Free Community Based Residential Facility (CBRF) Initial License Application-F-60287 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-60287 (Rev. 04/09)

STATE OF WISCONSIN Chapter 50.03(3)(b), Wis. Stats. Page 1 of 7

COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) INITIAL LICENSE APPLICATION
· · · · · Completion of this form is required by Chapter 50.03(3)(b), Wis. Stats. Failure to complete this form, completely and accurately, may result in licensure denial and/or delay in processing. Send the completed form, with the items listed below, to the Division of Quality Assurance (DQA) regional office assigned to the county in which the facility is located. DQA regional office locations are found at http://dhs.wisconsin.gov/rl_dsl/Contacts/ALSreglmap.htm Contact the appropriate regional office if you have questions about completion of this form. THE FOLLOWING ITEMS MUST BE SUBMITTED WITH THE APPLICATION FORM: · · · · Program Statement Fire Inspection Evidence of 60 day operating funds · · · License Fee ­ Check payable to DQA (NON-REFUNDABLE) Floor plan with dimensions, exits, and room usage Assisted Living Facility Model Balance Sheet, F-62674A

The licensee is responsible for notifying the Division of Quality Assurance, in writing, of any change in the information provided on this application.

Size of CBRF (Check one.) Small (5-8 residents) Medium (9-20 residents) Large (21 or more residents)

Class / Type of CBRF (Check one.) Ambulatory Class A (AA) Semi-Ambulatory Class A (AS) Non-Ambulatory Class A (ANA) Ambulatory Class C (CA) Semi-ambulatory Class C (CS) Non-ambulatory Class C (CNA)

NOTE: Any change in the above information requires submission of new documents.
I. GENERAL INFORMATION
Name ­ Facility Facility Telephone Number

Street Address / PO Box - Facility

FAX Number

City

State

Zip Code

County

Fire Number

Name ­ Administrator

Birth Date ­ Administrator

E-mail Address

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

Name ­ Licensee

Birth Date - Licensee

Telephone Number

Street Address ­ Licensee

FAX Number

City

State

Zip Code

E-mail Address

Does the Community Based Residential Care Facility have a contract with a county human services or social services department to serve Medicaid waiver eligible individuals? Yes No

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Provide the name and address of the person to whom mail and correspondence from the Department is to be addressed.
Name - Correspondent Title

Mailing Address

City

State

Zip Code

List the names of all persons, age 10 and older, who live in the facility and are not a resident. If more than four names, attach an additional sheet.
Last Name, First Name, and MI Relationship to Licensee Birth Date

II. RESIDENT INFORMATION
Total Resident Capacity

Female

Male

Both

Check the box indicating the primary client group(s) served by your CBRF. If more than one client group is served, see DHS 83.06(1), Wis. Admin. Code, for instructions. 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 List the days and hours when residents are NOT in the facility.
Days Hours

PWC Pregnant women who need counseling CC Correctional clients TI Terminally ill TBI Traumatic brain injury ADS Persons with acquired immunodeficiency syndrome (AIDS)

III. FINANCIAL INFORMATION (A current balance sheet must be submitted with this application.)
Monthly Operating Expenses All Salaries ( i.e., licensee, caregivers, contract providers, etc.) Lease or Mortgage All Other (i.e., food, supplies, utilities, insurance, taxes, etc.) TOTAL Monthly Expenses

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If income from residents would not be adequate to pay your 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. 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 two times your monthly operating expenses. Indicate the minimum and maximum monthly fees charged for resident care. Include fees paid from all sources including government and/or private agencies, the resident's family or relatives, and from the resident. If you charge the same fee to all of your residents, indicate the amount as the "Maximum" rate.
Minimum MONTHLY Rate Maximum MONTHLY Rate

IV. FIT AND QUALIFIED
The following information will be used to determine if the applicant meets the fit and qualified requirements under Chapter 50, Wis. Stats. 1. Have you ever applied for licensure for a residential facility, health care facility, or a day care program for adults or children and been denied licensure? Yes No If "Yes," explain and provide relevant information.

2.

Have you 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 phone number of the facility/program.

3.

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

4.

Have you ever had any license, certification, or governmental approval to operate a facility/program denied, revoked, suspended, or not renewed in Wisconsin or any other state? 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, phone number, and type of facility/program that was affected.

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5.

Do you presently have or intend to apply for another type of license, certification, or registration at this location? Yes No License Type a. b. c. d. e. f. g. Adult Family Home Facility for Developmentally Disabled Foster Home (Children) Group Home (Children) Residential Care Ctr. for Children & Youth Child Day Care Shelter Care (Children) a. b. c. d. e. f. If "Yes," check below all that apply. Certification Type Adult Day Care Residential Care Apartment Complex Alcohol and Other Drug Abuse Program Developmental Disabilities Program Mental Health Program Other (Specify.) Registration Type a. b. Residential Care Apartment Complex Other (Specify.)

Local fire departments have requested knowing where licensed facilities are located. Provide the name, address, and telephone number of your local fire department.
Name - Local Fire Department Telephone Number (Do NOT enter 911.)

