Name Address Identification no. Telephone no. Fax no.
Area office Regional office
Emergency/disaster plan Date tested
Approved/licensed capacity No. of Special care beds Facility CMI Additional beds available Accredited date Award yrs
List strengths and developments since the last review (attach pages as desired) *Please attach a copy of your organizational chart.
List internal committees
Resident involvement Family involvement
Resident involvement
Family involvement
Type of rooms (this refers to structural layout rather than what is charged as preferred accommodation)
Number of rooms with 1 bed Number of rooms with 2 beds Number of rooms with 3 beds Number of rooms with 4 beds Other (please specify)
Separate infirmarye
Room no.
Type of security system (please specify)
Year of construction
Opening date
Year(s) of renovation (if applicable)
No. of floors
Explanation if applicable
Comments
Services provided to the community (e.g. meals on Wheels, Day Care programs, Short Stay programs)
Do staff provide services such as laundry, housekeeping, dietary, maintenance to other than long term care residents? If so, how many?
2308-69 (97/02)*