NEW YORK STATE DEPARTMENT OF HEALTH
Adult Care Facility/Assisted Living
Adult Care Facility Inventory of Resident Property
FACILITY NAME:
OPERATING CERTIFICATE NUMBER:
RESIDENT NAME
ITEM
RESIDENT SIGNATURE
X
DOH-5194 (DSS-3027) (Revised 7/78, 6/14, 10/15, 12/15)
QUANTITY
ESTIMATED
$ VALUE (if known)
DATE
INVENTORY
DATE
DESCRIPTION
AUTHORIZED FACILITY REPRESENTATIVE SIGNATURE DATE
X
DATE
RETURNED
TO RESIDENT
RESIDENT
INITIALS