Form Fcr 3ffa - Days Of Care Schedule

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIADEPARTMENT OF SOCIAL SERVICES
DAYS OF CARE SCHEDULE (FCR 3FFA)
SUBMIT ONE FOR EACH PROGRAM FOR WHICH A RATE IS REQUESTED
AGENCY NAME
PROGRAM NUMBER
AGENCY FISCAL YEAR
—
PROGRAM NAME
•
•
Mo
Yr
Mo
Yr
(1)
(2)
(3)
(4)
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
OCTOBER
NOVEMBER
DECEMBER
Actual
SEPTEMBER
Total
(31)
(29)
(31)
(30)
(31)
(30)
(31)
(31)
(31)
(30)
(31)
Occupancy
(30)
1. Clients at Beginning of Month
2. Admissions
3. Discharges
4. Actual Number of Client Days
COMMENTS:
FCR 3FFA (7/03)

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