F60945 Form – Fill Out and Use This PDF

ADULT FAMILY HOME INITIAL LICENSE APPLICATION

●Completion of this form is required by Chapter 50.033(2m), Wis. Stats., and DHS 88.03(2)(a), (b) and (4)(b), Wis. Admin. Code. Failure to complete this form accurately may result in licensure denial and/or delay in processing.

●Send the completed form with attachments listed below to the Division of Quality Assurance (DQA) regional office assigned to the county in which the facility is located. Contact the appropriate regional office if you have questions about completion of this form. Regional office locations can be found at: http://dhs.wisconsin.gov/bqaconsumer/AssistedLiving/ALSreglmap.htm

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

DHS / Division of Quality Assurance

Office of Caregiver Quality

P.O. Box 2969

Madison, WI 53701-2969

YES NO Does the licensee currently hold another type of license or certification?

Facility Administrator Information

Designated Mail Recipient (Provide contact information for the individual to whom mail from DHS/DQA is to be sent.)

RESIDENT INFORMATION

LICENSEE INFORMATION (Check only one box.)

If the licensee currently holds another type of license or certification, identify the type of license or certification from the following list.

The following information will be used to determine if the applicant meets the fit and qualified requirements under Chapter 50, Wis. Stats.

1.Has the licensee ever operated a residential facility, health care facility, or a day care program for adults or children in Wisconsin or in any other state?

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

3.Has the licensee ever had a license, certification or governmental approval to operate a facility / program denied, revoked, suspended or not renewed?

Date of Action:

MONTHLY FEES

Enter the minimum and maximum monthly fees charged for resident care in the space below. Include fees paid from all sources including government, private agencies, residents, and / or resident’s family.

∙A current balance sheet must be submitted with this application. (See DQA form F-62674A, Assisted Living Facility Model

Balance Sheet.)

∙Submit copies of financial documents verifying your ability to operate the facility for 60 days. This amount must be equal to or more than 2 times your 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.

NON RESIDENT INFORMATION

List below the names of all persons, age 10 and older, who live in the facility and are not a resident.

FIRE DEPARTMENT INFORMATION

Local fire departments have requested knowing where licensed facilities exist. The Division of Quality Assurance will send a copy of the license to the local fire department. Enter the fire department’s name, address, and telephone number below.

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

The licensee is responsible for notifying the Division of Quality Assurance, in writing,

of any changes in the information provided on this application.

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.).