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HomeMy WebLinkAbout15785 ORD - 09/24/1980TEXAS: AN ORDINANCE /5 7 S • AUTHORIZING THE CITY MANAGER TO SUBMIT A PROPOSAL TO 'CONTINUE THE FUNDING OF THE SENIOR CENTERS, -MEAL SITES, AND THE NUTRITION PROGRAM TO THE COASTAL BEND COUNCIL OF GOVERNMENTS FOR $463,706, THE PROGRAM TO ..BEGIN OCTOBER 1, 1980 AND END SEPTEMBER 30, 1981, . • ALL AS MORE FULLY SET FORTH IN THE PROPOSAL, A SUB- "•STANTIAL COPY OF WHICH IS ATTACHED HERETO AND MADE A BART HEREOF, MARKED EXHIBIT "A"; AUTHORIZING THE CITY MANAGER TO EXECUTE ALL OTHER DOCUMENTS NECESSARY FOR THE OPERATION OF THE PROGRAM; AND DECLARING AN EMERGENCY. '+ BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CORPUS CHRISTI, SECTION 1. That the City Manager be authorized to submit a pro-;„, posal to continue the funding of the Senior Centers, meal sites, and the' Nutrition Program to the Coastal Bend Council of Governments for $463,706.= Total Program cost is $680,931, which includes $463,706 in Federal Funds, ' •Fr $90,232 in local funds, $31,125 in participant contributions,$1,289 in .1�,01,61•; County Funds and $94,579 in USDA commodities, the said program to commence ' October 1, 1980 and to continue for a twelve-month period, ending September, 30,1981, all as more fully set forth in the proposal, a substantial copy of which is attached hereto and made a part hereof, marked Exhibit "A". SECTION 2. That the City Manager be authorized to execute any and 01 documents necessary for the operation of the aforesaid program. SECTION 3. The necessity to authorize submission of the proposal to continue the funding of the Senior Centers, meal sites, and the Nutrition Program and to authorize execution of other documents necessary for operation of the said program creates a public emergency and an imperative public neces- sity requiring the suspension of the Charter rule that no ordinance or resolu- tion shall be passed finally on the date of its introduction but that such ordinance or resolution shall be read at three several meetings of the City Council, and the Mayor having declared that such emergency,and necessity exist, having requested the suspension of the Charter rule and that this nance be passed finally on the date of its introduction and take effect and be l�IIED. 'SEP 2 71984 15785 •t in full force and effect from and after its passage, IT IS ACCORDINGLY SO ORDAINED, this the 29day of September,1980. ATTEST: Cjty'Secretary r MAYOR pro•Tem THE CITY of CO PUS CHRISTI, TEXAS APPROVED: OF SEPTEMBER, 1980: J. BRUCE AYCOCK, CITY ATTORNEY By / /� Assistant Ci ,,�Jrtorney Corpus Christi, Texas 2' day of_ TO THE MEMBERS OF THE CITY COUNCIL Corpus Christi, Texas _ For the reasons set forth in the emergency clause of the foregoing ordinance, a public emergency and imperative necessity exist for the suspension of the Charter rule or requirement that no ordinance or resolution shall be passed finally on the date it is introduced, and that such ordinance or resolution shall be read at three meetings of the City Council; I, therefore, request that,you suspend said Charter rule or requirement and pass this ordinance finally on the date it is introduced, or at the present meeting of the City Council. Respectfully, MAYOR Pro -Tem ' �-,.., THE CITY OF CORPUS CHRISTI, TEXAS The Charter rule was suspendeby the following vote: Luther Jones Edward L. Sample Dr. Jack Best David Diaz Jack K. Dumphy Betty N. Turner Cliff Zarsky The above ordinance was Luther Jones Edward L. Sample; Dr. -Jack Best David Diaz Jack K. Dumphy Betty N. Turner Cliff Zarsky passe by the following vote: 15785 COASTAL L.1 COUNCIL OF GOVERNMENTS AREA AGENCY ON AGING * - CBI OG CONTRAC7� AMENDMENT NOS • I. GENERAL INFORMATION • Name of Proposed Project: Senior Community Services Name, address, and phone number Of applicant organization: City of Corpus Christi P.O. Box 9277 Corpus Christi, Texas 78408 Phone (512) 884-3011 Defined Service Area of Proposed Project:' • (Counties, Cities, etc.) . Nueces County/Corpus Christi . Type of proposed project: X Social Services Name of project director, supervisor, or coordinator: Sandra Gonzales, Director X Congregate Meals X Home -Delivered Meals Proposed contract period: Beginning 10/01/80 and ending ':09/30/81 Funding from Area Plan Year: • Beginning 10/01/80 and ending 09/30/81 II. COMPUTATION OF FUNDS REQUESTED A. ESTLMATED TOTAL COST OF PROJECT(p.2.Sec.III) B. LESS APPLICANT'S CONTRIBUTION (1) USDA Commodities • (2) Applicant's Additional Contribution..,, .. (3) Applicant's Required Contribution. C. GRANT AMOUNT REQUESTED •„ $ 609,808 $ 94,579 $ ' $ 51,523 $ 463,706 TERMS AND CONDITIQNS: It is understood and agreed by the undersigned that: 1) funds grance as a result of this request are to be expended for the purposes set forth herein and in ac cordance with all applicable laws, regulations, policies, and procedures of this State and the Administration on Aging of the U. S. Department of Health, Education, and Welfare; 2) any proposed changes in the proposal as approved by the Area Agency on Aging shall be deeme, incorporated into and become a part of this agreement: 3) the attached Assurance of Compli- ance (Form A9A-441) with the Department of Health, Education, and Welfare Regulations issued pursuant to Title VI of the Civil Rights Act of 1964 applies to this proposal as approved:. and 4) funds awarded by the Area Agency maybe terminated at any time for violations of any terms and requirements of this agreement. Name and title of individual authorized to commit applicant organization to this agreement: R. Marvin Townsend_ City Manner Contractor Signature Date • Ivan Arceneaux John -Buckner Area Agency on Aging Director Executive Director, Coastal Bend Council of Governments --• CBCOG FISCAL DEPARTMENT ATTEST: City Secretary J• APPROVED:)5 S ,Adr,/cM (d te) / Assistant City A S z R BUDGET SUMMARY FOR SOCIAL SERVICES - TITLE III -B • 0 BUDGET CATEGORY TITLE III B NON FEDERAL MATCH OTHER RESOURCES CASH IN KIND TOTAL 1. a. Personnel " Director 13,318 Center Supervisor 7,124 . Sr. Clerk Steno 5,837 471 Meal. Site Manager II 35,272 Sr. Clerk Typist 3,050 . . Clerk I 2,824 . Custodian 2,662 t Fbr iNringeaenentssi6_ga 14,049 0 84,601 0 7R,st1, 13,789 2. Travel Out of Town Travel 212 Center Supervisor 384 Meals Site Manager II 1,704 Recreation Aide 384 . 2,684 0 0 2,684 0 3. Equipment and Supplies Cleaning Supplies 4,032 Rec. Supplies 300 Rec. Equipment 150 Office Supplies 378 Xerox Rental 1,020 0 0 5,880 0 5,880 4. Other Costs Utilities 17,609 Telephone 4,745 Rents (Bldgs.) 6,137 Bldg. Maint. 2,835 County Contract 12,892 Postage 130 Printing 375 0 0 44,723 0 44,723 ". • TOTAL 124,099 13,789 0 137,888 0 amount o2 rroJectea rrogram Income Budgeted 0 Indicate method of utilizing Meal Contribution/Program Income: N/A Deductive-Alt=rnative (Program Income is used to reduce the charges against Federal funds during the current budget period.) N/A Cost Sharing Alternative (Program Income is used to support matching requirements during the current budget period.) --3- TITLE III -B SOCIAL SERVICES BUDGET - BY ACTIVITIES *Priority services (Items 1,2,3a) must equal 50% or more of the TOTAL Title III amount. Title III -B Match OtherResources SOCIAL SERVICES *1. Access Services a. Information & Referral b. Transportation/Escort c. Outreach d. • Subtotal (..5.% of S/S Funds) 51,571 3,330 0 16,761 3,329 0 463 0 0 FR 799 6 0 *2. In -Home Services a. Homemaker -Home Health Aid b. Visiting c. Chore Maintenance d. Telephone Reassurance-.'' Subtotal' (_j of S/S Funds) _699 • • f.� ._._.- ..' ''." i 0.•''" rte. ,/' *3. Community Services • *a. Legal Services b. Senior Center Operations o. Social/Recreational' Services d. Residential Repair Subtotal (45% of S/S Funds) 0 0 0 54,190 7,130 0 1,114 0 0 0 0 0 55.304 7.130 0 4. Services in Care Facilities (_% of S/S ponds) .•'�� 5. Senior Center Facilities ( % of S/S Funds) •'-.. .0' .�'...• l _.--•' / 6. Nursing Home Ombudsman ( % of S/S Funds) .. �--..-- TOTAL 124,099 13,789 • 0 *Priority services (Items 1,2,3a) must equal 50% or more of the TOTAL Title III amount. S �,cCE ', R • AMQLTNT . I. NON-FEDERAL LOCAL MATCH 1. Local Revenues - City/County City 19,109 (qualifying as local matching funds5ounty 1,289• 20,398 2. Estimated Program Income (Meal Contributions, etc.) 31,125 (qualifies as local matching funds) 3. Community Development Act funds (Federal cash which qualifies as local matching funds) 4. General Revenue Sharing (Federal cash which qualifies as local matching funds) 5. Other - Cash Sources (such as private contributions which qualify as local match) • 6. Other - In Kind Contributions * TOTAL: NON-FEDERAL LOCAL MATCH 51,523 II. OTHER RESOURCES (List By Sources) A. Other Non -Federal Cash Sub -Total for A 0 B. Local In -Kind Sub -Total for B . - - 0 C. USDA Commodities 94,579 Sub -Total for C 94,579 TOTAL: OTHER_RESOURCES - (1+41+C) 94,579 III. TOTAL: NON-FEDERAL LOCAL MATCH & OTHER RESOURCES 146,102 0 1 SUBCONTRACTORS Cl, C2, III -B COMBINED BUDGET JUSTIFICATION BY LINE ITEMS (L) Admin. Personnel - Director (101) Center Supervisor (101) • Sr. Clerk -Steno (101) Outreach Worker (101) 3 Meal Site Managers II (101) 3 Meal Site Managers I & II(101) Account Clerk ' (101) Receptionists: Sr. Clerk -Typist (101) Clerk I (101) Custodian (101) Sub -Total Fringe Benefits Insurance -Unemployment Insurance -Liability Nutritionist Consultant Total (109) (385) (389) (301) (2) Other Admin. Costs Office Supplies (244) Postage (328) Xerox Rental . (332) Office Equip. Maint. (347) Printing (362) - Total (3) Admin. Travel - Staff Vehicle Expenses Lease Car Fuel (216 Lease Car Maint. (317 Lease Car Rental (332 • Out-of-town Travel (352 Kitchen Supervisor (333 Outreach Worker (333 Total Page 1 of 3 Combined Cl. C2. III -8 Cl C2 III -B Total Total Total Other Federal Non -Fed. Resources $ • $ $ , Grand Total $ Other Federal Non -Fed. Resources $ $ $ Other Federal Non -Fed. Resources $ $ $ Other Federal Non -Fed. Resources $ $ $ 11,453 562 1,302 13,318 11,453 15,182 26,635 6,355 769 7,124 14,248 14,248 6,308 0 5,837 471 12,145 471 12,616 11,287 11,287 11,287 • 35,272 35,272 35,272 21,961 3,796 . 21,961 3,796 25,757 5,188 273 5,461 5,461 7,116 3,050 10,166 .'. 10,166 6,588 2,824 9,412 9,412 6,212 2,662 8,874 8,874 $ 71,181 $ 4,358 $ -0- $ 12,329 $ 1,302 $ -0- $ 56,769 $ 13,789 $ -0- $140,279 $ 19,449 $ -0- $159,728 10,214 1,450 9,164 20,828 20,828 785 110 702 1,597 1,597 3,552 625 4,177 - 8,354 8,354 4 114 670 4,784 4,784 $'89,846 $ '4;358 $''''-04' $'15,184 $ 1;302'$'"'-0-"$'70;812'$'13,789 $' -0- $175;842 $ 19;449'$ ' -0- $195,291 $ $ $ $ $ $ $ $ $ $ $ $ $ 953 55 378 1,386 1,386 485 15 130 630 630 1,380 1,020 2,400 2,400 380 380380 1,470 375 1,845 1,845 $ 4,668 $' --0.L.'$'" -0. " $' "'70'$ -0- $ -0-"$ '1;903'$ -0- $ -0- $ 6,641'$ -0-'$' ' -0- $ 6,641 $ $ $ $ $ $ $ $ $ $ $ $ $ 1,530 1,530 1,530 378 378 378 3,510 3,510 3,510 849 212 1,061 1,061 330 54 384 384 60 660 -.$ .-0-..$.... '$ 6,597.$.. .-0 .. 0 .. .714.$.... --.$. -0-..$.. .212'$ -0-.$ -0-- $ '7;523'$""-0-'$ '-0- $ 7,523 (4) Raw Food ,Commodities ' • Total (230 (471 (5)„ Transportation Transp. of Food: Kitchen Van Repair $ 570 (317 Kitchen Van Fuel 2,340 (216 Food Delivery to Centers 4,836 (301 Sub -Total $7,746 Soc. Service Related Transp: Center Sup'r. $ 384 (333 MSM II 1,704(333 MSM I & II 1,152(333 Recreation Aide 384(333 Sub -Total $3,624 Total (6) Food Storage - Commodities (332 (7) Labor Nutrition Personnel: Kitchen Supervisor (101 4 Cooks (101 Nutrition Clk.(Sr.Clk7Typ.X10 Trades Helper (101 3 Cook Aides (Crewmen) (101 Social Services Personnel: (All are included in Admin. Personnel) Sub -Total Fringe Benefits (109 Insurance -Unemployment (385 Insurance -Liability (389 Total Page 2 of 3 Combined Cl, C2, III -B Cl C2 III -B Total Total Total Other Federal Non -Fed. Resources $ 32,006 $ 32,074 $ 94,579 Grand Total $ 64,080 94,579 Other Federal Non -Fed. Resources $ 30,862 $ 27,716 $ 81,275 Other Federal Non -Fed. Resources $ 1,144 $ 4,358 $ 13,304 Other Federal Non -Fed. Resources $ $ $ $ 30,862 $'27,716 $'81;275' $"1;144 $"4;358'$'13;304' $ " =0= $' ' -0-'$' -0-' $ 32,006 $ 32,074'$ 94,579 $158,659 $ $ $ $ $ $ $ $ $ $ $ $ $ • 7,338 408 • 7,746 7,746 1,152 2,472 3,624 3,624 8,490 $"' -0-'$ -0-"$" -0- '408 $ -0- $ ' $"2;472'$'"'-0-'$' " -0- I$ 11,370 $ -0-'$ ' -0- $ 11,370 6,502 $ -0- $ -0- $ 1,058 $ -0- $ -0- $ -0- $ -0- $ -0- $ 7,560 $ -0- $ -0- $ 7,560 $ $ $ $ $ $ $ $ $ $ $ $ $ • 11,209 1,825 13,034 13,034 28,944 4,712 33,656 33,656 ) 8,801 1,433 10,234 10,234 1 7,592 1,236 ,828 8,828 1 19,578 3,187 22,765 22,765 $ 76,124 $ -0- $ -0- $ 12,393 $ -0- $ -0- $ -0- $ -0- $ -0- $ 88,517 $ -0- $ -0- 88,517 1 9,277 1,510 10,787 10,787 761 124 885 885 1 3,981 648 4,629 4,629 $ 90,143 $ ' -0- $ -0- $'14;675 $••• -0= $' '-0- $' ' -0-'$• '-0- $ -0-' $104,818'$ '-0-'$' --0- $104,818 (8) & (9) Equipment & Supplies Paper Goods: Congregate $16,128 ° Home Delivered 4,032 Cleaning Sup., Centers,Kitchen 5,040 Sub -Total $25,200 (209) Kitchen Equipment Repair (347) Total (10) Utilities Light, Heat & Power Utilities Telephone Rents: (Total, $14,824) Washington $12,274 Woodlawn 1,530 First Lutheran�1L,020 Bldg. Maintenance Total (312) (313) (344) (332) (345) (11) Meal Delivery Costs Labor (Transit) (301) (12) Other Costs Health Cards (460) Recreation Supplies (252) Recreation Equip. Repair (347) County Contract (301) Catering Contract (301) Total GRAND TOTALS c Page 3 of 3 Combined C1, C2, III -B' C1C2 III -B Total Federal $• Total Non -Fed. $ Total Other Resources $ Grand Total $ Federal $ • Other Non -Fed. Resources $ $ Federal $ Other Non -Fed. Resources $ $ Other Federal Non -Fed. Resources $ $ $ 16,128 16,128 16,128 4,032 4,032 4,032 1,008 4,032 5,040 5,040 $ 17,136 $ -0- $ ' -0- $ 4,032 $ -0- $ -0- $ 4,032 $ -0- $ -0- $ 25,200 $ -0- $ -0- $ 25,200 5,093 829 5,922 5,922 $ 22,229 $ -0- $ -0- $ 4,861 $ -0- $ -0- $ 4,032'$ ' -0- $ -0- $ 31,122'$ -0- $ -0- $ 31,122 $ $ $ $ $ $ $ $ $ $ $ $ $ 4,939 17,237 22,176 22,176 1,563 372 1,935 1,935 1,186 4,745 5,931 5,931 5,278 859 6,137 • 14,824 14,824 1,530 1,020 2,835 2,835 5,670 5,670 $ 18,351 $ -0- $ -0- $ ' 859 $ -0- $ " -0- $'31;326'$ " ' -0-'$" '.0- I$ 50,536 $' -0- $' -0- $ 50,536 $ -0- $ -0- $ -0- $ 11,968 $ -0- $ -0- $ -0- $ -0- $ -0- $ 11,968 $ -0- $ -0- $ 11,968 $ $ $ $ $ $ $ $ $ $ $ $ $ 140 140 140 300 300 300 150 150 150 • 12,892 12,892 12,892 10,838 10,838 10,838 $ 10,978 $ -0- $ -0- I$ -0-'$ ' -0- $ -0-'1$ 13,342'$ '" -0- $ -0- $ 24,320 $ =04. $ -0- $ 24,320 $288,666 $ 32,074 $ 81,275 $ 50,941 $ 5,660 $ 13,304 $124,099 $ 13,789 $ -0- $463.706 $ 51,523 $ 94,579 $609,808 BUDGET EXPLANATIONS AND/OR JUSTIFICATIONS 1. Explanation of mechanism for accounting for separation of costs between IIIB, C-1, C-2. 