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APPLICATION FOR A COMMUNITY CARE FACILITY …

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THE INFORMATION BELOW FOR ANY residential care OR HEALTH care FACILITY PREVIOUSLY OR CURRENTLY OPERATED. REFER TO NAME AND NUMBERLICENSING AGENCY NAMEA. ________________________________________ ________________________________________ ________________________________________ ________________________________________ ______________________B. ________________________________________ ________________________________________ ________________________________________ ________________________________________ ______________________ ADULT residential FACILITIES SOCIAL REHABILITATION FACILITIES residential FACILITIES--ELDERLY FOSTER FAMILY AGENCIES ADOPTION AGENCIES residential FACILITIES--CHRONICALLY ILL ADULT DAY PROGRAMS GROUP HOMES SMALL FAMILY HOMES TRANSITIONAL HOUSING PLACEMENT PROGRAMS CRISIS NURSERIES OTHER( SPECIFY)________________________FOR DEPARTMENT USE ONLYDISTRICT:COUNTY: FACILITY NUMBER:DATE:ACTION TYPE:REVIEWED BY.

17. enter the information below for any residential care or health care facility previously or currently operated. refer to ins tructions. facility …

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