------ 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 Persons to
Issuer (Check all applicable)
KHOURY ABDO H. ARV ASSISTED LIVING INC. (SRS)
--------------------------------------------- ---------------------------------------------- Director 10% Owner
(Last) (First) (Middle) 3. IRS Identification 4. Statement for --- ---
Number of Reporting Month/Year x Officer Other (Specify
245 FISCHER AVENUE, SUITE D-1 Person, if an entity OCTOBER, 2001 --- (give title --- title below)
--------------------------------------------- (Voluntary) ------------------ below)
(Street) 5. If Amendment,
Date of Original PRESIDENT AND CHIEF FINANCIAL
COSTA MESA CALIFORNIA 92626 (Month/Year) OFFICER
--------------------------------------------- -------------------------- -----------------------------------
(City) (State) (Zip) ------------------- 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. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature
(Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In-
Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct
(Instr. 8) End of Month Direct Benefi-
(Month/ (Instr. 3 and 4) (D) or cial
Day/ --------------------------------------- Indirect Owner-
Year) Code V Amount (A) or Price (I) ship
(D) (Instr. 4) (Instr. 4)
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COMMON STOCK 10/12/01 P 3,000 A $1.30 28,300 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)
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 D 1 COMMON 7,500
(RIGHT TO BUY) STOCK
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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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375,000 D
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Explanation of Responses:
1 OPTION GRANTED ON MARCH 19, 1998 FOR 7,500 SHARES AT A STRIKE PRICE OF $13.75
WAS SURRENDERED VOLUNTARILY TO THE COMPANY.
**Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ ABDO H. KHOURY
See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). -------------------------------
**Signature of Reporting Person
Note: File three copies of this Form, one of which must be manually signed. Abdo H. Khoury
If space is insufficient, see Instruction 6 for procedure.
November 12, 2001
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