Community Based Facility Form – Fill Out and Use This PDF

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:

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

I. GENERAL INFORMATION

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

NOTE: Any change in the above information requires submission of new documents.

Designated Mail Recipient (Provide the name and contact information of the person to whom mail from DHS/DQA is to be addressed.)

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.

II. RESIDENT INFORMATION

Total Resident Capacity

Check the box indicating the primary client group(s) you are requesting to serve.

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

III. FINANCIAL INFORMATION

A current balance sheet must be submitted with this application.

Monthly Operating Expenses

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.

All Other Sources of Income

Check all that apply.

Submit copies of financial documents (e.g., copies of bank balance sheets, evidence of line of credit) 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. If you charge the same fee to all of your residents, indicate the amount as the “Maximum” 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?

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?

3.Was the facility/program licensed, certified, or otherwise regulated by any government or private 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?

5.Do you presently have or intend to apply for another type of license, certification, or registration at this location?

Local fire departments have requested knowing where licensed facilities are located. Provide the name, address, and telephone number of your local fire department.

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.

V. OWNERSHIP

Attach separate sheet(s) with the following information, if applicable.

●List all names, principal business addresses, and the percentage and type of ownership interest of all persons or business entities having any ownership interest 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.

VI. LICENSEE

Additional Submittals

∙If the applicant is a Corporation, submit a copy of the Articles of Incorporation and by-laws.

∙If the applicant is a LLC, submit a copy of the articles of organization and operation.

∙If the applicant is a LLP, submit a copy of the partnership agreement.

NOTE: Attach additional pages if needed for the following questions.

1.The Licensee owns the:

2.Type of Licensee (Check one of the following.)

3. List the interested parties relative to the entity named as licensee. [Chapter 50.03(3), Wis. Stats.]

4.Has the licensee ever been adjudicated bankrupt?

5.Are there any unsatisfied judgments against the licensee?

6.Does the licensee owe any debts that are 90 days past due?

7.Are any liens filed against the licensee or the licensee’s property?

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 through 15, allowing one set of questions for each different partnership, corporation, and other type of owner.

9.Type of Owner (Check one of the following.)

10.Name and Address of the Owner

Name – Individual, Partnership, Corporation, etc.

11.List the interested parties relative to the entity in question 10. [Chapter 50.03(3), Wis. Stats.]

13.Type of Owner (Check one of the following.)

14.Name and Address of the Owner

Name - Individual, Partnership, Corporation, etc.

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.

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.

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.).