DEPARTMENT OF STATE subdivision/sole proprietors Be.Services & Solutions Agency. Lic No.4-4005478 VS.0050509 General Compliance Requirements

• Department of State Assessment Screening

  Sign

• Site/Destination

• Conducted on

  Date

• Prepared by

General Compliance

• Standard Policy signs clearly visible

  Select Yes No N/A

  • Yes
  • No
  • N/A

• First aid signs clearly visible

  Yes

  No

  N/A

• Lighting adequate and operational

  Yes

  No

  N/A

• Temperature is comfortable

  Yes

  No

  N/A

• Area is free from odours

  Yes

  No

  N/A

• Noise level is acceptable/adequately controlled

  Yes

  No

  N/A

• Ventilation is adequate

  Yes

  No

  N/A

• Stair treads in good condition

  Yes

  No

  N/A

• Handrails present, safe and secure

  Yes

  No

  N/A

• Electrical equipment tested, tagged and safe

  Yes

  No

  N/A

• Electrical switches/sockets in good condition

  Yes

  No

  N/A

Emergency

• Access and egress paths clear

  Yes

  No

  N/A

• First aid kit accessible

  Yes

  No

  N/A

• Fire fighting equipment easily accessible

  Yes

  No

  N/A

• Fire fighting equipment checked in last 6 months

  Yes

  No

  N/A

Title 45 Code Compliance Public Works

• Seating available and safe

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Tables safe and clean

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Policy ,Rule, Bill Of Rights Posted

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Supervisor on Site View

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Emergency Safeguard Procedure

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Adequate Notice Procedure Form

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Client’s Receipt of Appearance

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Assessment Request Form(s) Compliance Article 10

  Select Yes No N/A

  • Yes
  • No
  • N/A

Sec.195 Misconduct/Fraud/Disclosures

• Employee Behavior

  Compliant

  Non-Compliant

  N/A

• Communication to Visitors

  Select Compliant Non-Compliant N/A

  • Compliant
  • Non-Compliant
  • N/A

• Report and Forms in Filing

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Chain of Command Names Produced

  Select Yes No N/A

  • Yes
  • No
  • N/A

• E Workers Available to Enrollees

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Article 10 Fair Hearing To Clients Rts

  Yes

  No

  N/A

• HIPPA Form Management Processed

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Power of Authority Known

  Select Yes No N/A

  • Yes
  • No
  • N/A

Sign Off

• Violations/Civil Offense

  Select Yes No N/A

  • Yes
  • No
  • N/A

• On site representative

  Sign

• Auditor's signature

  Sign