Your Name Please Select Rosabelle Amano Raul Carrillo Eva Magie Daquioag Flor Galon Marylin Garcia Veronica Hernandez Andres Medina Lolita Mercado Luz Janzen Farrah Williams Rosa Armas Jean Skeens Arnel Ritualo Melinda Manongdo Ma Loreto Mirador Valerie Hernandez Benjamin Rodrin Diana Avila Victor Ramirez Yadira Lopez Lolita Santos Jasmine Cabrera Arlene L. Delfin Megan Amey Neil Mehta Hashonda Welch Natalia Cruz Genoveva Longobardi Azhane Wanton Karen Janethzy Corona Beltran Marilyn Tolete Jonathan Chavero Clarence Collantes Glynda Rotoni Israel Cruz Violeta Brabazon Evelyn Padilla Estefani Rivera Anita Crickenberger Jeremy James Crickenberger Sandra Carrillo

Resident Select Resident MC 201 - Maria Larin MC 202 - Wesley Mann AL 301 - Melba Osuna AL 301 - Dxi Peterson AL 401 - Tracy Maddux AL 402 - Wanda Yutig AL 304 - Darlene Whitehead AL 403 - Marina Nacionales AL 401 - Michael Solomon AL 402 - Rafael Sanchez AL 301 - Carl Fox AL 302 - John Townsend MC 201 - Elena Rodriguez MC 201 - Noho Nickerson AL 103 - Joseph Assmus MC 203 - Agnes Cendana MC 201 - Billy Ray Koinmn AL 402 - Dorothy Nelis AL 303 - Michael Keane AL 303 - Lawrence Walthall MC 101 - Eugene Remund AL 401 - Laura Bennet AL 405 - Timothy Freeman MC 202 - Lewis Wenzell MC 205 - Eula Gray MC 203 - Barry Lee MC 202 - Timothy Talley MC 202 - Delia Gutierrez AL 302 - Mary Llamas AL 301 - Janet MacNeill AL 302 - Felix Senquiz MC 103 - Paul Piatek AL 303 - Calvin Ebey MC 102 - Larry Everett MC 102 - Antonio Juarez MC 201 - Eleazer Oliverio AL 404 - Terry Kamp AL 302 - Jose Puerto Rodriguez AL 401 - Richard Fowler AL 303 - Silva Teresa AL 302 - Charles Hickey AL 305 - John Sandstrom AL 104 - Michael Pellatrue MC 203 - Jean Evans MC 203 - Aida Martinez MC 202 - Victoria Rose MC 204 - Geraldine Martinez MC 203 - Greg Coon MC 201 - Evelyn Beckemeyer MC 201 - Ted Howarth MC 204 - Adela Pena MC 204 - Maria Rincon AL 401 - Arnold Coleman MC 201 - Donna Freeman

Shift Please Select AM PM NOC

Personal Hygiene Please Select No Assistance Minimum Assistance Maximum Assistance Refused Not Done OOF

Showers Please Select Yes No Refused Bed Bath/Sponge Bath OOF

Brief Changes (How Many times Brief changes done)

Dressing / Cloth Changes Please Select Yes No Refused OOF

Breakfast (Even from outside) Please Select 1/4 1/2 3/4 Complete Meal Refused OOF

Lunch (Even from outside) Please Select 1/4 1/2 3/4 Complete Meal Refused OOF

Dinner (Even from outside) Please Select 1/4 1/2 3/4 Complete Meal Refused OOF

Skin Issues Please Select Yes No

Skin Issues detail

Laundry Please Select Yes No Refused OOF

Garbage Please Select Yes No Refused

Stool Passed Please Select Yes No OOF

Type of Stool Please Select Type 1: Hard Separate Pellets Type 2: Lumpy Sausage Type 3: Sausage with cracks on surface Type 4: Smooth, Soft Sausage Type 5: Soft, Blobs Type 6: Mushy, Ragged Pieces Type 7: Watery Liquid

Notes for Supervisor

Issues Identified