Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Office of Quality Assurance OQA-945 (Rev. 10-06)

STATE OF WISCONSIN

ADULT FAMILY HOME INITIAL LICENSE APPLICATION
Completion of this form is required by s. 50.033(2m), Wis Stats., and ss. HFS 88.03(2)(a), (b) and (4)(b), Wis. Adm. Code. Failure to complete this form accurately may result in licensure denial and/or delay in processing. Send the completed form, with attachments listed below, to the Office of Quality Assurance (OQA) regional office assigned to the county in which the facility is located. OQA regional office locations are found at http://www.dhfs.wisconsin.gov/bqaconsumer/AssistedLiving/ALSreglmap.htm Contact the appropriate regional office if you have questions about completion of this form.

THE FOLLOWING ITEMS MUST BE SUBMITTED
· Vehicle insurance coverage HFS 88.04(4)(a) · License Fee s. 50.033(2), Wis. Stats. (NON-REFUNDABLE) · Documentation of home owners or renters insurance HFS 88.04(4)(b) · Check payable to: Office of Quality Assurance · Program Statement HFS 88.03(2)(b)1. · Floor plan with room dimensions, exits and usage · Evidence of 60 day operating funds · Balance Sheet, OQA-2674 (model form)

The licensee is responsible for notifying the Office of Quality Assurance, in writing, of any change in the information provided on this application.
Name ­ Adult Family Home Manager / Administrator Telephone Number

Home Street Address

Fire Number

Fax Number

City, State and Zip Code

County

IDENTIFY THE INDIVIDUAL TO WHOM MAIL IS TO BE SENT
Name Telephone Number

Mailing Address

City

State

Zip Code

Total Resident Capacity Three Four

All Female All Male Both

Ambulatory Non-Ambulatory

Does the Adult Family Home have a contract with a county human services or social services department to serve Medicaid waiver eligible residents? Yes No

CHECK THE BOX(ES) THAT BEST DESCRIBE YOUR RESIDENTS
AA Advanced aged (60+ years) ALZ Irreversible dementia/Alzheimer's DD Developmentally disabled (DD) MH Emotionally disturbed / mental illness ADA Alcohol / drug dependent PD Physically disabled PWC Pregnant women who need counseling CC Correctional clients TI Terminally ill TBI Traumatic brain injury AIDS Persons with acquired immunodeficiency syndrome (AIDS)

List the days and hours when residents are NOT in the facility.

LICENSEE INFORMATION FOR PROFIT ORGANIZATION
Individual Married Couple Corporation Partnership Limited Liability Corp.

NON-PROFIT
Corporation Church Limited Liability Corp. Other

GOVERNMENT
State County Other

Licensee Name ­ Individual or Corporation (legal entity)

Birthdate ­ Licensee

Name - Owner or President

Mailing Address

Telephone Number

City

State

Zip Code

OQA-945 (Rev. 10-06) Page 2

Does the licensee currently hold another type of license or certification? If "yes," identify the type of license or certification from the following list. LICENSE TYPE
Foster Home (children) Group Foster Home (children) Residential Care Center for Children and Youth Shelter Care (children) Adult Family Home Nursing Home Hospital Community Based Residential Facility Day Care Center (family or group) Other

Yes

No REGISTRATION TYPE
Residential Care Apartment Complex

CERTIFICATION TYPE
Alcohol and Other Drug Abuse Program Mental Health Program Adult Day Care Certified Residential Care Apartment Complex Other

Has the licensee ever operated a residential facility, health care facility or a day care program for adults or children in Wisconsin or in any other state? Yes No If yes, provide the name, address and telephone number of the facility / program.

Was the facility / program licensed, certified or otherwise regulated by any government or private agency? Yes No If yes, provide the name, address, and telephone number of that agency.

Has the licensee ever had a license, certification or governmental approval to operate a facility / program denied, revoked, suspended or not renewed? Yes No If yes, specify the type of license, certification or approval affected, in which state the action occurred, which agency took the enforcement action, and the name, address, telephone number and type of facility / program that was affected.

Date of Action: Enter the minimum and maximum monthly fees charged for resident care in the space below. Include fees paid from all sources including government, private agencies, residents and / or resident's family. MINIMUM $ PER MONTH MAXIMUM $ PER MONTH

MONTHLY OPERATING EXPENSES All Salary Expenses, i.e., licensee, caregivers, contract providers, etc. Lease or Mortgage Expense All Other Expenses, i.e., food, supplies, utilities, insurance, taxes, etc. TOTAL Monthly Expenses

OQA-945 (Rev. 10-06) Page 3

If income from residents would not be adequate to pay the monthly operating expenses, you must have other sources of funds or income that may be used to continue the operation of the facility for at least a 60-day period. [HFS 88.04(3)] Check all other sources of income.
Savings or other financial reserves Purchase contract (County Department) Outside employment Line of credit Loan Other (specify)

Submit copies of financial documents verifying your ability to operate the facility for 60 days. This amount must be equal to or more than 2 times your monthly operating expenses. The licensee owns the: Building Land Operation

List below the names of all persons, age 10 and older, who live in the facility and are not a resident. HFS 88.03(3)(b) Last Name, First Name and MI Relationship to Licensee Date of Birth

Local fire departments have requested knowing where licensed facilities exist. The Office of Quality Assurance will send a copy of the license to the local fire department. Enter the fire department's name, address and telephone number below.
Name - Local Fire Department Telephone Number (DO NOT ENTER 911)

Address (Street / PO Box, City, State and Zip Code)

Provide specific directions to the facility from the closest major STATE highway.

The licensee is responsible for notifying the Office of Quality Assurance, in writing, of any changes in the information provided on this application. I understand, under penalty of law that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a fine of up to $10,000 or imprisonment not to exceed 6 years, or both (946.32 Wis. Stats.).
SIGNATURE IN FULL ­Licensee or Designee Title Date Signed