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6776 SW 64 ST_GREEN MISC m wog City of South Miami 6130 Sunset Drive,South Miami,Florida 33143 September 8, 1999 Juan Ramos 6776 SW 64 Street South Miami, FL 33143 Dear Mr. Ramos: Re: 6776 SW 64 Street(or Hardee Drive) I am writing in regard to your request involving the opening of an Adult Day Care Center at the above-referenced address in the City of South Miami. First, I apologize for the delay in this written response to your application,which was received on or about June 10, 1999. As you know from our past telephone conversations, however, I have been reviewing your request in regard to complying with this municipality's local zoning code (reference item number 5,Zoning Approval, of the cover letter included in the application package). As part of my review of your application, I have tried to determine whether or not an Adult Day Care Center (ADCC) may be considered a Community Residential Home (CRH), a category that is included in the city's code and which includes an adult living facility(ALF). Over the past two months (July and August), I have attempted to get adequate responses to questions and concerns I felt necessary to ask in making a well-informed determination that would comply with the city's zoning code. To date, I have been unsuccessful with each and every agency or person contacted and,unfortunately,I must return your application. In closing, Mr. Ramos, may I suggest that you resubmit an application for an ALF, which we received in May 1999, and perhaps attempt to co-locate an ADCC program with the ALF having a maximum of six persons. If you should need further assistance or information, please contact me at 305.663.6326. Thank you. Sincerely yours, David Struder Planning&Zoning Department "City of Pleasant Living" 4 STATE OF FLORIDA AGENCY-FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE ADULT DAY CARE CENTER LICENSE APPLICATION FORMS AND DOCUMENTATION BUREAU OF HEALTH FACILITY REGULATION ASSISTED LIVING UNIT Y AHCA AGENCY FOR HEALTH CARE ADMINISTRATION Dear Applicant: -- Attached please find information and forms needed to apply for a license as an Adult Day Care Center(ADCC). Also enclosed are copies of Chapter 400, Part V, Florida Statutes, Chapter 58A-6, Florida Administrative Code,the laws and regulations governing the licensing of an ADCC. Please read this information carefully before completing the forms. All forms must be completed fully and accurately before an application can be reviewed by the Agency for Health Care Administration(AHCA) and before a center can be scheduled for a survey by the agency area office. An incomplete application form will be returned for completion. Applications received without the license fee will be returned without processing. The application fee of$150.00 must be in the form of a check or money order made out to the State of Florida and is not refundable. Centers owned and operated by a county or municipality are exempt from the payment of a license fee. By the time you are ready to submit the completed application form,the fee and all the appropriate forms and information,your center should be ready, or very close to being ready,to have a survey conducted by the agency area office. Once a completed application has been received,the agency will send you a letter giving you 21 days to write the local agency office to schedule a survey. Failure to contact the agency within the 21 days will result in an initial application being denied. The ADCC applicant would have to start the licensing process over again and pay another fee. Information and instructions provided on the following pages are to assist you in understanding what the forms in this package are for and how to complete them. 1. Adult Day Care Center License Application,ADCC Form-1. September 1998 The enclosed application must be completed in its entirety, signed, dated, and notarized in order for your center to be considered for a license. The Chief Executive Officer of the center's governing authority must sign the application. Section I Day Care Center Information. Complete all the information requested. Be sure to show the name and correct street address of the center as you want it to appear on the license. Section II Owner Information. Specify if the center is owned by an individual(s), corporation, or trust. If a corporation owns the center complete all information requested regarding the officers in the appropriate spaces and list the corporations name under Center Owner's name. STATE OF FLORIDA - AGENC-Y- FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE 2727 MAHAN DRIVE - TALLAHASSEE, FLORIDA - 32309 Y Section III Service Provision. Check all of the services provided by the center.and.describe the frequency that the services will be provided. Keep in mind that the services listed under "required basic services"are required to be provided by law. Section IV Affidavit. This section must be signed, dated and notarized prior to submission. 2. Proof of Liability Insurance Proof of current liability insurance coverage for the operation of the ADCC must be submitted as required in Section 400.555(2)(c)Florida Statutes and Chapter 58A-6.003(5)(b),Florida Administrative Code. A copy of the certificate of insurance or a copy of the policy declaration page that includes the name and address of the center,the type of insurance issued, and the dates of coverage must be submitted. Binders are not acceptable. For required amounts of coverage please refer to Chapter 58A-6.003(5)(b),Florida Administrative Code. 3. Assets and Liabilities Statement This form is asking for the total amounts of the applicant's (owner, corporation, governing authority) assets, liabilities and equities. You must be able to show that you have the financial ability to operate and that your total assets equal total liabilities and equity. Additional instructions are located on the back of the form. 4. ADC Statement of Operations This is a projection of expected income and expenditures. Columns should total across and down. Project the number of participants you will have and how long it will take to reach your allowed capacity. You may want to seek the help of an accountant or bookkeeper to help you with this form. There are additional instructions on the back of the form. 5. Zoning Approval An Adult Day Care Center must comply with local zoning requirements. You must contact the local zoning office for the city or county where the center is located and submit approval from the local zoning authorities with your application. 6. Background Screening Requirements In 1998,new legislation was enacted concerning criminal and Florida Abuse Registry background screening requirements for Adult Day Care Centers. Please read very carefully the enclosed"Adult Day Care Center(ADCC) Background Screening Forms and Instructions"for detailed information about screening requirements, forms, and fees. 7. Addendum to Application The Addendum to application, Attachment E of the Adult Day Care Center(ADCC)Background Screening Forms and Instructions must be completed confirming whether or not the applicant, board member, officer,partner, or person owning 5%or more of the facility has been terminated, permanently suspended, or excluded from Medicare or Medicaid in any state. STATE OF FLORIDA - AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE 2727 MAHAN DRIVE - TALLAHASSEE, FLORIDA - 32308 i 8. Fire Safety Inspection An ADCC shall comply with applicable local fire safety standards. The applicant must furnish proof that the center has received a satisfactory fire safety inspection by the local fire safety authorities. 9. Food Service Inspection You must provide a copy of the food service report as proof that the center has received a satisfactory food service inspection from your local public health unit. 10. Change of Ownership Any Change in ownership during-the 2 year period covered by your license will require that the new owners file a new application. The AHCA must be notified a minimum of 60 days prior to the date of a change of ownership. 11. ADC Operator Identification Statement If the center operator changes during the period for which a license is issued,the owner or new operator must notify AHCA,Assisted Living Unit within 30 days and submit the completed abuse registration and criminal background check forms, and the required fees. 12. Submit Application To: Agency for Health Care Administration Assisted Living Unit 2727 Mahan Drive Tallahassee,Florida 32308-5403 Be sure to keep a copy of all the information you submit to the agency for your record. We look forward to working with you to provide quality services for ADCC participants. If you have any questions regarding this application material,please contact this office at (850)487-2515. Sincerely, Agency for Health Care Administration Division of Health Quality Assurance Assisted Living Unit STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE 2727 MAHAN DRIVE TALLAHASSEE, FLORIDA • 32309 Adult Day Care Center_ Application for License Initial Change of Ownership Renewal Capacity Increase/Decrease Section 1�Day Care Center Information • r��u� � � �r ��, > � � �� s '��#§� � �'� �� '�s Nameraf Center: County: Mailing Address: Street Address: City: -Zip Code: Telephone#: (_) Maximum participant capacity Total space available for participants: _'M„s of"` a�r. l§;xi''4q•,,0ap Section 2 owner Infoimatton _ � .� d .g.... ,,:� '-,N�.•,l.e „.r,,... x, „ .> WHAM Center Owner's Name: Owner's Address: Street/P.O.Box City State Center Operator's Name: Financial Officer's Name: Is this day care center owned by a county or municipal agency? Yes No Is this day care center operated by a county or municipal agency? Yes No Is this day care center owned by a corporation or trust? Yes No . For profit?Yes No If owned by a corporation or trust,provide the name, address, and date of birth for the following: President's Name: DOB: Street Address: City: State: Zip: Vice-President's Name: DOB: Street Address: City: State: Zip: Secretary's Name: DOB: Street Address: City: State: Zip: Treasurer's Name: DOB: Street Address: City: State: Zip: ADCC Form-1,September 1998 ti .-e. .,gyp �"skro.r�t x^asvrc�e ..� tea..: Section 3 Service�rovlSi4 ��k fi CGS £ 3 8 Av 9 .,ec `�.° -e D. _ &r Identify below all the`basic and optional services provided by the center by indicating the frequency with which the services are provided. No indication of frequency-assumes the service is not provided. Required Basic Services Frequency Optional Services Frequency Protective Environment Speech Therapy Social activities Physical Therapy Therapeutic activities,... Occupational Therapy Leisure activities Transportation Self-care training Follow-up Services Nutritional Services Adult Day Health Care Respite care Rest periods .S'eGtlOn 4lffidavlt � � _ ,z a r x r �sr 01 The undersigned hereby swears (or affirms)that the statements in this application, and its attachments, are true and correct and that to the best of my knowledge and belief, all persons in ownership or employment are of good moral character, and that the ownership possesses sufficient funds to operate this day care center in a satisfactory manner. I further agree to comply with all applicable civil rights laws,rules and regulations regarding admissions of participants to the center. I am aware that providing false or misleading information on this application may result in license denial or revocation. Signature of Center's Chief Executive Officer Chief Executive Officer's Printed Name NOTARY: State of County of On this day of , 19_,before me personally appeared , whom I know personally/whose identity was proved to me on the oath of , a credible witness by me duly sworn/whose identity was proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same. Notary Public Signature SEAL: My commission expires ADCC Form-1,September 1998 ti H W, H C, H H dl V O 11 0 H � •a H ' y H $4 U bl CI W 7 '� a •rl N iai o rl C: -'d H l� rl H 0 C: O H a O � > a COD z a (1) x •r+ .0 4-1 rl V H U 1+1 H a V CT' b .k � H Ei W r1 W Id .H.. b .H� b V W W 4.) O W w p a ++ a rn U) N r. o m a�i a 4.) 4N ° i Co a H N U O N m rb l EA E-4 H Z $4 a z O HO O NO 0 O DI N b QI a U H O H O C� H O H H E a H ca w H N H EH H w a N H V �a z a w u U N N rn rn 4► 0 t q 4 H H N al W O N dl .l.l _ 4J , E al U i,Cl m A r I �.. H N d) di 10 N G! b O Cl O O 13 N Q to U' rl � $1 8 � 0 � � � 0 � a dl H 01 a (1 d) o rn U (d •ri U fd 0 0) H rn r-I U i► U 4.) Vl U •rl 'b J.) U -rl a 4-) w H Id H 1.7 a `' r-1 N r..� a GU) •H -ri - rl �W a m & a H m o m 3 H N b ¢. aw N H 43 0) C x 47 O O d) N O b r i d! W rl d) m w O d) v1 C: 0 U v H V R r1 rl A r I A 4.)N H cd O d) U O 1► m U m m $4 z a z O — a ov z wv z O U w t INSTRUCTIONS FOR COMPLETING THE Land-Enter the amount paid for the land or fair market value as ASSETS AND LIABILITIES STATEMENT applicable. r INTRODUCTION Buildings-Enter the amount paid for the building or fair market value The Assets and Liabilities Statement(balance sheet)of owner identifies as applicable. If the building has been depreciated,list the amount the assets which will be available,as of the date this Statement is depreciated and subtract it from the original cost to obtain amount. completed,for use in operating the Adult Day Care Center(ADCC),and the current liabilities which represent claims of creditors against these Equipment-Enter the amount paid for the equipment or the fair assets. market value as applicable. If the equipment has been depreciated,list the amount depreciated and subtract it from the original cost to obtain INSTRUCTIONS FOR COMPLETING THE FORMS the figure"net equipment". Because this form has been designed to accommodate the spectrum of ADCC from-small individual propiietorsto corporations rraaWofthe Liabilities blanks will be applicable to all ADCC. As a result,it is anticipated that Liabilities-Liabilities are claims of outsiders against the ADCC or the in many cases several of the lines will be left blank and in other cases amount that the ADCC owes to persons other than the owners. several of the lines will need to be added under the"other"categories. Liabilities are reported as the amount owed as of the assests and liabilities statement date,including interest accumulated to date. Intrest The left hand or asset side of the form is completed by filling in the that will be owed subsequent to the assets and liabilities statement date applicable blanks of the current and fixed asset category and totaling as is excluded. indicated. Similarly,current liabilities,other liabilities,and stockholders'or owners'equity should be totaled to obtain total equities Current Liabilities-These are existing liabilities which must be paid for the right hand or liabilities and equity side of the balance sheet. within the next twelve(12)months. Total assets and total equity must equal. Definitions of the individual components of the balance sheet are as follows. Accounts Payable-the amount entered here should include the sum of the total unpaid salaries and payments of all unpaid bills and financial Assets obligations which fall due within the next(12)months with the Current Assets-These are assets which can be converted to cash exception of mortgage payments and installment loans. Examples quickly and are therefore reserved as ready sources of cash to meet include utility bills,unpaid wages to current employees,if any,charge immediate requirements. accounts and credit cards such as VISA,Master Card,American Express,etc. Cash-Enter the total of all forms of cash you have available which will be used to support operation of the ADCC. Items to be used to compute Notes Payable-This amount should include all payments which must this value include currency,cash in checking accounts and on passbook be made within the next twelve(12)months on existing contracts, savings accounts. The amount shown must be available now and mortgages and installment loans. available to support the operation of the center. Other-This amount should include any other existing obligations Monetary Investments-Monetary investments include primarily three which are due during the next twelve(12)months. It includes payments items:Certificates of Deposits,saving bonds and treasury bills or bonds of obligations which are in arrears such as income taxes,property taxes, owned by the applicant and identified for immediate use in operating insurance,etc.,Each item in this category must be itemized separately. the center. Other Liabilities-These are claims of outsiders that do not fall due Negotiable Securities-These include stocks,corporate bonds,etc., within one year. which are owned by the applicant and are identified for use,if necessary,in operating the center. Mortgage Payable-These include all first,second and other mortgages owed. Includes the unpaid balance of mortgages owed on land, Accounts Receivable-Any monies owed to the applicant which are building,equipment or other assets. due within one year and would be used as they materialize,if necessary in support of center operations. Stockholders'or Owners'Equity -The stockholders'or owners' equity section of the balance sheet shows the claims of the owners or Notes Receivable-Any promissory notes held by the applicant which stockholders. fall due within one year of the date of application and whose proceeds would be used,if necessary,to operate the center. Common Stock or Capital-The amount listed here is the stated value of the stock which may be the par value of the stock price if it was sold, Other-Any other assets such as prepaid expenses which could be or some other figure fixed by the board of directors. converted into cash within the operating year and used for operation of the center. Owners'Equity-The amount listed here is completed for ` proprietorship or partner's and is the amount of capital placed in the Fixed Assets-These are tangible,relatively long-lived resources. If ADCC by the owner(s). they have been acquired in the last year,they must be listed at the actual measurable money amount they were acquired for. If they have been Appreciated Value-This line will be completed when fixed assets on owned for more than one year,such as a person who is converting his debit side have been listed at their market value rather than their home into an ADCC,they should be listed at their fair market value. purchase price. This line should reflect the amount the assets(primarily Although this method of determining value is needed to adequately land and buildings)have appreciated over the purchase price. analyze an ADCC's ability to operate,operators are cautioned that generally accepted accounting principles require that assets be listed at Retain Earnings-The amount listed here should include the earnings the dollar amount actually paid for them. As a result this statement may of the ADCC to date,less the amount paid out in dividends. If the not be appropriate for other uses by the ADCC such as income tax-- difference is negative the item is labeled deficit. preparation. N r � .s U � o I SO d U Q ' d w O z a M U w O N w W Mj W rn En En b Cd - H to bA U N U U Cn U y U N U bA y rte. C3, Cd 0-4 O O O d d z ti INSTRUCTIONS FOR COMPLETING THE ! STATEMENT OF OPERATIONS""'- Raw Food-The amount to be entered here is the anticipated cost of food to be used in the ADCC. It includes the food required for at least INTRODUCTION one meal each day,and the cost of snacks which are required to be available on a daily basis. This amount should not include the cost of The Statement of Operations Form provides financial information food that is provided for the staff. regarding anticipated revenue(income)to the ADCC as well as anticipated operating expenses for 12 months of operation. Salaries and Wages-The cost of salaries and wages for all staff except the licensee or administrator's salary. INSTRUCTIONS FOR COMPLETING THE FORM Administration-This.entry.shot)dshow.the.costof.publicati®ns,.-- - - The Statement of Operations Form has been designed to accommodate organizational dues,accounting/bookkeeping services and the owner's the spectrum of ADCC from small individual proprietors to licensee's or administrator's salary. Any other cost associated with corporations. As a result,in some cases many of the lines will not be administrative functions of center operations should also be included. applicable and should be left blank. In other cases additional items will need to be added to the"other"categories. Amounts entered are to be Utilities-The cost of electricity,water,sewer,garbage,gas and/or oil based on valid sources of revenue and a realistic determination of used to heat or cool the center and hot water should be listed. anticipated expenses. The requested date is critical to the evaluation of the ADCC's capability to operate effectively and meet essential Maintenance and Repair-This entry should reflect the cost of all financial obligations during the first 12-months of operation. When items used to maintain and carry out necessary repairs on the center. completing this form do not include any revenue or expenses which are This would include such items as paint,lumber,nails,roofing materials not directly associated with operations of the ADCC. and grass seed. To predict the success or failure of the ADCC as accurately as possible, Depreciation-Include any depreciation expense on capital equipment the revenues and expenses on the Statement of Operations Form are in this item. displayed monthly for the first 12 months of operations. In this manner it can be demonstrated when probable early losses become profits. At Rent-The cost of centerrent should be included here(if the center is the option of the ADCC operator,additional months may be projected. paid for there would not be an entry here or in mortgage). Definitions of each of the items listed on the Statement of Operations Mortgage-The cost of mortgage interest payment for.the center Form is as follows: should be reflected here. The portion of the mortgage payment applied" to principal should not be included but should be footnoted at the Average Number of Participants-Indicate the anticipated number of bottom of the page(*). participant each month. Taxes-Enter the amount of all taxes which must.be paid by the Average Participant Fee-Indicate the proposed fee to be charged each center. This would include employer's FICA(Social Security)taxes, participant. If variable rates are charged,list the average fee. Florida and Federal Unemployment taxes which must be paid on employee's salaries and wages,as well as business license taxes and real Anticipated Revenue(Income)-This section should reflect anticipated estate taxes(if not included as part of the mortgage payment),etc. monthly income from valid sources to the ADCC. It should not include the personal income of the applicant(s)unless this income is to be used Motor Vehicle Expenses-Include here all expenses related to the for operating the center. Amount shown should be as accurate as maintenance,operation and insurance costs of cars,van,trucks,etc., possible and supported by confirming documentation to the maximum owned by the center and used in support of the operation of the center. extent feasible. Interest and Insurance-The cost of all insurance for the physical Fees for Participants-The anticipated revenue which will be received plant,such as fire and liability insurance,is shown here,as well as each month as fees or payment for participant'care should be entered interest payments on any outstanding long-term debts not included in here. This figure can be obtained by multiplying the number of the rent and mortgage payments. Payment to mortgage principal should participants by the applicable monthly participant fee and adding the be footnoted and included as provided at the bottom of the page(*). resulting two figures together. Other-Include the cost of any other items of expense not included in Endowments/Trust Fund(s)-Enter revenue to be received for the next the above items. Specify each item of expense 12 months from any endowment or trust funds which currently exist and the expense amount. and would provide income to be used to support center operations. Total Expense-Include the total of all of the expenses listed in this Income From Investments-Enter income to support center operations item. which will be provided by existing investment. Net Income(Loss)-Subtract the total expense line from the total Other(Specify)-Enter the amount of income to be received from any revenue line to get the net income(loss). other source(s)which will be used to operate the center.Specify each Principal Paid-List the amount of principal paid for mortgages. source and the amount. Anticipated Expenses-This section should reflect the anticipated expenses necessary for operation of the ADCC. As such,it shows the anticipated monthly operating expenses for the first 12 months of operation. AH CA AGENCY FOR HEALTH CARE ADMINISTRATION Adult Day Care Center Operator Identification Statement In accordance with Florida Statutes, Section 400, Part V, and Chapter 58A-6,Florida Administrative Code; it is necessary to provide.the Agency For Health Care Administration with the following information about the operator of an Adult Day Care Center. PLEASE PRINT LEGIBLY CENTER NAME: OPERATOR'S NAME: RACE: Male_ Female_ DATE OF BIRTH: MO. DAY YEAR SOCIAL SECURITY NUMBER: HOME ADDRESS: Street Address and P.O.Box(if any) Apt./Lot# City State Zip Code County Have you ever been arrested or convicted of a crime? Yes No If yes,what was the charge? Where arrested/convicted? Dates(s) of arrest(s)/conviction(s) Signature of Operator Date STATE OF FLORIDA AGENCY--FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE 2727 MAHAN DRIVE • TALLAHASSEE, FLORIDA • 32308 t . y AHCA AGENCY FOR HEALTH CARE ADMINISTRATION ADULT DAY CARE CENTER ZONING INFORMATION NOTICE: The information required on this form must be completed by the LOCAL ZONING official/authority,not by the Adult Day Care Center operator. Send To: Agency for Health Care Administration Assisted Living Unit 2727 Mahan Drive Tallahassee, Florida 32308-5403 Name of Center: Center Street Address: City, State, Zip Code: The maximum capacity of this center/building is participants. The location of the above referenced Adult Day Care Center has been reviewed and found that it is properly zoned according to local codes. NOTE: If more than one building is being reviewed for zoning as part of this Adult Day Care Center, on the same or connecting property, each building and its participant capacity must be listed below. Building#2 Address: Capacity: Building#3 Address: Capacity: Zoning Official's Signature: Date: Official's Printed Name: Zoning Official's Title: Zoning Agency's Name: Agency Street Address: City,Zip Code, Telephone#: STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE 2727 MAHAN DRIVE • TALLAHASSEE. FLORIDA • 32308 i t ADULT DAY CARE APPLICATION CHECKLIST This checklist is a guide to assist you in making sure you have included all of the required forms and documents necessary for the processing of your application. Be sure the forms/documents are complete. IMTIAL APPLICATIONS OR CHANGE OF OWNERSHIP APPLICATIONS 1. A completed, signed, dated, and notarized application form 2. Application fee (check/money order payable to the State of Florida for$150.00)unless you are exempt by law as stipulated under Chapter.400.554(4),F.S. 3. Verification of current liability insurance (refer to Chapter 58A-6.003(5)(b)for specific amounts of insurance required) 4. Assets and Liabilities Statement(a financial audit of the most recent fiscal year may be submitted) 5. Statement of Operation 6. A completed FBI fingerprint card,Florida Department of Law Enforcement and Florida Abuse Registry form for owner(s), if the owner(s)are individuals, operator, and financial officer, or documentation of compliance with the background screening requirements as stipulated in the enclosed Adult Day Care Center Background Screening Forms and Instructions. 