Assisted Living Inventory List Printable
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Assisted Living Move-In Inventory Checklist
This inventory checklist is designed to document the condition of the resident’s apartment or room at the time of move-in. Both the resident (or their representative) and a staff member should complete and sign this form. This helps protect both the resident and the assisted living facility by providing a record of the condition of the space and the items brought in.
Instructions:
- Inspect each item or area carefully.
- Indicate the condition of the item/area using the following codes:
- N = New
- G = Good
- F = Fair
- P = Poor
- NA = Not Applicable
- Note any specific damages or issues in the “Notes” column.
- After completing the checklist, both the resident (or representative) and a staff member should sign and date the form.
- Keep one copy of the completed checklist for the resident’s records and one copy for the facility’s records.
Resident Information
| Resident Name: | |
|---|---|
| Apartment/Room Number: | |
| Move-In Date: |
Apartment/Room Condition
| Item/Area | Condition | Notes |
|---|---|---|
| Walls | ||
| Ceiling | ||
| Floor | ||
| Windows | ||
| Window Coverings (Blinds/Curtains) | ||
| Door(s) | ||
| Lighting Fixtures | ||
| Outlets/Switches | ||
| Smoke Detector | ||
| Sprinkler System (if applicable) | ||
| Heating/Cooling System |
Bathroom Condition
| Item/Area | Condition | Notes |
|---|---|---|
| Toilet | ||
| Sink | ||
| Shower/Bathtub | ||
| Shower/Bathtub Door or Curtain | ||
| Mirror | ||
| Flooring | ||
| Towel Racks | ||
| Grab Bars (if applicable) | ||
| Ventilation Fan |
Kitchenette Condition (if applicable)
| Item/Area | Condition | Notes |
|---|---|---|
| Cabinets | ||
| Countertops | ||
| Sink | ||
| Refrigerator | ||
| Microwave | ||
| Stove/Cooktop (if applicable) |
Resident’s Personal Property Inventory
List all significant personal items brought into the apartment/room by the resident. This list does not need to be exhaustive, but should include valuable or easily damaged items such as electronics, furniture, and jewelry. Include a brief description and note the condition of each item.
| Item Description | Condition | Notes |
|---|---|---|
Add more rows as needed. For valuables, consider taking photographs for additional documentation.
Additional Notes
Please use this space to note any other observations or concerns regarding the condition of the apartment/room or the resident’s belongings:
Signatures
By signing below, both the resident (or their representative) and a staff member acknowledge that they have inspected the apartment/room and agree with the documented condition.
Resident (or Representative) Signature:
Date:
Staff Member Signature:
Date:
This inventory checklist is intended as a guide and may need to be adapted to meet the specific needs of the assisted living facility and its residents. It is not a substitute for legal advice.
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