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Community Name*:
License Number*
(this will be your user name):
Corporate Name*:
Corporate Contact*:
Administrator*:
Marketing Director*:
Address:
City:
State:
County:
Zip:
Phone:
Fax:
Cell:
Email:
Website:
Religious Affiliation:
Years of Ownership:

FACILITY TYPE (Select all that apply)

ALF
ALZ
BNC
CCRC
ILC
SNF
Total Beds

ON SITE PERSONNEL (Select all that apply)
RN
LVN
CNA
Caregiver
Social Worker
Other
Ratio (Staff to Resident)
Languages - Please list
Hours Nurses Available
Staff Turnover Rate
PrivateRoomRate
Available Private Rooms
Room Description (Male/Female/etc.)
Shared Room Rate
Available Shared Room
Shared Room Description (Male/Female, etc)
Dementia Unit Room
Dementia Rooms Available
Dementia Room Description
Care Fees
Care Fees Range
Community Fees Range
Pet Fees
Incontinence Fees
Supply Fees
Other Fees
SSI Accepted: ALWPP:

SERVICES AND AMENITIES (Select all that apply)

FamilyOvernight:

Unique:

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ABOUT SENIOR SOLUTIONS
174 West Foothill Blvd, #240,
Monrovia, CA 91016
626-359-0108
info@aboutseniorsolutions.com


       










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