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---------- UNITED STATES SECURITIES AND EXCHANGE COMMISSION -------------------------------
FORM 4 WASHINGTON, DC 20549 OMB APPROVAL
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STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OMB NUMBER: 3235-0287
[ ] Check this box if no EXPIRES: December 31, 2001
longer subject to Filed pursuant to Section 16(a) of the Securities ESTIMATED AVERAGE BURDEN
Section 16. Form 4 Exchange Act of 1934, Section 17(a) of the HOURS PER RESPONSE.........0.5
or Form 5 obligations Public Utility Holding Company Act of 1935 --------------------------------
may continue. See or Section 30(f) of the
Instruction 1(b). Investment Company Act of 1940
(Print or Type Responses)
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1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s)
to Issuer (Check all applicable)
Khoury Abdo H. ARV ASSISTED LIVING, INC. (SRS) Director 10% Owner
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(Last) (First) (Middle) 3. IRS Identification 4. Statement for X Officer Other
Number of Reporting Month/Year --- (give title --- (Specify title
245 Fischer Avenue, Suite D-1 Person, if an entity December, 2000 below) below)
--------------------------------------------- (Voluntary) ------------------- President and Chief
(Street) 5. If Amendment, Financial Officer
----------------------- Date of --------------------------------
Costa Mesa CA 92626 Original 7. Individual or Joint/Group Filing
--------------------------------------------- (Month/Year) (Check Applicable Line)
(City) (State) (Zip) X Form filed by one Reporting
------------------ --- Person
Form filed by more than
--- one Reporting Person
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TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
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1. Title of Security 2. Trans- 3. Trans- 4. Securities Acquired (A) 5. Amount of 6. Ownership 7. Nature of
(Instr. 3) action action or Disposed of (D) Securities Form: Indirect
Date Code (Instr. 3, 4 and 5) Beneficially Direct (D) Beneficial
(Instr. 8) Owned at or Ownership
(Month/ ------------- ------------------------- End of Month Indirect (I) (Instr. 4)
Day/ (A) or (Instr. 3 and 4) (Instr. 4)
Year) Code V Amount (D) Price
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Common Stock 22,300 D
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Common Stock 1,700 I By IRA
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
*If the Form is filed by more than one Reporting Person, see Instruction 4(b)(v). SEC 1474 (3-99)
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FORM 4 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
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1. Title of Derivative 2. Conver- 3. Trans- 4. Transaction 5. Number of 6. Date Exer- 7. Title and 8. Price of
Security sion or action Code Derivative cisable and Amount of Derivative
(Instr. 3) Exercise Date (Instr. 8) Securities Expiration Underlying Security
Price of (Month/ Acquired (A) Date Securities (Instr. 5)
Derivative Day/ or Disposed of (Month/Day/ (Instr.
Security Year) (D) (Instr. 3, Year) 3 and 4)
4, and 5) ---------------- -----------------
Date Expira- Amount or
-------------- ---------------- Exer- tion Number of
Code V (A) (D) cisable Date Title Shares
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EMPLOYEE STOCK OPTION Common
(RIGHT TO BUY) 12/14/00 A (1) 12/13/10 Stock 125,000 0.5625
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1. Title of Derivative 9. Number of 10. Ownership 11. Nature of
Security Derivative Form of Indirect
(Instr. 3) Securities Derivative Beneficial
Beneficially Security: Ownership
Owned at End Direct (D) (Instr. 4)
of Month or Indirect (I)
(Instr. 4) (Instr. 4)
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EMPLOYEE STOCK OPTION
(RIGHT TO BUY) 382,500 D
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Explanation of Responses:
(1) THE OPTION VESTS IN THREE EQUAL INSTALLMENTS OVER A THREE YEAR PERIOD. THE FIRST INSTALLMENT WILL VEST ON THE FIRST OF THE
QUARTER IMMEDIATELY FOLLOWING THE COMPANY ACHIEVING A POSITIVE CASH FLOW AND PROFITABILITY FOR TWO CONSECUTIVE QUARTERS AND
THE SECOND AND THIRD INSTALLMENTS WILL VEST ON THE FIRST AND SECOND ANNIVERSARIES OF SUCH DATE, RESPECTIVELY, PROVIDED THAT
IN NO CASE WILL VESTING BEGIN LATER THAN DECEMBER 14, 2005.
**Intentional misstatements or omissions of facts constitute Federal Criminal /s/ ABDO H. KHOURY May 15, 2001
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). -------------------- ------------
Abdo H. Khoury Date
**Signature of
Reporting Person
Note: File three copies of this Form, one of which must be manually signed. Page 2
If space is insufficient, see Instruction 6 for procedure. SEC 1474 (3-99)
Potential persons who are to respond to the collection of information contained
in this form are not required to respond unless the form displays a currently
valid OMB number.