1
B2
B3
C2
C3
Living Room (JT)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (JT)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Are walls clean? (no evidence of substances on walls-spills- tube feed etc.)
Hall Bathroom (JT)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (JT)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (JT)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (JT)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if not working, you must complete a Maintenance Request Form)
Wheelchair button works
(if not working, you must complete a Maintenance Request Form)
Kitchen (JT)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (JT)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (JT)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (JT)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (JT)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 5 (JT)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (JT)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (JT)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (A1)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (A1)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Are walls clean from any substances and wiped down (no evidence of stains, spills, tube feeding solution etc.)
Hall Bathroom (A1)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (A1)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (A1)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (A1)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if not working, you must complete a Maintenance Request Form)
Wheelchair button works
(if not working, you must complete a Maintenance Request Form)
Kitchen (A1)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (A1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (A1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (A1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (A1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (A1)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (A1)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (A2)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (A2)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (A2)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (A2)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (A2)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (A2)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (A2)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (A2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (A2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (A2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (A2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (A2)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (A2)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (A3)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (A3)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (A3)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (A3)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (A3)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (A3)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (A3)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (A3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (A3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (A3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (A3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (A3)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (A3)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (B1)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (B1)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (B1)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (B1)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (B1)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (B1)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (B1)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (B1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (B1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (B1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (B1)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (B1)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (B1)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (B2)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (B2)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (B2)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (B2)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (B2)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (B2)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (B2)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (B2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (B2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (B2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (B2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (B2)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (B2)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (B3)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (B3)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (B3)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (B3)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (B3)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (B3)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (B3)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (B3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (B3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (B3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (B3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (B3)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (B3)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (C2)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (C2)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (C2)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (C2)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (C2)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (C2)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (C2)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (C2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (C2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (C2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (C2)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (C2)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
(if no, you must complete a Maintenance Request Form)
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (C2)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Living Room (C3)
*
Yes
No
N/A
Furniture dust free
Ceiling vents clean
Floor vents clean
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Fire doors obstacle free
Activity table/desk area clean
Hallway/Office (C3)
*
Yes
No
N/A
Closet organized
Sufficient fire drill supplies (shoes, jackets, spare w/chair, blankets)
Items below 18" line
Hall free of items
Floor swept/clean
Apartment office door locked
Items not stored outside marked area (electric box)
Refrigerator plugged into wall (not protector)
Baseboards dust free
Exit lights working
(if no, you must complete a Maintenance Request Form)
Closet light working
(if no, you must complete a Maintenance Request Form)
Hall Bathroom (C3)
*
Yes
No
N/A
Floor swept and mopped
Trash can clean and lined
Adequate toilet paper
Towel dispenser filled
Ceiling vent cleaned
Mechanical Room (C3)
*
Yes
No
N/A
Door locked
Items stored correctly
Room free of chemicals
Floor clean
Mop bucket empty
Doors obstacle free
Laundry Room (C3)
*
Yes
No
N/A
Dirty laundry stored in ventilated hamper with lid
Adequate PPE
(5 disposable gowns, 3 masks, 1 CPR mask, 1 spill kit)
Dryer lint filter clean (N/A if in use)
Ceiling vent clean
Floor clean
Baseboards clean
Washer & dryer clean
Counters clean
Trash can clean and lined
Doors obstacle free
Behind washer & dryer clean
(if no, you must complete a Maintenance Request Form)
Exterior (C3)
*
Yes
No
N/A
Front door obstacle free
Front porch clean and swept
Front yard clean of litter and cigarette butts
Back door obstacle free
Back porch clean and swept
Back yard clean of litter and cigarette butts
Back door locked
Outside lights working
(if no, you must complete a Maintenance Request Form)
Wheelchair button works
(if no, you must complete a Maintenance Request Form)
Kitchen (C3)
*
Yes
No
N/A
Weather radio plugged in/on
Ceiling vents clean
Floor vents checked beneath the cover, clean, and free of cigarette litter
Floor swept/clean
Baseboards dust free
Blinds/curtains clean
Windows dust free
Windows locked (N/A if open)
Food in pantry dated and rotated
Container items match product
Pantry floor free of food/items
Pantry shelves clean
Pantry shelf liner in good condition
Trash cans clean
Trash cans have liners and lid
Food prep area free of ashtrays
Ashtray free of anything but cigarette/ash
Refrigerator/freezer clean inside
Refrigerator/freezer clean outside
Refrigerator temperature 40 degrees or below
Freezer temperature 0 degrees or below
Food in fridge/freezer covered, labeled, and dated
Appliances clean (if not, list which below)
Appliances not in use unplugged
Hood over stove clean
Stove clean under range top
Oven vent and screen clean and dust free
Oven clean
Towel dispenser filled
Gloves available
Soap dispenser available
Fire doors free of obstacles
Ceiling fan/light free of dust
Tables and chairs clean
Pantry doors clean
Cabinet doors clean
Cabinet shelves and drawers clean
Burners functional and free of bends
(if no, you must complete a Maintenance Request Form)
Exhaust fan works
(if no, you must complete a Maintenance Request Form)
Lights are working
(if no, you must complete a Maintenance Request Form)
Behind refrigerator clean
(if no, you must complete a Maintenance Request Form)
Bedroom 1 (C3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 2 (C3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 3 (C3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bedroom 4 (C3)
*
Yes
No
N/A
Dresser drawers organized
Room free of odor
Windows dust free
Window blinds/curtains clean
Windows locked (N/A if open)
Furniture free of dust
Ceiling free of dust
Ceiling vent free of dust
Floor clean
(including under beds- items stored under bed must be in boxes)
Baseboards clean
Room free of extension cords
Floor vents checked beneath the cover, clean, and free of cigarette litter
Beds made
(N/A if in use - don't count off if individuals clearly made the bed him/herself
Dirty laundry stored properly
(ventilated container with lid - not touching clean items or overflowing)
Closet organized
(no clothes on floor)
Items in closet below 18" line
Linen closet organized
Room is cobweb free
(if not, list where below)
Room is wheelchair accessible
Door latches
Trash can has lid
Ample supply of sheets and towels
(2 sets of everything)
Sheets and towels in good shape
Dresser knobs work
(if no, you must complete a Maintenance Request Form)
Dresser drawers work
(if no, you must complete a Maintenance Request Form)
Bedroom door shuts tightly
(if no, you must complete a Maintenance Request Form)
Bedroom door stays open
(if no, you must complete a Maintenance Request Form)
Mattress free of wears/tears
(if no, you must complete a Maintenance Request Form)
Bathroom 1 (C3)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
Bathroom 2 (C3)
*
Yes
No
N/A
Toilet clean
Catheters/urinals/bedpans stored properly
(nothing else on the same shelf)
Sinks clean
Shower chairs clean
Shower chairs have seat belts in good working condition
Bathmat clean and in good repair
Shower curtain clean and in good repair
Trash cans clean and lined
Floors clean
Baseboards clean
Razors/hairdryers stored properly
(not plugged in)
Cabinets over sinks clean
Shower floor mildew free
Windows and blinds free of dust
Window locked (N/A if in use)
Doors latch
Grab bars free of rust
Trash cans have lids
Lights work well
Heat lamp works
Floor free of discoloration
(if no, you must complete a Maintenance Request Form)
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