Home Assessment

Home for Life Design
Home Assessment Report
Patient Information:
------------------------------------------------------------Patient Name: ----------------Sliver, Tess
--------------------------------------------------------------------------------------------------------------------------Address:
2155
Sawtooth Mountain Dr.
==================
-------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------6/3/1930
Date of Birth:----------------------------------------------Gender:
Female
Henderson, NV 89044
Tennant Type:
Renter
Is Veteran:
No
Housing Type:
Single Family
Has HOA:
Yes
No. Floors:
Lives With:
Self
Special Considerations:
Inaccessible
Areas:
Assistive FWW, 4WW, SPC, SC

Devices:
If the client has fallen, did the most recent fall:
Where did the fall occur: Outside the Home
Result in Injury: No
What Room:
Result in Hospitalization: No
Fall Cause Type: Environmental
Result in Rehabilitation: No
Fall Cause Comments: Client reported that last fall occurred

inside of casino due to slippery floor (i.e., water spilled on floor).
This fall did not result in any injury.
Other Considerations:
Consideration Type
Therapist Note
Home and Personal Findings:

The following rooms assessed each indicate the Personal Safety Rating given by the patient and the Therapist
Accessibility Rating determined by activity analysis during skill performance:
A Home for Life Design Solution
http://www.homeforlifedesign.com
Page: 1 of 11
Pre-Assessment
Personal Safety
Rating %
Therapist
Accessibility
Rating %
Living/Family Room,
100.00 %
100.00 %
Kitchen,
80.00 %
71.43 %
Dining Space,
80.00 %
87.50 %
Bedroom,
80.00 %
75.00 %
Bathroom,
50.00 %
71.43 %
Laundry Room,
100.00 %
100.00 %
0.00 %
0.00 %
Hallway,
100.00 %
100.00 %
Outdoor Space,
80.00 %
0.00 %
Room Assessed
Entryway, Doesn't use
Post-Assessment
Therapist
Personal Safety
Accessibility
Rating %
Rating %
Page: 2 of 11
Home Recommendations Based on Findings:
Living/Family Room,
Personal Safety Rating
Accessibility Rating
100.00 %
100.00 %
Recommended Modifications:
- Add Furniture Risers
Pre-Assessment Notes: Living room was very spacious and organized. Room was very well lit. There was no clutter
and no throw rugs. Client mentioned that she did not use couch to sit on because it was difficult for her stand back up
due to sinking into the seat; thus, she uses the firm seats with armrests which make it easier for her to stand. A
furniture riser on the couch which would make it higher, might make it easier for her to stand up from it.
Post-Assessment Notes:
Kitchen,
80.00 %
71.43 %
- Add Lighting
- Add Accessible Shelving
Pre-Assessment Notes: Room is very spacious and organized. Even though there are many lights making it
potentially well-lit, four of the bulbs need to be changed. Cabinet shelves are very high and client only reaches up to
the second shelf of most cabinets. There is one throw rug at the entrance of this room that is a hazard because it is
slippery on the tile; using double sided tape on the bottom of this rug may prevent it from slipping. Client's main
concerns include carrying food from one place to the another.
Page: 3 of 11
Dining Space,
80.00 %
87.50 %
Pre-Assessment Notes: Client experiences no difficulties in this room other than fear of dropping plates when moving
them from the microwave to the table. However, the distance from the microwave is only about three feet and she
mentioned that she did not feel as though she needed any adaptations for this.
Page: 4 of 11
Bedroom,
80.00 %
75.00 %
- Create Accessible Closet
Pre-Assessment Notes: Room is very spacious and organized. Client does not experience any difficulty getting in/out
of bed. Client has 2 firm chairs with armrests in room that she uses for reading time. While closet is very organized,
shelves are high so she does not reach the top areas. She has a stool that she can used to reach the top areas, but
does not feel safe; thus, adding an accessible closet would be a safer option. Furthermore, the client has oxygen
tank in room and mentioned that she usually does not roll up the cord which is a potential fall hazard.
Page: 5 of 11
Bathroom,
50.00 %
71.43 %
- Toilet Safety Frame with Rails
- Rug w/ Anti Slip Backing
Pre-Assessment Notes: Room is very spacious and organized; toilet is in separate room. Client has grab bars in
shower, but was not allowed by landlord to add any by toilet. Thus, client would benefit from a toilet safety frame to
help her transfer on/out of toilet safely. Client has walk-in shower with shower chair inside of shower and one outside
of shower for drying. It is recommended that shower chair outside of shower have a backrest in order to help
maintain balance when bending down to dry lower extremities.
Page: 6 of 11
Laundry Room,
100.00 %
100.00 %
Pre-Assessment Notes:
Page: 7 of 11
Entryway, Doesn't use
0.00 %
0.00 %
- Add Security System
Pre-Assessment Notes: Client reported limited use of entry way; however, we recommend security system due to her
leaving the door unlocked when expecting visitors.
Hallway,
100.00 %
100.00 %
Pre-Assessment Notes: Room is well-lit and has night-lights. Client did not report any concerns. No
recommendations made.
Page: 8 of 11
Outdoor Space,
80.00 %
0.00 %
- Add Accessible Mailbox
Pre-Assessment Notes: Outdoor space is spacious and organized. Client reported limited use of it due to always
entering home through garage. However, client reported experiencing difficulty with opening mailbox due to height
and depends on neighbors to assist with opening mailbox and rolling her trash cans. Client reported not using back
patio.
Page: 9 of 11
Page: 10 of 11
Additional Service Recommendations (e.g. home health, medication management):

N/A
Additional Notes:
All rooms in home were very spacious, organized, and well-lit. Client had night-lights in every room and in hallways.
There was no clutter in any room. There were no apparent trip hazards besides throw rugs.
Submitted By:
Cynthia Sanchez, , License #

9/22/2015
Page: 11 of 11

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Home Assessment

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Home for Life Design

Home Assessment Report

Assistive FWW, 4WW, SPC, SC

If the client has fallen, did the most recent fall:

Where did the fall occur: Outside the Home

Fall Cause Type: Environmental

Fall Cause Comments: Client reported that last fall occurred

Home and Personal Findings:

A Home for Life Design Solution

Entryway, Doesn't use

A Home for Life Design Solution

Home Recommendations Based on Findings:

Personal Safety Rating

Personal Safety Rating

A Home for Life Design Solution

Personal Safety Rating

A Home for Life Design Solution

Personal Safety Rating

A Home for Life Design Solution

Personal Safety Rating

A Home for Life Design Solution

Personal Safety Rating

A Home for Life Design Solution

Entryway, Doesn't use

Personal Safety Rating

Personal Safety Rating

A Home for Life Design Solution

Personal Safety Rating

A Home for Life Design Solution

A Home for Life Design Solution

Additional Service Recommendations (e.g. home health, medication management):

Cynthia Sanchez, , License #

A Home for Life Design Solution

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