FLORIDA COALITION AGAINST DOMESTIC VIOLENCE Shelter Observation

							                           FLORIDA COALITION AGAINST DOMESTIC VIOLENCE
                                    Shelter Observation Checklist
                                               «Center_Name»
Use additional pages for explanations requiring more space.

Part I. Health                                                                       Yes   No    N/A
 1. Are floors, carpets, and area rugs clean with evidence of regular maintenance?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 2. Are all areas within the facility neat, sanitary, and properly maintained?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 3. Are all bathrooms operable?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 4.  Are there adequate supplies of hand soap, toilet paper, and towels located in
     the bathroom?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 5. Is the kitchen clean in all areas of food delivery, storage, and preparation?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 6. Are all kitchen equipment and utensils in safe, usable condition?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 7. Are the eating areas clean and have sufficient space for dining?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 8. Are beds and mattresses clean and in safe, usable condition?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 9. Is other bedroom furniture in safe, usable condition?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 10. Are there adequate supplies of clean linen and cloth hand and bath towels?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________



FCADV Monitoring Tool                                   1                                  Revised 7/26/05
                                                                                         Yes   No     N/A
 11. Are there any apparently negative environmental conditions noted anywhere
     within the facility?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 12. Does staff practice infection control by washing hands and by using latex
     gloves when appropriate?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 13. Is the facility well ventilated?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 14. Are all appliances, equipment, and furniture within the facility in safe, good
     working condition and properly maintained?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 15. Are the facility and surrounding grounds maintained for prevention against
     infestation of insects, rodents, and other pests?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

Part II. Safety                                                                         Yes    No    N/A
 16. Are the facility’s structure and additional amenities properly maintained and
     free of obvious hazards?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 17. Are entrances and exits clear of clutter, illuminated, and provide safe passage?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 18. Is a fire plan for exiting conspicuously posted at each designated exit?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 19. Is there a current fire inspection on file?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 20. Do all bathrooms and bedrooms have doors that provide safety and privacy?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________




FCADV Monitoring Tool                                        2                                 Revised 7/26/05
                                                                                          Yes   No     N/A
 21. Is the facility (entrances, exits, doorways, bedrooms, bathrooms, activity areas)
     accessible to persons with mobility limitations?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

Part III. Security                                                                       Yes    No    N/A
 22. Are all curtains, draperies, shades, or blinds in good condition and do they
     ensure privacy?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 23. Do the facility and surrounding area provide proper, adequate, and functional
     lighting?
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 24. Are there proper fencing and/or other protective barriers provided against busy
     streets, waterways, or other dangers? FAC 65C-6.004(3)(e) requires that, if the
     center has a playground in view of the public, privacy fencing is required.
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________

 25. Do the facility and surrounding area provide proper protection (i.e. functioning
     bolt locks)? FAC 65C-6(3)(e) requires that all outside doors shall remain
     locked from the outside at all times, all windows shall be secured against entry,
     outside and entrance way lighting shall be in place, and playground equipment
     shall be routinely checked for safety. The center shall also have sprinklers or
     smoke alarms in each resident’s bedroom and in all hallways.
 If No or NA, please explain.____________________________________________
 ___________________________________________________________________
 ___________________________________________________________________




FCADV Monitoring Tool                                        3                                  Revised 7/26/05