MemberProfile

The name and type of entity (corporation, association, governmental unit, person or partners) legally responsible for operating the business is a: Limited Liability Corporation

2. State License # N/A

3. Federal ID # On File with the Association

4. State Tax ID # On File with the Association

5. AHCCCS (authorized provider of service for ALTCS Arizona Long Term Care

service) # N/A

6. The names, titles and addresses of all officers, directors, owners and managerial employees, and the percent of ownership if proprietary.

Names of Officers, Directors,
Owners, and Managerial
Employees

Title (President, Director, Partner, Stockholder, etc.)

Address
(Street, City, Zip)

Percent of Ownership (if proprietary)

Bernard Capulong

President

3301 North Litchfield Road, Suite 800

Goodyear, Arizona 85395

50%

Jelyne Capulong

Director

3301 North Litchfield Road, Suite 800

Goodyear, Arizona 85395

50%

7. A Certificate of Good Standing for the corporation to do business in the State of Arizona from the Arizona Corporations Commission is on file with the Association. This certificate was valid as of the day of the Member's application.

8. List the name of the business, corporation, or LLC Agent(s): Richard Keyt

9. Other office locations: N/A

10. The owner(s) of Compassionate Home Care have owned and operated this company since 2008.

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Additional Member Information

Yes ____ No U	Have any of the Member’s Officers, Directors, Owners, or Managerial Employees ever been convicted of any criminal offense, other than a minor traffic violation?
Yes U No _____	Are any of the Member’s Officers, Directors, Owners, or Managerial Employees licensed or certified in any capacity of health or home care? Jeylene Capulong, LPN License expires 04/01/2014
Yes ____ No U	Have any of the Member’s Officers, Directors, Owners, or Managerial Employees had their license/certification ever revoked or suspended or any other disciplinary action taken against them by a licensing body?
Yes ____ No U	Have the owners or principals of the Member’s business been involved, had interest in, or owned a Non-Medical Home Care business, or other health care business, that has either shut down its operations or went out of business?

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B. Membership Category

U Business Member - Those who are exclusively engaged in the non-medical home care industry.

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C. Home Care Services Offered

Homemaker Services
Yes U No _____	Housekeeping or Home Management
Yes U No _____	Light house cleaning
Yes U No _____	Sweeping, vacuuming, mopping
Yes U No _____	Laundry
Yes U No _____	Ironing
Yes U No _____	Washing dishes and utensils
Yes U No _____	Bagging garbage and taking it out
Yes U No _____	Making beds and changing linens
Yes U No _____	Assisting client organizing household routines
Yes U No _____	Assisting with reading and writing tasks as requested (not financially related)
Yes U No _____	Assisting with organizing

Yes U No _____	Meal Preparation
Yes U No _____	Assisting with menu planning where appropriate
Yes U No _____	Preparing and serving meals using sanitary meal preparation practices

Yes U No _____	Transportation/Shopping
Yes U No _____	Accompanying a client on trips to obtain health care services or other necessary items or services.
Yes U No _____	Caregiver drives client’s vehicle for such trips.
Yes U No _____	Caregiver drives personal vehicle for such trips.

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Yes U No _____	Home Care Aide Tasks (Complete Hands-on assistance) Bathing/Showering/Bed Baths Dressing/Undressing Personal Hygiene Toileting/Peri Care Transfers Ambulation Medication Monitoring
Yes ____ No U	Home Care Aide Tasks (Limited Hands-on assistance) Bathing/Showering/Bed Baths Dressing/Undressing Personal Hygiene Toileting/Peri Care Transfers Ambulation Medication Monitoring
Yes ____ No U	Home Care Aide Tasks (No Hands-on assistance/ Stand-By Only) Bathing/Showering/Bed Baths Dressing/Undressing Personal Hygiene Toileting/Peri Care Transfers Ambulation Medication Monitoring

D. Other Home Care Services

Yes ____ No U	Registered Nursing Services
Yes ____ No U	Hospice Services
Yes ____ No U	Medical Social Services
Yes U No _____	Licensed Practical Nursing Services
Yes ____ No U	Nutritional Services by a Dietitian
Yes ____ No U	Occupational Therapy
Yes ____ No U	Speech Therapy
Yes ____ No U	Physical Therapy
Yes ____ No U	Respiratory Therapy
Yes ____ No U	Medical Supplies and Equipment
Yes U No _____	EMT Services

