E-Mail: info@eldercareservices.com
1911 Douglas Blvd., Suite 85-198 Roseville, CA 95661 (Suburb of Sacramento)
Facility Registration Form
Facilities in Sacramento, Placer, El Dorado, Yolo, Solano, Nevada and San Joaquin counties only should apply.
Interested facility administrators should complete this form and e-mail it to our offices.
INDICATIVE INFORMATION (check all that apply)
Facility Name:
Contact Person:
Address:
City:
State: CA
Zip Code:
Telephone No.:
Fax No.:
Email:
License No.:
Year Started:
Maximum No of Residents:
Number of Levels of Care:
Dementia Waiver:
Hospice Waiver:
Type of Facility (check all that apply)
Independent Living Facility
Assisted living (large facility)
Small residential board and care home
Skilled nursing facility
Accommodations (check all that apply)
Studio Private
One bedroom Semi-private
Two bedrooms
Ambulation Status (check all that apply)
Accept ambulatory clients only
Accept non-ambulatory clients
Accept clients in wheelchairs
Cognitive Status (check all that apply)
Alzheimer's special care unit
Accept clients with Alzheimer's/dementia
Accept clients with mental disorders
Accept alcoholics
Services Offered (check all that apply)
Bathing, dressing and grooming
Incontinence care
Diabetic diets
Short term feeding assistance
Medication management
Wheelchair transfer assistance
Night time assistance
Transportation services
Laundry and housekeeping
Awake staff at night
Special Needs (check all that apply)
Oxygen
Urinary catheter
Ostomy care
Insulin injections
Wanderers
Accept smokers
Pets
Additional Information Regarding Your Facility:(Do not exceed 2000 characters)
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