7. The appropriate fees to cover the cost of background screening as designated in the ADCC background Screening Forms and Instructions. 8. Addendum To Application(Attachment E of the ADCC Background Screening Forms and Instructions.) 9. Documentation of local zoning approval 10. Proof of a satisfactory fire safety inspection 11. Center Operator Identification Statement 12. Proof of a satisfactory food service inspection RENEWAL APPLICATIONS 1. A completed, signed, dated, and notarized application form 2. Application fee (check/money order payable to the State of Florida for$150.00)unless you are exempt by law as stipulated in Chapter 400.554(4), F.S. 3. Verification of current liability insurance (refer to Chapter 58A-6.003(5)(b)for specific amounts of insurance required) 4. Proof of financial ability to operate (financial audit of the most recent fiscal year) 5. A completed FBI fingerprint card,Florida department of Law Enforcement and Florida Abuse Registry form on the owner(s), if the owner(s) are individuals, operator, and financial officer of the ADCC, or documentation of compliance with the background screening requirements as stipulated in the enclosed Adult Day Care Center Background Screening Forms and Instructions. Please read this information thoroughly. 6. The appropriate fees to cover the cost of background screening as designated in the ADCC Background Screening Forms and Instructions. 7. Affidavit of Compliance with level 1 and level 2 background screening requirements (Attachment G in the ADCC Background Screening Forms and Instructions. 8. Late fee of$75.00 if application is mailed less than 90 days prior to date of licensure expiration 9. Center Operator Identification Statement CAPACITY EXPANSION 1. A completed, signed, dated, and notarized application form 2. Documentation of local zoning approval 3 A satisfactory fire safety inspection authorizing the increase in capacity. AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE r ADULT DAY CARE CHAPTER 400, PART V FLORIDA STATUTES HEALTH STANDARDS AND QUALITY UNIT PART V ADULT DAY CARE CENTERS 400.55 Purpose. 400.551 Definitions. 400.552 Applicability.. 400.553 Exemptions; monitoring of adult day care center programs colocated with assisted living facilities or licensed nursing home facilities. 400.554 License requirement; fee; exemption; display. 400.555 Application for license. 400.556 Denial, suspension, revocation of license; administrative fines; investigations and inspections. 400.5565 Administrative fines; interest. 400.557 Expiration of license; renewal; conditional license or permit. 400.5571 Patients with Alzheimer's disease or other related disorders; certain disclosures. 400.5572 Background screening. 400.5575 Disposition of fees and administrative fines. 400.558 Injunctive relief. 400.559 Closing or change of owner or operator of center. 400.56 Right of entry and inspection. 400.562 Rules establishing standards. 400.563 Construction and renovation; requirements. ' 400.564 Prohibited acts; penalty for violation. 400.55 Purpose.—The purpose of this part is to develop, establish, and enforce basic standards for adult day care centers in order to assure that a program of therapeutic social and health activities and services is provided to adults who have functional impairments, in a protective environment that provides as noninstitutional an atmosphere as possible. History.—s. 1,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss. 1, 17,ch.93-215. 400.551 Definitions.—As used in this part,the term: (1) "Adult day care center" or "center" means any building, buildings, or part of a building, whether operated for profit or not, in which is provided through its ownership or management, for a part of a day, basic services to three or more persons who are 18 years of age or older; who are not related to the owner or operator by blood or marriage, and who require such. services. (2) "Agency" means the Agency for Health Care Administration. (3) "Basic services" include, but are not limited to,providing a protective setting that is as noninstitutional as possible; therapeutic programs of social and health activities and services; leisure activities; self-care training; rest; nutritional services; and respite care. (4) "Department" means the Department of Elderly Affairs. (5) "Multiple or repeated violations" means 2 or more violations that present an imminent danger to the health, safety, or welfare of participants or 10 or more violations within a 5-year period that threaten the health, safety, or welfare of the participants. (6) "Operator" means the person having general administrative charge of an adult day care center. (7) "Owner" means the owner of an adult day care center. (8) 'Participant" means a recipient of basic services or of supportive and optional services provided by an adult day care center. (9) "Supportive and optional services" include,but are not limited to, speech, occupational, and physical therapy; direct transportation; legal consultation; consumer education; and referrals for followup services. History.—s.2,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss.2, 17,ch.93-215;s.55,ch.95-418. 400.552 Applicability.—Any facility that comes within jhe definition of an adult day care center which is not exempt under s. 400.553 must be licensed by the agency as an adult day care center. History.—s.3,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss.3, 17,ch.93-215. 400.553 Exemptions; monitoring of adult day care center-programs colocated with assisted living facilities or licensed nursing home facilities.— (1) The following are exempt from this part: (a) Any facility, institution, or other place that is operated by the Federal Government.or: any agency thereof. (b) Any freestanding inpatient hospice facility that is licensed by the state and which provides day care services to hospice patients only. (2) A licensed assisted living facility, a licensed hospital, or a licensed nursing home facility may provide services during the day which include, but are not limited to, social, health, therapeutic, recreational, nutritional, and respite services, to adults who are not residents. Such a facility need not be licensed as an adult day care center; however, the agency must monitor the facility during the regular inspection and at least biennially to ensure adequate space and sufficient staff. If an assisted living facility, a hospital, or a nursing home holds itself out to the public as an adult day care center, it must be licensed as such and meet all standards prescribed by statute and rule. History.—s.4,ch.78-336;s.2,ch.81-318;ss.79,83,ch. 83-181;s.6,ch.88-235;ss.4, 17,ch.93-215;s.20, ch.95-210. 400.554 License requirement; fee; exemption; display.- (1) It is unlawful to operate an adult day care center without first obtaining from the agency a license authorizing such operation. The agency is responsible for licensing adult day care centers in accordance with this part. (2) Separate licenses are required for centers operated on separate premises, even though operated under the same management. Separate licenses are not required for separate buildings on the same premises. (3) The biennial license fee required of a center shall be determined by the department, but may not exceed $150. (4) County-operated or municipally operated centers applying for licensure under this part are exempt from the payment of license fees. (5) The license for a center shall be displayed in a conspicuous place inside the center. (6) A license is valid only in the possession of the individual, firm,partnership, association, or corporation to which it is issued and is not subject to sale, assignment,or other transfer, voluntary or involuntary; nor is a license valid for any premises other than the premises for which originally issued. History.—s.5,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss.5, 17,ch.93-215. 400.555 Application for license.— (1) An application for a license to operate an adult day care center must be made to the agency on forms furnished by the agency and must be accompanied by the appropriate license fee unless the applicant is exempt from payment of the fee as provided in s. 400.554(4). (2) The applicant for licensure must furnish: (a) A description of the physical and mental capabilities and needs of the participants to be served and the availability, frequency, and intensity of basic services and of supportive and optional services to be provided; (b) Satisfactory proof of financial ability to operate and conduct the center in accordance with the requirements of this part,which must include, in the case of an initial application, a 1-year operating plan and proof of a 3-month operating reserve fund; and (c) Proof of adequate liability insurance coverage. (d) Proof of compliance with level 2 background screening as required under s. . 400.5572. (e) A description and explanation of any exclusions,permanent suspensions, or terminations of the application from the Medicare or Medicaid programs. Proof of compliance with disclosure of ownership and control interest requirements of the Medicare or Medicaid programs shall be accepted in lieu of this submission. History:s.6,ch.78-336;s.2,ch. 81-318;ss.79,83,ch.83-181;ss.6, 17;ch.93-215;s.50,ch.98-171. 400.556 Denial, suspension, revocation of license; administrative fines; investigations and inspections.— (1) The agency may deny, revoke, or suspend a license under this part or may impose an administrative fine against the owner of an adult day care center or its operator or employee in the manner provided in chapter 120. (2) Each of the following actions by the owner of an adult day care center or by its operator or employee is a ground for action by the agency against the owner of the center or its operator or employee: (a) An intentional or negligent act materially affecting the health or safety of center participants. (b) A violation of this part or of any standard or rule under this part. (c) A failure of persons subject to level 2 background screening under s. 400.4174(1)to meet the screening standards of s. 43 5.04, or the retention by the center of an employee subject to level 1 background screening standards under s. 400.4174(2)who does not meet the screening standards of s. 435.03 and for whom exemptions from disqualification have not been provided by the agency. (d) Failure to follow the criteria and procedures provided under part I of chapter 394 relating to the transportation, voluntary admission, and involuntary examination of center participants. (e) Multiple or repeated violations of this part or of any standard or rule adopted under this part. (f) Exclusion,permanent suspension, or termination of the owner, if an individual, officer, or board member of the adult day care center, if the owner is a firm, corporation, partnership, or association, or any person owning 5 percent or more of the center, from the Medicare or Medicaid program. (3) The agency is responsible for all investigations and inspections conducted pursuant to this part. History.—s.7,ch.78-336;s.2,ch.81-318;ss.79,83,ch..83-181;ss.7, 17,ch.93-215;s.40,ch.96-169;s.51, ch.98-171;s. 143,ch.98-403. 400.5565 Administrative fines; interest.— (1)(a) If the agency determines that an adult day care center is not operated in compliance with this part or with rules adopted under this part,the agency,notwithstanding any other administrative action it takes, shall make a reasonable attempt to discuss with the owner each violation and recommended corrective action prior to providing the owner with written notification. The agency may request the submission of a corrective action plan for the center which demonstrates a good faith effort to remedy each violation by a specific date, subject.to the approval of the agency. (b) The owner of a center or its operator or employee found in violation of this part or of rules adopted under this part may be fined by the agency. A fine may not exceed$500 for each violation. In no event, however, may such fines in the aggregate exceed$5,000. (c) The failure to correct a violation by the date set by the agency, or the failure to comply with an approved corrective action plan, is a separate violation for each day such failure continues, unless the agency approves an extension to a specific date. (d) If the owner of a center or its operator or employee appeals an agency action under this section and the fine is upheld,the violator shall pay the fine,plus interest at the legal rate specified in s. 687.01 for each day that the fine remains unpaid after the date set by the agency for payment of the fine. (2) In determining whether to impose a fine and in fixing the amount of any fine, the agency shall consider the following factors: (a) The gravity of the violation, including the probability that death or serious physical or emotional harm to a participant will result or has resulted,the severity of the actual or potential harm, and the extent to which the provisions of the applicable statutes or.rules were violated. (b) Actions taken by the owner or operator to correct violations. (c) Any previous violations. (d) The financial benefit to the center of committing or continuing the violation. History.—ss.64,83,ch.83-181;ss.8, 17,ch.93-215. 400.557 Expiration of license; renewal; conditional license or permit.— (1) A license issued for the operation of an adult day care center,unless sooner suspended or revoked, expires 2 years after the date of issuance. The agency shall notify a licensee by certified mail,return receipt requested, at least 120 days before the expiration date that license renewal is required to continue operation. At least 90 days prior to the expiration a date, an application for renewal must be submitted to the agency. A license shall be renewed, upon the filing of an application on forms furnished by the agency, if the applicant has first met the requirements of this part and of the rules adopted under this part. The applicant must file with the application satisfactory proof of financial ability to operate the center in accordance with the requirements of this part and in accordance with the needs of the participants to be served and an affidavit of compliance with the background screening requirements of s. 400.5572. (2) A licensee against whom a revocation or suspension proceeding is pending at the time for license renewal maybe issued a conditional license effective until final disposition by the agency of the proceeding. If judicial relief is sought from the final disposition,the court having jurisdiction may issue a conditional permit effective for the duration of the judicial proceeding. (3) The agency may issue a conditional license to an app icant for license renewal or change of ownership if the applicant fails to meet all standards and requirements for licensure. A conditional license issued under this subsection must be limited to a specific period not exceeding 6 months, as determined by the agency, and must be accompanied by an approved plan of correction. History.—s. 8,ch.78-336;s.2,ch. 81-318;ss.79,83,ch.83-181;ss.9, 17,ch.93-215;s.52,ch.98-171. 400.5571 Patients with Alzheimer's disease or other related disorders; certain disclosures.—A center licensed under this part which claims that it provides special care for.. persons who have Alzheimer's disease or other related disorders must disclose in its advertisements or in a separate document those services that distinguish the care as being especially applicable to, or suitable for, such persons. The center must give a copy of all such advertisements or a copy of the document to each person who requests information about the center and must maintain a copy of all such advertisements and documents in its records. The agency shall examine all such advertisements and documents in the center's records as part of the license renewal procedure. History.—s.4,ch.93-105. '400.5572 Background screening.— (1)(a) Level 2 background screening must be conducted on each of the following persons, who shall be considered employees for the purposes of conducting screening under chapter 435: 1. The adult day care center owner if an individual,the operator, and the financial officer. 2. An officer or board member if the owner of the adult day care center is a firm, corporation,partnership, or association, or any person owning 5 percent or more of the facility, if the agency has probable cause to believe that such person has been convicted of any offense prohibited by s. 435.04. For each officer, board member, or person owning 5 percent or more who has been convicted of any such offense, the facility shall submit to the agency a description and explanation of the conviction at the time of license application. This subparagraph does not apply to a board member of a not-for-profit corporation or organization if the board member serves solely in a voluntary capacity, does not regularly take part in the day-to-day operational decisions of the corporation or organization, receives no remuneration for his or her services, and has no financial interest and has no family members with a financial interest in the corporation or organization,provided that the board member and facility submit a statement affirming that the board member's relationship to the facility satisfies the requirements of this subparagraph. (b) Proof of compliance with level 2 screening standards which has been submitted within the previous 5 years to meet any facility or professional licensure requirements of the agency or the Department of Health satisfies the requirements of this subsection. (c) The agency may grant a provisional license to an adult day care center.applying for an initial license when each individual required by this subsection to undergo screening has completed the abuse registry and Department of Law Enforcement background checks,but has not yet received results from the Federal Bureau of Investigation,or when a request for an exemption from disqualification has been submitted to the agency pursuant to s. 435.07, but a response has not been issued. (2) The owner or administrator of an adult day care center must conduct level 1 background screening as set forth in chapter 435 on all employees hired on or after October 1, 1998,who provide basic services or supportive and optional services to the participants. Such persons satisfy this requirement if. (a) Proof of compliance with level 1 screening requirements obtained to meet any professional license requirements in this state is provided and accompanied, under penalty of perjury,by a copy of the person's current professional license and an affidavit of current compliance with the background screening requirements. (b) The person required to be screened has been continuously employed, without a breach in service that exceeds 180 days, in the same type of occupation for which the person is seeking employment and provides proof of compliance with the level 1 screening requirement which is no more than 2 years old. Proof of compliance must be provided directly from one employer or contractor to another, and not from the person screened. Upon request, a copy of screening results shall be provided to the person screened by the employer retaining documentation of the screening. (c) The person required to be screened is employed by a corporation or business entity or related corporation or business entity that owns, operates, or manages more than one facility or agency licensed under this chapter, and for whom a level 1 screening was conducted by the . corporation or business entity as a condition of initial or continued employment. (3) When an employee, volunteer, operator, or owner of an adult day care center is the subject of a confirmed report of adult abuse, neglect, or exploitation, as defined in s. 415.102, and the protective investigator knows that the individual is an employee, volunteer, operator, or owner of a center,the agency shall be notified of the confirmed report. History.—ss.53,71,ch.98-171. 1Note.- A. Section 70,ch.98-171,provides that"[t]he provisions of this act which require an applicant for.licensure, certification,or registration to undergo background screening shall apply to any individual or entity that applies;on or after July 1, 1998,for renewal of a license,certificate,or registration that is subject to the background screening required by this act." B. Section 71(1),ch.98-171,provides that"[t]he provisions of this act which require an applicant for licensure, certification,or registration to undergo background screening shall stand repealed on June 30,2001,unless reviewed and saved from repeal through reenactment by this legislature." 400.5575 Disposition of fees and administrative fines.—Fees and fines received by the agency under this part shall be deposited in the Health Care Trust Fund established pursuant to s. r • 408.16. These funds may be used to offset the costs of the licensure program, including the costs of conducting background investigations,verifying information submitted, and processing applications. History.—ss.65,83,ch.83-181;ss. 10, 17,ch.93-215;s. 173,ch.98-166. 400.558 Injunctive relief.— (1) The agency may institute an action forinjunctive relief in a court of competent jurisdiction to: (a) Enforce the provisions of this part or any standard,rule, or order issued or entered into pursuant to this part;or (b) Terminate the operation of an adult day care center for: 1. Failure to take preventive or corrective measures in accordance with an order of the agency; 2. Failure to abide by a final order of the agency; or 3. Violation of any provision of this part or of any rule or standard adopted pursuant to this part, which violation constitutes an emergency requiring immediate action. (2) The court may grant temporary or permanent injunctive relief. History.—s.9,ch.78-336;s.2,ch. 81-318;ss.79,83,ch.83-181;ss. 11, 17,ch.93-215. 400.559 Closing or change of owner or operator of center.— (1) Before operation of an adult day care center may be voluntarily discontinued,the operator must inform the agency in writing at least 60 days prior to the discontinuance of operation. The operator must also, at such time, inform each participant of the fact and the proposed date of such discontinuance. (2) Immediately upon discontinuance of the operation of a center,the owner or operator shall surrender the license for the center to the agency, and the license shall be canceled by the agency. (3) If a center has a change of ownership,the new owner shall apply to the agency for a new license at least 60 days before the date of the change of ownership. (4) If a center has a change of operator,the new operator shall notify the agency in writing within 30 days after the change of operator. History.—s. 10,ch.78-336;s.2,ch. 81-318;ss.79,83,ch.83-181;ss. 12, 17,ch.93-215. 400.56 Right of entry and inspection.—Any duly designated officer or employee of the agency or department has the right to enter the premises of any adult day care center licensed pursuant to this part, at any reasonable time, in order to determine the state of compliance with this part and the rules or standards in force pursuant to this part. The right of entry and inspection also extends to any premises that the agency has reason to believe are being operated as a center without a license, but no entry or inspection of any unlicensed premises may be made without the permission of the owner or operator unless a warrant is first obtained from the circuit court authorizing entry or inspection. Any application for a center license or license renewal made pursuant to this part constitutes permission for, and complete acquiescence in, any entry or inspection of the premises for which the license is sought in order to facilitate verification of the information submitted on or in connection with the application. History.—s. 11,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss. 13, 17,ch.93-215. r 400.562 Rules establishing standards.— (1) The Department of Elderly Affairs, in conjunction with the agency, shall adopt rules to implement the provisions of this part. The rules must include reasonable and fair standards. Any conflict between these standards and those that may be set forth in local, county, or municipal ordinances shall be resolved in favor of those having statewide effect. Such standards. must relate to: (a) The maintenance of adult day care centers with respect to plumbing, heating, lighting, ventilation, and other building conditions, including adequate meeting space,to ensure the health, safety, and comfort of participants and protection from fire hazard. Such standards may not conflict with chapter 553 and must be based upon the size of the structure and the number of participants. (b) The number and qualifications of all personnel employed by adult day care centers who have responsibilities for the care of participants. (c) All sanitary conditions within adult day care centers and their surroundings, including water supply, sewage disposal, food handling, and general hygiene, and maintenance of sanitary conditions,to ensure the health and comfort of participants. (d) Basic services provided by adult day care centers. (e) Supportive and optional services provided by adult day care centers. (f) Data and information relative to participants and programs of adult day care centers, including, but not limited to,the physical and mental capabilities and needs of the participants, the availability, frequency, and intensity of basic services and of supportive and optional services provided,the frequency of participation,the distances traveled by participants, the hours of operation,the number of referrals to other centers or elsewhere, and the incidence of illness. (2) Pursuant to s. 119.07,the agency may charge a fee for furnishing a copy of this part, or of the rules adopted under this part,to any person upon request for the copy. (3) Pursuant to rules adopted by the department,the agency.may conduct an abbreviated biennial inspection of key quality-of-care standards, in lieu of a full inspection, of a center that has a record of good performance. However, the agency must conduct a full inspection of a. center that has had one or more confirmed complaints within the licensure period immediately preceding the inspection or which has a serious problem identified during the abbreviated inspection. The agency shall develop the key quality-of-care standards,taking into consideration the comments and recommendations of the Department of Elderly Affairs and of provider groups. These standards shall be included in rules adopted by the Department of Elderly Affairs. History.—ss. 13, 18,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss. 14, 17,ch.93-215;s.56,ch. 95-418. 400.563 Construction and renovation; requirements.—The requirements for the construction and the renovation of a center must comply with the provisions of chapter 553 which pertain to building construction standards, including plumbing, electrical code, glass, manufactured buildings, accessibility by physically handicapped persons, and the state minimum building codes. History.—s. 14,ch.78-336;s.4,ch.79-152;s.2,ch.81-318;ss.79,83,ch.83-181;ss. 15, 17,ch.93-215. 400.564 Prohibited acts; penalty for violation.— r, (1)(a) It is unlawful for any person or public body to offer or advertise to the public, in any way,by any medium whatever, adult day care center basic services without having a license under this part. (b) It is unlawful for any holder of a license issued under this part to advertise or hold out to the public that it holds a license for an adult day care center other than the one for which it actually holds a license. (2) Any person that violates paragraph(1)(a)or paragraph(1)(b) is guilty of a misdemeanor of the second degree,punishable as provided in s. 775.083. Each day of continuing violation is considered a separate offense. History.—s. 15,ch.78-336;s.2,ch.81-318;ss.79,83,ch.83-181;ss. 16, 17,ch.93-215. '4 AGENCY FOR HEALTH .CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE ADULT DAY CARE CHAPTER 58-A FLORIDA ADMINISTRATIVE CODE HEALTH STANDARDS AND QUALITY UNIT a V. 7, p. 751 ADULT DAY CARE 58A-6.002 CHAPTER 58A-6 operation, and financial viabaity of the.center. ADULT DAY CARE (j) Holding_Itself Out to the Public.shall mean making 58A-6.001 Purpose. (Repealed) any announcement, solicitation, display or advertis:merf—to 58A-6.002 Definitions. inform the general public of services provided by the center 58A=6.003 Licensure Application Procedures. designed to attract new or additional participants to a center 5SA-6.004 Unlicensed Centers.• providing adult day care services. 58A-6.005 Closing of a Center.(Repealed) (k) Major Incident shall mean any incident for which the 5SA-6.0051 :Chang; of Owner or Agency, center, employee-or other person associated with g Operator, Marketing.. the center may be liable, or which has resulted in serious 58A-6.006•.. Governing Authority, Administration and Staffing. injury, death or extensive property damage. Major incidents 5SA-6.007 Participant Care Standards: shall include: , 58A-6.008- Program Requirements. 1. Death of a participant from other than natural causes, 58A-6.009 Basic Services. 2..Threats or occurrences of riots, bombings, or other 58A-6.010. Optional Supportive Services.• extreme violence, 58A-6.011. Participant and Program Data, Emergency 3. Disappearance from the center of a participant, Procedures. 4• Assaults resulting in severe injury or death, sexual 58A-6.012: Fiscal Standards. assaults or rape, on or by a participant, 58A-6.013 -, Physical Plant, Sanitary Conditions, . S. Property damage from any cause that would interrupt Housekeeping Standards and Maintenance. routine operations or disrupt service delivery, 58A-6.014 Administrative Enforcement. 6. Auto accidents with injuries involving participants, 7. Involuntary center closure, 58A-6.002 Definitions. 8. Incidents of abuse, neglect, or fraud, (1) The following terms are defined in s. 400551, F S., 9. Employee work conduct which results in a criminal and are applicable to this rule chapter adult day care center law violation, or center, agency, basic services, department, multiple or 10. Attempted suicide by a participant while under center repeated violations, operator, owner, participant, and supervision. supportive and optional services. 0) Net Floor Space shall mean the actual .climatically (2) Additional definitions applicable in this rule chapter controlled occupied area, not including accessory unoccupied are as follows: areas such as hallways, stairs, closets, storage areas, (a) Activities of Daily Living or ADL shall mean the bathrooms, kitchen or thickness of walls, set aside for the functions or tasks for self-care and shall include: ambulation, use of the day care center participants. . bathing, dressing, eating, grooming, transferring, and (m) Operator shall mean an individual who has daily toileting, self-administration of medications, and other administrative charge of an adult day care center and who personal hygiene activities. shall be designated in writing as such by the owner or (b) Adult shall mean any person 18 years of age or older. governing authority. (c) Applicant for licensure shall mean the owner or (n) Orientation and Training Plan shall mean a written operator of a center or, if the owner is a business entity, the plan developed and reviewed at least annually and person (i.e., corporate officer, general or limited partner) implemented_ throughout 'the year which describes a acting in behalf of the entity coordinated program for staff training for each service and (d) By-laws shall mean a set of rules adopted by the for orientation of each new staff member on center policies, center for governing its operation. A charter, articles of procedures, assigned duties and responsibilities, and which incorporation, or a statement of policies, procedures and shall begin no later than the first day of employment objectives shall be acceptable equivalents. (o) Participant File shall mean a written 'record, prepared (e) Capacity shall mean the number of participants for and kept by the center which shall include a care plan; which a center has been licensed to provide care at any medical and social history or copies_ of- an examination given time and shall be based upon required net floor space. completed by a physician and social history completed by a (f) Daily Attendance shall mean the number of case manager or social worker, diagnosis; disabilities and participants who, during any one calendar business day, limitations; rehabilitation potential,short and long-term goals attend the center.This count is not dependent upon, nor does for rehabilitation, and recommended activities; orders for it include, the number of types of services a participant medication or modified diet; such as supervision .of receives, but is an actual, individual unduplicated census self-administered medication; special needs for health or coanL safety; permitted levels of physical activity; frequency of (g) Full-time shall mean a time period of not less than 35 attendance at the day care center, the frequency with which hours, established as a full working week by the center. the participant shall be seen by the participant's-physician; (h) Functional impairment means a physical, mental, or and notes as required in this Rule Chapter. social condition or cognitive deficit .which restricts an (p) Participant Space shall mean the required net floor' individual's ability to perform the tasks and activities of space per participant. Maximum participant capacity shall daily living and which impedes the individual's capability refer to the licensed capacity. for self-care and independent living without assistance or (q) Personal Supervision of a Participant shall mean supervision from others on a recurring or continuous basis observation of the participant to maintain safety and for extended periods of time. well-being, including supervision of self-administered (i) Governing Authority shall mean the organization, medications. person, or persons designated to assume full legal (r) Preventive Service shall mean that service which responsibility for the determination of policy, management, precludes or deters development of disabilities including ti L 5S.A-6.003 DEPARTMENT OF ELDER AFF.AIRS V. 7, p. 752 nutritional counseling, leisure activities,. in-facility respite provided in Section 400553,-FS., as listed below: care and social and health activities and services. (a) Any facility, institution, or other place that is operated (s) Respite Care or Respite in an adult day care center is by the federal government or any agency thereof. defined as a service provided to relieve the caregiver. (b) A licensed assisted living facility, licensed hospital, or (t) Significant Change shall mean a deterioration or licensed nursing home facility which does not hold itself out improvement in ability to cant' out activities of daily living; to the public as an adult day care center. a deterioration in behavior or mood to the point where daily (2) In accordance with Section • 400554(4), F.S., _problems arise or relations become problematic or. an county-operated or-municipailyoperated centers applying for improvement to the point that these problems are eliminated; licensure under this part shall be exempt from the payment or a substantial deterioration in health status or reversal of of license fees. such condition. Ordinary day-too-day fluctuations in (3) The Agency shall grant a biennial license to an functioning and behavior and acute short-term illness such as applicant center in compliance with the minimum standards a cold are not considered significant changes unless such set forth in this rule. fluctuations persist to the extent that"a trend is established (4) A license issued for,the operation of a center, unless (u) Staff shall mean any person employed by a center sooner suspended or revoked, shall expire two years from who provides direct or indirect services to the participants the date of issuance. and volunteers who provide direct services. (5) Owners or'operators of adult day care centers subject (v) Supervision of self-administered medication shall to licensure shall submit a completed application for a mean reminding participants to take medication at the time license through the Agency for Health Care Administration, indicated on the prescription; opening or closing medication 2727 Mahan Dr., Tallahassee, FL 32308. The Licensure container(s) or assisting in the opening of prepackaged Application for Adult Day Care Center, ADCC Form-1, medication; reading the medication label to participants; dated August 1996, which is incorporated by reference, may observing participants while they take medication; checking be obtained from the AHCA,Adult Day Care Program,2727 the self-administered dosage against the label of the Mahan Drive, Tallahassee, Florida 32399. The cost of the container, reassuring participants that they have obtained and application package, which includes Chapter 400, Part V, are taking the dosage as prescribed; keeping daily records of F.S., and this rule chapter, is $5.00, in' accordance with when participants received supervision pursuant to this s. 400562(3), F.S. Attached to the application.shall be:. subsection; and immediately reporting apparent adverse (a) A check or money order made payable to the AHCA effects on a participant's condition to the participant's for payment of the licensure fee. The biennial licensure fee physician and responsible person. Supervision of shall be 5150 per,center. Each separate premise shall be self-administered medication shall not be construed to mean licensed as a separate facility. that a center shall provide such supervision to participants (b) For centers with seven or more participants, proof of who are capable of administering their own medication. liability insurance coverage of $100,000 per participant for (w) Supervision of staff shall mean guidance by a bodily injury and $300,000 per occurrence for the center, qualified person for a staff member's performance of and proof of liability insurance coverage of $100,000 per job-related functions and activities, with initial direction and participant for bodily injury and $300,000 per occurrence for periodic on site inspection of the performance. Supervision the vehicle if uransportation services are provided by the of participants shall mean guidance and care necessary for center. For centers with six or less participants, proof of the health, safety and well-being of participants. liability insurance coverage of $50,000 per participant for (x) Termination Summary shall mean a written summary bodily injury and $150,000 per occurrence for the center, prepared by the center staff at the time of participant and proof of liability insurance coverage-.of $50,000 per termination and documenting services which the participant participant for bodily injury and $150,000 per occurrence for has mceived, and which includes any treatment provided, the vehicle(s) if transportation services are provided by the results, reasons for termination and recommendations for the center. participant's continued care. (6) The agency shall notify a licensee by certified mail at (y) Transportation Services shall mean the conveying of least 120 days before the expiration date of the center's participants between the center and a designated location, as license.Applications for relicensure must be submitted to the well as to and from services provided directly or indirectly agency at least 90 days before the expiration date of the by the facility. No participant's transportation to and from a existing license. Failure to file a timely renewal application designated location and the center shall exceed 1117. hours if will result in a fine of $75.00 pursuant to Chapter the transportation is provided or arranged by the center. 4005565(l)(b) and 400557(1) being assessed against the. (z) Volunteer shall mean an individual not on the payroll center. , of the adult day care center, whose qualifications shall be (7) The AHCA shall, upon receipt of an application or determined by the center, for whom a written job change of center operator notice, search the Department of description, plan of orientation and training shall be provided Children and Family Services' Abuse Registry for the and implemented. existence of a confirmed report ronceming the applicant or Specific Authority 400562 FS. Law Implemented Ch. 400, Pert V operator and the results of the adult or child protective FS. Kirtary—New 7,881. Amended 2-27-84, Formerly IOA-6.02, assessment conducted, in accordance with Sections 415.102 10A-6.002, 59A-16.00Z Amended 11-9-95, 3-29-98. and 415503, F.S. (8) The AHCA shall schedule and conduct an assessment 58A-6.003 Licensure Application Procedures. and evaluation survey of the applicant center, in accordance (1) All adult day care centers, as defined in s. 400551, with this Rule Chapter. F.S., shall be licensed by the Agency for Health Care Specific Authority 400.562 FS. Law Implemented CIc 400, Part V Administration (AHCA), unless otherwise exempt as FS. History—New 7.8-81, Amended 2-27-84, Formerly IOA-6.03, V. 7, p. 753 ADULT DAY CARE 58A-6.006 IOA-6.003, 59A-16.003, Amended 11-9-95, 3-29-98. documenting freedom from tuberculosis in the communicable 58.4-6.004 Unlicensed Centers. form and documenting freedom from signs and symptoms of (1) An adult day care center's owner or operator who other communicable disease. Any participant who is fails to make application for licensure shall be advised by diagnosed as having a communicable disease shall be the AHCA by certified mail that the center is subject to excluded from participation until deemed non-infectious. licensure requirements. The letter shall state the basis upon However, participants who have Human Immunodeficiency which the AHCA has determined the center to be eligible Vets (HIV) infection may be admitted to the center, for licensure and shall include notice that the center is to provided that they would otherwise be eligible according to - submit the S5.00 fee for an application for license packet to this rule. AHCA,2727 Mahan Drive,Tallahassee, FL 32308 within 10 2- No participant shall be admitted or retained in..a center days of receipt of the notice. if the required services from the center are beyond those that (2)"The letter shall cite Sections 40055-400564, F.S., the center is licensed to provide. that the offering of adult day care center basic services 3. No participant who requires medication_ during the time without a valid license is a misdemeanor of .the second spent at• the center and who is, incapable of degree'punishable'as provided in Section 775.083, F.S. The self-administration' of'medications shall be admitted or center shall be granted ten calendar days from the receipt of t retained unless there- is a person licensed according to the certified letter to apply for license in accordance with Florida law to,-administer medications who will provide this this Rule Chapter. Failure to comply..within the allocated ten service. A person licensed according to Florida law includes days shall cause the agency to initiate injunction proceedings a physician licensed under chapters 458 and 459, FS., an in a court of appropriate jurisdiction to terminate the advanced registered nurse practitioner, a dentist, a registered operation of the center. nurse, licensed practical nurse, or a phvsician's assistant. Specific Authority 400562 FS. Law Implemented Ch 400 Parr V (b) Provision is made for a safe physical plant equipped FS. Hirror.,- 'ew 7-8-81, Amended 2-27-84, Formerly 10A-6.04, and staffed to maintain the center and services provided as 10A-6.004, 59A-16.004, Amended 11-9-95, 3-29-98. defined in this Rule Chapter. (2) The governing authority shall ascertain that the owner 58A-6.0051 Change of Owner or Operator, Marketin& or operator or the designated responsible person shall be on (1) The center must notify the AHCA at 2727 Mahan the premises during the center's hours of operation. Drive, Tallahassee, FL 32301, at least 60 days before the (3) Each center shall comply with all standards, rules and date of a change of ownership. The new owner must request regulations and shall be under the control of the Iicensed and submit a check for 55.00 for the initial application owner or operator or an agent designated in writing by the package, which includes the ADC rules and regulations. owner or operator as having full responsibility and authority (2) The agency shall issue the change of ownership for the daily operation of the facility. The owner or operator applicant a conditional license pending confirmation that the may supervise more than one center, provided that a applicant meets all standards and requirements for licensure. qualified, responsible assistant operator, duly appointed in A conditional license issued for this purpose is limited to 6 writing, is in charge of each facility. months' duration. (4) The center shall employ qualified staff to provide the (3) If the center's owner changes operators, the owner or services, personal assistance and safety measures required by new operator must notify the AHCA within 30 days at the the participants. address in subsection (1), and include the complet:,d abuse (o-) The owner or operator shall: registry and criminal background check forms. (a) Develop a written job description for each center staff Specific Authority 400562 FS. Law Implenenred Ch. 400, Pan V member containing a list of qualifications, duties, FS Hirrory—,tiew 11-9-95, Amended 3-29-98. responsibilities and accountability required of each staff- 58A-6.006 Governing Authority, Administration and member. SiafEi g. (b) Establish and maintain a personnel file for each staff (1) The center shall have a governing authority which to include: shall establish policies in compliance with this Rule Chapter. 1. Name, home address, phone number, Governing Authority, as defined in this Rule Chapter, may 2. Name, address and phone number of physician(s) to be consist of as few as one person, and designation of its contacted.in case of emergency; membership or composition shall be determined by the 3. Name, address and phone number of person(s) to be owner or operator. The governing authority shall be contacted in case of emergency; responsible for ensuring compliance with standards requiring 4. Education and experience; - that: 5. Job assignment and salary; (a) Admission criteria shall limit participant eligibility to 6. Evaluation of performance at least yearly; adults with functional impairments in need of a protective 7. Dates of employment and termination; environment and a program of therapeutic social and health 8. Character references which include former employers activities and services as defined in this Rule Chapter, and and supervisors; assure that the admission of each participant shall be made 9. A statement from a Florida licensed health care under the supervision of the owner or operator within the provider that the employee is free from tuberculosis in a confines of specific requirements set forth below: communicable form and apparent signs and symptoms of 1. Within forty-five days prior to admission to the center, other communicable diseases within 45 days prior to each person applying to be a participant shall provide a beginning work in the center. In accordance with subsection statement signed within said forty-five days by a Florida 76050, F.S., a center shall not exclude a potential employee licensed health care provider under the direct supervision of who is infected with human immunodeficiency virus who a physician, physician or a county public health unit would otherwise meet the conditions of employment. 58A-6.007 DEPARTMENT OF ELDER AFFAIRS V. 7, p. 754 ' (6) The owner or operator also shall be responsible for 760.50 FS. History--lVew 7.4.-81, Amended 2-27-,84, Formerly the administration of all components of the facility and 10A-6.06, IOA-6.006, 59.4-16.006, Amended 11-9=95, 3-29-98. accountable for the implementation and enforcement of all 58A-6,007 Participant Cane Standards. policies and procedures, standards of care, and program (1) The center shall make a statement or summary development in accordance with the social, physical and statement of policies and procedures for participant care mental capabilities and needs of the participants served. available to participants, to the responsible person, to the (7) The owner or operator shall assure that each employee public, and to each member of the center staff. The shall:.. statement or summary"statement shall be displayed in a a Maintain personal cleanliness and hygiene;. ( ) pe Y� conspicuous place in the facility. (b) Refrain from abusive, immoral or other unacceptable (2) The center staff shall be trained to implement these conduct such as use of alcohol, illegal use of narcotics or policies and procedures, as specified an the staff orientation other impairing drugs, and behavior or language which may and training plan. be injurious to participants; (3) Participant care;policies, and procedures shall-ensure (c) Any -employee who is :diagnosed as :having a dA as a minimum' all participants admitted to the center communicable disease after beginning work in the center (a) Are informed of-provisions for service as evidenced shall be excluded from working until deemed non-infectious by written ackgowledgment from the participant or in the work setting. responsible party'prior to or at the time'of admission, and (8) The owner or operator or designated administrator given a statement or summary statement of the center shall be responsible for. enforcing the following minimum policies and procedures, and an explanation of the personnel staffing for adult day care centers and shall participant's responsibility to comply with these policies and designate substitute staff to be available in emergencies. procedures and to respect the personal rights and pvate (a) A minimum staff ratio of one staff member who property of other participants; provides direct services for every 6 participants shall be (b) Are informed, and are given a written statement prior present in the center at all times. to or at the time of admission and during stay, of services (b) No less than 2 staff, one of whom has a certification available at the center and for any related charges including in an approved first aid course and CPR, shall be present in those for services not provided free or not covered by the center at all times. sources of third party payments or not covered--by- the (c) At all times staffing shall be maintained to meet the facility's basic per diem rate. This statement shall include needs of the participants as required by the participant file, the pavment, fee, deposit, and refund policy of the center, including centers which sere persons with Alzheimer's (c) Are promptly informed of substantive changes in disease and related dementias, persons with physical policies, procedures, services, and rates; handicaps, or other special target populations. (d) Are informed during the intake process of the local (d) The owner or operator may serve in dual capacity as a registered nurse, occuoational therapist, physical therapist, emergency management agency's registry of disabled spe.°°^h-language pathologist, or social worker, if licensed as persons who need assistance during evacuations or when in required by Florida law and qualified to provide such shelter because of physical or mental handicaps and the assistance provided by center staff to register such persons services. with the local emergency management agency; (e) The owner or operator may be counted as one of the (e) Are allowed to retain the services of their personal required staff members provided the ovmer or operator physician at their own expense or under a health care plan; provides direct services and is included in the work schedule for the center. However, the owner or operator shall not be e assured of services provided, and are, offered p the opportunity to participate in the planning of their care; - counted more than once in the staff/participant ratio, (f) Are assured of remaining free from abuse, neglect, and alculated on the basis of daily census. exploitation as defined in s. 415.102, ES., and free from (9) Center staff whose conduct constitutes abuse, neglect, chemical and physical restraints Drugs and other or exploitation of a participant shall immediately be medications shall not be used for punishment, for terminated from employment and shall be reported to the convenience of center personnel, or in quantities that Department of Children and Family Services in accordance - interfere with a participant's rehabilitation or activities of with Section 415.103, F.S. (10) No administrator who has been terminated pursuant. daily living; to the.provisions of subsection (9) shall accept employment (g) Are assured privacy in treatment of their persona] and in an adult day care center and no owner or operator of a medical records; center shall knowingly employ any person who has been (h) Are treated with consideration, respect, and full terminated pursuant to subsection (9). recognition ..of their dignity, individuality, and right to (11) The governing authority shall establish policies and privacy; procedures to facilitate reporting of abuse,. neglect or (i) Are not required to perform services for the center, exploitation as defined in Section 415.102 and in accordance 0) Are permitted to associate and communicate privately with Section 415.103, F S., and shall insure that the with persons of their choice, join with other participants or statewide toll free telephone number of the Central Abuse individuals within or outside the center to work for Registry, accompanied by the words "To Report the Abuse, improvements in participant care, and, upon their request, Neglect, or Exploitation of an Elderly or Disabled Person, shall be given assistance in the reading and writing of Please Call the Toll Free Number 1-800-96-ABUSE" is correspondence; posted in a prominent place in the center and made clearly (k) Are permitted to participate in center activities, and visible. meet with and participate in activities of social, religious and Specific Authority 400.562 FS. Law Implemented Ch 400, Pan V, community groups at their discretion; V. 7, p. 755 ADULT"DAY-CARE 58.4-6.009 p) Are assured of the opportunity to exercise civil and related to emergency •.preparedness and emergency religious liberties, including the right to independent management: personal decisions. No religious beliefs or practices, or any (a) The registration process for persons who need attendance at religious services, shall be imposed upon any assistance during evacuations or when in shelter, participant. The center shall encourage and assist in the (b) The center's activities and staff available to assist in exercise of these rights;. participant's registration efforts; and (m) Are not the object of discrimination with respect to (c) The implications of having a functional limitation in a participation in activities which include recreation, meals, disaster. leisure, other social-activities because of age, race, religion, (7) If a participant needs assistance when evacuating or sex, or nationality as defined in Tide VI of the Civil Rights when in an emergency shelter, the center shall register the Act of 1964, or Americans with Disabilities Act of 1990; peen with the local emergency management agency as a (n) Are not deprived of any constitutional, civil, or legal person with special needs. right solely by reason of admission to the center Specific Audwruy 400.562 FS.Law Implemented 25235S, Ch 400, (o) For protection of .the participants, are allowed to Parr V FS. Hisrory—New 78.81, Formerl)i 10A-6.08, 10A-6.008, discharge themselves from the center`upon presentation of a 59A-16.008,Amended 11-9-95, 3-29-9& request, preferably in writing-, or, if the participant is an : ices. A-6.009,Basic Services. - adjudicated mental incompetent, upon the written consent of 58 58 To be licensed v an Adult Day Care Center, the his next of kin, ss sponsor or guardian or responsible person, following minimum basic services shall.be provided: However, if assessed by social workers, center staff, responsible persons at the time of intake as confused, the (a) A protective .. environment that. promotes a participant shall not be allowed to discharge himself until non-institutional atmosphere where supervision for: the after the center notifies the participant's guardian, spouse, or health, safety and well-being of adults who have functional person having durable power of attorney; impairments is provided; . (p) Are informed of the right to report abusive, neglectful, (b) A variety of therapeutic, social and health activities or exploitative practices. and services which help to restore, remediate, or maintain (4) The center shall not be required to accept or retain optimal functioning of the participants- and to increase any applicant or participant whose behavior and physical interaction with others. Examples of such_programs include limitations are deemed hazardous to the safety' of the exercise, health screening, health education,..interpersonal individual or other participants. Such conditions shall communication, and behavior modification; constitute a basis for termination of center participation. (c) Leisure-time activities or spectator or participant Participation may be terminated after reasonable alternatives programs designed to assist participants self-expression, have failed, upon written notification of the participant, enhance self esteem and provide mental stimulation or social guardian and responsible person. Fifteen calendar days shall participation. Examples of such - programs include be allowed for arranging for alternative services for the opportunities for arcs and crafts; daily exercise as can be participant except in cases of emergency as determined by tolerated by the participant or as prescribed by the the governing authority of the center. participant's physician; development of hobbies; excursions Specific Authoruy 400.562 FS. Law Implanerued 252355, Ch. 400, or outings to points of interest to the participants; and other Part V, 415.103, 76050 FS Hisrory—New 7-8-81, Amended outside activities which may include picnics, cookouts; 2-27-84, Formerly 10.4-6.07, 10A-6.007, 59A-16.007, Amended (d) Self-care training activities designed to assist 11-9-95, 3-29-98. functionally impaired adults to restore or maintain the ability 58A-6.008 Program Requirements. to perform activities of daily living, (1) Each center shall offer a planned program of varied (e) Rest or period of relaxation or inactivity during the --tivities and services promoting and maintaining the health day, that meets the needs of the individual participants; of participants and encouraging leisure activities, interaction (f) Nutritional services or food provided or prepared in'a and communication among participants shall be available on central location in a center or by formal agreement with a a daily basis at each center in order to enhance the third parry; the activities performed and the resources participant's well-being and to maximi= individual _utilized in the planning, processing, preparing, and serving functioning-' unctioning Such activities and services shall be available of meals or snacks; nutritional education; and nutritional during at least 60 percent of the time the center is open to counseling, and participants and shall be documented in accordance with (5). (g) In-facility respite care for a functionally impaired (2) The center shall make available basic services as adult for the purpose of relieving the primary caregiver:, defined in Chapter 400, Part V, F.S., and may make (2) To be licensed as an Adult Day Care Center, the available other supportive and optional services. following nutrition services shall be provided: (3) The center shall provide for family consultation or (a) Participants attending or in transit to the center for referral service to community agencies, clinics, or physicians four or more hours daily shall be served a meal which when the participant or family is observed to be in need of provides at least one-third of the current.Recommended intensive counseling, health, or mental health services. Dietary Allowances (RDA), of the Food and Nutrition (4) There shall be a written description of the range of Board, National Academy of Sciences, National Research services to be provided to participants. Council, adjusted for age, sex and activity. Modified diets, if (5) A monthly schedule of daily activities, shall be required, shall meet these nutritional standards to the extent maintained on a current basis and displayed in a conspicuous medically possible. Menus approved and provided by Title place. M-C of the Older Americans Act or the Adult Care Food (6) The center shall provide programs and information to Program of USDA shall be evidence of meeting the increase the participant's awareness of the following factors one-third of the RDA requirement. 58A-6.010 DEPARTMENT OF ELDER AFFAIRS V. 7, p. 756 (b) The dietary allowances shalt be met by offering a 4. Hand washing facilities,•provided with hot and cold variety of foods adapted to the food habits, preferences, and running water, shall be located within the food preparation ph}lsical abilities of the participants and prepared by the use area in new adult day care facilities and adult day care of standardized recipes. A copy of the Recommended facilities which are extensively altered. Dietary Allowances interpreted by a daily food guide shall 5. Multi-use equipment and utensils shall be constructed be available at no cost by writing to the Department of and repaired with materials_ that are non-toxic, corrosion Elder Affairs, 4040 Esplanade Way, Tallahassee, Florida resistant and'nonabsorbent; and shall be smooth, e'asily 32399-7000 or the.local..county .public..health..unit._ cleanable and durable under conditions of normal°use; and (c) Participants in the center 3 hours before the noon shall not impart odors, color or taste nor contribute to the meal or 2 hours after the noon meal: must be provided a contamination of food. snack consisting of at least 2 servings from the following 6. All multi-use eating and drinking utensils shall be four food groups: milk, bread or bread alternate, meat or thoroughly cleansed with'-"hot water and as effective meat alternate, and vegetables or fruits. detergent, then shall be rinsed free of such solution, then (d) When food service is provided by the center, the shall be sanitized ardefined in Chapter 64E-11, FAG. following requirements shall be met: 7. A three compartment sink or a two compartment sink 1. The owner or operator or person designated by the and a dishwasher with an. effective, automatic sanitizing owner or operator shall be responsible for the' total food cycle, shall be provided. Machine sanitization may be service and the day-to-day supervision of food services staff. accomplished by the use of chemical solutions, hot water or 2. The designated person shall be responsible for hot air. After sanitizing, utensils shall be air dried and coordinating food services with other services; developing properly stored, work assignments; purchasing food; and orienting, training S. Refrigeration units and hot food storage units used for and supervising food service employees. the storage of potentially hazardous foods shall be provided 3. The person designated by the owner or operator as with a numerically scaled indicating thermometer accurate to responsible for food service shall perform their duties in a plus or minus 3 degrees Fahrenheit The thermometer shall safe and sanitary manner, be knowledgeable of foods that be located in the warmest or coldest part of the units and of meet regular diet requirements, participate in on-going such type and so situated that the temperature.can be easily orientation and training, and participate in biennial in-service and readily observed. provided by a Registered Dietitian. 9. No live animals or fowl shall be kept or allowed in the 4. Menus not approved by or meeting the requirements of kitchen or in the dining areas where food is being served, Title III-C of the Older Americans Act or the Adult Care with the exception of dogs assisting persons with disabilities, Food Program of USDA shall be reviewed by a Registered which are permitted in the dining area. or Florida Licensed Dietitian or-a Dietetic Technician (g) If food is catered fiom outside sources, the catered supervised by a Registered or Florida Licensed Dietitian to meals must be prepared in an approved food establishment ensure that the menus are commensurate with the current No w•arewashing may take place onsite. Catered food, once Recommended Dietary Allowances established by the Food delivered to an adult day care facility, must be adequately and Nutrition Board National Research Council, adjusted for protected. A copy of the formal contract between licensee age, sex and activity. Documentation of review of the menus and provider containing assurances that the provider will shall be maintained in the center files and shall include the meet all food service and dietary standards should be kept signature and registration or license number of the reviewer on file and date reviewed. Menus shall be kept on file for one year (h) Duty Assignments. for person responsible..for food and shall be accessible to participants and families of service shall be posted in the kitchen area in centers having- participants. five or more food service staff.. ie) In,centers with 17 or more participants, all matters Specific Authority 400.562 FS. Law Implemented Ch, 400, Pan V pertaining to food service shall comply with the provisions FS. Hisrory--New 7.881, Amended 2-27-84, Formerly IOA-6.09, of Chapter 64E-11, Florida Administrative Code. 10A-6.009, 59A•16.009,Amended 11-9-95, 3-29-98. (f) In centers with 16 or less participants, the owner or operator shall ensure that food preparation is accomplished 58A-6.010 Optional Supportive Services. In addition to in a safe and sanitary manner in accordance with rules the minimum basic services, the center may choose to 64E-11.002, Definitions; 64E-11.003, Food Supplies; provide optional supportive services. If provided, such 64E-11.004, Food Protection; 64E-11.005, Personnel; and services must be administered by staff qualified to provide 64E-13.007, Sanitary Facilities and Controls; and that the such services and within the criteria established by relevant following minimum conditions shall be met: Florida Statutes. The following are examples of such 1. The floor surfaces in kitchens, all rooms and areas in services: which food is stored or prepared and in which utensils are (1) Health or social services such as assessment, washed or stored shall be of smooth nonabsorbent material counseling, treatment and referral. and constructed so it can be easily cleaned and shall be (2) Speech therapy provided by or under the supervision' washable up to the highest level reached by splash or spray. of an individual licensed under Chapter 468, Part L-FS., 2. The walls and ceilings of all food preparation, utensil who has certification of clinical competence from American washing and hand washing rooms or areas shall have Speech and Hearing Association, and who has completed the smooth, easily cleanable surfaces. Walls shall be washable equivalent education requirements and work experience up to the highest level reached by splash or spray. necessary for certification, or who has completed the 3. Hot and cold running water under pressure shall be academic program and is acquiring supervised work easily accessible to all rooms where food is prepared or experience to qualify for the certificate. Progress notes shall utensils are washed. be maintained and must be written in the client's record and ti e V. 7; p. 757 ADULT DAY CARE 58A-6.011 signed by the speech therapist as services are provided. 5. Transportation to and from the adult day health care (3) Physical therapy must be provided by, or under the services. supervision of, an individual who is a graduate of a program (c) In addition to the minimum staffing required in Rule of physical therapy approved by both the Council on Chapter 58A-6, provide the following staff: Medical Education of the American Medical Association and 1. The operator shall have a minimum of a Bachelor's the American Therapy Association, or the equivalent, and degree in a health or social services or related field with one licensed by the'State. Progress notes shall be maintained and year of supervisory experience in a social or health service must be written in the client's record*and.signed by the setting or hold a registered nurse license—Aith one year of - physical therapist as services are provided: supervisory experience or have 5 years of supervisory (4) Occupational therapy as an.adjunct. to treatment of experience in a social or health service setting. persons with physical and "mental limitations must be 2. A registered nurse (RN) or licensed practical nurse provided by, or under the supervision of, an individual who (LPN) shall be on site during the primary hours of program is registered by the American Occupational Therapy operation and on call during all hours the center is open. Association; or a graduate of a program approved by the Arrangements.shall-:be.formalized for obtaining the.services Council on Medical Education of the American Medical of an LPN or RN in anticipation of potential absences, Association-- and engaged. in - the supplemental clinical planned and unplanned, of the'.regular nursing staff. All experience required before registration by the American LPNs must be supervised in accordance with Chapter 464, Occupational Therapy Association. Progress notes shall be F.S. written in the client's record and signed by the occupational 3. A social worker with a minimum of a Bachelor's therapist as services are provided. degree in social work, sociology, psychology or nursing or a (5) Modified diets or diets based on the normal diet and Bachelor's degree with at least 2 years of experience in a designed to meet the requirements of a given situation such human service field. Services provided by program aides in as altering individual nutrients, caloric values, consistency, this service area must be provided under the direct flavor, techniques of service or preparation, content' of supervision of a social worker or of a case manager who specific foods, or a combination of these factors, may be meets or exceeds these standards (e.g., a-Master's degree in provided as an optional service. When modified diets are a related field). provided, a physician's written or documented oral order for 4. An activity director or Recreational Therapist with a each participant receiving a modified diet shall be on file. A Bachelor's degree in a social or health.service field or an menu including types and amounts of food to serve will be Associate's degree in a related field plus 2 years of on file in the food service area Diets shall be prepared and experience. All services provided by program aides must be served as ordered by the physician. provided under the direct supervision of the activity director (6) Adult day health care services for disabled adults or or recreation therapist. The certified racreatioa.1herapist may aged persons, provided the center complies with the be retained as a consultant followwns: (d) Documentation of services provided under this section (a) Make services available for a minimum of 5 hours per must be in the participants' files. Participant care plans must day 5 days per week, excluding legal holidays as posted by be reviewed at least quarterly by a multidisciplinary team. the facility; At a minimum, narrative nursing, social work, and activity (b) Provide or coordinate, in addition to the basic services notes must be entered in the participant's record quarterly specified in Rule 58A-6.009 and optional services pursuant indicating the participant's progress toward achieving health to paragraphs (1), (2), (3), (4) and (5), the following: goals. More frequent notes are required if indicated by the 1. Medical screening emphasizing prevention and participant's condition. continuity of care which include routine blood pressure (e) Centers providing adult day care or adult day health checks or blood glucose diabetic maintenance checks; care services to Medicaid clients through a Medicaid waiver 2. Nursing services including a configuration of services must also comply with the following. at different levels of intensity as determined by the nursing 1. Be enrolled as a Medicaid provider thugh the Agency assessment, participant care plan, and physician's orders. for Health Care Administration's Medicaid Services shall include: 2. Have a current authorization for services from an a. Health education and counseling including nutritional enrolled Medicaid waiver case manager. Case_managers in a advice, liaison with the participant's personal physician, and specific waiver program will authorize ADHC services for notification of physician as well as the caregiver or family of any changes in the participant's health status; enrolled waiver recipients.Those ADHC providers must also b. Coordination of the provision of other health services a enrolled in the same waiver as those for whom services are authorized. provided outside the center, 3. Comply with all provisions of the program and c. Supervision of health services provided by program aides. Medicaid waiver requirements. 3. Social services including counseling for participants Specifrc Audwriry 400562 FS. Low Impkmenred CIL 400, Pen Y. families and caregivers; compilation of a social History and '� FS. HisroendNew 7-95, Formerly 10A�.10, IDAG.O70, psychosocial assessment of formal and informal support 59A-16.010, Amended I1-9-95, 3-29-98. systems, mental and emotional status, caregiver data, and 58A-6.011 Participant and Program Data, Emergency information on planning for discharge; and referral for Procedures. persons not appropriate for adult day care. (1) The owner or operator shall establish, maintain and 4. Additional medical services such as dental, make available and ready for immediate use to the AHCA, ophthalmology, optometric, hearing aid, or laboratory complete and accurate social, medical and fiscal records services. which fully disclose the extent of services to be maintained ti 58A-6.011 DEPARTMENT OF ELDER AFFAIRS V 7, p. 758 by the center and for the periods of time required by State current in the participant's record. Documentation shall mean and Federal law. a written, signed and dated notation or statement- (2) The Participant File shall include a Participant Data (5) A record shall be kept of staff assignments. Sheet which shall be completed for each participant within (6) If the center accepts fee-for-service participants, there forty-five days prior to or twenty-four hours after admission shall be a signed agreement documenting the amount of fee, to the center and which shall include: hours and days of attendance, services to be provided, and (a) Full name, birthday, address; frequency of payment This agreement shall be signed-by-.the.... (b) Date admitted• as- a• participant and services-to be enter'owmer or operator, the participant or responsible provided; - person, recorded in the participant's record 'and current (c) Social security number, through the last payment period (d) Next of kin, address and photle number, (7) A written record shall be kept of major incidents (e) Guardian or responsible person and address and phone affecting participants,.employees, volunteers or the program number. Responsible Person shall mean any person who has of the center. assumed the responsibility to manage the affairs and protect (8) Major incidents;as defined in this Rule Chapter shall the rights of any participant of the center. The responsible be reported to the* AHCA immediately. Reports shall be person is not a legal entity,but may be a caregiver or friend 1 made by the indjvidual having first-hand knowledge of the and shall in no case be affiliated with the facility, its incident and performing functions and responsibilities as an operations, or its personnel, unless so ordered by the court; authorized agency and may include paid, emergency and (f) Medicaid and Medicare identification and other health temporary staff, volunteers and student interns. insurance numbers; (9) In case of emergency, such as acute illness, if family (g) Emergency contact person, home or office address and or responsible person cannot be reached, a signed release phone numbers; shall be on file stating that the participant may be sent to the (h) Name and telephone number of attending physician to nearest hospital emergency room for treatment be contacted when there appears to be significant deviation (10) Each center shall develop. and. follow a written. from normal appearance or state of well-being of'.a Comprehensive Emergency Management Plan for emergency participant; and physician's or hospital discharge statement care during an internal or external disaster. no older than forty-five days indicating. prescribed (a) The Emergency Management Plan shall-:.include_the medications and dosage and updated as changes are made by following:. physicians or, until a statement is received, a dated and 1. Provisions for both internal and external disasters and signed statement by the participant or guardian or emergencies which could include hurricanes, tornadoes, fires, responsible person stating that specific-medication may be power outages, floods, bomb threats, hazardous materials given as ordered by the attending physician; notation of and nuclear disasters. physical and emotional conditions requiring care and of 2. Provisions for care and services to participants during medications administered; diet and mobility restrictions; and the emergency including pre-disaster or preparation, a statement that the participant is free from tuberculosis in a notification of family members or responsible parties, communicable form; securing the center, supplies, staffing and emergency (i) The Participant File shall be updated when there is a equipment simificant change in the participant, or at least quarterly; 3. Provisions for care and services to participants who 0) The owner or operator or staff designated by the must evacuate during the emergency including emergency owner or operator shall review and approve each participant evacuation transportation. care plan. 4. Identification .of staff position responsible for — - (.il The operator shall be responsible for the recording, implementing each aspect of the plan. reporting and availability of participant data or those records 5. Identification of and coordination with designated required for each center participant and program data or agencies including Red Cross and the county emergency those records required for services made available to and management office. provided to participants by the adult day care center which 6. Post-disaster activities including responding to family shall include:- inquiries, obtaining necessary emergency medical. attention (a) Number of participants enrolled to current date; or intervenfon for participants, and transportation. (b) Average daily attendance as defined in this Rule (b) Tae plan shall be available for immediate access by Chapter, based upon attendance through the end of the center staff. preceding month, (c) The Plan shall be approved by the local Emergency (c) Distance traveled by participants and hours of travel Management Agency. time current through the previous month, if the (11) Fire safety protection shall_be governed by the local transportation, as defined in this Rule Chapter, is provided fire code applicable to day care centers. In areas where no or arranged by the center. Hours of daily attendance shall local fire code applies, the standards contained in Rule exclude transportation time to and from the center, 4A-40, FAC., Uniform Fire Safety Standards for Assisted (d) Business hours of operation shall be posted in a Living Facilities, may be used to determine compliance with conspicuous place. Business hours shall mean a time period fire safety standards. In every instance, a center shall comply established by the center, as defined in its policies, and shall with local and state standards before a license may be be no less than five hours per day on week days of center issued. operation and may include a reduced schedule of weekend (a) A fire evacuation drill shall be conducted once a hours. month for the center staff and once every three months for (4) Documentation shall be made of services, medication participants; and special diets provided or administered and shall be kept (b) A written record of each fire drill, indicating the date, J V. 7, p. 759 ADULT DAY CARE " 58.4-6.013 hour and general description of each drill,.,the extent of staff- accessible to the AHCA written policies and procedures for involvement, and-the name of the person in-charge shall be the cleaning of the physical plant and equipment and for its maintained and available for review; maintenance. (c) Evacuation routes shall be posted conspicuously in the (5) Center facilities shall consist of, but not be limited to, center. the following: Specific Authority 252.36, 400.562 FS. Law Implemented 25236, (a) bathrooms. 252365, Ch. 400, Part V FS History—New 7-8-81, Amended (b) dining areas 2-27.84, Formerly 10A-6.11, IOA-6.011, 59A-16.011, Amended (c) kitchen areas. . . -11-9-95, 3-29-98. (d) rest areas 58A-6.012 Fiscal Standards. (e) recreation and leisure time areas (1) The center shall establish and-maintain a record of all (6) A private area shall-be available for the provision of funds held in trust, if any, and the participant funds shall be first aid,special care and counseling services when provided, kept separate from the center funds. Such funds shall be or, as necessary for other services required by participants. used or expended-only at-the request o€.:the participant, the This:area shall-be.appmpriately..fumished and equipped. participant's representative, designee, surrogate, guardian, or (7) Each participant shall be provided with adequately attorney-in-fact, if applicable. padded, clean, comfortable seating, with support meeting the (2) The center shall furnish at least'aanually, a complete needs of each participant Rest areas shall be provided for at verified statement of such funds or property to the -least.one-fourth of the participants who are present for four participant or to the guardian or responsible person, detailing or more hours a day or additional as needed by the the amount and items received with sources and disposition. participants: =. Such a report also shall be made at termination or transfer (a) Bed and mattress, or from the center. (b) Recliner, or - (3) Any agency, governmental or private, contributing (c) Sofa, or funds or property to the account of a participant, shall, upon (d) Chair with back and arm support. request, be entitled to receive such a statement annually and (8) Bathrooms shall be ventilated and have hot and cold upon termination or transfer. = running water, supplying hot water at a minimum of 105 degrees. -Fahrenheit- and a maximum of (4) Centers shall maintain liability insurance coverage in ti degrees force at all times. On the renewal date of the center's policy Fahrenheit Facilities licensed prior to the effective date of or whenever a center changes policies, the center shall file w rule are exempt from the requirement for hot running documentation with the AHCA, ADC Program, 1-727 Mahan watt er only. Drive, Tallahassee, FL 32308. Such documentation shall be (9) Recreation and leisure time areas shall be provided "'here participant may read, engage in socialization or issued by the insurance company, shall include the name of the center, dates of coverage and shall meet the criteria of other Iei time activities. The recreation areas also may this Rule Chapter. be utilized d for for dining areas. Specific Authority 400.562 FS. Law Implemenred Ch. 400. Pan V (10) All areas used by participants shall be suitably FS. Hisroryew :-8-81, Formerly 10A-6.12, IOA 6.072 liehted and ventilated and maintained at a minimal inside 59A-16.012, Amended 11-9-95, 3.29-98. temperature of 72 degrees F. when outside temperatures are 65 degrees F or below, and all areas used by participants 58A-6.013 Physical Plant, Sanitary Conditions, must not exceed 90 degrees R Mechanical cooling devices Housekeeping Standards and Maintenance. must be provided when indoor temperatures exceed 84 (1) The center shall provide adequate, safe and sanitary degrees F The facility shall have a thermometer which_ facilities appropriate for the services provided by the center accurately identifies the temperature. and for the needs of the participants. All centers receiving (11) The kitchen or food preparation areas.shall comply federal funds shall meet regulations for access to the with rule 58A-6.009(2). handicapped in compliance with Americans With Disabilities (12) Medicines, cleaning supplies, flammables and other Act of 1990. potentially poisonous or dangerous supplies shall be stored (2) The participant capacity shall be determined by the out of the participant's reach, and in such manner as to total amount of net floor space available for all of the ensure the safety of participants. participants. Centers licensed prior to the effective date of (a) No prescription drug shall be brought into the center this rule shall provide 30 square feet of.net floor area per unless it has been legally dispensed and labeled by a participant For centers initially licensed_after November 9, licensed pharmacist for the person for whom it is pmscn-bed. 1995, there shall be not less than 45 square feet of net floor (b) Participants who can self-administer medications may area per participant Centers shall be required to provide bring and be.responsible for their own medications. additional floor space for special target populations to (c) Medications shall be centrally stored when: accommodate activities required by participant care plans. 1. The preservation of medicines requires refrigeration; (3) Facilities exempt pursuant to 400553, F.S. shall 2. Medication is determined, and documented by the utilize separate space over and above the minimum physician, to be hazardous if kept in the personal possession requirement needed to meet their own licensure certification of the person for whom it was prescribed; approval requirements. Only congregate space shall be 3. Because of physical arrangements and the conditions or included in determining minimum space..For purposes of habits of other persons in the center, the medications are this rule, congregate space shall mean climatically controlled determined by the operator or physician to be a safety living room, dining room, specialized activity rooms, or hazard to others. other rooms to be commonly used by all participants (d) Centrally stored medications shall be: (4) The center shall have available and shall make 1. Kept in a locked cabinet or container, and refrigerated, 58.E-6.014 DEPARTMENT OF ELDER AFFAIRS V. 7, p. 760 , if required; - -- (f) Keeping the grounds-and buildings-in a safe, sanitary 2 Accessible only to the authorized staff responsible for and-_presentable condition. Grounds-and building shall be distribution of medication; kept free from refuse, litter, and insect and rodent breeding 3. Located in an area free from dampness and abnormal areas. temperatures. (16) A space use change that increases or decreases the (e) Each container of medication shall be labeled center's participant capacity shall not be made without prior according to state law, and shall include the name of the approval from the AHCA central office, which shall ensure_ person.for whom it is prescribed, the name of the drug, and that such space use change would not place a center out of instructions for use. compliance with standards contained in this Rule Chapter. (f) No person other than the dispensing pharmacist shall: Specific Auahoray 400.562 FS. Law Implanenred Ch 400, Pan V 1. Alter the prescription label; _ FS. Hiroo—New 7.881, Amended 2-2,7-84, Formerly 10A-6.13, 2. Transfer medication from one storage container to 10A-6.013, 59A-16.013, Amended 11-9-95, 3-29-98. another. 58A-6.014 Administrative EnforcemenL (g) Prescription medications which are not taken with the (1) Deficiencies. person upon discharge shall be destroyed by the center (a) The agency shall conduct on-site surveys of centers operator or designee in the presence of one other staff Ifor the purpose ofdetermining compliance with Chapter 400, member. Both shall verify in the participant's record, listing Part V, F.S, and this rule chapter, and specifically the the prescription number, the name of the pharmacy, the drug following surveys: name, strength and quantity destroyed and the date 1. Initial licensure survey; destroyed. Such records shall be maintained by the center 2. Biennial license renewal survey; for at least three vears. 3. Follow-up survey; (h) There shall be a staff person available at all times who has access to and is responsible for distribution of 4. Complaint investigation; centrally stored medications. 5. Special survey; and (i) The container of centrally stored medication shall be 6. Change of ownership survey. given to the person for whom it is prescribed, at the time (b) The agency shall issue licensure deficiency statements indicated by the prescription, for the participant to take as in accordance with the provisions of s. 4005565, F.S, for prescribed deficiencies that are observed by agency personnel at any.. 0) In no instance shall a medication prescribed for one inspection of the center. person be taken by any other person. 1. Major deficiencies shall constitute conditions affecting (k) In no instance shall medication, be administered by a the health, safety, and well-being of participants. The person other than one licensed, according to Florida law, to licensure deficiency statement for a major deficiency shall administer medication including a physician, a dentist, a state a time period for correction of the deficiency. The time nurse. or a physician's assistant. period established by the agency shall be based on the (13) Centers that provide their own laundry services shall severity of the threat to health, safety,and well-being and on have a sufficient area and the appropriate equipment for the the nature of the actions necessary to correct the deficiency. laundry to be processed by the center. The time period for correction of major deficiencies (14) Furniture to be used by participants shall be sturdy, considered to be life-threatening shall not exceed 48 hours. clean, comfortable and designed for participant use. 2. Minor deficiencies, not affecting the health, safety, and (b-) Every center shall be maintained for the comfort and well-being of participants, shall be noted and a reasonable safety of the participant. Centers providing their own and fair period of time, not to exceed 60 days, shall be maintenance shall have an effective written maintenance plan granted for the correction and elimination of the deficiencies. wtiich will assure preventive maintenance as well as 3. Unclassified deficiencies shall include the following- immediate attention to and correction of hazardous or a Exceeding licensed capacity. potentially hazardous conditions. The plan shall provide for b. Providing services beyond the scope of the license. (a) Keeping the building in good repair and free of c. Failure to correct a violation by the date set by the hazards such as cracks in floors, walls, or ceiling-, warped or agency which therefore is a separate violation for each day loose boards, tile, Iinoleum, handrails or railings, broken such failure continues unless the center has an agency window panes, and any similar hazards. approved extension or has exercised the right to request a (b) Keeping all beating, air conditioning, electrical, bearing under Chapter 120, F.S. mechanical, water supply, fire protection and sewage d. Continued operation of an unlicensed center exceeding disposal systems in a safe and functioning condition. 10 days after notification by the agency. Electrical wiring cords and appliances shall be maintained in e. Failure to adequately maintain and provide access to a safe condition.Emergency generators,where existing, shall required records. be tested monthly. (c) The center shall be responsible for informing the (c) Keeping all plumbing fixtures in good repair, properly agency when deficiencies are corrected. The agency shall functioning and satisfactorily provided with protection to schedule and conduct reinspection visits with appropriate prevent contamination from entering the water supply. survey representation to assure compliance. (d) Painting the interior and exterior of the building as (d) The agency shall impose a fine for deficiencies in an needed to keep it reasonably attractive. Loose, cracked or amount not to exceed $500.00 for each survey deficiency peeling wallpaper or paint shall be promptly replaced or and not to exceed $5,000.00 in the aggregate per survey. repaired to provide a satisfactory finish. (e) Administrative fines shall be imposed for deficiencies (e) Keeping all furniture and furnishings clean and in which are not corrected within the time frame set by the good repair agency in its written notification and for multiple or repeated • 5 ' V. 7, p. 761 ADULT DAY CARE 5SA-6.014 violations, as defined in s. 400551(5), F.S. operation of an adult day care center, (f) If a center appeals an agency action under this section, 4. Any person who is under'18 years of age. and the fine is upheld, the violator shall pay the fine plus (b) Applicants denied a license shall be notified by interest of 12% per annum for each day that the fine terrified mail and shall be given the specific authority for remains unpaid after the day set by the agency. the denial. (2) License denial, suspension, and revocation. (3) If a center has had no conditional licenses issued due (a) A license sliall not be granted to: to survey deficiencies within the 2 licensure periods 1.. An applicant whose center has a major deficiency immediately preceding the current renewal -date, or if a which remains uncorrected after the date set by the agency center has had no confirmed complaints within the licensure pursuant to Rule 58A-6.014(1)(b); period immediately preceding the inspection, the AHCA area 2. An applicant'whose center has multiple and repeated office shall perform an abbreviaped biennial inspection. violations which remain uncorrected after the date set by the However, the AHCA must conduct a full inspection if the agency pursuant to Rule 59A-6.014(1)(b); center has a major deficiency identified during the 3. Any person who-has been convicted of..a felony which abbreviated survey. would affect performance of duties and responsibilities in the Specinc Authority 400.562 FS. Law Implemented Ch 400, Port V FS. History—New 11-9-95, Amended 3-29-98. 4 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE ADULT DAY CARE .CENTER (ADCC) BACKGROUND SCREENING FORMS AND INSTRUCTIONS BUREAU OF HEALTH FACILITY COMPLIANCE Dear Applicant: Effective July 1, 1998, Florida law requires ADCC individual owner(s), operators, and financial officers be screened by the: • Federal Bureau of Investigation(FBI); and • Florida Department of Law Enforcement(FDLE), and • Florida Abuse Registry. These background checks are referred to in Chapter 435, Florida Statutes, as level 2 screenings. Effective October 1, 1998, the law also requires ADCC owners or operators to screen all newly hired employees who provide basic services, or supportive and optional services to participants through: • FDLE, and • Florida Abuse Registry. These background checks are referred to in Chapter 435,Florida Statutes, as level 1 screenings. Level 2 Screening Level 2 Screening must be completed on: • Owner(s) of an ADCC, if the owner(s) is an individual(s), as opposed to a corporation, partnership, etc.; and • ADCC operators; and • a center's financial officer Screening Compliance An owner, operator, or financial officer who holds a current Florida professional license or facility license issued by the Agency for Health Care Administration, or Department of Health, demonstrates compliance with the level 2 screening requirement by providing each of the following documents with the ADCC application: • a copy of the current professional or facility license; and • proof that the FBI, FDLE, and Florida Abuse Registry screening was conducted within the previous 5 years, and • an affidavit of current compliance with Chapter 435. If an owner, operator, or financial officer cannot produce all 3 of the documents above,the FBI, FDLE, and Florida Abuse Registry screenings must be conducted at the time of application, or at anytime if there is a change of operator, owner(s), or financial officer. • The applicant must go to the local sheriff's office,police station, or nearest available Florida Department of Law Enforcement fingerprinting location to obtain a set of fingerprints on each individual owner, operator,and financial officer. • The enclosed card(s) must be used to obtain the fingerprints. Use the attached instructions to correctly complete the card(s). Cards not completed correctly will be rejected by the FBI, redone and resubmitted, and can delay the processing of your application. • Each completed fingerprint card must be submitted to the Agency for Health Care Administration, Assisted Living Unit, with the ADCC application package. The Agency will submit the fingerprint cards to the appropriate screening authority: • The Florida Abuse Hotline Information System Background Check form for each individual owner, operator, and financial officer must also be completed and submitted with the ADCC application. Level 2 Background Screening Fees In addition to the ADCC application fee, you must include the correct screening fee in a check made payable to the State of Florida. One check can be submitted with your ADCC application for both the screening and the application license fee. The background screening fees are (for each person screened): FBI/FDLE $39 Abuse Registry $ 6 Total fee $45 Level 1 Screening Employee screening results must be maintained in the center's employee file. Do not submit employee screening results with your ADCC application package. Level l Screening must be completed on: • All employees hired on or after October 1, 1998,who provide basic services or supportive and optional services to participants. Screening Compliance An employee who has a current Florida professional license demonstrates compliance with the level 1 screening requirement providing each of the following documents are in the employee's file: • a copy of their current professional license; AND • proof that FDLE and Florida Abuse Registry screening was conducted to meet the professional licensing requirements,AND • an affidavit of current compliance with Chapter 435. OR • proof of continuous employment in the same type of occupation without a break in employment exceeding 180 days, AND • proof that FDLE.and Florida Abuse Registry screening was conducted within the previous 2 years as documented in the employee's file. Proof of compliance shall be provided directly from one employer or contractor to another, and not from the person screened. OR • proof of employment with a corporation/business entity or related corporation/business entity that owns, operates, or manages more than one facility or agency licensed as a nursing home, assisted living facility,home health agency, adult day care center, hospice, adult family care home, or intermediate, special services; and transitional living facility licensed under Chapter 400, AND • proof that FDLE and Florida abuse registry screening was conducted by the above corporation/business entity. An ADCC that cannot produce the required documents for any employee that provides basic services or supportive and optional services hired--on or after October 1, 1998, must complete and submit the enclosed FDLE Criminal History form and Florida Abuse Hotline Information System Background Check form for each employee requiring a level 1 screening. When submitting the FDLE Criminal History form and Florida Abuse Hotline Information System Background Check form to the Agency, you must include the correct screening fee in a separate check(from the licensing fee) made payable to the State of Florida. The FDLE background screening fee is $15, and the Florida Abuse Registry background screening fee is $6 (total $21). The Agency for Health Care Administration Background Screening 2727 Mahan Drive Tallahassee,Florida 32308 License Renewal An affidavit of compliance with the level 2 and level 1 must be submitted with each request for an ADCC license renewal. See attachment G for a model affidavit. If you have any questions, please call the Agency's background screening staff at (850)410-3400. I I I i I I li I INSTRUCTIONS FOR BACKGROUND SCREENING All forms must be thoroughly and accurately completed before the background screening process can proceed. Incomplete forms will be returned for completion which may cause a delay in the licensing process. Information and instructions provided below are to assist yowin understanding what the forms in this package are for and how to complete them. Please read this information carefully before completing the forms. I. Florida Abuse Hotline Information System Background Check Form AHCA 3110-0003 (Revised July. '98) (Attachment A,-Required for levels 1 & 2) Be sure that the entire form is completed and appropriately signed. You should make additional copies of the form as necessary. The fee for the Florida abuse background screening is $6 per applicant. II. FDLE Criminal History form (Attachment B, Required for level 1) Complete each item on the form. You should make additional copies of the form as necessary. The fee for the FDLE Criminal History background screening is $15 per applicant. Level 1 background screening only requires completion of attachments A&B. The forms and fees should be submitted to the address listed under level 1 screening in the cover letter. III. Applicant Fingerprint Card (FD-258) (Attachment C, Required for level 2) The enclosed card(s)must be used to obtain the fingerprints. The card will be used to obtain both the Florida Department of Law Enforcement(FDLE) and Federal Bureau of Investigation (FBI) checks. A separate fingerprint card (FD-258) must be completed by each owner, operator, and financial officer. The information should be typed, or if typing is not possible,printed clearly so it can be read. The fee for the FDLE and FBI screenings is $39 per applicant. If a fingerprint card is rejected the applicant must be fingerprinted again and the card resubmitted to FDLE. There is no additional fee for the second set of fingerprints. A fee will be charged for the third or subsequent sets. The following instructions should assist you in completing the fingerprint card: 1. NAM Print or type the Last Name, First Name,Middle Name, Suffix (Jr., II etc., Example: Doe, John Wayne)A comma should separate the Last Name and first Name. If the person has no middle name or initial, indicate this as NMN. If the person has an initial only for their first and/or middle names indicate this as IO,place the "I" under first name and "O" under the middle name. If both letters are the first name place IO under first name and NMN in the space for middle name. 2. Signature of Person Fingerprinted The person being printed must sign his or her legal name in this block. The card should be signed prior to taking the prints to avoid the possibility of smearing the prints on the card. 3. Aliases (AKA) List the Last Name,First Name, Middle Name, and Suffix as indicated in item number 1. If the alias is one or two-words or a nickname such as (Example: Duke, Little Man, Ace, etc.) separate each by a comma and a space. Women applicants using a married name in the "NAM" block should enter the maiden name in the "Aliases" block. 4. Date of Birth (DOB) The applicant must enter the complete date of birth,the.,month, day, and year. If the applicant's date of birth is unknown enter the age of the applicant. When the month and day are unknown, enter two zeros (00) in the month and two zeros (00)in the day and enter the year of birth. 5. Residence of Person Fingerprinted Give the present street address, city and state of the person required to be fingerprinted. 6. Citizenship Enter in this space the country of which the applicant is a citizen. 7. Sex Use the following letters to indicate: M Male F Female 8. Race Use the following letters to indicate: W White (includes, Mexicans and Latins) B Black I American Indian or Alaskan Native A Asian or Pacific Islander(includes,Asian Indians, Eskimos, Filipinos, Indonesians, Koreans,Polynesians and other non-whites) U Unknown 9. HGT (Height) Enter height in feet and inches. Example: Height Enter on Card As 5'11" 511 6'0" 600 (Do not use fractions of an inch.) 10. WGT (Weight) Enter weight in pounds. Example: Weight Enter on Card As 94lbs. 094 1861bs. 186 (Do not use a fraction of a pound.) 11. & Eves and Hair 12. Color of eyes and hair are to be entered on fingerprint card as follows: Color Enter on Card As Bald* BAL (Hair only) Black BLK Blond or Strawberry BLN Blue BLU Brown BRO Gray or Partially Gray GRY Green GRN (Eye only) Hazel HZL (Eye only) Maroon MAR (Eye only) Pink PNK (Eye only) Red or Auburn RED (Hair only Sandy SDY (Hair only) White WHI (Hair only) Unknown XXX (Eyes and Hair *Bald(BAL) is to be used when the applicant has lost most of the hair on the top of their head. 13. Place of Birth Enter the state,territorial possession,province or country of birth. 14. Signature of Official taking Fingerprints and Date The official taking the fingerprints(local sheriffs office,police station or FDLE fingerprinting location) should sign his or her name in this block and the date the card. 15. Employer and Address List your current employer or the facility to be employed by and their complete address in this block. 16. FBI No. ffBD Leave this space blank. 17. Social Security Number(SOC) Enter the social security number of the person to be screened in this block 18. Reason Fingerprinted Do Not Complete 19. Miscellaneous No CMM/Armed Forces No. (MM Record the Miscellaneous number in this block as follows: AF-Air Force Serial Number AR-Alien Registration Number AS-Army Serial Number,National Guard Serial Number or Air National guard Number(regardless of state) CG-U.S. Coast Guard Serial Number MD-Mariner's Document or Identification Number MC-Marine Corps Serial Number MP-Royal Canadian Mounted Police Identification Number(FPS Number) NS-Navy Serial Number PP-Passport Number PS-Port Security Card Number SS-Selective Service Number VA-Veteran's Administration Claim Number *Omit any alpha character(s)prefixed to Army,National Guard, and Air National Guard serial numbers. Enter the serial number only. For Example: Serial Number Should Be Written As Army serial number RA 18901645 AS-18901645 National Guard serial number NG 21001999 AS-21002999 The appropriate two-letter identifying code from the list above must precede the number and is separated from the miscellaneous number by a hyphen(-). Any alpha character(s)that are part of the miscellaneous number area to be included. IV. Volunteer Board Member Statement (Attachment D) Board members of a not for profit corporation or organization are not required to undergo background screening if the individual serves in a voluntary capacity, does not take part in the day to day operational decisions,receives no compensation or financial benefit,has no financial interest in the corporation or organization, and has no family members with a financial interest in the corporation or organization. The board member must complete, sign and date the Volunteer Board Member Statement affirming the board member's relationship to the facility if the above criteria is met. i V. Addendum To Application (Attachment E) Any member of the Board of Directors, or any officer or individual owning 5%or more must submit the Addendum to Application detailing convictions of any level 2 offense,terminations, permanent suspensions or exclusions from Medicare or Medicaid. VI. ADCC Background Screening Affidavit of Compliance (Attachment F) This form is completed when documenting an individual's level l screening compliance in conjunction with their current professional license. Refer to level 1 screening compliance in this package. Please ensure the document is notarized. VII. ADCC License Renewal Application Background Screening Affidavit of Compliance (Attachment G) At each ADCC license renewal,the center owner or operator must document current compliance with level 1 and level 2 background screening requirements pursuant to section 400.5572, Florida Statutes. This document is completed by the center's owner or operator and submitted with the ADCC license renewal application. VIII. Section 435.04,Florida Statutes,Level 1 Screening Standards (Attachment H) IX. Section 435.03,Florida Statutes,Level 2 Screening Standards (Attachment I) Attachment A Agency for Health Care Administration FLORIDA..ABUSE HO.TLINE-- INFORMATION" SYSTEM—'BACKGROUND CHECK Name of Agency/Facility: License Number: Address: _ City State Zip Phone Number Name of Owner of Facility: Address: City State Zip Phone Number To Be Completed by the Applicant: PLEASE PRINT LEGIBLY. All information must be completed or form will be returned: I (we) hereby give consent for the Department of Children and Families to conduct a search for confirmed reports of abuse, neglect, or exploitation on record concerning me. Applicant's Signature Date Current Phone Number Applicant's Present Address: Street City State Zip County Type of Applicant: _ Owner or Operator with 5% interest or more; _Administrator; _ Employee; CNA; Financial Officer; . Relief Person; Other Type of Facility: Home Health Agency Nursing Home Facility Laboratory Homemaker, Companion, Sitter Agency Adult Day Care Center Hospital Assisted Living Facility Adult Family Care Home* Nurse Registry Other (see instructions): Name Maiden/Prior R S Date Social Last First Full Middle Last Names a e of Security c x Birth Number e Applicant *AFCH Only Household Members age 18 or above DO NOT WRITE HERE-OFFICIAL USE ONLY Response to Inquiry: No Confirmed Report: Confirmed Report: Report#: Signature of Employee Completing Record Check Date Suncom We agree to keep confidential all information received as a result of background checks conducted, as required by Florida Statutes. I (we) understand that release of this information to unauthorized persons is prohibited by law. AHCA 3110-0003 (Revised July '98) a ' n Attachment A INSTRUCTIONS Please complete each of the requested items. Please type or print your responses,except for your signature. Illegible forms will be returned. Name of Agency/Facility:Please use the name the facility uses for day to-day business. 7f you are a homemaker/companion/sitter,doing business for yourself or if you have an Adult Family Care Home please put your name. License Number: If the Agency/Facility has been licensed,provide the license number exactly as it appears on the license. Homemaker/companion/sitters should indicate their registration number. Address:Provide the mailing address for the agency/facility. Name of Owner of Facility(optional): Please provide the name of the owner of the agency/facility or of the corporate headquarters'personnel manager. Address: Provide the mailing address for the owner of the agency/facility or of the corporate headquarters' personnel manager. Applicant's Signature: The person being screened must sign the form. Date:provide the date the applicant signed. Current Phone Number: Provide the applicants phone number,please include area code. Applicant's Present Address:Please provide the mailing address of the person being screened. Type of Applicant: Mark the item which best identifies you. If you both own and administer the facility,please mark administrator. Alternate administrators,assistant administrators,and directors of nursing are considered employees. Type of Facility: Please indicate the type of facility the person being screened is employed by. Currently, in addition to the facility types listed on the front of the form,we are also providing screening for the following types of facilities: Drug free workplace—Laboratories Organ Procurement Organizations Birth Centers Tissue Banks,and Eye Banks Abortion Clinics Intermediate Care Prescribed Pediatric Extended Facilities for the Crisis Stabilization Units Care Centers Developmentally and Residential Treatment Disabled Facilities Private Utilization Review Transitional Living Hospice Homes for Special Services Facilities Multi-Phasic Health Testing Service Short Term Residential Treatment Facility Applicant information: Please provide the last name,first name,and full middle name as well as the maiden or prior last name of the person being screened. Race should be indicated by using B for Black;W for white, I for American Indian or Alaskan;A for Asian or Pacific Islander,U for unknown. Hispanics should indicate black or white based on skin color. Adult household members of"Adult Family Care Homes"must also be listed. i �:;; Attachment B AGENCY FOR HEALTH CARE ADMINISTRATION Request for Level I Criminal History Check Account Code Number(s) Name of Agency/Facility: Address: ( ) City State tip Phone Number Name of Owner of Facility: Address: City State Zip Phone Number Type of Applicant: _ Administrator _ Relief Person _ Financial Officer _ CNA _ Owner or Operator with 5% interest or more _ Other Employee Type of Facility: Home Health Agency Nursing Home Facility Laboratory Homemaker, Companion, Sitter Agency Adult Day Care Center Hospital Assisted Living Facility Adult Family Care Home* Nurse Registry Other please specify: PRINT OR TYPE ALL INFORMATION THIS SPACE RESERVED FOR FDLE USE ONLY Name: Last first middle maiden in't-M., Race: ( )W, ( )B, ( )I, ( )A, ( )U Y Race codes are below _ : Sex: DOB: t � ^ G Social Security No.: ate* Current Address: Street: City: State: Zip Code: RACE CODES: W=WHITE B=BLACK I=AMER. INDIAN OR ALASKAN A=ASIAN OR PACIFIC-ISLANDER U=UNKNOWN "1 NOTE: INDICATE-HISPANIC AS BLACK OR WHITE BASED ON SKIN COLOR Solicitantes hispanos deben marcar, en el codigo di ra_a, blanco(white)o negro(black) basado en sit color de piel AHCA 3110-0002 Revised June 1998 ATTACHMENT B Criminal History Check continued PRINT OR TYPE ALL TNFOR'VMATION THIS SPACE RESERVED FOR FDLE USE ONLY Name: Last . First Middle Maiden Race: Sex: DOB: Social Security Number: _ Street Address: City, State, Zip code: Name: Last First Middle Maiden Race: Sex: DOB: Social Security Number: Street Address: City, State, Zip code: Name: Last First Middle Maiden Race: Sex: DOB: Social Security Number: Street Address: City, State, Zip code: AHCA 3,110-0002 Se-c. 96 2 ATTACHMENT C LEA'/—c BLANK z--!,C.< L---.47E NAME F-j*. APPLICANT sect- -4.1 C; A..z--- FL922013z . MEDICAID PRVOR SVCS 1:5.1�:Ncn C; TALLAHASSEE.- FL C A Chapter 409. 907 and 435 R61 gis t a. a ATTACHMENT C �cI3� ? �. ��7r�'c113 �3F INVEST]i:Ai"it3ill UNITED STATES 0EPARTAAENT Of JUSTICE 1.LOOP WASHINGTON, D.C. 20537 . APPLICANT,, -m—, � vR--- a CENTER CFL OP TOO?A!VC:A^S:FA3_F�hi?A.r:s.9`` 7•j./ 4 j��\\, \:.•\ax US-9'.-C<ri:1::E:'S•M. .\\\ 2. 0:$7119U'E INK=_vEN!Y C`INKING S!A3. /�•Lr,l1jl�\• \`\�\;\�::. 3 V:ASr ANO CZY Faai2:S T601000�vIY r�P A TC::fL\•^a:a F?C•A N.':TC NA:!.AND A;=A•:Ow•NG Fw^a?7:To s:r. e—, n--'^ '�`��y• S °_E SCiE:m712S3.C`.S Ail iE:Ci^.:::N COTS.-CT O:CE3 a, _- ` _ If.>•.A:A>: .)`. r. CaM.'i MALI/:T WPOSS-3.-TO PR.`/'A F•\::E3 MAR!A N Ati ilk_ G•�1_ � L`t irE tN:.'::OL AI F..'.,;E:3:::C_c - !'.'.mE---S TO CVA••:a!?FE:-LMrRESS:CNS.SC3.u^ihE 3E5 •->'C C3:A^.:?:'//'r A tllA'.S-+':':TOT E CA:.j cc-.A.�::Nr:>e C.TCJ��S:ANClS 9 E�.A•A.•t:• _.�_•a..N?:. ?"..47S:G S-' _. CA• BE C.A;31'E:.__.•a...,:N.v.::0.. _.A•.0 : T=�U.'c.ac i..cc.:CE?d T�;CF C•.•�'S CA.:(C—!;+A::S?�S CC__T.Nfi! Ll::!Y A V•-.A:E NC.'S-C/• . LOOP A.aiC C..T:&:US 2. THIS CARD FOR USE BY: LEAVE THIS SPACE BLANK 4V�i0nL 1 .Y _ : :[y'- A:_ Ei I`. Fi?:. !°a.....`., A= . C::C C: S A%' JI:•.%-%"S FC: F.:;- . �._ .� r• /i�� .�` �ti\.C.'d.�..�. �_T�.S __.a C? E:•._ '•5:.' =:..G- A•.O PlT•A::S. AS A'J::. iC:- ,a, s:A'c S'>:.. A:.: AF•i.�.vEJ BY L-= wT:C: lY i//'. j:iai•';.� a`• psi%1.:: 1i: _ - +>s _ ��^ .:\�\:_:.,.._:'�.�%_I I ] J n_-:e:, ems• _ C'r E: _ .. ..�_.--� T.'ES-c L'.:_S nJ`...L'.a E-c i va:"cN 1PJSTRUCT;O.iS: �C==TA_A' r:.:.T_ u r TsY _ C-!_aE. T R::G J-. uric L15'E.CL=P.R . F:.A•S S.i-E I.?•••:''� _. _. A7 C:•C/ .: cl.•:GIT. kA" aeE. Foc.e ...AS'H A:- o° I:'A Vr: ci 177: ?lC'.T53 TrAT .. •� //� '��.��\.�::^• 3'>:.. GT ICCA :n%i.::/ 1?:0w0:A:S w-CiE SCCi.+: SEC:T:'Y T.L; IS FEC_E3:E0 Va-'I,ER S:Cr O-SCIASURE IS . X` %tA:._A-C?Y C: VO:.;N:ATY. RAM CF AJ:"CT.Y FOX SCC� sG:'CPA'Gt:Aa.:'.E?;',•.r:C`-S�'::S?MAAZECft. ' i�/��j��\\��\�� ' 1:3 t-:r CF r.:•::'_ CO�TIAC tOAS•S-CI•:: 8? SrO:•:. ��/y��\,�••...Y -1% S"-- •E•: GAS .Ar.:'..O::ESS'. THE C=':':'d.:'::7 IS Tel `�-\w•-'+•.../ .arA3 C- I— AC:`.CY S.?•.t:T:.xG i:,. f:r:Jl�?.a. CARD TO t ,Fl h......;. IN v. A'. IA:.. Pcc- A- J Attachment D VOLUNTEER BOARD MEMBER STATEMENT A member of the Board of Directors is not required to undergo background screening if the individual of a not-for-profit corporation or organization serves solely in a voluntary capacity, and submits a statement affirming that the directors relationship to the corporation or organization meets the terms on this form. Name of Agency or Center: Name of member of Board of Directors: I affirm that I: -Serve in a voluntary capacity -Do not take part in day to day operational decisions -Receive no compensation or financial benefit -Have no financial interest in the corporation/organization -Have no family members with a financial interest in the corporation/organization Signature: Date: Attachment E ADDENDUM TO APPLICATION 1. Please identify all members of the Board of Directors, officers,partners, or individuals owning 5%or more of the facility who have been convicted of any level 2 offense. (See enclosed section 435.04, Florida Statutes,which lists the offenses.) Name: Social Security number: Provide a description and explanation of any conviction of a level 2 offense in the space provided below. (Attach additional pages if necessary.) 2. Has the applicant, board member, officer,partner,or person owning 5%or more of the facility been terminated,permanently suspended, or excluded from Medicare or Medicaid in any state? YES NO If yes,please provide a description and explanation of any exclusions,permanent suspensions, or terminations from Medicare or Medicaid programs. Proof of compliance with the requirements for disclosure of ownership and control interest under the Medicaid or Medicare programs may be accepted in lieu of this submission. Attachment F ADULT DAY CARE CENTER(ADCC)BACKGROUND SCREENING AFFIDAVIT OF COMPLIANCE SECTION 400.5572,FLORIDA STATUTES Under penalty of perjury, I, do hereby (Print Name) certify that I currently comply with the background screening requirements of Chapter 435,Florida Statutes, for(please check the appropriate box): [ ] Level 1 Screening [ ] Level 2 Screening (Signature) (Date) STATE OF FLORIDA COUNTY OF BEFORE ME,the undersigned authority, personally appeared, and after first being duly sworn in, did depose and say that he/she did- execute the foregoing Adult Day Care Center Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. SWORN TO AND SUBSCRIBED before me this day of NOTARY PUBLIC My commission expires: Personally known or Produced identification Type of identification produced r Attachment G ADULT DAY CARE CENTER(ADCC) LICENSE RENEWAL APPLICATION BACKGROUND SCREENING AFFIDAVIT OF COMPLIANCE SECTION 400.5572,FLORIDA STATUTES Under penalty of perjury,I, as owner (Owner or Operator Name) and/or operator of do hereby certify that all (Center Name) persons for whom background screening is required pursuant to..section 400.5572, Florida Statutes, are in compliance, and have no disqualifying offenses. (Signature) (Date) STATE OF FLORIDA COUNTY OF BEFORE ME,the undersigned authority, personally appeared, and after first being duly sworn in, did depose and say that he/she did execute the foregoing Adult Day Care Center Background Screening Affidavit of Compliance and that the same is true, accurate and correct to the best of his/her knowledge, information and belief. SWORN TO AND SUBSCRIBED before me this day of ) 199—. NOTARY PUBLIC My commission expires: Personally known or Produced identification Type of identification produced 2' ATTACHMENT H Florida Statutes 435.03 Level 1 screening standards (1) All employees required by law to be screened shall be required to undergo background screening as a condition of employment and continued employment. For the purposes of this subsection, level 1 screenings shall include,but not limited to,employment history checks and statewide criminal'correspondence checks-through the Florida Department of Law Enforcement and my include local criminal checks through local enforcement agencies. (2) Any person for whom employment screening is required by statute must not have been found guilty of, regardless of adjudication,or entered a plea of nolo contendere or guilty to any offence prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: (a) Section 415.111,relating to adult abuse,neglect,or exploitation of aged persons or disabled adults. (b) Section 782.04,relating to murder. (c) Section 782.07,relating to manslaughter. (d) Section 782.071,relating to vehicular homicide. (e) Section 782.09,relating to killing of an unborn child by injury to the mother. (f) Section 784.011,relating to assault, if the victim of the offense was a minor. (g) Section 784.021,relating to aggravated assault. (h) Section 784.03,relating to battery if the victim of the offense was a minor. (i) Section 784.045 relating to aggravated battery. (j) Section 787.01,relating to kidnapping. (k) Section 787.02,relating to false imprisonment. (1) Section 794.011,relating to sexual battery. (m)Section 794.041,relating to prohibited acts of persons in familial or custodial authority. (n) Chapter 796,relating to prostitution. (o) Section 798.02,relating to lewd and lascivious behavior. (p) Chapter 800,relating to lewdness and indecent exposure. (q) Section 806.0 1,relating to arson. (r) Chapter 812,relating to theft,robbery,and related crimes, if the offense was a felony. II I 1 (s) Section 817.563,relating to fraudulent sale of controlled substances,only if the offense was a felony. (t) Section 826.04,relating to incest. (u) Section 827.03;relating to aggravated-child abuse:" (v) Section 827.04,relating to child abuse. (w) Section 827.05,relating to negligent treatment of children. (x) Section 827.071,relating to sexual performance by a child. . (y) Section 847,relating to obscene literature. J t (z) Chapter 893,relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor. (3) Standards must also ensure that the person (a) For employees and employers licensed or registered pursuant to chapter 400,does not have a confirmed report of abuse,neglect,or exploitation as defined in s. 415.102(5), which has been uncontested or upheld under s.415.103. l (b) Has not committed an act that constitutes domestic violence as defined in s. 741.30 i History—S.47,ch 95-228 Note-Section 64,.ch 95-228,provides that(e)xept as otherwise provided herein,this act shall take effect October 1,1995 and shall apply to offenses committed on October 1,1995 and shall apply to offenses committed on or after that date. 1 y I I if E i I 'f �j I f i ATTACHMENT I Florida Statutes 435.04 Level 2 screening standards (1) All employees in positions designated by law as positions of trust or responsibility shall be required to undergo security background investigatins as a condition of employment and continued employment. For the purposes of this subsction, security background investigations shall include, but not be limited to, employment history checks, fingerprinting for all purposes and checks in this subsection, statewide criminal and juvenile records checks through th Florida Department of Law Enforcement, and the federal criminal records:checks- - through the Federal Bureau of Investigation, and may include local riminal records checks through local law enforcement agencies. (2) The security background investigations under this section must ensure that no persons subject to the provisions of this section have been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to , any offense prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: (a) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults. (b) Section 782.04, relating to murder. (c) Section 782.07, relating to manslaughter. (d) Section 782.071, relating to vehicular homicide. (e) Section 782.09, relating to killing an unborn child by injury to the mother. (f) Section 784.011, relating to assault if the victim was a minor. (g) Section 784.021, related to aggravated assault. (h) Section 784.03, relating to battery if victim was a minor. (i) Section 784.045, relating to aggravated battery. (j) Section 787.01, relating to kidnapping. (k) Section 787.02, relating to false imprisonment. (1) Section 794.011, relating to sexual battery. (m)Section 794.041, relating to prohibited acts of persons in familial or custodial authority. (n) Chapter 796, relating to prostitution. (o) Section 798.02, relating to lewd and lascivious behavior. (p) Chapter 800, relating to lewdness and indecent exposure. (q) Section 806.01, relating to arson. (r) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony. (s) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a (Over) i ATTACHMENT I t i felony. (t) Section 825.102, relating to the abuse or neglect of a disabled adult or'an elderly person. (u) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult. (v) Section 825..103,.relating to the.exploitation,of.a disabled-adult.or an elderly person (w) Section 826.04, relating to incest. (x) Section 827.03, relating to aggravated child abuse. (y) Section 827.04, relating to child abuse. r (z) Section 827.05, relating to negligent treatment of children. (aa) Section 827.071, relating to sexual performance by a child. (bb) Chapter 847, relating to obscene literature. (cc) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any involved in the offense was a minor. Standards must also ensure that the person: (3) P (a) For employees or employers licensed or registered pursuant to chapter 400, does not have a confirmed report of abuse, neglect, or exploitation as defined in s. 415.102(5), which has been uncontested or upheld under s. 415.103. (b) Has not committed an act that constitutes domestic violence as defined in s. 741.30. (4) Under penalty of perjury, all employees in such postitions of trust or responsibility shall attest to meeting the requirements for qualifying for employment and agreeing to inform the employer immedicatelyu if convicted of anyu of the disqualifying offenses while employed by the employer. Each employer of employees in such positions of trust or responsibilities which is licensed or registered by a state agency shall submit to the licensing agency annually, under penalty of perjury, an affidavit of compliance with the provisions of this section. History.—s.47,ch.95-228;s. 16,ch.96-268;a22,ch.96-322. r -- 2 i �I f 2,31 4� S oar- A�-Mlffph- _ ?cs—co vey _�� or► 6-�0-�9 bp � --g G' s 1 . 'r i - i 1,1 REQUEST FOR PUBLIC RECORDS For reference purposes, may we have your. Name: = t 1 �'�^ 5 Address: - to ( Daytime Telephone Number: -2)p s- (o(o S-- o f) F-11 REQUEST TO VIEW THE FOLLOWING.DOCUMENTS: ' a 4 v tpotL. Poo�t 1pc�( C ot� t CATi N . ❑ I.REQUEST COPIES OF THE FOLLOWING DOCUMMNTS: STAFF THE FOR MONTI'OR _hour(s)x $25 00/hour= STAFF IBM FOR RESEARC$_hour(s) x $2500/hour= NUIVMER OF 8 x 11 inch PHOTOCOPIES x 15 cents/sheet= _ NUMBER OF OTIMR ORIGD ALS (special order) x PRICE PER ITEM _ SUB-TOTAL TOTAL PRICE FOR THIS REQUEST FOR PUBLIC RECORDS Customer's Signature Today's Date II ' City of South Miami 6130 Sunset Drive,South Miami,Florida 33143 . May 6, 1999 Juan Ramos 6776 SW 64 Street South Miami,Florida 33143 Dear Mr. Ramos: Re: 6776 SW 64 Street(or Hardee Drive) We have reviewed your application to establish an assisted living facility (ALF) at the above- referenced address in the City of South Miami, particularly in regard to this municipality's local zoning code, and have found the following: that the property, being 6776 SW 64 Street and having folio number 09-4026-008-0160, is zoned RS-1 (Estate Residential) and that the intended use, an ALF, being categorized as a Community Residential Home(CRIO, is a permitted use in RS-1, with the CRH having 6 or less residents. For your future reference, Mr. Ramos, we are attaching copies of information pertaining to the current zoning code for the district in which your property is located. For our reference and files, we understand that the local government, the City of South Miami, will receive notification from HRS as to when the home has been licensed by the department. Also, as an additional note, in retrieving information on the property via Metro-Dade County's real estate database, it shows an address of 6776 SW 64 Avenue. This caused a delay in accessing information, so you may,wish to contact the County in order to have this error corrected. If you should need further assistance or information, please contact the Planning & Zoning Department, City of South Miami, at 305.663.6327. Thank you for this opportunity to be of service. Sincerely yours, David Struder Planning&Zoning Department attachments "City of Pleasant Living" " ff jr, t f _ , o • s " v Dods Coo�,ly r � s • ,f � t � � ,^ � � v I s > Pl ' INK P1L1 46 1 114, 00 ` • (a -1) s K 1,f r, 2 I Q f o s b� o e>• 2 •f it ��► S UTH MIAMI FIELD r �: s s �a , • f ,� ~ n ! - -� - Z 1 • li 'f 1 'f M} N PR * � ss . s � n ►, is 1A '! s• Z"" 1• --- --� r >rf 14. V a Jw 42-i 2 31 e t '` k f Sw &J _ s ' • s ♦ Z 4 h II 1 a 7 6 s • i, • • - I /, Ilk I 2 3 a I .� War rre , se t j , sw ij 1w ripe + • I '�. 1 z � , if + i , s , . s _♦ t 11 ,, Qr 6 ', 2♦ f ' • , „ I' , ^y ,1 ., .. f • 7 III y 13 TRACT IS TRACT IS It '6 •jiy • , l {�� ,. t.6 i A ` f I Q f 11 7 ,� --t ,�} __-•tom ♦ I � ll I, ,s • ti _ s ,: o ti 12 TRACT 11 TRACT 1 TRAC I V1 A j ,/., of" TfiP t. �� R . 4 T � V p f � ,• � i V v 1 ,► 1 a. I�!� t f , , ,♦ , A TRACT O TRACT 7 i TRACT s �• • j �� f ! •• i • _� } 2 h ,� f • t „ • i S #i f ,1 SO TRACT TRA(�T 2 TRACT 1 to 7 to t Mamma -LJOL r • �1 ZQ — � Y I ' •srl/ jai 5 . • V� ' If •,tom .i Z • fill , � .1• I , t i 1p IF S 1 1 O DRIVE S• w• 64 ST. 6800 6790 f 16.1 16 6776 - ` 17 TRACT 14 n7 I�r TRACT 15 I T. }C} V 115 T• 10,1 6790 10 pg o TRACT 1� TRACT PAR;;`!_ p - TR PARCEL 1 6750 ^. °6 _ :} 74 l �7 07.1 O� TRAC T � { TRACT 7 TRgIC i 1 ZONING REGULATIONS 20-3.1 ARTICLE III. ZONING REGULATIONS 203.1 Zoning use districts and purposes. (A) Zoning Districts Established. In order to implement the intent of this Code and the city's adopted Comprehensive Plan, the City is hereby divided into eighteen (18) zoning use districts with the symbol designations and general purposes listed below and permitted uses set forth in Section 20-3.3(D).A planned unit development (PUD) district is also created in Section 20-3.7. Standards shall be uniform throughout each zoning use district District symbols and names shall be known as: Symbol Name ' RS-1 , --� Estate Residential RS-2 Semi-Estate Residential RS-3 Low Density Single-Family RS-4 Single-Family RS-5 Single-Family(S('lots) RT-6 Townhouse Residential RT 9 Two-Famikyl7bwnhouse Residential RM-18 Low Density Multi-Family Residential RM-24 Medium Density Multi-Family Residential RO Residential Office LO Low-Intensity Office MO Medium-Intensity Office NR Neighborhood Retail SR Specialty Retail GR General Retail I Intensive Use H Hospital Pi Public/Institutional PR Parks and Recreation (B) District Purpose Statements. (1) 'RS-1'Estate Residential District. The purpose of this district is to provide for estate type single-family residential development located in a spacious rural-bike setting which emphasizes the preservation of open space. This district is appropriate in areas designated "Single-Family" on the city's adopted Comprehensive Plan. .; 20-3.5 SOLI MIAMI LAND DEVELOPMENT CODE Section 20-3.5E DIMENSIONAL REQUIREMENTS SINGLE-FAMILY DISTRICTS REQUIREMENT RS-1 RS-2 RS-3 RS-4 RS-5 Min. Lot Size Net Area(sq. ft.) 40,000 15,000 10,000 6,000 6,000 Frontage (11.) 125 100 75 60 50 Min. Yard Setbacks (ft.) Front 50 35 25 25 25 Rear 25 25 25 25 25 Side (InteriorY 12.5 10 7.5 7.5b 7.5b Side (Street) 720' 15 15 15 15 Max. Building Height Stories 2 2 2 2 2 Feet 25 25 25 25 25 Max. Building Coverage M 20 30 30 30 30 Max. Impervious Coverage M 30 40 40 45 45 Cumulative width of both side yards shall be not less than 20 percent of total lot width. b Except that additions to existing structures may have 5 feet interior side setbacks where any portion of the building already has a 5 feet setback. Supp. No. 3 50 i 20-3.3 SOUTH MIAIYU LAND DEVELOPMENT CODE I SECTION 20-3.3(D) USE SCHEDULE P PERMITTED BY RIGHT S = PERMITTED AS SPECIAL USE COND = SPECIAL USE CONDITIONS (See Section 20-3.4) PARK = PARE3NG REQUIREMENTS (See Section 20-4.4(B)) z = No conditions were adopted ZONING DISTRICT . It R R R R R R R R L M N S G T H P P C P USE TYPE S S S S T T M M 0 0 0 R R R O I R 0 A 1 2 3 4 6 9 1 2 D N R 8 4 D D K PLANNED UNIT DEVEL- OPMEMP RESIDEN- S S S S S S S S S S S S' S S S S 8 TIAL USES Dwelling,Single-family P P P P P P P P 3 1 171 1 Dwelling,Townhouse P P P P S P 1 17 2 Dwelling,Two-Family P P P S 17 1 Dwelling,Multi-Family P P S P 17 3 Community Resid Home,6 or P P P P P P P P P P 1 less Community Resid Home,71; P P 1 more PUBLIC AND INSTITUTIONAL USES Adult Congreg Living Fad- S S I S IS 1 1 1131 1 ity Church,Temple or Syna- S S S S S I I IS I S I 1 1 6 gogue Convalescent Home P P1 P IP 1 113 Day Care Center P P P P P P P P P 10 (7 or more children) Fraternal Organization or S S S S S P P 2 7 Private Club Governmental Administra- P P P P P 10 tioa Hospital S 14 5 * TODD(TRANSIT-ORIENTED DEVELOPMENT DISTRICT: SEE ORDINANCE#9-97-1630 Supp. No. 2 30 20.2.3 SOUTH MIAMI LAND DEVELOPMENT CODE Church, mosque, synagogue,or temple. Shall mean a building, a building and other struc- tures,or a group or buildings and structures which by design and construction are intended for organized worship and commonly related services, such as educational, recreational, and social services, including day care. (Ord. No. 5-94-1554, 3-1-94) City. Shall refer to the City of South Miami, Florida. ' City Commission. Shall refer to the City Commission of the City of South Miami, Florida. City Manager. Shall mean the City Manager of the City of South Miami, Florida. ' Code enforcement agency. Shall mean the Building and Zoning Department of the City of South Miami, Florida. ' Community residential home. Shall mean a dwelling unit licensed to serve clients of the Department of Health and Rehabilitative Services, which provides a living environment for ' unrelated residents who operate as the functional equivalent of a family, including such supervision and care by supportive staff as may be necessary to meet the physical, emotional and social needs of residents. Comprehensive Plan. Shall mean the adopted Comprehensive Plan of the City of South Miami. . I Counseling services. Shall mean service by individuals licensed by the State of Florida as mental health or nutrition counselors; marriage and family therapists; psychologists; and I social workers. (Ord. No. 12-90-1452, 7-24-90; Ord. No. 10-92.1505, 6-2-92) Day care center. Shall mean any establishment providing for the daytime care of seven(7) I or more children which are not members of the resident family. Deli - Delicatessen. Shall mean an establishment where prepared foods are sold not for I consumption on the premises. (Ord. No. 7-92-1502, 5-5-92) Demolition. Shall mean the partial or complete destruction or removal of a building or portion thereof on any site. Development order. Shall mean any order granting, denying, or granting with conditions an application for a development permit. Development permit. Shall mean any building permit, zoning permit, subdivision ap- proval, rezoning, certification, special exception, variance or any other official action of the City having the effect of permitting land development. Diameter at breast height(D.B.H.). Shall mean the diameter of a tree trunk at a height of four and one-half(4.5) feet above grade. Director. Shall mean the Director of Building and Zoning of the City of South Miami, Florida. 8 20-2.3 SOUTH MIAMI LAND DEVELOPMENT CODE Accessway. Shall mean a driveway which traverses the perimeter of a vehicular use area, thereby connecting said area with and providing access to an abutting street, alley or other vehicular use area. Acupuncturist.Shall mean a person who is licensed in accordance with,and who practices acupuncture as defined in, Chapter 457 of the Florida Statutes. (Ord. No. 7.91-9091, 3.19-91) Addition. Shall mean an extension or increase in floor area or height of a building. Adult congregate living facility.Shall mean any building or buildings,section of a building or distinct part of a building, residence, private home, boarding home, home for the aged or other place, whether operated for profit or not, which undertakes through its ownership or management to provide, for a period exceeding twenty-four (24) hours, housing, food service and one or more personal services for four (4) or more adults, not related to the owner or administrator by blood or marriage, who require such services and to provide limited nursing services, when specifically licensed to do so pursuant to Florida Statutes. A facility offering personal services or limited nursing services for fewer than four (4) adults is within the meaning of this definition if it formally or informally advertises to or solicits the public for residents or referrals and holds itself out to the public to be an establishment which regularly provides such services. Advanced registered nurse practitioner. Shall mean a person who is licensed in accordance with,and who practices advanced or specialized nursing practice as defined in,Chapter 464 of the Florida Statutes. (Ord. No. 7-91-9091, 3-19-91) Aggregate area or width. Shall mean the sum of two(2)or more designated areas or widths to be measured, limited, or determined under these regulations. Alcoholic beverage. Shall be as defined by Section 561.01(7), Florida Statutes. Alley. Shall mean a public or private street which affords only a secondary means of access to abutting property and which is not otherwise designated as a street. Alteration. Shall mean any change or modification of construction, space arrangement or occupancy of a building, or decreasing or increasing the.floor area thereof. Antennas, microwave. Shall mean antennas restricted to the sole purpose of receiving and/or transmitting and amplifying microwave signals and shall be permitted in commercial districts only. Antennas, satellite earth station. Shall mean antennas restricted to the sole purpose of receiving and amplifying microwave signals for television reception and shall be permitted in residential and commercial zoning districts. Archeological zone. Shall mean an area designated by this Code which is likely to yield information on the history and prehistory of South Miami based on prehistoric settlement patterns as determined by the results of the Dade County Historic Survey. These zones will tend to conform to natural physiographic features which were focal points for prehistoric and historic activities. 6 FLORIDA DEPARTMENT OF Jeb Bush C H I L D R E N Governor d Kathleen A. Kearney FAM i L 1 E S Secretary District 11 Sarah Herald Dade& Monroe Counties Acting District http://www.state.fl.us/cf web/districtll Administrator COMMITTED TO EXCE LLENCE April 27, 1999 Mr. Eddie Cox City Manager APR 2 91999 City of South Miami 6130 Sunset Drive {pNq $ ��:R , .a>s.�•,°; South Miami FL 33143 ° Dear Mr. Cox: The attached copy of the Community Residential Home Registry is provided according to Chapter 419, Florida Statutes. Please deliver it to the appropriate departments within your organization. This report consists of an updated list of,Com munityResidential_Homes (CRHs)'in Dade and Monroe Counties. �CRHs incldd-E..Assisted Living Facilities (ALFs), Adult Family Care Homes '(AFCHs), Alcohol, Drug Abuse and Mental Health Residential Treatment Facilities Levels II -!and IV, Residential Child Caring Agencies, and Developmental Services Group and Intermediate Care Facilities for the Mentally Retarded, with a licensed capacity of one (1) to fourteen (14). For information on the Community Residential Home Project, please contact me at 401 N.W 2nd Avenue, Room #N-514, Miami, Florida 33128, (305) 377-7511. Sincerely, 94WIWII-V� Ellison A. Shapiro Community Residential Home Coordinator Angelo Parrino,Deputy Division Director,Divisions of Adult Care and Family Support 401 NW 2nd Avenue,Suite N-812, Miami,Florida 33128 Working in partnership with local communities to help people be self-sufficient and live in stablefamilies and communities. �• Know about and provide information on local ordinances "h 8• Develop mechanisms,procedures or cooperative agreements with local ov cOunty--for the exchange of information o facilitate and regularize this g ernments--city and 9, g process Provide local governments and citizens with a single problems regarding community residential homes �m t of contact to resolve questions or 10. Provide public information and education regarding arise m that district in the district g ing Chapter 419,F.S.and its implementation PROVIDER RESPONSIBILITIES A. Contact HRS district community residential home coordinator as soon as the decision to look for a site is made in order to check registry and discuss need for home B. All providers must ensure on HRS Form 1786,March 90 that applicable dispersion been met. cae dis p sion requirements have C- Providers of homes of 7-14 residents must submit notification to the local government of the selection of site for the community residential home,including-- 1• The spec address of the site 2• The residential licensing category 3• Number of residents 4• Community support requirements of the program 5• Statement from the HRS district administrator(HRS Form 1785,March 90 indicating__ a. The need for and the licensing status of the proposed home b• Specifying how the home meets or will meet applicable licensin criteria f care and supervision of the clients in the home g or the safe D. Providers of homes of 7 44 residents must certify notification has been made. The provider should attach proof of notification date stamped on HRS Form 1786,March,90 that local government. other document) to HRS Form 1786• Providers must notify the HRS licensing Office u expiration of 60 days following local ( amped letter or deny the siting within that time period.government notification if the local Pon the government fails to approve or LOCAL GOVERNMENT RESPONSIBILITIES A. In the case of homes of 1-6 residents, an the local government will department at the time of home occu receive notification from the p cy that the home has been licensed by the department. B. Review notification by the providers of homes of 7-14 residents in accordance with Chapter 419,F.S. 12 C. In reviewing notification of homes of 7-14 residents,the local government may-- 1. Fail to respond within 60 days, a. In which case,the home may be established at the site selected. 2. Deny the siting of the home. a. To deny,local government must establish that the siting of the home at the place selected-- 1) Does not otherwise conform to e3dsting zoning regulations applicable to other multi-family uses in area 2) Does not meet applicable licensing criteria established as determined by the department,including the requirement that the home be located to assure the safe care and supervision of the clients 3) Would result in such a concentration of community residential homes in the area or a combination of such-homes with other residences such that the nature and character of the area would be substantially altered. 3. Approve the siting. DEFINITIONS A. Community Residential Home. A dwelling unit licensed to serve clients of HRS,providing a living environment for 7-14 residents who operate as the functional equivalent of a family,including such supervision and care by support staff as may be necessary to meet the physical,emotional and social needs of the residents. Homes of six or fewer residents that otherwise meet the definition of a community residential home are regarded as single-family units and non-commercial residences for the purpose of local laws and ordinances and are defined as community residential homes by the department. B. Providers/sponsors or sponsoring agency or owner/operator means an agency or unit oEgovernment,a profit or non-profit agency or any other person or organization that intends to establish or operate a community residential home. C. District community residential home coordinator means the individual appointed by the district administrator to maintain registry and provide local government and providers/sponsors with assistance. 13 05/06/1999 * * * PUBLIC VALUE INQUIRY * * * PTXM0186 FOLIO 09 4026 008 0160 PROP ADDR 6776` HARDEE DR - MCD 0900 NAME AND LEGAL VALUE HISTORY JUAN RAMOS YEAR 1997 1998 01/01/1999 6776 SW 64 AVE LAND 123008 123008 MIAMI FL BLDG 78207 84712 MARKET 201215 207720 331433232 26 54 40 ASSESS 201215 207720 NELSON HOMESITES PB 39-57 HEX E1/2 OF TRACT 15 WVD LOT SIZE IRREGULAR TOT EX OR 17357-3978 0896 1 TAXABLE 201215 207720 STATE EXEMPT: SALE DATE 08/1996 SALE AMT 243500 SALE TYPE 1 I/V I SALE 0/R 17357-3978 PF1-MORE LEGAL PF2-PARCEL INFO PF3-FOL SRCH PF5-TAX COLL PF7-PREV OWNER PF8-MENU PF13-OCCUP LIC * * * PARCEL INFORMATION * * * PTXM018 FOLIO 09 4026 008 0160 PROPERTY ADDRESS 6776 HARDEE DR CLUC RESIDENTIAL - SINGLE FAMILY SLUC RESIDENTIAL - SINGLE FAMILY PRI ZONE ESTATES - 1 ACRE SEC ZONE LOT SIZE 43211.52 SQ FT YEAR BLT 1956 EXTRA FEA POOL & AC LIVING UNITS 1 BEDROOM 2 BATH 3 1/2 BATH ADJ SQFTG 2177 NO FLOORS 1 ZONING RESOLUTION LEASE AREA SQFTG LOC CODE SD ENTER - VALUE INQUIRY PF8 - MENU • * * * * * PUBLIC MENU * * * * * PTXM0185 REAL ESTATE / PERSONAL PROPERTY INQUIRY REAL ESTATE FOLIO: 00 0000 000 0000 REAL ESTATE PROPERTY ADDRESS: 6776 SW 64 ST SUITE REAL ESTATE NAME: REAL ESTATE SUBDIVISION NO: 00 0000 000 REAL ESTATE SUBDIVISION NAME: PERSONAL PROPERTY FOLIO: PERSONAL PROPERTY ADDRESS: 00000 SUITE PERSONAL PROPERTY NAME: ENTER REAL ESTATE FOLIO, ADDRESS, NAME (LAST NAME, FIRST INITIAL) OR SUBDIVISION NUMBER OR SUBDIVISION NAME FOR REAL ESTATE INQUIRY ENTER PERSONAL PROPERTY FOLIO OR ADDRESS OR NAME FOR PERSONAL PROPERTY INQUIRY AND PRESS ENTER PRESS PF5 FOR TAX COLLECTION MENU PF10-FINISH ADDRESS NOT ON DATA BASE • Assisted Living Facilities Ir License Application E 4D" F State of Florida — 2727 Mahan Drive MAY " 5 1" Agency for Health Care Administration Tallahassee,Florida 32308-5403 Please complete the application in pen or type with an original signature �+ h I. :Faciliiy' nformabon A. _ �S�1SZC� �COML 1,�V 1hl 6 -To C- Z- CS) Cei tvS- 5001 Facility Name Telephone# Facility Street Address City County Zip Code ,, C. Mailing Address(if different) City Zip Code II Application-andFacility Type r T } Please Check All Appropriate Boxes ( Initial License Application ( ) Bed Increase ( ) Renewal License Application ( ) Bed Decrease ( ) Change of Ownership: ( ) Add Specialty License Date Ownership Transferred i ( ) Facility Name Change: t Facility Name as Currently Licensed Jnder the Authority of Chapter 400,Part III,F.S., and Chapter 58A-5,F.A.C., application is hereby made to i )perate Assisted Living Facilities of the following type(s): ( Stan dard ( ) Limited Nursing Services(LNS) ( ) Extended Congregate Care(ECC) ( ) Limited Mental Health(LMH) II Application and Bed Fees 3 4 .Enter the current Standard ALF application fee: i . Total number of ALF beds to be licensed l Note. Each bed must be designated as either private pay or OSS . Of the total beds in#2 above,license is requested for private pay beds O O { Multiply this number times the private pay bed fee: $ �$ If applying 1 in for an LNS license,enter the LNS application fee: $ Multiply the total number of ALF beds in item#2 above times the LNS bed fee: $ If applying for an ECC license,enter the application fee: $ Add the dollar amounts in items 1, 3,4, 5,and 6 and enter here: TOTAL iCA Form 3110-1008,October 1998 1 f t 4ucreaseecreaSe • Bed Ca laaci If thus application ' renewal, or c is 0R1y to request an -. 1. T change of own,WP,PI easease or decrease in Total number of c complete thus section, e number of lice Stan tin ently licensed ALF be rased beds,not for an n Standard beds: LI1gI LNS � ECC 2. Number of be �-� ds requested to be: a. Private Pay B eds; � Increased b. OSS Designated Beds: –�—Decreased INS Beds: d. L11gI Beds e. ECC Beds Identify the location or section w facility is licensed as an ECC: the facility where the ECC beds are located 3. If aP unless the whole Plying beds requested.g for an $ in the number of licensed beds `'• A -- _. Ply the co fe multi PPlicanr fo` n correct per bed e �?�$tio r: by the n A. Applicant is y umber a( ) n : - . ( ) Individual(s) (>C) Corporation or ? ( ) General p Limited Partnership ( ) Other artne1ShiP (Specify) B• If the aPPlic ant is .............. a corporation or 1' Of State,Division of C° united Partnershi rPorations: _ A enter the n A copy of the current cert fca S t $ name registered wi to of status L �; the Florida De Document must be submitted vvi>b u Z Department number issued by Division this a °f Co PPlication. i Federal.Employer rporations; mployeTIdentificationNumber: �S_ C. The facility p �'is operated ( � a. E �)For Profit ( . (Requd for all o Is the facility mans Not For Bed b Profit, wners who Pay waged ' If yes Y someone other give Inana than the name of the the aPPIicant? Bement com ( ) Yes PanY or individ (�No Name uah(s)°n the line behove Address Telephone# HCA Form 3110-1008,pctober 1998 2 F. The property&building(s) are: (x)Owned by the applicant ( )Leased or rented. If the property&building(s)are leased or rented,give the following information on the property owner: Name Address Telephone# G. Complete the following information for each applicant,partner, or corporate officer: (Add sheet if necessary.) Name: Owner ( ) Partner ( ) President Sex: (X )Male ( )Female Date of Birth: 0\—O 3 - (0 1 SSN: 'A-6 i- l46j-1 ti C1 A X0-1-1 (3 SU-) ("�A S* . So h r1'�1.Prnnt ��A 12 4 39s- (a�s-5ob1 Mailing Address Telephone# 2. Name: ( ) Owner ( ) Partner ( ) Vice-President Sex: ( )Male ( ) Female Date of Birth: SSN: Mailing Address Telephone# 3. Name: ( ) Owner ( ) Partner ( ) Secretary Sex: ( )Male ( )Female Date of Birth: SSN: Mailing Address Telephone# 4. Name: ( ) Owner ( ) Partner ( )Treasurer Sex: ( )Male ( )Female Date of Birth: SSN: Mailing Address Telephone# H. List the name,address, and telephone number of three separate references for each individual owner,partner, financial officer or corporate officer. Each individual must use different references. Attach separate sheet, if needed. Name: Address Telephone# sU� a�E thI►� �ZS mss- gam-3a9� ,� 1 ilea --� �tL�s �[' `3i1 SW 2 A 2j.r A .� (�urn ciS 2� lc� 33 5f _zo— ©Geri t O� n i. m`.A -�-_ — AHCA Form 3110-1008,October 1998 3 I• Has any owner(s), administrator,or financial officer resident care facility within 5 been affiliated through ownership or em to j Years of the date of this application? 1�) Yes P yment with an If yes,provide the individual's ( )No name,facility name and address,and dates of affiliation. Attach additional she v J. For co orations onl . q interest in the corporation which otert e n b es(s)and address(es)of each person having t le ° least 5%of the business,please mark that this question its of aditli ableheets if necessary.g least 5/o ownership PP ary. If no individual owns at Name • ( )Not Applicable. A- ddr_ %Ownershi a °lo K. Does any individual listed in V.,I. or J.,have at least a ° ' association,partnership, or corporation Providing /o interest in any professional service,firm, g goods, leases or services to the facility? ( ) yes ( ) No. If yes, list the foil name and address of the professional service, firm, assocat' which such interest is held. Attach additional sheets if necessary.' ion,Partnership, or corporation in 1. Name of Individual: Service/Business Address: 2. Name of Individual: Service/Business Address: t '%T MIMI .strator. �,R Information :r -: A. - - , Administrator's Name i— ( 2,(,o k— Sex Does a Date of Birth SSN administrator live in the facility? ( ) yes (� No. If yes,how long? g Home Mailing Address City Zip Telephone# B. What is the highest grade or level of education completed? If graduated,provide the school name, address,and date of graduation for highest gh st grade completed: AHCA Form 3110-1008,October 1998 4 'C• List the names,addresses and telephone numbers three references. References may not be the same as those listed for the owner. If the administrator is also the owner,references do not need to be listed again. 1. 2. 3. Background - _. Has any individual owner, corporate officer,partner, administrator, or financial officer held any financial or ownership interest in any entity licensed by this state or another state to provide health or residential care that was closed or ceased to operate due to financial problems,had a receiver appointed, license denied, suspended, or revoked, was subject to a moratorium on admissions, or had an injunction proceeding against it within 5 years of the date of this application? ( )Yes ( )No. If yes, list the individuals involved,the facility/entity type, adverse action, dates of occurrence, and provide a detailed description and explanation of the occurrence(s). Use additional sheets as necessary. A background check will be made for each applicant,partner, officer, and administrator. Giving a false statement could result in denial of a license. VIII :Specialty License Information A. Has the facility maintained a standard license for the past two calendar years or since initially Iicensed if licensed less than two years? ( ) Yes ( )No. B. Has the facility received administrative sanctions during the past two calendar years? ( )Yes ( )No. C. Please check the specialty license requested: 1• Limited Nursing Services. Nursing Services to be provided by: ( )Facility Staff; ( )Home Health Agency; or( ) Other Specify Other 2• Limited Mental health Services. Total number of LMH beds requested: 3• Extended Congregate Care Services. Identify the building,wing,floor, or rooms designated for ECC services provided: Total Number of ECC beds requested: AHCA Form 3110-1008,October 1998 5 IX. ...Surety-Bond : Is the applicant,administrator,staff,or any facility representative serving as a representative payee or as power of attorney for any ALF resident? ( )Yes (><)No. If yes, attach a copy of the surety bond or continuation bond that meets the requirements of s. 400.427(2),F.S., and Chapter 58A-5.021(3)(a),F.A.C. X. -.Continuing Care.Agreem6nts . Does the facility also have a separate license issued by the Department of Insurance as a continuing care retirement community as defined in Ch. 651,F.S.? ( ) Yes (x)No. If yes,attach a copy of your current certificate of authority. For more information contact the Florida Dept. of Insurance,Specialty Insurers,200 East Gaines Street,Larson Bldg,Tallahassee,Florida 32399-0300. Telephone number(904)922-3144. XI. .Services Offered By The Facility Please indicate below all of the services that are offered by the facility.. ( ) Special diets ordered by health care provider. ( >)Assistance with bathing. ( Transportation to medical appts. (�)Assistance with toileting. ( X) Wheelchair accessibility. (�)Assistance with eating. (X)Disabled and elderly residents. (X)Assistance with ambulation. (><)Incontinent residents: ( )bladder ( )bowel. ()<)Assistance with dressing. ( )Medication: ( )supervision ( )administration ( )assistance with self administered ( )Nurse on staff. ( )RN, ( )LPN, ( )gyp, Number of hours per day?( ) ( )Alzheimer's residents,or( )memory impaired residents. ( ) Special programs for memory impaired residents. ( )Day care services. - ( )Respite care services. AHCA Form 3110-1008,October 1998 6 XII. Affidavit -.(NOTE; This application must be notarized.) The undersigned hereby swears or affirms that the statements in this application and its attachments are true and correct and that to the best of my knowledge and belief, all persons in ownership or employment are of good moral character,and that the ownership possesses sufficient funds to operate this facility in a satisfactory manner. The information provided herein is true and correct to the best of my knowledge. I understand that providing false or misleading information on this application may result in license denial or revocation. 41e of Applicant or Administrator Signer's Printed Name Title Date NOTARY State of County of On this day of , 19 ,before me personally appeared whom I know personally/whose identity was proved to me on the oath of a credible witness by me duly sworn/whose identity was proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument,and acknowledged that(s)he executed the same. SEAL Notary Public Signature My commission expires AHCA Form 3110-1008,October 1998. 7 ALF Application Checklist Initial Application or Change of Ownership Ap _cation Completed and notarized application form,AHCA Form 3110-1008,October 1998. Application fee(check or money order payable to State of Florida). Assets and Liabilities statement or balance sheet. Statement of Operation Form. Liability insurance verification. Background screening documents completed for individual owner(s), administrator,and financial officer. Correct background screening fee in a separate check(check or money order payable to the State of Florida). Affidavit of compliance with background screening requirements. Fire safety inspection approved and signed by the local Fire Marshall. Sanitation inspection by the county Public Health Department. A floor plan of the facility. Blue prints are not needed;hand drawn to scale is acceptable. Zoning approval letter from local zoning authority. Community Residential Homes Sponsor Certification(if located in single family or multi-family zoned area and to be licensed for 1-14 beds),DC&F Form 1786. Completed affidavit of compliance with First Aid training. Certificate of status form if a corporation or limited partnership. Surety Bond or continuation bond if a representative payee or power of attorney. Certificate of Authority if licensed as a continuing care retirement community facility. Recorded warranty deed or lease agreement. NOTE: If this is a change of ownership application,the warranty deed/lease agreement must not be entered into and therefore submitted, until 60 days after the change of ownership application has been filed with the Agency. Volunteer board member statement of involvement in prior facilities or health care companies(if applicable) Renewal Application Completed and notarized application form,AHCA Form 3110-1008,October 1998. Application fee(check or money order payable to State of Florida). Liability insurance verification. Affidavit of compliance with background screening for all direct care employees,and owner(s)administrators,& financial officer, or all forms completed and submitted to determine compliance including the fee. Current year Certificate of Status if corporation or limited partnership. Surety bond or continuation bond if representative payee or power of attorney. Certificate of Authority if a Continuing Care Retirement Community facility. Late fee if application mailed less than 90 days prior to the license expiration date(half of the current license fee). All outstanding fines paid. Capacity Expansion Completed and notarized application form,AHCA Form 3110-1008,October 1998. Application fee in the form of a check or money order payable to State of Florida. Zoning approval letter from the local zoning authority. Community Residential Homes Sponsor Certification,DC&F Form 1786, if located in a single family or multi- family zoned area&expanding from 1-6 beds to 7 to 14 beds. Satisfactory fire safety report to include the expansion. Satisfactory sanitation report to include the expansion. Specialty License Completed and notarized application form,AHCA Form 3110-1008,October 1998. Application fee in the form of check or money order payable to State of Florida. NOTE: There is no fee for a limited mental health license. October 1998 J q I ! 0 t� 43 O i of VLI o' a , c. v+ 4A K w w 61. r. K Ce 'nl u 6r. u ri ar ' 4 N oI = T I 4. 0 I � K H H H H O O i a !� II nn N H M H H 4A N H H H H Y. �I OD 1 Cl ILO P r � ✓• = ¢ t Q C Y G O c Y v Y r ro so Gi C N V) Y r 00 V C . E •C O h Lo ONO u ti V v !" < LZ y n u C = a G < L V Z C INSTRUCTIONS FOR COMPLETING THE ASSETS AND - L:.BILITIES STATEMENT a result this statement may not be appropriate for other uses b%•the INTRODL'CT10N ALF such as income tax preparation , Land-Enter the amount paid for the land or fair market value as Tne Assets and Liabilities Statement (balance sheer)of owner applicable. icemifies the assets which will be available.as of the date this Buildings- Enter the amount paid for the buildm_or fair marke: Statement is completed,for use in operating the Assisted Living value as applicable. If the buildm=has been depreciated. Its:the Facilities(ALF),and the current liabilities which represent ciauns of amount depreciated and subtract it from the onainai cos:to obtain creditors aeanst these assets. )gut ment - Enter the amoun:paid for the equipmen: o-the fa:- INSTRUCTION FOR COMPLETING THE FORAf market value as applicable. if the equipment has been depreciated. its fours is desr_tted to accommodate various types of AL' =s. Its:the amount depreciated and subrac: r from the onainai cos:to from small individual proprietors to corporations, bur not all of the obtain the fteure"net equipment". :rformarion requested will be applicable to iA A::rs. I- u LIABILITIES _. created that in some cases several of the lines will be le`, biank Liabilities are claims or debts owne� b% the AL=. the amount the and in other cases lines will need to be added und:-the"oche-" A:.F owes to persons other than the ALF owners Liabilities are -a:eeories. reporter:as the amours: ow•e,:as of the assets and liabilities -ne left hand or arse:side of the form is cornmeted f.5irc in :n_ statement data. rnciuding trice-es:accumulated LO pat:. lnt:res:tit: applicable blanks of the current and nxed arse:cateeon and will be owed subsequent to the assets and liabilities staternen: dz:: totaling as indicated. Stmiiariy. current liabilities. other liabilities. is excluded. and stockholders' or owners equity should be totaied to ootain totai Current Liabilities - These are existing liabilities which mus: of equities for the right hand or liabilities and equity side of the paid within the next Twelve(12)months. oaia'ice sheer. Total asses and total eouin•must eoual. Definitions Accnunts Pavable-the amount entered 'here should include the o:the individual components of the balance sheer are as follows. sum of the total unpaid salaries and payments of all unpaid bills and ASSETS financial oblieations which fall due within the next(13)months Current Assets- These are assets which can be converted to cash with the exception of mortgage payments and installment loans. ouickh•and are therefore reserved as ready sources of cash to meet Examples include utiiiry bills,unpaid wages to current employees. r.-nmediate requirements. if any,charge accounts and credit cards such as VISA,Maste.