Adult Foster Home Weekly Plan of Operation
|[pic] |Adult Foster Home |
| |Weekly Plan of Operation |
|Licensee: | |Co-licensee (if applicable): | |
|AFH address: | |Phone: | |
Who is the live-in primary caregiver? (Check all that apply)
Licensee Co-licensee Administrator 1 resident manager 2 resident managers Shift caregivers
List all caregivers including substitute caregivers, shift caregivers, resident managers and licensees, and identify how daily 24-hour coverage is provided in a typical work week.
|Caregiver’s name |Job title |Sunday |Monday |
|Name of qualified back-up provider: | |
|Address of back-up provider: | |
|Class level of back-up provider: | |Phone number of back-up provider: | | |
|Licensee or Administrators signature: | |Date: | |
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