Facilities Maintenance Check Sheet

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1.0 - Previous inspection

• 1.1 - Has the last inspection been reviewed?

  Yes

  No

  N/A

• 1.2 - Are there no outstanding actions?

  Yes

  No

  N/A

2.0 - Room Condition

• 2.1 - Carpet Condition

  Safe

  At Risk

  N/A

• 2.2 - Tile Condition

  Safe

  At Risk

  N/A

• 2.3 - Covebase/Baseboard Condition

  Safe

  At Risk

  N/A

• 2.4 - Area Rug Condition

  Safe

  At Risk

  N/A

• 2.5 - Heat/Cooling System Condition - Record Temperature:

  Safe

  At Risk

  N/A

• 2.6 Equipment Condition

  Safe

  At Risk

  N/A

• 2.7 - Lighting Condition

  Safe

  At Risk

  N/A

• 2.8 - Emergency Lighting Condition

  Safe

  At Risk

  N/A

• 2.9 - Condition of Walls

  Safe

  At Risk

  N/A

• 2.10 - Condition of Ceilings/Vents/Air Return Duct

  Safe

  At Risk

  N/A

• 2.11 - Condition of Doors

  Safe

  At Risk

  N/A

• 2.12 - Condition of Fire Extinguisher

  Safe

  At Risk

  N/A

• 2.13 - Condition of Carbon Monoxide Detectors

  Safe

  At Risk

  N/A

• 2.14 - Condition of Sink - Record Water Temperture

  Safe

  At Risk

  N/A

• 2.15 - Bubbler/Water Cooler Condition

  Safe

  At Risk

  N/A

• 2.16 - Diapering Table - Record Water Temperature

  Safe

  At Risk

  N/A

• 2.17 - Condition of Windows

  Safe

  At Risk

  N/A

• 2.18 Condition of Blinds / Shades

  Safe

  At Risk

  N/A

• 2.19 - Condition of Storage Cabinets

  Yes

  No

  N/A

• 2.20 - Condition of Shelving Units

  Safe

  At Risk

  N/A

• 2.21 - Condition of Exit Signs

  Safe

  At Risk

  N/A

• 2.22 - Locked Cabinet

  Yes

  No

  N/A

• 2.23 - Outlet Cover Condition

  Safe

  At Risk

  N/A

• 2.25 - Is Preventive Maintenance Checklist Updated? (Check with Center Director)

  Yes

  No

  N/A

3.0 - Bathroom

• 3.1 - Tile Condition

  Safe

  At Risk

  N/A

• 3.2 - Covebase/Baseboard Condition

  Safe

  At Risk

  N/A

• 3.3 - Condition of Walls

  Yes

  No

  N/A

• 3.4 - Lighting Condition

  Safe

  At Risk

  N/A

• 3.5 - Condition of Ceilings/Vents/Air ReturnDuct

  Yes

  No

  N/A

• 3.6 - Condition of Doors

  Yes

  No

  N/A

• 3.7 - Condition of Sink - Record Water Temperature

  Safe

  At Risk

  N/A

• 3.8 - Condition of Toilet/Urinal

  Safe

  At Risk

  N/A

• 3.9 - Bathroom Daily Check List Updated?

  Yes

  No

  N/A

Sign Off

• Center Director

  Sign

• Inspector's Signature

  Sign