Senior Care Home Options will schedule an onsite evaluation visit with new residential care residences interested in an association with our company. 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.

Facility Name*
Contact Person*
Address*
City*
Zip Code*
Telephone number*
Fax number
E-mail
License number*
Year started*
Maximum capacity*
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  One bedroom  Two bedrooms  Private  Semi-private
Ambulation Status (check all that apply)	Accept ambulatory clients only  Accept non-ambulatory clients only  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  Pets
Additional Information Regarding Your Facility: (Do not exceed 500 characters)