Form 3681 A PDF Details

In May 2014, the Texas Department of Aging and Disability Services introduced a comprehensive framework aimed at streamlining the application process for Assisted Living/Residential Care (AL/RC), Out-of-Home Respite (OHR), and Adult Foster Care (AFC) through the Form 3681-A. This critical document serves as an Addendum A, detailing the prerequisites for entities seeking to establish or maintain their operations within these vital community services sectors. It encompasses a wide range of information, from the legal name of the entity and its doing business as (DBA) status to specific operational details such as facility physical address, assisted living facility license number, and the size of the establishment categorized by bed capacity. Moreover, it ventures into the licensure specifics, distinguishing between various types of assisted living facility licenses and outlining the program offerings alongside the number of beds dedicated to each program. Additionally, a significant portion of the form is dedicated to square footage calculations for both assisted living and residential care apartments, emphasizing the importance of space per resident to ensure comfort and compliance with regulations. Through a methodical approach, the form also guides applicants in assessing private and common area square footage, thereby ensuring facilities meet the minimum space requirements mandated for a quality living environment. This meticulous documentation underscores the state's commitment to safeguarding the well-being of its aging and disabled population by setting forth clear, comprehensive guidelines for service providers.

QuestionAnswer
Form NameForm 3681 A
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesdads ers form 3681c, section 7b form 3681, form 3681 application, form 3681

Form Preview Example

Texas Department of Aging

 

 

 

 

 

Form 3681-A

and Disability Services

 

 

 

 

 

May 2014-E

 

Assisted Living/Residential Care (AL/RC), Out-of-Home Respite (OHR) and Adult Foster Care (AFC)

 

Community Services Contract Application – Addendum A

 

 

 

 

 

 

 

 

1.

Legal Name of Entity

 

 

2. Doing Business As (DBA), if applicable

 

 

 

 

 

 

 

 

3.

Facility Physical Address (Street, City, State, ZIP code)

 

 

 

 

 

 

 

 

 

 

 

 

4.

Assisted Living Facility License No.

 

5. Size of Assisted Living Facility (Check one)

 

 

 

 

 

 

Small (16 or fewer beds)

Large (17 or more beds)

Other (specify):

 

 

 

 

 

 

 

 

6.

Licensed Capacity

 

7. Nursing Facility License No.

 

8. Type of Assisted Living Facility License (check one)

 

 

 

 

 

 

A

B

C

 

 

 

 

 

 

 

 

 

I.Assisted Living/Residential Care – Non-Apartment

Check the program(s) and enter the number of beds you wish to offer for each program.

Program

No. of Beds

Community Care for Aged and Disabled (CCAD)

Community Based Alternatives (CBA)

Community Based Alternatives Out-of-Home Respite (CBA-OHR)

II.Assisted Living/Residential Care – Personal Care 3

Check the program(s) and enter the number of beds you wish to offer for each program.

Program

No. of Beds

Community Based Alternatives (CBA)

III.Assisted Living/Residential Care – Assisted Living Apartment

1.Check the program(s) and enter the number of beds you wish to offer for each program.

2.Complete the Square Footage Calculation for Assisted Living Apartments table in this section.

Program

No. of Beds

Community Based Alternatives (CBA)

Community Based Alternatives Out-of-Home Respite (CBA-OHR)

Form 3681-A

Page 2 / 05-2014-E

1. Legal Name of Entity

2. Doing Business As (DBA), if applicable

III. Assisted Living/Residential Care – Assisted Living Apartment (continued)

Square Footage Calculation for Assisted Living Apartments

 

 

A.

 

B.

C.

D.

E.

 

 

 

Private Space Square Footage

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CBA

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Storage

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

 

 

 

 

F. Total Private Space Square Footage

 

 

 

 

 

 

 

(Sum E1-E4)

 

 

 

 

 

 

 

 

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

Private Space Square Footage

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CBA

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Storage

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

 

 

 

 

F. Total Private Space Square Footage

 

 

 

 

 

 

 

(Sum E1-E4)

 

 

 

 

 

 

 

 

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

Private Space Square Footage

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CBA

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Storage

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

 

 

 

 

F. Total Private Space Square Footage

 

 

 

 

 

 

 

(Sum E1-E4)

 

 

 

 

 

 

 

 

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

Private Space Square Footage

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CBA

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Storage

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

 

 

 

 

F. Total Private Space Square Footage

 

 

 

 

 

 

 

(Sum E1-E4)

 

1. Legal Name of Entity

Form 3681-A

Page 3 / 05-2014-E

2. Doing Business As (DBA), if applicable

IV. Assisted Living/Residential Care – Residential Care Apartment

Check the program(s) and enter the number of beds you wish to offer for each program.

Program

No. of Beds

Community Care for Aged and Disabled (CCAD)

Community Based Alternatives (CBA)

Community Based Alternatives Out-of-Home Respite (CBA-OHR)

Square Footage Calculation for Residential Care Apartments

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

 

Private Space Square Footage

 

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CCAD

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

CBA

 

 

4.

Storage

 

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

F. Total Private Space Square Footage (Sum E1-E4)

G. Private Space Square Footage per Resident (F ÷ 2)

H. Allocated Common Area Square Footage (See footnote below.)

I. Total Square Footage per Resident (G + H)

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

 

Private Space Square Footage

 

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CCAD

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

CBA

 

 

4.

Storage

 

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

F. Total Private Space Square Footage (Sum E1-E4)

G. Private Space Square Footage per Resident (F ÷ 2)

H. Allocated Common Area Square Footage (See footnote below.)

I. Total Square Footage per Resident (G + H)

Footnote: If the private space square footage per resident (G) is less than 350 square feet, complete the Allocated Common Area Calculation table in this section and enter the result here.

Form 3681-A

Page 4 / 05-2014-E

1. Legal Name of Entity

2. Doing Business As (DBA), if applicable

IV. Assisted Living/Residential Care – Residential Care Apartment (continued)

Square Footage Calculation for Residential Care Apartments

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

 

Private Space Square Footage

 

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CCAD

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

CBA

 

 

4.

Storage

 

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

F. Total Private Space Square Footage (Sum E1-E4)

G. Private Space Square Footage per Resident (F ÷ 2)

H. Allocated Common Area Square Footage (See footnote below.)

I. Total Square Footage per Resident (G + H)

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

 

Private Space Square Footage

 

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CCAD

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

CBA

 

 

4.

Storage

 

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

F. Total Private Space Square Footage (Sum E1-E4)

G. Private Space Square Footage per Resident (F ÷ 2)

H. Allocated Common Area Square Footage (See footnote below.)

I. Total Square Footage per Resident (G + H)

 

 

 

A.

 

B.

C.

D.

E.

 

 

 

 

Private Space Square Footage

 

 

 

Identifying Information

 

Private Space Area

Area Width

Area Length

 

 

 

 

 

 

 

 

(CxD)

Apt. No.

 

Address

1.

Living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Bedroom

 

 

 

Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Kitchen

 

 

 

CCAD

CBA-OHR

 

 

 

 

 

 

 

 

 

 

 

CBA

 

 

4.

Storage

 

 

 

 

 

 

 

 

(within private Space Area)

 

 

 

F. Total Private Space Square Footage (Sum E1-E4)

G. Private Space Square Footage per Resident (F ÷ 2)

H. Allocated Common Area Square Footage (See footnote below.)

I. Total Square Footage per Resident (G + H)

Footnote: If the private space square footage per resident (G) is less than 350 square feet, complete the Allocated Common Area Calculation table in this section and enter the result here.

Form 3681-A

Page 5 / 05-2014-E

1. Legal Name of Entity

2. Doing Business As (DBA), if applicable

IV. Assisted Living/Residential Care – Residential Care Apartment (continued)

Allocated Common Area Calculation

Address

A.

B.

C.

E.

Area Square Feet

Useable Area Description

Area Width

Area Length

(BxC)

 

 

 

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

E. Useable Common Area Square Footage (Sum of D 1-10)

F. Licensed Capacity

G. Allocated Common Area Square Footage per Resident (C+F)

1. Legal Name of Entity

Form 3681-A

Page 6 / 05-2014-E

2. Doing Business As (DBA), if applicable

V.Adult Foster Care

Check the program(s) and enter the number of beds you wish to offer for each program.

Program

AFC Level (I,II or III)

No. of Beds

Community Care for Aged and Disabled (CCAD)

Community Based Alternatives (CBA)

Community Based Alternatives Out-of-Home Respite (CBA-OHR)

Square Footage Calculation for AFC Bedrooms

 

A.

 

B.

C.

D.

E.

 

 

Area Square Feet

Bedroom No. and Occupancy

 

Program

Bedroom Width

Bedroom Length

 

(CxD)

 

 

 

 

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

Bedroom No.

 

 

CCAD

 

 

 

Single (80 sq. ft)

 

CBA-OHR

 

 

 

Double (120 sq. ft)

 

CBA

 

 

 

 

 

 

 

 

 

 

Form 3681-A

Page 7 / 05-2014-E

1. Legal Name of Entity

2. Doing Business As (DBA), if applicable

VI. Other Out-of-Home Respite

Check the program(s)/setting(s) you wish to offer.

CBA Out-of-Home Respite Nursing Facility

VII. Certification

I certify that all information provided in this application is true and correct.

If applicable, I also certify that the bedrooms(s)/apartment(s) documented above have previously been approved under a DADS contract and

were removed from a DADS contract on. I further certify that the bedroom(s)/apartment(s) have not been modified since they were under a DADS contract.

 

Signature – Authorized Person

 

 

Date

 

 

 

 

 

Name of Authorized Person (please print or type)

 

Title of Authorized Person (please print or type)

 

 

 

 

 

 

 

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Completing this form requires care for details. Ensure each field is completed correctly.

1. While submitting the hhsc form 3681, be certain to complete all necessary blanks within its corresponding form section. It will help facilitate the work, which allows your details to be processed quickly and properly.

Filling in part 1 in texas dads form 3681

2. Once your current task is complete, take the next step – fill out all of these fields - Program, No of Beds, Community Based Alternatives CBA, and Community Based Alternatives with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step no. 2 for completing texas dads form 3681

Lots of people generally get some things wrong when completing Community Based Alternatives CBA in this part. Ensure that you reread whatever you enter right here.

3. This next portion will be focused on Identifying Information, Private Space Area, Area Width, Area Length, CxD, Apt No, Address, Program, CBA, CBAOHR, Living, Bedroom, Kitchen, Storage, and within private Space Area - complete each one of these empty form fields.

Completing part 3 of texas dads form 3681

4. Filling out Identifying Information, Private Space Area, Area Width, Area Length, CxD, Apt No, Address, Program, CBA, CBAOHR, Living, Bedroom, Kitchen, Storage, and within private Space Area is paramount in this next section - you should definitely don't hurry and take a close look at every empty field!

Stage number 4 for completing texas dads form 3681

5. The document should be finished by filling in this area. Here you can find a full set of blanks that have to be filled out with correct information for your document submission to be complete: Program, No of Beds, Community Care for Aged and, Community Based Alternatives CBA, Community Based Alternatives, Square Footage Calculation for, Identifying Information, Private Space Area, Area Width, Area Length, Private Space Square Footage, CxD, Apt No, Address, and Program.

Completing section 5 of texas dads form 3681

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