Lifeworks Supported Living Group Homes

• Site Name

• Conducted on

  Date

• Prepared by

• Inspected by

• Location
  Address

Entry

• Entry doors are locked and in working condition?

  Yes

  No

  N/A

• Entry areas are clean and in a safe condition?

  Yes

  No

  N/A

• Lobby areas are clean and free from safety concerns or issues?

  Yes

  No

  N/A

• Occupancy document posted inside, next to front door?

  Yes

  No

  N/A

• Hallways leading to client areas are clean and free from safety concerns or issues?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to entry or lobby areas?

Common Areas- Client Care

• Furniture in client common areas is clean, safe and in good condition?

  Yes

  No

  N/A

• Common areas appear clean?

  Yes

  No

  N/A

• Common area is free from safety issues?

  Yes

  No

  N/A

• Common area vents are free from dust and/or dust build-up?

  Yes

  No

  N/A

• Trash in common areas is contained?

  Yes

  No

  N/A

• Common areas are clean, safe and in good functioning?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to the common/group areas?

Bathroom

• Location of bathroom

• Client bathrooms are clean?

  Yes

  No

  N/A

• Client bathroom doors were unlocked at time of inspection? If no, note why in comments section (if known).

  Yes

  No

  N/A

• Client bathrooms are safe?

  Yes

  No

  N/A

• Trash in client bathroom areas is contained?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to the client bathroom?

Laundry

• Lint trap is free of excessive lint?

  Yes

  No

  N/A

• The floor is clear of client clothes and/or items?

  Yes

  No

  N/A

• Any additional compliance, safety, security, or cleanliness concerns related to the laundry area?

Kitchen Areas

• Kitchen areas are clean?

  Yes

  No

  N/A

• Refrigerator and freezer logs are present and completed to date?

  Yes

  No

  N/A

• On inspection, refrigerator is holding proper temperature?

  Yes

  No

  N/A

• Refrigerator is free from expired items?

  Yes

  No

  N/A

• Refrigerator and freezer are clean?

  Yes

  No

  N/A

• Food stored in kitchen is being stored at proper temperature and condition?

  Yes

  No

  N/A

• Ovens, microwaves, and dishwashers are clean?

  Yes

  No

  N/A

• Area under sink is clear of any client items? If no, note what is being stored under sink.

  Yes

  No

  N/A

• Any additional compliance, safety, security or cleanliness concerns related to the kitchen area?

Client Rooms

• Room identifier

• Furniture is in good repair and is safe for client use?

  Yes

  No

  N/A

• Overall the room is clean for client?

  Yes

  No

  N/A

• Light fixtures are in working condition?

  Yes

  No

  N/A

• Overall the room is safe for client care?

  Yes

  No

  N/A

• Any additional compliance, safety, security or cleanliness concerns related to client rooms?

Additional Questions, All Areas

• Areas deemed as "secure" are locked upon inspection? (Examples: Medication closets, utility closets, janitor closets, etc.

  Yes

  No

  N/A

• Ceiling is clean and in good condition?

  Yes

  No

  N/A

• Flooring is in good condition and free from trip hazards?

  Yes

  No

  N/A

• Vents are clean and in good condition?

  Yes

  No

  N/A

• Storage areas are orderly and free from excessive clutter?

  Yes

  No

  N/A

• Overall walls are clean and in good condition?

  Yes

  No

  N/A

• Entry and exits are clear at time of inspection? If no, note what is blocking and where.

  Yes

  No

  N/A

• There is clearance of at least 24 inches from ceiling in all areas? If no, note where and what is stored.

  Yes

  No

  N/A

• Utility Rooms are labeled with shut-offs?

  Yes

  No

  N/A

• Fire extinguishers are labeled and have monthly inspection?

  Yes

  No

  N/A

• All clean supplies are stored under proper conditions?

  Yes

  No

  N/A

• SDS sheets are present?

  Yes

  No

  N/A

• Are areas storing hazardous waste is marked?

  Yes

  No

  N/A

• Is there an emergency kit with food, water and a working flashlight?

  Yes

  No

  N/A

• Is there Paper Emergency Plan (EOP)?

  Yes

  No

  N/A

• Are there paper downtime procedures?

  Yes

  No

  N/A

• Is there an egress map with the exit routes marked and "you are here" notations?

  Yes

  No

  N/A

• Any additional compliance, safety, security or cleanliness concerns related to the general site?

Exterior Client Care Spaces

• Exterior spaces are secure?

  Yes

  No

  N/A

• Exterior client space are in good condition?

  Yes

  No

  N/A

• Client space is free from hives/holes or damage related to pests?

  Yes

  No

  N/A

• The area is free from tripping hazards or fall risks?

  Yes

  No

  N/A

• Furniture in client spaces is in good condition?

  Yes

  No

  N/A

• Any additional compliance, safety, security or cleanliness concerns related to outdoor client spaces?

Building Exterior- Non Client Care

• Sidewalks leading to the building are safe and in good condition?

  Yes

  No

  N/A

• Lighting to the building is in good working condition?

  Yes

  No

  N/A

• The exterior is free from holes/hives/ nests or damage related to pests?

  Yes

  No

  N/A

• Entry ways are free from tripping hazards and maintained according to season?

  Yes

  No

  N/A

• Exterior paint, caulking and tuck-pointing is in good condition?

  Yes

  No

  N/A

• Fences/retaining walls are in good condition?

  Yes

  No

  N/A

• Exterior windows are in good condition?

  Yes

  No

  N/A

• Gutters and downspouts are in good condition?

  Yes

  No

  N/A

• Any additional compliance, safety, security or cleanliness concerns related to the exterior of the building?