------ UNITED STATES SECURITIES AND EXCHANGE COMMISSION ------------------------------
FORM 4 WASHINGTON, D.C. 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 Investment Company
Instruction 1(b). 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)
PASQUALE DOUGLAS M. ARV ASSISTED LIVING, INC. (SRS) to Issuer (check all applicable)
-------------------------------------------- ---------------------------------------------- X Director 10% Owner
(Last) (First) (Middle) 3. IRS Identification 4. Statement for ---- ---
245 FISCHER AVENUE, SUITE D-1 Number of Reporting Month/Year X Officer Other (specify
-------------------------------------------- Person, if an entity OCTOBER, 2001 ---- --- below)
(Street) (Voluntary) ------------------- (give title below)
COSTA MESA CALIFORNIA 92626 5. If Amendment, CHIEF EXECUTIVE OFFICER
-------------------------------------------- Date of Original ------------------------------------
(City) (State) (Zip) (Month/Year)
7. Individual or Joint/Group Filing
------------------- (Check Applicable Line)
X Form filed by One
---- Reporting Person
Form filed by More Than
---- One Reporting Person
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TABLE I -- 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 Beneficial
(Instr. 8) Owned at (D) or Ownership
(Month/ End of Month Indirect (Instr. 4)
Day/ --------------------------------------- (Instr. 3 and 4) (I)
Year) Code V Amount (A) or Price (Instr. 4)
(D)
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COMMON STOCK 10/24/01 P 2,000 A $1.23 99,500 D
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COMMON STOCK 10/25/00 P 200 A $1.35 99,500 D
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COMMON STOCK 10/29/01 P 2,800 A $1.23 99,500 D
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COMMON STOCK 10,500 I BY IRA
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
*If the form is filed by more than one reporting person, see Instruction 4(b)(v).
(Over)
SEC 1474 (3-99)
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. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price
Security sion or action action Derivative cisable and of Underlying of
(Instr. 3) Exercise Date Code Securities Expiration Securities Deriv-
Price of (Month/ (Instr. Acquired (A) Date (Instr. 3 and 4) ative
Deriv- Day/ 8) or Disposed (Month/Day/ Secur-
ative Year) of (D) (Instr. Year) ity
Security 3, 4, and 5) (Instr. 5)
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Date Expira- Amount or
-------------------------- Exer- tion Title Number of
Code V (A) (D) cisable Date Shares
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EMPLOYEE STOCK OPTION COMMON
(RIGHT TO BUY) D(1) STOCK 150,000
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9. Number of 10. Ownership 11. Nature of
Derivative Form of Indirect
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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900,000 D
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Explanation of Responses: (1) OPTION GRANTED ON JUNE 1, 1998 FOR 35,936 SHARES AT
A STRIKE PRICE OF $11.13 WAS SURRENDERED VOLUNTARILY
TO THE COMPANY.
OPTION GRANTED ON JUNE 1, 1998 FOR 114,064 SHARES AT
A STRIKE PRICE OF $11.13 WAS SURRENDERED VOLUNTARILY
TO THE COMPANY.
**Intentional misstatements or omissions of facts constitute Federal /s/ DOUGLAS M. PASQUALE NOVEMBER 12, 2001
Criminal Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------------ ------------------
**Signature of Reporting Person Date
Note: File three copies of this Form, one of which must be manually signed. Douglas M. Pasquale
If space is insufficient, see Instruction 6 for procedure.
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.