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L RE: ADULT FOSTER CARE APPLICATION GROUP HOME (Michigan)

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P.O. BOX 30650
•
LANSING, MICHIGAN 48909-8150
www.michigan.gov/dhs
•
(517) 284-9727
BCAL-1049 (Rev. 1-15) MS Word
RE: ADULT FOSTER CARE APPLICATION – GROUP HOME LICENSE
Dear Applicant:
Enclosed is the application you requested.
The following is information regarding application for an adult foster care group home.
Your application for licensure will not be considered complete until you have
demonstrated compliance with all applicable licensing requirements. Instructions and
additional materials are included to assist you in completing the application.
Please return all of the completed and required application materials with a check or
money order (which is non-refundable) for the appropriate license fee, payable to the
“State of Michigan,” to:
Michigan Department of Human Services
Cashier’s Office
P.O. Box 30759
Lansing MI 48909-8259
Please note that once you have submitted your application you may not add or delete a
licensee name from the application or change the facility type you have indicated on
your application. These changes require that you submit a new application and a new
fee. Fees are non-transferable. When a new application is required, fees previously
submitted cannot be credited to the new application.
It is therefore strongly recommended that you contact the local field office and speak
with a licensing consultant prior to submitting your application and fee to assure that you
are submitting the correct application, for the correct facility type, with the appropriate
licensee name. You may find the local field office listing online at
http://www.michigan.gov/dhs/0,4562,7-124-5455_27716_27717-80929--,00.html.
For additional information, please contact the Licensing Unit at 866-685-0006 or Fax at
(517) 284-9709.
Thank you.
Enclosure
NICK LYON
INTERIM DIRECTOR
RICK SNYDER
GOVERNOR
S
TATE OF
M
ICHIGAN
DEPARTMENT OF HUMAN SERVICES
L
ANSING
BCAL-1049 (Rev. 1-15) MS Word 2
Adult Foster Care Inquirer & Applicant Assistance
In an effort to better serve Adult Foster Care (AFC) inquirers and applicants, the Bureau of
Children and Adult Licensing (BCAL) offers application assistance. There is an online tutorial
on our website located at: http://www.michigan.gov/dhs/0,1607,7-124-5455_27716_27717---
,00.html. Field office staff also provide this assistance; some may present this information in a
group-meeting format.
The information provided on the website or by individual local office staff:
• Presents an overview of the licensing application process
• Is intended to assist you in making an informed decision about applying for an AFC license
• Is intended to assist you in identifying the type of license application to complete and the
category of AFC facility you wish to apply.
You are encouraged to review the online tutorial and/or contact your assigned BCAL field
office before submitting an application. Please review the BCAL AFC office area coverage
list, find the county where the proposed facility will be located, and contact the assigned BCAL
field office indicated for application assistance.
The following BCAL field offices provide one-on-one technical assistance in individual
meetings and phone conferences; you must call your assigned office for appointments:
Escanaba, Flint, Grand Rapids, Kalamazoo, Lansing, Marquette, Midland, Saginaw and
Traverse City.
The Metro Detroit office provides group orientation meetings for facilities that will be located in
Wayne County. You must call the Detroit office for an appointment to attend a group
orientation at the Detroit office.
BCAL-1049 (Rev. 1-15) MS Word 3
PART I
ORIGINAL APPLICATION INSTRUCTIONS
ADULT FOSTER CARE GROUP HOMES
ALL APPLICANTS
This instruction sheet specifies forms and information that must be completed.
A. THE APPLICATION
(1) WHICH APPLICATION SHOULD YOU USE?
• If the applicant is an individual(s), use BCAL 569-I.
• If the applicant is any type of corporation or LLC, government agency or other
organization, use BCAL 569-C.
• If the license is to be issued in the name of a Corporation or Limited Liability
Company (LLC), Use BCAL 569-C.
NOTE: Prior to submitting a corporate application, you must first form your
corporation/LLC through the Department of Licensing and Regulatory Affairs AND
obtain a Federal Identification Number from the Internal Revenue Service.
Complete all areas, SIGN AND DATE
(2) APPLICATION FEE ONLY
Using the fee schedule included on the application, select the appropriate fee. Write a
check payable to the State of Michigan. Please do not send cash.
NOTE: Both a completed license application and license application fee MUST
be received before your application will be enrolled.
