A Community Residence Facility is:

A facility providing safe, hygienic, sheltered living arrangements for one or more individuals who are:

• Not related by blood or marriage to the Resident Director
  
• Ambulatory (able, with or without mechanical assistance, to get in and out of bed, walk or move from place to place with more than minimal assistance from another person)
  
• Able to perform the activities of daily living with more than minimal assistance.

The definitions above do not include facilities providing sheltered living arrangements to persons who are in the custody of the District of Columbia, Department of Corrections.

Describe Your Program

What type of Program has been developed for your residents?

Physical Description of The Facility

Exterior:

Brick  Wood  Brick/wood  Aluminum Siding

Other:

Attached  Detached  Semi-detached  Row

Other:

Interior:

1. Toilet Facilities (number and location)
2. Handwashing Facilities (number and location)
3. Bedrooms (number and location)

Staffing Pattern

Type of Staff Employed (list types and numbers)

1. Name of licensee(s) with days of week and hours of the day in the facility:

2. Names of other staff (days of week, hours of the day and description of their responsibilities) working in the facility:

3. Names of volunteers (days of week, hours of the day and description of their responsibilities) working in the facility.

Population Serviced
Men Only
Women Only
Women and Men

Age Rage: 

Services Provided

Mark the appropriate box, indicating how the service is provided.

Service Provided	Direct	Contract	Resources
Housekeeping
Laundry Services
Social Work Services
Dietary Services
Recreation Activities
Emergency Mental Care
Medicine
Dentistry
Education
Nursing
Occupational Therapy
Physical Therapy
Psychology
Speech and Language Therapy

Resident Activities

Admission Policy