2. Explanation and justification of one-time expenditures, such as: equipment, renovations, etc. 1. Costs were distributed between III -B, C-1, and C-2 according to guidelines furnished by the CBCOG, AAA, using appropriate columns for expenses involved, i.e., cooks' salaries distributed between C-1, 86%, and C-2, 14%, under Meal Costs, Labor. 2. Only one-time expenditures provided under budget as requested are those for equipment repair and building maintenance as required or when need arises. 1 • SUMMARY .BUDGET FOR NUTRITION: CONGREGATE MEALS - T€ITLE Crl l.a. IIIC-1 Non-FedCas Director 11,453 562 Center Supr. 6,355 Sr. Clk.-Steno 6,308 MSM I&II 21,961 3,796 Account Clerk 5,188 Receptionists 13,704 Custodian 6.212 71,181 4,358 Nutr.Clerk 8,801 Trades Helper 7,592 3 Cook Aides 19,578 76,124 *Note: Approximately 86% of total raw food costs is expected to be used in the congregate meals program; however, only $30,862 will be picked up by federal sources, remainder to be paid 1y other local resources, if needed. Indicate method of utilizing Meal Contribution/Program Income: N/A Deductive Alternative (Program Income is used to reduce the charges against Federal funds during the current budget period.) X Cost Sharing Alternative (Program Income isused to support matching requirements during the current budget period.) NON FEDERAL`iIATCH TOTAL OTHER BUDGET CATEGORY. TITLE D1 C 1 CASH IN KLYD BUDGET RESOURCES 1. Project Management a. A4minis,rative Personnel (include Fringe) From Below 71,181 4,358 Fringe 14,551 Nutritionist 4,114 89,846 4,358 94,204 b. Other administrative Costa Office Sup./Postage 953/485 -Xerox/Off.Equip.Main_.1,380/380 Printing 1,470 4,668 CTravel Out-of-town 849 Staff Vehicle •5;418 Kitchen Supervisor ' 330 . A.,s47 6,597 Total Project Management Costs 101,111 4.358 I 105.469 2. Meal Costs a. Raw Food* 30,862 27,716 58,578 Commodities 81,275 • b. T rtaon of Food 7,338 tic gcil1Van 1,152 8,490 n 4Nu C. Food Storage 6,502 6,502 d. Labor From Below 76,124 Fringe 14,019 • 90,143 90,143 e. Equipment Kitchen Equip. Rpr. 5,093' 5,093 e. Supplies Paper Goods 16,128 Cleaning Supplies 1,008 17,136 • 17,136 g. utiitiesBld$ Maint. 2,835 Utilities/Phone 7,688 • Rents '•7,828 18.351 18,351 h. Other Catering Contract 10,838 Health Cards 140 10,978 10,978 Total Meal Coca 187,555 27;716 -0- 215,271 81,275 TOTAL COSTS 288,666 32,074 -0- 320,740 81,275 Amount oe Participant Meal Contributions Budgecad 26,767 2.d. IIIC-1 -0- Amount of Projected Program Income Budgeted Kitchen Supr. 11, 209 l.a. IIIC-1 Non-FedCas Director 11,453 562 Center Supr. 6,355 Sr. Clk.-Steno 6,308 MSM I&II 21,961 3,796 Account Clerk 5,188 Receptionists 13,704 Custodian 6.212 71,181 4,358 Nutr.Clerk 8,801 Trades Helper 7,592 3 Cook Aides 19,578 76,124 *Note: Approximately 86% of total raw food costs is expected to be used in the congregate meals program; however, only $30,862 will be picked up by federal sources, remainder to be paid 1y other local resources, if needed. Indicate method of utilizing Meal Contribution/Program Income: N/A Deductive Alternative (Program Income is used to reduce the charges against Federal funds during the current budget period.) X Cost Sharing Alternative (Program Income isused to support matching requirements during the current budget period.) SUMMARY BUDGET'FOR NUTRITION: HOME DELIVERED MEALS — I C -2s BUDGET CATEGORY TITI2nic.a., NONFEDERAL MATCH TOTAL BUDGET OTHER RESOURCES CASH IPI KIND 1. Project ManagementDirector' a. administrative Personnel 1,302 . (include Fringe) Center Shier. 7694 , Outreach Worker 117287 Account Clerk 273 Fringe 2,185 Nutritionist .670 1,302 0 16,486 0 b. Other Admi ni �T"'R9e t.ObLS 15,184 Office Supplies 55 Postgge 15 70 0 0 70 11 e. Travel Kitchen supervisor 54 Outreach Worker 660 714 0 0 714 0 Total Project Management Costs 15,968 1,302 1 17,270 2. Meal Cosa _ a. Raw Food * 1,144 4,358. 0• 5,502 Commodities , 13,304 b. Transponation of Food 408 0 0 408 0 w c. Food Storage 1,058 0 0 1,058 0 d. Lor Supervisor, Clerk, • Cooks, Crewmen, Trade Helper & Fringe 14,675 ' 0 0 14.675 0 e. Equipment Kitchen Equip. Rpr. 829 0 0 829 0 L Supplies • kaker Goods 4,032 0 0 4,032 0 g. Utilities Rents 859 0 0 859 0 3. Meal Delivery Costs a. Lir (Transit) b. Thermo Carriers c. Maintenence of Equipment d. InsuraneafFees e. Mileage 11,968. _ 11,968 . Total Meal Delivery Coats 34,973 4,358 39,331 4. Other TOTAL COSTS 50.941 5.660 0 54;601 _. 13.304 Amount of Particlpart Meal Contributions Budgeted Amount of Projected Program Income Budgeted *NOTE: Approximately 14% of total raw food costs is expected to be used in the home delivered meal program; however, only $1,144 will be picked up by federal sources, remainder to be paid by other local resources, if needed. Indicate method of utilizing Meal Contribution/Program Income: N/ Deductive Alternative (Program Income is used to reduce the charges against Federal • funds during the current budget period.) X Cost Sharing Alternative (Program Income is used to support matching requirements during the current budget period.) i - ;/ THE PROFILE OF THE DEFINED SERVICE AREA Th'—Three Year Area Plan for the Coastal Bend Council of Governmc7nts Area Agency o Aging lists 11 defined service areas or counties in the region (p.D-1-d) and states: "It will be the policy of the Coastal Bend Area Agency on Aging in the area of Service Delivery - (1) To consider as the target population or constituents for each service provider all persons over age 60 in the defined service area,(D-3-e). In three separate paragraphs describe: (1) The Elderly Population of the defined service area; (2) The General Population of the defined service area; (3) The geographic and/or social dimension of the defined service area. (1) The Elderly are estimated to number 23,000 in Nueces County, or ten percent (10%) of the total population. The ethnic breakdown of that number is: 5% Black, 27% Mexican American, and 68% Anglo. Thirty-six percent (36%) of these elderly fall below the poverty level. 'While this is a lower per- centage than in many other counties, the number accounted for 48.1% of the poverty level elderly in the Coastal Bend Region. 1977 census estimates show the elderly population to be 29,400 or 11.7% of the total population; a growth rate of 27.1%. 19,700 seniors are reported to be over 65 years or 7.9%, a growth of 32.4%. Included in the services area are eleven nursing homes with a resident count of 1,328. Of this number, 1,138 (85.7%) are seniors (60 + years). The capacity exists for 1,521 beds, which indicates that there is an 87.3% occupancy rate. (attached are specificfigures for each home) (2) The 1970 population count in Nueces County was 237,544. Of this number, 204,525 lived in Corpus Christi. Other major population centers in the • county included Robstown, 11,217; Bishop, 3,466; San Pedro, 5,234 (adjacent to City of,Robstown); Port Aransas( 1,218; Ague Dulce, 742; and Driscoll, 626. (3) Ethnically, Nueces County registered 50.6% Anglo, 43.6% Mexican American and • 5.8% other. - Nueces County is 838 square miles offlat, rich coastal soil. The County has a high_mineral value (oil, gas, building material) and a diversified economy, including agriculture (sorghum, cotton), shipping, manufacturing, and tourism. Because of the coastal nature of the area, and the economic stability of the Port of Corpus Christi, to some extent, Nueces County serves as the hub of the Coastal Bend Region. Most of the county is urban oriented, and serves as the economic, educational, medical, social and tourist center for the entire region. See attached chart for additonal statistical data - 11970 Census Data. (2 Attachments) B - r STATUS OF THE AREA'S OLDER POPULAT] ON N uEC6S COU,v ; y (Based on Best Available Information) A. General Population Information:* 1. Total Area Population :- ,2.5 7/ Z 53 cy 2. % Area Population Rural gll /,3. % /a 3. % Area Population Urban Z g (o_/ % B. Older Population Information* 1. Total 60+ Population 60+ population _ 2. H. 7. a. Total Black P„,53— a. % Black cit b. Total Hispanic 13 8 8 — $ c. Total Am. Indian �' 1 b. % Hispanic `1 776-" d. Total Other Minority c. % Am. Indian e. Non -Minority d. % Other Minority - 3. Total 60+ Rural - i 2,/30 .• 4.% Non -Minority _ `fs�d 5. Total 60+ Urban % 60+ Rural /,r-2 7. Total Below Poverty Level 3 8 % Be+ wrbon y Level 76 X *Source of information: "The Elderly P ulation: Estimates by County, t1977", pulshed by Indicators of Need the Office of Human Development Services, Administration 604 1'.rs. on Aging. Need (: _ - (7) Income: Number below povertySOURCES OF INFORMATION:' (Mr. Joe Garza, Social SecurityAdm.) .5 7QO (2) Housing: Number in substandard housing (Ruthmary Price, Housing 3 /06) Authority) y- - (3) Health: Number with mental/physical disabilities (Social Sec.) ,537E0. 80 (4) Education: Number needing continuing education (Del Mar) ii000 (5) Employment: Number unemployed (Texas Employment Commission, 44,_ CETA Program) (6) Social Services: Cc • Access Services: Number needing transportation (City Transit, Operation Bridge) Number needing I & R• services(SCS** La Retama Library) • In -Home Services: Number needing homemaker/home health aid (UpJohn) Number needing visiting/telephone reassurance(SCS, Telecare:of Number needing •chore se.rvices(Chore Program) Spohn Hosp., RSVP) Number needing' -home -delivered meals (SCS) Community Services: Number needing legal services (Legal Aid) Number needing social/recreational services (SCS, 13 local Number needing residential repair services (Neniunohmmp rov,)Number needing congregate meals (SCS) -.Institutional Services: Number institutionalized needing advocacy services (13 local nursing homes) **SCS indicates Senior Community Services statistical information. U .s-oa pry- The /4 /AEA' r fo "page 3-I (1) B2 CURRENT HUMAN SERVICE PROVIDED NON-SOCIAL SERVICE CATEGORIES 60+ Persons Being Served Income Obtain best information available from the Social Security Office. • Persons currently receiving S.S.I (Social Security Admin.)) 3 4/57 • Persons receiving Social Security (Social Security Adm.) / 71 (2) Housing Obtain best information available from local Housing Authority. • Persons living in public housing (Housing Authority) / �� y • Persons receiving some level of rent subsidy (Hous.Auth.) _ __ sal • Persons receiving some other housing support Unavailable • Persons using property homestead exemption 65+(office Tax rl�� Office) Health Obtain best information available from Social Security Office and/or H.S.A. • Persons served annually through Medicaid (Social Security) 3/.780 • Persons served annually through Medicare (Social Security) / 9 "2,66) . (4) Education Obtain best information available from High Schools, Universities, Community Colleges, and Senior Centers. (3) • Persons enrolled in adult education programs (Del Mar, / DD O Institute of Lifetime Learning) �— (5) Employment Obtain best information available from unemployment office. • Persons employed in the work force (full-time) (TEC)* • Persons who are employed part-time (MR -MR State School) • Persons employed through CETA (CETA Program) • Persons 55 and over employed through Title V (Older Worker Program) *TEC indicates Texas Employment Commission. 13 1/3 SD CURRENT SOCIAL SERVICE PROVIDED (From All Resources) (6) Social Services • Access Services - Persons receiving information and referral services (SCS, La Retama Library) - Persons receiving transportation services(SCS, Operation Bridge) - Persons receiving reduced mass transit fare - Persons receiving outreach services (SCS) - Persons receiving case management services • In -Home Services - Persons receiving home delivered meals (SCS) - Persons receiving homemaker/home health aide services - Persons receiving visiting nurse services - Persons receiving telephone reassurance or home(SCS) visitation services - Persons receiving chore services - Persons receiving home repair ser'ices • Community Services - Persons receiving congregate meals (SCS) - Persons participating in senior center programs (SCS) - Persons in day care, and day hospitals - Persons receiving legal services (Legal Aid) - Persons participating in volunteer activity (SCS) • Institutional Services - Persons receiving skilled nursing care - Persons receiving intermediate or custodial care B:3 O tWOuecteRTEO Est. # Persons 6( Served in Current Program Year 5-700 -ice--- / gDO Unavailable X32 Unavailable 33G Unavailable:. Unavailable SOD Unavailable Unavailable J 0/D 3/o3_ Unavailable A i?4o SOD Unavailable Unavailable ESTIMATE OF UNMET NEED This information reflects the needs that exist after considering the available services (1) Housing • Persons in need of housing assistance. B4 O Persons 60+ Remaining In Need (Housing Authority) 502. (2) Health • Persons in need of health care. Unavailable (3) Education • Persons in need of education services.