(3) LICENSING RECORD CLEARANCE REQUESTS (BCAL-1326A)
1979 PA 218, Sec. 13 (3)(c)(e) requires that an applicant, all employees and all
members of the household be of good moral character. In order for the department to
determine compliance, a Licensing Record Clearance Request will need to be
completed and submitted for:
• The License Applicant, if the license applicant is an individual.
• The Licensee Designee, if the license applicant is a corporation/LLC, etc. This
is the individual authorized to act on behalf of the corporation/LLC, and must be
named on the application. You may only designate one individual.
• The Administrator. This is the person responsible for the daily operation of the
facility and must be named on the application. You may only designate one
individual.
BCAL-1049 (Rev. 1-15) MS Word 4
• Members of the household, 18 years of age or older, who live in the facility
and are not AFC residents or staff of the facility. These individuals must be
listed on the application.
1979 PA 218, Sec. 12(21) requires the applicant, if an individual, the licensee
designee, owner, partner, or director of the applicant who has regular direct
access to residents or who has on-site facility operational responsibilities
to submit fingerprints for a criminal history check. (If any of these individuals
submitted fingerprints for employment in an adult foster care or home for
the aged facility through the Workforce Background Check Program, and
have remained continuously employed at the facility since submitting
fingerprints, a new fingerprint submission is not required.)
Persons completing this form should ONLY complete Section II of the Clearance
Request (BCAL-1326A). After completing the fingerprint process, return the
completed, signed and dated form with your application. If additional forms are
needed, please go to www.michigan.gov/afchfa. This information is mandatory.
Your application will not be processed until this information has been
received and the Clearance Request conducted.
B. Fire Safety Plan Review (7 or more residents)
See enclosed instructions. If your application is for 7 or more residents, your facility will
need to be inspected by the Bureau of Construction Codes and Fire Safety.
You are required to submit building plans to the Department of Licensing and Regulatory
Affairs (LARA), Bureau of Construction Codes and Fire Safety (BCCFS) for approval. You
must submit form BCC-979 with your plans. This form, and the fire safety administrative
rules for AFC’s of 7 or more, may be obtained by visiting the LARA-BCCFS website.
C. ENVIRONMENTAL HEALTH INSPECTIONS
The local county health authority must inspect all facilities for 7 or more residents.
The local county health authority must inspect all facilities for 6 or less residents that have
well and/or private sewage disposal systems.
NOTE: UPON ASSIGNMENT OF A LICENSING CONSULTANT AND PRIOR
TO COMMENCEMENT OF NEW CONSTRUCTION, YOU ARE REQUIRED TO
SUBMIT YOUR FLOOR PLANS TO YOUR CONSULTANT FOR REVIEW AND
FOR APPROVAL.
The Department will arrange both the fire and environmental health onsite inspections.
Upon receipt of your completed application, application fee, and the receipt and processing of
all record clearance requests, your application will be forwarded to the appropriate field office
and assigned to a licensing consultant. The licensing consultant will contact you regarding your
application.
If you are applying as an INDIVIDUAL, you should have the documents listed in PART II of
these instructions prepared.
If you are applying as a CORPORATION/LLC, you should have the documents listed in PART
III, of these instructions prepared.
BCAL-1049 (Rev. 1-15) MS Word 5
Enclosures:
BCAL-569-I License Application for Individuals
BCAL-569-C License Application for Corporations
BCAL-1326A AFC Licensing Record Clearance Request
BCAL-3704-AFC Licensee Medical Clearance Request
Criminal record clearance requirement information
Fire safety plan review information
BCAL-1049 (Rev. 1-15) MS Word 6
STATE OF MICHIGAN
RICK SNYDER
GOVERNOR
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
LANSING
STEVEN H. HILFINGER
DIRECTOR
NOTICE TO ALL ADULT FOSTER CARE APPLICANTS/LICENSEES Issued: November 3, 2006
Subject: Requirements for Plan Review of AFC Facilities
Plan examination approvals, and subsequent inspections of the Bureau of Fire Services, are required
for facilities that are licensed for seven or more residents. Signed and sealed architectural plans are
required to be submitted for review of construction, remodeling, alterations, and change of licensee in
accordance with Rule 104 of the 1994 Adult Foster Care Fire Safety Rules. Plans shall have all
information as stated in Rule 104.
A complete copy of the 1994 Adult Foster Care Fire Safety Rules and the required “Application for
Fire Safety Plan Examination” form can be obtained from our website at www.michigan.gov/bfs .
Once in the website, click Bureau of Fire Services and then scroll down to “Public Acts & Admin.
Rules” then ‘Admin Rules’ then ‘Adult Foster Care Facilities’ to get the rules. The application can be
found under forms then select “Application for Fire Safety Plan Examination”. This application must
be filled out in its entirety in order to be considered.
1. Facility Size: 7-12 or 13-20 residents
2. Application for Fire Safety Plan Examination
3. Complete floor plan drawn accurately to scale, signed and sealed by an architect or engineer
4. Use and dimensions of each room
5. Location and size of windows
6. Size, clear width, location, direction of swing, and fire rating/construction of doors
7. Location and enclosure of exits
8. Type of construction: (per NFPA 220)
9. Interior finish: (plaster, gypsum board, paneling)
10. Location of fuel-fired devices: (furnace, water heater, etc.)
11. Heating system: (forced-air, hot water boiler, electric, etc.)
12. Type, size, and location of fire extinguishers
13. Exit sign locations
14. Any additional information to indicate compliance with the fire safety rules.
Submit your plans to:
(Via regular U.S. Mail) (Via all other courier services)
Bureau of Fire Services Bureau of Fire Services
Plan Review Division Plan Review Division
P.O. Box 30700 300 N. Washington Square, 4
th
Floor
Lansing, MI 48909 Lansing, MI 48913
If you have any questions regarding the submittal process, please contact the Plan Review Division at
517-241-8847.
BUREAU OF FIRE SERVICES
P.O. BOX 30700,• LANSING, MICHIGAN 48909
Phone (517) 241-8847
Fax (517) 335-4061
www.michigan.gov/bfs
BCAL-1049 (Rev. 1-15) MS Word 7
PART II
APPLICATION INSTRUCTIONS
GROUP HOMES
DOCUMENTS REQUIRED FOR INDIVIDUAL APPLICANTS
“PA 218 Sec.” is referring to Act No. 218 of the Public Acts of 1979, as amended. “R...” is referring to
licensing rules for Adult Foster Care Small Group Homes (12 or less).
_____ PA 218 Sec 13 (4)/R103 (f) Proof of ownership. You will need to submit proof of ownership (e.g., copy of
registered deed, property tax statement with owner’s name on it)
_____ PA 218 Sec 13 (4)//R103 (1)(f) Right to occupy/permission to inspect. If you do not own the property, you will
need to submit written verification of your right to occupy (i.e. lease or purchase agreement) and permission to inspect
from the legal owner.
FACILITIES FOR 7 OR MORE RESIDENTS
_____ P.A. 218 Sec, 16 (2) Zoning Approval. You will need to obtain and submit written zoning approval, a variance or a
special use permit from the local zoning authority. If local zoning approval is not obtained, a license cannot be issued.
NOTE: AN ONSITE INSPECTION WILL NOT BE CONDUCTED UNTIL THE LICENSING
CONSULTANT HAS RECEIVED THE ABOVE DOCUMENTS.
_____ PA 218 Sec 26a/R102 (1)(r)/R103 (1)(a) Program Statement. You will need to submit a written description of the
home’s program according to the definition in R 102(1)(r).
Note: If your program statement indicates that you will be providing services to persons with Alzheimer’s disease, your
program statement must meet the requirements of PA 218 Sec 26b.
_____R102 (1)(c)/R102 (1)(i) Admission/Discharge Policy. You will need to submit a written admission policy according
to the definition in R102 (1)(c). You will need to submit a written discharge policy, which must comply with R102 (1)(i) and
all the requirements in R302 (4) and (5).
_____R103 (1)(b)(i)/R207 (1)(a-f) Required Personnel Policies. You will need to develop, and make available for your
consultant to review, the personnel policies outlined in R207 (1) (a-f).
_____R103 (1)(b)(ii) Job Descriptions. You will need to develop, and make available for your consultant to review, all
facility job descriptions.
_____R103 (1)(b)(iii) Standard or Routine Procedures. You will need to develop, and make available for your
consultant’s review, any standard or routine procedure.
_____R103 (1)(b)(iv) and R206 (1) and (2) Proposed Staffing Pattern. You will need to develop, and make available for
your consultant’s review, your proposed staffing pattern for the facility. The staffing pattern must identify the staffing ratio
that will be maintained in the home 24 hours per day, 7 days a week.
_____R103 (1)(b)(v) Organizational Chart. You will need to develop, and make available for your consultant’s review, a
chart of your organizational structure.
_____R103(c) Contract(s). You will need to make available for your consultant’s review, copies of agreements or
contracts.
_____R103 (1)(d) Floor Plan. You will need to submit a floor plan of the facility, which meets the requirements of R103
(1)(d). 400.14405 (1-9), 400.14407 (1-7), 400.14408 (1-9), 400.14409 (1-9) and all five safety rules.
NOTE: UPON ASSIGNMENT OF A LICENSING CONSULTANT AND PRIOR TO
COMMENCEMENT OF NEW CONSTRUCTION, YOU ARE REQUIRED TO SUBMIT
YOUR FLOOR PLANS TO YOUR CONSULTANT FOR REVIEW AND FOR
APPROVAL.
BCAL-1049 (Rev. 1-15) MS Word 8
_____R103 (1)(e) Financial Documents. You will need to make available copies of the proposed annual budget and
financial statement.
_____R103 (1)(h) Credit Report. You will need to submit a copy of a current credit report for each person listed as an
“applicant”.
_____R201 (3)(a-i) Applicant and Administrator Training. You will need to submit verification that all applicants and the
administrator are competent in all required areas.
_____R201 (6) Applicant and Administrator Education and Experience. Each person listed on the application as an
applicant and the administrator will need to provide proof that he/she has a high school diploma or equivalent and at least
one year of experience working with the population(s) identified in the home’s program statement and admission policy.
_____R201 (10) Suitability. You are responsible for assuring that the employees, direct care staff and volunteers under
the direction of the licensee are suitable. You must, therefore, have a method for determining the suitability of these
individuals. Your determination must be documented for each individual.
_____R201 (14) Food Preparation. For homes of 7 or more only. You will need to provide proof that you have at least
one individual that is qualified by training, experience and performance to be responsible for food preparation.
_____R204 (3)(a-g) Staff Training. It is your responsibility to assure that all staff are competent in all of the required
areas prior to performing assigned tasks.
_____R312 (4)(a) Proper Handling of Medications. You will need to provide proof that all staff that administer
medications have been trained in the proper handling and administration of medication.
_____R205 (2) Health of Licensee and Administrator. You will need to have the enclosed Licensing Medical Clearance
form (BCAL-3704) completed by a licensed physician or his/her designee and signed and dated within 6 months prior
to the issuance of an original license, for each license applicant and the administrator.
_____R205 (4) and (5) TB Testing. You will need to submit proof of TB testing results dated within 3 years prior to the
issuance of the original license for each applicant and the administrator.
_____R206 (5) Designated Person. You will need to designate, in writing, a person who has the authority to carry out the
licensee’s or administrator’s responsibilities in his/her absence.
_____R209 (2) Emergency Repairs. You will need to have available for review a copy of your arrangements for
emergency repairs for heating, cooling, plumbing and electrical equipment.
NOTE: The items above are only some of the required documents and information needed. You consultant may ask for
additional information based on your situation as part of the licensing process. It is your responsibility to review the rule
and statutory requirements and demonstrate compliance to the department.
PA 218, sec 13(19) “Completed application” means an application complete on its face and submitted with
any applicable licensing fees as well as any other information, records, approval, security, or similar item
required by law or rule from a local unit of government, a federal agency, or a private entity but not from
another department or agency of this state.
Your application will not be considered complete until all items listed above, as well as any requested by your licensing
consultant, have been reviewed and approved AND compliance with all licensing requirements has been determined. A
recommendation for licensure cannot be made until your application is complete.
REMINDER:
Rule 103(5) requires that “an applicant or licensee shall give written notice to the department of any changes in
information that was previously submitted in or with an application for license, including changes in the
household and in personnel-related information, within 5 business days after the change occurs.”
