Shelter Dorm Inspection Form Complete the inspection below This form is only available to shelter sites. Open it from the Encounter Forms page Shelter Dorm Inspection Form Weekly dorm/room environmental inspection for shelter sites. Mark each item OK or Needs Attention. For anything that needs attention, set a priority and describe the deficiency. 1Details2Unit Interior3Bathroom, Cleanliness & Safety4Outcome Inspection Date(Required) Shelter(Required)Pick a site locationClient(Required)Pick a tenant or clientSub Residents Include Sub ResidentsRoom / Bed #(Required)Pick a roomInspector Name(Required)Inspector Email(Required) A copy of any deficiency notice is sent here.Inspector Role(Required)Select a roleCase ManagerCase Manager SupervisorSocial ServicesOperationsProgram DirectorOtherInspection Type(Required) Routine Follow-up For cause For cause: after an incident, complaint, or suspected contraband or smoking.Was the client present during the inspection?(Required) Yes No Is there a second client in this room?(Required) Yes No Client B Name(Required)Does the room have its own bathroom?(Required) Yes No Are there any children under 2 in this unit?(Required) Yes No Family sites only. Answering Yes adds the safe sleep checks. Unit InteriorSmoke Detector(Required) OK Needs Attention Is the detector blinking? Does it appear functional?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Carbon Monoxide Detector(Required) OK Needs Attention Is the detector blinking? Does it appear functional?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Window Stopper Secure(Required) OK Needs Attention Is the window stopper secure and in place?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Window Ledge Clear(Required) OK Needs Attention Are any items being stored on the window ledge?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Curtains Not Blocking AC(Required) OK Needs Attention Are the window curtains blocking the AC?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Windows(Required) OK Needs Attention Any visible cracks? Does the window close securely?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Electricity / Lights / Wiring(Required) OK Needs Attention Are the lights working? Do any bulbs need replacing? Do any outlets need covers?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Walls & Ceiling Paint(Required) OK Needs Attention Any peeling wallpaper or chipped paint?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Floors(Required) OK Needs Attention Are the floors level and in good condition?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Doors & Locks(Required) OK Needs Attention Does the door close on its own? Is the lock working? Do the door batteries need changing?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)PTAC System (Heat/AC)(Required) OK Needs Attention Is the PTAC working? Is the vent clean and free of trash? Any missing ribs? Is the hatch present?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Bed Frame / Mattress(Required) OK Needs Attention Is the bed frame and mattress in good condition?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required) BathroomCaulking around Tub / Shower / Sink(Required) OK Needs Attention Is the caulking separated? Is there mold?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Shower Head Plate Secure(Required) OK Needs Attention Is the plate secure to the wall?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Drainage (Tub / Shower / Sink)(Required) OK Needs Attention Is anything draining slowly? Is the water pressure good?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Toilet Seat & Bathroom Handles(Required) OK Needs Attention Is the toilet seat secure? Are the shower and sink knobs secure?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Cleanliness & ContrabandFor the client named on page 1.Bed Made with Clean Linen(Required) OK Needs Attention Is the bed made with clean linen free of stains?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Floor Swept & Unobstructed(Required) OK Needs Attention Is the floor swept and clear of obstructions?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No Food Hoarding(Required) OK Needs Attention Is there excess food in the room, in the locker or near the bed?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No More Than 2 Bags(Required) OK Needs Attention Does the client have more than 2 bags, or property that can't fit in the locker?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Nothing Stored on Furniture(Required) OK Needs Attention Are the bed frame, mattress and locker clean, with nothing stored on top?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No Contraband(Required) OK Needs Attention Is there any contraband or any unauthorized item in the area or locker?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No Smoking(Required) OK Needs Attention Any ashes, cigarette butts or smell of smoke?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No Pests or Vermin(Required) OK Needs Attention Any evidence of pests, vermin or bed bugs?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Area Smells Clean(Required) OK Needs Attention Are there any foul odors?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Exit Not Blocked(Required) OK Needs Attention Can the door open completely? Is anything blocking it? Is the evacuation sign posted behind the door?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Second Client (Client B)Clutter checks for the second client in this room.No Food Hoarding (Client B)(Required) OK Needs Attention Does Client B have excess food in the room?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No More Than 2 Bags (Client B)(Required) OK Needs Attention Does Client B have more than 2 bags of belongings?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)No Contraband (Client B)(Required) OK Needs Attention Is there any contraband or any unauthorized item in Client B's area or locker?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Safe Sleep (Children Under 2)Required for every unit with a child under 2.Approved Crib or Pack 'n Play(Required) OK Needs Attention Is a DHS-approved crib or DOHMH Pack 'n Play present, intact and undamaged?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Crib Away from Hazards(Required) OK Needs Attention Is it away from radiators, riser pipes, windows and hanging objects?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Firm Mattress & Fitted Sheet(Required) OK Needs Attention Does the crib have a correctly sized firm mattress with a fitted sheet?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Crib Clear of Loose Items(Required) OK Needs Attention Is the crib free of clutter, toys, bumpers, pillows and blankets?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required)Safe Sleep Flyer Posted(Required) OK Needs Attention Is the Safe Sleep flyer posted above the crib?Priority(Required) 1 - Immediate attention 2 - Repair within 7 days 3 - Repair within 14 days Describe the deficiency(Required) OutcomeOverall Condition(Required) Good Fair Poor Is a work order needed?(Required) Yes No Work Order Details(Required)Operations submits the work order to the DPO/PD and tracks it on the Work Order Tracker.Were any items confiscated or discarded?(Required) Yes No Items Confiscated or Discarded(Required)If drugs, weapons or other evidence of a crime were found, also report it to Administrative Staff.Was the client given an excess items notice?(Required) Yes No Excess items must be removed from the shelter within 7 days.Was a Dorm/Unit Inspection Notification left for the client?(Required) Yes No Next Steps & Commentse.g. counsel the client, request a work order, schedule a case conference.
