At the heart of ensuring that specialty care assisted living facilities operate within the bounds of state regulations, the SCALF-1 Form emerges as a critical document, reflecting a facility's annual performance, demographic reach, and fiscal health. Revised in January 2010 and due by April 15 of the same year, this comprehensive report mandates facilities to provide a wealth of information, from basic identifiers like addresses and telephone numbers to detailed data concerning ownership structures, management affiliations, and the facility's capacity. Not only does it require insights into admissions, discharges, and the demographic profiles of residents, but it also demands meticulous recordings of financial operations, including revenue streams and expense accounts, ensuring a transparent view into the economic stability of these essential care providers. The SCALF-1 Form embodies the state's initiative to maintain high standards of care and accountability in specialty care assisted living facilities, serving as a testament to the facility's commitment to its residents and their well-being.
| Question | Answer |
|---|---|
| Form Name | Form Scalf 1 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | 2010 SCALF Interactive Annual Report Form state of alabama scalf report form |
FORM |
THIS REPORT IS DUE ON OR BEFORE APRIL 15, 2010 |
||
Revised 1/2010 |
|||
|
|
||
STATE HEALTH PLANNING AND DEVELOPMENT AGENCY |
|||
MAILING ADDRESS (U.S. POSTAL SERVICE) |
STREET ADDRESS (COMMERCIAL CARRIER) |
||
PO BOX 303025 |
|
100 NORTH UNION STREET STE 870 |
|
MONTGOMERY AL |
|
MONTGOMERY AL 36104 |
|
TELEPHONE: (334) |
|
FAX: (334) |
|
www.shpda.alabama.gov |
|
bradford.williams@shpda.alabama.gov |
|
2010 ANNUAL REPORT FOR SPECIALTY CARE ASSISTED LIVING FACILITIES
Mailing Address:
STREET ADDRESSCITYSTATEZIP
Physical Address: |
|
|
|
|
|
|
|
|
|
AL |
|||
|
|
STREET ADDRESS |
|
|
CITY |
|
|
|
|
|
|
ZIP |
|
County of Location: |
|
|
|
|
|
|
|
|
|
|
|
|
|
Facility Telephone: |
|
|
|
|
Facility Fax: |
|
|
|
|
|
|
|
|
|
|
(AREA CODE) & TELEPHONE NUMBER |
|
|
|
(AREA CODE) & TELEPHONE NUMBER |
|||||||
This reporting period is for March 1, 2009, through February 28, 2010*; or for partial year of operation beginning |
|||||||||||||
|
|
and ending |
|
|
a period of |
|
|
|
|
|
|
days. |
|
MONTH DAY |
|
|
MONTH DAY |
|
|
|
|
|
|
|
|
|
|
*Data for the agency’s fiscal year, other than the time frame specified, may be provided, but no more than 12 months of consecutive data should be reported. If there was a change in ownership during the reporting period, data for the full year should be reported by the current owner.
We hereby affirm and attest that the reported information has been verified, and to the best of our knowledge, the information contained in the following pages of this report is a true and accurate representation of the services, equipment, and utilization of this facility.
PRINTED NAME OF PREPARER |
|
SIGNATURE OF PREPARER |
|
DATE |
|
|
|
|
|
DIRECT TELEPHONE NUMBER |
|
TITLE OF PREPARER |
|
A member of administration MUST also sign below verifying the accuracy of the information contained herein, as reported by the preparer listed above.
|
PRINTED NAME OF ADMINISTRATION OFFICIAL |
|
SIGNATURE OF ADMINISTRATION OFFICIAL |
|
|
DATE |
|||||
|
|
|
|
|
|
|
|||||
|
DIRECT TELEPHONE NUMBER |
|
TITLE OF ADMINISTRATION OFFICIAL |
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FOR OFFICE USE ONLY |
|
|
|
|
||
|
Facility Verified: |
|
|
|
Initial Scan: |
|
|
Completed: |
|
|
|
|
Entered: |
|
Final Scan: |
Audited: |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Page 1
FORM |
THIS REPORT IS DUE ON OR BEFORE APRIL 15, 2010 |
|
Revised 1/2010 |
||
|
IOWNERSHIP
Corporation |
Partnership |
|
Individual |
Healthcare Authority |
LLC |
Joint Venture |
Government |
Other (specify) |
II MANAGEMENT |
|
|
Does this facility operate under a management contract? |
Yes |
No |
Management Firm:
Name
Base Address |
City |
State |
Zip |
III FACILITIES
Total number of licensed beds:
Number of beds set up in this facility for use:
IV ADMISSIONS
Total Admissions for the reporting period:
Admissions by source of payment:
Private Pay
Long Term Care Insurance
Other (specify)
V DISCHARGES
Total discharges (include deaths)
Discharges due to death
Page 2
FORM |
THIS REPORT IS DUE ON OR BEFORE APRIL 15, 2010 |
|
Revised 1/2010 |
||
|
VI. DEMOGRAPHICS
A.TOTAL ADMISSIONS BY RACE FOR THE ENTIRE REPORTING PERIOD (Total must agree with The totals provided in Section IV and Section
a.White/Caucasian
b.Black/African American/Negro
c.Hispanic/Spanish/Latino
d.Asian
e.American Indian/Alaskan Native
f.Pacific Islander g. India
h. Middle Eastern
i.Other (specify)
TOTAL
B.TOTAL ADMISSIONS BY AGE AND GENDER FOR THE ENTIRE REPORTING PERIOD (Total must agree with the totals provided in Section IV and Section
AGE GROUPS |
MALE |
FEMALE |
TOTALS |
18 & under
19 – 34 Years
35 – 54 Years
55 – 64 Years
65 – 74 Years
75 – 84 Years
85 Years and Older
TOTALS
Page 3
FORM |
THIS REPORT IS DUE ON OR BEFORE APRIL 15, 2010 |
|
Revised 1/2010 |
||
|
VII RESIDENT DAYS
Number of licensed beds
1.(Section III of this report)
x 365
2. Multiply line 1 by 365 for total available days |
= |
3.Total number of days beds were unoccupied due to vacancies, discharges and deaths (also include 365 days for each bed that is licensed but not set up for use in this facility)
4.TOTAL RESIDENT DAYS (subtract line 3 from line 2)
VIII REVENUES AND EXPENSES
These amounts DO NOT have to be audited prior to reporting.
|
Expenses |
|
|
Payroll |
$ |
|
.00 |
$ |
|
.00 |
|
TOTAL EXPENSES |
$ |
|
.00 |
|
Revenues |
|
|
Long Term Care Insurance |
$ |
|
.00 |
Private Pay |
$ |
|
.00 |
Other |
$ |
|
.00 |
TOTAL REVENUES |
$ |
|
.00 |
VIII BASIC RESIDENT CHARGE |
|
|
|
|
|
||
|
|
|
Monthly |
|
Daily |
||
Private Room |
$ |
|
|
.00 |
$ |
|
.00 |
$ |
|
|
.00 |
$ |
|
.00 |
|
Page 4