State of California -California Department of Aging STAFFING/SERVICES ARRANGEMENT ADH 0006 (. 09/14) Community-Based Adult Services 1. LICENSEE NAME: 2. HOURS OF 3. LICENSED 4. for previous quarter: SERVICE: CAPACITY: 5. CENTER NAME: 6. Also Provides Adult 7. SIGNATURE OF ADMINISTRATOR OR PROGRAM DIRECTOR: Day Program Services? Yes No DATE: 11. LICENSE/ STAFFING 8. NAME 9. Scheduled REGISTRATION/ Number of 10. Date of CERTIFICATION Hours per Hire: Expiration Month: Number: Date: ADMINISTRATOR PROGRAM DIRECTOR REGISTERED NURSE(s) LICENSED VOCATIONAL NURSE(s) SOCIAL WORKER(s) SOCIAL ASSISTANT(s) ACTIVITY COORDINATOR AIDES PHYSICAL THERAPIST (PT) PT ASSISTANT PT AIDE(s) OCCUPATIONAL THERAPIST (OT) CERTIFIED OT ASSISTANT (COTA) OT AIDE(s) SPEECH THERAPIST STAFF PHYSICIAN PSYCH CONSULTANT DIETITIAN DRIVERS PHARMACIST OTHER STAFF POSITIONS
State of California -California Department of Aging STAFFING/SERVICES ARRANGEMENT ADH 0006 (. 09/14) Community-Based Adult Services 1. LICENSEE NAME: 2. HOURS OF SERVICE: 3. LICENSED CAPACITY: 4. for previous quarter: 5. CENTER NAME: 6. Also Provides Adult Day Program Services? Yes No 7. SIGNATURE OF ADMINISTRATOR OR PROGRAM DIRECTOR: DATE: STAFFING 8. NAME 9. Scheduled Number of Hours per Month: 10. Date of Hire: 11. LICENSE/ REGISTRATION/ CERTIFICATION Number: Expiration Date: ADMINISTRATOR PROGRAM DIRECTOR REGISTERED NURSE(s) LICENSED VOCATIONAL NURSE(s) SOCIAL WORKER(s) SOCIAL ASSISTANT(s) ACTIVITY COORDINATOR AIDES PHYSICAL THERAPIST (PT) PT ASSISTANT PT AIDE(s) OCCUPATIONAL THERAPIST (OT) CERTIFIED OT ASSISTANT (COTA) OT AIDE(s) SPEECH THERAPIST STAFF PHYSICIAN PSYCH CONSULTANT DIETITIAN DRIVERS PHARMACIST OTHER STAFF POSITIONS
ADH_0006_Staffing_Services_Arrangement_Rev_0914.docx