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Home Safety Assessment

Home Safety Assessment

The home safety assessment provided by Agewell Home Solutions LLC is based on the professional judgment of our staff and the conditions observed during the assessment. While we endeavor to identify potential safety concerns and provide recommendations, the assessment is not exhaustive and may not detect all hazards or necessary modifications.
By accepting the assessment and report, you acknowledge that AgeWell Home Solutions LLC, its employees, and agents cannot be held liable for any accident, injury, damages, or safety issues, including those related to conditions not identified in the report. Implementing the recommendations does not guarantee future safety or prevent falls or injuries.
This assessment is for informational purposes only and does not replace medical or legal advice. Please consult your physician regarding your health needs and a qualified attorney for legal counsel related to home modifications and aging in place.
By proceeding with the assessment, you agree to release, indemnify, and hold harmless AgeWell Home Solutions LLC from any liability, claims, and legal actions arising from the assessment, report, and any unidentified safety risks.
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Name
Address
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Referral Made By:

Name

General Information:

1) Does the client live alone?
Select up to 2 choices.
2) Is the client completing the following tasks or do they have assistance (either family or paid help):
Cooking:
Select up to 2 choices.
Cleaning:
Select up to 2 choices.
Laundry:
Select up to 2 choices.
Trash/Recycling Removal:
Select up to 2 choices.
3) Assistive devices used by the client:
Select up to 5 choices.
4) If so, do devices seem in good working order?
Select up to 2 choices.
6) Does client have arthritis/grip issues?
Select up to 2 choices.
5) Does client have personal monitoring device?
Select up to 2 choices.

General Safety:

1) Is there a working smoke detector on each floor?
Select up to 2 choices.
1A Are there any hearing impaired residents in need of strobe/flashing smoke detectors?
Select up to 2 choices.
2) Is there a working carbon monoxide detector?
Select up to 2 choices.
3) Can client change the batteries?
Select up to 2 choices.
5) Does client have emergency supplies (batteries)?
Select up to 2 choices.
7) Can client change furnace filters?
Select up to 2 choices.
8) Does the client know how to change the fuses/reset the circuit breakers?
Select up to 2 choices.
9) Can the client access the circuit breakers/fuses?
Select up to 2 choices.
10) Can the client access and control the thermostat?
Select up to 2 choices.
11) Does the client need rocker light switches?
Select up to 2 choices.
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Exterior-General Safety:

1) Are there house numbers on the home that are visible from the street?
Select up to 2 choices.
2) Can the client independently exit the front entrance?
Select up to 2 choices.
4) Can the client access the mailbox independently?
Select up to 2 choices.
5) Can the client deal with trash/recycling independently?
Select up to 2 choices.
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Accepted file types: jpg, jpeg, png, gif.

Exterior-Lighting:

1) Is there automatic lighting for the most used entrance?
Select up to 2 choices.
2) Is there an outside light for the entrance?
Select up to 2 choices.
3) Is there adequate light in the driveway area?
Select up to 2 choices.
4) Is there adequate light in the garage?
Select up to 2 choices.
5) Is there adequate light along the walkways & paths?
Select up to 2 choices.
6) Is there adequate light at the back door?
Select up to 2 choices.
7) Is there adequate light at the side entrance?
Select up to 2 choices.
8) Is there adequate light in areas such as trash/recycling bins?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Exterior-Driveway:

1) Is the driveway smooth and evenly paved with no tripping hazards?
Select up to 2 choices.
2) Is the yard next to the driveway smooth and free of tripping hazards?
Select up to 2 choices.
3) Is the slope of the driveway low enough to provide a safe walkway?
Select up to 2 choices.
4) Can the client safely access the sidewalk to leave the home?
Select up to 2 choices.
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Exterior-Walkways:

1) Are walkways smooth and evenly paved?
Select up to 2 choices.
2) Are steps on walkway clearly visible?
Select up to 2 choices.
3) Are the transitions between different surfaces (walk to patio) even and level?
Select up to 2 choices.
4) Are shrubs, bushes and groundcovers trimmed so as not to be tripping hazard?
Select up to 2 choices.
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Accepted file types: jpg, jpeg, png, gif.

Exterior-Steps to Front Door:

1) Does the client need to go up/down steps outside the home?
Select up to 2 choices.
2) Do the steps have sturdy, easy to grip handrails?
Select up to 2 choices.
3) Are the stair and step risers all the same height?
Select up to 2 choices.
4) Are the stair treads level, sturdy and in good condition?
Select up to 2 choices.
5) Are there steps at other entrances?
Select up to 2 choices.
6) Are there handrails at other entrances?
Select up to 2 choices.
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Exterior-Garage:

1) Is there adequate lighting in the garage?
Select up to 2 choices.
2) Are there steps between the garage and the house?
Select up to 2 choices.
3) Do stairs or steps into house have handrails?
Select up to 2 choices.
4) Is there a clear pathway to the house without tripping hazards?
Select up to 2 choices.
5) Can the client open the garage door independently?
Select up to 2 choices.
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Accepted file types: jpg, jpeg, png, gif.

Exterior-Ramps:

1) Are there any mobility ramps?
Select up to 2 choices.
2) Is there need for any ramps?
Select up to 2 choices.
3) Does the ramp have the correct slope (1:12 or 1:10 max)?
Select up to 2 choices.
4) Does the ramp have sturdy, easy to grasp handrails?
Select up to 2 choices.
5) Is there a 5x5 landing for the ramp?
Select up to 2 choices.
6) Is there a smooth transition from the ground or sidewalk to the ramp?
Select up to 2 choices.
7) Does the ramp have a non-skid surface or non-skid treads?
Select up to 2 choices.
8) Does the ramp have an interior width of 36” or more between the handrails?
Select up to 2 choices.
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Exterior-Entrance Landings- Front:

1) Is the area free of tripping hazards?
Select up to 2 choices.
2) Is the landing large enough to safely open the door?
Select up to 2 choices.
3) Is there a sturdy railing?
Select up to 2 choices.
4) Is there a non-skid surface on porch?
Select up to 2 choices.
5) Does doormat have non-skid backing and low profile?
Select up to 2 choices.
6) Is there a table or surface to set things down ?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Exterior-Entrance Landings- Rear:

1) Is the area free of tripping hazards?
Select up to 2 choices.
2) Is the landing large enough to safely open the door?
Select up to 2 choices.
3) Is there a sturdy railing?
Select up to 2 choices.
4) Is there a non-skid surface on porch?
Select up to 2 choices.
5) Does doormat have non-skid backing?
Select up to 2 choices.
6) Is there a table or surface to set things down?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Exterior-Exterior Doors- Front:

1) Is doorway wide enough to accommodate wheelchair (min. 32”)?
Select up to 2 choices.
2) Are locks in good condition?
Select up to 2 choices.
3) Are locks easy to use?
Select up to 2 choices.
4) Is there a deadbolt for extra security?
Select up to 2 choices.
5) Are the latches and door handles in good condition?
Select up to 2 choices.
6) Can the client easily manage the door handle?
Select up to 2 choices.
7) Do the doors open and close without sticking?
Select up to 2 choices.
8) Is the door threshold less than 1” in height?
Select up to 2 choices.
9) Is the door threshold in need of transition(s)?
Select up to 2 choices.
10) Does the door have a peephole for security?
Select up to 2 choices.
11) If there is a storm door is the client able to easily open?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Exterior-Exterior Doors-Rear:

1) Is doorway wide enough to accommodate wheelchair (min. 32”)?
Select up to 2 choices.
2) Are locks in good condition?
Select up to 2 choices.
3) Are locks easy to use?
Select up to 2 choices.
4) Are the latches and door handles in good condition?
Select up to 2 choices.
5) Can the client easily manage the door handle?
Select up to 2 choices.
6) Do the doors open and close without sticking?
Select up to 2 choices.
7) Is the door threshold less than 1” in height?
Select up to 2 choices.
8) Is the door threshold in need of transition(s)??
Select up to 2 choices.
9) if there is a storm door is the client able to easily open?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior-General Safety:

