PROSPECTIVE EMPLOYEE APPLICATION PACKET

Dear Applicant: PROSPECTIVE EMPLOYEE APPLICATION PACKET Thank you for your interest in Catharine s Quality of Life Homes (CQLH). As a prospective employee, we want you to know as much as possible about us in our interview process so that you are comfortable as you consider us for employment. Catharine s Quality of Life Homes was started in 1992, by Dick and Penny Page in response to care needs of Dick s mother (Catharine) who had both Alzheimer s and Parkinson s diseases. Catharine s quality of life in a nursing home became such an issue that Dick built a home for her and took a leave of absence from the corporate world to care for her personally. Caring for his mother became such a life-changing experience he never returned to the corporate world, and he and Penny provided the hands-on care for his mother and other persons for nine years. With this background, Dick and Penny personally understand the concerns and fears of resident families and the challenging work of dedicated and loving staff. Catharine s Quality of Life Homes operates Assisted Living Homes located in Lakewood and Littleton. Each home is a beautiful large ranch style suburban residence for up to nine senior residents. CQLH specializes in caring for persons who suffer from Alzheimer s disease and related dementias. Our residents are all ambulatory, sleep through the night and are semiindependent but have a range of care needs. Our full-time staff works 12 hour shifts. Medication administration, charting and daily written observations are made in a professional manner to ensure the safety of our residents. Meals are nutritious, balanced and prepared according to CQLH s specifications and planned methods of on-site preparation. Our main focus is on interacting with our residents in a wide range of small-family planned and informal activities. To this end we also employ part-time staff who work in our homes during the mornings and evenings. The purpose of the part-time staff is to ensure that one staff member can ALWAYS be interacting with residents NOT so that both staff can be cleaning or preparing meals. Please read the Job Description included next in this packet, then fill in the Application for Employment giving details about your background, references, experience and skills. You will hear from us in a few days to discuss our mutual interest. Thank you for interviewing with Catharine s Quality of Life Homes. Dick & Penny Page

Catharine s Quality of Life Homes (CQLH) Full-time Care Provider: Job Description Primary Objective: Employees must provide quality care to all residents, treating each with compassion, dignity, and respect. Care Providers will encourage all residents to function as independently as possible focusing on their remaining strengths rather than the many things they can no longer do. Staff will focus on keeping residents meaningfully engaged in a variety of activities designed to meet their individual needs and provide mental, physical and social stimulation. Reports To: House Manager Qualifications: You must be eighteen (18) years of age; successfully complete a medication administration class (QMAP) approved by the State of Colorado; complete a State approved First Aid course; have a negative tuberculosis test; undergo a criminal background check; have a genuine empathy for persons with dementia; and have the ability to work effectively with them Duties and Responsibilities 1. Personal Care of Residents: Duties include, but are not limited to, assistance with dressing, grooming, bathing, hygiene, eating, incontinence management, changing bed linens, laundry and meal preparation. Care staff will follow each resident s personal care plan (which identifies the level of care needed); develop and follow schedules as outlined in the resident s care plan. (Benchmark: NO instances of failing to provide personal care assistance to the residents.) 2. Administration of Medication: Follow written physician s orders in the administration of medications; notify the house manager of any medication order changes, delivery of medications to the home during your shift, or any changes/adverse reactions to the resident after the administration of a medication. (Benchmark: one or fewer medication errors per quarter; no failures to notify house manager of medication changes, the delivery of resident medications to the home, or a resident s adverse reaction to a medication.) 3. Activities: Follow Daily activities as posted, in addition to standard activities determined for each home; document all activities each resident participates in; encourage all residents to participate in activities. (Benchmark: Scheduled and standard activities are implemented with residents 75% of the opportunities as reflected in daily documentation and house manager oversight visits.) 4. Meal Preparation: Cook three meals per day as defined on the posted weekly menu; never change the meal from that scheduled on the menu unless approved by the house manager in advance; present all meals and two daily - 2 -

