Va Form 10-0388-4 - State Home Construction Grant Programadult Day Health Care Page 2

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PROPOSED BY
PROPOSED BY
TOTAL VA
TOTAL VA
(Continued)
VA CRITERIA
VA CRITERIA
1. SUPPORT FACILITIES
STATE
STATE
ALLOWED
ALLOWED
MULTIPURPOSE ROOM
15/PARTICIPANT
EMPLOYEE LOCKERS # EMPL.
6/EMPL.
LOUNGE
120
TOILETS
25/FIXTURE
25/FIXTURE
PHYSICAL THERAPY
5/PARTICIPANT
OFFICE, IF REQUIRED
120
OCCUPATIONAL THERAPY
5/PARTICIPANT
OFFICE, IF REQUIRED
120
LIBRARY
1.5/PARTICIPANT
BUILDING MAINTENANCE STORAGE
2.5/PARTICIPANT
RESIDENT STORAGE
6/PARTICIPANT
(medical, dietary)
GENERAL WAREHOUSE STORAGE
6/PARTICIPANT
AR
AR
GENERAL LAUNDRY
AS REQUIRED
SUPPORT FACILITIES SUB-TOTAL; (No "As Required" Areas)
AS REQUIRED AREAS:
AS REQUIRED
AR
AR
2. OTHER AREAS
RESIDENT QUIET ROOM
3/PARTICIPANT
CLEAN UTILITY
120
SOILED UTILITY
105
LINEN STORAGE
150
GENERAL STORAGE
100
NURSES STATION, WARD SECRETARY
260
MEDICATION ROOM
75
EXAMINATION/TREATMENT ROOM
140
WAITING AREA
50
50
PROGRAM SUPPLY AND EQUIPMENT
STAFF TOILET
25/FIXTURE
100
STRETCHER/WHEELCHAIR STORAGE
KITCHENETTE
120
JANITOR CLOSET
40
RESIDENT LAUNDRY
120
TRASH COLLECTION
60
(Justify)
OTHER
UNIT SUB-TOTAL:
x
x
TIMES NO. UNITS:
SUB TOTAL:
VA FORM
Page 2 of 4
10-0388-4
MAR 2005

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