(Del Mar) 3/ (4) Employment ,c� • Persons in need of additional employment. (See Below) / 60 8 Source ---` Applications: TEXfJJ EhfP4OyMENr ( 3) /v1 WMi2 (300) 7-ITGE . J (/3-) • O miEJ21 Nor R6G1J TEREO65-0, TbTrtL &b8) (6) Social Services (All information below from SCS) BS O Number of Persons in Need • Access Services - I•& R services 6 000 - Transportation services Unavailable - Outreach services 3000 - Case management services Unavailable • In -Home Services - Home delivered meals "100 - Homemaker/home health aide services Unavailable - Visiting nurse services " - Chore Services/Home Repair - Telephone reassurance or home visitation services 11667° Home Repair Unavailable • Community Services - Congregate meals /MO Some type of Senior Center programs OO - Day care Unavailable • Institutional Services - Skilled nursing care - Intermediate or custodial care �� NUECES COUNTY LONG TERM FACILITIES Name of Facility Capacity 41 of Beds Present Census Number of Census 60+ Corpus Christi Manor 62 60 48 *Corpus Christi Nursing Center 204 . 178 158 *Lynnhaven 180 175 160 Retama Manor West 106 78 65 *South Park Manor 194 184 173 Retama Manor (Robstown) 98 79 74 The Hearth 107 100 97 *Retama Manor North 180 146 121 *Medicenter 174 163 153 *Retirement & Nursing 116 99 89 Human Development Center 100 66 - TOTALS 1,521 1,328 1,138 * Homes that have residents who are senior volunteers, who work for agencies within the community. (In some cases, they volunteer within their own residence.) There are presently 63 RSVP volunteers who visit in the nursing homes, averaging 1000 hours each month. 08-80 AiiprCHMEAIT to /\ THE PROFILE OF THE SERVICE PROVIDER DL)ibe in chart form and/or narrative the following components of the Provider t� ving the elderly: (1) The staffing pattern of the component serving the elderly. (2) The organizational chart of the contracting agency, indicating where the elder- ly component is situated. (3) The governing body of the contracting agency - officers, members, meeting time and place. (4) The Senior Advisory Board - officers, members, meeting time and place. (1) Attached chart (2) Attached chart (3) Mayor Luther Jones City Council: (4) Edward L. Sample, Mayor Pro Tem. Dr. Jack Best David Diaz Jack K. Dumphy Betty N. Turner Cliff Zarsky City Manager: R. Marvin Townsend The City Council meets each Wednesday in the Council Chambers at the City Hall at 2:00 p.m. Attached list The Senior Community Services Advisory Council meets regularly each month, on the first Thursday, at 3:00 p.m. at the Lindale Senior Center. (3 Attachments) ACCOUNT CLERK I DIRECTOR SENIOR CLERK- CLERK-TYP I RSVP COORDINATOR PROJECT ASS'T/H VAN OPERATOR -1 CLERK -TYPIST I COMMUNITY SERVICE OFFICER I 436 VOLUNTEERS 6 Banquete 7 Bishop 22 Robstown 401 Corpus Christi I WORK STATIONS SUPERVISORS 1 Banquete 1 Bishop 6 Robstown 84 Cor us Christi 1 KITCHEN SUPERVISOR ROBS OWN 1 Kitchen l COOK COOK AIDE SENIOR CLERK( CORPUS CHRISTI "-- 1 Kitchen II 1 1 3 3 COOKS COOK AIDES RECREATION AIDE 11 1. MEAL SITE AIDE MEAL SITE MANA- ICU RECEPTIONIST GER I - Bishop NUTRITIONIST CONSULTANT_ 1 TRADES HELPER 1 R'. ME; MA 2 BUS OPERATORS CITY OF CORPUS CHRISTI \ Gt'�'/ CITIZEN; • DEVELOPMENT SOVIETS NUBIAN ORGANIZATIONAL CHART CIVIL DEFENSE TOURIST AND GONvENTIDN ADMINISTRATIVE PLANNING ovnTcnvEN MINFEEZENIIME POLL PIA LK VITLITIER GAS wAA TRANBIT 1 1 / INSPECTION, NTMb / \ EWlp ITT 1 BOLDING 1 -1 BRAINY { COLISEUM 1 N.RIN 11'11' NGG , 1 lit/ UNE 1 -1 •41.4g,5' FINANCE ACCEUNTI { RY1Krt.DIxO ... AUDITING STAFF BUDGET ..)10 EVALLIATICN DATA ABFEET 3. ft SENIOR COMMUNITY SERVICES ADVISORY COUNCIL 1. Mrs. Barbara Alvarez 4406 Lamont (11) 853-5469 Work: 888-5301, Ext. 306 ' 2. Dr. Roemer Best 3544 Santa Fe (11) 854-5683 3. Mr. Charles C. Bradshaw 3221 Ocean Drive (04) 883-8205 4 4. Mrs. Catherine Chambers 246 Leming (04) 888-6454 ,� 5. Mrs. Josephine Dobson 4438 Wesley Drive (12) 992-9688 4.- 6. Mrs. Felipita Lopez 1409 14th Street (04) 882-8700 7. Mr. James R. Muzzy . 414-N. Chaparral, Apt. 1004 (01) 884-6546 ,* 8. Mrs. Flora Pockrus 1914 Hawthorne (04) 882-8608 4- 9. Mrs. Elizabeth Price 4309 Loma Alta (10) 241-1981 10. Dr. Charlotte Rappsilber 225 Waverly (12) 991-3282 Work: 991-6810, Ext. 248 Mr. C. C. Sampson 2318 Summers (07) 884-7006 12. The Reverend Rudy Sanchez 3334 Casa De Amigos (11) 852-8072 Work: 884-3582 4-11. 4, 13'. Mr. Albert Struller 4945 Willowbrook (11) 992-9540 • '- 14. Mr. Joseph Tassler 113 Tarlton (15) 883-8898 * 15. Mr. Sergio Tremolada 5025 Golden Eye Dr. (13) 991-4770 *16. Mrs. Virginia Vargas 820 Bloomington (16) 852-0229 *17. Mrs. Evelyn Wilson 5607 Everhart Rd., Rm. 403 (11) 854-3816 • .Revised 1/22/80 Term to 12-26-81 Term to 12-26-80 Term to 12-26-81 Term to 12-26-81 Term to 12-26-80 Term to 12-26-81 Term to 12-26-81 Term to 12-26-80 Term to 12-26-80 ' Term to 12-26-81 Term to 12-26-81 Term to 12-26-80 Term to 12-26-81 Term to 12-26-80 Term to 12-26-80 Honorary Life Member Term to 12-26-80 C /-I Tr AC111,1 Carr r0- /.6.(4) THE PROFILE OF THE PERSONNEL IN THE DELIVERY OF SERVICES Profile: 1. .The Project Management staffing pattern (Administrative Personnel). 2. The staffing of senior centers. 3. The personnel utilized in meal costs. 4. The utilization of STEP/CETA/other personnel, funded other than by AAA. 5. The utilization of senior volunteers. 6. Other. (1) Senior Community Services Director, Sandra Gonzales Center Supervisor, Allen Ketcham Administrative Secretary, Connie Dowell Account.Clerk, Belen Galvan (4 hours) (2) Briarwood - staffed by RSVP volunteers - contact persons: + Richard Tolen (4) BobBie Burkhart First Lutheran - Velma Darwin (4 hours), Older Worker Program Greenwood - Mary Louise Barrera, Site Manager Juanita De La Fuente, Receptionist Meal Site Aides - Victoria Ledesma ), . - Belen Garcia Recreation Aides - Maria Lopez Tillie Mendoza Custodian - Victor Limon - CETA Older Worker Program Lindale - Florence Henry, Site Manager Hortencia Hinojosa, Receptionist Meal Site Aide - Lenna Alford,. Older Worker Program Custodian - Raul Gamez Wayside - San Juanita Vela, Site Manager (6 hours) Washington - Mildred Jackson, Site Manager Receptionist - Vacant (CETA) Custodian - Oristez Miller - Older Worker Program Woodlawn - Edna Koonce, Site Manager (6 hours) Zavala - Carrie Stoney, Site Manager (6 hours) Meal Site + Recreation Aides - Rosa De Leon - Older Worker Program Jesus Gutierrez - Older Worker Program Banquete - Site Manager - Vacant' Bishop - Janie Dominguez, Site Manager (6 hours) Robstown - Cora Upshaw, Site Manager Meal Site Aide, Lydia Chapa - Older Worker Program Custodian - Vacant Van Drivers - Arnold Garza, Jimmy Herrera Edna McDonald - In -Kind, City of Robstown (Continued on P.2 8-3 THE PROFILE OF THE PERSONNEL IN THE DELIVERY OF SERVIC$S, PAGE 2 (3) Nutritionist Consultant - Sharon Basile Kitchen Supervisor - Faye Angell Outreach Worker - Diana Hurd Nutrition Clerk - Tommie Koehn Corpus Christi Kitchen Freddie Gonzales Mike Lerma Ramona Moreno Marjorie Merriweather Anita Santoya Robstown Kitchen Maria Rocha Lupita Pena Crewman (Cook aide) - Valentina Torres - CETA Trades Helper - Vacant (5) Although the count varies from time to time, the number of senior volunteers involved in our senior center activities remains fairly constant. A typical monthly statistical report: Total number of volunteers: 184 Mexican American - 107 Black - 10 Anglo - 67 Total number hours: 6,6951 Recreation - 2,861 Nutrition - 3,4387 3/4 Telephone Reassurance - 8414 Escort Service - 1751 Home Delivered Meals - 42 Continuing Education - 45 All of the senior volunteers are registered with the Retired Senior Volunteer Program. B-3 C • jg T. 'THE PLAN OF OPERATION -FOR SERVICE DELIVERY - TITLE III -B Qce componnts of a comprehensive and coordinated seice delivey system thQ mfunded are services which (1321.75 (b))are listed on the following page. (1) Access (2) In Community (3) In Home (4) To residents. Define measurable objectives followed by action plans to accomplish each objective for each service to be delivered. Access Outreach - Home visitation is provided to Project participants and to the elderly of the community on an on-call and/or referral basis. Home delivered meal recipients are provided with extensive home visitation by personnel assigned to evaluation and re-evaluation of home delivered recipients. The program will make 75 home visits per month. Information and Referral - This service is provided from each center and meal site five (5) days a week, fifty-two (52) weeks a year, except holidays. The elderly community may call well advertised numbers to obtain information on available services. Follow-up is done on those cases which are involved or are of a particularly serious nature. The Centers supervisor makes random calls periodically to recipients of the service in order to measure the appropriateness of the referral and accuracy of the information provided. The program will handle 350 calls per month. Escort - The transportation program carries most of the elderly needing transportation to doctors' offices, social service agencies and to other necessary appointments.. Occasionally a senior citizen requires personal assistance when visiting an agency or in obtaining services. The meal site manager and/or outreach worker will be involved in transportation•and.person- ally assisting an elderly person in need of special attention. The program will escort 21 persons needing individualized attention on a monthly basis. Individual Needs Assessment and Service Management - Individual assessments are an on-going process. The in -take form used to certify a person wishing to participate in the program provides the staff with the necessary tool for needs assessment and service management. Each program participant is surveyed to determine their particular needs and appropriate services are then offered. Intake forms are reviewed as needed and periodically updated as personal situations change. (See attached form.) Service in the community, Congregate Meals - Congregate meals are served five (51 days per week, except holidays. Eleven centers and meal sites serve 617 Csix hundred seventeen) meals per day. The meals are hot and well balanced. Each item on the menu is analyzed -- taking into account health and religion requirements as well as ethnic, cultural, and regional preferences. A nutritionist is employed by•contract to assure that the meals are properly balanced. Continuing education - Educational programs are scheduled at the senior centers and meal sites. Guest speakers are invited to speak on subjects of interest to the elderly community. The Institute of Lifetime Learning, Corpus Christi Chapter, enlists instructors to teach courses at the centers at no cost to the program. The Institute does charge a nominal fee to persons who enroll in the program. At least one program will be -offered per month at the Senior Centers. THE PLAN OF OPERATION FOR SERVICE DELIVERY -TITLE III -B, PAGE.2 • 7. Health - Blood pressure screening is the only regularly scheduled health- related activity occuring at the Congregate sites. Meal site managers and volunteer nurses take blood pressure readings and advise the participants of any abnormally high reading. Blood pressure screening will be scheduled in each center/meal site at least once a month. Upjohn Healthcare Services Inc. has come to the larger centers to screen for the unintentional misuse of prescribed drugs. Drug counseling is also offered by the Upjohn staff at no cost to the program. The Upjohn volunteers are registered nurses. 8. Legal Services - The majority of centers and sites are used as intake centers for Cctal Bend Legal Services on a regular basis. Meal site managers refer participants with legal problems to the Legal Aide staff. 9. Program Development and Coordination Activities - In the main, it is the responsibility of the professional staff to involve themselves in program development and coordination activities. , Extensive coordination with other agencies occurs before and during the Senior Citizen's May Fair. The Fair brings together the services and opportunities available to senior citizens. All the major service providers participate in this event. Prpgram development is done only to the extent it does not involve program expansion. Due to limited monetary resources, expansion is not possible; however, other opportunities not involving long-term fiscal or programmatic commitment are explored. The program has, over the past year, concentrated on medical problems. The Nueces County Medical Auxiliary has been working with the program in surveying the elderly community's use of prescription drugs as well as their relationship with their physicians. In the next year, the program will do a study on the effects of retirement. Depression among the elderly will be the focus of this study. Program development is presently geared toward strengthening the statistical information available to program supervisors, administration funding sources and potential funding sources. 10. Advocacy - The Program serves as an advocate to the elderly in assuring the best possible use of resources, the best possible delivery of services and the best possible program administration. 11. Counseling - The program provides short-term social services counseling, i.e., financial and lifestyle adjustment, mental/physical well-being, housing and home -related, nutritional and personal hygiene, and utilization of community programs. The program will counsel 150 persons per month. 