Adult Foster Home
Ventilator-Assisted Care
License Application
Office of Licensing and Regulatory Oversight
To be completed by licensee applicant
Choose one:
Initial application
Renewal application
Section 1: General information
A.
Applicant’s name (full legal name):
B.
Contact information:
Applicant’s home number:
Adult Foster Home landline number:
Applicant’s email:
Applicant’s cell number:
C.
Adult Foster Home address:
Street:
City/State/ZIP:
D.
Mailing address (if different):
Street/P.O. Box:
City/State/ZIP:
E.
Applicant’s social security number:
Required to verify applicant is not on the OIG’s or the GSA’s Exclusion Lists as required in
OAR 411-050-0635(5).
F.
Classification: How long have you been licensed as a Class 3 AFH?
G.
Level: Select the ventilator-assisted care level you are requesting:
Level A
H.
Level B
Level C
Capacity:
How many AFH residents do you want to provide care for?
Of those residents, how many do you wish to provide ventilator-assisted care for?
How many relatives need care and services, including children?
Number of day care persons?
Number of room and boards occupants?
Section 2: Applicant information
A. Applicant’s date of birth:
B. Emergency contact(s): Provide current information for at least one contact.
Name:
Name:
Phone:
Phone:
Relationship:
Relationship:
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SDS 0448V (03/14)
Section 2: Applicant information
C. Applicant’s history: Have you ever had a license or certificate for a foster home or other longterm care facility denied, suspended, revoked or non-renewed, or have you voluntarily
surrendered a license or certificate while under sanction?
Yes
No
If yes, by whom?
Date:
Have you ever had a substantiated finding of abuse or neglect?
Yes
No
If yes, by whom?
Date:
D. Are you now, or have you ever been, licensed or certified as a provider or approved as a resident
manager or shift caregiver in a foster home?
Yes
No
If yes, what county?
Identify the agency or agencies that issued the license(s) or certificate(s):
AMH (Addictions and Mental Health)
APD (Aging and People with Disabilities, formerly Seniors and People with Disabilities)
County Ordinance (Check the appropriate box
Clackamas
Multnomah)
DD (Developmental Disabilities)
DHS (Child Care, Child Welfare, Self-Sufficiency)
Veterans Administration
Other states (please list):
E. Are you currently on the Office of Inspector General’s (OIG) or the General Services
Administration’s (GSA) exclusion lists?
Yes
No
Note: Individuals on the OIG or GSA exclusion lists are prohibited from participating in
any federally funded health care program.
F.
Education
School
City
(Country if outside the US)
Degree/number
of years
Year
G. Special qualifications (attach copies of all licenses and certificates listed):
Registered Nurse
License number:
Licensed Practical Nurse
License number:
Certified Medical Assistant
Certificate number:
Certified Nursing Assistant
Certificate number:
American Sign Language
Fluent in language(s) other than English
List languages:
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Section 2: Applicant information
Other (please list):
H. Training (attach a copy of all certificates checked):
West Park Healthcare Centre Long-term Mechanical Ventilation online course
DHS Invasive Ventilation Skills Competency Check
Ensuring Quality Care Course and Exam
Fire and Life Safety
Basic First Aid (attach copy of both sides of certificate)
Cardiopulmonary Resuscitation (CPR) (attach copy of both sides of certificate)
I.
J.
Do you plan to live in the adult foster home?
Yes
No
Do you plan to be the primary caregiver in the adult foster home?
Yes
No
Do you plan to work outside the adult foster home?
Yes
No
If yes, how many hours per week?:
List all occupants in your home: include all persons who live in your adult foster home.
Examples: children, spouse, live-in caregivers, room and board tenants (attach additional
pages if necessary).
AFH occupant names
Relationship to applicant
Date of birth
K. Work history: List your caregiving experience starting with your most current job (attach a
separate sheet of paper if you would like to include additional work history).
1. Contact person:
Name of employer:
Title:
Phone:
Mailing address:
Your job title:
Start date (month/year):
End date (month/year):
Hours worked per week:
Did you provide care to persons who required mechanical ventilation?
Did you provide care to persons who were dependent in 4 or more activities of
daily living (ADLs)?
Yes
No
Yes
No
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Section 2: Applicant information
Describe your job duties:
2. Contact person:
Title:
Name of business:
Phone:
Mailing address:
Your job title:
Start date (month/year):
Hours worked per week:
End date (month/year):
Did you provide care to persons who required mechanical ventilation?
Yes
No
Did you provide care to persons who were dependent in 4 or more activities of
daily living (ADLs)?
Describe your job duties:
Yes
No
Yes
No
Yes
No
3. Contact person:
Name of business:
Title:
Phone:
Mailing address:
Your job title:
Start date (month/year):
End date (month/year):
Hours worked per week:
Did you provide care to persons who required mechanical ventilation?
Did you provide care to persons who were dependent in 4 or more activities of
daily living (ADLs)?
Describe your job duties:
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Section 2: Applicant information
4. Contact person:
Title:
Name of business:
Phone:
Mailing address:
Your job title:
Start date (month/year):
Hours worked per week:
End date (month/year):
Did you provide care to persons who required mechanical ventilation?
Yes
No
Did you provide care to persons who were dependent in 4 or more activities of
daily living (ADLs)?
Yes
No
Yes
No
Yes
No
Describe your job duties:
5. Contact person:
Name of business:
Title:
Phone:
Mailing address:
Your job title:
Start date (month/year):
End date (month/year):
Hours worked per week:
Did you provide care to persons who required mechanical ventilation?
Did you provide care to persons who were dependent in 4 or more activities of
daily living (ADLs)?
Describe your job duties:
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SDS 0448V (03/14)
Section 2: Applicant information
L.
General references: Provide three references that are not related to you. Current or potential
AFH licensees and co-workers of the applicant are not eligible to be a general reference.
1. Name:
Mailing address:
Relationship:
Phone:
2. Name:
Mailing address:
Relationship:
Phone:
3. Name:
Mailing address:
Relationship:
Phone:
M. Medical professional references: Identify two medical professionals who have direct knowledge
of your ability and past experience providing ventilator-assisted care.
Note: Medical professional means licensed health care professionals such as a medical
doctor, osteopathic physician, nurse practitioner, registered nurse, physical
therapist, occupational therapist or respiratory therapist. Do not include the name
of your personal health care provider unless he or she has direct knowledge of your
ability and past experience providing ventilator-assisted care.
1. Name and title:
Mailing address:
Phone:
2. Name and title:
Mailing address:
Phone:
Section 3: Ventilator-assisted care requirements
A. Structural requirements:
Check the corresponding boxes to indicate compliance with OAR 411-050-0660.
Resident bedrooms minimum 100 sq. ft. or larger
Emergency back-up generator, type:
Interconnected carbon monoxide and smoke alarms with battery back-up
Functional sprinkler system
Mechanism in each bedroom to summon caregiver’s for assistance
B. Operational requirements:
Sufficient caregiving staff who have successfully completed required training (attach certificates)
Medical professional consultants retained (list below)
Physician name and title:
Phone:
Mailing address:
Registered Nurse name:
Phone:
Mailing address:
Respiratory therapist name:
Phone:
Mailing address:
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Section 4: Application requirements checklist
Include copies of the following documents with your completed application. Check the
corresponding boxes to indicate completion or check the box marked N/A if it does not apply
to you.
Application fee: $20.00 per bed (maximum $100.00)
Physician or Nurse Practitioner’s Statement: Submit the completed, signed and
dated original of the Department’s current Health History and Physician/Nurse
Practitioner’s Statement (SDS 0903).
Background check verification: Enclose verification of submission of a background
check or an approved background check for all persons 16 years of age and older
who are occupants on the AFH premises, the licensed provider, resident manager,
shift caregiver substitute caregiver, trainee or other employees and according to
OAR 411-050-0620. This verification must be less than a year old.
Training: Attach proof of required training and any special credentials, as identified in
sections 2(G) and 3(H).
Financial information: Submit the completed, signed and dated original of the
department’s current AFH Financial Information sheet (form SDS 448A). For initial
applications, attach copies of last three months of bank statements and a current,
complete credit report.
Private-pay contract: Provide a copy of your admission agreement (contract) for
private-pay residents. Refer to OAR 411-050-0615 for specific requirements.
House policies: Attach a copy of your house policies written in accordance
with OAR 411-050-0645.
Ownership of AFH: Attach proof that you are purchasing or own the facility to be
licensed, if applicable.
N/A
Lease or rental agreement: Attach a copy of the completed lease or rental agreement
for residential use. Include the landlord’s name, verification that the rent is a flat rate,
and signatures and date(s) signed by the landlord and the applicant.
N/A
Resident manager: Enclose completed Resident Manager/Shift Caregiver Application
for each resident manager, if applicable.
N/A
Shift caregivers: Enclose completed Resident Manager/Shift Caregiver Applications
for each shift caregiver, if applicable. Note: The use of shift caregivers in an AFH
must be authorized by written variance of the local licensing authority (see OAR 411050-0602 and OAR 411-050-0625).
N/A
Multiple AFHs: If you are requesting to operate more than one AFH, attach a written
plan that includes at least the following information:
N/A
1. Describes how you will manage the additional administrative responsibilities;
2. Describes how you will maintain adequately qualified staff for all your
AFHs; and
3. Indicates how you will manage the additional financial responsibility.
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Written Plan of Operation (SDS 351): Provide a written statement that includes
at least the following information:
1. Indicates how substitute caregivers and any other staff will be used in
the AFH and demonstrates there will be two qualified staff on duty at all times;
2. Identifies a qualified ventilator-assisted care back-up licensee or resident
manager, approved by the local licensing authority, who has agreed to be
your back-up caregiver and has signed form SDS 350
(attach a copy); and
3. Plan for coverage of resident manager or shift caregiver absences,
if applicable.
Floor plan: Provide a current and accurate floor plan for all levels of your AFH that
includes the following information:
1. The size of the rooms;
2. Identifies which rooms are to be resident bedrooms, caregiver bedrooms,
day care bedrooms and room and board bedrooms;
3. Location of all exits including emergency exits such as windows;
4. Location of any wheelchair ramps;
5. Identifies the location of all smoke and carbon monoxide alarms and
fire extinguishers;
6. Identifies the planned evacuation routes and initial and final points of
safety; and
7. Designated smoking areas if any.
Section 5: Certification and signature
I declare, under penalties of perjury, this information is true, correct and complete to the best of my
knowledge. I understand that:
 Failure to provide accurate information may result in the denial of my application;
 My application is not complete until all required items have been submitted; and
 An incomplete application will become void 60 days from the date the application and bed fee
are received by the local licensing authority.
I authorize the Department and the local licensing authority to verify the information provided on
this application.
Applicant’s printed name
Signature of applicant
Date
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