Senior Living Facility Accommodation Safety Form
Resident Information
Name
Resident ID
Date
Room Number
Accommodation Safety Inspection
Fire Safety (alarms, extinguishers, exits)
Pass
Fail
Needs Attention
Emergency Access & Egress
Accessible
Obstructed
Medical Equipment Condition
Operational
Needs Repair
Fall Risk (handrails, rugs, wet floors)
Safe
Needs Attention
Additional Notes
Comments or Safety Concerns
Inspector Information
Inspector Name
Signature