10-0388-4 Adult Day Health Care

OMB Number 2900-0661
Estimated Burden: 6 hours

STATE HOME CONSTRUCTION GRANT PROGRAMADULT DAY HEALTH CARE
PROJECT LOCATION
PROJECT NAME:

FAI#
Number of Participants
in Program

1. SUPPORT FACILITIES

NUMBER BEDS
IN PROJECT
PROPOSED BY
STATE

VA CRITERIA

ADMINISTRATOR'S OFFICE

200

ASST. ADMINISTRATOR

150

MEDICAL OFFICER, DIRECTOR OF NURSING OR EQUIVALENT

150

NURSES' OFFICE AND DICTATION AREA

120

GENERAL ADMINISTRATION (each

120

office/person)

TOTAL VA
ALLOWED

120
120
120
120
120
120
120
120
MAY INCLUDE: MEDICAL RECORDS

120

SOCIAL SERVICES

120

RECEPTION / INFORMATION

120

CLERICAL STAFF (Each) #

80@

COMPUTER AREA

40

CONFERENCE ROOM / CONSULTATION AREA/IN-SERVICE TRAINING

500
3/PARTICIPANT
(150 min. 600

LOBBY / WAITING AREA
PUBLIC TOILETS (MALE, FEMALE)
DIETETIC SERVICE
DINING AREA

25/FIXTURE
AR

AS REQUIRED
20/PARTICIPANT

CANTEEN, RETAIL SALES

2/PARTICIPANT

VENDING MACHINE

1/PARTICIPANT

PARTICIPANTS TOILETS
MEDICAL SUPPORT (Each)

AR

25/FIXTURE
140@
140
140
140
140
140

MAIL ROOM
JANITORS CLOSET
VA FORM
MAR 2005

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120
40
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PROPOSED BY
STATE

1. SUPPORT FACILITIES (Continued)
MULTIPURPOSE ROOM

VA CRITERIA

TOTAL VA
ALLOWED

15/PARTICIPANT

EMPLOYEE LOCKERS # EMPL.

6/EMPL.

LOUNGE

120

TOILETS

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

GENERAL WAREHOUSE STORAGE (medical,

dietary)

AR

GENERAL LAUNDRY

6/PARTICIPANT

AR

AS REQUIRED

SUPPORT FACILITIES SUB-TOTAL; (No "As Required" Areas)
AS REQUIRED AREAS:

AR

AS REQUIRED

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

PROGRAM SUPPLY AND EQUIPMENT

50

STAFF TOILET

25/FIXTURE

STRETCHER/WHEELCHAIR STORAGE

100

KITCHENETTE

120

JANITOR CLOSET

40

RESIDENT LAUNDRY

120

TRASH COLLECTION

60

OTHER (Justify)
UNIT SUB-TOTAL:
TIMES NO. UNITS:

x

x

SUB TOTAL:

VA FORM
MAR 2005

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PROPOSED
BY STATE

3. BATHING AND TOILET FACILITIES

TOTAL VA
ALLOWED

VA CRITERIA

A. PRIVATE OF SHARED FACILITIES

WHEELCHAIR FACILITIES #

ROOMS X

@=

25/FIXTURE

(50% OF TOTAL, MINIMUM COMPLIANCE WITH UFAS)
STANDARD FACILITIES #

25/FIXTURE

ROOMS X

@=

ROOMS X

@=

15/FIXTURE
25/FIXTURE

FULL BATHROOM #

75
25/FIXTURE

CONGREGATE BATHING FACILITIES - FIRST TUB/SHOWER

80

EACH ADDITIONAL FIXTURE #

25
UNIT SUB-TOTAL:

x

TIMES NO. OF UNITS:

x

SUB-TOTAL - ALL UNIT TOILETS

Mechanical, electrical and other engineering/utility areas, in addition to engineering workshops and circulation space, are not
included in the Space Analysis or the Percentage of Participation calculations.
NOTE 2: All areas not shown on this form must be justified, on a programmatic medical care or state imposed regulatory basis, in order
for VA to participate in the funding of that space.
NOTE 1:

TOTALS
COMPREHENSIVE SUB-TOTALS

PROPOSED BY
STATE

TOTAL VA
ALLOWED

VA CRITERIA

SUPPORT FACILITIES - CRITERIA
SUPPORT FACILITIES - AS REQUIRED

AR

AR

AR

AR

BATHING AND TOILET FACILITIES
GRAND TOTALS - CRITERIA AREAS:
GRAND TOTALS - AS REQUIRED AREAS:

If prepared by State:

I certify that this accurately reflects the proposed Space Program Analysis for this project:
Date (mm/dd/yyyy)

Signature
COMPUTATIONS

PROPOSED BY STATE

ALLOWED BY VA

ANALYSIS
CRITERIA AREAS

+
+

10% DEVIATION

+

AS REQUIRED AREAS
TOTAL STATE PROPOSED:
FORMULA FOR % OF VA PARTICIPATION:

TOTAL VA ALLOWED:
VA ALLOWED:

x 0.65
=

%

STATE PROPOSED:
OFFICIAL PERCENTAGE OF VA PARTICIPATION

%

CERTIFIED
State Home Grant Program, Office of Facilities Management (181A), 811 Vermont Avenue, NW, Washington, D.C. 20420
VA FORM
MAR 2005

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Date (mm/dd/yyyy)
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you are entitled.
VA FORM
MAR 2005

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