12. Emergency Services - Disaster Relief -'Senior Community Services, as part of the City of Corpus Christi, is on-call 24 hours a day during times of natural disaster. Disaster shelters operated by the Red Cross are available to elderly persons who have been evacuated or have chosen to leave their homes. B-4 THE PLAN OF cPERAT±ON FOR SERVICE DELIVERY - TITLE III-B,.PAGE•,3 12. A shelter especially designated for the elderly and handicapped is usually available. Relocation, assistance in obtaining financial assistance and other support -services are provided by Senior Community Services after a natural disaster has occured. 13. Physical Fitness and Recreation Services - Senior Centers and meal sites strive to be the focal point of social, mental and physical activity. Activities, which are developed primarily by participants, encourage social.. support systems through interaction among participants. Educational programs are developed to stimulate the mental capacities of participants. Exercise programs are geared to the physical capacity of those interested in increasing their physical abilities. All of the programs described are available to elderly persons living in the vicinity of the centers and meal sites as well as to the meal program recipients. Recreational activities, particularly dances, are popular at all centers. Each center will continue providing a well rounded recreational program. A total of 1,500 persons will be involved in recreation per month. 14. Multipurpose Senior Centers - There are four senior centers which operate as community focal points/multipurpose centers; they are Lindale Center, Greenwood Center and Washington Center in Corpus Christi, and Robstown Center in Robstown, Texas. Service providers are urged to come to the focal point - collocation of services - as their schedule permits. Information and referral services are high priority at these centers as they receive calls for.services frequently. Staff are trained to monitor lists of persons requesting services, follow-up is done and current information with respect to services available is kept. 0 Multipurpose centers are differentiated from meal sites in that they (1) are open eight (8) hours per day or longer; (2) have a full complement of personnel, i.e., meal site manager, recreational aides, meal site aides, receptionist, custodian; (3) provide a variety of services; (4) serve larger numbers of elderly persons; and (5) are in a vantage point with respect to community exposure. 15. Shopping Assistance - Provision is made for shopping assistance as needed, to program participants to assist them in the selection of proper.food items which will improye.their nutritional intake. Non -program elderly will be accommodated as time. and space permits on Transit van services. The service is well advertized and will service as many persons as is feasible. In -Home Services 16. Counseling - Homebound recipients are counselled by the Outreach Worker and meal site managers assigned to outreach services. Homemaker and other services are suggested if indicated. Housing, nutritional and health counseling are also provided. 17. Telephone Reassurance - Staff members or volunteers enlisted by staff members call participants on a regular basis'if requested. The condition of the person being called is noted and any unusual circumstance is brought to the attention of the Outreach Worker or meal site manager. B-4 TODAY'S DATE / SENIOR COMMUNITY SERVICES INFORMATION FORM Participant's Name Last First Middle Present Address treet City Zip Home Phone( ' ) Date of Birth / / CENTER NUMBER I. Medical Information 1. In case of emergency, call: Name Name ge Address Address Phone Phone Relationship Relationship 2. My physicians are: Name Home Phone Office Phone Home Phone Office Phone Name 3. Blood Type Allergies 4. I am being treated for the following conditions: (Such as diabetes, heart attack, high blood pressur.'e) 5: I am taking the following prescription medications: Pharmacy: 6. I am taking the following drugs which are not prescription medicines: 7. My medications and drugs are kept: B. Hospital 'preferred: it ` 9. Health Insurance: Medicare No. Medicaid No. Private health insurance policy with Number of Policy 0 10. I am a veteran Yes No 11. Religion Clergyman Phone No. 12. Currently, have you any of the following illnesses? Arthritis, rheumatism, or chronic bursitis Heart trouble High blood pressure Low blood pressure Asthma Emphysema or chronic bronchitis Tuberculosis Stomach or intestinal disorders Glandular disorders Liver disease • Urinary tract disorders Skin disorders Bone disorders Diabetes Cancer or leukemia • Multiple gclerosis' " " . . •' ..• Muscular dystrophy Problem with nerves, or emotional problems Glaucoma or cataracts Speech impairment Hearing loss Dental problems • Alcohol problem Other physical problems or current illnesses? Hospitalized within the past year? How long? Other comments for the physicians A. II. Ethnic Identification a. Eastern European b. Western European c. Carribean Hispanic d. Mexican -American Hispanic e. American Indian/ Alaskan Native f. Asian/Pacific Islander g. Afro American not of Hispanic Origin h. Other III. Gender a. Male---- f 1 b. Female -- 0 IV. Financial PLEASE INDICATE INCOME RANGE Income not in A Income is 0 Column A Q Income is up to $500 Income is up to $1,000---- Q3 Income is up to $1,500 ---- Income is up to $2,000---- (� Income is up to $2,500----1-61 Income is up to $3,000----ni Income is up to $3,500----n Income is up to $4,000---- Place the appropriate number in the above box. 191 C.O.G. Data a, b = 1 c, d = 2 e=3 f=4 g=5 h=6 Place the appropriate number in the above box. Place the appropriate number in the above box. INDEPENDENT OF SPOUSE'S FINANCES! Column B W Income not in B Income is up to $5,000----M Income is up to $6,000----f T Income is up to $8,000 ---- Income is up to $11,000--- ri Income is Income is Income is Income is up to $16,000---1- 1 up to $22,000-71 up to $30,000 --- over $30,000 --- Will not give data Place thel appropriate number in the above box. 17) 18 1 U Education a. Elementary, less than 5 years -11] b. Elementary, 5 to 7 years c. Elementary, 8 years d. High School, 1 to 3 years e. High School, 4 years f. College, 1 to 3 years g. College, 4 years or more VI. Services Types of services now receiving: Check all boxes that are appropriate. a. None b. Chore Program c. Human Resources --- d. Food Stamps e. Medicare f. Medicaid g. SSI h. Legal Aid VII. Language(s) Spmken a. English only b. Spanish only c. Bilingual (English and Spanish) d. Bilingual (English and language other than Spanish) e. Polylingual P1 Indicate language(s) other than English and Spanish Place the appropriate number in the above box. Number ofboxes checked, except for box a. Place the appropriate number in the above box. VIII. Living Arrangements 1. a. Live alone b. Live with others 2. a. Own own home (no mortgage) Q b. Own own home (with mortgage) c. Subsidized. renting d. Non -subsidized renting e. Live at other's dwelling, no rentrn f. No permanent address IX. Employment a. Employed full-time b. Employed part-time c. Not employed d. Volunteer staff e. Seeking employment (not employed now) m m fel .Nature of past or present employment Place the appropriate number in the above box. Place the appropriate number in the above box. Place the appropriate number in the above box. X. Transportation Indicate your main mode of transportation: a. Car b. City bus c. S.C.S. van d. Taxi e. Walking f. Other DJ f j41 co m Place the appropriate number in the above box. 0 XI. Marital Status a. Single b. Married U c. Widowed 111 d. Divorced (� e. Separated Place the appropriate number in the above box. XII. General Questions 1. Recreation What recreational programs would you like offered at the centers? 2. Agency Awareness Would you know what agency to go to if you had the following problems? NO YES a. Legal problems b. Drug problems c. Day care of children d. Emergency financial aid e. To find a job f. Housing discrimination g. Welfare §ervices h. Job discrimination i. To get rid of junk cars j. Recreation k. Transportation 1. Nutrition m. Will not give data 3. Continuing Education a. I am interested in continuing education classes b. I am interested in periodic lectures at centers 4. Volunteerism a. Are you an RSVP volunteer: NO YES b. If not, would you be interested in the program? STATEMENT OF CONFIDENTIALITY Senior Community Services is a division of the Department of Planning and Urban Development, City of Corpus Christi. All information, except for the medical information that will be given to the physician in case of emergency, is confidential and will be used only for the purpose of providing services to you, as a senior citizen, and for statistical information. I, the undersigned, authorize the use of the information I have provided for the above -stated purposes. SIGNATURE: DATE: INFORME CONFIDENCIAL Senior Community Services es una division del Departamento de Planacion Y Desarrollo Urbano de la ciudad de Corpus Christi. Toda informacion, con excepcion de la informacion medica que se dare en caso de emergencia, es confidencial y sera usada solamente para el proposito de proveerle servicios a'usted, comp ciudadano mayor, y para informacion estadistico. Yo, el subscrito, autorizo el use de la informacion proveida para el proposito mencionado arriba. FIRMA: FECHA: THE PROFILE ON INFORMATION AND REFERRAL IN THE DEFINED SERVICE AREA Profile compliance with #1321.161. The Centers providing intensive information and referral are the centers designated as community focal points, Greenwood, Lindale, Washington, and Robstown. The Meal Sites also provide information and referral but not to the extent offered by the Centers. Greenwood Center, located on the westside (Spanish speaking) area of Corpus Christi, and Robstown Center, located in a community with a large Spanish speaking population, have a bilingual staff capable of giving information and making referrals in English and Spanish. Lindale Center, although predominantly English speaking, has bi-lingual capabilities and can provide information and make referrals in either English or Spanish. The form used for information and referral services asks for thenrame of the"person makin request in order that follow up may be done. Also a list is developed of those persons in need of services and opportunities. Staff are trained at centers and meal sites to provide accurate and appropriate information and referral. The program will provide 350 persons with information and referral services per month. Q -S th 1 ri . 'Av I"I IL LI ...LMi di I THE PRQFILE,ON TRANSPORTATION IN THE DEFINED SERVICE AREA 0 PROFILE: 1. The transportation needs. 2. The service provider's response to these needs. 3. The number, type, capacity of vans, etc. 4. The personnel involved in transportation. 5. The unmet needs. The Older Americans Act funding does not support the transportation program. Funding is provided through other sources: Nueces County Commissioners, ACTION, and the Urban Mass Transit Administration (UMTA). Senior Community Services coordinates closely with City Transit, Elderly and Handicapped Division, in an attempt to see that the transportation needs of the elderly in Corpus Christi are met. That department has one bus, eight vans nad seven drivers. Three of the aforesaid vehicles are equipped with wheehchair lifts. . During the preceding twelve month period, E & H transportation provided 29,262 rides to senior centers for a monthly average of 2,439. 1,125 trips were made for medical purposes, for a monthly average of 94. 778 rides were given for other purposes, such as shopping, food stamps, banking, et cetera, for a monthly average of 65. 'The County supports two vans in Robstown. These vans are used for rides to the senior centers, medical facilities, food stamps, banking, stores, et cetera, for an average of 962 rides per month. In Bishop, the meal site manager furnishes transportation to the center and other agencies, as above, for an average of 420 rides per month. The Retired Senior Volunteer Program supports a van which is used to transport seniors to agencies where their skills and experience are used to the benefit of both agency and volunteer. An average of 350 rides are provided each month. The County and RSVP vans are released by Senior Community Services to be used for evacuation purposes in times of weather crises. It is•an accepted frustration among senior service providers, that transportation services do not meet the ever increasing need. .4. V WM.RNM�'Tli`A! THE PROFILE 01 MULTIPURPOSE SENIOR CENTERS IN THE DEFINED SERVICE AREA Profile each center using the following forms. Attached chart and forms will give a profile of Senior Community Services Center and Meal Site operations. (12 Attachments) 8 -7 08-28' 80 SENIOR COMMUNITY SERVICES SENIOR CENTERS AND MEAL SITES Center Hours Address Phone Number Corpus Christi: ` **Briarwood Apts. 11:30 A.M. - 12:30 P.M. 1701 Thames 991-8081 (Satellite) **First Lutheran 11:30 A.M. - 12:30 P.M. 1201 Morgan 884-9676 (Satellite) Greenwood 8:00 A.M. - 5:00 P.M. 4040 Greenwood 854-4628 Lindale 8:00 A.M. - 5:00 P.M. 3135 Swantner 854-4508 Wayside 9:00 A.M. - 3:00 P.M. 3312 Wayside 883-4183 Washington 8:00 A.M. - 5:00 P.M. 1114 Sam Rankin 882-6279 Woodlawn 10:00 A.M. - 2:00 P.M. 3757 UpRiver Road 883-7841 Zavala 9:00 A.M. - 3:00 P.M. 442 Mohawk 882-1561 Bagnuete: r **Banquete 12:00 P.M. - 1:00 P.M. Farm Market 666 387-7621 (Satellite) Bishop: Bishop 10:30 A.M. - 3:30 P.M. 301 West Main 584-3211 Robstown: Robstown 8:00 A.M. - 5:00 P.M. 206 North Sixth S:. 