REPORT  

OF  HOME  ASSESSMENT  
 
       
th
Date  of  visit:    March  9 ,  2017       Follow  up  visit  (tentative):  ____________________  
 
Client’s  Name:  Elsa  Ramos  
 
Interviewer:  Jessica  Gutierrez  
 

RESULTS  OF  THE  HOME  ASSESSMENT:  

Hazard Recommendation Material Vendor

Exterior Client lives in an GE white Home Depot

entrance/exit area where there
is no light. Clients wireless motion
1. Lack of sensor driveway is very
light at night dark with no sensing LED
sensory light at
night. Without sconce
light, client can
easily fall or miss
a step when
walking into and
out of home.

Living room Clients nephew VELCRO brand Amazon

has a PlayStation
2. Electric cords connected to the electrical tie
across the floor T.V with
electrical cords wrap
running across the
floor. Untied
electrical cables
are unsafe for
client when
ambulating across
living room, client
may trip and fall
over the electrical
cords.

3. Unsafe chair Client enjoys Stretch Oxford Target

(no arm rest) watching T.V on a
reclining chair
 that does not have Recliner
arm rest. Client
displays difficulty
when going from
a sit to stand
position. Chairs
with no arm rest
allow no support
and can cause
client to lose
balance and lean
forward which can
result in client
falling forward.

Kitchen Client has not Rubber Maid Amazon

been able to cook
4. High cabinets due to the height pull down
of the cabinets.
Many of the items shelves
the client uses are
out of her reach,
resulting in the
client having to
use a chair or an
unstable item to
stand on top of,
causing her to

5. No fire No fire First alert home Target

extinguisher extinguisher near
or in the kitchen fire extinguisher
can pose as a
hazard if a fire
erupts while client
is cooking and has
no way of
extinguishing fire.
6. Rugs Client has a Mohawk stay ‘n’ Bed, Bath &
padded rug in
front of the sink to place rug tabs Beyond
stand on while
washing dishes.
Rug can pose as a
hazard to client
because she can
slip on the rug and
fall.

Laundry To enter the No drill required Home Depot

laundry, client has
7. Steps to enter to go down one grab bar
laundry room steep step without
support. This step
can pose as a
hazard because
client is unable to
maintain balance
when going down
the stair to enter
the room.

Bedroom Clients room is Real simple over Target

too small for the
8. Clutter amount of things the door
she has inside.
Clutter can pose multipurpose
as a hazard to
client because she organizer
can trip over
things that are on
the floor or cause
client to become
frustrated because
there is no space
for her things.

9. Bed too high Client has Handy support Amazon

difficulty getting
in and out of bed step with handle
because the bed is
too high for her.
This can pose as a
hazard to the
client because she
 can lose her
balance when
trying to climb in
and out of the bed.

10. Lack of light Although client Luna tap light Home Depot
has a light in her
in Closet bedroom, her
closet space does
not. This can pose
as a hazard to the
client when
reaching for
clothes, the client
may fall forward
because she
cannot see or she
may become
frustrated because
she cannot choose
the item she
would like, due to
lack of light.

11. Unstable The clients floor 2 Oz clear wood Target

Threshold in the bedroom is
wood. Upon Gorilla Glue
entering the
clients room, the
threshold is
unstable and
moves from side
to side. This can
pose as a hazard
when client enters
the room, the
wood from the
threshold may
slide out and
client can fall.
Bathroom Client has a Medline bath bar Home Depot
tub/shower and
12. Difficulty has difficulty (locks to side of
entering brining her leg
Shower/Tub over when tub)
entering the
shower. This can
pose as a hazard
since the client
has nothing to
grab onto and can
fall inside the
shower or outside
the shower.

13. No shower Due to the clients Medline bath Home Depot

bench/chair lack of exercise,
client becomes bench
fatigued. Inside
the shower, client
does not have a
shower bench.
This can pose as a
hazard because
client may
become fatigued
and will not have
anything to sit
down on if she
needs a break.

14. Low toilet Clients toilet is Nova raised Walgreens

too low for
stature. Client toilet seat with
cannot come from
sit to stand or arms
stand to sit when
using the
bathroom. This
can pose as a
hazard because
client can lose her
balance and fall,
or hurt herself if
she sits down too
hard.
15. Slippery bath Clients bath tub Slip X Solutions Home Depot
floor becomes slippery
and can pose a bath mat
hazard to the
client when
bathing. Client
can easily slip and
fall inside the
shower.

 
Other  referrals:  (Client  may  need  to  request  from  PCP)  
 
1.   Optometrist  _____  
2.   Ophthalmologist    ______  
3.   Physical  Therapy  ______  
4.   Occupational  Therapy  X  
5.   Dietitian  and/or  Nutritionist  __  
6.   Mental  Health  Counselor  ______  
7.   Social  Worker  ______  
8.   Estate  Planner  _______  
9.   Advance  Directives  
 
10.    Other______  Specify:  ________________________________________  
 
 
 
Interviewer’s  name:  Jessica  Gutierrez    
 
 
 
Signature:  _____________________________________________  
 
 
 
 
Approved  by:  _______________________________