Lifeworks Supported Living ICFs

• Site Name

• Conducted on

  Date

• Prepared by

• Inspected by

• Location
  Address

Entry

• Entry doors are locked and in working condition?

  Yes

  No

  N/A

• Licensure and accreditation documents posted with current dates?

  Yes

  No

  N/A

• Occupancy posted with expiration date?

  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

• 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

• Bathroom Location

• Client bathrooms are clean?

  Yes

  No

  N/A

• Client bathroom doors were unlocked at time of inspection?

  Yes

  No

  N/A

• Client bathrooms are safe?

  Yes

  No

  N/A

• Trash in client bathroom areas is contained?

  Yes

  No

  N/A

• Area under sink is clear of client items?

  Yes

  No

  N/A

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

Laundry

• The lint traps are clean and free from excessive lint?

  Yes

  No

  N/A

• Floor is clear of client 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 client items?

  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 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 18 inches of the ceiling and within 18 inches of sprinkler heads? If no, note what is stored within 18 inches of the ceiling and/or sprinkler heads and where that is located.

  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 cleaning supplies are stored under proper conditions?

  Yes

  No

  N/A

• SDS sheets are present in the facility?

  Yes

  No

  N/A

• Do the SDS sheets match up with available cleaning supplies?

  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)?

  Select Yes No N/A

  • 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 exterior 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 if 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

• Overall the area is free from additional compliance, safety, security or cleanliness concerns related to the exterior of the building?