COVID-19 Survey

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* 1. Is/are your program(s) residential, outpatient, or both?

Residential

Outpatient

Both

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* 2. Please indicate what type of payments your organization accepts:

Cash payments

Drug Medi-Cal ODS (Waiver)

Drug Medi-Cal (Non Waiver)

Private Pay

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* 3. For residential, indicate how many beds you currently have (maximum capacity under normal circumstances)

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* 4. For outpatient, what is the maximum number of clients you can serve under normal circumstances?

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* 5. Has the COVID-19 virus reduced your capacity?

No

Yes - but less than 10%

Yes - but less than 25%

Yes - but less than 50%

Yes - by more than 50%

Yes- by more than 75%

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* 6. Have there been changes to your staff due to the virus?

No

Yes - I have lost some staff but am able to provide all services

Yes - I have lost significant staff making it not possible to provide all necessary services

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* 7. Has the virus impacted the financial health of your organization?

No

Slightly

Dramatically

If there is no assistance I will need to discontinue operations.

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* 8. Please estimate, in dollars, what losses your organization stands to incur if the emergency, shelter in place, order stays in effect for 90 days:

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* 9. If you have furloughed or laid off employees, please indicate the number of employees released:

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* 10. Are you currently accepting new clients?

Yes

No

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* 11. If you are accepting new clients, please describe your efforts to prevent new clients from transmitting the virus:

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* 12. Should a client test positive for COVID-19, do you presently have personal protective devices (gowns, masks, gloves) to protect staff members from contracting the disease?

Yes

No

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* 13. CCAPP is working around the clock to address the needs of our programs and the clients you serve. Are there any needs you wish to communicate to us so that we can put them before the appropriate state government officials: