Transcription of COMMUNITY CARE LICENSING DIVISION MONTHLY …
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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYFACILITY NAME:FACILITY ADDRESS:PREPARED BY:LIC 401 (3/01)TITLE:APPLICANT/LICENSEE SIGNATURE:DATE:$$$$$$$$ REVENUESLn #PROGRAM REVENUESLn #1. SSI Revenue ( MONTHLY SSI Rate) x (Number of SSI Clients)Rate $ _____ x # _____ = 12. Voluntary 3rd Party Contributions23. Private RevenueNumber of Private Pay Residents # _____3 OTHER REVENUES RELATED TO THE 56. Total Revenue (add lines 1 through 5 and any attached). Worksheet attached?.. YES NO6 operating COSTSCARE AND SERVICES7. Food Costs ..78. Household Supplies ..89. Laundry and Dry Cleaning ..910. Personal Hygiene Items ..1011. Recreational Activities ..1112. Newspapers, Magazines, Cable TV ..1213. Medical and First Aid ..1314. Client Transportation .. Care & Services (add lines 7 through 14)..15 GENERAL ADMINISTRATION16. Salaries and Wages ..1617. Payroll Taxes and Employee General Transportation ..1819. Telephone ..1920.
MONTHLY OPERATING STATEMENT GENERAL INFORMATION AND INSTRUCTIONS GENERAL INFORMATION- Each applicant/licensee (sole proprietorship, partnership, …
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