This government document is issued by Aging & Independence Services for use in San Diego County, CA
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https://www.google.com/url?client=internal-element-cse&cx=015466730696295969998:wokiau6kw8k&q=https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/ais/documents/VSD-001%2520Rev%25202021%2520(Fillable).pdf&sa=U&ved=2ahUKEwi657aL78z4AhVS_CoKHd0ZBC8QFnoECAgQAQ&usg=AOvVaw1Ur73VDqb_eIaSKa1qb30Y