Address - Street / PO Box

City

State

Zip Code

A request will be sent to the city, township, or village to identify any possible hazard that may affect the health and safety of the residents. No license may be granted until a 30-day period has expired or until we receive a response from the city, township, or village. City
Name - Municipality Address - Street / PO Box

Township

Village
Name - Clerk City State Zip Code

V. OWNERSHIP
List all names, principal business addresses, and the percentage and type of ownership interest of all persons or business entities having any ownership interest whatsoever in the facility, whether direct or indirect, and whether the interest is in the profits, land, or building, including owners of any business that owns any part of the land or building. If a partnership, then list each partner. If a corporation, then list each officer and director of the corporation. If any person or business entity named is a bank, credit union, savings and loan association, investment association, or insurance corporation, it is sufficient to name the entity involved without providing information regarding the officers and directors of the entity. NOTE: Attach additional pages if needed for the following questions.



VI. LICENSEE
1.

The Licensee owns the:
Operation Building Land

Yes 2.

No

Yes

No

Yes

No

Type of Licensee (Check one of the following.)
Governmental Proprietary Voluntary Non-Profit

City County State

Individual Married Couple Partnership Corporation Limited Liability Co.

Corporation Church Association Church/Corporation Limited Liability Co.

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3.

List the interested parties relative to the entity named as Licensee. [Chapter 50.03(3), Wis. Stats.]
Name (Last, First, MI) and Title Percent of Financial Interest

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

Name (Last, First, MI) and Title Address (Street / PO Box, City, State Zip Code)

Percent of Financial Interest

Name (Last, First, MI) and Title

Percent of Financial Interest

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

Name (Last, First, MI) and Title

Percent of Financial Interest

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

4.

Has the Licensee ever been adjudicated bankrupt? Yes No If "Yes," give full details on a separate page including dates, court, and the disposition of each matter.

5.

Are there any unsatisfied judgments against the Licensee? Yes No If "Yes," list all judgments on a separate page listing names and addresses of creditors, amounts, and reasons for non-payment.

6.

Does the Licensee owe any debts that are 90 days past due? Yes No If "Yes," list all debts 90 days past due on a separate page listing the names and addresses of creditors, amounts, and reasons for non-payment.

7.

Are any liens filed against the Licensee or the Licensee's property? Yes No If "Yes," indicate on a separate page who filed the lien(s), where filed, when filed, and amount of each lien.

If someone other than the Licensee / Operator has ownership interest in the building and / or land, complete questions 8 through 11 and, if applicable, questions 12 through15, allowing one set of questions for each different partnership, corporation, and other type of owner. 8 9. Owner of the: Building Land

Type of Owner (Check one of the following.)
Governmental Proprietary Voluntary Non-Profit

City County State

Individual Married Couple Partnership Corporation Limited Liability Co.

Corporation Church Association Church/Corporation Limited Liability Co.

10.

Name and Address of the Owner
Name ­ Individual, Partnership, Corporation, etc.

F-60287 (Rev. 04/09) Address (Street / PO Box, City, State and Zip Code)

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11.

List the interested parties relative to the entity in question 10. [Chapter 50.03(3), Wis. Stats.]
Name (First, Last, MI) Percent of Financial Interest

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

Name (First, Last, MI)

Percent of Financial Interest

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

12. 13.

Owner of the

Land

Type of Owner (Check one of the following.)
Governmental Proprietary Voluntary Non-Profit

City County State

Individual Married Couple Partnership Corporation Limited Liability Co.

Corporation Church Association Church/Corporation Limited Liability Co.

14.

Name and Address of the Owner
Name - Individual, Partnership, Corporation, etc. Address (Street Address / PO Box, City, State and Zip Code)

15.

List the interested parties relative to the entity in question 14. [Chapter 50.03(3), Wis. Stats.]
Name (First, Last, MI) and Title Percent of Financial Interest

Name (First, Last, MI) and Title

Percent of Financial Interest

VII. CREDITORS
1. List the names, principal business addresses, telephone numbers, and type and extent of obligation, in dollars, for all creditors holding a security interest in the premises, whether land or building. Include any mortgage, note, deed of trust, or other obligation secured in whole or in part by the land on which, or building in which, the facility is located. Attach additional pages if necessary.
Name - Individual, Partnership, Corporation, etc.

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

Telephone Number

Type

Extent

Name - Individual, Partnership, Corporation, etc.

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

F-60287 (Rev. 04/09) Telephone Number Type Extent

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Name - Individual, Partnership, Corporation, etc. Address (Street / PO Box, City, State and Zip Code) Telephone Number Type Extent

2.

List the names, principal business addresses, telephone numbers, and type and extent of agreement, in dollars, for all persons and business entities holding any lease or sublease for the land where the building is located. Attach additional pages if necessary.
Name - Individual, Partnership, Corporation, etc.

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

Telephone Number

Type

Extent

Name - Individual, Partnership, Corporation, etc.

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

Telephone Number

Type

Extent

The licensee is responsible for notifying the Division of Quality Assurance, in writing, of any changes in the information provided on this application. VIII. ATTESTATION
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 (Chapter 946.32 Wis. Stats.).
SIGNATURE (In Full) - Licensee or Designee Date Signed

Name (Print or type.)

Title (Must be Owner or Board Member)