Environmental services - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Resident room clean

• Room

• High dusting done?

  Yes

  No

  N/A

• Bed stand cleaned?

  Yes

  No

  N/A

• Matteress free rips

  Yes

  No

  N/A

• Over bed table cleaned?

  Yes

  No

  N/A

• Clean behind all furniture

  Yes

  No

  N/A

• Light fixtures and lamps free of dust?<br>

  Yes

  No

  N/A

• Arm chairs cleaned?

  Yes

  No

  N/A

• Cubical curtain cleaned?

  Yes

  No

  N/A

• Waste basket cleaned ?

  Yes

  No

  N/A

• Toilets cleaned?

  Yes

  No

  N/A

• Sinks cleaned?

  Yes

  No

  N/A

• Walls cleaned?

  Yes

  No

  N/A

• Clean under the bed

  Yes

  No

  N/A

• Drapes free of dust?

  Yes

  No

  N/A

• Free of rodent dropping?

  Yes

  No

  N/A

• Free of cob webs?

  Yes

  No

  N/A

• Dust mop floor done?

  Yes

  No

  N/A

• Mop floors done?

  Yes

  No

  N/A

• Soap dispenser cleaned?<br>

  Yes

  No

  N/A

• Windows cleaned?

  Yes

  No

  N/A

• Free of any odor?

  Yes

  No

  N/A

• Furniture cleaned?

  Yes

  No

  N/A

• Mirrors cleaned?

  Yes

  No

  N/A

Physical environment

• All lights are in working order

  Yes

  No

  N/A

• Scrape marks on doors and frames and kick plate

  Yes

  No

  N/A

• Electrical wiring free of damages in anyway

  Yes

  No

  N/A

• Any doors and smoke door from being blocked or wedged open

  Safe

  At Risk

  N/A

• Door latches when close

  Yes

  No

  N/A

• Fire extinguishers is serviceable

  Yes

  No

  N/A

• Free of stained ceiling tiles in room

  Yes

  No

  N/A

• Test call light in the bathroom and make sure it works

  Yes

  No

  N/A

• Wall free of damages

  Yes

  No

  N/A

Life Safety

• Exit doors are operation and snow blocking door opening

  Safe

  At Risk

  N/A

• Any extension cords find

  Yes

  No

  N/A

• Flammable material stored properly

  Yes

  No

  N/A

• Fire exit are illuminating and working properly?

  Safe

  At Risk

  N/A

• Room