Form Lic 281 - Application Instructions For A Facility License (Page 20 of 22) in pdf

B11.

CONTROL OF PROPERTY

It is necessary for the licensing agency to determine that the applicant/licensee has control over

facility property. Once licensed, the licensee must be able to ensure that the facility and grounds are

maintained and are in compliance with regulations (i.e., repairs made to physical plant, swimming

pools fenced, etc.).

•

Name and address of the owner must be provided.

•

A copy of the lease agreement or rental agreement must be provided. (There are no requirements

related to length of the lease or rental agreement.)

If the agreement precludes the use of the property as a facility, prevents the

applicant/licensee from achieving compliance with regulations, or the operation of a facility

is contrary to the terms of the agreement, the license must be denied/withdrawn as the

licensee would not have adequate control over the property (i.e., the agreement states that

Susie and Mary are to be the persons residing in the house and anyone else needs to be

approved or the agreement states that the property cannot be used for business purposes

and the applicant wishes to operate a facility for more than six persons).

•

Proof of ownership must be provided if the applicant is the owner of the property.

The licensing agency can verify this by a Property Tax bill, Deed or other related document.

The documents provided must contain the facility street address within the document or its’

attachments.

B12.

BACTERIAL ANALYSIS OF WATER

This form is to be completed ONLY if the facility gets water from a well or other private source.

This is required of all categories at initial licensure if water for consumption is from a private source,

regardless of the number of clients served. Submit evidence of on-site inspection of the source of the

water and a bacteriological analysis by a local or state health department or other qualified laboratory

which establishes the safety of the water. If the analysis provided gives only a

chemical/bacteriological analysis and not a specific statement as to whether or not the water is safe to

drink, the licensing agency will request that the applicant get such a statement from the laboratory.

The analysis must be signed by a qualified agency representative.

B13.

INSURANCE INFORMATION (APPLIES ONLY TO RESIDENTIAL CARE FACILITIES FOR THE

ELDERLY)

A statement concerning whether or not there will be insurance covering the facility operation. If there

is insurance coverage, what type of coverage and with whom. If there is no insurance coverage, a

statement of such is sufficient.

B14.

THEFT AND LOSS POLICY

This policy shall include the provisions for inventory of personal property at the time of admission,

modification of the inventory, practices used to safeguard personal property upon the death of the

resident, documentation and reporting of loss of personal property, method of marking personal

property, and method for providing a secure area for safekeeping of resident personal property.

Form Lic 281 - Application Instructions For A Facility License Page 20

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