ASSISTED LIVING CENSUS REPORT

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Provider Name:

Provider Address:

City:

State:

Email Address:

Telephone:

Date:

Private Pay

Total Paid Days

Waivered Assisted Living

Days in Agency     Days in Hospital

Days in Excess of 5 Hospital Days     Days out on Leave

Days in Excess of 5 Leave Days

State Pay Assisted Living

Days in Agency     Days in Hospital

Days out on Leave

Total Days

Total Days