BCAL-1049 (Rev. 1-15) MS Word 9
PART III
APPLICATION INSTRUCTIONS
ADULT FOSTER CARE GROUP HOMES
DOCUMENTS REQUIRED FOR CORPORATE/LLC APPLICANTS
“PA 218 Sec.” is referring to Act No. 218 of the Public Acts of 1979, as amended. “R...” is referring to
licensing rules for Adult Foster Care Small Group Homes (12 or less).
_____PA 218 Sec 13(4)/R103 (f) Proof of ownership. You will need to submit verification of proof of ownership (e.g.
copy of registered deed, property tax statement with owner’s name on it).
_____PA 218 Sec 13(4)/R103 (1)(f) Right to occupy/permission to inspect. If you do not own the property, you will
need to submit written verification of your right to occupy (i.e. lease or purchase agreement) and permission to inspect
from the legal owner.
_____PA 218 Sec 16(2) Zoning Approval For facilities of 7 or more. You will need to obtain and submit written zoning
approval, a variance or a special use permit from the local zoning authority. If local zoning approval is not obtained, a
license cannot be issued.
NOTE: AN ONSITE INSPECTION WILL NOT BE CONDUCTED UNTIL THE LICENSING
CONSULTANT HAS RECEIVED THE ABOVE DOCUMENTS.
_____PA 218 Sec 26a/R102 (1)(r)/R103 (1)(a) Program Statement. You will need to submit a written description of the
home’s program according to the definition in R 102(1)(r).
Note: If your program statement indicates that you will be providing services to persons with Alzheimer’s disease, your
program statement must meet the requirements of PA 218 Sec 26b.
_____R102 (1)(c)/R102 (1)(i) Admission/Discharge Policy. You will need to submit a written admission policy according
to the definition in R102 (1)(c). You will need to submit a written discharge policy, which must comply with R102 (1)(i) and
all the requirements in R302 (4) and (5).
_____R103 (1)(b)(i)/R207 (1)(a-f) Required Personnel Policies. You will need to develop, and make available for your
consultant to review, the personnel policies outlined in R207 (1) (a-f).
_____R103 (1)(b)(ii) Job Descriptions. You will need to develop, and make available for your consultant to review, all
facility job descriptions.
_____R103 (1)(b)(iii) Standard or Routine Procedures. You will need to develop, and make available for your
consultant’s review, any standard or routine procedure.
_____ R103 (1)(b)(iv) and R206 (1) and (2) Proposed Staffing Pattern. You will need to develop, and make available
for your consultant’s review, your proposed staffing pattern for the facility. The staffing pattern must identify the staffing
ratio that will be maintained in the home 24 hours per day, 7 days a week.
_____R103 (1)(b)(v) Organizational Chart. You will need to develop, and make available for your consultant’s review, a
chart of your organizational structure.
_____R103(c) Contract(s). You will need to make available for your consultant’s review, copies of agreements or
contracts.
_____R103 (1)(d) Floor Plan. You will need to submit a floor plan of the facility that meets the requirements of R103
(1)(d). 400.14405 (1-9), 400.14407 (1-7), 400.14408 (1-9), 400.14409 (1-9) and all five safety rules for facilities to be
licensed for 6 or l4ss.
NOTE: UPON ASSIGNMENT OF A LICENSING CONSULTANT AND PRIOR TO
COMMENCEMENT OF NEW CONSTRUCTION, YOU ARE REQUIRED TO SUBMIT
YOUR FLOOR PLANS TO YOUR CONSULTANT FOR REVIEW AND FOR
APPROVAL.
BCAL-1049 (Rev. 1-15) MS Word 10
_____R103 (1)(e) Financial Documents. You will need to submit copies of the following documents:
1. A Newly Formed Corporation/LLC will need to submit:
• An annual budget projecting expenses and income.
• A letter of intent to contract for services from a placing agency, if applicable.
2. An Existing Corporation/LLC (1 year or more) will need to submit:
• An annual budget showing expected expenses and income.
• A current financial statement for the corporation/LLC.
• A letter of intent to contract for services from a placing agency, if applicable.
3. A component of Government (i.e. community mental health, county infirmary, etc.) will need to provide
a:
• Statement of financial accountability from the primary unit of government for the component unit of
government.
• Current financial statement for the component unit of government.
• Operating budget showing expected expenses and income.
_____R103 (1)(g) Other Corporate/LLC Documents
1. Corporations are required to provide:
• A current listing of the corporation’s board of directors.
• The current articles of incorporation.
• The current by-laws.
• A letter of authorization from the board of directors that designates the individual who is authorized to act on
behalf of the corporation in licensing matters (also referred to as the licensee designee on the application).
2. Limited Liability Companies (LLC) will need to provide:
• A current listing of the members and managers, including names, addresses and telephone numbers.
• Current articles of organization.
• A letter of authorization from the manager(s) that designates ONE individual who is authorized to act on
behalf of the LLC in licensing matters (also referred to as the licensee designee on the application).
_____R201 (3)(a-i) Licensee Designee and Administrator Training. You will need to submit documentation that the
licensee designee and the administrator are competent in all required areas.
_____R201 (6) Licensee Designee and Administrator Education and Experience. The license designee and the
administrator will need to provide proof that each has a high school diploma or equivalent and at least one year of
experience working with the population(s) identified in the home’s program statement ad admission policy.
_____R201 (10) Suitability. You are responsible for assuring that the employees, direct care staff and volunteers under
the direction of the licensee are suitable. You must, therefore, have a method for determining the suitability of these
individuals. Your determination must be documented for each individual.
_____R201 (14) Food Preparation. For homes of 7 or more only. You will need to provide proof that you have at least
one individual who is qualified by training, experience and performance to be responsible for food preparation.
_____R204 (3)(a-g) Staff Training. It is your responsibility to assure that all staff are competent in all of the required
areas prior to performing assigned tasks.
_____R312 (4)(a) Proper Handling of Medications. You will need to provide proof that all staff that administer
medications have been trained in the proper handling and administration of medication.
_____R205 (2) Health of Licensee and Administrator. You will need to have the enclosed Licensing Medical Clearance
form (BCAL-3704-AFC) completed by a licensed physician or his/her designee and signed and dated within 6 months
prior to the issuance of an original license. This form is to be used for the licensee designee and the administrator.
You will need to submit the enclosed form to your consultant.
BCAL-1049 (Rev. 1-15) MS Word 11
_____R205 (4) and (5) TB Testing. You will need to submit proof of TB testing results dated within 3 years prior to the
issuance of the original license for the licensee designee and the administrator.
_____R206 (5) Designated Person. You will need to designate in writing the person who has the authority to carry out
the licensee designee’s or administrator’s responsibilities in their absence.
_____R209 (2) Emergency Repairs. You will need to have available for review a copy of your arrangements for
emergency repairs for heating, cooling, plumbing and electrical equipment.
NOTE: The items above are only some of the required documents and information required. You consultant may ask for
additional information based on your situation as part of the licensure process. It is your responsibility to review the rule
and statutory requirements and demonstrate compliance to the department.
PA 218, sec 13(19) “Completed application” means an application complete on its face and submitted with
any applicable licensing fees as well as any other information, records, approval, security, or similar item
required by law or rule from a local unit of government, a federal agency, or a private entity but not from
another department or agency of this state.
Your application will not be complete until all items listed above, as well as any requested by your licensing consultant,
have been reviewed and approved AND compliance with all licensing requirements has been determined. A
recommendation for licensure cannot be made until your application is complete.
REMINDER:
Rule 103(5) requires that “an applicant or licensee shall give written notice to the department of any changes in
information that was previously submitted in or with an application for license, including changes in the
household and in personnel-related information, within 5 business days.
BCAL-569-I (Rev. 1-14) Previous edition obsolete. MS Word Page 1 of 4
ADULT FOSTER CARE LICENSE
FOR DHS USE ONLY – Cashier Code: 40
INDIVIDUAL APPLICATION
License Number:
Michigan Department of Human Services
Paid Amount:
Bureau of Children and Adult Licensing
Cashier:
SECTION I – FACILITY INFORMATION
1. Facility Name
2. Application Type
3. License Number
Original Renewal Amended
4. Facility Street Address
5. City/Village
6. Township
7. State
8. Zip Code
9. County
10. Zoning Authority
11. Telephone Number
12. Fax Number
13. New Construction
Township City/Village ( ) ( ) Yes No
14. Proposed Capacity
15. I would prefer:
16. Ages
17. Currently Certified As A Specialized Program or Requesting
Males Females Both
Certification
Yes No
18. Program Type(s)
19. Water System
20. Sewer System
Mentally Ill
Developmentally Disabled
Aged
Alzheimer’s
Wheelchair Accessible
Physically Handicapped
Traumatic Brain Injured
Public
Private
Public
Private
21. Facility Type
Family Home 1-6 Small Group 1-6 Small Group 7-12 Large Group 13-20 Congregate 21 or more – EXISTING ONLY
SECTION II – APPLICANT LICENSEE INFORMATION
All original applicants must complete a Licensing Record Clearance Request form.