-Card. Cash -Enter the total of all forms of cash you have available which American Express.etc. will be used to support operation of the ALF. Items to be used to Notes Pavable-This amount should include all payments which compute this value include currency,cash m checkme accounts and must be made within the next twelve(13)months on existing oz passbook savings accounts. The amount shown must be contracts,mortgages and installment loans. available now and available to support the operations of the facility. Other-This amount should include any other existine obligations Monetar-Investments-Monetary investments include primarily which are due during the next twelve(12)months. It includes :at= items: Certificates of Deposits.saving bonds and treasury bills payments of obligations which are in arrears such as income taxes. c-ponds owned by the applicant and identified for immediam use property taxes,insurance, etc.,Each item in this category must be in operating the facility. itemized separately. Negotiable Securities-These include stocks. corporate bonds,etc., Other Liabilities-These are claims of outsiders that do not fall which are owned by the applicant and are identified for rue,if due within one yeamn necessary, m operating the facility. Mortgage Pavable-These include all first,second and other Accounts Receivable-Any monies owed to the applicant which mortgages owei!L Includes the unpaid balance of mortgages owed we due within one year and would be used as they materialize, if on land,building,equipment or other assets. :necessary in support of facility operations. Stockholders' or Owners' Eg} ii t The stockholders' or owners' Notes Receivable - Any promissory notes held by the applicant equity section of the balance sheet shows the claims of the owner •x•hieh fall due within one year of the date of application and whose or stockholders. proceeds would be use,'-, if necessary,to operate the facility. Common Stock or Capital -The amount fisted here is the stated Other-Any other assets suer,as prepaid expenses which could be value of the stock which may be the par value of the stock pn= if i converted into cash within the operating year and used for was sold,or some other figure fixed by the board of directors. operation of facility. Owners' Eouin•-The amount lismd here is completed for Other-Any other. assets such as prepaid expenses which could be propriewnship or.parmer's and is the amotmt of capital placed in the conversed into cash within the operating year and used for ALF by the owner(s). operabon of facility. Appreci2ted value-'Kris line will be completed when fixed arse'u, Fired Assets-These are tangible,relatively long-lived resources. on debit side have berg listed at their market value rather than ther- !f they have been acquired in the last year,they must be listed at the purchase price. This line should reflect the amount the assets ac sal measurable money amount they were acquired for. If they (primarily land and buildings)have appreciated over the purchase rave been owned for more than one year,such as a person who is price. converting his home into an ALF,they should be listed at their fair Retain Earnings-The amount listed here should include the market value. Although this method of determining value is needed earnings of the ALF to date. less the amount paid out in dividends. to adequately analyze an ALF's ability to operate,operators If the difference is negative the items is labeled deficit zm:auttzzed that generally accepted accounting principles require that assets be listed at the dollar amount actually paid for them. As � o �� i �o�a�° I°��{• .01',a1 '01 1191110 11 1 11,11 • Q oil I .9 I a v o a °44 ► r It✓ � � � �� I o O I — v I ® o 0000 0 I � o l � ► ► � l � Pn ., a 40 I ► � I � � � I • _ a � I . I I I I � ° z 0 4 I � o I I I o r I I Z v I Id -.9� d i I I l I °— 1. 0-1 ° d $I I I r C� �I I f . d I I I I I Ln o 4 ► I 'O U I � _ �I '_' �3' E� a0 E A I � D � � � •� I� I � _ I I 1I _ d 0p � o _ � I ai I � ►I o d � I I � I _ II 9 _ I �yI cA I I ° O O O O a I Q ° O + ' I �O I I p o � � I l a I tJ I • I I I - I I j N C7 j I O 's9 y H 'n zn > m = - m Es t cl INTRODUCTIp�, vFpp£�TIONS T'H£STA7EM£NT The Statement Of ardin" O ns FO anciaated�UciPated revenue Provides financial opeTatin£er. (income)to the ALF infortnation an necessa�,for opera This section uld - Th-'STRUCT1pl�,S - '. uses for l2 as w shO ` eat of OPerauonsO LET.months rati on!az Operation.Py mouthy ope ti CX 0fthe"ALF Af, acc° expenses for the fi Proprietors the spectrum of°L has been desi_ ORo� _a -The amoc rs to corporations. ALF ' ened to of rood to be n'to be entered iihes Will no*e mom small ' used in th. '�a result, mdividuai three meals beta!s the additional i- -applicable in so a day,and F' !t includes th- A J°ounts entered terms will need t b�should be left blame:s many of the be 0f food that is the cost of `foot are added to „ In other cases W Provided for the snacrs w'hicc 'aiistic dete t0 be based the other" c_ staff 'tamation On valid sources categ0r/es. except the licens The cost sal :s critical to the ev °i a•^Icipatcd of r: °{ aries an =ffectively and aluation Of the expense S. venue and a ee or adt"u'tsmator' d"'ag s The reOU: O'aaiiizationaJ -This entry should s salad•, I2_ meet essential fin ALF caPabillty tO o . sred date dues, show anvmonths°{oPh'atio , ancial oblipatio Prate Owner's licensee' a�c°unune/boo the Cost o °P- .venue or expenses w h completing this fns Off°the fit associated s Or adra kkeeping servic; ns of�e ALF are not also with adin- - trat°r's salad TO Pre directl • do include be included. native functions Any Oti Predict the succe 3 associated wig ns o{home Ope Possible, the rev ss°r failure of _-�[ttCS-The cost of .=orm enue and the ALF oil used to electric! are expanse as accu,-at:Iv heat the house h�' water sewer, :a tba manner it ed monthly for the f the Statement of as i[e and hot water should be °-come prO�ts b„dem°nstruted*st 12 months Operations ms used to main this entry liste it fi motr • At the o when Of operations This would ' tam and carte should reflect ti as of each of tedPaon of the open ojbl earl),aa! s materials and cgliasa eecd out as Paint,lumb Tepairs De projected. ALF Joss: ms aS Fo ms c� R-Include 'aaiis,rc v moo N rut rs as follows.. listed°tr the Statement 0f $ meat 1°this item. any depreciation expense_ttticipated The cost Of facility e On cap v atiaiber Ofprivare ` -Ind! Mis Paid for tben u'OUId rent should be Mumb Pay residents cat`the �..��o not be included er Of SSI/pSS each month. —" .s-The cost as enr v h hen(i ,.v O residenu each mo -Indlcau thshould be Teflected gage intern a r m ntort>:aP: -_ cn�ed each ` - nth. anticipated at applied to principal should The Portion of the Ytaen�for fa lut the averac Priest:pay resid ladicau die trro0 the bottom of the not be included mortgve pay. v �e fee. eat If variable Osed fee to 'Enter Page( )• but should ,� rates are charged, facility, This would include all taxes which m be fc Indicate the currear o�es,Florida and F employer' ust be paid b, zauci v SSI/pSS mplov Federal lia s flCA (Social Paced in 013 and real s salaries and wa PJOYment taxes Which Secu; 3nouJd not includel��COme fro - section should ref] must �rs'acOme is to Personal inco�d sources to the ect PaYment elate taxes(ifnot inc uded as pan business icens. should be as k used for income ae of the aPPli ALP, It �f the moat)=fie dot accurate 'fig the facia" caaKs)iialess detergent etc• s-7bis imm u, tttnentation tO as Possible and supported Amoutru shown used by the 'n9utnd for l would nilect the the maximum extent f Ported by con f�l wn V facility and the CO table linens COQ°f sOz r_re�iv easibie. g st,if ,bed maintenance airy for otits- ��'e should bed each month as fee or �U_'Pated revenue which etc. o •operation and include here all expenses sen err Dum entered here. u Paytaenu for aside will caned by the facility insurance costs 0fpenses related to r addiag the of Tesidents by the gee�'be obraitred by residents,care the facility, n'and used in supp0ft of 'irticl�s 11.111 w esulting two__cures PP ecable month resident fee Piaa the operation c �:xt 12 flier. nt fee and such as 'The cost =ttrrentl mends from any endo Eater revenue to be mt`'est PaYtaents on d liability Ins_ranee, tiratrce for the ph st• Y exist and endowments or received for ' m the rent arty outstanding g shown he Y :acility 0pe1atio would provide is iiust funds which the should and mO} age a tsrandiag long_Letm re,as well ' ns. conic to be used to su Page be fopmoted and incidents. payment tO m n�not include. riv�d oligious or fraternal Enter income to be received PPOr � Include the cost as Provided at the bo�mPo gip; Lcitatio from such Y other i e oaeraa0�whi as,and a Other fitad rais United �d,fund the expense AMO . SPect'fy each item O e or expense not includ Ing cb will ter income to viry. Pease included ec Provided b suPport faciJ' t. `Include the to bare and any other s0 'Eater the amount f existing investments. tai oral]Of the e �pecr 3 eacb s'0111c dcthe 'll be us m opere a be received frow revenue line tO -Subtract the total xPeases listed m Z}r!s iirce amOUnLed to the facility, and get Lisc the t L°c°me(loss) Pease Ilse from�e total IoansPaYable. amountofprinclpal aid P for mortgages •-E } _ STATE OF FLORIDA AGENCY CY FOR HEALTH CARE AD MINISTRATION LOC2l 7nn�.�m This form is to be completed b y the local zoning office and not b y � ate } TO: The Agency for Healthy �� facility applicant, Assisted Li'•ing unit Care Administration 2727 Mahan Drive Tallahassee, Florida 32308-5403 RE ARDING: Name of Facili Street Address ' (ro C . �- City, State R Zip S �{�421�f� We have reviewed the �3 �� l status of the above referenced Assisted Living Facility zoned according to local codes. ility (ALF) and fin Build�o yI d that it is properly -Max. resident capacity : ST NOTE: When more than one building Street Address N and its resident capacity.must be listed belox,. licensed on the same roe DR �Ctry P P tt, or connecting Zip e Propertt••, each building Building#2 -Resident capacity Building r3 -Resident capacit} Street Address City Zip Add additional sheets i'necessary. Street Address City Zip Signature of Zoning p Printed Name of Official p� T Title Agency Name . Street Address 60-777 1 -- � l�� City and Zip Code � 0 CP 13 b C S u Mj ti s ef. �- (�� 3 . �3a� F+Y, 3os. ,9 . Ys9 I 331 y3 LACA Form 3180-1021, Sept. 127 7 MAHAN DRIVE TALLApI ASSEE. FLORIDA 32308 _ _ = Q s_ °° n _. = w X e, - e. ate, > >' �' > 41 ct co 9 pr 1� w `e m'. H NC ^ cm x x = R c pr— as n R° O W. f9 c d I - c c � CD W LA O Di pr Im O d W to O .� re O :n 9 no ew c 7 W O R 'T7 p b O f9 C 00 7 c C H '� S = V ., "y . O _S N Ir S tr ° N H O' S N r c r 7 d d •�". y3' c � � � G7 O 0-0 `� fCD9 O A n• A C y J N o � w > c Jn f7 'i7 �CJ � a o � 'iC) o°`oY C. — n tr > L0NC� wC� o > > oo >y m °° cam 3 gx w > �, > °i• g > ER tTj I w >LA cry cn Z m C 3 =_ — r7 ' t-1 n o h y > N _ o '9 in Ml V1 fA ? O y m Cn y ? O O y z > 'T) C w < C <. O N c w ; w .4 Z7s�ceo w � c w � w � �° to '� — _' s � r07c�a N7C �' wf9 w 77F v Z `t1 .p O 0, a wd o Cc, wc9T p a ,7, °_� � r R rn o — c n Z wOa C w0 AC 00 o w N Nc9 ri W g w t4 C6 a.> t° R' w Aw? R o Ox y A LA e '7 � y l[tf" P' t�CrJ1 X ^ y w e cn W O O c ° A c y to 00 c p, �• N N �9• N• "' t�J �• p y y J y O 8 y S X0,1 C O > N cn O� f7 00 v Atli, r) na C7 � no n � r) y'1 y `^w^ r) �� v v v v W A to OOA, a, to,Nv AN LA 00 UoNO tyi, J O, tD bA O, %A co b w00 W " AA 00 L4 LA LA 00 000 JJ NN J �I WN p, Q � co NN tO°/, t�i, .r NN O AA vJ NN tQ �7 to AA 0000 N .J.. — AA cn 0 y N y� y^ y^ y^ ^p ^ cn En n A A A � AA AO A .y.. A :.° S AtWi, A � AH W LA O _J _JN J v NNr. , N A tA a b LA 00 " LA %0 %0 0 a A A i, t Ch O\ W ,N oo N b 00 Op 1 to %O °D O, O, to to N w LLA LLA ,gyp ,GO .%0. 1ii�CC DISTRICT COMMUNITY RESIDENTIAL HOME COORDINAT ORS District community residential home coordinators may be reached by calling or writing the. g district office DISTRICT 1 (Counties—Es cambia Okaloosa Santa Roca Sandra Hill Senior Human Services Pro ••41on1 3300 North Pace Blvd,Suite 520 Manager Pensacola,Fla. 32505 (850)595-8003/SC 695-8005 FAX (850)595-8511 /SC 693-851.1 DISTRICT 2 Counties—Bay Calhoun Franklin Gadsden Gulf Holmes Jacks6n.Jefferson Leon Libe Madison Taylor,Wakulla and Washin ton Ima Brown—Operations and Management Consultant District Program Management 2639 North Monroe Street, Suite 100-A Cedars Executive Center Tallahassee,Fla. 32399-2949 (850)499 70569/SC 278-0569 FAX (850)488-6513/SC 278-6513 DISTRICT 3 Counties—Alachua,Bradford.Columbia Dixie Gilchrist Hamilton Lafa ette Le Putnam Suwannee and Union) Rebecca Quandt—Human Services Program Specialist Adult and Developmental Services 1000 NE 16"Avenue—Box 18 Gainesville,Fla. 32601 (352)955-5798/SC 625-5798 FAX (352)955-7190/SC 625-7190 DISTRICT 4 Counties—Baker Clay,Duval Nassau and St.Johns Ellen Weston-Operations and Management Consultant 5920 Arlington Expressway Jacksonville,Fla. 32211 P.O.Box 2417. Jacksonville,Fla. 33231-0083 (904)723-2045/SC 841-2045 FAX (904)723-5389/SC 841-5389 DISTRICT 5(Counties Pasco and Pinellas) Lorraine Grant—Staff Assistant -ommunity Affairs 11351 Ulmerton Road cargo,Fla. 33778 727)588-7059/SC 513-2845 ?AX (727)588-7016/SC 513-3802 )ctober 1998 1 Wile ti Counties—Hillsborou_..ph nd 4000 West Martin Lions and Management Consultant 1I W.T Edw artn Luther King,Jr.Blvd. ards Facility,Room 243 Tampa,Fla. 33614-7093 (8 13)871-7544/SC 512-6010 FAX (8 13)871-75631 SC 512-6011 Y DISTRICT 7 Countie�7s" evard Ora n Sandy Dawson—Secre a Osceola and Seminole 400 Wei Robi taialist Orlando,Fla. 32801 Street (407)245-0410/SC 344-0410 FAX (407)425-0579/SC 344-0579 DISTRICT g Counties—CharIotte Collier Desoto G Nancy L. Starr—Cross Pro lades Hen P.O.Box 60085 ��License Administrator Lee and Sarasota Fort Myers,Fla. 33906 (941)33 8-13 1 g/SC 722_1318 FAX (941)338-1287/SC 722-1287 Rob�'RICT 9 Counties_palm Beach Robyn Johnson—Senior Clerk 111 South Sapodilla Avenue West Palm Beach,Fla. 33401 (561)837-5247/SC 252-5247 FAX (561)837-5290/SC 252-5290 DISTRICT 10 Bill Doble—Operations Counties—Broward 201 West Br ard v and Management Consultant I Ft.Lauderdale,Fla. 32301 (954)467-4404/SC 453-4404 FAX (954)467-4414/SC 453-4414 DISTWCT 11 Counties— Ellison Sha iro_O Dade and Monroe 401 NW 20' Aerations and Avenue Management Consultant II , Suite N-514 Miami,Fla. 33128 .305)377-7511 /SC 452-7511 'AX(305)377-7438/SC 452-7438 FIST CT 12 Counties— im Herneneral Service sia don—G3Managerd Volu 10 N.Palmetto Avenue,Room 138 )aytona Beach,Fla. 32114-3269 904)947-4090/SC 380-4090 :AX (904)238-4644/SC 380-4644 ►ctober 1998 2 DISTRICT 13 (Counties—Citrus Hernando Lake Marion and Sumter) Tim Travis—Human Services Program Specialist ADM Program Office 1601 West Gulf Atlantic Highway Wildwood,Fla. 34785 (352)3300.2177 ext.6263/SC 895-6356 FAX (352)330-1322/SC 668-1322 DISTRICT 14 (Counties—Hardee Highlands and Polk) Robert King—Management and Review Specialist 4720 Old Highway 37 Lakeland,Fla. 33813-2030 (941)619-4156/SC 561-4156 FAX (941)648-3346/SC 515-2893 DISTRICT 15 (Counties—Indian River Martin Okeechobee and St.Lucie) Pearl Clark—Operations and Management Consultant II Department of Children and Families 337 North 4m Street, Suite 327-A Ft.Pierce,Fla. 34950 (561-467-4176/SC 240-4176 FAX (561)467-4169/SC 240-4169 October 1998 3 k _ Escambia CPHU P:O . Box 12604 Jackson CPHU Citrus CPHU Pensacola,FL 32574-2604 P.O. Box 3103 700 W. Sovereign Path 904/435-6557 Marianna,FL 32446 Lecanto, FL 34461 904/526-2412 904/527-1288 Okaloosa CPHU Jefferson CPHU 221 Hospital Drive,N E 1255 W. Washington St. Columbia CPHU Ft. Walton, FL 32548-5066 Monticello,FL 32344 249 East Franklin Street 904/833-9244 904/342-0170 Lake City, FL 32055 904/758-1037 Santa Rosa CPHU Leon CPHU 5527 Stewart Street 2965 Municipal Way ixie ox 20 Milton, FL 32570-4375 Tallahassee, FL 32304-3800 CrOos Box 2099 FL 32628 904/623-4604 904/487-3146 904/498-1360 Walton CPHU Liberty CPHU Gilchrist CPHU 493 North.Ninth Street P.O. Box 489 DeFuniak Springs,FL 32433-9401 Bristol,FL 32321 P.O. Box 368 904/892-8027 Trenton, FL 32693 r 904/643-2415 904/463-3120 • iM1• .r. :ji'JM:• 4+:.i {t%C•5:..fvr.'.:...;2fv; ..,3..ccac.•a;s�w«L..:�ors;{::.:: :�.:`�:4:as cols>3ca�s: .z:�..;viv Bay CPHU Madison CPHU Hamilton CPHU 605 North MacArthur Avenue 801 Southwest Smith Street P.O. Box 267 Pamana City, FL 32401-3680 Madison FL 32340 904/872-4455 904/973-6651 Jasper, FL 32052 904/792-1414 Calhoun CPHU Taylor CPHU Hernando CPHU 1507 West Central Avenue 1215 North Peacock Street Blountstown, FL 32424 300 South Main Street 904/674-5645 PO4/5 4- 32347 Brooksville, FL 34601 904/584-5087 904/7544067 Franklin CPHU Wakulla CPHU Lafayette CPHU P.O. Box 490 P.O. Box 368 Apalachicola, FL 32329 Crawfordville,FL 32327 Route 3,Box 8 904/653-2111 904/926-3591 Mayo, FL 32066 904/362-2708 Gadsden CPHU Washington CPHU Lake CPHU P.O. Box 1000 404 South Boulevard, West Quincy, FL 32351-1000 Chipley, FL 32428 P.O. Box 1305 904/875-7200 904/638-6240 Tavares,FL 32778-1305 904/742-6320 3'J"7i:• f M' . '>:ti'ii.:3�itia�3r>ri4r'irr%:f:'.�yi4;..Y�s.>''. r`'coCL�I'•'.w:rS7aS Gulf CPHU Alachua CPHU Levy CPHU 502 Fourth Street P.O. Box 1327 Port St. Joe,FL 32456-1776 Gainesville, FL 32602-1327 P.O. Box 40 904/227-1276 904/955-2356 Bronson, FL 32621 904/486-5305 Holmes CPHU Bradford CPHU P.O. Box 337 329 North Church Street Marion CPHU Sta Bonifay, FL 32425 P.O. Box 2408 904/547-3691 Starke, - 32091 Ocala,FL 32678 904/964-7 7732 904/629-0137 Putnam CPHU St. Johns CPHU Brevard Environmental Health Unit 2801 Kennedy Road 180 Marine Street 2725 St. Johns Street Palatka,FL 32177 St.Augustine,FL'32084 Melbourn,FL 32940 904/329-0420 904/825-5055 407/633-2053 Sumter.CPHU Volusia CPHU Orange CPHU P.O. Box 98 P.O. Box 9190 P.O. Box 3187 Bushnell,FL 33513 Daytona Beach,FL 32120 Orlando,FL 32802-3187 904/793-6979 904/947-3414 4.07/836-2656 m{i\:hivwvJ4 J.+nwwr.rn�JOJi••. Suwannee CPHU Pasco CPHU Osceola CPHU 1001 Nobles Ferry Road 10841 Little Road P.O. Box 450309 Live Oak,FL 32060 New Port Richey,FL 34654 Kissimmee,FL 347442005 904/362-2708 813/869-3900 407/870-1416 Union CPHU Pinellas CPHU Seminole CPHU 495 East Main Street P.O. Box 13549 400 West Airport Boulevard Lake Butler,FL 32054 St. Petersburg,FL 33733 Sanford,FL 32773 904/496-3211 813/8246900 407/322-2724 ..X;.,. ...Yyr„ . .;r,::;g:.;.''�i>.:�:�41n...{:ni'lniY:n„vry;:,\'•.{v:•i:+i::^:::fv.r. �::`Siy:�::r�v^e;:a>:ys`,2::; .'I, :• n. .:;.. y,•;...,� .{.: ••••:•• .. .... .: ..: • •wieiwa`,e:G::io,}dii:c iva2.•..•..•..r,,.... Baker CPHU Hardee CPHU Charlotte CPHU 657 South 6th Street P.O. Box 788 514 East Grace Street MacClenny,FL 32063 Wauchula,FL 33873 Punta Gorda,FL 33950 904/259-6291 941/7734161 941/639-1181 Clay CPHU Highlands CPHU Collier CPHU P.O. Box 566 7205 S. George Boulevard P.O. Box 428 Green Cove Springs,FL 32043 Sebring, FL 33872 Naples, FL 33939 904/284-6340 941/386-6040 941/774-8201 Duval CPHU Hillsborough CPHU Desoto CPHU 515 We'st-Sixth Street P.O. Box 5135 34 South Baldwin Avenue Jacksonville,FL 322064397 Tampa,FL 33675-5135 Arcadia,FL 33821 904/630-3220 813/272-6300 941/993-4601 Flagler CPHU Manatee CPHU Glades CPHU P.O. Box 847 410 Sixth Avenue,East P.O.. Box 489 Bunnell,FL 32110 Bradenton,FL 33508 Moore Haven,FL 33471 904/437-7350 941/748-0666 9411946-0707 Nassau CPHU Polk CPHU Hendry CPHU P.O. Box 517 1290 Golfview Ave.,4th Floor P.O. Box 70 Fernandina Beach,FL 32034 Bartow,FL 33830.. LaBelle,FL :33935 904/277-7280 941/5334276 941/6744041 Lee CPHU 3920 Michigan Avenue Okeechobee Ft. Myers,FL 33916 1728 N-W Ninth Avenue Broward CPHU 407/332-9511 Okeechobee, FL 34972 2421-A S.W. Sixth Avenue 407/763-3419 Ft. Lauderdale,FL 33315-2613 407/467-4811 Sarasota CPHU '` P.O. Box 2658 Palm Beach CPHU Sarasota, FL 34230-2658 P-O- Box 29 Dade CPHU 407/954-2947 West Palm Beach, FL 33402 1350 N.W, 14th Street ..` >.;, r:.....:. . : 3119 FL 33125- <<�<�;; ` 407/355- Miami, 1694 305/324-2418 Indian River CPHU .1900 27th Street St. Lucie CPHU Vero Beach, FL 32960-3383 P.O. Box 580 Monroe CPHU 407/778-6301 Ft. Pierce, FL 34950-4206 5100 West College Road 407/462-3939 Key West, FL 33040 305/292-6894 Martin CPHU 620 South Dixie Highway Stuart, FL 34994 407/221-4000 Fire Safety Authorities 'Pensacola _Te Dect_ 1 mac_.. R4 cnev Dixon .7: . , :'_:a ._e. �ta�ce - C` 1 may , De?u- 239 N. Sprinc _ tree;. 6121 r?` c:,, S=_ =Et -- - - �e^saco_a , . X200'_ New Port Richey, Pas= ^=es-v4 e�: 'F-4 --e De== Deb any �� De- Joseph-C. Traylor , ==e C.`.:e_` Jc.`- ... C. 'O_ i -.t , -e C ie` 203 west woocruf ,-.ve . 201 W. _o;,rvS:.ree- CGestview, :'i. ':36 (904 } '=4-3495 � C4 ) 6GL-.�._�1 1'10• .x. ,% - 3`-- � Gulf Pree=e V01u-- e e- Fire St . Beach ^ ire Deg` R JErt G . P!_nshL'11 , E C.-.-=- CiIm r_' 2s -:rt7,-.n - -e C:.=cf. '13 .ai=ooint D==`'= 3�7 '- r 1 vul BoL'_eva__ Gulf 3256- c- PE:.ersbL'rg Beach, FL :3706 (904 ) 934-=_?3 ( 813) 36=-- 06 2 COL=tV- : Santa -Rosa County: ,Pi_^.ellas 'C=ited vol untee= Fire De= :nc., Ts- - 6�ames c a'ro:as:-, a C� -= RT. E ' r:=--_a- ... :ust=n, Fire C=-`-- Box 1164 S'00_2 _as- Zack Stree- :js, �. � _'a��a , �. 33cC (904) E92-5341 (941) 227-7011 County: Wa3ton County: ..ilis�er ough ?taa=a C4 lv Beach 74=e De^.` ?-aaenton ^i=e ` Mike Brown, :ire C- e= Vernon C. iorne, C .ief 110 S. Arnold -Road ?. 0. Box !971 Panama City Beach 'L 37413 Bradenton - 1206 (904) 2:35_20 - :1 3� ' (813) 74?- 161 ccu'=tr. Bav cc -v: t *:ant ee Marianna 7i=e De== Xelbourne Fire Dent rack Barwick , Fire Chief t:alter C:;a..,berlin Fire chief P.O. Box 936 665 _au Gallie Boulevard Marianna, 22446 (904 ) 5_26-4612 (40i) 254628 County: Jackson County: B=evard Jefferson Coen}v Fire Rescue Orlando =e Debt. Larry Yates, =E C.`.ie: Sa.;� walthour , Fire Ch.ie: Courthouse Circle, Room _0 ?. 0. Bo:: 2"46 Monticello, 223;4 C:lando 'T "2E02 .r s (904 ) 9C7-6654 (407) 246-2386 CoLnty: Jefferson County: orange Tali a1hassee :'_re Deat. City' Of xi ssy--gee re De2Q _ 'ire Chief Las- <. Beal-, F' Chief �'hamas C. Q1. 1 �% 200 W. Da?'in Avenue 32, N. AGcws S_ree' rL ':'a iahassee, - 301 (904) E91-6600 (407 ) 04;-3_�3 Court v: Qs=ecla county.: Leon Sar.`o-d 'r; �e Dent _ Madison r,re Dev _ m -•=cyson, rise Chie_ =av�ond Linke=d, . _ire Ci:ie= ,i. :hC..�es .. 1 W. Dade S�re=_� 1303 =nch Iv-. 904) •/ ( �9i3-277:, (407) 32= County. !!adiscn County: Se=Lir.cle ' Punta Gc= r da ;_e Dent �a-w Fire Den` City e_ ..1e- -fro C::ief c 1 . _re Ch1 --lwar d . ;:e - , Fire ney Lyt e, e� _� , 0 Ta ^=ail P.O. Box 1901 ��' _d,T =; 33°50 Pe--y, FL ' 32347 sn�a Gc (904) 584-3311 (613) 63,-4129 ` county: Taylor County: Cra:lotte Gainesville Fire Rescue , Dent. Nznles Fire Dea` . RiCIl . . Wig lien s ire Chief :':w1 Siui�r, :j ae`Cllic� r sou-,.n n.0• esvi11�0 34 49 Naples, . - 33940 Gc n _, '2002-0 0 (904) 334-2590 County: Collie= Cozen=y: nlachua rice Dent. A_cadia r_r a Dept. Lake C�_+-v - r Tony Messina, -ire Chief Z. RCSc a Fire C^ - - ayne _. _ , 2, ::ickc'-y 5 e== 151 h'. =first $ire=� W. __ 1 Lake Cit T 32055 y, - rcadia, _-L 333'2 (904) 758 county:, Soto county: Colu�ia county: ='=-a Deat. T_nverness volunteer Fire Deat. La3e Ile n.volunteer Curtis, sire Chief Ray Hardy, Fire re Chief Harold .,0, 2E5 S. Kensincton Avenue - Box 1214 33925 LaBelle,1e, (E13) 675-1537 (9 04)726-1400 County: Hendry County: Citrus Fort X.vers Fire Deaartment Brooksville rite Dent. . Janes E. Adkins, Fire Chief Killian H. Conred, Fire Chief E5 Veterans Avenue 2404 Dr. martin Luther King Blvd. Fort Myers, FL 33901 Brooksville, FL 34601 (813) 334-6222 (•904)799-0186 County: Lee County: Hernando Leesburc rise Deat . Lakeland £ire Deat. Jinn y M. Hyatt Fire Chief Janes G. Works , Fire Chie 1-1-7 N. V.&Ssachusetts Ave. 201 S. Canal Street Lakeland, FL 33801-5069 Leesburg, FL 34748 (813) 499-8200 (304)728-9780 County: Polk County: Lake Ocala Fire De=t. Sarasota Countv Fire Rescue Dent. William Woods, :;-e Chief John H.. Albrittton Fr _re Chief 410 NE T .irc Sere=t 2200 Stic}:ney Point ?ce^ Ocala, FL 34470 Sarasota, FL '34231 (904) 629-2513 ( S1 3) 951-4211 County: *:arion County: Sarasota Live Cak 'Fire De=t Indian River County ^__e De=t Howard F.r i c:.=, -it e Otis s, __re C:,isf .;,ane� 102 E. Duval 1500 Old Dixie Highway Live Oak, FL 32060-2422 Vero Beach, FL 32=60 (904 ) 362-2076 (407) 562-2026 County: Suwannee County: Indian River Wildwood Volunteer re De=t. Martin County 7- ire Rescue T.L. Smart, Fire Chief Steven Wolfbere, Fire ._S . 227 'call Stres= 2401 SE Nonterev Roar Wildwood, FL 34795 Stuart, FL 34996 (904) 749-4435 . (407) 2SS-5710 County: Sumter County: Martin Baker County volunteer FD Okeechobee City Fire De=t. Richard Dolan, Fire C:^_1E_ L. Keith ='omliv, IZ , 55 Ncrth Street �55 S Third Avenue ?_acclerm, 7T. 32063 Okeechobee, FIT, 34974 (904) 259-1331 (613 ) 763-4423 County: Baker County: Okeecho!Dee Green Cove Sm- n=s "ire :)emt. Palm Beach Gardens Fi=-e Dent Richard L. Knoff , Fire Fire Chi=-=c 2229 Walnut Street 10500 'N. Military Trail Green Cove Sp_inc s , =T. 22013 Palm Beach Gar-dens, FL 3 410 (904) 204-9073 (407) 775-6260 County: Clay County: Palm Beach Jacksonville Fire Rescue St. Lucie County-Ft. ?ierce Charles D. Clark, Fire Chief Paul C. Haiglev, Fire Chief 107 N. Market Street P. O. Box 3030 Jacksonville, FL ..2202 't. Pierce, FL 34946-3030 (904) 630-2456 (407) 467-2300 County: Duval County: St. Lucie Palm Coast Fire Rescue Pompano Beach Fire Rescue Howard Peiffer, Fire Chief James E. Bentley, Fire Chief. 46 Cormorant Cour- P. O. Box 1300 Palm Coast, FL 32137 Pompano Beach, FL 33060 (904) 445-100"16 (305) 766-4510 County: Flagler County: Broward Fernandina Beach Fire De=t . Metro-Dade Fire Rescue William J. Vanzant, Fire, Chief R. D. Paulison, Fire Chief P.O. Box 666 6000 SW 67th Avenue Fernandina Beach, FL 32034 Miami, FL 33173 (904) 227-7331 (305) 596-8593 County: Nassau County: Dade Palatka Fire Dev Nev Lara ) volunteer Fire /Rescue Rudy Howard, 'ir e• Chie: Ron F-obley, Fire Chief 100 bT. 11th S:reet P.O. Sox 782 Palatka, 32177 Kev Larco, 3.L 3303 / (900 329-0:29 Cc^n�y: ps Ccua`y: 2:orroe "a-c)ee Countv Fire Rescue Fire/ f'::S C.-lEr David Sc oan' - r _07 N Pven t wauchula, FL =73 �E13) 7'�-4302 _ NOTIFICATION OF CHANGE OF ADMINISTRATOR Facility Name: Street Address/P.O. Box: City/County/Zip Code: Sianature of Owner/Autho-rized Agent: Facility Telephone Number: L_) Date: The following data is needed for the person to be designated as the new administrator. Effective Date: Name: Maiden: Last First Middle,-- if applicable Date of Birth: Female Male; SSN: Home Address: Apt./Lot City: County: Zip Code: Criminal History Have you ever been arrested or convicted of a crone involving injury or harm to persons, or financial or business m na?ement(e.g., assault, battery, robbery, embezzlement or fraud?) _ Yes No. If yes,what charge(s)? Where arrested/convicted? Date(s) of arrests)/conviction(s): _ NOTE: A criminal history check will be made through the Florida Department of Law Enforcement. References Provide the name, address, and telephone number of three references (Do not include relatives or previous employers). 1. 3. AHCA Form 3180-1006 July 1995 * y Employment History Provide the name, address. and telephone number of former'employers,your title/position. and special educational, or training experience relative to providing care in a facility: f Have you ever been an oN&mer or administrator or been employed in a facility which offered room. board. and personal services in the united States? Yes No. If yes, provide the name and address of the a::iiity(ies j. Education What is the highest grade level completed? Graduated? Yes No. Year: G.E.D? Yes No. Year? If you don't have a high school diploma or G.E.D.,have you owned, operated, or been the administrator of an Assisted Living Facility in Florida at anv time during the past 5 years? Yes No. If yes,provide the name and address of facility,position you held and period of time o%%medlemploved. .Affidavit I herebv swear or affirm that the statements contained herein,including any attachments hereto, are true and correct' hereby authorize the Agency for Health Care Administration to make inquiry into the Central Abuse Registry in accordance with section 415,Florida Statutes,regarding the existence of an indicated report of abuse or neglect and the results of any investigation pursuant thereto. Signature of Administrator NOTARY SEAL AHCA Form 3180-1006 July 1995 �a�,N ' �� -�Z Z 1 LIDIA FERNANDEZ E, RECORDS CLERK City of South Miami 6130 Sunset Drive,South Miami,Florida 33143 6683865 Fax:666-4591 "City of Pleasant Living