Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • Hot water tank temps being taken and logged?

  • Client water temps being taken and logged weekly?

  • Medication refrigerator temps checked and logged?

  • Medication refrigerator calibrated monthly?

  • Fire Drills up-to-date?

  • AED-Daily & Monthly logs up-to-date?


Lobby Area

  • Lobby is clean and safe? No client information to view?

  • Licenses are current in the lobby area?

  • Furniture is cleanable and non-porous?

  • Furnishings are inviting to clients and visitors, clean and well maintained?

  • Signage is professional, cleanable and up to date?

Kitchen/Dining Room

  • Food handlers cards up-to-date?

  • Food temps are recorded with every meal? Hot 135°F. Cold 41°F. Code 3-401.103.

  • Sink temps are recorded weekly?

  • Dishwasher temps are recorded weekly? 180°F

  • Food is appropriately wrapped, labeled, stored and dated? WAC 246-215-03309.

  • Food prep sink is clean and used for food only. WAC 246-215-04325.

  • Hood is cleaned, logged and maintained per Fire Marshal and State Fire Code?

  • Stove/Oven/Fridge/Freezer are cleaned? WAC 246-215-06505

  • Microwave is clean?

  • 2 week menus are posted?

  • Alternate menus are posted? WAC 246-337-090

  • Client allergy list posted and being utilized? WAC246337.111

  • Frozen food is thawed appropriately and stored correctly? WAC 246-215-03510.

  • Client meals are recorded at every meal?

  • No expired food in the kitchen?

  • Sanitizer Solution log is maintained? WAC 246-215-04565

  • Wiping towels are stored in sanitizing solution? WAC246-215-04565

  • Vents are clean?

  • Fridge and freezer are temped and recorded daily?

Laundry Areas

  • Is there Clean/ Dirty linen signage?

  • Unidentified belongings not stored on counters?

  • Dryer lint trap clean?

  • Washing machine clean?

  • Washing machine free of rust?

  • There are NO non-comprehensive approved chemicals in the building?

  • Is the thermometer hanging up?


  • Toilets are free from stains?

  • Toilet caulking is in good condition and free from stains?

  • All items in bathroom are safe and secured, no ligature points?

  • Floor corners are clean and free of debris?

  • Restroom is free from mold and soap scum build up?

  • Vents are clean?

Maintenance/Custodial Rooms

  • Mops and brooms are stored appropriately?

  • Sink and counters are clean from stains and dirt?

  • Items are put on shelves and organized?

  • Floor is clean from debris?

  • Electrical panels are not blocked, 3 feet of clearance?

Staff Station

  • Staff Station is clean and free from hazards?

  • Staff Station furniture is in good repair and clean?

  • Area has items that can be used as a weapon?

  • Staff personal items are stored appropriately?

  • Office area has no identified concerns?

Office Areas

  • Staff offices are free from any identified safety risks? Such as extension cords, fire hazards, unsafe items, water damage risks, ceiling tile stains, tripping hazards.

  • Chair mats are in good condition?

  • Task chairs are in good condition?

  • No unapproved electrical items in offices?

  • Offices are clean, orderly and professional in appearance?

  • Office has personal furniture in use? Cleanable non porous?

  • Toys in office area that need a cleaning log?

Client Rooms

  • Client room is safe from hazards, tripping and ligature?

  • Lighting is working in client room?

  • Furniture is good, not falling apart, everything in working order?

Client Care Areas

  • Signage is appropriate, no paper or tape?

  • Is the lighting working?

  • Furniture is free from rips or tears?

Client Storage Area

  • Client belongings are in clear bags and secured?

  • Client belongings are labeled with first and last name?

  • Client left over belongings are labeled with discharge date and first and last name?

Staff Storage Area

  • Staff storage areas are free from clutter?

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First Aid/PPE-Medical

  • First aid kit current? PPE kit has adequate supplies?

  • Medical/Emergency equipment up-to-date and calibrated?

Safety and Security

  • No chemicals found in area of client care?

  • No identified ligature risks in client areas?

  • Interior/Exterior doors latch and secure appropriately?

  • All exposed work areas are free from hazards to clients?

  • Signage in building is appropriate, cleanable and professional?

  • Keys and scan cards are maintained appropriately? Secure, identified and accounted for?

  • Extra client locker keys are maintained and secured appropriately?

Fire Safety

  • Fire Extinguishers are unobstructed

  • Pull stations are unobstructed?

  • Electrical items are approved and tagged?

  • Fire Riser sprinkler system does not have items stored in front of it?

  • Extension cords are not being used?

  • Fire doors close and latch with no obstructions?

  • Fire sprinkler heads are clean. the escutcheons are secure. No obstructions 18" clearance from ceiling?

  • Nurse call light tested monthly?

  • All exit doors unobstructed?


  • Landscaping is well maintained? Parking lot is in good condition? Parking lot is well striped? Grass is green and well trimmed?

  • Emergency shutoff signs on Gas meter?

  • Area is free of garbage?

  • Dumpsters have a closing lid free of cracks?

  • Dumpster area is free of garbage on ground?

  • Parking lot is safe, no pot holes, large cracks or raised areas?

  • Weeds are pulled?

  • Dead bushes are pulled?

  • Fences are in good repair, no holes, not leaning and slats are in good condition?

  • Fire connections intact?

Identified Risks for Mitigation

  • Risks that need future mitigation

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Capital Budget Items

  • Bookcase needed?

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  • Desks needed?

  • Common room furniture needed?

  • Side chairs needed?

  • Task chairs needed?

  • Other items needed?


  • Comments for Custodial Staff

  • Comments for Maintenance Staff

  • Comments for Maintenance Supervisor

  • Comments for Purchasing

  • Comments for Environmental Coordinator

  • Comments for Property Management Coordinator

  • Comments for Program Manger/Director/VP

  • Exterior Comments


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  • Add signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.