91119-ORCF Schedule of Facilities Owned, Operated or Managed

Schedule of Facilities Owned, Operated or Managed Section 232

U.S. Department of Housing and Urban Development Office of Residential Care Facilities

OMB Approval No. 9999-9999 (exp. mm/dd/yyyy)

Public reporting burden for this collection of information is estimated to average 1.5 hours. This includes the time for collecting, reviewing, and reporting the data. The information is being collected to obtain the supportive documentation which must be submitted to HUD for approval, and is necessary to ensure that viable projects are developed and maintained. The Department will use this information to determine if properties meet HUD requirements with respect to development, operation and/or asset management, as well as ensuring the continued marketability of the properties. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. 

Warning: Any person who knowingly presents a false, fictitious, or fraudulent statement or claim in a matter within the jurisdiction of the U.S. Department of Housing and Urban Development is subject to criminal penalties, civil liability, and administrative sanctions. 

Project Name: FHA Project Number:	Entity Name FHA Project Number
Facility (name, address)	Other Information	Roles	Facility Type
Name of Facility Address Line 1 Address Line 2 Beds:      	Open judgments or legal actions2 Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findings3Error: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing
                  Beds:      	Open judgments or legal actionsError: Reference source not found Bankruptcy claimsError: Reference source not found Open professional liability insurance claimsError: Reference source not found Open State findingsError: Reference source not foundError: Reference source not found	Owner Operator Mgmt Agent License Holder	Independent Board & Care Assisted Living Skilled Nursing

Additional pages attached. Initial: ______

2 If checked, attach a detailed explanation on a separate sheet.

3 Only check if there are open instances of actual harm and/or immediate jeopardy (G or higher for skilled nursing)

Previous versions obsolete Page 3 of 3 form HUD-91119-ORCF (mm/dd/yyyy)