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STATE OF TENNESSEE DEPARTMENT OF HEALTH DIVISION OF HEALTH LICENSURE AND REGULATION OFFICE OF HEALTH CARE FACILITIES 665 MAINSTREAM DRIVE, SECOND FLOOR NASHVILLE, TENNESSEE 37243 (615) 741-7221 ADULT CARE HOME APPLICATION FOR RENEWAL LICENSURE All applicable laws, rules, policies, and guidelines affecting your practice are available for viewing at www.state.tn.us/health. Please check this website periodically for updates. Name of the Adult Care Home Facility Location of the Facility: Street City County State Phone Number ( ) Fax Number ( Twenty-four (24) Hour Emergency Phone Number ( Zip ) ) E-Mail Address Mailing address (if different from the Facility location address): Name__________________________________________________________________________________________ Street__________________________________________________________________________________________ City_______________________________________State___________________________Zip __________________ Number of Residents How many residents by blood/marriage are related to the provider ____________ Adult Care Home Provider: Name of Provider________________________________________________________________________________ Residential Manager(s): Manager__________________________________ Substitute Caregiver (if applicable)_________________________ a. Have you (Manager) ever been convicted of a crime involving injury or harm to person(s), financial or business management (e.g., assault, battery, robbery, embezzlement or fraud)? Yes _____ No _____ If yes, what charge(s)? Location of Conviction Date (City) (County) (State) b. To what extent will the resident manager, substitute caregivers and other staff be used in the facility? PH-4123 (REV 11/13) 1 RDA-10139 ________________________________________________________________________________________ ________________________________________________________________________________________ c. Has a policy of informing employees of their obligations to report incidents of abuse or neglect been implemented? Yes___________ No___________ SPECIALIZED SERVICE(S) (check appropriate service) ________ Ventilator Dependent ________ Traumatic Brain Injury FEE SCHEDULE: (FEES ARE NON-REFUNDABLE) - $1080.00 OWNERSHIP OF BUSINESS: 1. a. Check the type of Legal Entity: _____ Individual _____ Partnership _____ Corporation _____ Limited Liability Company _____ Church Related _____ Government/County _____ Other b. Check One: _____For Profit _____ Non-profit c. Legal Entity checked in 1.a: Name Phone Number ( ) Address d. List name(s) and address(s) of individual owners, partners, directors of the corporation, or head of the governmental entity: Name Address City, State, Zip Name Address City, State, Zip (If additional space is needed, please use a separate sheet) 2. If you have a parent company please provide the following information: Name Phone Number ( ) Address 3. a. Are any owners of the disclosing entity also owners of other health care facilities in Tennessee and/or other states? Yes ____ No ____ b. If yes, list names and addresses of all such facilities: 4. Separately attach proof the adult care home’s financial ability to maintain sufficient financial resources to support the operating costs of the adult care home. PH-4123 (REV 11/13) 2 RDA-10139 5. Separately attach a Comprehensive Business Plan for the first two years of operation. 6. a. Have any owners of the disclosing entity ever been denied a license, had a license suspended or revoked, had a suspension of admissions, paid any civil monitory penalties or other disciplinary actions for a health care facility in Tennessee or in any other state? Yes _____ No _____ b. If yes, where? c. For what reason? When? 7. List any unsatisfied judgments ____________________________________________________________________ VERIFICATION BY APPLICANT: Signee for application verifies that he or she is of responsible character and able to comply with the minimum standards and regulations established by Tennessee pertaining to the type of facility or agency for which application for licensure is made and with the rules promulgated under Tennessee Code Annotated (TCA) § 68-11-201. Signee also verifies that a policy has been implemented to inform all employees of their obligation under TCA 71-6-103 to report incidents of abuse or neglect. Applicant Signature PH-4123 (REV 11/13) Title or Position 3 § Date RDA-10139