Senior Care Provider Partnership Questionnaire

1. Provider Information

Community / Facility Name *

Administrator / Primary Contact Name *

California RCFE License Number

Facility Type *

Physical Address

City *

Phone Number *

Email Address *

Preferred Method of Communication

Languages Spoken by Staff

2. Capacity and Availability

Licensed Capacity

Do You Currently Have Resident Availability? *

Number of Current Openings

Room Types Currently Available

Please select the room types that may currently be available. Availability should be reconfirmed before referral or tour.

Availability changes frequently and should be reconfirmed before any referral or tour.

3. Pricing

Please provide approximate current rates for preliminary matching. Final pricing should be confirmed directly with your community.

Approximate Monthly Starting Rate

Approximate Monthly High-End Rate

Are Rates Based on Care Needs?

Rates submitted here are for preliminary referral matching only and should be confirmed directly with the provider before placement.

4. Payment and Funding

Payment Sources You May Accept

Private Pay Long-Term Care Insurance VA Benefits Medi-Cal-related program participation, if applicable Assisted Living Waiver participation, if applicable Other

Submitted payment-source information is informational only and does not imply eligibility or participation is guaranteed.

5. Resident and Care Needs

All care needs and admission suitability are subject to the provider’s assessment, licensing, staffing, and admission policies.

Memory Care / Dementia Support

Care Needs or Situations Your Community Generally Cannot Accommodate

6. Accessibility and Environment

Wheelchair Accessible?

Awake Staff Available Overnight?

Accessibility Features

Safety / Security Features

Door alarms Secure perimeter Secured memory-care area Common-area monitoring Other

7. Lifestyle and Preferences

Cultural / Religious Accommodations

Pets

Outdoor Space Available?

8. Referral Partnership

Are You Interested in Receiving Resident Referrals From Lightbearer? *

Would You Like to Discuss a Written Referral Partnership Agreement With Lightbearer?

Are You Interested in Receiving Caregiver Candidate Introductions From Lightbearer?

Do You Offer Virtual Tours?

What Sets Your Community Apart?

Anything Else You Would Like Lightbearer to Know?

9. Provider Confirmation

I understand that information submitted through this form is used for preliminary referral and partnership purposes. Current availability, pricing, services, care capabilities, licensing status, and admission suitability must be confirmed directly with the provider before placement. Submission of this form does not guarantee referrals or create a referral agreement with Lightbearer Senior Care Solutions.

Please do not submit resident medical records, Social Security numbers, banking information, passwords, or other unnecessary sensitive information through this form.