387-6396 **Only Meals are served at these locations. Present actual number of participants served in nutrition programs at centers are as follows: Briarwood: 15 Wayside: 40 First Lutheran: 18 Washington: 75 Greenwood: 185 Woodlawn: 40 Lindale: 115 Zavala: 65 Banquete: 25 Bishop: 15 Robstown: 82 F CENTER Eria!wnnd Apartmrnta DATE OPENED STREET LOCATION 1701 Thames MAILING ADDRESS (If 'Different) CITY, STATE, ZIP Corpus Christi, Texas 78412 COUNTY Nueces AGENCY Senior Community Services TYPE OF FACILITY '(Satellite) Meal Site CENTER MANAGER Staffed by RSVP volunteers TET.VPHONE :UMBER 991-8081 DAYS OPEN Mnnday through Friday (except Holidays) HOURS OF OPERATION_ 11;30 - 12:30 SERVICES AND AVERAGE NUMBER OF PARTICIPANTS DAILY NUTRITION 15 TRANSPORTATION ESCORT LNFORMATION & REFERRAL ��4- 4y$4043 0 �ti`r• OUTREACH 5 4) LEGAL TELEPHONE REASSURANCE RECREATION Bingo, Coffee hours EDUCATIONtype of) (Specify type of) COUNSELING (Specify type of) EMPLOYMENT (Specify type of) HEALTH (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENTER DHR ME/BR SSA Other OTHER Titles Briarwood Meal Site Paid/Volunteer STEP/CETA 0 Name Part Time Full Time Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance • •Other NO.PAID STAFF:AT THIS MEALSITE. CENTER STREET LOCATION First Lutheran Church 1201 Morgan DATE OPENED MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi. Texas 78404 COUNTY Nueces AGENCY Senior Community Services TYPE OF FACILITY (Satellite) Meal Site CENTER MANAGER Velma Darwin TELEPHONE NUMBER 884-9676 DAYS OPEN Monday -through Friday (except Hol -Maya) HOURS OF OEERATION_11:00 a.m. - 1:30 11..m. SERVICES AND AVERAGE NUMBER OF PARTICIPANTS DAILY NUTRITION 18 TRANSPORTATION 1 ESCORT 0 INFORMATION & REFEZRAL OUTREACH 1 3 LEGAL 0 1hLEPHONE REASSURANCE 0 RECREATION Mnvies, Ringo (Specify type of) EDUCATION Travel Education (Specify type of) COUNSELING - General (Specify type of) EMPLOYMENT (Specify type of) HEALTH (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENTER DHR MG/MR SSA Other OTHER ST First Lutheran Church Paid/Volunteer STEP/SETA Titles 0 Name Part Time Full Time Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide -Cook 'Community Service Custodian Dietician Driver Driver Assistant Escort Hone Repairman 1 & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance •Other Older Worker Program Velma Darwin Part Time NAt CENTER STREET LOCATION Greenwood Senior (nnrnr 4040 Greenwood DATE OPENED MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi, Texas 78416 COUNTY AGENCY Nueces Senior Community Services TYPE OF FACILITY Multipurpose Senior Center CENTER MANAGER Mary Louise Barrera TET.FPHONE NUM3ER 854-4628/29 DAYS OPEN Monday through Friday (except Holidays) HOURS OF OBERATION_ 8 a.m. to 5 p.m. SERVICES AND AVhNAGE NUMBER OF- PARTICIPANTS DAILY NUTRITION 185 TRANSPORTATION ESCORT 80 10 INFORMATION & REFERRAL OUTREACH 2 LEGAL 4 15 TELEPHONE REASSURANCE RECREATION 150 4 EDUCATIONtype of) 0 (Specify type of) COUNSELING 35 (Specify type of) EMPLOYMENT 2 (Specify type of) RF ALTH 20 (Specify type of) otani 40 OTHER AGENCIES PROVIDING SERVICES AT CENTER DHR MH/MR SSA. Tax Aide when applicable . Other Legal Aid. 10 weekly. OTHER SO v Titles Paid/Volunteer STEP/CETA Name Part Time Full Time Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide Cook • Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance •Other lder Worker Program aid aid CETA Older Worker'Program Older Worker Program elder Worker Program Victoria Ledesma Mary Louise Barrera Juanita De La Fuente Victor Limon Otilia Mendoza Maria Lopez Belen Garcia Part Time Full Time Full Time Full Time Part Time Part Time Part Time iF CENTER STREET LOCATION Lindala Sanior 3135 Swantner DATE OPENED MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi. Texas 78404 COUNTY Nueces AGENCY Senior Community Services TYPE OF FACILITY Multipurpose Senior Center CENTER MANAGER Florence Henry TET,VPHONE NUMBER 854-4508/09 DAYS OPEN MOndary Through Friday (except Holidays) HOURS OF OPERATIOIL 8 a.m. to 10 p.m. SERVICES AND AVERAGE NUMBER OF- PARTICIPANTS DAILY NUTRITION 115 TRANSPORTATION 15 ESCORT 1 IFORMATION & REFERRAL 18 OUTREACH 5 LEGAL 1 TELEPHONE REASSURANCE 5 Arts and crafts;Classes: exercise, ballet and tap, ceramics, Spanish, RECREATION German. sewing. pool. cards. dominoes. dances. (Specify type of) EDUCATION Spanish, German, Bridge classes (Specify type of) COUNSELING (Specify type of) F'NPLOYMENT Referral, reassurance Referred to individuals and agencies (Specify type of) HEALTH Rlnnd pressnra rheeks nntritinn films (Specify type of) Widowed Persons,_ Clubs, RSVP, AARP, OTHER Defensive Driving, Adult Learning OTHER AGENCIES PROVIDING SERVICES AT CENTER DER Yes MH/MR q¢A Yes Other Tax Aide Services OTHER S1.—_ Lindale Senior Center Titles Paid/Volunteer STEP/CETA Name Part Time Full Time Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen Aide Outreach Program Director Receptionist Secretary Telephone Reassurance •Other Older Worker Program Paid Paid Paid Lenna Alford Florence Henry Raul Gamez Hortensia Hinojosa Part Time Full Time Full Time Full Time Ne ? CENTER %Ayside Meal Site DATE OPENED STREET LOCATION 3312 Wayside MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi. Texas 78415 COUNTY Nueces AGENCY Senior Community Services TYPE OF FACILITY Meal Site CENTER MANAGER San Juanita Vela TE7 SHONE NUMBER 883-4183 DAYS OPEN MOndav-through Friday (Except Holidays) HOURS OF OEERATION_ 4!00 a_m_ to 100 p�m. SERVICES AND AVERAGE NUMBER OF- PARTICIPANTS DAILY NUTRITION 40 TRANSPORTATION 2 ESCORT 0 INFORMATION & REFERRAL OUTREACH 7 LEGAL 2 TELEPHONE REASSURANCE 5 RECREATTON 12 IDpecify UCATIONtype of) 8 English Class (Specify type of) COUNSELING 37 Nutrition, Health and Welfare (Specify type of) PLOYMENT (Specify type of) HEALTH 37 Exercises (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENTER DHR ME/MR SSA Other OTHER S1._ _ 'WAyside Center Titles Paid/Volunteer STEP/CETA Name Part Time Full Time Bookkeeper Case Worker Center Aide Canter (Site) Manager Chore Worker Clerk/Typist ,Cook Aide Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance ' • Other Paid San Juanita Vela Part Time (6 hours) Ni , CENTER Washington Senior Center DATE OPENED STREET LOCATION 1114 Sam Rankin MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi, Texas 78401 COUNTY Nueces AGENCY Senior Community Services TYPE OF FACILITY Multipurpose Senior Center CENTER MANAGER Mildred B. Jackson TE7.FPH0NE NUMBER 882-6279/70 DAYS OPEN Monday through Friday (Except Holidays) HOURS OF OPERATION____8:O0 a.m. — 5:00 p.m. SERVICES AND ANt2AGE NUMBER OF PARTICIPANTS DAILY NUTRITION 75 TRANSPORTATION 12 ESCORT N/A INFORMATION & REFERRAL OUTREACH 3 LEGAL 1 3 (This service will be emphacioed in tho fntnre ) TELEPHONE REASSURANCE RECREATION 35 to 40 EDUCATIONtype of) (Specify type of) COUNSELING • (Specify type of) CLOYMENT (Specify type of) SFALTH Exercise, movies on health. Blood Pressure checks (Specify type of) OTHER Nutrition, Snrial Security, Um -glary Home. Apartment, Nursing Home Referral to agency OTHER AGENCIES PROVIDING SERVICES AT C'EER DHR MH/MR SSA Other Crime Prevention, Police Department. OTHER S Washington Senior Center Titles Paid/Volunteer S i'hr / CETA Name Part Time Full Time Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide Cook Community Service Custodian Dietician Driver Driver Assistant • Escort Home Repairman I & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance '•Other Paid lder Worker Program Mildred B. Jackson Oristez 0. Miller Full Time Part Time NI ' CENTER Woodlawn Meal Site DATE OPENED STREET LOCATION 3757 UpRiver Road MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi, Texas 78407 COUNTY AGENCY Nueces Senior Community Services TYPE OF FACILITY Meal Site CENTER MANAGER Edna Konnre TET•FPHONE NUMBER 883-7841 DAYS OPEN HOURS OF OEERATION_ Monday through Friday (Except Holidays) 10 a.m. to 2 p.m. SERVICES AND AVERAGE NUMBER OF PARTICIPANTS DAILY NUTRITION 40 TRANSPORTATION Varies ESCORT 1 INFORMATION & REFERRAL 2 OUTREACH 1 LEGAL TELEPHONE REASSURANCE 20 RECREATION Bingo, music, cards, games EDUCATIy ON type of) (Specify type of) COUNSELING • Nutrition (Specify type of) EMPLOYMENT (Specify type of) NFALTH Blood Pressure Checks (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENTER DHR MJEU R SSA Other OTHERS Woodlawn Meal Site Titles Paid/Volunteer STEP/CETA .lame Part Time Full Time ' Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide .Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance '•Other Paid Edna Koonce Part Time (6 hours) Ni F CENTER Zavala'Meal Site DATE OPENED STREET LOCATION 442 Mohawk MAILING ADDRESS (If Different) CITY, STATE, ZIP Corpus Christi, Texas 78405 COUNTY AGENCY Nueces Senior Community Services TYPE OF FACILITY Meal Site CENTER MANAGER Carrie Stoney TELEPHONE NUMBER 882-1561 DAYS OPEN Monday through Friday (except Holidays) HOURS OF OEERATION_ 9 a.m. to 3 p.m. SERVICES AND Av1 AGE NUMBER OF PARTICIPANTS DAILY NUTRITION 65 TRANSPORTATION 5 ESCORT 1 LYFORMATION & REFERRAL 4 OUTREACH 4 LEGAL TELEPHONE REASSURANCE 3 RECREATTON Cha1u'.a bin• Nutrition (Specify type of) COUNSELING General (Specify type of) EDUCATION 0 9 19 (Specify type of) EMPLOYMENT (Specify type of) HEALTH Blood Pressure Cherke (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENI'UR DHR `R/NR SSA Other el OTHERS'. Zavala Meal Site Titles Paid/Volunteer STEP/CETA Name Part Time Full Time Bookkeeper Case Worker Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide .Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen Aide- Outreach Program Director Receptionist Secretary Telephone Reassurance ' • Other Older Worker Prograa Older Worker Prograa Paid Rosa De Leon Jesus Gutierrez Carrie Stoney Part Time Part Time Part Time (6 hours) NA CENTER Banquete Meal Site STREET LOCATION FM 666 DATE OPENED MAILING ADDRESS (If Different) (Nn Mailing AAArass) CITY, STATE, ZIP Banquete, Texas 78339 COUNTY AGENCY Nueces Senior Community Services TYPE OF FACILITY Meal Site (Satellite) CENTER MANAGER (Position vacant at present time) TE7,FPHONE NUMBER No Phone DAYS OPEN Monday.through Friday (Except Holidays) HOURS OF 0EERATION_ 12:00 noon to 1:00 p.m. SERVICES AND ANtaAGE NUMBER OF PARTICIPANTS DAILY NUTRITION 25 TRANSPORTATION ' ZS tis ' ESCORT INFORMATION & REFERRAL h4> OUTREACH 'oma LEGAL �4 TELEPHONE REASSURANCE RECREATION EDpecify UCATIONtype of) (Specify type of) COUNSELING • Pool,. cards, domtnoeq Health and Welfare Counseling (Specify type of) EMPLOYMENT (Specify type of) HEALTH (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENTER DHR MR/MR ec\ Other OTHER S_ Titles Paid/Volunteer STEP/:ETA .lame Part Time Full Time Bookkeeper Case Worker - Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman I & R Specialist Kitchen. Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance •Other Paid (Vacant) *Employee assists at Robst Center - Part Time (6 hours)* wn NA CENTER Bishop '60 Site STREET LOCATION 301 West Main DATE OPENED MAILING ADDRESS (If Different) CITY, STATE, zip Bishop, Texas 78343 COUNTY AGENCY Nueces Senior Community Services TYPE OF FACILITY Meal Site CENTER MANAGER Janie Dominguez TET.FPHONE :UMBER 584-3211 DAYS OPEN Monday through Friday (except Holidays) HOURS OF OBERATION 9:00 a.m. to 3:00 p.m. SERVICES AND AVERAGE NUMBER OF PARTICIPANTS DAILY NUTRITION 15 TRANSPORTATION ESCORT 20 3 INFORMATION & REFERRAL 2 OUTREACH 1 LEGAL 1 TELEPHONE REASSURANCE 1 RECREATTON 20 EDUCATIONtype of) 2 (Specify type of) 1 COUNSELING (Specify type of) EMPLOYMENT 0 (Specify type of) HEALTH 2 (Specify type of) OTHER OTHER AGENCIES PROVIDING SERVICES AT CENn A DER. Food Stamps - AFDC ME/MR CCA Every three months Other OTHER S_ Bishop Meal Site Titles Paid/Volunteer STEP/CETA Name Part Time , Full Time ' Bookkeeper Case Worker - Center Aide Center (Site) Manager Chore Worker Clerk/Typist Cook Aide Cook Community Service Custodian Dietician Driver Driver Assistant Escort Home Repairman t & R Specialist Kitchen Aide - Outreach Program Director Receptionist Secretary Telephone Reassurance '•Other aid Janie Dominguez Part Time (6 hours) NA CENTER Ytobstarn Senior Center STREET LOCATION 206 North Sixth Street DATE OPENED MAILING ADDRESS (If Different) CITY, STATE, ZIP Robstown, Texas 78380 COUNTY AGENCY Nueces Senior Community Services TYPE OF FACILITY Multipurnosp Senior Canter CENTER MANAGER Cora M. Upshaw TETT PHONE NUMBER 387-6396 DAYS OPEN HOURS OF OPERATION_ Monday through Friday (except Holidays) 8:00 a.m. — 5:00 p.m. SERVICES AND AVtatAGE NUMBER OF PARTICIPANTS DAILY NUTRITION 82 TRANSPORTATION 25 ESCORT INFORMATION & REFERRAL OUTREACH As needed LEGAL 4 TELEPHONE REASSURANCE 4 RECREATION Cards 11, Bingo 44, Pool 12, Dominoes 8 EDUecifyyCATIONtype of) (Specify type of) COUNSELING (Specify type of) FpLOYM NT Health and Welfare 6 (Specify type of) UFO= 14 Blood Pressure Screening (Specify type of) • OTHER Tax Aide OTHER AGENCIES PROVIDING SERVICES AT CENT*tt DER MH/MR SSA Other PROFILE ON OUTREACH, TRAINING AND COORDINATION REQUIREMENTS IN THE D.S.A. Profile, according to 61321.107, compliance for - 1. Outreach 2. Training 3. Coordination 1. Outreach.- All the meal site managers are trained to do outreach and home visits. Each manager attends to the home visits in the area surrounding his/her center or meal site. The managers, in doing gutreach, evaluate the situation, call in the appropriate service, and invite the person to the center or meal site. An Outreach Worker concentrates on those requests to visit the homebound or ill elderly. The Outreach Worker evaluates the situation and calls in the appropriate_ service. If home meals are needed the person is either placed on the homebound meal program or on a waiting list. 2. Training - Staff are given training as part of their staff meetings. They -- also attend any special training session sponsored by community agencies, which pertains to their area of specialization. The Outreach Worker receives ongoing specialized training in the techniques of behavior shaping. The Meal Site Managers are given inservice in management behavior objective setting; training in elderly and aging laws; conducting meetings and parlia- mentary procedures; gerontological concerns. Additional planned workshops: 1st Quarter - Operant Conditioning - techniques in positively handling the elderly in groups. 2nd Quarter - Reinforcement Schedule - how to handle specific problem seniors. 3td Quarter - Geriatric Psychiatry - a look at mental disorder affecting older people. 4th Quarter - Attitudes toward Death. 18-8 , J /� THE'PROFILE ON, THE OPPORTUNITY TO CONTRIBUTE IN THE DEFINED SERVICE AREA (Th Profile compliance with #1321.111 Participants contribute to the meal program at each center and meal site. Contributions are on a voluntary basis. A suggested contribution schedule is posted for the contributors benefit. The contributions allow the program to serve more than the required number of meals for which the program has contracted. Contributions are placed in unmarked envelopes and put into a locked money box. Daily deposits are made by the staff. Sample of suggested contribution schedule: Yearly Income Suggested Contribution $ 0 - $1,200 $ .10 $1,200 - $2,400 .20 $2,400 - $3,600 .30 $3,600 - $4,800 .45 $4,800 - $6,000 .60 $6,000 - $7,200 .80 $7,200 - $8,400 or more 1.10 B -`f • 1'HE PROFILE•ON PREFERENCE PRIORITIES IN THE DEFINED SERVICE AREA rofile the preference for older persons with greatest economic or social needs in compliance with #1321.109. Attached find graphs which demonstrate the socio-economic data on participants. ( Attachments) -/O NUICES BAY CONCENTRATIONS OF CERTIFIED PERSONS BY CENSUS TRACTS (Corpus Christi only) Shotflne PJ:!•!2., • "::XORPUS CHRIST/ BA Y - OM Primary Concentration of Certified Persons // Secondary Concentration of Certified Persons Data complied Aua Oben!" Mold 0 W.Idro,r7-›*4 . 1 , Average Age: J 68 years, 0 months - • Mali Gender -u Female 1 T. - - Spanish Anglo Ethnic Background • A Annual ,Mean Income 4' Per 1; Participant 1 $3,320.00 —17 —I - . . . ..- — . . 2. 2 . 'I r 4 -1-4 • , Annual Income in Thousand nrmumnr,,r nnAlltie ra 0 cIDr 0 -h ; ID rt- Alone Others Living Arrangement mr n - II English 4 Spanish Only Languages AUSTIN MEAL SITE Bi -Lingual Eng.+Span WS" .r Average Age: • _ 72 years, 11 months Male Gender Female 0 m 0 - h - ▪ 2 -s -o in -7 2 Span sh Anglo 7% -- Alone Others Ethnic Background Living Arrangement Annual Mean Income Per Participant - $2,783.33 1 • 7 q r 1I -4 1 IF Annual Income in Thousands iL -1 -1i41-1-1,r-- --A rnMoncrrr I PAP4IC % a- 0.. N 0 - w r) • English Only -- --- Spanish Only Bi -Lingual Eng.+Span. Languages BANQUETE MEAL SITE � Average Age: 72 yeur,,o months . '- Male Gender Female r - • 7�— 0 ~ Black Spanish Ang o A one . Others Ethnic Background Living Arrangement / [/ | Annual Mean Income Per Participant $2,055.55 11 r ^| r� �. |! . ' y : o • English Only Spanish On y Languages Annual Income in Thousands BISHOP MEAL SITE COMPOSITE GRAPHS 9 Bi -Lingual 9i • Average Age: 69 years, 10 months Male Gender Female • o% - Spanish Anglo Ethnic Background Living Arrangement Alone Others Annual Mean Income Per Participant $3,652.17 - ?"IIS . 4 I 7 -I- - - , ,. �-{- Annual Income in Thousands +7 COMPOSITE GRAPHS 10 _ 3 ma 0 v- 0 - I zr _r Languages FIRST LUTHERAN MEAL SITE Average Age: 69 years, 5 months Male Gender Female 9� ---- 4v4 B ack Spanish Oriental Anglo Ethnic Background =C Annual Mean Income . Per Participant $3,062.00 9' a l-1-1 { - f- 1 t- —F$- - 11 1 14 Annual —I - Annual Income in Thousands COMPOSITE GRAPHS 11 c 0 0 v -4 - 4 n a ✓ t. N Id Go 0 Alone Others Living Arrangement 1 Pt% { 1%i M VI m w cn m w —I 7 V 0-IOl0 c, W f01 O110 I• 7 —• 7 7 • r7. r I. i. r '< N. '< N• N 7 N -{- 7 Jo S 3 -0 l0 = 40 7 sv c Ni. c c0 7 0) W7 • —. - y Languages GREENWOOD CENTER 0 Average Age: _71 years 4 months 1 =t3_yx ale Female Gender -1- -s.1- COMPOSITE xt- ��=Hi-= F=:xa Spanish Anglo American Indian Ethnic Background Annual Mean Income Per Participant $4,209.64 0 0 m B■Cu■CC■C.Ciui ■0 ■ iii:i::i 0 Average Age: - - 72 years, 3 months • Male Gender L Female - - - - .171 ndian Black Spanish Anglo Ethnic Background Annual Mean Income Per Participant $2,101.77 f _L 1Z -. ' .��LL Annual Income in Thousands -1- COMPOSITE GRAPHS 13 Alone Others Living Arrangement _x_ English Only. 1 3 Spanish Only Lanugages ROBSTOWN CENTER Bi -Lingual Eng.+Spa¢ Average Age: • .' 68 years, 0 months so Male Gender Female • • Hz S. COo 7 - w n 0 ec• 7 r* 9 Ethnic Background Annual Mean Income Per Participant $2,587.50 Z=kJ it Annual Income in Thousands -- •ib COMPOSITE GRAPHS 14 Q• 1 0 7 i n v • Y$ Alone Others Living Arrangement English Bi -Lingual Only Eng.+Span. Languages WASHINGTON CENTER Quin - Lingual ' Average Age: 73 years, 1 month Male Female Gender • 3 2 6 Black Anglo Spanish Ethn'c Background Annual - Mean Income Per Participant $2,875.00 s ?i -r# .1 0 Annual Income in Thousands Alone Others Liv'ng Arrangement 69: CO to m CO V/ •w • % O170 0 W IC N 10 I' 7 7 7 --, r 7 -I I- N t< N N 7 N N 7 - S - SIO 7' 7-!O +a +a J (1 `II. - 1't_'L- 'rl _L0 -- COMPOSITE GRAPHS 15 Languages WAYSIDE MEAL SITE -S 0 w - = Average Age: 71 years, 8 months _7 • " - • 3 Male CD 0• 0 -S cytn 131 Female Indian Spanish Anglo Gender Ethnic Background • 11 - English Bi -Lingual Bi -Lingual Eng.+Span. English -E# ) Spanish •EELanguages 4 7 - - • - 14. ir -1 0 Annual Income in Thousands WOODLAWN MEAL SITE - Annual Mean Income Per • Part'cipant $3,253.09 a o- = o • --- - Alone Others Living Arrangement 7 12 7g. COMPOSITE GRAPHS 16 Average Age: 71 years, 4 monihs ' Male Gender Female ��� � American Spanish zox'an . Ethnic Background Annual Mean Income Per Participant $2,567.57 - • -• •^�/ •�� ^ |� � �� ' i|*��Annual Income in Thousands f fD� -5 0 � 131 cr ° -- _ COMPOSITE GRAPHS 17 A one Others Living Arrangements ' ~ MI CO CO 1 tO Languages ZAVALA MEAL SITE '7' ICI 14 CO r Average Age: _78 years, 0 months • 3 Male Gender Female 36 N 4 - 9 Sp Black Spanish Anglo Ethnic Background - s1 • Annual Mean Income Per Participant . $2,646.55 • ( - 1 7 -!-a r. Annual Income in Thousands COMPOSITE GRAPHS 18 Alone Others Living Arrangement ix English Spanish Only Only Languages OUTREACH COMPONENT (Home Delivered Meals) _AgriJK Bi -Lingual Eng.+Span. THE PROFILE. ON OTHER REQUIREMENTS IN THE DEFINED SERVICE AREA Profile compliance with - 1. Licensure and safety requirements, #1321.105. Art 2. Maintenance of non-federal support for services #1321.113. 3. Advisory role of older persons to service providers #1321.115. Senior Community Services complies with state and local safety and health require- ments. All facilities are inspected on a regular basis by safety and health offi- cials. The eity of Corpus Christi provides the local match for the program. The match requirement is 10%, the City has consistently overmatched in recent years. Senior Community Services has had an Advisory Council for several years. The Council is composed primarily of older persons. (See B-2 (4) for listing) The Council meets monthly at the Lindale Senior Canter, on the first Thursday, at 3:00 p.m. Proposals, budgets and policy changes are reviewed and recommended, or not recommended, for approval. Site Councils, composed of participants at the meal sites, are active at each of the centers and meal sites. Members provide input into the daily operation of their individual centers/meal sites. 8-1/ THE PLAN'OF OPERp.TION•FOR SERVICE DELIVERY OF CONGREGATE NUTRITION SERVICES ('-1 Profile the compliance with 111321.141, 145, 147 and indicade 1. Meals - (number, type, 5 days a week except) - list holidays. 2. Menu 3. Meals to be prepared. 4. Meals to be delivered. 5. Other specifics on Congregate Meals, food stamps etc. 1. Meals - The program is contracted to serve 718 meals daily. Congregate sites receive 617 meals, homebound recipients receive 101 meals. The meals are hot and balanced to provide one-third (1/3) of the minimum daily requirement of essential vitamins. The meals are served five (5) days a week, 52 weeks a year except for New Year's Day, Memorial Day, -Fourth of July, Labor Day, Thanskgiving Day and Christmas Day. Participants are advised that food stamps are accepted as contributions for the meal. All meals are prepared from a central kitchen and delivered by Transit vans to six (6) Corpus Christi centers. Robstown cooks its own meals from the auxiliary kitchen in Robstown, Texas. Meals•to Bishop Meal Site in Bishop, Texas, and Banquete Meal Site in Banquete, Texas, are catered. The Community Action Cor- poration of Soutb_Texas CCACOST) prepares meals for Banquete in Alice, Texas, and for Bishop in Kingsville, Texas. Attached are sample menus for one six week cycle. .4 (6 Attachments) 8 -12- MENU FOR JULY 28-31 and August 1, 1980 MONDAY Pork and Cabbage Casserole 1 - 6 oz scoop of Casserole Baked Beans in Tomato Sauce 1 - 4 oz scoop beans ' Whole Wheat Bread 1 - slice bread Margarine 1 - pat margarine Plums 2 - Plums Milk 1 - k pt milk TUESDAY Carne Guisada 1 - 6 oz scoop Carne Guisada Pinto Beans 1 - 4 oz scoop Beans Toss Salad 1 - 4 oz scoop salad Whole Wheat Bread 1 - slice bread Margarine 1 - pat margarine Applesauce 1 - 4 oz scoop applesauce Milk • 1 - '-q pt milk WEDNESDAY Chicken Fry Steak w/Creamed Gravy 1 - portion steak w/ 1 - 2 oz -scoop gravy Mashed Potatoes _ 1 - 4 oz scoop Potatoes ' Succatash 1 - 4 oz scoop Succatash Plain Roll 1 - plain roll Margarine 1 - pat margarine ' Pears w/Grated Cheese 1 - pear half w/ 2oz cheese Milk 1 - k pt milk THURSDAY ' Turkey Salad on Lettuce Leaf 1 - 4 oz scoop Turkey Salad on lettuce leaf Tomato Wedges 1 - 4 oz scoop tomatoes Spicy Peach Mold 1 - 4 oz scoop Peach mold Whole Wheat Bread - 1 - slice bread Margarine 1 - pat margarine Pineapple Oatmeal Dessert 1 - 4 oz scoop dessert Milk 1 - k pt milk FRIDAY Lasagna 1 - portion Lasagna Seasoned Green Beans 1 - 4 oz scoop Beans Toss Salad 1 - 4 oz scoop Salad French Bread 1 - slice bread Margarine 1 - pat margarine Mixed fruit w/coconut 1 = 4 oz scoop mixed fruit Milk 1 - k pt milk MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MENU FOR JULY 28-31 and August 1, 1980 MONDAY Pork and Cabbage Casserole Baked Beans in Tomato Sauce Whole Wheat Bread Margarine Plums Milk TUESDAY Carne Guisada Pinto Beans Toss Salad Whole Wheat Bread Margarine Applesauce Milk - WEDNESDAY Chicken Fry Steak w/Creamed Gravy Mashed Potatoes Succatash Plain Roll Margarine Pears w/Grated Cheese Milk THURSDAY Turkey Salad on Lettuce Leaf Tomato Wedges Spicy Peach Mold Whole Wheat Bread Margarine Pineapple Oatmeal Dessert Milk FRIDAY Lasagna Seasoned Green Beans Toss Salad French Bread Margarine Mixed fruit w/coconut Milk SPICES & INGREDIENTS MEAT: Fresh pork,cabbage,canned tomatoes, fresh bell peppers,garlic & cumin powder,pepper, flour,water. BEANS:Canned beans,onions, catsup,prepared mustard. FRUIT: Plums MEAT:Beef stew meat,comino,canned tomatoes, garlic powder,tomato paste,fresh bell peppers & onions,flour,black pepper. BEANS: Dry beans, bacon,water. SALAD: Lettuce,tomatoes,ready to serve dressing. APPLESAUCE: Canned apple sauce. MEAT:Beef cutlet,oil,flour. GRAVY:Flour,milk, margarine,chicken base,black pepper. POTATO: Instant potatoes,butter,black pepper. VEGETABLE: Frozen succatash. DESSERT:Canned pears,processed cheese. TURKEY:Turkey roll,cooked eggs,mayonnaise, celery,pimento,pickle relish. TOMATOES:Fresh tomatoes. PEACH MOLD:Canned peaches,cinnamon, orange gelatin,whole cloves,vinegar,water. DESSERT:Canned pineapple, sugar,cornstarch, vanilla,shortening,brown sugar,flour,rolled oats, baking soda. LASAGNA:Ground beef & pork, lasagna noodles, tomato paste,onions,garlic,oregano,black pepper, basil,mozzarella and parmessan cheese,cottage cheese,water. BEANS:Canned beans,bacon,butter. SALAD: Lettuce,carrots,tomatoes,ready to serve dressing. DESSERT:Pineapple,peaches,pears w/ coconut. MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MENUS for August 4th thru August 8th; 1980 MONDAY Burritos w/Chili 1 Spanish Rice 1 Lettuce & Tomatoes w/mayonnaise 1 Saltine crackers 1 Margarine 1 Pineapple -Lemon Dessert w/Fresh Cherriesl Milk 1 TUESDAY BBQ Chicken Potato Salad Pinto Beans Plain Roll Margarine Plum Milk WEDNESDAY Diced Pork Salad on Lettuce Leaf English Peas,Cheese &.Egg Salad Tomato Aspic Whole Wheat Bread Margarine Peanut Butter Chocolate Cake Milk THURSDAY Quiche Loraine (Baked Eggs w/Bacon) Broccoli Spears Mixed Vegetable Salad Saltine crackers Margarine Peach Shortcake Milk FRIDAY Hamburger on Bun Shoestring potatoes,. Hamburger salad ' Cabbage,carrot & Raisin Salad Vanilla Pudding w/Cherries Milk PORTIONS - Burrito w/ 1 - 2 oz ladle chili - 4 oz scoop Rice - 4 oz scoop Lettuce & Tomatoes - pkg crackers - pat margarine - 4 oz scoop dessert - ki pt milk 1 breast; or 1 short thigh; or 1 wing & 1 leg. 1 - 4 oz scoop Potato Salad 1 - 4 oz scoop Pinto Beans 1 - Roll 1 - pat margarine 2 - plums 1 - k pt milk 1 - 4 oz scoop Pork salad on 1 lettuce leaf 1 - 4 oz scoop Salad 1 - 4 oz scoop Tomato Aspic 1 - slice bread 1 - pat margarine 1 - portion cake 1 - pt milk 1 - portion Quiche Loraine 1 - 4 oz scoop Broccoli 1 - 4 oz scoop Salad 1 - pkg crackers 1 - pat margarine 1 - portion cake 1 - pt milk 1 - pattie meat on 1 bun to make hamburger 1 - 2 oz scoop shoestring potatoes, 1 lettuce leaf; 2 slices tomato;pickles & onions 1 - 4 oz scoop salad 1 - 4 oz scoop dessert 1 - k pt milk MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE ( MENUS for August 4th MONDAY Burritos w/Chili Spanish Rice Lettuce & Tomatoes w/mayonnaise Saltine crackers Margarine Pineapple -Lemon Dessert w/Fresh Milk TUESDAY BBQ Chicken Potato Salad Pinto Beans Plain Roll Margarine Plum Milk WEDNESDAY Diced Pork Salad on Lettuce Leaf English Peas,Cheese & Egg Salad Tomato Aspic Whole Wheat Bread Margarine Peanut Butter Chocolate Cake Milk thru August 8th, 1980 SPICES & INGREDIENTS Meat: Purchased burrito. Ground meat,chili powder, tomato paste,onions,garlic powder, flour, comino,paprika,black pepper,water. RICE:Rice,canned tomatoes,bell peppers, deyh onions,comino,garlic & chili powder.SALAD: Cherries Fresh lettuce & tomatoes. DESSERT: Pineapple, pistachio pudding,marshmellows,whipped topping. THURSDAY Quiche Loraine (Baked Eggs w/Bacon) Broccoli Spears Mixed Vegetable Salad Saltine crackers Margarine Peach Shortcake Milk • FRIDAY Hamburger on Bun Shoestring potatoes,catsup,mustard & Salad Dressing Cabbage,carrot & Raisin Salad Vanilla Pudding w/Cherries Milk CHICKEN:Fresh fryers,BBQ sauce. POTATO SALAD: Instant potato,boiled eggs,pimentos,celery, pickle relish,may:,nn,ise,mustard. BEANS:Dry beans,bacon,water. FRUIT: Fresh plum Pork Salad: Canned pork,celery,cook eggs, olives with pimentos,onions,lemon juice, lettuce, black pepper. SALAD: Canned peas,cheddar cheese,boiled eggs,black pepper,may:.nn ise.' TOMATO ASPIC:Tomato sauce,lemon gelatin, vinegar,onion,tabasco sauce,cloves,celery, water,mayonnaise. CAKE:Flour,sugar,coco, dry milk,baking powder,baking soda, shortening, eggs,vanilla,peanut butter,salt,water. Quiche Loraine: Eggs,bacon bits,canned milk, cheese,pie crust. VEG:Frozen broccoli.SALAD: Canned.mixed vegetables,mayonneise. CRACKERS: Purchased crackers. CAKE: Flour,sugar,eggs, dry milk,shortening,baking powder,salt,vanilla, water, canned peaches. HAMBURGER: Meat pattie,purchased bun, lettuce, mustard,tomato,pickles & onions, cateup, Purchased shoestring potatoes. SALAD: Cabbage, carrots,raisins,lemon juice,mayonneise. DESSERT: Canned pudding with c':erries. MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MONDAY MENUS FOR AUGUST llth thru 15th, 1980 PORTIONS Spagetti w/Meat Sauce 1 - 4 oz scoop spagetti Green Beans 1 - 6 oz scoop Meat Sauce Lettuce Wedge w/1000 Island Dressing 1 - 4 oz scoop Green Beans French Bread 1 - slice bread Margarine 1 - pat margarine Pears w/Grated Cheese 1 - 4 oz scoop dessert Milk 1 - k pt milk 1 - 4 oz lettuce w/dressing TUESDAY Liver and Onions /Gravy 1 - portion liver with onions/gravy Blackeyed Peas [[�� • 1 - 4 oz scoop peas • Yellow Hominy/�C 1 - 4 oz scoop hominy Whole Wheat Bread 1 - slice bread , Margarine 1 - pat margarine Red Jello w/Peaches 1 -4 oz scoop dessert Milk 1 - pt milk WEDNESDAY King Ranch Chicken 1 - 6 oz scoop chicken Zucchini Squash 1 - 4 oz scoop squash Whole Wheat Bread 1 - slice bread Margarine 1 - pat margarine Cantaloupe 1 - portion cantaloupe Milk 1 - kZ pt milk THURSDAY Tuna Cakes Lima Beans Carrots in Mustard Sauce Crackers Margarine Prune -Pineapple Dessert Milk FRIDAY . Creole Turkey Gumbo Buttered Corn Whole Wheat Bread Margarine Rosy Applesauce Milk 2 - Tuna Cakes 1 - 4 oz scoop beans 1 - 4 oz scoop carrots 1 - pkg crackers 1 - pat margarine 1 - 4 oz scoop dessert 1 - k pt milk 1 - 6 oz scoop gumbo 1 - 4 oz scoop corn 1 - slice bread 1 - pat margarine 1 - 4 oz scoop applesauce 1 - z pt milk MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MENUS FOR AUGUST llth thru 15th, 1980 • _4JNDAY Spagetti w/Meat Sauce Green Beans Lettuce Wedge w/1000 Island Dressing French Bread Margarine Pears w/Grated Cheese Milk TUESDAY Liver and Onions/Gravy Blackeyed Peas Yellow Hominoy Whole Wheat Bread Margarine Red Jello w/Peaches Milk WEDNESDAY King Ranch Chicken Zucchini Squash Whole Wheat Bread Margarine Cantaloupe I4ilk THURSDAY Tuna Cakes Lima Beans Carrots in Mustard Sauce Crackers Margarine Prune -Pineapple Dessert Milk FRIDAY Creole Turkey Gumbo Buttered Corn Whole Wheat Bread Margarine Rosy Applesauce Milk SPICES & INGREDIENTS Spaghetti & Sauce: Ground beef, deyh celery, onions,bell pepper,chili powder, garlic powder, comino,canned tomatoes,tomato paste,cheese, regular spagetti,margarine. GREEN BEANS:Canned beans,bacon,onions. Salad:Lettuce with ready to serve dressing. Dessert:Canned pears,cheddar cheese. MEAT: Beef liver,flour,oil & pepper,onions. Gravy:Beef base,onions,flour,butter,gravy color,black pepper. PEAS:Canned blackeyed peas, bacon,pepper. HOMINOY:Canned hominoy,butter, pepper. DESSERT:Strawberry jello,canned peaches. CHICKEN: Canned chicken,tortillas,cheese, mushroom suoup,onions,canned tomatoes, jalapeno peppers. SQUASH: Zucchini,onions, butter,pepper. FRUIT: Cantaloupe. TUNA CAKES: Tuna fish,onions,eggs,catsup, shortening,mashed potatoes,dry bread crumbs. BEANS: Canned Limas,bacon,onion;pepper.CARROTS:' Canned carrots,prepared mustard,brown sugar, butter. DESSERT:Canned prunes & pineapple, marshmellows,whipped topping. GUMBO:Turkey roll,frozen okra,dehyd onions, garlic powder,dehy green pepper & celery,flour, butter,black pepper,parsley. CORN.Canned corn, butter,pepper. APPLESAUCE:Canned applesauce, strawberry gelatin,water. MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MONDAY MENUS FOR AUGUST 18th thru 22nd, 1980 PORTIONS 'Swiss- Steak w/Onions & Gravy 1 - Portion Beef Cutlet Scalloped Potatoes 1 - 4 oz scoop potatoes Okra and Tomatoes 1 - 4 oz scoop Okra and Tomatoes Whole Wheat Bread 1 - slice bread Margarine 1 - pat margarine Pears 2 - Pear Halves or 1 - 4 oz scoop Diced Milk 1 - 1 pt milk TUESDAY Beef Open Face Sandwich 1 - 4 oz scoop meat on 1 piece bread Seasoned Green Beans 1 - 4 oz scoop beans Cucumber & Onion Salad w/Tomatoes 1 - 4 oz scoop Cucumbers and onions Margarine 1 - pat margarine Peach Cobbler 1 - 4 oz scoop cobbler Milk 1 - 1 pt milk WEDNESDAY Carne Guisada Pinto Beans Toss Salad Saltines Margarine Pineapple Upside Down Cake Milk THURSDAY Oven Fried Chicken Mashed Potatoes Vegetable Medley Plain Roll Margarine Fruit in Season Milk ' FRIDAY BBQ Pork on Bun Baked Beans Cabbage -carrot slaw, Vinegar Dressing Jellied Applesauce w/Topping Milk 1 - 6 oz scoop meat 1 - 4 oz scoop beans 1 - 4 oz scoop salad 1 - pkd crackers 1 - pat margarine 1 - portion cake 1 - 1 pt milk 1 breast; or 1 thigh; or 1 wing & 1 leg. 1 - 4 oz scoop potatoes 1 - 4 oz scoop vegetable medley 1 - roll 1 - pat margarine 1 - fresh fruit 1-1ptmilk 1 - 4 oz scoop meat on bun.' 1 - 4 oz scoop beans 1 - 4 oz scoop salad 1 - 4 oz scoop dessert 1 -1 pt milk MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MONDAY MENUS FOR AUGUST 18th thru 22nd, 1980 SPICES & INGREDIENTS SWISS: Steak /Onions & Gravy Scalloped Potatoes Okra and Tomatoes Whole Wheat Bread Margarine Pears Milk TUESDAY Beef cutlet,flour,oil,water,onions,pepper. Gravy: Beef base,onions,flour,butter,black pepper,gravy color. POTATOES: Fresh potatoes, butter,flour,milk,onion.OKRA & TOMATOES: Frozen okra,canned tomatoes,onions,garlic, black pepper, DESSERT: Canned pears. Beef Open Face Sandwich - - BEEF SANDWICH: Canned beef,gravey,bread. Seasoned Green Beans Beef base,onions,flour,butter,black pepper. Cucumber & Onion Salad w/Tomatoes BEANS: Canned beans,bacon,pepper,butter. Margarine SALAD: Cucumbers,onions,tomatoes,vinegar. Peach Cobbler pepper. DESSERT: Canned peaches,sugar,salt, Milk cornstarch,lemon juice,oatmeal,butter, cinnamon. WEDNESDAY Carne Guisada MEAT: Beef stew meat, comino,canned tomatoes, Pinto Beans garlic powder, tomato paste, fresh bell peppers Toss Salad onions, flour,black pepper. BEANS:Dry beans, Saltines onions,bacon,water. SALAD:Lettuce,tomatoes, Margarine carrots,ready to serve dressing. CAKE:Canned Pineapple Upside Down Cake pineapple,flour,butter,dry milk,shortening, Milk eggs,vanilla,baking powder,brown sugar,salt. THURSDAY Oven Fried Chicken Mashed Potatoes Vegetable Medley Plain Roll Margarine Fruit in Season Milk • FRIDAY BBQ Pork on Bun Baked Beans Cabbage -carrot slaw, Vinegar Dressing Jellied Applesauce w/Topping Milk CHICKEN: Fresh chicken,flour,cornmeal, black pepper, oregano. POTATOES:Instant potatoes,milk,butter,black pepper.Vegetable Medley: Frozen peas, carrots,cauliflowe'r & asparagus, butter,cornstarch. DESSERT:Fruit in season BBQ Pork on Bun: Canned pork, BBQ sauce, purchased bun. BEANS:Canned beans,catsup, prepared mustard,onions. SALAD:Cabbage, carrots,pepper,vinegar and sugar. DESSERT: Canned applesauceGelatin,applesauce,celery, ,pineapple tidbits, dry topping,water. MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MONDAY f MENUS FOR AUGUST 25th thru AUG 29, 1980 PORT IONS 2 - slices bread & 1-4 oz scoop chicken 1 - 4 oz scoop potato salad 1 - 4 oz scoop salad 1 - 4 oz cup tomato juice 1 - 4 oz scoop peaches 1 - k pt milk Chicken Salad Sandwich Potato Salad Cabbage -Carrot -Raisin Salad Tomato Juice Canned Peaches Milk TUESDAY Calabasa con Puero 2 - 4 oz scoop calabasa con puero Pinto Beans 1 - 4 oz scoop beans Lettuce Salad/Italian Dressing 1 - 4 oz scoop salad Cornbread 1 - portion cornbread Margarine 1 - pat margarine Fresh Pear 1 - Pear Milk 1 - k pt milk WEDNESDAY Polish Sausage 1 - Sausage Blackeyed Peas 1 - 4 oz scoop blackeyed peas Cabbage Salad 1 - 4 oz scoop salad Whole Wheat Bread 1 - slice bread Margarine 1 - pat margarine Rosy Applesauce 1 - 4 oz scoop applesauce Milk 1 - k pt milk THURSDAY Roast Turkey w/Gravy Orange Sweet Potatoes Corn & Green Beans Whole Wheat Bread Margarine Cranberry Crunch Milk FRIDAY Beef Strogonoff Egg Noodles Seasoned Broccoli French Bread Margarine Tapioca Pudding Milk 1 - slice turkey & 2 oz ladle gravy 1 - 4 oz scoop sweet potatoes 1 - 4 oz scoop corn &'green beans 1 - slice bread 1 - pat margarine 1 -portion 1 - 'k pt milk 1 - 8 oz scoop beef strogonoff over 4 oz noodles 1 - 4 oz scoop broccoli 1 - slice bread 1 - pat margarine 1 - 4 oz scoop pudding 1 - i pt milk MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MENUS MONDAY (- • FOR AUGUST 25th Chicken Salad Sandwich Potato Salad Cabbage -Carrot -Raisin Salad Tomato Juice Canned Peaches Milk TUESDAY Calabasa con Puerco Pinto Beans Lettuce Salad/Italian Dressing Cornbread Margarine Fresh Pear Milk WEDNESDAY Polish Sausage Blackeyed Peas Cabbage Salad Whole Wheat Bread Margarine Rosy Applesauce Milk THURSDAY Roast Turkey w/Gravy Orange Sweet Potatoes Corn & Green Beans Whole Wheat Bread Margarine Cranberry Crunch Milk FRIDAY ' Beef Strogonoff Egg'Noodles Seasoned Broccoli French Bread Margarine Tapioca Pudding Milk thru AUG 29, 1980 SPICES & INGREDIENTS SANDWICH:Canned chicken,celery,cooked eggs, pickle relish,mayonnaise,pimentos,black pepper. POTATO SALAD: Instant potatoes,boiled eggs, pimentos,pickle relish,mayonnaise,celery, mustard. SALAD:Cabbage,carrots,raisins,lemon juice, mayonnaise. DESSERT:Canned peaches. JUICE:Canned tomato juice. MEAT:Mexican squash,canned pork,corn,onions, tomatoes, bell pepper,black pepper. BEANS: Dry pintos,bacon,onion. SALAD:Lettuce w/ready to serve dressing. CORNBREAD:Cornmeai,flour, milk,eggs,butter,baking powder,shortening. DESSERT:Fresh Pear. SAUSAGE: Sausage,BBQ Sauce. PEAS:Canned blackeyes bacon,black pepper. SALAD:Cabbage,fresh green onions & tomatoes,mayonnaise,mustard,vinegar, sugar,salt pork. DESSERT:Canned applesauce, strawberry gelatin,water. TURKEY & GRAVY: Turkey rolls, Gizzards & livers, boiled eggs,chicken stock & base food coloring, flour,water. POTATOES: Canned sweet potatoes, canned orange juice,cornstarch,sugar,brown sugar, butter. VEGETABLE:Canned corn & green beans, butter,pepper. DESSERT: Canned cranberries, rolled oats, dry milk,flour,light brown sugar, butter, cinnamon, salt. MEAT:Canned beef, canned tomatoes,dehyd celery & onions,worchestershire sauce, bay leaf, flour, mushrooms & liquid + water,Sour cream. NOODLES: Purchased egg noodles. BROCCOLI:Frozen broccoli, butter,pepper. DESSERT: Ready to serve Tapioca. MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD 1•MEALS ARE NOT TOTALLY SALT.FREE MENUS FOR SEP 1st thru 5th,,1980 MONDAY r PORTIONS HOLIDAY CLOSED FOR LABOR DAY TUESDAY Ham w Raisin Sauce 1 - Slice Ham with 1 - 2 oz ladle sauce Sweet Potatoes 1 - 4 oz scoop Sweet Potatoes Buttered Cauliflower 1 - 4 oz scoop Cauliflower Wheat Bread 1 - slice bread Margarine 1 - pat margarine Pineapple Tidbits 1 - 4 oz scoop pineapple Milk 1 - '%L pt milk 'WEDNESDAY Sliced Turkey,Salami,Cheese 1 slice each of turkey,salami and cheese Mustard '1 pk mustard Perfection Salad on Lettuce 1 - 4 oz scoop salad on lettuce leaf Wheat Bread 1 - slice bread Margarine 1 - pat margarine Tropical Apples 1 - 4 oz scoop tropical apples Milk 1 - pt milk THURSDAY Beef Paprika Seasoned Corn Seasoned Okra Whole Wheat Bread Margarine Peanut Butter Balls Milk FRIDAY 1 - 6 oz scoop meat 1 - 4 oz scoop corn 1 c 4 oz scoop okra 1.