1) Are there emergency numbers listed by the telephone?
Select up to 2 choices.
2) Can the client hear the telephone ring?
Select up to 2 choices.
3) Does the client have a portable phone?
Select up to 2 choices.
4) Would a different type of phone increase independence and safety?
Select up to 2 choices.
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Interior- Entry-Front:

1) Have throw rugs been removed to prevent tripping?
Select up to 2 choices.
2) Is there a clear pathway, free of clutter, into the home?
Select up to 2 choices.
3) Is there adequate lighting?
Select up to 2 choices.
4) Is there a light switch within easy reach of the door?
Select up to 2 choices.
5) Is the entry wide enough to accommodate a wheelchair (32")?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Entry-Rear:

1) Have throw rugs been removed to prevent tripping?
Select up to 2 choices.
2) Is there a clear pathway, free of clutter, into the home?
Select up to 2 choices.
3) Is there adequate lighting?
Select up to 2 choices.
4) Is there a light switch within easy reach of the door?
Select up to 2 choices.
5) Is the entry wide enough to accommodate a wheelchair (32")?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Hallways:

1) Are hallways free of clutter and tripping hazards?
Select up to 2 choices.
2) Do carpet runners have non-slip backing or adhesion?
Select up to 2 choices.
3) Do interior doors open easily?
Select up to 2 choices.
4) Are door thresholds less than 1” in height?
Select up to 2 choices.
5) Is there adequate lighting?
Select up to 2 choices.
6) Is there a light switch at either end of the hall?
Select up to 2 choices.
7) Are there night lights in hall?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Stairs:

1) Are there stairs that are used regularly?
Select up to 2 choices.
2) Are the clients able to traverse the stairs safely?
Select up to 2 choices.
3) If not, what are possible solutions?
Select up to 4 choices.
4) Do stairs have sturdy handrails on both sides?
Select up to 2 choices.
5) Do handrails extend to the landing?
Select up to 2 choices.
6) Are the stair treads sturdy and in good shape?
Select up to 2 choices.
7) Are the edges of the stair treads easily visible?
Select up to 2 choices.
8) Are there non-skid surfaces on the stair treads?
Select up to 2 choices.
9) Is the carpet on the stairs securely attached?
10) Are the stairs free of tripping hazards and clutter?
Select up to 2 choices.
11) Are there light switches at the top and bottom of the stairs?
Select up to 2 choices.
12) Are there motion detection or night lights in the stairwell?
Select up to 2 choices.
13) Is there an out-swing door at top of stairs or need for gate?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Kitchen:

1) Is there a working fire extinguisher in sight?
Select up to 2 choices.
2) Is there a working ventilation system, such as range hood?
Select up to 2 choices.
3) Is there a step stool with grab rail to allow client to reach upper cabinets?
Select up to 2 choices.
4) Is the sink faucet easy to reach?
Select up to 2 choices.
5) Is the sink water temperature easy to control?
Select up to 2 choices.
6) Is the hot water set at 120 degrees to minimize scald risk?
Select up to 2 choices.
7) Are the stove burners and controls easy to use and clearly marked?
Select up to 2 choices.
8) Are the controls located on the front or side of cooktop?
Select up to 2 choices.
9) Is the microwave easy to read and control?
Select up to 2 choices.
10) Are the outlets on GFCI circuit?
Select up to 2 choices.
11) Is there adequate task lighting?
Select up to 2 choices.
12) Is kitchen free of tripping hazards and clutter in walkways?
Select up to 2 choices.
13) Is there adequate countertop space to minimize carrying and lifting?
Select up to 2 choices.
14) If the client uses a mobility device, can they transfer food for serving?
Select up to 2 choices.
15) Would the client benefit from a basket, tray or rolling cart?
Select up to 2 choices.
16) If the client uses a wheelchair are they able to get close enough to appliances and countertops for safe access?
Select up to 2 choices.
17) Can client access lower cabinetry easily? Would pull-out shelves be helpful?
Select up to 2 choices.
18) Are there D-Ring pulls on cabinetry? Can client open easily?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Bathroom-Primary:

1) Is there a light switch at entrance to bathroom?
Select up to 2 choices.
2) Is there adequate task lighting with redundancy?
Select up to 2 choices.
3) Is there a night light?
Select up to 2 choices.
4) Is the flooring non-slip, including throw rugs, if present?
Select up to 2 choices.
5) Is there a timer on the heater?
Select up to 2 choices.
6) Is there adequate ventilation?
Select up to 2 choices.
7) Are the sink, tub and shower controls easy to reach and read?
Select up to 2 choices.
8) Is it easy to mix the temperatures at the faucets?
Select up to 2 choices.
9) Is there an anti-scald valve on the tub/shower controls?
Select up to 2 choices.
10) Is the sink accessible for a client using a mobility device?
Select up to 2 choices.
11) Is there adequate room for transfer to the toilet?
Select up to 2 choices.
12) Are the mirrors located at appropriate height for client?
Select up to 2 choices.
13) Are there safety bars in the shower area?
Select up to 2 choices.
15) Is there a non-skid bath mat in the tub or shower?
Select up to 2 choices.
16) Is there a hand-held shower head?
Select up to 2 choices.
17) Is the toilet seat sturdy and secured?
Select up to 2 choices.
18) Is the toilet comfort height?
Select up to 2 choices.
19) Are there grab bars by the toilet? Risk of TP holder?
Select up to 2 choices.
20) Can client get on and off toilet without assistance?
Select up to 2 choices.
21) Are the electrical outlets on GFCI circuit?
Select up to 2 choices.
22) Is there need for offset hinges? Three inch clearance?
Select up to 2 choices.
23) Is the door out-swing or a sliding,door?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Bathroom-2:

1) Is there a light switch at entrance to bathroom?
Select up to 2 choices.
2) Is there adequate task lighting with redundancy?
Select up to 2 choices.
3) Is there a night light?
Select up to 2 choices.
4) Is the flooring non-slip, including throw rugs, if present?
Select up to 2 choices.
5) Is there a timer on the heater?
Select up to 2 choices.
6) Is there adequate ventilation?
Select up to 2 choices.
7) Are the sink, tub and shower controls easy to reach and read?
Select up to 2 choices.
8) Is it easy to mix the temperatures at the faucets?
Select up to 2 choices.
9) Is there an anti-scald valve on the tub/shower controls?
Select up to 2 choices.
10) Is the sink accessible for a client using a mobility device?
Select up to 2 choices.
11) Is there adequate room for transfer to the toilet?
Select up to 2 choices.
12) Are the mirrors located at appropriate height for client?
Select up to 2 choices.
13) Are there safety bars in the shower area?
Select up to 2 choices.
14) Are there safety bars near the toilet? Risk of grabbing TP dispenser?
Select up to 2 choices.
15) Is there a non-skid bath mat in the tub or shower?
Select up to 2 choices.
16) Is there a hand-held shower head?
Select up to 2 choices.
17) Is the toilet seat sturdy and secured?
Select up to 2 choices.
18) Are the electrical outlets on GFCI circuit?
Select up to 2 choices.
19) Are the faucet handles easy to use/lever handles?
Select up to 2 choices.
20) Are the doors out-swing or pocket doors??
Select up to 2 choices.
21) Is there need for offset hinges? Three inch clearance?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Bedroom-Primary:

