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* 1. What program does your loved one participate in? Click all that apply.

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* 2. What is your relationship to the person who attends a Villa Esperanza Services Program? Click all that apply

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* 3. Prior to Covid 19, was your loved one transported to and from their program by a Villa Esperanza Services staff?

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* 4. How comfortable would you be sending your loved one Monday through Friday, starting mid July 2020, if group sizes remained the same as the previous year and additional precautions such as increased use of personal protective equipment (PPE), daily temperature checks, hand washing, and frequent cleaning were in place?

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* 5. How comfortable would you be sending your loved one on a part time schedule (2-3 days a week) with remote support offered during the days they were not physically at program?

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* 6. How comfortable would you be sending your loved one on a part time schedule that entailed them attending program 5 days per week but with reduced hours (as an example attending Monday through Friday from 8am – 12:00pm or Monday through Friday from 1pm-4pm)

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* 7. Would continuing with an online/remote support model with no physical presence at the program create a hardship for your family?

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* 8. Would returning to program with a higher support ratio (fewer persons served with each staff) change your comfort level (as an example, if your loved one was in a group of 6 persons served and one staff, would changing that to 2 people with one staff make you more likely to have your loved one return to program).

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* 9. Please rate your preference for the following Day Support options for the coming fiscal year (July 1, 2020 through June 30, 2010).

  Traditional on-site support with all program participants back in their program (in person support) Attend program 2-3 days per week with remote support the days the person is not physically attending Attend program 5 days per week but with reduced hours (example: attending Monday-Friday 8am–12pm) Continue with remote support full time Returning to program with a higher support ratio (question #8 above)
Strongly Preferred
Preferred
Opposed

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* 10. Looking at your answers to the previous question, what is the primary reason for your top choice?

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* 11. When in person programming resumes will your loved one be able to wear a face mask?

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* 12. If your loved one wears a cloth face mask, are you aware and understand that cloth masks must be washed after each use and are you able to comply with that requirement?

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* 13. As per California guidelines, program participants, staff and visitors must have a temperature of under 100.4 to be at one of our programs. Do you understand this guideline? By stating yes, you are agreeing to adhere to this guideline.

As you are aware, and depending on which program your loved one participates in, transportation to and from the program as well as throughout the day was a normal part of Pre-Covid 19 operations.  The following questions are about transportation.  If we assume the following precautions take place:

·  All persons in the vehicle are wearing a facemask
·  All persons entering the vehicle have their temperature taken before they enter and can only enter the vehicle if their temperature is below 100.4 degrees
·  All persons must use hand sanitizer before entering the vehicle

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* 14. With the aforementioned precautions, how comfortable are you with a Villa Esperanza Services staff, or other company, picking up your loved one from their home and transporting them to their program (and then home at the end of the day)?

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* 15. With the aforementioned precautions, how comfortable are you with a Villa Esperanza Services staff driving the person they are serving into the community for “outings” during the time they are in the program?

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* 16. If we are able to limit the number of people riding in each vehicle, would that change your answer? As an example, instead of having 3 participants and a driver in a standard passenger vehicle limiting passengers to 2 persons served and one driver. For larger vehicles, not allowing anyone to sit directly next to another person.

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* 17. If programs have difficulty with transporting participants to and from their program due to social distancing guidelines, are you able to transport your loved one to and from their program?

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* 18. We are aware that not everyone will be able to immediately return to one of our programs. As such remote support is likely to continue, in some form, for the foreseeable future. With that said, is remote support easy for your loved one to access?

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* 19. Are you able to assist your loved one with remote support if needed?

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* 20. What is/was the most challenging part of remote support for your loved one?

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* 21. If there is anything else you would like us to consider, please let us know by writing it here or you can feel free to contact any member of the Villa Esperanza Services Management team at (626) 449-2919

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* 22. Your Name (optional)

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* 23. Your Phone Number (optional)

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* 24. Name of Person(s) Served (optional)

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