WLR - Assisted Living | Preplacement Appraisal Form

The Western Lights Residences

The Western Lights Residences - Assisted Living, Hesperia | Preplacement Appraisal Form

Please complete this preplacement appraisal as accurately as possible so our team can review the applicant's care needs, safety needs, and suitability for admission.

This information may be obtained from the applicant or an authorized representative. Relatives, social agency, hospital, or physician may assist. This form is not a substitute for the Physician's Report, LIC 602.

1

Applicant Information

2

Health, Disabilities, Mental Condition, History, and Social Factors

Describe overall health condition, including any dietary limitations.

Describe any physical limitations, including vision, hearing, or speech.

Specify extent of any symptoms of confusion or forgetfulness. Include participation in social activities, such as active or withdrawn.

List current prescribed medications and major illnesses, surgeries, or accidents. Specify whether hospitalized in the last 5 years and the length of hospitalization.

Describe likes, dislikes, interests, and activities.

3

Bed Status

Bed Status *
4

Tuberculosis Information

Any history of tuberculosis in applicant's family? *
TB Test Result
Any recent exposure to anyone with tuberculosis? *
5

Ambulatory Status

Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device.

This person is *
Question Yes No

Able to walk without any physical assistance, such as walker, crutches, another person, or able to walk with a cane.

Mentally and physically able to follow signals and instructions for evacuation.

Able to use evacuation routes, including stairs if necessary.

Able to evacuate reasonably quickly, such as walking directly through the route without hesitation.

6

Functional Capabilities

Capability Yes No

Active, requires no personal help of any kind - able to go up and down stairs easily.

Active, but has difficulty climbing or descending stairs.

Uses brace or crutch.

Feeble or slow.

Uses walker.

Uses wheelchair.

Requires grab bars in bathroom.

7

Services Needed

For each item, select Yes or No and add an explanation when applicable.

Help in transferring in and out of bed and dressing *
Help with bathing, hair care, personal hygiene *
Does client desire and is client capable of doing own personal laundry and other household tasks? *
Help with moving about the facility *
Help with eating, including adaptive devices or assistance from another person *
Special diet or observation of food intake *
Toileting, including assistance equipment, or assistance of another person *
Continence, bowel or bladder control. Are assistive devices such as a catheter required? *
Help with medication *
Needs special observation or night supervision due to confusion, forgetfulness, wandering *
Help in managing own cash resources *
Help in participating in activity programs *
Special medical attention *
Assistance in incidental health and medical care *
Other services needed not identified above *
8

Additional Admission Information

Is there any additional information which would assist the facility in determining applicant's suitability for admission? *
9

Certification and Signatures

To the best of my knowledge, the above person does not need skilled nursing care.

By submitting this form, you authorize The Western Lights Residences team to review the information for admission planning and follow-up.