RestCare.com

Contact Information

Name:

Address:

City:

*
(currently California only)

ZIP:

Daytime Phone:

Email Address:

* = required field

Detailed Information

Who will use the facility?

Age of Senior:

How soon do you need a facility?

Search Information

Retirement	Active Senior Community
Assisted Living	Continuing Care Retirement Community
Nursing Care	Continuing Care Retirement Community
Alzheimer Specialized Care	Adult Day Care

Below are a number of considerations to help you determine if a move to a facility is for you:

YES	NO	N/A	MOBILITY
			I want to remain independent I am capable of moving about independently.
			Ambulatory with cane or walker. Independent with wheelchair.
			Require occasional assistance to move about.
			Mobile but may require assistance due to confusion, poor vision or weakness.
			May require assistance when transferring from bed, chair or toilet.
			Require turning in bed and wheelchair.

YES	NO	N/A	NUTRITION
			Eat meals without assistance.
			Need all meals prepared and served.
			May require assistance getting to meals and or assistance when eating.

YES	NO	N/A	HYGIENE
			Independent in all care including bathing, shaving and dressing.
			May require assistance with bathing or hygiene.
			Dependent on other for most of personal hygiene tasks.

YES	NO	N/A	HOUSEKEEPING
			Need laundry and housekeeping services.

YES	NO	N/A	DRESSING
			May need assistance with zippers, shoelaces or medical appliances.
			Dependent on others for dressing.

YES	NO	N/A	TOILETING
			Independent and completely continent.
			May have incontinence, a colostomy or catheter but is independent in caring for self through proper use of supplies.
			May have occasional problems with incontinence, colostomy or catheter care, or may require assistance in caring for self through proper use of supplies.
			Regularly and uncontrollably incontinent, dependent or unable to communicate needs.

YES	NO	N/A	MEDICATIONS
			Responsible for self-administration of medications.
			Able to self-administer medications, but others may need to remind and monitor the actual process.
			Family or home health agency has arranged a medication administration system with reminders and monitoring by family members or others.
			Cannot administer own medications, even with supervision.
			Medications must be administered by licensed personnel.

YES	NO	N/A	MENTAL STATUS
			Memory in tact but may have occasional forgetfulness with no pattern of memory loss.
			Able to reason, plan and organize daily events. Has mental capacity to identify environmental needs and meet them.
			May require occasional direction or guidance in getting from place to place, or may have difficulty with occasional confusion that may result in anxiety, social withdrawal or depression.
			Judgment may be poor. May not attempt tasks that are not within capabilities. May require strong orientation assistance and reminders..
			Disoriented to time, place and person, or memory is severely impaired. Usually unable to follow directions.

YES	NO	N/A	BEHAVIORAL STATUS
			Deals appropriately with emotions and uses available resources to cope with inner stress. Deals appropriately with others.
			May require periodic intervention from others to facilitate expression of feelings in order to cope with stress.
			May require regular intervention from others to facilitate or deal with periodic outburst of anxiety or agitation.
			Physical danger to self or others, or is abusive or unacceptably uncooperative..

Any additional comments:

Monthly budget for restcare facility living:

County:

City: