Adult Foster Home - Renewal License Application



| [pic] |Adult Foster Home |

| |Renewal License Application |

| |

|Type of Adult Foster Home (AFH) application (check one): |

| Licensee Administrator Co-licensee Resident manager Shift caregiver |

|Part 1 - to be completed by applicant |

| | |

|1 ― General information |

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|A. |Applicant name: |      |

|B. |Phone: |      | |      |

| | |Applicant’s home phone | |Applicant’s cell number | |

|C. |Adult Foster Home (AFH) address: |      |

| |City: |      |State: |      |ZIP code: |      |

|D. |Licensee's primary residence (address) if not living in the AFH: |

| |Address: | |

| |City: |      |State: |      |ZIP code: |      |

|E. |Mailing address (if different): |      |

| |City: |      |State: |      |ZIP code: |      |

|F. |Applicant’s email address: |      | check if none |

| | Required for co-applicant |

|G. |Classification: What is the licensee classification of the AFH where you intend to work? (See OAR 411-049-0105(9) for specific classification criteria.) |

| | Class 1 Class 2 Class 3 |

| |Note: The classification of your AFH license will be determined based on OAR 411-049-0105(9) for specific classification criteria. |

|H. |Capacity: How many AFH residents do you want to provide care for? |      |

| |Number of day care persons: |      | |

| |Number of room and board residents: |      | |

| |Number of relatives needing care and services (including children): |      |

| |

|I. |List the designated back-up licensee, resident manager or administrator who can act for you in case of an emergency (required):       |

| |In what county is the back-up licensee or resident manager located? |

| |       | |

| |

| |Staffing plan: Identify all individuals you plan to use as substitute caregivers (Attach a separate piece of paper if necessary.) |

| | |

| |Name |Typical weekly schedule |Phone number |Lives in your AFH? |

| | | | | |

| |      |      |      | Yes | No |

| |      |      |      | Yes | No |

| |      |      |      | Yes | No |

| |      |      |      | Yes | No |

| |      |      |      | Yes | No |

|2 ― Applicant information |

| | |

|A. |Emergency contact(s): Provide information for at least one contact. |

| | |

| |Name |Phone number |Relationship to applicant |

| |      |      |      |

| |      |      |      |

| | |

|B. |Special skills: Please describe any professional licenses, languages spoken fluently and any other special skills you may have:       |

| | |

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| | |

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|C. |Applicant history: |

| |Since submitting your last application for an AFH license: |

| |Have you had a license or certificate for a foster home or other long-term care facility denied, suspended, or revoked or voluntarily surrendered while under |

| |sanction? Yes No |

| | |

| | If yes, by whom? |      |Date: |      |

| |Have you had a substantiated allegation of abuse or neglect? Yes No |

| | If yes, by whom? |      |Date: |      |

| |Have you or any AFH employee been placed on the Office of Inspector General’s (OIG) exclusion list or the General Services Administration (GSA) exclusion |

| |list? (Individuals on the OIG or GSA exclusion lists are prohibited from participating in any Federally funded health care program.) Yes No |

| | |

|D. |List all occupants in your home - Include all persons who live in or on the adult foster home premises. Examples: children, spouses, residents, live-in |

| |caregivers, room and board occupants and individuals living in a trailer on the AFH premises. (Attach a separate paper if necessary.) |

| | |

| | |

| |Is this AFH your primary residence? Yes No |

| | |

| |Occupant names |Relationship to applicant |Date of birth |

| | | | |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |      |      |      |

Applicant information (continued)

|3 ― Additional application requirements checklist |

|Attach or enclose copies of the following documents to your completed application. Check the corresponding boxes to indicate completion. Check the box marked NA if |

|it does not apply to you. |

| | |

| | |Physician or Nurse Practitioner’s Statement ― Submit the completed, signed and dated original of the Department’s current Health History and |

| | |Physician/Nurse Practitioner’s Statement (APD 0903). (Required every third year or sooner if cause for health concern.) NA |

| | | |

| | | |

| |

| | |Background Check Request ― Enclose completed Background Check Request form (DHS 0301AD), required for all persons 16 years of age and older who are |

| | |occupants in or on the AFH premises, the licensed provider, resident manager, substitute caregiver, trainee or other employees, according to OAR |

| | |411-049-0120(1) and OAR 411-049-0102(88). NA |

| | | |

| | | |

| | | |

| |

| | |Application fee ― $20.00 per bed application fee (maximum $100.00) |

| | | |

| | |Training/special qualifications ― Attach proof of required training and any special credentials. NA |

| | | |

| | | |Fire and Life Safety ― Required during the first year as available. |

| | | |Basic First Aid ― Attach a copy of both sides of your certification ― (first Aid certification is required to be maintained after your first year|

| | | |of licensure) |

| | | | |

| | | |Cardiopulmonary Resuscitation (CPR) ― Attach a copy of both sides of your certification card if you currently have Adult CPR Certification |

| | | |(CPR certification is required to be maintained after your first year of licensure). |

| | | |Twelve hours of approved continuing education, up to four of those hours may be related to the business operation of the AFH ― (Required after |

| | | |the first year of licensure.) |

| | | | |

| |

|4 ― Certification and signature |

|I declare, under penalty of perjury, this information is true, correct and complete to the best of my knowledge. I understand that failure to provide accurate |

|information may result in the denial of my application and: |

|the denial of my application; |

|my application is not complete until all required items have been submitted; and |

|an incomplete application will become void sixty (60) days from the date the application and fee are received by the division. |

|I authorize the department to verify the information provided on this application. |

|      | |      |

|Applicant’s printed name | |Date |

| | |      |

|Signature of applicant | |Date |

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