Golden Star Residential Care Home Rio Vista California

Golden Star Residential Care Home
Rio Vista, California

Application Form (No obligation/hassle. Help us to supply the information you need)

We will not share the information that you provide to us with anybody else. Please note our Privacy Policy (below).

Please fill in the fields below and then press the Submit button.

Your First Name:
Your Last Name:
Your E-Mail Address:
Your Telephone Number:
How would you like us to contact you?	Telephone Email

Applicant's Full Name:
Applicant's Age (Years):
Is the applicant taking any medication?	Yes No
If you answered Yes to the previous question:
- Can the applicant manage their any medication?	Yes No Not Applicable
Is the applicant using any medical equipment?	Yes No
If you answered Yes to the previous question:
- Can the applicant manage their own medical equipment?	Yes No Not Applicable
Is the applicant ambulatory?	Yes No
If you answered No to the previous question:
- Can the applicant feed themself?	Yes No
- Does the applicant need assistance dressing?	Yes No
- Does the applicant need assistance in the bathroom?	Yes No
- Can the applicant walk unassisted?	Yes No
- Can the applicant get in and out of bed unassisted?	Yes No

Is the applicant suffering from Mild Cognitive Impairment?	Yes No
Is the applicant suffering from Dementia?	Yes No
Do you have a completed Physician's Report for RCFEs?	Yes No
Is the applicant an SSI recipient by RCEB?	Yes No
When would the applicant like to move in?:
Comments: