Temporary and Disability Assistance icon

Temporary and Disability Assistance



Similar
  1   2   3


New York State

Office of

Temporary and Disability Assistance

Bureau of Shelter Services

Andrew M. Cuomo- Governor













Application for

Operating Certificate

Adult Care Facility - Shelter for Adults


Contents of Application Page(s)



DIRECTIONS 3


PHASE I

□ Notarized Certification by applicant 4

□ Questionnaire 5

□ Board of Directors Information 6

□ Certificate of Incorporation 6

□ Residential facilities Listing 6

□ Financial Information 7-8

□ Proposed Shelter Budget 9

PHASE II

□ Demonstration of Public Need 10

□ Resident Services 11

□ Description of Physical Plant 12

□ Personnel & Staff Qualifications 13

□ Form DSS-3233- Statement of Administrator Qualifications 14-17

□ Schedule of Staff Hours 18

□ Facility Policies (admission, transfer, discharge; resident rights; house rules; personnel) 19

□ Nutrition Plan 20


^ PHASE III


□ Architectural Plans 21

□ Fire Safety Equipment 22

□ Disaster & Emergency Evacuation Plan 23

□ Facility Exits and Evacuation Information form 24

□ Relocation Procedures form 25


ATTACHMENTS


□ A- Principal Board of Directors History Form 26-28

□ B- Request for Regulation Waiver Form 29

□ C- Model Emergency Disaster Plan 30-38

□ D- Form DSS-2789- Personal Financial Statement for Proprietary applicants 39-43


The New York State Office of Temporary and Disability Assistance, Bureau of Shelter Services, may issue an operating certificate only to a natural person or partnership composed only of natural persons, a not-for-profit corporation, a public corporation, a social services district or other governmental agency for the purpose of operating an adult care facility –shelter for adults. The operation of an adult care facility-shelter for adults is governed by applicable rules and regulations of the State of New York, Department of Social Services (the department) 18 NYCRR Chapter II, subchapter D. Any person, partnership, corporation, organization, agency, governmental unit or other entity which operates an adult care facility is subject to the jurisdiction of the department and must comply with these regulations or cease operation.


DIRECTIONS


Please complete this application in its entirety, where applicable. An operating certificate will not be issued until all documents and information have been submitted and determined to be satisfactory.


^ SOCIAL SERVICE DISTRICTS seeking to operate a shelter for adults, regardless of bed capacity, must apply for certification. The application must be completed, excluding page 6. A district budget form may be submitted in lieu of the proposed shelter budget form on page 9.


NOT-FOR- PROFIT & PROPRIETARY ORGANIZATIONS seeking to operate a shelter for adults of twenty (20) or more beds must apply for certification and complete the application in its entirety.


If the proposed operator is a Not-for-Profit Corporation, the following additional documents are required:


1. Listing of Board of Directors.

  1. Personal History Form for the Executive Director or Chief Administrative Officer (per 485.6 (d) (7)) and for all principal officers of the Board of Directors.

  2. Proposed or existing Certificate of Incorporation.

  3. Name and address of all residential care facilities owned, operated or administered by this Not-for-Profit within the last ten (10) years.



Note: This application is divided into three Phases- I, II, III, however, please provide any documentation or information that is available with your initial application submission.





^ NOTARIZED CERTIFICATION OF APPLICANT(S) TO OPERATE

ADULT CARE FACILITY - SHELTER FOR ADULTS

PHASE I

--------------------------------------------------------------------------------------------------------------------

Shelter Name Sponsoring Agency

_____________________________ _________________________________

I (we) declare that to the best of my (our) knowledge and belief all information provided herein is true, correct and complete. Further, if this application is approved, I (we) agree to operate the facility in accordance with all Department Regulations and the proposal contained herein.

I (we) agree to comply with the provision of the Civil Rights Act of 1964 (P.L. 88-352) and all requirements imposed pursuant thereto, to the end that no person shall, on the grounds of race, color or national origin be excluded from participation in, be denied benefit of, or be subjected to discrimination in the provision of any assistance, care or services.

In addition, I (we) authorize all corporations, companies, credit agencies, education institutions, lending institutions, law enforcement agencies and persons to release information that they may have about me (us) to the Office of Temporary and Disability Assistance or its agents; further I (we) authorize the procurement of such an investigation and understand that such report may contain information as to my (our) background, character, personal reputation.

____________________________ ______________________________

Print Name & Title Print Name & Title


____________________________ _______________________________

Signature of Proposed Operator Signature of Proposed Operator


____________________________ ______________________________

Date Date


^ STATE OF NEW YORK) STATE OF NEW YORK)

) ss: ) ss:

COUNTY OF ) COUNTY OF )


On this ______day of ___________, 2010, before me, the undersigned, personally appeared _____________________, personally known to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or then person upon behalf of which the individual acted, executed the instrument and that he signed his name thereto by like order.

On this ______ day of ___________, 2010, before me, the undersigned, personally appeared _____________________, personally known to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or then person upon behalf of which the individual acted, executed the instrument and that he signed his name thereto by like order.



Notary Public


My Commission Expires: ______


Notary Public


My Commission Expires: ______

I


QUESTIONAIRE


1. Why are you applying for an operating certificate?


A. ___ New Facility

____ 1. New Construction

____ 2. Substantial Renovation or Rehabilitation or Change of Building Use

____ 3. Existing Building or Change of Building Use


B. ___ Change in Operator. If this application is for a change of operator, is the current operator or owner subject to any bankruptcy or foreclosure procedures?

Yes ___No___. If yes, specify the details of the bankruptcy or foreclosure proceedings including details of the resolution of the proceedings prior to change of ownership. Attach a narrative and supporting documentation on additional sheets as required.


C. ___ Other (please specify) __________________________________________


2. What is or will be the name of this facility?

_______________________________________________________________________


3. What is or will be the exact address of the facility?

_______________________________________________________________________


4. What is or will be the capacity of the facility? _________ Beds.


a. What population will be served? Male/ Female/ Mixed


5. How is or will this facility be sponsored?


A. ___ Not-for-Profit

B. ___ Public
C. ___ Proprietary


6. Enter the contact information for the Chairman or President of the Board of Directors, or Local Department of Social Services (LDSS) Commissioner:


Name Address Telephone Number
_____________________ ____________________________ ( )______________

_____________________ ____________________________ ( )______________


PHASE I


^ BOARD OF DIRECTORS


A. Provide information for all members of the Board of Directors as follows:


Name, Title, and Address

Current Employment /Business

Name and Address








NOTE: No officer of the board of directors of a not-for-profit corporation may be, either at the time of application or thereafter, the chief administrative officer, executive director, administrator, or an employee responsible for any financial operation of the facility or program ( per regulation18 NYCRR 485.4 (f)).


^ B. PERSONAL HISTORY FORM -- Must be comp1eted for the Executive Director or Chief Administrative Officer and all principal members/officers of the Board of Directors. This is not required of LDSS Commissioners. See Personal History Forms- Attachment A





^ CERTIFICATE OF INCORPORATION


C. Submit a copy of your agency’s Certificate of Incorporation.


RESIDENTIAL FACILITIES


D. Provide the name and address of all residential care facilities owned, operated or administered by this Not-for-Profit within the last ten (10) years.


PHASE I


^ FINANCIAL INFORMATION


1. Proposed method for establishing shelter: (check one)


_____ Lease(s) - Attach copy of current or proposed facility lease(s).

_____ Purchase - Attach a copy of the following:

  1. contract of sale

  2. down payment agreement; method of payment

  3. mortgage commitment; total mortgage amount, payback period; interest rate; holder of mortgage

  4. documentation to show any other purchase agreement not covered in a, b and c of this part.


2. Answer either a, b or c:

  1. Existing Not-for-Profit Corporations who wish to establish a shelter should submit a copy of the annual report as a charitable organization on file with the Secretary of State for the last fiscal year. Applicants who wish to incorporate for the purpose of establishing and operating a not-for-profit shelter should submit documentation of sources of funding for establishment and operation of the shelter. This documentation could be in the form of letters of intent or pledge.

  2. If applying as a private proprietary shelter, complete the Personal Financial Statement (DSS-2789), Attachment D.

  3. When applying for certification of a publicly operated shelter, Social Services Districts are required to submit authorization to establish and operate a shelter issued by the appropriate governing body and either a letter guaranteeing funding or evidence of appropriated funds.



3. Complete the Proposed Shelter Budget on page 9.


4 Please answer the following questions and provide the name(s) and address(s) and a description of the interest held by names provided for any applicable person:



  1. Does any person, directly or indirectly, beneficially own any interest in the land on which the facility is located? Yes______ No________




  1. Does any person, directly or indirectly, beneficially own any interest in the building in which the facility is located? Yes_______ No________




  1. Does any person, directly or indirectly, beneficially own any interest in any mortgage, note, deed of trust or other obligation secured in whole or in part by the land on which the facility is located? Yes______ No________




  1. Does any person, directly or indirectly, have any interest as lessor or lessee in any lease or sub-lease of the land on which, or the building in which, the facility is located? Yes______ No________



5. If any person named in response to this question is a partner, then provide the name and address of each partner. If any person named in response to this question is a corporation, then the name and address of each officer, director, stockholder and, if known, each principal stockholder and controlling person of such corporation. If applicable, please attach a copy of the current partnership agreement.


PHASE I


^ PROPOSED SHELTER BUDGET



BUDGET For Twelve Months Ending: _____________



Dollar

Amount

Department

Use Only

Anticipated Revenues

Room, Board and Routine Care

Other Resident Revenue (Attach Schedule)

Other Revenue (Attach Schedule)

Total Anticipated Revenue

^ Anticipated Expenses
Salaries and Wages (Schedule A)
Payroll Taxes
Other Fringe Benefits
Dietary Consultant
Raw Food Costs — Resident Meals
Raw Food Costs — Emp1oyee Meals
Food Supplies
Rental of Facility
Rental of Equipment
Real Estate Taxes (Documentation Required)
Water and Sewer (Documentation Required)
Heat, Light, Power (Documentation Required)
Repairs and Maintenance
Housekeeping Supplies
Laundry and Linen
Social and Recreation
Security
Insurance (Documentation Required)
Interest Expense (Attach Schedule)
Telephone (Documentation Required)
Legal and Accounting
Advertising
Unincorporated Business Taxes
Other Administrative and General Expenses (Attach Schedule)
Depreciation and Amortization
Other Expenses (Attach Schedule)
Purchase Contracts (Attach Schedule)
Total Anticipated Expenses

Anticipated Resident Care Days


________________

________________

________________

________________


________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________


________________

________________

________________

________________

________________



________________

________________

________________

________________


________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________

________________


________________

________________

________________

________________

________________



PHASE II


^ DEMONSTRATION OF PUBLIC NEED


Publicly Operated Shelters —Pursuant to Social Services Law 461-b (6) (c), shelters operated by a Local Department of Social Services (LDSS) are exempt from demonstrating public need. Only questions 1 and 2 need be completed for LDSS applications; all other applicants answer questions 1 through 3.


1. Please describe the type of population you plan to serve in your facility.


______________________________________________________________________


______________________________________________________________________


2. How many persons are you aware of that require the type of care your facility proposes to offer? ______. If you have a waiting list for your facility, how many names are currently listed? _______. State the reason(s) why this care is not obtainable from other facilities near your proposed one.


______________________________________________________________________


______________________________________________________________________


______________________________________________________________________


3. Exp1ain how the proposed facility will meet a public need in the area to be served. Include such factors as the need for additional bed capacity, geographical factors (distance to other facilities and access roads for police and emergency vehicles), availability of qualified staff and the special needs of the population you intend to serve. (Attach additional sheets as necessary.)


______________________________________________________________________


______________________________________________________________________


PHASE II


^ RESIDENT SERVICES


1. Describe in detail, how you plan to provide, either directly or by cooperative agreement, the following mandated services: room, board, supervision, information and referral on a daily basis. Where services are provided by a contract or cooperative agreement, submit a copy of executed or proposed agreement(s). Note: Local department of social services applicants must provide, either directly or through contract or cooperative agreement, social rehabilitation services and should describe accordingly (See regulation 18 NYCRR 491.8).

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


2. Describe any services your agency provides in addition to the mandated services.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


3. List the major community support services available for use by the proposed resident population, in-house and outside community resources. For each service outside community resource or facility, indicate: (1) how far in miles from the proposed site, (2) the type of transportation available between the proposed site, and the service. (Attach additional sheets as necessary.)


^ SERVICE DISTANCE TRANSPORTATION


_______________________ ___________________ _____________________


_______________________ ___________________ _____________________


_______________________ ___________________ _____________________


4. Attach original letters of community support and need for your proposed facility. Required is a letter from the local department of Social Services attesting to the need for additional beds to serve your target population. Additiona1 letters from the Parole Board, Community Mental Health Board, Local Office for the Aging, or other appropriate service providers may be included as applicable to the population you intend to serve.


PHASE II


^ DESCRIPTION OF PHYSICAL PLANT


If you have a facility, answer the following questions about your physical plant. If you do not have a facility, please attach a description of the physical plant you are planning to acquire.


1. Facility Information Describe/Explain


  1. Facility capacity ____________________________________

  2. Construction type ____________________________________

  3. Total square footage ____________________________________

  4. Age ____________________________________

  5. # of stories/floors ____________________________________

  6. # of beds planned per floor ____________________________________

  7. #of bathrooms per floor ____________________________________

  8. Basement ____________________________________

  9. Elevator (s) ____________________________________

  10. Cooking facilities ____________________________________

  11. Dining space square footage ____________________________________

  12. Leisure space square footage ____________________________________

  13. Office/Staff space ____________________________________

  14. CCTV on site ____________________________________



2. Is the facility currently under renovation? Yes / No If yes, please explain and include the anticipated completion date.

______________________________________________________________________ ______________________________________________________________________


3. Was lead or asbestos abatement completed for the property? Yes / No. If yes, when?


____________________________________________________________________


4. Are there laundry facilities on the premises? Yes _____ No_____. If no, how will this service be provided? _________________________________________________


5. Are there any outstanding violations cited by the local code enforcement agency or under review by the Environmental Control Board (NYC) (i.e., structural, foundation, electrical, system, plumbing, asbestos, infestation, mold, etc) Yes/ No? If yes, please describe deficiencies and the corrective measures to be taken or in process.

______________________________________________________________________

______________________________________________________________________

PHASE II


^ PERSONNEL & STAFF QUALIFICATIONS


  1. The Facility Director must complete, sign and date form DSS-3233, Statement of Administrator Qualifications, pages 14-17, in accordance with regulation 18 NYCRR 491.13(d) (3).




  1. Complete the (proposed) Schedule of Staff Hours, Schedule A, page 18. Per regulation 18 NYCRR 491.8 (10), staff hours must include the required minimum number of supervision staff on duty and on site at all times according to the following resident census:




Resident Census

Supervisory Staff

1-19

1

20-40

2

41-80

3

81-120

4

121-150

5

151-200

6




  1. Submit job descriptions for staff listed on the proposed staffing schedule.




  1. Submit documentation of training or copies of fire safety coordinator certificates for on-duty staff on each shift responsible for fire safety and evacuation (see regulation 18 NYCRR 491.8 (3) and 491.10 (g) (12)).




  1. Submit documentation indicating that at least one staff member on each shift has completed an approved basic first aid training course or its equivalent, as required by regulation 18 NYCRR 491.12 (e).




  1. Submit documentation verifying that all food service employees have had a Tuberculin Skin Test or Chest X-rays at the time they begin employment as required by regulation 18 NYCRR 491.12(f).




  1. If applicable, please describe how you plan to utilize volunteers, including resident volunteers (see regulation 18 NYCRR 491.12 (g), (h), (i) (1) - (4), (j)).

______________________________________________________________________

____________________________________________________________________________________________________________________________________________


^ DSS-3233 NYS OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE


STATEMENT OF ADMINISTRATOR QUALIFICATIONS

FOR ADULT RESIDENTIAL CARE FACILITIES


Name (Last, First, M.I.):

Sex:

Social Security #:

Birth date (Mo/Day/Yr):

Home Telephone:

Business Telephone:

Home Address (Number, Street, City, State, Zip Code):



EDUCATION: (Submit High School Diploma and transcripts of grades from other schools

or college degrees).

High School

Name of School and City in where located:


Dates of Attendance (Mo/Yr):


Graduated? (Yes/No)


Major/Minor


Number of College Credits


Degree Received/ Date of Degree


Junior/Community College

Name of School and City in where located:


Dates of Attendance (Mo/Yr):


Graduated? (Yes/No)


Major/Minor


Number of College Credits


Degree Received/Date of Degree




^ DSS-3233 NYS OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE


College/University

Name of School and City in where located:


Dates of Attendance (Mo/Yr):


Graduated? (Yes/No)


Major/Minor


Number of College Credits


Degree Received/Date of Degree


Graduate School

Name of School and City in where located:


Dates of Attendance (Mo/Yr):


Graduated? (Yes/No)


Major/Minor


Number of College Credits


Degree Received/Date of Degree


Other (Specify)

Name of School and City in where located:


Dates of Attendance (Mo/Yr):


Graduated? (Yes/No)


Major/Minor


Number of College Credits


Degree Received/Date of Degree


If you are not a High School Graduate, do you have a High School Equivalency diploma?

Yes/No:

Issuing Authority:

Diploma Number:

Date:




Download 315.97 Kb.
Page1/3
Date conversion03.05.2013
Size315.97 Kb.
TypeДокументы
  1   2   3
Place this button on your site:
end.exdat.com


The database is protected by copyright ©exdat 2000-2012
При копировании материала укажите ссылку
send message
Documents