Fillable Attachment #4 New York State Department of Health (New York State)

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Attachment #4 New York State Department of Health (New York State)

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Page 1 of 7
Attachment #4
New York State Department of Health
Nursing Home Transition and Diversion Traumatic Brain Injury Housing Subsidy Program
Housing Quality Standards Checklist
________________________________________________________________________________
Name of Waiver Participant Date of Last Inspection
(mm/dd/yyyy)
________________________________________________________________________________
Inspector (Service Coordinator) Date of Last Inspection
(mm/dd/yyyy)
Type of inspection: ☐ Initial ☐ Annual ☐ Emergency
Addr
ess of the unit inspected:
Nam
e and phone number of the authorized agent for the inspected unit:
Housing Type (check as appropriate)
Si
ngle Family Detached ☐
Duplex or Two Family ☐
Row House or Town House ☐
Low Rise: 3, 4 Stories ☐
Including Garden Apartment ☐
High Rise; 5 or More Stories ☐
Manufactured Home ☐
Cooperative ☐
Condominium ☐
Shared Housing ☐
Other ☐
Inspection Checklist
1. Living Room Yes No Comment
1.1 Living Room Present
1.2 Electricity: sufficient outlets and lighting in the
room
1.3 Electrical Hazards are not present
1.4 Security: doors and window locks
1.5 Window Condition: open and close
adequately and have screens
Provide a brief description of the unit: (number of rooms etc)
Attachment #4
Page 2 of 7
Living Room cont’d Yes No Comment
1.6 Ceiling Condition is free of cracks and bulges:
no sign of water leaks
1.7 Wall Condition: free of cracks and holes, good
wall paper condition
1.8 Floor Condition: carpet clean and free of
tears, no sign of damage
2. Kitchen
Yes No Comment
2.1 Kitchen Area Present
2.2 Electricity: sufficient outlets and lighting in the
room
2.3 Electrical Hazards are not present
2.4 Security: doors and window locks
2.5 Window Condition: open and close
adequately and have screens
2.6 Ceiling Condition is free of cracks or bulges:
no sign of water leaks
2.7 Wall Condition is free of cracks and holes.
Wall paper is in good condition
2.8 Floor Condition is free of cracks and trip
hazards
2.10 Stove or Range with Oven are clean and in
working order
2.11 Refrigerator is clean and in working order
2.12 Sink drains effectively and is free of leaks
2.13 Space for Storage, Preparation, and Serving
of Food
3. Bathroom
Yes No Comment
3.1 Bathroom Present
3.2 Electricity: sufficient outlets and lighting for
the room
3.3 Electrical Hazards are not present
3.4 Security: door and window locks
3.5 Window Condition: opens and closes no
cracks, has window screens, locks
Attachment #4
Page 3 of 7
Bathroom cont’d
Yes No Comment
3.6 Ceiling Condition: no cracks or bulges. No
sign of water leakage or condensation
3.7 Wall Condition: no holes, cracks or peeling
wall paper
3.8 Floor Condition is good and water precautions
are in place (floor mats) free of trip hazards
3.9 Flush Toilet in Enclosed Room in Unit and
free of leaks with sufficient pressure
3.10 Fixed Wash Basin or Lavatory is in the Unit
and free of leaks with sufficient water pressure
3.11 Tub or Shower in Unit is clean and free from
leaks with sufficient water pressure
3.12 Ventilation is sufficient
3.13 There is no sign of mold
3.14 There is sufficient hot and cold water
3.15 All fixtures drain properly
4. Bedroom(s)
Yes No Comment
4.1 Bedroom present
4.2 Electricity: has sufficient outlets and lighting
for the room
4.3 Electrical Hazards are not present
4.5 Security: door and window locks
4.6 Window Condition: open, closes, locks and
have screens
4.7 Ceiling Condition: is free of cracks or bulges:
no sign of water leaks
4.8 Wall Condition: no holes, cracks or peeling
wall paper
4.9 Floor Condition carpet clean and free of tears,
no sign of damage
4.10 Smoke /Carbon Monoxide Detectors are within
at least 20 feet of the bedroom
5. General Health and Safety
Yes
No
Comment
5.1 Access to Unit: Locks to the home are solid and
secure
Attachment #4
Page 4 of 7
General Health and Safety cont’d
