<p> Provider Profile This service may not be appropriate for every individual. Please work with the regional center service coordinator/case manager and the Interdisciplinary Team to determine the community option that best meets the individual’s unique service needs.</p><p>General Information: Name of Home: Parent Company: City/Zip Code : License Number: Service Design:</p><p>Regional Center Contact: Contact Person: Phone Number: Fax Number: Email Address:</p><p>Provider Information: Director Name: Qualifications: Administrator: Qualifications:</p><p>Business Information: Years Experience: </p><p>Existing Homes: Specialty Services: Provider Statement:</p><p>Staffing Pattern: </p><p>Staffing Information: </p><p>Training Requirements: Average Length of Service: </p><p>Physical Characteristics and Special Features: Sq. Ft.: Lot Size: Bedrooms: Baths: Lay out: Number of ambulatory bedrooms: Number of non-ambulatory bedrooms: Provider Profile Ramps: Guide Rails: Wheel Chair Accessible: Back Yard: Patio: Grass: Garden: Wheel Chair Accessible: </p><p>Special Features: Safety Features: Neighborhood Amenities: ( proximity ) select from drop down menu Hospital: Parks: Shopping: Entertainment: Freeways: Places to Worship: Other: </p><p>Community Programs:</p><p>Volunteer Programs:</p><p>Types of Transportation Services: </p>