State of California - DOC 2 by CH2e39

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									State of California – Health and Human Services Agency                                                                California Department of Aging
CDA 174 (Rev. 04/12)
                                                     COMMUNITY-BASED ADULT SERVICES (CBAS)
                                                       Monthly Statistical Summary Report (MSSR)

Complete Center Name and City: _________________________________________________________                                     Report Year: ________

Days of Center Operation (circle): M            T   W   TH      F     SA     SU                                       Licensed Capacity: _________

Hours of Service: ________________ to ______________


                     Participants                        Jan.       Feb.   Mar.   Apr.   May   June   July   Aug   Sept.   Oct.    Nov.     Dec.


1.     Individuals Pending Admission
       a. Medi-Cal
       b. Private Pay
       c. Total Pending Admission (a + b)


2.     Admitted (Approved) Participants
       a. Medi-Cal
       b. Private Pay
       c. Total Admitted Participants (a + b)


3.     Participant Attendance Days
       a. Medi-Cal
       b. Private Pay
       c. Total Attendance Days (a + b)


4.     Days of Center Operation


5.     AVERAGE DAILY ATTENDANCE
       (#3c divided by #4)


California Department of Aging:
         Fax No.: (916) 928-2507
         Address: 1300 National Drive, Suite 200, Sacramento, CA 95834
         E-Mail Address: cbascda@aging.ca.gov

								
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