Yes
No
Comment
5.2 Fire Exits: Provisions for fire evacuation and
sufficient egress from the building
5.3 The SC has designed and reviews the
evacuation plan with the tenant
5.4 Garbage and Debris is stored appropriately
5.5 Refuse Disposal: routine removal is provided
5.6 Interior stairs, halls and common space are
clean and free from hazards
5.7 Elevators are clean and operational
5.8 Interior air quality is clean and ventilation
sufficient.
5.9 Overall site condition
5.10 Window guards are installed if children are
present in the home
5.11 Emergency telephone numbers are posted
and the closest hospital identified
5.12 The home has a working telephone or cell
phone
5.13 Tenant is provided free exterminator
services
5.14 All light switches and outlets work
5.15 Building has central air conditioning or can
support outlet for air conditioning
5.16 Lead-Based Paint Are all painted surfaces
free of deteriorated paint? If not, do deteriorated
surfaces exceed two square feet per room and/or
is more than 10% of a component?
6. Heating and Plumbing
Yes
No
Comment
6.1 Living arrangement is adequately heated
between October 15 and April 15
6.2 Living arrangement has sufficient ventilation
and/or cooling
6.3 Sufficient hot water and water pressure
6.4 Potable water and free of rust
6.5 Adequate Plumbing: No leaks
6.6 Sufficient sewer connection free of back up
Attachment #4
Page 5 of 7
7. Building Exterior
Yes No Comment
7.1 Condition of Stairs, Rails and Porches are
safe and can hold sustained weight
7.2 Condition of Roof/Gutters: free of leaks and
back up
7.3 Condition of Exterior Surfaces: no holes,
properly painted, no peeling paint or missing
siding
7.4 Condition of Chimney: does not present a
hazard
7.5 Intercoms and buzzers are in working order
7.6 Safety bars and gates are in place for security
7.7 Tenant has access to a secure mailbox
7.8 Manufactured Home: have sufficient Tie
Downs
Special Amenities
This Section is designed to collect additional information about other positive features of the unit that may be present.
Living room has:
Yes No
Comment
High quality flooring or wall coverings
Patio, deck, porch, special windows or doors
Offers exceptional space and/or comfort
Fireplace
Kitchen provides:
Yes No
Comment
High quality cabinets
Good counterspace/quality (granite)
High quality appliances
Dishwasher
Additional appliances such as freezer and/or
microwave
Attachment #4
Page 6 of 7
Bathroom provides:
Yes No
Comment
High quality cabinets
Good counterspace/quality (granite)
Special feature shower head, heat lamp, glass
doors/mirror
Separate dressing room
Special sink or lavatory
Special Accessibility adaptations
Exterior provides:
Yes No
Comment
Additional weatherization
Garage and/or parking facilities
Snow removal is provided
Lawn mowing and landscaping
Accessible entry
Attachment #4
Page 7 of 7
The participant has agreed to the location and neighborhood
☐ Yes ☐ No If no, describe
The participant was involved in the selection of the home:
☐ Yes ☐ No If no, describe
The participant understands that they are responsible for the care and maintenance of the living arrangement and is responsible for
any damages caused by the participant, family and/or guests:
☐ Yes ☐ No If no, describe
Recommendation of inspector:
☐ Unit is approved ☐ Unit is not approved ☐ Unit is approved pending plan of correction (attached)
Signature of Inspector/Service Coordinator:
_____________________________________________________________________
Date: __________________
I have reviewed the Housing Inspection with my Service Coordinator and agree to the findings. I understand that I am responsible
for the care and maintenance of the living arrangement and the terms of the lease:
Signature Participant/Housing Subsidy Recipient:
________________________________________________________________
Date: __________________
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Attachment 4 New York State Department of Health (New York State)

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Completed 14 August 2020

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