MONTHLY FACILITY REVIEW FORM
Please complete one form per facility, per month, and return to Karen Doyleby the 5th of each month

Program Address: Charlton Road

Date of Review: Date Received:

ROOM / Floor # / ISSUE NOTED / Work
Order?
(If yes, show date) / COMMENTS
Office
BATHROOM #1
BATHROOM #2
BATHROOM #3
SUPERSHOWER #1
SUPERSHOWER #2
Bathrooms can sometimes have problems with moisture.
If you see any black dots or other unusual substance anywhere in your home, check YES and submit WORK ORDER
YES
BEDROOM #1
BEDROOM #2
BEDROOM #3
BEDROOM #4
BEDROOM # 5
BEDROOM # 6
BEDROOM # 7
BEDROOM # 8
BEDROOM #9
DINING ROOM
GARAGE
HALLWAY
KITCHEN
LAUNDRY ROOM
CLOSETS:
Are not stacked too high with boxes
APPLIANCES:
All are in safe operation
EGRESS:
All paths clear to exit and meeting spots.
EXTERIORofRESIDENCE:
Check for debris in yard/roof
SMOKING AREA: Please be sure that your smoking urn is clean and is cleaned
out regularly. Please also assure us that, per company policy, there are no smoking
materials (cigarette butts, matchbooks, etc.) strewn about the property. If you can
attest that these areas are taken care of, please write YES on the line to the right. / YES
If you are a LIFE SAFETY CODE home or have SELF CLOSING DOORS, please check that all of your fire doors close and latch every time. ( IF NO SUBMIT WORK ORDER) / YES NO
FIRE EXTINGUISHERS all need to be inspected by each house manager on a
MONTHLY basis. Please indicate that you have checked your fire extinguishers
and signed each of the tags for this month by writing YES on the line to the right.
FIRE EXTINGUISHERS all need to be inspected annually by a professional
Fire Extinguisher Inspection company. That fact needs to be noted on each fire
extinguisher by the inspection company. If each of your fire extinguishers has
been inspected within the past 12 months, and each has the professional indication
that the inspection has been performed, please check YES / YES
YES
FIRE EXTINGUISHERS must be located off the floor, Are all extinguishers off the floor?
If anyfire extinguishers in your home are located on the floor, please submit a work order to have them hung. / YES
OTHER ISSUE:
If you are waiting for any additional work orders to be completed, please list them here:

Pls

AED Check Chk.

Green Light√please check if OK

Red Light √please check if you require service

N/A√please check if you do not have an AED Machine

cc: Patrick Tefft √Date: ______

All window screens are in place? YES NO

List windows where screens are missing and submit WORK ORDER:

Additional Comments:

INVENTORY:Please label and, list any new items purchased for your home this month. If you need Inventory labels please contact Karen Doyle.

Inventory : Anything purchased for the house or program (i.e. appliances, furniture, etc)

Have any NEW items been purchased this month? YES NO

ITEM / DATE PURCHASED / LABEL # / SERIAL # / MODEL # / LOCATION

DICARDED INVENTORY: Please list any inventory items that you have discarded this month below.

Have any items been DISCARDED this month? YES NO

ITEM / DATE PURCHASED / LABEL # / SERIAL # / MODEL # / LOCATION

Additional Comments:

Submitted By:

Signature: Date:

Rev: 4/22/14 Rev: 1/13/2012 j/admin data/ all Facility Reviews Rev9.19.2014

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