Community assessment-form

1. IS YOUR HOUSE STILL THE RIGHT HOME? COMMUNITY ASSESSMENT FORM
Try to plan ahead. If you are still
Community Assessment
happy and able to remain in your current Please feel free to photocopy these pages and use
home, that choice may be best for you. them as you contact various senior communities. We hope you find
However, it’s still a good idea to do some
this useful as you gather information.
preplanning in the event that circumstances
suddenly change, such as an illness, injury, Name of community _______________________________________
or loss of a spouse. A bit of research and
Address ________________________________________________
planning now will keep you in control of
most situations. _______________________________________________________
Telephone number ________________________________________
Enjoy your next adventure. When you come to the
conclusion that your current home no longer meets all your needs and Name of contact person____________________________________
now is the time to make your move, have fun with the process. Take E-mail address ___________________________________________
this opportunity to talk with others and ask questions. Learn all you
Appointment scheduled for (date and time) _____________________
can. Look at this as yet another chapter in your life to be anticipated
and savored. Directions to community __________________________________
Yes, the rewards of choosing the right home are many: Enjoy! _______________________________________________________
_______________________________________________________
Names of friends and family who are considering—or who already
Remember, all of life is an are—living in this community _______________________________
adventure. Relax and enjoy _______________________________________________________
_______________________________________________________
the entire journey!
_______________________________________________________
________________________________________________________
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2. IS YOUR HOUSE STILL THE RIGHT HOME? COMMUNITY ASSESSMENT FORM
Community Assessment Community Assessment
Name of community __________________Date of visit/call ____________
Name of community __________________Date of visit/call ____________
Feature yes/no notes
Feature yes/no notes
Physical appearance and amenities
Physical location
Main building
Neighborhood pleasant
and safe Age of building
Shopping Clean/maintained
Doctors Grounds
Dentists Comfortable lobby
Hospital Other public areas
Banks Apartments
Beauty/barber salon High ceilings
Place of worship Lighted hallways
Cultural events Library
Near family/friends Exercise/fitness facilities
Services offered Housekeeping
Independent Living Linen service
Assisted Living Laundry facilities
Memory Care Beauty/barber salon
Respite Care Multipurpose room
Skilled Nursing & Rehab. Craft room
Home Health Private party room
Home Care
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3. IS YOUR HOUSE STILL THE RIGHT HOME? COMMUNITY ASSESSMENT FORM
Community Assessment Community Assessment
Name of community __________________Date of visit/call ____________ Name of community __________________Date of visit/call ____________
Feature yes/no notes Feature yes/no notes
Banking services Health and personal care services
Chapel Medicare certified
Billiard/game room Staff to resident ratio
Country store (and hours) Number of hours staffed
Walking paths/gardens RN (number of hours)
Cable TV Licensed social worker
Guest room(s) EMT or licensed nurse
Covered/underground parking Medication assistance
Surface parking Escorts to activities
Pool Therapists available
Restaurant or meal service Medical direction
Meals available On-site doctor
Meals prepared on site Individual care plans
Meal plans Emergency pendant or pull cord
Menu choices 24-hour on-site staff
Room service to apartments Front desk monitor
Choice of dining rooms 9-1-1 available
Private dining room Security
Served by wait staff
Escorts to meals
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4. IS YOUR HOUSE STILL THE RIGHT HOME? COMMUNITY ASSESSMENT FORM
Community Assessment Community Assessment
Name of community __________________Date of visit/call ____________ Name of community __________________Date of visit/call ____________
Feature yes/no notes Feature yes/no notes
Activities and transportation Management and staff
Personalized plan Length of time in business
Social Maintains accurate records
Entertainment Owner is involved in business
Lifelong learning
Resident council
Exercise/fitness classes
Smoking policy
Outings
Firearms policy
Spiritual
Pet policy
Volunteer opportunities
License/certification
Near bus line
Compliance history
Bus/van operated by center
Staff know residents’ names
Scheduled transportation
By appointment Happy/smiling
Scheduled group outings Service oriented
Costs Enthusiastic
Monthly rental Well groomed
Deposit
Lease terms
Entry fee
Move-out terms
Good value
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