Facilities Staff Work Schedule printable pdf download

Facilities Staff Work Schedule

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING

FACILITIES STAFF WORK SCHEDULE

INSTRUCTIONS: This form is to be completed by the licensing evaluator and reviewed by the licensing supervisor.

The purpose of this form is to review staff coverage in large Residential Facilities for 24-hours per day covering a (3) three-week period to

ensure sufficient staff coverage. CAREFULLY review split shifts, weekend coverage and irregular days off to ensure sufficient staff coverage.

FACILITY NAME

FACILITY NUMBER

FACILITY TYPE

FACILITY CAPACITY

CLIENT/RESIDENT CENSUS

LICENSING EVALUATOR

DATE

Enter Dates of Week

For The Month(s)

SERVICE AREA AND WORK TITLE

Sun

Mon Tues Wed Thurs Fri

Sat

Sun Mon Tues Wed Thurs Fri

Sat

Sun Mon Tues Wed Thurs Fri

Sat

Care and Supervision (e.g., Aides)

Enter Work Hours

Employee Name(s)

Food Services (e.g, includes cook, dishwasher)

Employee Name(s)

LIC 507 (1/00)

Facilities Staff Work Schedule