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 |
| |
|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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|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 |
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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 |
| | | |
| | | |
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| |
| | |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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