Senior Care Facility Licensing Requirements Checklist Form
Use this form to review whether a senior care facility has the licensing documents, safety items, and operational records needed for licensing readiness. Fill out the facility details, checklist items, and any follow-up actions needed.
Facility Information
Facility Name
*
Facility Type
Please Select
Assisted Living
Nursing Home
Memory Care
Independent Senior Living
Other
Street Address
*
City
*
State/Province
*
Postal Code
*
Primary Contact Name and Title
*
Licensing and Compliance Checklist
Current license status
*
Active
Pending renewal
New application
Expired
Unknown
Required licensing documents available
*
Operating license
Inspection report
Fire safety approval
Occupancy certificate
Emergency evacuation plan
Staff training records
Resident rights posting
Medication management procedures
Maintenance logs
Last inspection date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Compliance gaps found
Corrective action needed
Target completion date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Review and Submission
Reviewer Name
*
Reviewer Role
*
Overall Readiness Summary / Final Notes
*
Submit
Should be Empty: