Helpful Information Information

Information that helps us, to help you

Senior Living Alternatives Self-Assessment Checklist

The purpose of this document is to help in making an accurate choice of accommodations, and the level of care that is needed. The lack of the right choice is not only eventually inconvenient, it can also be costly and upsetting to a senior. Inaccurate assessment can result in an unhappy resident by being placed where the other residents are in greater need of care, and the resident feels out of place in that community. Higher costs for a higher level of care will be also incurred.

Please Help Make the Best Choice of Care by Careful Consideration of the Following

Are You OR Is Your Loved One Ambulatory? *YesNo

While a limited number of assisted living facilities can offer a 2-person transfer, (Wheelchair to Bed, or Wheelchair to Commode) most of the time assisted living may not be the best choice for someone that is not ambulatory.

Do You OR Does Your Loved One Have a Chronic Wound, Colostomy, or Require Insulin Injections? *YesNo

Assisted Living Communities are NOT allowed to care for someone with these conditions. Some are allowed to measure out the amount of insulin needed, but not the actual puncture of the skin to perform the injection.

Do You or Does Your Loved One Require Ongoing Medical Attention? *YesNo

Assisted living communities can provide bathing, dressing, toileting etc. But, if you/your loved one is in need of ongoing care from a doctor or nurse, a Skilled Nursing Facility is the best fit for their needs.

Do You OR Does Your Loved One Require Rehabilitation? *YesNo

Medicare typically covers 100 days of rehabilitation in a skilled nursing facility. It is wise to consider the possibility that after the rehabilitation, many seniors are best off to consider a move to, at very least, an Independent Retirement Community or Assisted Living

Do You OR Does Your Loved One Have Late-Stage Alzheimer's or Dementia? *YesNo

In some cases, assisted living communities can offer sufficient care for seniors with early to moderate symptoms, but advanced stages require the care of a skilled nursing facility or assisted living with a specialized memory care unit.

Other Responses Helpful in Guiding the Best Choices for Senior Living Alternatives

Based on the items below, depending on how many of the items check-marked here, and the above responses, you or your loved-one may do well in an Independent Retirement Community or Assisted Living

Eating *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Toileting *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Bathing *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Dressing *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Grooming *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Walking *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Transferring *Needs No AssistanceNeeds Some AssistanceNeeds A Lot of Assistance

Dollar amount available for rent and/or care on a prolonged basis

Please include a biography, or autobiography, so that a sufficient level of activities, and willingness to participate, can be known. Also provide some history so that the staff, and residents, can have some familiarity with their incoming resident and neighbor.

Please Indicate and Sign *SelfResponsible PartyPower of Attorney (P.O.A.)

Please type name of person being referred *Typed Entry Represents Signature

AssistedLivingVisalia.com

Date *

Prospective Resident

Person/Persons in Need of In-Home Care,
Independent Retirement Community,
Or Assisted Living Placement

Please type name *Typed Entry Represents Signature

If You Are Solely Responsible and Competent
for Your Own Decisions

Please type nameTyped Entry Represents Signature

OR Prospective Resident's Representative

Please type nameTyped Entry Represents Signature

Senior Living Alternatives (hereafter referred to as SLA) offers our services free of charge to clients. This free service is made possible by the financial participation of local senior housing communities, and In-Home Care providers, that compensate SLA for services. SLA provides information that allows interested parties that are seeking care, help, or information on Assisted Living & Care providers, to connect and make informed decisions. SLA does not employ or endorse any facility, care giver, or service provider. Each individual party is solely responsible for selecting an appropriate facility or service/care provider, verifying all certificates, licenses and any or all documentation needed to be current to care for themselves or their loved one. Parties making an agreement with a facility or service provider will provide a Power of Attorney as needed/requested. SLA offers content that represents general information on individual facilities, and providers, and the services that they provide. No warranties or guarantees are expressed or implied. SLA is not held liable or responsible for any conditions or outcome, (physical, financial, or otherwise), as a result of providing this free informational service, before during or after an agreement is made with the facility or service provider. Furthermore, SLA will not be held liable for a person choosing a care provider or assisted living for themselves, or any person/person(s) misrepresenting themselves as Competent, Responsible Party, or Power of Attorney and consequences resulting thereof.

If care needs, or placement at assisted living, or another facility are felt necessary, please advise Senior Living Alternatives and allow us to give further assistance.

Contact Information

Phone Number *

Email Address *

For SLA and Facility Office Use Only

Senior Living Alternatives
Ph (559) 901-6968 Fx (559) 625-4170
AssistedLivingVisalia.com
[email protected]

Referral Acknowledgment

Facility Representative
Typed Entry Represents Signature

Serving Fresno, Kings, and Tulare Counties



(559) 901-6968



[email protected]



121 E. Main Street #307
Visalia, CA 93291