Survey Application ORGANIZATION INFORMATION. Organization/Unit Name Acronym Federal Tax Identification Number

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1 Survey Application ORGANIZATION INFORMATION ORGANIZATION TO BE SURVEYED Organization/Unit Name Acronym Federal Tax Identification Number The Arbors Community TAC Organization Website (Example: Telephone (Example: ) Fax (Example: ) Street Address (no P.O. Box) 123 Arbors Way Suite Number, Floor, Department, or OTHER City Washington Country US State/Province/Territory DC OTHER State/Province/District (outside rth America Only) Zip/Postal Code County ORGANIZATION CHARACTERISTICS Total annual operating revenue for the organization being surveyed Annual operating revenue for the programs seeking accreditation Fiscal Year End 13,000,000 13,000,000 12/31 Locale Metropolitan Description Washington, DC Company Affiliation (if any) Health Care System (Hospital System) Description Arbors Health System Ownership Type Private, not for profit Type of Government Entity Other Ownership Description Other Government Entity Description CORPORATE STRUCTURE 1. Is your organization a unit or department within a larger entity (i.e., not a distinct legal entity and has the same federal tax identification number as the larger entity)? CARF International Survey Number Page 1 of 15 7/3/2017

2 Name of larger entity Street Address (no P.O. Box) Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Country Briefly describe the larger entity and how your programs fit into its operations. 2. If your organization is a unit or department within a larger entity, is the larger entity a subsidiary of a parent company (i.e., a distinct legal entity with a separate federal tax identification number from the parent company)? Name of Parent Company Street Address (no P.O. Box) Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Country Federal Tax Identification Number 3. If your organization is not a unit or department within a larger entity, is it a subsidiary of a parent company (i.e., a distinct legal entity with a separate federal tax identification number from the parent company)? Yes Name of Parent Company Street Address (no P.O. Box) Suite Number, Floor, or Department Arbors Health Seervices City 100 1st St. NE State/Province/Territory Bethesda MD Country US Federal Tax Identification Number Zip/Postal Code SIGNIFICANT CHANGES/EVENTS Indicate if your organization experienced any significant changes or events in the past year for the programs seeking accreditation. Change/Event Type Yes/ Explanation Change in leadership Change in ownership Organization name change Change in mailing and/or addresses Significant reorganization of personnel Relocation, expansion, or elimination of program, service, or site Severe financial distress Merger, consolidation, joint venture, acquisition of accredited program/service Investigations Material litigation Catastrophes Sentinel events Governmental sanctions, bans on admissions, fines, penalties, loss of programs CARF International Survey Number Page 2 of 15 7/3/2017

3 SOURCES OF FUNDING/REFERRAL Category Funding Referral Name of Funding/Referral Source Long-Term Care Insurance þ Medicaid/MediCal/AHCCCS þ Medicare þ Self-Pay/Self-Referral þ þ CARF International Survey Number Page 3 of 15 7/3/2017

4 OTP organizations must list a State Methadone Authority contact. This section is not applicable to organizations applying as a Continuing Care Retirement Community. FUNDING/REFERRAL Reference #1 Title First Name Middle Initial Mrs. Gloria D. Last Name Suffix (Jr., Sr., etc.) Credentials Jones Work Telephone Extension Address Gloria.Jones.Test@carf.org Job Title Organization Name Heritage Foundation, Inc. Mailing Address US Highway 19S Country US Suite Number, Floor, Department, or OTHER State/Province/Territory GA City Thomasville OTHER State/Province/District (outside rth America Only) Zip/Postal Code County Thomas FUNDING/REFERRAL Reference #2 Title First Name Middle Initial Mr. Walker Henry Last Name Suffix (Jr., Sr., etc.) Credentials Work Telephone Extension Address Henry.Walker.Test@carf.org Job Title Workforce Administrator Organization Name Arkansas Employment & Training Assoc. Mailing Address P.O. Box 190 Country US Suite Number, Floor, Department, or OTHER State/Province/Territory AR City Harrison OTHER State/Province/District (outside rth America Only) Zip/Postal Code County INFORMATION AND OUTCOMES MANAGEMENT (IOM) CARF International Survey Number Page 4 of 15 7/3/2017

