Transcription of COMMUNITY CARE LICENSING DIVISION MONTHLY …
{{id}} {{{paragraph}}}
Example: quiz answers
COMMUNITY CARE LICENSING DIVISION MONTHLY …
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.
31. Costs for water, including bottled water. 32. Costs for disposal of garbage. 33. Costs for building repair and maintenance. 34. Costs for furniture and equipment repair and maintenance. 35. All other expenses. SIGNATURE BLOCK The name of the preparer is to be printed in the space provided. The applicant or licensee is required to sign this ...
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: