HOLI-KARE

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Room #

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Entry

• 1.Entry door / 2. Deadbolt / 3.Viewer , <br>Working and free from defects?

  Yes

  No

  N/A

• 4. Security lock <br>Working and free from defects?

  Yes

  No

  N/A

• 5. Emergency evac. Sign in place?<br>Free from defects?

  Yes

  No

  N/A

• 19. Door stop<br>Free from defects?

  Yes

  No

  N/A

• 6. Entry light <br>Working and free from defects?

  Yes

  No

  N/A

• 7. Closet doors<br>Working and free from defects?

  Yes

  No

  N/A

• 18. Iron and board<br>Working and free from defects?

  Yes

  No

  N/A

• 8. Coat rack secure<br>Working and free from defects?

  Yes

  No

  N/A

• 9. Luggage rack<br>Working and free from defects?

  Yes

  No

  N/A

• 10. Closet walls / 11. Carpet<br>Free from defects?

  Yes

  No

  N/A

• 12. Coffee station secure / 13. Electrical outlet <br>Working and free from defects?<br>

  Yes

  No

  N/A

• 14. Full length mirror in place<br>Working and free from defects?

  Yes

  No

  N/A

• 15. Corner guards in place<br>Working and free from defects?

  Yes

  No

  N/A

Bedroom

• 16. Luggage bench<br>Free from scratches and defects?

  Yes

  No

  N/A

• 17. TV cabinet and backboard <br>Free from scratches and defects? Do cabinet doors open correctly?

  Yes

  No

  N/A

• 23. Mini-fridge <br>Freezer working, free from scratches and defects?<br>

  Yes

  No

  N/A

• Mini-fridge ice build-up

  Safe

  At Risk

  N/A

• 24. Microwave <br>Working and free from defects?

  Yes

  No

  N/A

• 25. Safe<br>Working and free from defects? Battery level ok?

  Yes

  No

  N/A

• 20. Dresser <br>Working and free from defects?

  Yes

  No

  N/A

• 21. Desk<br>Free from scratches and defects?

  Yes

  No

  N/A

• 22. Desk chair<br>Arms and fabric tight and free from defects? All adjustments working?

  Yes

  No

  N/A

• 26. Desk phone / 27. Desk lamp<br>Both working and free from defects?

  Yes

  No

  N/A

• 28. Ethernet jack and Wi-Fi<br>Working and good signal?

  Yes

  No

  N/A

• 29. Sofa chair<br>Free from defects?

  Yes

  No

  N/A

• 30. HVAC and Thermostat <br>Working, Case free from defects, filters cleaned?

  Yes

  No

  N/A

• 31. Window and drapes <br>Window free from leaks? Both drapes open & close? Free from stains or cuts?

  Yes

  No

  N/A

• 32. Small round table<br>Legs tight and free from defects?

  Yes

  No

  N/A

• 33. Bed 1 <br>Frame secure free from defects?

  Yes

  No

  N/A

• 34. Bed 2<br>Frame secure free from defects?

  Yes

  No

  N/A

• 35. Headboard<br>Secure and free from defects?

  Yes

  No

  N/A

• 36. Nightstand 1<br>Drawer opens correct? Free from defects?

  Yes

  No

  N/A

• 37. Nightstand 2<br>Drawer opens correct? Free from defects?

  Yes

  No

  N/A

• 38. Nightstand lamp 1<br>Working and free from defects?

  Yes

  No

  N/A

• 39. Nightstand lamp 2<br>Working and free from defects?

  Yes

  No

  N/A

• 40. Nightstand Phone<br>Working and free from defects?

  Yes

  No

  N/A

• 41. Nightstand Clock<br>Working, Alarm working, Time adjusted? Battery in place?

  Yes

  No

  N/A

• 42. Tall lamp<br>Working and free from defects?

  Yes

  No

  N/A

• 43. Artwork <br>Secure and free from defects?

  Yes

  No

  N/A

• 44. TV / 45. Remote<br>Working with clear channels, batteres in remote? Secure coards and base?

  Yes

  No

  N/A

• 46. Ceiling / 47. Walls / 79. Carpet<br>Free from scratches, stains and waterspots or defects?

  Yes

  No

  N/A

• 48. Electrical outlets <br>Working and secure, free from defects?

  Yes

  No

  N/A

• 78. Smoke detector<br>Working and secure?

  Yes

  No

  N/A

Bathroom

• 49. Vanity <br>Secure, caulked and free from defects?

  Yes

  No

  N/A

• 50. Vanity sink<br>Working, chrome looks good? No leaks or cracks?

  Yes

  No

  N/A

• 51. Vanity Mirror<br>Secure and free from defects?

  Yes

  No

  N/A

• 52. Vanity lights <br>Working, secure and free from defects?

  Yes

  No

  N/A

• 53. Toilet<br>Working, calked, secure and free from defects?

  Yes

  No

  N/A

• 77. Toilet Seat<br>Secure and free from defects?

  Yes

  No

  N/A

• 54. Toilet paper holder<br>Working and secure?

  Yes

  No

  N/A

• 55. Towel bar<br>Secure and free from defects?

  Yes

  No

  N/A

• 70. Exhaust fan<br>Working and clean?

  Yes

  No

  N/A

• 71. Bathroom door and hardware<br>Coat hook, locks and free from defects?

  Yes

  No

  N/A

• 72. Walls and cileing <br>Free from scratches, defects and waterspots?

  Yes

  No

  N/A

• 75. Hairdryer <br>Working and free from defects?

  Yes

  No

  N/A

Bathtub

• 56. Bathtub / 57. Bath fauset <br>Tub caulked, free from scraches and defects? Fauset secure free from defects?

  Yes

  No

  N/A

• 58. Grab-bar / 59. Soap-dish / 60. Drain<br>Working, caulked and secure, free from defects?

  Yes

  No

  N/A

• 61. Shower head<br>Working and free from defects?

  Yes

  No

  N/A

• 76. Bathtub walls<br>Caulk looks good? Free from defects?

  Yes

  No

  N/A

• 62. Curtain rod<br>Secure and free from defects?

  Yes

  No

  N/A

• Handicap accessible?

  Yes

  No

  N/A

Shower

• 63. Shower surround / 64. Shower handle <br>Shower caulked, free from defects, shower handle secure and free from defects?

  Yes

  No

  N/A

• 65. Grab-bar / 66. Soap-dish / 67. Drain<br>Secure caulked and free from defects?

  Yes

  No

  N/A

• 68. Shower head<br>Working and free from defects?

  Yes

  No

  N/A

• 69. Shower door<br>Door handles secure, track correct, caulked and free from defects?

  Yes

  No

  N/A

• Handicap accessible?

  Yes

  No

  N/A

Suite

• 73. Sofa bed<br>Working, fabric free from stains and cuts, free from defects?

  Yes

  No

  N/A

• 74. Table and chairs<br>Legs secure, free from scratches, defects and stains?

  Yes

  No

  N/A

• Select date

  Date

• Completed by

  Sign