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Get CA CDPH 709 2008-2024

Facility name Facility address number street City State ZIP code California Building Floor Room Activity Room Size Floor Area Approved Capacity Nonambulatory Ambulatory Individual s Room Common Rooms Dining Recreation Living Library Storage CDPH 709 10/08 Page 1 of 2 over Additional Rooms This space may also be used for individual rooms where necessary. State of California - Health and Human Services Agency California Department of Public Health CLIENT ACCOMMODATIONS ANALYSIS This form is designed to provide a record of client accommodations approved for licensed care. It identifies the approved use of individual rooms and approved capacities. This is intended to be completed on initial license and subsequent changes of capacity classification or accommodations. When a number of buildings are part of a licensed facility a rough plot plan should be attached designating separate building by a letter or number code. Additional Information Use this space to list information necessary to ensure adequate accommodation* Example Type of ventilation number of windows important furnishing number of toilets showers tubs. Note allowance for activity area parking garage detached building etc* Name of person completing form Date Page 2 of 2. State of California - Health and Human Services Agency California Department of Public Health CLIENT ACCOMMODATIONS ANALYSIS This form is designed to provide a record of client accommodations approved for licensed care. It identifies the approved use of individual rooms and approved capacities. This is intended to be completed on initial license and subsequent changes of capacity classification or accommodations. It identifies the approved use of individual rooms and approved capacities. This is intended to be completed on initial license and subsequent changes of capacity classification or accommodations. When a number of buildings are part of a licensed facility a rough plot plan should be attached designating separate building by a letter or number code. Additional Information Use this space to list information necessary to ensure adequate accommodation* Example Type of ventilation number of windows important furnishing number of toilets showers tubs. Note allowance for activity area parking garage detached building etc* Name of person completing form Date Page 2 of 2. State of California - Health and Human Services Agency California Department of Public Health CLIENT ACCOMMODATIONS ANALYSIS This form is designed to provide a record of client accommodations approved for licensed care. It identifies the approved use of individual rooms and approved capacities. This is intended to be completed on initial license and subsequent changes of capacity classification or accommodations. When a number of buildings are part of a licensed facility a rough plot plan should be attached designating separate building by a letter or number code. .

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