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1. Today's Date (Required.)

Date

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2. Location (Required.)

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3. Reviewer's Name and Title (Required.)

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4. Date of Last Fire Extinguisher Inspection (Required.)

Date

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5. Fire Exits Cleared? (Required.)

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6. Smoke detectors checked and are operating properly? (Required.)

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7. Emergency Lighting: Unobstructed, operational, emergency lights, and flashlights available? (Required.)

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8. Combustibles stored near heat source/water heater (Required.)

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9. Exits are unobstructed (Required.)

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10. Evacuation maps are accurate and properly located at height of viewing (Required.)

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11. Non-Approved Items (Candles, Warmers, Unapproved Space Heaters, etc.) observed (Required.)

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12. Kitchen exhaust hood: maintained, clean & free of grease, inspected (oven clean) (Required.)

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13. Kitchen hood extinguishing system: operational, inspected (oven and stove working properly) (Required.)

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14. Proper storage in refrigerator / freezer (no mixing of meds/food/blood products) (Required.)

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15. Is there food that has past expiration dates? (Required.)

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16. Refrigerator/Freezers/Ice Machines: clean, maintained in good repair (Required.)

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17. Kitchen: area clean, appropriately furnished; appliances are clean and in good working order (Required.)

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18. The organization stores and disposes of infectious waste (such as used sharps and body fluids) in a
manner that minimizes the risk of infection (Required.)

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19. Chemicals are properly stored in locked closets/cabinets (Required.)

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20. All sharps, including knives and scissors, are disposed of properly and locked. (Required.)

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21. The organization uses standard precautions, including the use of personal protective equipment (such as
gloves and face shields), to reduce the risk of infection. (Required.)

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22. Latex free gloves are available (Required.)

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23. Adequate separation of clean and soiled supplies (Required.)

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24. Hand Hygiene procedures properly performed by staff during rounds (all sinks have hand soap, paper
towels) (Required.)

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25. Non-Alcohol Gel/Soap dispensers available and utilized (Required.)

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26. Medication is placed in a safe or filling cabinet etc. and is locked (Required.)

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27. First Aid Kits are current with no dates expired (Required.)

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28. Over-the-counter medication are current (within one year) (Required.)

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29. Medications are current and do not need to be destroyed (Required.)

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30. The organization provides outside areas for use by clients, based on the individual’s needs and are
suitable to the individual’s age or other characteristics (Required.)

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31. Landscaping: appropriate, good overall appearance, free of debris, lawn mowed, shrubs trimmed, raked,
free of weeds (Required.)

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32. Walkways and patios: are clean and uncluttered, used appropriately, in good condition, and resistant to
trips and falls (Required.)

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33. Fencing / Gates: appropriate, in good condition, secured as appropriate (Required.)

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34. Exterior doors, windows, screens, etc. in good repair and operational (Required.)

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35. Exterior building condition: appropriate and in good repair (paint, stucco, etc.) (Required.)

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36. Exterior furniture: appropriate and in good condition (Required.)

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37. Exterior lighting: appropriate and functional (Required.)

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38. All windows close and open properly (they do not get stuck), if any windows are fire exits are they
accessible (Required.)

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39. Areas used by individuals served are safe, clean, and comfortable and are maintained in an orderly
fashion. (Required.)

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40. Floor covering: appropriate, clean, vacuumed, and in good repair (Required.)

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41. Walls: in good repair (Required.)

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42. Client beds: have mattress cover, pillow with cover, sheets, blankets, as appropriate. Beds are made,
and clean for new intake. (Required.)

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43. Stairs: unobstructed, clean, in good repair, not storage in stairwells (Required.)

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44. Furnishings and equipment reflect the ability and needs of the individual served. (Required.)

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45. The organization keeps furnishings and equipment safe and in good repair. (Required.)

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46. Furniture: appropriate, clean, free of tears, breakage, and free of odor. (Required.)

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47. Shelves / Bracketing: appropriate and in good repair (Required.)

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48. Washer & Dryers: clean, in good repair (Required.)

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49. Restrooms: clean, odor free, non-slip devices in tub/shower (Required.)

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50. The organization provides storage space to meet the needs of the individual served. (Required.)

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51. Lighting: appropriate and functioning; is controlled by the individuals served, consistent with care, treatment, or services provided (Required.)

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52. The organization maintains ventilation, temperature, and humidity levels suitable for the care, treatment, or
services provided. (Required.)

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53. Vehicles meet state and city legal requirements (insurance, current registration are in vehicles) (Required.)

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54. Vehicle is properly maintained and has service checks, as appropriate (Required.)

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55. Vehicle drivers have completed driver safety training (Required.)

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56. Vehicle drivers are listed as a driver in HR and copy of DL & Insurance is on file with HR manager (Required.)

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57. What are your recommendations for any areas needing improvement? (Required.)

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58. What actions have been taken to respond to the recommendations? (Required.)

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