36C25519Q0564-005.pdf

Attachment 2: Hotel/Motel Evaluation Checklist

NAME OF FACILITY:

St. Louis VA Health Care System, John Cochran Division

ADDRESS:

915 N. Grand Boulevard St. Louis, MO 63106

ROOM REQUIRMENTS (40 out of 50 = 80%) YES NO NA

1 Primary lock on all doors/dead-bolt/all windows 2 Door has a viewport/window 3 Smoke detector 4 Active light switch at main entry to unit 5 Sufficient lamps to properly illuminate the room for reading or writing 6 At least one chair (in good condition) 7 Writing surface (in good condition) 8 A night stand or equivalent ( in good condition) 9 Clothes hanging facilities; drawers or clothes storage area 10 Television (if provided/functioning) 11 Telephone (functioning/direct dial or 24 hour switchboard) 12 Waste basket 13 Electrical Outlets (functioning) 14 Alarm/clock radio 15 Adequate space for one piece of luggage 16 Shades, draperies or blinds on all windows 17 Window covering effectively shut out light from outside 18 Heating system (functioning/reasonably quiet) 19 Air Conditioning system (functioning/reasonably quite)

OVERALL ROOM CLEANLINESS

20 Free of insects/rodents 21 No dust/dirt/liter/stains/cobwebs 22 Odorless/Clean windows

ROOM CARPETING

23 Not dirty/stained/worn-out/torn

ROOM WALLS/CEILING

24 Clean/no peeling paint 25 Free of defects such as cracks, holes or stains

MATTRESS/BOX SPRINGS

26 Non-sagging/ sized to fit bed frame 27 Odorless, not stained 28 Non protruding/unbroken

OTHER BEDDING REQUIREMENT

29 Clean pillow(s)/pillow cases 30 Two clean sheets, mattress pad 31 Clean pillow case(s) 32 Suitable, clean blanket, bedsheet

BATH AREA

33 Private bath (with no carpeting in commode area 34 Adequate ventilation (fan/window) 35 Adequate lighting

TOILET

36 Functioning/clean

SHOWER/TUB

37 No grout problems/cracks 38 Adequate water pressure/hot water 39 Non-skid pad/strips 40 Shower curtain/tub enclosure clean and free from tears and mildew

VANITY/SINK

41 Functioning/clean 42 Adequate water pressure/hot water 43 Adequate light fixture above vanity/mirror/electrical outlet convenient to mirror

BATH TOWELS

44 One quality bath/hand/wash towel/bath mat 45 Towel rack

OTHER BATH REQUIREMENTS

46 Spare toilet tissue/facial tissue 47 One wrapped drinking glass per person 48 Bathroom waste basket 49 One individually wrapped bar of soap per person

OVERALL BATH AREA CLEANINESS/WALLS/CEILING

50 No hair/stains/odor/no peeling paint/free of defects such as cracks, holes or stains

TOTAL SCORE:_____________

EVALUATORS:

NAME TITLE SIGNATURE/DATE