Residential ICES

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Hot water tank temps being taken and logged?

  Pass

  Fail

  N/A

• Client water temps being taken and logged weekly?

  Pass

  Fail

  N/A

• Medication refrigerator temps checked and logged?

  Pass

  Fail

  N/A

• Medication refrigerator calibrated monthly?

  Pass

  Fail

  N/A

• Fire Drills up-to-date?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

Lobby Area

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

  Pass

  Fail

  N/A

• Licenses are current in the lobby area?

  Yes

  No

  N/A

• Furniture is cleanable and non-porous?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Signage is professional, cleanable and up to date?

  Yes

  No

  N/A

• Food handlers cards up-to-date?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Sink temps are recorded weekly?

  Pass

  Fail

  N/A

• Dishwasher temps are recorded weekly? 180°F

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Microwave is clean?

  Pass

  Fail

  N/A

• 2 week menus are posted?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Client meals are recorded at every meal?

  Pass

  Fail

  N/A

• No expired food in the kitchen?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Vents are clean?

  Pass

  Fail

  N/A

• Fridge and freezer are temped and recorded daily?

  Pass

  Fail

  N/A

• Is there Clean/ Dirty linen signage?

  Compliant

  Non-Compliant

  N/A

• Unidentified belongings not stored on counters?

  Select Pass Fail N/A

  • Pass
  • Fail
  • N/A

• Dryer lint trap clean?

  Pass

  Fail

  N/A

• Washing machine clean?

  Pass

  Fail

  N/A

• Washing machine free of rust?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Is the thermometer hanging up?

  Pass

  Fail

  N/A

• Toilets are free from stains?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Floor corners are clean and free of debris?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Vents are clean?

  Pass

  Fail

  N/A

• Mops and brooms are stored appropriately?

  Pass

  Fail

  N/A

• Sink and counters are clean from stains and dirt?

  Pass

  Fail

  N/A

• Items are put on shelves and organized?

  Pass

  Fail

  N/A

• Floor is clean from debris?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Staff Station is clean and free from hazards?

  Pass

  Fail

  N/A

• Staff Station furniture is in good repair and clean?

  Good

  Fair

  Poor

  N/A

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

  Pass

  Fail

  N/A

• Staff personal items are stored appropriately?

  Pass

  Fail

  N/A

• Office area has no identified concerns?

  Pass

  Fail

  N/A

• 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.

  Select Safe At Risk N/A

  • Safe
  • At Risk
  • N/A

• Chair mats are in good condition?

  Select Good Fair Poor N/A

  • Good
  • Fair
  • Poor
  • N/A

• Task chairs are in good condition?

  Select Good Fair Poor N/A

  • Good
  • Fair
  • Poor
  • N/A

• No unapproved electrical items in offices?

  Pass

  Fail

  N/A

• Offices are clean, orderly and professional in appearance?

  Pass

  Fail

  N/A

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

  Yes

  No

  N/A

• Toys in office area that need a cleaning log?

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

• Lighting is working in client room?

  Yes

  No

  N/A

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

  Good

  Fair

  Poor

  N/A

• Signage is appropriate, no paper or tape?

  Yes

  No

  N/A

• Is the lighting working?

  Yes

  No

  N/A

• Furniture is free from rips or tears?

  Good

  Fair

  Poor

  N/A

• Client belongings are in clear bags and secured?

  Pass

  Fail

  N/A

• Client belongings are labeled with first and last name?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Staff storage areas are free from clutter?

  Pass

  Fail

  N/A

• Add media

  Media

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

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• No chemicals found in area of client care?

  Yes

  No

  N/A

• No identified ligature risks in client areas?

  Yes

  No

  N/A

• Interior/Exterior doors latch and secure appropriately?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Signage in building is appropriate, cleanable and professional?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Extra client locker keys are maintained and secured appropriately?

  Yes

  No

  N/A

• Fire Extinguishers are unobstructed

  Pass

  Fail

  N/A

• Pull stations are unobstructed?

  Pass

  Fail

  N/A

• Electrical items are approved and tagged?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Extension cords are not being used?

  Pass

  Fail

  N/A

• Fire doors close and latch with no obstructions?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Nurse call light tested monthly?

  Pass

  Fail

  N/A

• All exit doors unobstructed?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Emergency shutoff signs on Gas meter?

  Pass

  Fail

  N/A

• Area is free of garbage?

  Pass

  Fail

  N/A

• Dumpsters have a closing lid free of cracks?

  Pass

  Fail

  N/A

• Dumpster area is free of garbage on ground?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Weeds are pulled?

  Pass

  Fail

  N/A

• Dead bushes are pulled?

  Pass

  Fail

  N/A

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

  Pass

  Fail

  N/A

• Fire connections intact?

  Pass

  Fail

  N/A

• Risks that need future mitigation

• Add media

  Media

• Bookcase needed?

• undefined

• 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

• undefined

• Add media

  Media

• Add signature

  Sign