An application for an AFH-DD license must
include the following:
(a) The applicant's
mailing address, if different from the address of the AFH-DD, and a business
address for electronic mail.
The maximum capacity in accordance with OAR 411-360-0060
Identification of the following:
(A) Each person that resides in the home and
receives care, including family members that require care and recipients of
respite, relief care, or day care services; and
(B) All other occupants that reside in the
home or on the property of the home, including family members, friends, and
room and board tenants.
The classification being requested in
accordance with OAR 411-360-0070
, including information and supporting
documentation regarding qualifications, relevant work experience, and training
of caregivers as required by the Department.
(e) The statement of a health care provider,
on the applicable Department form, regarding the ability of the applicant to
information, including the following:
completed Financial Information Sheet on the applicable Department form.
(i) An applicant must demonstrate the
financial ability and maintain sufficient liquid resources to pay the operating
costs of an AFH-DD for at least two months without solely relying on potential
income from individuals and room and board payments.
(ii) An applicant applying to operate more
than one AFH-DD must demonstrate the financial ability and maintain sufficient
liquid resources to pay the operating costs of all the homes for at least two
months without solely relying on potential income from individuals and room and
(iii) If an
applicant is unable to demonstrate the financial ability and resources required
by this rule, the Department may require the applicant to furnish a financial
guarantee, such as a line of credit or guaranteed loan.
(B) Copies of bank statements from the last
three months demonstrating banking activity in both checking and savings
accounts, as applicable, or demonstration of cash on hand, if
Documentation of the
following, if applicable:
judgments, liens, and pending lawsuits where a claim for money or property is
made against the applicant.
Bankruptcy filings by the applicant.
(iii) Unpaid taxes due from the applicant
including, but not limited to, property taxes, employment taxes, and state and
federal income taxes.
(D) A copy of a complete and current credit
report for the applicant, if requested.
If an applicant is leasing or rents the
home, a copy of the lease or rental agreement. The agreement must be a standard
lease or rental agreement for residential use and include the following:
(A) Name of the owner and landlord;
(B) Verification the rent is a flat rate;
(C) Signatures of the landlord
and applicant and date signed.
(h) If an applicant is purchasing or owns the
home, verification of purchase or ownership.
A current and accurate floor plan for the
home that indicates the following:
of each room;
(B) Size of each
(C) Bedrooms to be used by
individuals, the provider, and as applicable, caregivers, room and board
tenants, and recipients of day care, relief care, or respite
(D) Each exit on each
level of the home, including emergency exits such as windows;
(E) Wheelchair ramps, if
(F) Each fire
extinguisher, smoke alarm, carbon monoxide alarm, and sprinkler if the home has
an interior sprinkler system;
Planned evacuation routes; and
Designated smoking areas in or on the premises of the home, if
non-refundable fee for each individual service recipient as described in
section (1) of this rule.
personal references for the applicant. The personal references may not be
family members, current or potential licensees, or co-workers of current or
applying to operate more than one AFH-DD, a plan covering administrative
responsibilities and staffing qualifications for each home.
A written description of the daily
operation of the AFH-DD, including the following:
(A) The use of a resident manager and
substitute caregivers, as applicable.
(B) The schedule of the provider, resident
manager, and substitute caregivers, as applicable.
(C) The plan for coverage in the absence of
the provider, resident manager, or substitute caregivers, as
Documentation of the following for each subject individual as defined in OAR
(A) Signed background check,
and if needed, the mitigating information and fitness determination
(B) Signed consent form for a
background check with regards to abuse of children; and
(C) Founded reports of child abuse or
substantiated adult abuse allegations, including the dates, locations, and
(o) A copy
of the Residency Agreement for the AFH-DD.
After receipt of the completed
application materials, including the non-refundable fee, the Department shall
investigate the information submitted and inspect the home. Compliance is
determined upon submission and completion of the application and the process
described in these rules.
(a) An applicant
shall receive a copy of the Department's inspection form citing any
deficiencies and specifying a time frame for correction, no later than 60
calendar days from the date of inspection.
(b) Deficiencies noted during an inspection
of the home must be corrected in the time frame specified by the