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Residential Summary Form
Please complete one form per residential facility.

This form should only be completed by providers who are contracted with Community Care, Inc. If you have questions about whether or not you are contracted please call 866-937-2783 and select option 2 prior to submitting this form.
Live-in Staff:
Owner Occupied:
Facility is Licensed/Certified to Serve:
Intellectual or Developmental Disabilities:

Serious & Persistent Mental Illness:
Advanced Age:
Physically Disabled:
Traumatic Brain Injury:
Facility Capabilities

Behavioral Needs. Check one box in each category to indicate the capability of your facility to serve members displaying the described behavior.
Verbal Aggression:

Physical Aggression:

Property Destruction:

Sexual Behaviors:

Nursing and Medical Needs Accomodation
Do you have a nurse on staff?

If yes to the previous question, is your nurse an RN or LPN?

Medical Needs: Please check all that apply to indicate your facility's capability to serve members with the listed medical need.

Facility Accessibility
Only Check One:

Wheelchair Accessible Entrances? (Two Entrances to Grade.)

Is the facility able to serve members who require a Hoyer?

It is the responsibility of the provider to own and/or purchase a hoyer lift.
Transfer Status:

Is the Facility Alarmed? (All exits are equipped with a system to alert staff if an exit is opened and can only be turned off with a code or a key. Inter-connected)

Does the Facility Have Pets?

Are Members Allowed to Smoke?

Consumer Transportation Options
Agency Vehicle(s):
Consumer Resources
Owner/Operator, Site Management and Staff
Do the owners/operators have any criminal charges pending against them or have they ever been convicted of a crime?

Does the on-site manager have any criminal charges pending against him/her or has he/shee ever been convicted of a crime?

Attestation Statement

I certify that the information completed on this residential summary is true and accurate as of its completion. If the residential summary information changes at any time, I will submit a new residential summary.

PLEASE NOTE: Upon pressing the submit button, you should see a message stating that we have received your information. If you do not, please scroll up, complete any of the required fields noted in red, then submit the form again.

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