1) Is there a light switch at the entrance to the room?
Select up to 2 choices.
2) Is the bed at a proper height to allow easy transfers into and out of the bed?
Select up to 2 choices.
3) Is there enough room for the client to walk around the bed?
Select up to 2 choices.
4) Can the client access the closet and dresser drawers easily and safely?
Select up to 2 choices.
5) Is the bedroom free of tripping hazards and clutter?
Select up to 2 choices.
6) Is the bedroom free of extension cords and cable wires in the walkways?
Select up to 2 choices.
7) Is there a bedside light and can the client access the light?
Select up to 2 choices.
8) Is there a flashlight handy for emergencies?
Select up to 2 choices.
9) Is there an adequate-sized nightstand for glasses or other important items?
Select up to 2 choices.
10) Is there a telephone in the bedroom?
Select up to 2 choices.
11) Is there a night light between the bedroom and the bathroom?
Select up to 2 choices.
12) Do throw or area rugs have non-skid backing?
Select up to 2 choices.
13) Are uncarpeted floors non-slip?
Select up to 2 choices.
14) Is the carpet smooth and securely in place?
Select up to 2 choices.
15) Are the windows easy to open and close?
Select up to 2 choices.
16) Are the window blinds and shades in good working order?
Select up to 2 choices.
17) Are closet rods and shelving sturdy and easy to reach?
Select up to 2 choices.
18) Do closets have light that is easy to locate and operate?
Select up to 2 choices.
20) Is there need for offset hinges? Three inch clearance?
Select up to 2 choices.
19) Do closet doors open/close easily?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Bedroom -2:

1) Is there a light switch at the entrance to the room?
Select up to 2 choices.
2) Is the bed at a proper height to allow easy transfers into and out of the bed?
Select up to 2 choices.
3) Is there enough room for the client to walk around the bed?
Select up to 2 choices.
4) Can the client access the closet and dresser drawers easily and safely?
Select up to 2 choices.
5) Is the bedroom free of tripping hazards and clutter?
Select up to 2 choices.
6) Is the bedroom free of extension cords and cable wires in the walkways?
Select up to 2 choices.
7) Is there a bedside light and can the client access the light?
Select up to 2 choices.
8) Is there a flashlight handy for emergencies?
Select up to 2 choices.
9) Is there an adequate-sized nightstand for glasses or other important items?
Select up to 2 choices.
10) Is there a telephone in the bedroom?
Select up to 2 choices.
11) Is there a night light between the bedroom and the bathroom?
Select up to 2 choices.
12) Do throw or area rugs have non-skid backing?
Select up to 2 choices.
13) Are uncarpeted floors non-slip?
Select up to 2 choices.
14) Is the carpet smooth and securely in place?
Select up to 2 choices.
15) Are the windows easy to open and close?
Select up to 2 choices.
16) Are the window blinds and shades in good working order?
Select up to 2 choices.
17) Are closet rods and shelving sturdy and easy to reach?
Select up to 2 choices.
18) Do closets have light that is easy to locate and operate?
Select up to 2 choices.
19) Do closet doors open/close easily?
Select up to 2 choices.
20) Is there need for offset hinges? Three inch clearance?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Bedroom -3:

1) Is there a light switch at the entrance to the room?
Select up to 2 choices.
2) Is the bed at a proper height to allow easy transfers into and out of the bed?
Select up to 2 choices.
3) Is there enough room for the client to walk around the bed?
Select up to 2 choices.
4) Can the client access the closet and dresser drawers easily and safely?
Select up to 2 choices.
5) Is the bedroom free of tripping hazards and clutter?
Select up to 2 choices.
6) Is the bedroom free of extension cords and cable wires in the walkways?
Select up to 2 choices.
7) Is there a bedside light and can the client access the light?
Select up to 2 choices.
8) Is there a flashlight handy for emergencies?
Select up to 2 choices.
9) Is there an adequate-sized nightstand for glasses or other important items?
Select up to 2 choices.
10) Is there a telephone in the bedroom?
Select up to 2 choices.
11) Is there a night light between the bedroom and the bathroom?
Select up to 2 choices.
12) Do throw or area rugs have non-skid backing?
Select up to 2 choices.
14) Is the carpet smooth and securely in place?
Select up to 2 choices.
15) Are the windows easy to open and close?
Select up to 2 choices.
16) Are the window blinds and shades in good working order?
Select up to 2 choices.
17) Are closet rods and shelving sturdy and easy to reach?
Select up to 2 choices.
18) Do closets have light that is easy to locate and operate?
Select up to 2 choices.
19) Do closet doors open/close easily?
Select up to 2 choices.
20) is there need for offset hinges? Three inch clearance?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Living Room:

