Form Sr 5 - Group Home Program Days Of Care Schedule
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2STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GROUP HOME PROGRAM
DAYS OF CARE SCHEDULE (SR 5)
Submit One For Each Program
CORPORATE NAME:
PROGRAM NAME:
PROGRAM NUMBER
PROVIDER FISCAL YEAR
•
•
MO
YR
MO
YR
(1)
(2)
(3)
(4)
(5)
YEAR
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
TOTAL
AVERAGE
CDSS USE ONLY
MONTH
(31)
(28)
(31)
(30)
(31)
(30)
(31)
(31)
(30)
(31)
(30)
(31)
1. Clients at Beginning of
Month
2. Admissions
3. Discharges
4. Actual Number of
Client Days
5. Licensed Program
Capacity
6. 90% of Licensed Program
Capacity
KDE DATE:
CDSS USE ONLY
•
SR 5 (12/04)
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