New Facility Registration

NEW RESIDENTIAL CARE FACILITIES
(Sacramento, CA area only)
About Elder Care will schedule an onsite evaluation visit with new Sacramento area senior care residences interested in an association with our company. 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.:

E-mail:

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 retirement community

Assisted living (large facility)

Small residential care home

24-hour a day 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

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)

Please mail us brochures, price lists and other information about your facility.

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About Elder Care
(division of Elder Care Referral Services, Inc.)
3800 Auburn Blvd., Suite C
Sacramento, California 95821
Telephone: (916) 489-8779
Auburn: (530) 889-0303
Placerville (530) 626-5900
Fax: (916) 489-0191
E-Mail: info@eldercareservices.com
URL: www.eldercareservices.com