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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 September, 2001 below) below)
--------------------------------------------- (Voluntary) ------------------- President and
(Street) 5. If Amendment, Chief 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 09/21/01 P 3,000 A $1.40 25,300 D
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Common Stock 1,700 1 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) Stock
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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 382,500 D
(Right to Buy)
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Explanation of Responses:
**Intentional misstatements or omissions of facts constitute Federal Criminal /s/ ABDO H. KHOURY October 3, 2001
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- ---------------
**Signature of Reporting Person Date
Abdo H. Khoury
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.