- slice bread 1 - pat margarine 1 - Peanut Butter ball 1 - kZ pt Milk Chicken & Corn Casserole 1 - 4 oz scoop casserole Seasoned Collard Greens, 1 - 4 oz scoop greens B1Dekeyed Peas 1 - 4 oz scoop peas Biscuit 1 - biscuit Margarine 1 - pat margarine Peaches 1 - 4 oz scoop peaches Milk 1 - 3Z pt milk MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE MENUS FOR SEP 1st thru 5th, 1980 MONDAY HOLIDAY TUESDAY Ham w Raisin Sauce Sweet Potatoes Buttered Cauliflower Wheat Bread Margarine Pineapple Tidbits Milk WEDNESDAY Sliced Turkey,Salami,Cheese Mustard Perfection Salad on Lettuce Wheat Bread Margarine - Tropical Apples Milk THURSDAY Beef Paprika Seasoned Corn Seasoned Okra Whole Wheat Bread Margarine Peanut Butter Balls Milk FRIDAY Chicken & Corn Casserole Seasoned Collard Greens Blackeyed Peas Biscuit Margarine Peaches Milk SPICES & INGREDIENTS CLOSED FOR LABOR DAY HAM & SAUCE:Baked ham; Raisins,cornstarch, sugar. Potato:Canned sweetpotato,butter. Cauliflower: Frozen cauliflower,butter. Dessert:Canned pineapples. COLD CUTS: Turkey roll,salami,cheese. Purchased mustard.SALAD: Lime gelatin,water, vinegar,lemon juice,satt,sugar, fresh cabbage, celery,& green peppers,pimintos and paprika. DESSERT: Canned sliced apples,sugar,flour, butter,orange juice,yellow food coloring. BEEF PAPRIKA:Canned beef,fresh onion,garlic, catsup, worchestershire sauce,brown sugar, dry mustard,paprika,cayene pepper,water,noodles, flour. CORN: Canned corn,butter,pepper. OKRA: Frozen okra;butter. DESSERT: Peanut butter, peanut granules,sugar,flour,butter,milk,salt, coconut,oatmeal,vanilla. MEAT:Canned chicken,canned corn,cheese,butter, pimientos,flour,salt & pepper,minced onions, GREENS: Canned collards,bacon. PEAS: Canned blackeyed peas,bacon,pepper. BISCUIT:Flour, dry milk,shortening,baking powder,salt. DESSERT: Canned peaches. MENUS ARE SUBJECT TO CHANGE DEPENDING ON AVAILABILITY OF FOOD MEALS ARE NOT TOTALLY SALT FREE 9E PLAN OF OPERATION FOR SERVICE DELIVERY OF OCNGREGATE NUTRITION SERVICES Explain how you will comply with 1,11321.144(a) "The Area Agency on Aging may award nutrition services funds received under this part to provide meals and other nutrition services." 1. Outreach 2. Nutrition Education 3. Assessment of needs Outreach - Covered in Part 1 , Page B-8 Nutrition Education - The staff nutritionist is responsible for development of a Nutrition Education Program. Each month a nutrition education program is pre- sented at a center or meal site. In the next year she will be developing a weight watchers program at specific centers. Assessment of Needs - An apprppriate sampling of participants will be involved in a survey to ascertain the adequacy of their nutritional intake. The results of the survey will be incorporated in the nutritionist's planning and for the participants' nutrition education program. a -/3 ._Tr AN OE. OPERATION'FOR SERVICE DELIVERY OF HOME DELIVERED NUTRITION SERVICES C-2 .11 Ex plain,according to #1321.141 (b) 2, and 1421.145(b), your plan of opera- tion for home delivered meals. 1. The assessment of needs. 2. The criteria for priorities and preference. 3. The manner of delivery, etc. 4. The arrangement for service in weather related emergencies. 5. Other specifics on Home Delivered Meals. The assessment of needs is done by a specially trained Outreach Worker. The primary source of information concerning the needs of the applicant is the applicant himself. This is done by asking the applicant to state his/her needs in his/her own words. The resulting data is placed in the "Presenting Problem" of the Senior Community Services Need Evaluation Form. If the needs stated are found to be appropriate and the applicant's environment is "one - of -need" (no family to come and help, no spouse to help with cooking, etc.), then the criteria for priorities and preference are utilized. In an effort to objectify and make consistent the use of a needs assessment tool, three -categories of impairment and 13 to 17 questions within each category were created. Each of the 44 questions is rated from 1 (no impairment) to 4 (total impairment). Therefore, each applicant will have a needs evaluation score of anywhere between 44 to 176. The scores are ranked and those with top priority and preference are then placed on home delivery meal routes. The assessments and priorities control are done on the attached form (see "Directions for Home Delivery Need Evaluation Form" and "Home Delivery Need Evaluation Form"). 3 The meals are delivered by City Transit, with the Nutrition Program assuming the cost of the delivery. 4. During weather related emergencies, homebound recipients will be evacuated . & from their homes if necessary. Shelters equipped to handle the elderly, 5. handicapped or ill usually provide meals to the people at the shelter. In extremely bad weather, i.e., hurricanes, meals are not delivered until the weather has improved. (2 Attachments) DIRECTIONS FOR HOME DELIVERY NEED EVALUATION FORM General Points 1) Interview to be in an informal conversational style. 2) Family members shouldnot be allowed to answer for participants. 3) Reduce the opinion variables to the most minimal point possible. The three categories of impairment are taken directly from paragraph 2.a.iii. of the eligibility guidelines. I. Physical Impairment.' ' 1. Hospitalization or Extended Care Facility. Rationale: If physical health is problematic enough that hospitalization is periodically required, then we consider it a physical impairment. 2. Eyesight. Rationale: The lack of visual ability creates many secon- dary problems for participants. a. Can you read a newspaper, your Bible, other books? b. Do you watch T.V.? c. Do you know your corrected vision strength? d. Do your glasses help you? 3. Hearing. Rationale: The lack of auditory abilities creates primary and secondary problems for participants. a. Do you wear a hearing aid? b. Can you hear me all right? c. Do you listen to radio, phonograph? 4. Speech: Rationale: 'The loss of speech because of a disorder (such as a stroke) can create intense secondary problems. Caution: Interviewer must be aware of cultural and dialectic pattern differences which are generally not considered as a speech impediment. 5. Illness. (In this case illness can be defined as a handicap) Rationale: The loss of mobility, dexterity, or a particular skill is considered an impairment. a. Does your illness interfere with your daily acitivites? 6. Medicines. a. Do you know what your medicines are for? ' b. Have you ever taken too much by accident? c. Are you able to open the containers? d. Do you find the timing confusing? 7. Exercise. Rationale: The loss of the ability for intentional exer- cise is perceived as an impairment for a participant. a. Do you now, or have you ever had an exercise period? b. Has anything (physical) interferred with your exercising? ATTAcHMENT +. 8. Walking. (Mobility in the home, walking to stores, etc.) a. Do you use a cane or walker? b. Can you climb steps or stairs? c. Do you use a wheelchair? d. Can you walk to the store or shops? 9. Health. Rationale: It is believed that the participants are able to reflect their own general physical status. a. Do you rate your own physical status as: 1) Good, 2) Fair, 3) Poor, 4) Very poor? 10. Loss of Leg(s). 11. Loss of Arms(s). 12. Loss of Foot/Feet. 13. Loss of Eye(s). 10, 11, 12 and 13 can be asked at the same time. Loss includes either the actual'physicalldss or the'lOts"of use of the particular appendage(s). II. Social Impairments. General Rationale: These items are meant to determine an individual's ability and opportunity to interact with others on a social plane. 14. Phone: a. Do you have a phone? b. How often do you use the phone? c. Do you have any problems with people on the phone? 15. Money. Rationale: Utilizing our currency base is seen as an impor- tant social skill. a. Do you pay your own bills? (Possible abuse of a participant's financial resources by other persons can be checked here.) b. Do you have any particular troubles with checks, checking accounts, money handling (making change, etc.)? 16. Bathing. Rationale: The success of social intercourse can be de pendent on cleanliness and the lack of intense body odor. a. Do you have bathing facilities? b. Are you able to utilize the bathing facilities? 17. Grooming. a. Do you have any particular problems caring for your hair? (Washing, shaving, haircuts, cleaning your teeth, etc.) 18. Clothing. a. Are you able to buy and repair your own clothing? b. Do you have problems with dry cleaning or washing your clothes? • 19. Home Tasks. a. Do you have any particular problems with household tasks? 20. Conversation. Will be rated by interviewer during needs assessment meetings. The standards will be the interviewer's own experiences concern- ing average conversational ability. 21. Transportation. a. Do you have and use your own transportation? b. Do you have any particular problems with transportation? 22. Family Activities. Does the family live close? 23. Housing Conditions. Interviewer's own observation, be specific -- no opinions. 24. Outside Activities. Non -family, non -group. 25. Regular Visits, Internal: Those visits received from outside. 26. Regular Visits, External. Those visits made to others. 27. Group memberships. . Clubs or organizations 4=0, 3=1, 2=2, 1=3 III.Mental Impairments. General Rationale: The staff is aware of the role of emotional support in the prevention of mental disorder through the reinforcement of per- ceived self-esteem and reduction of anxiety and hostility. The outreach worker will be active in the secondary prevention of mental disorder only in the form of recognition and referral. Any form of secondary treatment is strictly forbidden. The outreach worker will also be con- cerned with primary and tertiary prevention. Primary - Education, consultation and counseling of community leaders such as legislators, social agency workers, ministers, etc. Secondary - Therapeutic treatment. Tertiary'- Community -wide effort aimed at reducing the rate of defective functioning induced by mental disorder. • 28. Affect. Appropriate affect can be defined as reasonable level of facial and gesticular intensity. a. Flat affect - no smiles, no frowns, no matter what. A mono- tone voice: Generally no gesticulation. b. Inappropriate affect - expressions of joy when you normally should be sad. 29. Modd Swing. a. The rapid periodical changes in emotional content. b. Rapid changes in intense emotions. c. Moods that are inappropriate for thought content. 30. Hostility. Overt verbal or physical acts of aggression. a. b. c. Threatening gestures. Non -elicited verbal abuse. Actual physical striking. 31. Anxiety. Free floating - intens4 long-lasting, subjective feelings of discomfort. a. b. Are you nervous for long periods of time? Does your nervousness interfere with your daily activities? (Note: Other than coming to the center.) 32. Grandiose - Inappropriate statements of power'and importance. 33. Erotic. Stated ideas of sexual molestation, physical sexual acting out or general preoccupation with sexual -activity. - (Caution: Many _- times this may actually be true.) a. Extreme statements: "All the men in the neighborhood. . " b. Overt sexual gestures to the interviewer. 34. Paranoid. Stated persecutory thoughts which seem not to be affected by experiential logic. (Caution: Many times may actually be the case.) 35. Memory. Loss of the ability to retain information in the long-term memory. a. What did you do last Christmas? b. Repeat four' digits backwards. 36. Fears: Exaggerated and/or specific fears focused on one particular entity or obstruction. 37. Orientation. The ability to understand and to verbalize person, place, and time. a. What is your name? b. What year is this? 38. Blocked Thinking. Suddenly interrupted thought as evidenced through verbalization. I must tell you, I . . ." Unable to continue without difficulty. 39. Logorrhea. Excessive, endless, trivial talk. 40. Despondent. Impoverished thought and inadequate intensity. a. Crying. b. Statement of severe disappointment. c. Inappropriate or flat expression of anger. 41. Sleep: Manifested insomnia. a. Have you been sleeping soundly? 42. Crisis: Severe situational disorder in participant's environment. 43. Concentration. The lack of ability to maintain attention. 44. Obsession. Recurrent thoughts that involuntarily intrude upon thought. We will also include compulsive behavior in this category. a. Ritualistic behavior. b. Inappropriate, repetitive acts. ' HOME DELIVERY NEED EVALUATION FORM Date of evaluation or reevaluation Ilst 2nd 3rd 4th 5th 6th 17th 7 Name of Participant (Last, First, Middle) (Date of Birth AddreeG Phone No. Center Number: Directions to Home: Presenting Problem (Briefly describe the circumstances that brought the seniors case to the attention of S.C.S.) - Source of Referral • - Source of Interview Data Name of Senior's Physician 1 Phone No. Name of Guardian or Managing Conservator Phone No. Name of Person to be notified in case of emergency -Phone No. Medications Purpose of Medications Dosage 1 FrrrAsi-tMeur fin —PrgE 13 i f Unless otherwise noted: •+ No impairment or self-sufficient Slight impairment o; some. assistance. . Severe impairment or much assistance needed Total impairment or completely dependent I. Physical Impairments 1. No. of days requiring Dat hospitalization in Evalua of past six months. (1=0, 2=3, 3=10, 4=11+) 2. Eyesight - with aid 3. Hearing - with aid 4. Speech ---- 5. Does illness interfere with normal activities 6. Assistance required in taking medication 7. Regular exercise 8. Walking 9. Rates own health 10. Loss of leg(s) 11. Loss of arm(s) 13. Loss of eye(s) il-.- •RRRRUR 1111111111111111111111111111mmunina C 1111111111111111111 1111111111111111111111111. 12. Loss of foot/or feet 111111111111111111111111 II. Social Impairments 14. Use of phone 15. Handle money 16. Bathing --- 17. Grooming 18. Clothing 19. Home tasks 20. Conversation — 21. Transportation ---------- 22. Family activities — 23. Housing condition ------- 24. Outside activities — 25. Regular visits internal -- 26. Regular visits external --- 27. Group memberships III. Mental Impairments 28. Affect 29. Mood swing 30. Hostility 31. Anxiety 32. Grandiose 33. Erotic 34. Paranoid 35. Memory — 36. Fears 37. Orientation 38. Blocked thinking 39. Logorrhea 40. Despondent 41. Sleep 42. Crisis 43. Concentration 44. Obsessive Pertinent criteria: • Additional data: