Title Page
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Report Title:
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Client/Site:
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Conducted on
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Date Constructed:
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Facility Front with Signage
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Prepared by
General Conditions
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Describe the general impression of the facility:
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Is the facility sign in good condition?
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Does the facility have blueprints?
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Is the facility free from any Asbestos containing material?
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Does the facility have an asbestos material control plan, and is any remaining material in a non-friable condition?
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Detail what materials and locations, or attach asbestos report if available.
Entrance
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Does the front entrance have an automatic opening door that is ADA compliant?
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Does the front entry have a mag-lock or other security measure?
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Does the entrance have a patient elopement system installed?
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Entrance is free from trip hazards?
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Entrance to the facility does not create risk for a fall?
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Facility entrance has handrails or is configured for safe access?
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Facility entrance to meets code and does not require any repairs?
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Are all exterior entrances to the facility safe from obvious hazards and are in good condition?
Exterior Envelope
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What type of construction is the exterior of the facility?
- Stucco
- Wood Siding
- Cement
- T-111
- Vinyl
- Other/Mixed
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What is the condition of the paint and finish on the exterior of the building?
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What is the condition of the soffit?
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What is the condition of the facia?
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What type of windows are installed?
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Are all windows double pane?
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List type and location of windows:
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Are all windows in working condition with screens and latches?
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Do all windows and doors positively shut and latch (applicable code)?
Parking Lot
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What is the general condition of the parking lot(s)?
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All areas in good condition with no needed repairs?
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List each area and provide pictures of needed work:
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Is the parking lot and building exterior adequately lit at night for security? (1-5 fc)?
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Do all parking areas have bumpers or curbs?
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What condition is the parking lot line striping?
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Are all ADA Markings or signs clear and to code?
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What is the general condition of the facility sidewalks?
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Are all sidewalks in good condition with no needed repairs?
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Describe needed repairs and attach pictures:
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Are all sidewalks ADA complaint (ramps as required)?
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Is the garbage area clean and free of excessive odors?
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Does the facility use a trash compactor?
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Describe the condition of the trash compactor:
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Describe specific repairs needed and pictures as needed.
Landscaping
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What is the general condition of the facility landscaping?
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Who is the facility landscape contractor(provide contact number)?
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Is there a functioning irrigation sprinkler system?
Fencing
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Does the facility have any fences on the property?
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What is the general condition of any fences on the property?
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Do all gates open and close properly?
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Is panic hardware installed on any secured gates if they are in a evacuation pathway?
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Fences do not require any repair or replacement?
Roof/Gutters
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What is the general condition of the roof?
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Describe the roof composition(3-tab, membrane, tile ect.) of each section as appropriate and age:
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Roofs are free from ponding or standing water?
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Drains are properly installed to avoid standing water?
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Are tree's cut back 3 feet from roof-line?
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Is the roof system clean and well maintained?
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Are a all gutters clean and draining properly?
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Are splash-blocks or site drainage positioned for each downspout?
Generator
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Does the facility have an emergency generator?
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Describe the general condition of the Generator and Automatic Transfer Switch?
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Location:
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Make:
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Model:
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Age:
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Size(KW):
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Fuel Type:
- Gas
- Diesel
- Natural Gas
- Propane
Fire Alarm
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What is the general condition of the Fire Alarm system?
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Make:
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Has the system been service in the last 12 month, and no deficiencies or repairs needed?
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Model:
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FACP Location:
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Installed Date:
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Is the Fire Alarm system Addressable or Zoned?
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Describe system and the locations each portion serves:
Nurse Call
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Describe the general condition of the nurse call system(s)
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Is the nurse call system operational with no needed repairs?
Interior of Facility
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Does the facility have a dedicated reception area?
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What is the condition of the flooring in the lobby area (take picture and note type of material)?
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What is the condition of the flooring in the corridors (take pictures and note what type of material?
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What is the general condition of the common spaces (walls, wall covering, artwork ect)?
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Is the lighting in the common spaces adequate?
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What is the general condition of the handrails?
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What is the condition of the doors in the corridor?
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Describe needed repairs or improvements and take pictures as appropriate:
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Are all resident door and bathrooms ADA lever set door knobs?
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Do all facility entrances and exit able to be secured staff?
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Describe needed repairs or changes to provide for adequate security:
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Does the staff have any concerns regarding security?
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Describe specific concerns and staff names for follow-up.
Resident Rooms
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What is the general condition of the resident rooms?
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What condition is the flooring in resident rooms and bathrooms?
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Describe the flooring type and age for the resident room and bathrooms:
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What is the general condition of the plumbing fixtures in the resident rooms?
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What is the condition of the facility equipment?
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Please describe any additional repairs or equipment needed and provide photo graphs and documentation as appropriate:
Kitchen
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What is the general condition of the kitchen?
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Is the kitchen clean and organized?
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What type of suppression system is installed in the kitchen hood?
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What is the Make of the Suppression system?
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What is the model of the suppression system?
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Has the kitchen hood and suppression system been inspected every 6 months by a service company?
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Service Date #1: (mm/dd/yy)
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Service Date #2: (mm/dd/yy)
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Has the kitchen hood been cleaned in the last 12 months?
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Are all hood baffles tightly fitting with no gaps or movement when unit is turned on?
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Is the facility dish machine owned or leased?
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Who is the leasing company?
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Is the dish machine a high temp (booster) or low temp (chemical injection) machine?
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Has the booster been serviced in the last 6 months?
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Does the dish machine records indicate that the rinse temp reaches 180 F?
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Does the final rinse temp exceed 120 degrees, and records indicate chlorine level is above 200 ppm?
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Are the facility ice machines drained, cleaned, and filters checked quarterly?
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What is the location of the facility grease trap and has records of being routinely maintained?
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All kitchen and equipment are in good condition, no repairs or replacement needed?
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Describe the needed repairs or replacements, photograph as necessary.
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Does the facility have a deep fryer?
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Is that equipment kept under the hood and at least 16" from any potential ignition source?
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In the last 12 months has the facility had any issue with buildup of any Fats, Oils, or grease issues requiring service work?
Refrigerators/ Freezers
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Refrigeration Equipment is in good condition and needs no repairs or replacements?
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Describe and needed repairs or replacements:
Laundry
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Does the facility have an on-site laundry?
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What is the general condition of the laundry area( clean, organized, good repair)?
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How many tumblers are on site?
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How many extractors are on site?
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Laundry Equipment is in working condition, no repairs or replacements needed?
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Describe issue or repairs:
Electrical
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Facility has no identified electrical issues?
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Describe issue or repairs needed (photos as needed).
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Has the facility had the electrical service inspected and thermal scan per NFPA 70 in the past 5 years?
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Does the facility have a lockout/tag out program and current training?
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Are quarterly inspections and logs of GFI testing being done?
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Is the facility testing receptacle tension to ensure safe electrical receptacles in patient care areas?
Plumbing
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How many water heaters are on site?
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How many boilers are on site?
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Is the water management plan and flow diagram accurate?
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What is the general condition of the water heating systems?
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Describe the types of water heating or boiler equipment is in service?
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Facility needs no additional water heating related equipment repairs or replacements?
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Describe needed repairs or replacements and estimate of cost.
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Are all hot water appliances set to deliver the correct temperature of water for their application?
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How many mixing valves are in operation, major distribution, showers. (not tempering valves i.e. sinks)
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Does the facility have a water softening system?
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Does the Facility have any plumbing or sewer repairs presently?
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Describe repairs or replacements needed:
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Has there been any sewer or subterranean issues in the last 12 months?
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Describe situation and any mitigations performed.
HVAC
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What is the general condition of the HVAC systems in the facility?
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Are there any specific HVAC unit repairs or replacements needed?
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Describe repairs or replacement as necessary:
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Are all the HVAC units labeled indicating coordinating systems?
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Are all HVAC filters dated and replaced per their PM schedule?
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Are all exhaust fans functioning and clean?
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Exposed duct work do not show any signs of leaking or deterioration?
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Are all HVAC discharges and returns balanced and clean?
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Resident Room heat is provided by what type of system(select all as needed)?
- Baseboard
- Cadet Heater
- PTAC
- Fan Coil
- DX System
- VRF
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Resident Room Cooling is provided by what type of system(select all as needed)?
- DX System
- Fan Coil
- VRF
- PTAC
- None
- Window AC
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Does the facility have defined plans to provide alternate heating / cooling during extreme weather?
Elevator
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Does the facility have an elevator?
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Who is the service company?
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When was the last date of service?
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Was the service completed in the last 12 months?
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Is the permit current and on file?
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Was the elevator shaft and sump clean?
Capital Projects
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Facility Identified Top 5 Capital Projects:
Capital Projects:
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Describe Scope and budgeted cost of project:
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Pictures supporting project.
Facility Needs (Other)
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Please document any other facility issues:
Issue #
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