Resident/Guardian/Family Member Survey – Valley Residential Services

Resident/Guardian/Family Member Survey

Valley Residential Services is committed to providing the best services possible for the people we serve. Thank you in advance for your time!

Home(Required)

Resident Initials(Required)

Please fill in the home and the initials (no full names) of the resident you are completing the survey for. If you are guardian for multiple residents, a new survey should be completed for each individual.

1. Overall satisfaction with placement and provider agency (Valley Residential)(Required)

Please explain why you chose this rating(Required)

2. Satisfaction with Person-Centered Plan(Required)

Please explain why you chose this rating(Required)

3. Home staff knowledge of individual resident needs/likes/hopes/desires(Required)

Please explain why you chose this rating(Required)

4 . Physical appearance of the residents (neat, clean, appropriately dressed)(Required)

Please explain why you chose this rating(Required)

5. I am adequately informed regarding care (health issues, programs, etc.)(Required)

Please explain why you chose this rating(Required)

6. I feel comfortable making suggestions or requests to home staff(Required)

Please explain why you chose this rating(Required)

7. The home fulfills reasonable requests and recommendations in a timely manner(Required)

Please explain why you chose this rating(Required)

8. Physical appearance of the home (neat, clean, free of offensive odors)(Required)

Please explain why you chose this rating(Required)

9. I am made to feel comfortable when I visit the home(Required)

Please explain why you chose this rating(Required)

10. The home provides a safe environment(Required)

Please explain why you chose this rating(Required)

11. The home addresses resident's specific cultural needs(Required)

Please explain why you chose this rating(Required)

12. Choices are offered and accommodated(Required)

Please explain why you chose this rating(Required)

13. I am satisfied with the community outing opportunities that are offered(Required)

Please explain why you chose this rating(Required)

14. Additional recommendations/Comments

Optional

Name of person completing survey

Optional

Contact Information

Optional. If you would like a copy of our Annual Outcomes report, please fill out your name and mailing address. If you would prefer a copy emailed to you, please fill out your email address. The report is an overview of the services we’ve provided and our goals for the future. Thank you.