Community Based Facility Form PDF Details

Community-based facilities come in all shapes and sizes, from small neighborhood hubs to large regional centers. They can be public or private, secular or religious, and offer a variety of services. Regardless of their specific configuration, these organizations play an important role in community life by providing a focal point for socializing, interacting with others, and accessing needed resources. In addition to the obvious benefits that these facilities offer their users, they also have a positive impact on the surrounding neighborhood by helping to create a sense of place and promote social cohesion. This paper provides an overview of community-based facilities and describes some factors that you may want to consider when choosing one for your community.

Question	Answer
Form Name	Community Based Facility Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	f 60287, wi residential facility, cbrf initial, based cbrf license online

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DEPARTMENT OF HEALTH SERVICES	STATE OF WISCONSIN
Division of Quality Assurance	Chapter 50.03(3)(b), Wis. Stats.
F-60287 (03/2013)	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	∙ Resident Rights and House Rules policies
∙	Background check	∙ Grievance procedure
∙ Floor plan with dimensions, exits, room usage		∙ Evidence of site approval, if zoned
∙	Fire inspection	∙ Verification of Completion of CBRF webcast, if a new provider
∙	Emergency plan	∙ Biennial license fee (NON-REFUNDABLE) – Check payable to: DQA
∙	Admission agreement	∙ Assisted Living Facility Model Balance Sheet (DQA form F-62674A)
∙ Community Advisory Committee documentation		∙ Evidence of 60-day operating funds

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

Yes

No	Did you submit form F-82064 (BID) and form F-82069 (BID Appendix) to the Office of Caregiver Quality at the address
	listed below?
	DHS / Division of Quality Assurance
	Office of Caregiver Quality
	P.O. Box 2969
	Madison, WI 53701-2969

Yes

No	Does the Community Based Residential Facility have a contract with a county agency or managed care organization
	to serve publicly funded individuals?

I. GENERAL INFORMATION


Name – Facility				FEIN

Address – Facility (Street / PO Box)	City	State	Zip Code	County

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

Telephone Number - Facility

FAX Number - Facility

E-mail Address – Facility

Name – Administrator

Birth Date – Administrator

E-mail Address - Administrator

Size of CBRF (Check one.)	Class / Type of CBRF (Check one.)
Size of CBRF (Check one.)	Class / Type of CBRF (Check one.)
Small (5-8 residents)	Ambulatory Class A (AA)	Ambulatory Class C (CA)
Medium (9-20 residents)	Semi-Ambulatory Class A (AS)	Semi-ambulatory Class C (CS)
Large (21 or more residents)	Non-Ambulatory Class A (ANA)	Non-ambulatory Class C (CNA)

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

Name – Licensee [Individual or Corporation (legal entity)]

Birth Date - Licensee

Street Address – Licensee

City

State

Zip Code

Telephone Number - Licensee

FAX Number - Licensee

E-mail Address - Licensee

F-60287 (03/2013)

Page 2 of 7

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

Name – Designated Mail Recipient

Title

E-mail Address

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) you are requesting to serve.

AA - Advanced aged

ALZ - Irreversible dementia/Alzheimer’s DD - Developmentally Disabled

MH - Emotionally disturbed/Mental illness ADA - Alcohol/Drug dependent

PD - Physically disabled

PWC - Pregnant women who need counseling

CC- Correctional clients TI - Terminally ill

TBI - Traumatic brain injury

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

Days

Hours

III. FINANCIAL INFORMATION

A current balance sheet must be submitted with this application.

Monthly Operating Expenses

All Salaries (licensee, caregivers, contract providers, etc.)	$

Lease or Mortgage	$

All Other (food, supplies, utilities, insurance, taxes, etc.)	$

TOTAL Monthly 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.

Savings or other financial reserves

Purchase contract (county agency or managed care organization) Outside employment

Line of credit Loan

Other (Specify.)

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.

