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Facility Closure Survey
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1.
What is the name of the facility that is closing?
(Required.)
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2.
What is your facility number?
(Required.)
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3.
In what ZIP code is your facility located? (enter 5-digit ZIP code; for example, 00544 or 94305)
(Required.)
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4.
What is your facility type?
(Required.)
Adult Day Care
Adult Residential Care Facility for Persons with Special Health Care Needs
Adult Residential Facility
Community Care Crisis Home
Enhanced Behavioral Support Home
Residential Care Facility for the Elderly
Residential Care Facility for the Elderly - Continuing Care
Residential Care Facility for the Chronically Ill
Social Rehabilitation Facility
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5.
What is the capacity of your facility?
(Required.)
1-3
4-6
7-15
16-30
31-49
50-74
75-100
101-150
151-200
201-250
251-300
301-350
351-400
401-500
501-600
601-700
701+
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6.
What are the reason(s) you are closing your facility? Please choose all that apply.
(Required.)
Conversion to a different operation type (ex: independent living)
Licensee - Retiring
Licensee - Decline in health condition / death
Low Profits - Low census / not enough clients
Low Profits - High cost of operating business / increased labor costs
Neighborhood or city opposition
Relocating to a new location
Selling facility for profit
Unanticipated expenses
Unavailable Resources - Foreclosure or Bankruptcy
Unavailable Resources - Lease expired and not renewing
Unavailable Resources - Unable to secure qualified staff
Unavailable Resources - Property unsuitable to operate / lack of funds to make structural improvements
Other (please provide details below)
Other/Comments - Please provide details for "other" closure reasons and/or elaborate on any choices selected above.
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7.
Is your facility building owned or rented?
(Required.)
I own the facility building.
I rent the facility building.
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