1) Does the client need to hold onto walls and furniture to walk inside the home?
Select up to 2 choices.
2) Is there a light switch at the entrance to the room?
Select up to 2 choices.
3) Is the lighting adequate in the room?
Select up to 2 choices.
4) Has the fireplace been cleaned professionally?
Select up to 2 choices.
5) Is there a clear, unobstructed path through the room without tripping hazards?
Select up to 2 choices.
6) Do throw rugs have non-skid backing?
Select up to 2 choices.
7) Are any bare floors non-skid?
Select up to 2 choices.
8) Do the windows open and close with easy to reach handles?
Select up to 2 choices.
9) Are window shades or blinds easy to operate?
Select up to 2 choices.
10) Can client get in and out of furniture easily Risers? LIfts?
Select up to 2 choices.
11) Are chairs and sofas sturdy and secure?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Dining Room:

1) Is there a light switch at the entrance to the room?
Select up to 2 choices.
2) Is the lighting adequate in the room?
Select up to 2 choices.
3) Is there a clear, unobstructed path through the room without tripping hazards?
Select up to 2 choices.
4) Do throw rugs have non-skid backing?
Select up to 2 choices.
5) Are any bare floors non-skid?
Select up to 2 choices.
6) Do the windows open and close with easy to reach handles?
7) Are window shades or blinds easy to operate?
Select up to 2 choices.
8) Can client get in and out of furniture easily?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Family Room/Den:

1) Is there a light switch at the entrance to the room?
Select up to 2 choices.
2) Is the lighting adequate in the room?
Select up to 2 choices.
3) Is there a clear, unobstructed path through the room without tripping hazards?
Select up to 2 choices.
4) Do throw rugs have non-skid backing?
Select up to 2 choices.
5) Are any bare floors non-skid?
Select up to 2 choices.
6) Do the windows open and close with easy to reach handles?
Select up to 2 choices.
7) Are window shades or blinds easy to operate?
Select up to 2 choices.
8) Can client get in and out of furniture easily?
Select up to 2 choices.
9) Are chairs and sofas sturdy and secure?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Laundry Room:

1) Does the client do the laundry independently?
Select up to 2 choices.
2) Is the lighting adequate and accessible in this area?
Select up to 2 choices.
3) Is there a GFCI circuit in the laundry room?
Select up to 2 choices.
4) Is the dryer vented to the exterior?
Select up to 2 choices.
5) Can the client see and manipulate the dials on the washer & dryer?
Select up to 2 choices.
6) Are the laundry supplies easy to reach?
Select up to 2 choices.
7) Is there a non-slip floor surface?
Select up to 2 choices.
8) Is there adequate workspace for loading, unloading and folding clothes?
Select up to 2 choices.
9) Is this space easily accessible for the resident (basement/upstairs)?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.

Interior- Basement:

1) Is there a light switch at the top and bottom of the stairs?
Select up to 2 choices.
2) Is the lighting adequate in the basement?
Select up to 2 choices.
3) Is there a clear, unobstructed path through the basement?
Select up to 2 choices.
4) Are the bare floors slip-resistant?
Select up to 2 choices.
5) Do the windows operate easily?
Select up to 2 choices.
6) Are there hazardous materials stored in the basement?
Select up to 2 choices.
7) Are there any visible signs of water leaks?
Select up to 2 choices.
Choose Image
Accepted file types: jpg, jpeg, png, gif.