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Name Change Verification of Closure Status Change Inspection Re-inspection Community On-Site System Visit Water Community Transient Non-Community Non-Transient Non-Community Non-Public
Water Supply LOBBY, HALLS AND STAIRS (.1808) 1. Ventilation clean and in good repair ......................................................................... 2. Lighting meets requirements
..................................................................................... 3. Floors, walls and ceilings clean and in good repair ..................................................
4. Furniture and accessories clean and in good repair .................................................. LAVATORIES, TOILETS, AND BATHS (.1809) 5. Sewage and other liquid waste disposed
of by approved methods ........................ 6. Properly operating sewage systems ........................................................................ 7. Fixtures clean and in
good repair, provided in each room if required ...................... 8. Lavatory and vanity sanitized, testing method available and used ......................... 9. Towels provided
clean and in good repair, soap ..................................................... 10. Floors, walls and ceilings cleanable, clean and in good repair .................................
WATER SUPPLY (.1809, .1810) 11. Meets requirements in 15A NCAC 18A .1700 or 15A NCAC 18C .......................... 12. Cross-connections prohibited ..................................................
.................................... 13. Hot and cold running water provided; (116°-128° F) in guestrooms .......................... DRINKING WATER FACILITIES (.1811) 14. Water cooler,
fountain or dispenser approved ............................................................. 15. Multi-use utensils washed, rinsed, sanitized, properly stored and handled; approved facilities
if required ................................................................................................... 16. Ice buckets with liners, ice bucket lids washed, washed, rinsed and
sanitized in an approved manner ....................................................................................................................... 17. Ice machines clean and in
good repair; ice machines meet requirements ................. 18. Ice stored and handled to prevent contamination, scoops provided ....................... 19. Single service articles
properly stored and handled ................................................. BEDROOMS (.1812) 20. Ventilation clean and in good repair ...............................................................
.......... 21. Outside openings screened unless air conditioned .................................................. 22. Lighting meets requirements ....................................................
................................. 23. Window coverings clean and in good repair ............................................................. 24. Two clean sheets on each bed, folded
under mattress and over cover 6 inches ...... 25. Sheets, Sheets, pillow cases, blankets and bed spreads clean and in good repair ............... 26. Floors, walls, and ceilings clean
and in good repair ................................................. 27. Furniture, fixtures and accessories clean and in good repair ................................... 28. No roaches,
flies or other pests ............................................................................... 29. Coffee and tea makers kept clean .............................................................
................ STORAGE (.1813) 30. Storage provided for supplies, linen and equipment; kept clean ............................ 31. Linen properly handled and stored ................................
.......................................... 32. Supplies on carts properly stored, carts clean and stored properly ....................... TRASH; DISPOSAL OF GARBAGE AND PREMISES (.1814)
33. Garbage containers covered, kept clean, facilities for cleaning................................ 34. Rubbish, litter and other items not permitted to accumulate on the premises .......
35. No undrained areas, no fly or mosquito breeding places or rodent harborages ...... 36. Premises kept neat and clean ...............................................................................
.... N.C. Department of Environment and Natural Resources Division of Environmental Health Inspection of Lodging Establishment Health Department Current Facility ID Old Facility ID Score:
Date of Insp/Chg: Status Code: Wastewater System: Water sample taken today? NC Name of Establishment: Owner/Operator: Mailing Addr: State: Zip City: Location Address: City: Inspection
by: ________________________________________________ EHS I.D. # Rept Received by: _____________________________________________ Owner/Operator Purpose: General Statute 130A-248 requires
the Commission for Health Services to adopt rules governing the sanitation of establishments where lodging is provided for pay. 15A NCAC 18A .1805 specifies the contents of an inspection
form to record the results of inspections made of such establishments. This form is developed to be used in making inspections of hotels, motels, tourist homes and similar establishments.
Preparation: Local environmental health specialists shall complete the form every time they conduct an inspection. Prepare an original and two copies for: 1. Original to be left with
the responsible person. 2. Copy for the local health department. 3. Copy for the Environmental Health Services Section, Division of Environmental Health. Disposition: This form may be
destroyed in accordance with Standard-8.B.6., Inspection Records, of the Records Disposition Schedule published by the N.C. Division of Archives and History. Additional forms may be
ordered from: Division of Environmental Health, 1632 Mail Service Center, Raleigh, NC 27699-1632, (Courier 52-01-00) DENR 3977 (Revised 7/05) Environmental Health Services Section (Review
7/08) Deduction Full/half Comment Sheet Attached COMMENTS TOTAL DEDUCTIONS _________ 12 34 1 2 12V 3 1.5 1 .5 1 .5 1 .5 1 .5 2 1 3 1.5 3 1.5 2 1 2 1 2 1 6 3 3 1.5 4 2 4 2 4 2 3 1.5 3
1.5 3 1.5 1 .5 1 .5 1 .5 2 1 3 1.5 4 2 4 2 4 2 4 2 3 1.5 3 1.5 3 1.5 3 1.5 4 2 4 2 3 1.5 2 1 ** SEE COMMENT SHEET ATTACHED ** Yes No St Zip: Yes No //18 2018200006 98.5 0 6 1 4 2 0 1
0 A HICKORY INN PIEDMONT CENTER ASSOCIATION 1520 13TH AV DR SE HICKORY 28602 1.5 1654
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM Time In: Time Out: Total Time: City: Street: ID: Name: am pm am pm : HICKORY INN
: 2018200006 1520 13TH AV DR SE HICKORY 1 1 1 2 7 repair tile grout in showers as needed
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: HICKORY INN 2018200006 1520 13TH AV DR SE HICKORY
N.C. Department of Environment and Natural Resourses Division of Environmental Health COMMENT ADDENDUM City: Street: ID: Name: General Comments: HICKORY INN 2018200006 1520 13TH AV DR
SE HICKORY some older sink vanities stained, scratched. replace as needed