DocHub form-library471765Assisted Living Facility Disclosure Statement - Dss Virginia 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section I, where you will enter the facility's name, licensee name, and ownership structure. Ensure all information is accurate and clearly presented.
3. Move to Section II to detail accommodations, services, and fees. List the base fee along with any additional fees for services not included in the base fee.
4. In Section III, outline the admission, transfer, and discharge criteria. Be specific about any restrictions or conditions that apply.
5. Proceed to Section IV to describe activities provided for residents. Specify types of activities and their frequency while noting any limitations on participation.
6. For Section V, provide details on staff qualifications per shift. Include total staff numbers and their roles.
7. In Section VI, indicate whether liability insurance is maintained by selecting 'Yes' or 'No'.
8. Complete Section VII regarding on-site emergency electrical power sources by providing necessary details and initialing as required.
9. Finally, review all sections for accuracy before saving your completed form. Ensure initials are present where needed.

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