Yes	No	N/A
			As you arrive at the residence, do you like the location and outward appearance of the residence?
			As you enter the lobby and tour the residence, is the decor attractive and home-like?
			Did you and your potential resident both receive a warm greeting from staff welcoming you to the residence?
			Does the administrator/staff call residents by name and interact warmly with them as you tour the residence?
			Do residents socialize with each other and appear happy and comfortable?
			Are you able to talk with residents about how they like the residence and staff?
			Do the residents seem to be appropriate housemates for your loved one?
			Are staff appropriately dressed, personable and outgoing?
			Are the staff members that you pass during your tour friendly to you?
			Are visits with the resident welcome at any time?
			Is the residence clean, free of odors and appropriately heated/cooled?
			Does the residence meet local and/or state licensing requirements?
Is the community well-designed for resident's needs?
Yes	No	N/A
			Is the floor plan easy to follow?
			Are doorways, hallways and rooms accommodating to wheel chairs and walkers?
			Are elevators available for those unable to use stairways?
			Are hand rails available to aid in walking?
			Are cupboards and shelves easy to reach?
			Are doors of a non-skid material and carpets firm to ease walking?
			Does the residence have good natural and artificial lighting?

Yes	No	N/A
			Is there a written plan for the care of each resident?
			What is the procedure for assessing a potential resident's need for services? _________________________________
			Are those needs reassessed periodically? _________________________________
			Can a resident be discharged for refusing to comply with a care plan?
			Can the contract for service be terminated?
			When may a contract by terminated? _________________________________
			What are the refund policies? _________________________________
			Are there any government, private or corporate programs available to help cover the cost of services to the resident?
			What are they? _________________________________
			Is a contractual agreement available to include accommodations, personal care, health care and supportive services?
			Are additional services available if the resident's needs change?
			Are there different costs for various levels or categories of services?
			How do you pay for additional services such as nursing care when needed on a temporary basis? _________________________________
			What are the billing, payment and credit policies? _________________________________
			May a resident handle their own finances with staff assistance if able or should a family member or outside party be designated to do so?
			Is insurance required to cover personal property?
			Is staff available to meet scheduled and unscheduled needs?

Yes	No	N/A
			Is there a medication regarding storage of medication, assistance with medications, training and supervision of staff and record keeping?
			What is the policy?__________________________________
			Is self-administration of medication allowed?
			Does a staff person coordinate home care visits from a nurse, physical therapist, occupational therapist, etc. if needed?
			What is the name/title of this staff member? __________________________________
			Are staff available to assist residents who experience memory, orientation, or judgment losses?
			Does a physician or nurse, visit the resident regularly to provide medical checkups?
			What is the schedule? __________________________________
			Is there a procedure for responding to a resident's medical emergency?
			What is the procedure? __________________________________

Services
Is staff available to provide 24-hour assistance with activities of daily living (ADL) if needed? ADLs include:

	Dressing		Using the telephone
	Eating		Shopping
	Mobility		Laundry
	Hygiene and grooming		Housekeeping in unit
	Bathing, toileting and incontinence		Transportation to doctor, hairdresser, activities, etc.

Features of individual apartments

Yes	No	N/A
			Are different sizes and types of units available?
			Are units for single and double occupancy available?
			Do residents have their own lockable doors?
			Is a 24-hour emergency response system accessible from the apartment?
			Are bathrooms private with handicapped accommodations to accommodate wheelchairs and walkers?
			Are residents able to bring their own furnishings for their unit?
			What may they bring? __________________________________
			Do all units have a telephone and cable TV?
			How is billing handled? __________________________________
			Is a kitchen area/apartment provided with refrigerator, sink and cooking element?
			May residents keep food in their units?
			May residents smoke in their apartments?
			Can residents smoke in public spaces?

Social and recreational activities

Yes	No	N/A
			Is there evidence of an organized activities program, such as a posted daily schedule, events in progress, reading materials, visitors, etc?
			Do residents participate in the neighboring community?
			Do volunteers, including family members, come into the residence to help with or conduct programs?
			Does the residence require residents to undertake any chores or perform specific activities that benefit all residents?
			Are residents' pets allowed in the residence?
			Who is responsible for their care? __________________________________
			Does the residence have its own pets?

Food Service

Yes	No	N/A
			Does the residence provide three nutritionally balanced meals a day, seven days a week?
			Are snacks available?
			May a resident request special foods?
			Are common dining areas available?
			May residents eat meals in their units?
			Are meals only for a set time?
			May residents request times for their meals?