Long Term Care Ombudsman Program of Santa Barbara County

123 W Gutierrez St, Santa Barbara CA 93101

Phone: (805) 922-1236 Fax: (805) 922-1541
Email: LTCO@fsacares.org

ADMISSIONS INFORMATION FORM

Month: Year:

Name of Facility: Number of beds:

Number of residents on oxygen: Current census:

Total number of New Admissions (for the month): Male: Female:

Under 60: Age 60-64: Age 65-74: Age 75-84: Age 85+:

Afr. Amer: Hispanic: Native Amer./American Indian:

Asian/Pacific Islander: Caucasian/White: Other:

New Admissions on Medi-Cal/SSI (if any):

Number of New Residents Admitted from:

Carpinteria: Goleta: Lompoc:

Santa Barbara: Santa Maria: Santa Ynez:

Solvang: Buellton: Outside of California:

Please complete form and fax it to (805) 922-1541 or email it to: LTCO@fsacares.org
by the 7th of each Month.

Thank you!