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E. Member’s Employment Information and Practices

Yes U No _____	The Member has provided verifiable evidence of current workers' compensation coverage as required by the State of Arizona. (This policy expires: 12/10/2012)
Yes U No _____	The Member has provided verifiable evidence of liability insurance coverage for all its employees. (This policy expires: 12/06/2012)
Yes U No _____	The Member has provided verifiable evidence of a bond against theft for its employees. (This policy expires: 12/06/2012)
Yes U No _____	Does the Member classify its Caregivers as "Employees?" (If so, the business maintains a payroll process which includes reporting of employment, wages, collecting state and federal withholding payroll taxes, and the payment of these taxes and all other state and federal payroll taxes to the appropriate governmental institutions.)
Yes ____ No U	Are the Caregivers working for the Member considered private contractors or self employed individuals?
Yes ____ No U	Are private contractors or self-employed individuals ever referred to clients or potential clients by the Member?
Yes U No _____	Does the business have and perform criminal background checks for all individuals who have direct contact with clients in their homes or in the community?
Yes U No _____	Does the Member have and perform criminal background checks for all managerial officials, supervisors, office personnel and volunteers?
Yes U No _____	Does the Member operate the business from a commercial office space, in a commercially zoned area or from a private residence zoned for commercial use?
Yes U No _____	Does the Member enter into a written service agreement with each client to provide home care services, signed by the client’s financially responsible person and by the company or business organization?
Yes U No _____	Does the Member have an abuse prevention plan for each vulnerable adult receiving services from your company?
Yes U No _____	Does the Member require your Caregivers to have clean driving records and provide a copy of the Caregiver’s DMV driving record?
Yes U No _____	Does the business obtain at least two positive references from two previous employers in the past five years for each Caregiver applicant?
Yes U No _____	Does the Member validate home making and home care skills of Caregivers through demonstration and written questionnaires?
Yes U No _____	Does the Member require all caregivers to read and write English?
Yes U No _____	Does the Member require its Caregivers to maintain current CPR and First Aide certification and have policies in place to ensure these are updated on a timely basis?
Yes U No _____	Does a Staff Person of the Member conduct a face to face interviews with Caregiver applicants, in English, that covers employment history, experience, training issues, skill knowledge, and employment preferences?
Yes U No _____	Have all personnel in the Member’s business, who require direct contact with clients, had tuberculosis screening performed at least annually?
Yes U No ____	Has every individual who provides direct care or manages services in the Member’s business been oriented to the home care duties and skill requirements necessary in order for him or her to perform his or her duties as a care provider?
Yes U No ____	The Member has a client problem resolution and/or client complaint process policy in place that promptly addresses and resolves problems, issues or conflicts?
Yes U No ____	Does the Member drug test all new employees?
Yes U No ____	Does the Member have an established on-going policy and practice that randomly drug tests current employees?

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F. Member's Client/Consumer Information and Practices

Yes U No _____	Does the Member perform any type of evaluation or assessment prior to providing care for a client?
Yes ____ No U	Does the Member charge a prospective client a fee for any type of evaluation or assessment prior to providing care for a client?
Yes U No _____	Does the Member require a deposit from the customer in order to perform services? 1 week deposit required. Can be applied to final bill or refunded at the termination of service.
Yes ____ No U Yes ____ No U Yes ____ No U Yes ____ No U Yes ____ No U	Does the Member have any of the following fees: a. Set-up/Start-up fees? Amount Charged: b. Administrative fees? Amount Charged: c. Cancellation fees? Amount Charged: d. Client Visit fees? Amount Charged: $_________________ e. Managerial fees? Amount Charged: $_________________
Yes U No _____	Does the Member have a minimum amount of hours, whether per day, per week, or per month, or minimum charge that is required before for the business will provide services? If Yes, what are those minimum hours and/or minimum charges? 3 hour minimum per day.
Yes U No _____	Does the Member have a business policy on a client canceling services? Please indicate issues such as amount of notice required, any penalties, and etc.? We charge 1 hour minimum if canceled when caregiver arrives at the client and they cancel.

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