Home for Life Design

Home Assessment Report

Patient Information:
PatientName:

Katow,Ron

DateofBirth: 1/1/1935

Address:

1657Warringtondrive

Gender:

Male

Henderson,Nv89052
TennantType:

Owner

IsVeteran:

No

HousingType:

SingleFamily

HasHOA:

No

No.Floors:

LivesWith:

Spouse

Special Considerations:
Inaccessible
Areas:

Assistive
Devices:

Iftheclienthasfallen,didthemostrecentfall:

Wheredidthefalloccur:OutsidetheHome

ResultinInjury:No

WhatRoom:

ResultinHospitalization:No

FallCauseType:Environmental

ResultinRehabilitation:No

FallCauseComments:

OtherConsiderations:
Consideration Type
HasaHistoryofFalls

Therapist Note
Clientisconcernedwithonefrontstepthatisneededto
enterthehomebecausehehasfalleninthepast.However,
noinjuryoccurredfromthefall.

Home and Personal Findings:

ThefollowingroomsassessedeachindicatethePersonalSafetyRatinggivenbythepatientandtheTherapist
AccessibilityRatingdeterminedbyactivityanalysisduringskillperformance:

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Pre-Assessment
Room Assessed

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100%

100%

100%

100%

100%

100%

80%

100%

100%

100%

100%

100%

100%

100%

100%

100%

Bathroom,Bathroomonfirstfloorwithtub,
shower,andtoilet.
Bedroom,Themasterbedroomwaslocatedon
thefirstfloor.
DiningSpace,Thediningspacewasinabig
roomconnectedtothekitchenandlivingroom.
Entryway,Therearemultiplelargestepsthat
leadtotheentryway.
Kitchen,Thekitchenisonthefirstfloor.
Living/FamilyRoom,Thelivingroomisonthe
firstfloorconnectedtothekitchenanddining
room.
Hallway,Therewasonlyonehallwayinthe
homeonthefirstfloor.
OutdoorSpace,Accessedbythelivingroom
backslidingglassdoor.

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Post-Assessment
Therapist
Personal Safety
Accessibility
Rating %
Rating %

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Home Recommendations Based on Findings:

Pre-Assessment
Bathroom, Bathroom on first floor with tub,
shower, and toilet.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:
-AngledGrabBar
-GrabBarOppositeSideofBathingEntry
-DiagonalGrabBar
-12"-Textured
-RaisedToiletSeat
Pre-Assessment Notes:
Theclienthadnoproblemsutilizingalltheitemsinhisbathroom.Therecommendationsareforfutureproblemsthatmay
occurwithanincreaseinage.

Post-Assessment Notes:

Pre-Assessment
Bedroom, The master bedroom was located
on the first floor.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

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Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Page: 3 of 11

Recommended Modifications:

Pre-Assessment Notes:
Theroomwasspaciousenoughtomaneuveraroundandtherewasaccesstoeverythingthattheclientneededtoutilize.

Post-Assessment Notes:

Pre-Assessment
Dining Space, The dining space was in a big
room connected to the kitchen and living
room.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:

Pre-Assessment Notes:
Theroomdidnothaveanyadaptationsthatneededtobemade.

Post-Assessment Notes:

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Pre-Assessment
Entryway, There are multiple large steps that
lead to the entry way.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

80.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:
-AddLighting
-AddVisibleSteps
Pre-Assessment Notes:
Themainissuewiththeentrywaywasthestepshadnocontrastofcolor.Theclientstatedhehasfallenbeforedueto
thisissuebecausehecannottellwherethestepsstopandbegin.

Post-Assessment Notes:

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Pre-Assessment
Kitchen, The kitchen is on the first floor.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:

Pre-Assessment Notes:
Thekitchenwasspaciousandtherewerenorecommendationsneeded.

Post-Assessment Notes:

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Pre-Assessment
Living/Family Room, The living room is on
the first floor connected to the kitchen and
dining room.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:

Pre-Assessment Notes:
Thelivingroomwaswellorganizedandnorecommendationswereneeded.

Post-Assessment Notes:

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Pre-Assessment
Hallway, There was only one hallway in the
home on the first floor.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:

Pre-Assessment Notes:
Thehallwaywaswelllitandeasytomaneuverthrough.Norecommendationswererequired.

Post-Assessment Notes:

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Pre-Assessment
Outdoor Space, Accessed by the living room
back sliding glass door.

Personal Safety
Rating %

Therapist
Accessibility
Rating %

100.00 %

100.00 %

Post-Assessment
Personal
Safety
Rating %

Therapist
Accessibility
Rating %

Recommended Modifications:

Pre-Assessment Notes:
Theoutdoorspacewaswellorganizedandeasytomaneuveraround.Norecommendationswereneeded.

Post-Assessment Notes:

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

Additional Notes:
Currentlytheclientisnotexperiencinganydifficultiesinhishome.Heabletoambulatewithoutanyconcernsor
environmentalhazards.Themainconcernisthestepsintheentryway.

Submitted By:

Samantha Burneo, , License #

3/1/2016

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