5 Identify any outcomes systems used. Name ne Description Identify any outcomes tools/measures used. Name Organization-developed/unpublished outcome tool Description Identify any satisfaction tools used. Name Organization-developed/unpublished satisfaction tool Description CARF International Survey Number Page 5 of 15 7/3/2017

6 CONTACT INFORMATION SURVEY KEY CONTACT Title First Name Middle Initial Ms. Dixie Last Name Suffix (Jr., Sr., etc.) Credentials King Job Title Executive Director Address Work Telephone Extension Fax ORGANIZATION INFORMATION þ Same as Organization to Be Surveyed CONTACT INFORMATION ACCREDITATION LIAISON þ Same as Survey Key Contact CONTACT INFORMATION AFTER-HOURS CONTACT þ Same as Survey Key Contact After-Hours Telephone CARF International Survey Number Page 6 of 15 7/3/2017

7 CONTACT INFORMATION TRAVEL & LODGING CONTACT þ Same as Survey Key Contact CONTACT INFORMATION INFORMATION & OUTCOMES MANAGEMENT (IOM) CONTACT þ Same as Survey Key Contact CONTACT INFORMATION COMPANY LEADERSHIP þ Same as Survey Key Contact CARF International Survey Number Page 7 of 15 7/3/2017

8 PERSONNEL STATISTICS AND DEMOGRAPHICS Information reported below is for all programs seeking accreditation and should be reported in numbers (not percentages). Total Full-Time Equivalent (FTE) Personnel Actual number of direct-service personnel Employees 180 Volunteers 16 Contracted Personnel 25 Total Direct-Service Personnel 221 PERSONS SERVED Information reported below is for all programs seeking accreditation and should be reported in numbers served annually (not percentages). Total Number of Persons Served Annually 115 Race/Ethnicity Number of Persons Served Other Race/Ethnicity Description Asian 26 Hispanic/Latino (Ethnicity) 20 African American/Black 25 First Nation/Aboriginal Canadian 20 White 48 Gender Number of Persons Served Male 36 Female 79 Age Number of Persons Served Other Age Description (Adult) (Adult) 15 Additional information regarding the community, population, or cultures you serve that would be helpful. CARF International Survey Number Page 8 of 15 7/3/2017

9 STANDARDS MANUAL INFORMATION FOR SCHEDULING Primary Standards Manual 2017 Aging Services COLLABORATIVE/RELATED SURVEYS CARF/EAGLE Collaborative Survey Are there any other surveys that should be considered when scheduling this survey? If yes, please describe. CONFLICTS OF INTEREST Have any CARF International surveyors served as consultants to your organization in the last four years? If yes, please list names. Would surveyors from any specific states/provinces/territories represent a conflict of interest? (DMEPOS surveys, choose N/A option.) Yes If yes, please list the states/provinces/territories. Washington, DC Would you accept one team member being assigned to your survey from your own state/province/territory? (DMEPOS surveys, choose N/A option.) Are there any organizations/suppliers considered to be in direct competition with your organization? Are there any geographical areas outside of your state/province/territory from which referrals or significant funding is received? (DMEPOS surveys, choose N/A option.) If yes, please list the organizations/suppliers. If yes, please list the geographical areas. Are any of your organization's employees current or former CARF International surveyors? If yes, please list names. AIRPORT INFORMATION Nearest/Most Convenient Airport Name and City Distance/Time from Hotels Other tes/instructions þ Reagon International, Washington, DC 30 miles OTHER SURVEY LOGISTICS Will your organization provide transportation for surveyors between survey locations? Yes Provide any additional information that may assist us in arranging your survey logistics. CARF International Survey Number Page 9 of 15 7/3/2017

10 PROGRAMS TO BE SURVEYED GOVERNANCE STANDARDS APPLICABILITY Governance Standards Applied INFORMATION AND COMMUNICATIONS TECHNOLOGIES STANDARDS APPLICABILITY Information and Communication Technologies Applied PROGRAMS TO BE SURVEYED The grid below identifies the program(s) that are a part of this survey. Program Administrative Location Only Assisted Living CARF International Survey Number Page 10 of 15 7/3/2017

11 AGING SERVICES STANDARDS MANUAL Assisted Living PROGRAM INFORMATION Total number of persons served annually 116 Number of locations where this program is provided 1 Direct-service personnel in full-time equivalents (FTEs) Does this program/service use Electronic Health/Medical Records for persons served? MEDICAL DIRECTION First Name James Last Name Smith Credentials MD Work Telephone Extension Address jsmith@test.org Type of Medical Direction Advisory committee/physician member Description TYPE OF SETTING Type of Setting Type of Larger Organization Description Freestanding NUMBER OF UNITS AVAILABLE Semiprivate Units 25 Single Units 54 1 Bedroom Units 2 Bedroom Units Bedroom Units 3 Total number of units 160 CARF International Survey Number Page 11 of 15 7/3/2017

12 LOCATIONS FOR SURVEY LOCATIONS FOR SURVEY Contact us if changes to locations visited during the survey are necessary. The grid below identifies the location(s) that are required to be visited during this survey. Refer to each location page for details about programs to be surveyed at the location. Location Name Street Address City State/Province/Territory The Arbors Community 123 Arbors Way Washington DC CARF International Survey Number Page 12 of 15 7/3/2017

13 LOCATION INFORMATION LOCATION Location Name The Arbors Community Street Address (no P.O. Box) 123 Arbors Way Country US Zip/Postal Code Is this location acting as the survey headquarters? Yes Distance from survey headquarters 0 Describe any accessibility issues at the location. ne Suite Number, Floor, Department, or OTHER State/Province/Territory DC County Is WiFi available for the survey team's use at this location? Yes Miles or kilometres? Location Type Owned/leased Does this location operate solely as an administrative site? Yes City Washington OTHER State/Province/District (outside rth America Only) Telephone Direction from survey headquarters Do you want this location's address and phone number to be published in our listings of accredited organizations? Yes Days and Hours of Operation 24 hours a day, 7 days a week Other Days/Hours Description If any program/service is provided at this location during limited days/hours, list the CARF program name and description of days/hours of operation Direct-service personnel in full-time equivalents (FTEs) at this location for the programs seeking accreditation Average number of persons served daily at this location for the programs seeking accreditation STAFF MEMBER RESPONSIBLE FOR OPERATIONS þ Same as Survey Key Contact PROGRAMS AT THIS LOCATION The grid below identifies the program(s) to be surveyed at this location. Program Administrative Location Only Assisted Living PROGRAM LICENSING Indicate in the grid below the type and name of each license for each program, if applicable. License Type Description Name of Licensing Body Provider/License Number Assisted living DC Department of Health CARF International Survey Number Page 13 of 15 7/3/2017

14 OTHER OFFERINGS AT THIS LOCATION Indicate in the grid below the types of services offered at this location. Type Activities Hospice Occupational therapy Pharmacy Physical therapy Wellness/fitness Description CARF International Survey Number Page 14 of 15 7/3/2017

15 SURVEY ACCESSIBILITY OTHER INFORMATION Does CARF International need to provide an interpreter for the survey team to conduct the survey? If yes, specify language(s). In what primary language are your organization documents written? English If other, specify language. CARF International Survey Number Page 15 of 15 7/3/2017

Survey Application ORGANIZATION INFORMATION

ORGANIZATION TO BE SURVEYED Survey Application ORGANIZATION INFORMATION Organization/Unit Name Acronym Federal Tax Identification Number La Frontera Inc. Hope Center Hope Center 123456789 Organization