DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62416 (Rev. 04/09)
STATE OF WISCONSIN Page 1 of 2
COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) INITIAL LICENSURE CHECKLIST
Name - CBRF Name Reviewer Address - Facility (Street Address) City County Date Form Completed Zip Code
A completed application includes the following items.
1. 2. 3. 4. 5. 6. 7. 8. 9. Completed CBRF Initial License Application (F-60287) Background check completed by Office of Caregiver Quality on the licensee and all non-residents age 10 and older. Floor plan. DHS 83.05(2)(b) A licensing fee of $306, plus $39.60 per resident based on capacity of facility. NOTE: For a PROBATIONARY LICENSE, the fee for 12 months is 1/2 this amount. Evidence of financial ability to operate for 60 days. DHS 83.05(2)(f) Balance sheet. DHS 83.05(2)(e) Program statement. DHS 83