Application for License 660-05-20-15

(Revised 1/1/09 ML 3174)

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An application for licensure must be made to the County Social Service Agency in the county where the applicant proposes to provide adult family foster care.

A non-refundable fee of twenty-five dollars must accompany the application. The fee will be retained by the county agency and used for training and education of the county agency staff who perform the licensing responsibilities.

The applicant may withdraw an application at anytime during the licensing process by notifying the Division or the County Social Service Agency.

An application is not complete until all required information and verifications are submitted to the County Social Service Agency, Human Service Center and Division. This includes:

1. A completed SFN 1013, “Application to Provide Adult Family Foster Care”
2. A completed SFN 669, “Initial Licensing Study – Adult Family Foster Care”
3. A completed SFN 615, “Medicaid Program Provider Agreement”
4. Evidence that all applicants have requested qualified service provider status and completed:

1. SFN 980, “Individual Request to be a Qualified Service Provider/AFFC Provider”
2. SFN 750, “Documentation of Competency,” or applicable license, certification, or accreditation

5. Evidence that all AFFC applicants and individuals age 18 or over living in the potential AFFC home have completed:

1. SFN 467, “Personal Authorization for Criminal Record Inquiry”
2. SFN 466, “Background Check Address Disclosure”
3. Two fingerprinting cards, if required

6. A signed SFN 800, “Fire Safety Self Declaration,” form relating to fire safety of the home
7. Documentation of applicant’s completion of a Department of Human Services approved Fire Prevention and Safety Course
8. Proof of insurance on home and auto (Section 05-30-40)
9. A report of professional inspection of the heating and electrical system for operability and safety. (Section 05-30-30 (2))
10. A copy of the applicant’s home floor plan indicating escape routes (Section 05-30-30 (11))
11. A copy of the provider’s preadmission information and house rules (Section 05-30-45)
12. Examples of service logs that will be used to account for service time and tasks performed (Section 660-05-65-95 for examples)
13. Examples of daily menu plans
14. Three reference letters (Section 05-65-25 for examples)
15. If applicable, proof of current pet vaccinations
16. Additional information and verifications as requested by the Division (Section 05-20-15-05)
17. Complete a SFN 823, "Family Evacuation Disaster Plan" (Section 05-65-90)