snacks in an appetizing manner. (Benchmark: No instances of not preparing daily meals and snacks for residents; no instances of not following the menu; and two or fewer instances per quarter of food not being presented in an appetizing manner.) 5. House Maintenance: Keep the house clean and presentable at all times as indicated by the house maintenance chart or as necessity dictates. Contact house manager of immediate/emergency maintenance needs (clogged toilet, incontinence on carpets etc.) (Benchmark: two or fewer instances per quarter of not completing all duties as indicated by the maintenance log/chart.) 6. Compliance with ALL CQLH Policies and Procedures: Adhere to all policies and procedures as outlined in CQLHs Policies and Procedures Manual. (Benchmark: two or fewer instances of failing to adhere to CQLH policies or procedures per quarter. Failure to follow policies pertaining to safety or care of a resident will not be tolerated and could result in immediate termination. 7. Documentation: Complete daily documentation on ALL forms and charts (hygiene/bathing, medication administration records, resident daily log, shift change form etc.) (Benchmark: 98% documentation accuracy per quarter as indicated by house manager review.) 8. Physical Requirements: Care staff must be in good physical health, must be able to stand on feet for long periods of time and must be able to physically lift or transfer a resident from a lying to sitting position. 9. Other duties as assigned. * Please Note: Care Provider may be transferred from one CQLH location to another home location if necessary at the discretion of CQLH. Date: Staff Signature: CQLH Management Signature: - 3 -

Catharine s Quality of Life Homes APPLICATION FOR EMPLOYMENT - AN EQUAL OPPORTUNITY EMPLOYER Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. Use blank paper if you do not have enough room on this application. PLEASE PRINT, except for signature. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information. Job applied for: Today s Date: Salary Desired: Are you seeking: Full-time Part-time Temporary employment? When could you start work: Last Name First Name Middle Name Phone Present Street Address City State Zip Code Are you 18 years of age or older Yes No (If you are hired, you may be required to submit proof of age.) Who referred you to this company? Are you presently employed? Yes No If Yes, whom do you suggest we contact? Please carefully read the job description attached to this application. Are you able to perform the essential duties of the job for which you are applying (with or without reasonable accommodation )? Yes No Please explain as necessary: Are you now or do you expect to be engaged in any other business employment? Yes No If yes, please explain How many days of work have you missed during the past year? (Exclude absences due to disability or those covered by FMLA.) List Name and Address of Schools Attended Number of Diploma Graduation Years Degree Date High School or GED: College or University: Vocational or Technical: Have you worked or attended school under another name? Yes No If yes, give names: What skills or additional training do you have that relate to the job for which you are applying? - 4 -

List names of employers by dates with present or most recent employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and business references. Name of Employer Job Description Date From To Address City, State, Zip Code Pay: Start $ Final $ Supervisor - May we Contact? Telephone Reason for Leaving Name of Employer Job Description Date From To Address City, State, Zip Code Pay: Start $ Final $ Supervisor - May we Contact? Telephone Reason for Leaving Name of Employer Job Description Date From To Address City, State, Zip Code Pay: Start $ Final $ Supervisor - May we Contact? Telephone Reason for Leaving Name of Employer Job Description Date From To Address City, State, Zip Code Pay: Start $ Final $ Supervisor - May we Contact? Telephone Reason for Leaving Give three references, not relatives or former employees: Name Address Telephone - 5 -

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SIGNING I certify that all information provided by me to the questions and statements contained in this application and other pre-employment forms are true and correct without consequential omissions of any kind whatsoever. I understand that falsification, omission or misstatements are grounds for refusal to hire or, if hired, dismissal. I understand that CQLH, as the employer, may request an investigative criminal background check and consumer report from State or private reporting agencies. This report may include information as to my criminal record, my character and reputation as obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer-reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and post-employment drug screen as a condition of employment, if required. If an offer of employment is made, I consent to the release of any and all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. Although the management of Catharine s Quality of Life Homes makes every effort to accommodate individual preferences, CQLH needs may at times make the following conditions mandatory: additional 24-hr shifts, overtime, shift work, a rotating work schedule, budget days, or a work schedule other than what is normally scheduled, and if an employment offer is made, I accept these as conditions of my continuing employment. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT CATHARINE S QUALITY OF LIFE HOMES INC., MAY CHANGE WAGES, BENEFITS, AND CONDITIONS AT ANY TIME. I FURTHER UNDERSTAND THAT IF I AM HIRED IT WILL BE AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED BY EITHER ME OR CQLH, AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE. I have read, understand and, by my signature, consent to these statements. Signature: Date: - 6 -

JOB APPLICATION BACKGROUND, EXPERIENCE AND SKILLS Name: Date: The following items are to be indicated by Yes or No and discussion as applicable in order that we may assess your appropriateness, skills and experience for the job of Personal Caregiver. Criminal History: Yes No Discuss Have you ever been convicted of any law violation(except a minor traffic violation)? If yes, give details: (A yes will not by itself disqualify you from employment, since nature of offense, date, and the job for which you are applying are also considered. Have you had any Skilled Licenses Revoked or Voluntarily Surrendered? If you are hired, you must sign a Medication Administration Disclosure Statement TB Test: Do you have a negative TB Test? You must have a negative TB test before starting work Medication Certification: Have you successfully completed a Colorado medication administration course? You must successfully complete a state-required medication certification course before starting work Personal: Yes No Discuss Do you have Good Moral Character? Do you have any Communicable Diseases? Are you Physically and Mentally able to perform the Job as described in the Caregiver Job Description? JOB EXPERIENCE AND SKILLS Personal Demeanor: Yes No Discuss Are you Responsible and Caring? Do you use a Loud Voice, Yelling, Belligerent? Work Schedules: Are you willing to fill in for other staff-shifts as needed? - 7 -

Are you willing to do Weekend/Holiday rotation as needed? Resident Care: Please note your experience below Yes No Discuss Activities Participation and Supervision Stand-by Assist Bathing, Sponge Bath, Shower, Tub Lift, etc. Resident Care (Continued) Bed Pan, Bedside Commode, etc. Catheter, Colostomy Bag Care Dental Hygiene Dressing and Undressing Hair Care Incontinence Care and Clean up Clothing Selection Lifting Assistance Making Beds General Housekeeping Laundry Oxygen Care Wound Care - First Aid Transfer Assist Skin Care Yes No Medications: Yes No Discuss Do you have medication training and a Colorado QMAP certificate? Are you attentive to detail? Do you have legible handwriting? Can you write daily log assessments? Emergency Procedures: Yes No Discuss - 8 -

Are you levelheaded in crisis situation? Do you have assessment capability? Do you have a good sense of awareness? Cooking: Yes No Discuss Can you cook & follow Recipes, improvising as necessary? Are you familiar with food storage and food handling? Can you handle grocery planning and ordering? Team Association: Yes No Discuss Are you willing to help fellow workers? Are you able to work easily with others? Are you willing to work added shifts in critical situations? Do you have any history of being late to work? Transportation: Yes No Discuss Do you have the Ability to get to work on schedule? Other: Signature Date - 9 -

Criminal Background and History Investigation Waiver In accordance with Chapter VII for Residential Care Facilities in Colorado, any staff employee who has direct personal contact with residents of a facility shall be of good moral and responsible character. In making such determination, CQLH may have access to and shall obtain any criminal history record information from a criminal agency, subject to restrictions imposed by such agency, and verify social security number and birth date for any person responsible for the care and welfare of residents in CQLH s homes. Please Print Clearly Social Security Number: / / (Please provide us a copy) Driver s License: State: Driver s License Number: (Please provide us a copy of a photo identification) Date of Birth: (Please provide us copy evidence of at least two sources to document your birth date. OTHER NAMES USED: CURRENT ADDRESS: PRIOR ADDRESSES IN LAST FIVE YEARS: LIST OTHER STATES AND COUNTIES OF PRIOR EMPLOYMENT: By affixing my signature below, I grant permission to CQLH to conduct an investigation into my background, confirm my social security identification and birth date and call references about me for purposes of this application. - 10 -

Signature Date While you are a Staff Member of CQLH in this home, and by agreeing to work as an employee, you have accepted the responsibility to never, under any circumstances, leave the home or leave Residents unattended. The relief shift has a responsibility to be on the job on time. If you or your relief makes a practice of being tardy, and by so doing you continue to be discourteous to your fellow Staff member, then the offended Staff member is to write a complaint to the CQLH Administrator. Disciplinary action will be considered which may result in dismissal and forfeiture of a portion of compensation to be used in compensating the offended Staff member. If you have an emergency, you will need proof of such even though you have called in. Regardless, immediately call your Manager if you have a problem so other plans can be made. Duties: 1. Must be Medication Certified by successful completion of state-required medication administration course before you start work. Must be familiar with Residents' medications. Administer medications and record the same in CQLH's Medication Records Book for each Resident in accordance with CQLH's Medication Administration Procedures. Medicines and records are to be locked in designated cabinets when not in use. New staff pays for their Medication Certification Course (MCC). Once you have worked for 12 months, CQLH will reimburse you for the cost of the course. If you resign or are terminated before 12 months of employment, the cost of the MCC is not refunded by CQLH. Must document having a negative TB test before starting work. 2. Follow the Board and Care Plan for each Resident, located in each Resident's record book or detailed on back of each Resident's room door. Directly assist Residents or provide reminders for dressing, bathing, shaving, dental hygiene, hair care, selecting clothes, eating, and getting in and out of bed. Maintain Residents' rooms in neat, clean, sanitary manner including making beds, changing linens, dusting, emptying bedside commodes. Assist Residents with special bladder or bowel incontinence by following a toileting schedule and assisting with any clean-up and/or clothing changes. 3. Follow the daily menu plan, prepare and serve meals. Must have ability to cook and follow recipes in order to prepare attractive, nutritious and good-tasting meals. You need the capability to deviate from menus when necessary and have knowledge of food storage and handling requirements. Assist residents to the table and provide proper portions food and beverages; be available to assist residents as needed during mealtimes. Clean up kitchen area as quickly as possible after meals and maintain kitchen in neat, clean and sanitary condition. Prepare and serve snacks at mid-morning and mid-afternoon. Check up-coming menus and inform management of grocery needs. Communicate to management when certain groceries are needed in between major shopping days. Plan ahead and have next day's food defrosted and/or available at cooking time. 4. Provide protective oversight and monitor the Residents' activities by observing Residents on a regular basis to be able to detect any needs that the Residents may have. Remember each Resident has an optimum level of operating independence. Help them achieve that level at all times. 5. Assist with activities schedule and remind, encourage and assist Residents to join in activities. 6. On a daily basis, write in Residents' Daily Log & Shift-Change Log regarding various health problems, falls, mishaps, or any critical or concerning incidents relating to Residents' health and indicate changes in Residents' health and mental conditions. - 11 -

7. Answer house telephones and assist Residents with telephone calls, if needed, and record the long-distance calls in the Telephone Log. Assist with letter writing, if necessary. If calls made by Resident or to Resident by another seems excessive, report to management by keeping a log of such calls, i.e., day, time, who., etc. 8. Maintain cleanliness of all rooms, bathrooms and common areas. Residents' rooms should be dusted and cleaned at least once per week on the day when beds are routinely changed. Kitchen and bathroom floors should be swept and mopped as needed, but at least once a day. Dust and vacuum rooms and common areas as needed. Keep all areas safe and free of obstructions that could cause falls or harm to Residents in any way. Keep dangerous toxic chemicals in designated locked compartments at all times. Possess knowledge and ability to do laundry for Residents, including folding and placing in appropriate storage. 9. Bring in mail from mail box (only if another staff is inside the home) and distribute to Residents, placing CQLH's mail in the in-box on the dining room shelves. 10. Understand fire safety, rules, alarm control disable and reset procedures and help to conduct fire drills. Also know fire escape plan and evacuation diagrams, disaster plan, emergency action plans. 11. Have ability to assess Residents' first aid emergencies in a calm, efficient way and properly identify and deal with difficult situations and behaviors. 12. Remove trash and garbage to outside containers and place at street side for trash pickup. Water plants on scheduled days. 13. Provide relieving staff member with pertinent information about Residents needs. Gather the same information from the prior staff member when coming on duty. Be courteous to your relief staff member by making advance preparations (if possible, on your shift) of main entree meals, desserts, etc. which have to be started well in advance to make it easier on your fellow staff. Turn over to relieving staff a clean home. (This does not infer that you have to arise so early in the morning to have a perfect home to be turned over to your fellow staff. But, it does mean that you are expected to cooperate on a plan with the fellow staff for the home s condition when you start and end your shift.) Remember to acknowledge your appreciation when a fellow staff does things for you. Remember we are a team in a family with a primary goal to serve our Residents. 14. Communicate with management regarding Residents' needs and changing conditions. 15. Employment will be on an employment-at-will basis and that I can resign or be terminated at will. As a new employee, you will be on probation through an introduction orientation period for up to 90 days of actual work time unless at the end of that time, after performance evaluation, there is cause for CQLH to extend the probation period or terminate your employment. 16. Represent CQLH as a professional caregiver with a friendly and cheerful attitude toward Residents, their families and visitors. 17. Provide a loving, caring, dignified, safe and clean environment for the Residents at all times. Signature Date - 12 -