F-60287 (03/2013)

Page 3 of 7

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.

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. (continued on next page)

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

Yes

No	If “Yes,” check below all that apply.

F-60287 (03/2013)					Page 4 of 7

		License Type		Certification Type	Registration Type
	a.	Foster Home (Children)	a.	Alcohol and Other Drug Abuse Program	a. Residential Care
	b.	Group Foster Home (Children)	b.	Mental Health Program	Apartment Complex
	c.	Residential Care Ctr. for Children & Youth	c.	Adult Day Care
	d.	Shelter Care (Children)	d. Certified Residential Care Apt Complex
	e.	Adult Family Home	e.	Other (Specify.)
	f.	Nursing Home
	g.	Hospital
	h. Community Based Residential Facility
	i. Day Care Center (family or group)
	j.	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

Township

Village

Name - Municipality

Name - Clerk

Address - Street / PO Box

City

State

Zip Code

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:

Operation

Yes

Building			Land
Building			Land
Yes	No	Yes	No

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

Governmental	Proprietary	Voluntary Non-Profit
City	Individual	Corporation
County	Partnership	Church
State	Corporation	Limited Liability Corp
Tribal	Limited Liability Corp

F-60287 (03/2013)

Page 5 of 7

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

Name (Last, First, MI)

Title

Percent of Financial Interest

Address – Street / P.O. Box		City	State	Zip Code

Name (Last, First, MI)	Title		Percent of Financial Interest

Address – Street / P.O. Box		City	State	Zip Code

Name (Last, First, MI)	Title		Percent of Financial Interest

Address – Street / P.O. Box		City	State	Zip Code

Name (Last, First, MI)	Title		Percent of Financial Interest

Address – Street / P.O. 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 through 15, allowing one set of questions for each different partnership, corporation, and other type of owner.

8Owner of the:

Building

Land

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

Governmental	Proprietary	Voluntary Non-Profit
Governmental	Proprietary	Voluntary Non-Profit
City	Individual	Corporation
County	Partnership	Church
State	Corporation	Limited Liability Corp
Tribal	Limited Liability Corp

10.Name and Address of the Owner

Name – Individual, Partnership, Corporation, etc.

Address – Street / P.O. Box

City

State	Zip Code

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

F-60287 (03/2013)

Name (First, Last, MI)

Page 6 of 7

Percent of Financial Interest

Address – Street / P.O. Box

City

State	Zip Code

Name (First, Last, MI)

Percent of Financial Interest

Address – Street / P.O. Box

City

State	Zip Code

12.Owner of the

Building

Land

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

Governmental	Proprietary	Voluntary Non-Profit
Governmental	Proprietary	Voluntary Non-Profit
City	Individual	Corporation
County	Partnership	Church
State	Corporation	Limited Liability Corp
Tribal	Limited Liability Corp

14.Name and Address of the Owner

Name - Individual, Partnership, Corporation, etc.

Address – Street / P.O. Box

City

State	Zip Code

15.List the interested parties relative to the entity in question 14. [Chapter 50.03(3), Wis. Stats.]

Name (First, Last, MI)	Title

Name (First, Last, MI)	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 / P.O. Box		City		State		Zip Code

Telephone Number	Type of Obligation		Extent of Obligation

Name - Individual, Partnership, Corporation, etc.

Address – Street / P.O. Box		City			State	Zip Code

Telephone Number	Type of Obligation		Extent of Obligation

Name - Individual, Partnership, Corporation, etc.

Address – Street / P.O. Box		City			State	Zip Code

Telephone Number	Type of Obligation		Extent of Obligation

F-60287 (03/2013)

Page 7 of 7

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 / P.O. Box		City		State	Zip Code

Telephone Number	Type of Agreement		Extent of Agreement

Name - Individual, Partnership, Corporation, etc.

Address – Street / P.O. Box		City		State	Zip Code

Telephone Number	Type of Agreement		Extent of Agreement

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)

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