House Cleaning List Template

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DHS: Seniors and People with Disabilities
State Operated Community Program
House Cleaning List
Month / Year: _______________
Shift
Chores
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Empty dishwasher
Day
Swing
Prior to end of shift
Day
Check: Med / Mar’s /
Swing
TAR’s for accuracy
Night
Mop and sweep floors,
Day
prior to end of shift
Swing
Night
Empty trash cans
Day
Swing
Night
Wipe off counter tops
Day
and tables, prior to
Swing
end of shift
Night
Deep clean
Day
bathrooms: Each Shift
Swing
Night
Toilets, counters, sink, mop
Vacuum floors
Day
Swing
Laundry: Dry and Fold
Day
House/client laundry.
Swing
Alert next shift of laundry in
Night
washer/dryer.
Clean Adaptive
Day
Equipment.:
Swing
Follow
protocols for: wheel chairs,
Night
tables, Ankle Foot Orthotics
(AFO), etc.
Staff initials after chore has been completed (before end of shift)
0 = chore not done with explanation on back of form.
House Cleaning List _ Page 1 of 3
07/08
DHS: Seniors and People with Disabilities
State Operated Community Program
House Cleaning List
Month / Year: _______________
Shift
Chores
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Empty dishwasher
Day
Swing
Prior to end of shift
Day
Check: Med / Mar’s /
Swing
TAR’s for accuracy
Night
Mop and sweep floors,
Day
prior to end of shift
Swing
Night
Empty trash cans
Day
Swing
Night
Wipe off counter tops
Day
and tables, prior to
Swing
end of shift
Night
Deep clean
Day
bathrooms: Each Shift
Swing
Night
Toilets, counters, sink, mop
Vacuum floors
Day
Swing
Laundry: Dry and Fold
Day
House/client laundry.
Swing
Alert next shift of laundry in
Night
washer/dryer.
Clean Adaptive
Day
Equipment.:
Swing
Follow
protocols for: wheel chairs,
Night
tables, Ankle Foot Orthotics
(AFO), etc.
Staff initials after chore has been completed (before end of shift)
0 = chore not done with explanation on back of form.
House Cleaning List _ Page 1 of 3
07/08
Shift
Cleaning chores
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Wipe out fridge spills
Day
Swing
Night
Dust
Day
Wash wood work
Swing
Inside ALL cabinets
Night
(laundry/Kitchen)
Vacuum furniture
Day
Vents
Swing
Oven and burners
Night
Remove cob webs
Day
Supply/heater room
Swing
Fridge remove drawers
Night
Wash inside windows
Day
Kitchen drawers (wipe)
Swing
Under fridge/stove
Night
Walls
Day
Light fixtures
Swing
Under washer/dryer
Night
Doors/frames/knobs
Day
Spot clean carpets
Swing
Page reinforceres
Night
Exhaust fans
Day
Deep clean Assigned
Day
Individuals’ bedroom
Swing
Initials
Signature
Initials
Signature
Initials
Signature
Weekly: Site Managers signature: Verify chores
Staff initials after chore has been completed (before end of shift)
0 = chore not done with explanation on back of form.
House Cleaning List _ Page 2 of 3
07/08
Chore
Shift
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MISCELLANEOUS:
Items to complete upon completion of assigned chores and assigned individual do not need assistance or is sleeping.
• Assist/help other staff
• Straighten closets
• Decorate for holidays
• Do the dishes
• Deep clean areas
• Reinforce pages in books
• Bake something
• Do house laundry
• Clean gutters
• Toss outdated/unmarked fridge food
• Do mending
• Clean light switches
• Rotate food in cupboards
• Turn in recycling
• Organize scrapbooks for clients
• Review clients’ BSP
• Wash state vehicles
• Do crafts/projects for clients if pre-approved by management.
Activities limited to staff breaks:
2 (15 minutes) Management must be aware of scheduled breaks.
• Hand held games or laptop computer
• Personal knitting/crafting
• Personal paperwork or homework
• Watching TV
• Games not with client
• Relaxing with feet up
• Scrap booking (personal)
• Card playing
• Reading books, magazines, and newspapers
NEVER APPROVED for staff:
NO sleeping NO use of blankets/pillows NO loud music NO visitors/visiting staff
NO horseplay
NO lights off in living areas during evening/night hours.
Initials
Signature
Initials
Signature
Initials
Signature
Weekly: Site Managers signature: Verify chores
Date:
Date:
Date:
Date:
Staff initials after chore has been completed (before end of shift)
0 = chore not done with explanation on back of form.
House Cleaning List _ Page 3 of 3
07/08

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