Ahca Form 3180-1006 - Assisted Living Facilities Notification Of Change Of Administrator
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1Assisted Living Facilities
NOTIFICATION OF
CHANGE OF ADMINISTRATOR
AUTHORITY: In accordance with section 429.11(1), Florida Statutes (F.S.), each assisted living facility
must identify the administrator of the facility and each facility that he/she currently operates. The law also
provides disclosure of the administrator’s social security number. The social security number will be used
to secure the proper identification of the person listed on this notification.
ALF License #:
Assisted Living Facility Name
Telephone Number
Street Address
Fax
City
County
State
Zip
Signature of Owner/Authorized Agent
Date
Please provide the following information for the person to be designated as administrator:
Effective Date of Change:
Administrator Name
Social Security Number
Date of Birth
Mailing Address
Telephone Number
City
County
State
Zip
A.
Does the administrator have a high school diploma?
YES
NO
GED?
Please attach a copy of the high school diploma or GED certificate.
B.
Is the administrator a licensed nursing home administrator pursuant to Chapter 468, Part II F.S?
YES
NO
If yes, License Number:
C.
Will the administrator be serving as the administrator for more than this ALF?
YES
NO
NOTE: An administrator may manage a maximum of 3 ALFs.
If yes, please complete the following:
Name of Facility
License Number
AHCA Form 3180-1006, Revised May 2013
Section 429.11(1), Florida Statutes
Page 1 of 1
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