|
Name of Facility:
Type of Facility:
Address:
,
Residence
Director:
First
Name
Middle Name
Last Name
Assistant Residence
Director:
First
Name
Middle Name
Last Name
Facility License Number:
Authorized Facility Capacity:
Total Number of Admissions:
Total Number of Discharges:
Total Number of Resident Days:
Total Number of Deaths:
Total Number of Residents Presently in Your Facility:
Signature:
________________________________
Date: / /
Month
Day
Year (yyyy) |