22. Applicant Name
23. Social Security
Federal Tax ID Number
24. Date of Birth
25. E-mail Address
26. Telephone Number
27. Fax Number
( ) ( )
28. Street Address
29. City
State
Zip Code
30. Mailing Address, if different (i.e. P.O. Box)
City
State
Zip Code
31. Joint Applicant Name (if applicable)
32. Social Security
Federal Tax ID Number
33. Date of Birth
34. E-mail Address
35. Telephone Number
36. Fax Number
( )
( )
37. Street Address
38. City
State
Zip Code
39. Mailing Address, if different (i.e. P.O. Box)
City
State
Zip Code
SECTION III – RESPONSIBLE AGENCY INFORMATION (If Applicable) Attach Additional sheets, if necessary
40. Agency Name and Address
41. Name of Contact Person
42. Telephone Number
✔
BCAL-569-I (Rev. 1-14) Previous edition obsolete. MS Word Page 2 of 4
SECTION IV – ADMINISTRATOR or RESPONSIBLE PERSON INFORMATION
Administrators must complete a Licensing Record Clearance Request form.
43. Group Home/Congregate Applicants. Print Name of Person Responsible for Daily Operation
of the Facility (Administrator)
Date of Birth
Social Security Number
44. FAMILY HOME APPLICANTS ONLY: Provide the name(s) of at least one responsible adult, other than the applicant or joint applicant, who can provide up
to 72 hours of emergency coverage for you. Responsible persons must have proof of current T.B. test results and a physician’s statement that they are both
physically and mentally capable of caring for and being around residents.
Name (Last, First, Middle)
Date of Birth
Social Security No.
Street Address (city, state and zip)
Telephone Number
45. Describe any convictions of the applicant, joint applicant, administrator, and non-employee adult members of the household. Do not include minor traffic
violations.
46. Has the applicant or joint applicant now, or ever, operated an adult foster care facility, children’s foster care facility, children’s day care facility, child caring
institution, child placing agency, or adult or children’s camp? If “yes” please complete Item 48. Yes No
47. Have you ever been denied a license to operate an adult foster care facility, children’s foster care facility, children’s day care facility, child caring
institution, child placing agency, or adult or children’s camp? If “yes” please complete Item 48. Yes No
48. If “YES” to either Item 47-48, complete the following information. Include all currently and previously licensed programs and denied license applications.
Attach additional sheets, if necessary.
Name of licensing/certifying agency
Type of care
License Number
Application Date
Open
Closed
49. Provide the following information for all persons who live in the facility, including relatives, roomers and boarders and live-in staff and children. Do not
include adult foster care residents. All non-employee adult household members who are not residents must complete a Licensing Record Clearance Request
form. Attach additional sheets, if necessary.
Name (Last, First, Middle)
Position or Relationship
Date of Birth
50. Directions for reaching family from Bureau of Children and Adult Licensing field office.
BCAL-569-I (Rev. 1-14) Previous edition obsolete. MS Word Page 3 of 4
SECTION V – OWNERSHIP INFORMATION
51. Identify all ownership interest in the business. Include additional sheets if necessary.
NAME
ADDRESS (City, State and Zip Code)
52. Ownership of facility to be licensed: Own Rent/Lease Buying
53. Identify all ownership interest in the property. Include additional sheets, if necessary.
NAME
ADDRESS (City, State and Zip Code)
SECTION VI – FINANCIAL INFORMATION
All questions must be answered by the Applicant and Joint Applicant to the best of his/her knowledge. Attach an explanation for each question answered
“Yes.”
54. HAS THE APPLICANT OR JOINT APPLICANT EVER:
a. Filed for Bankruptcy?
Yes
No
f. Had a default judgment?
Yes
No
b. Had a seizure of assets?
Yes
No
g. Had a repossession or foreclosure?
Yes
No
c. Had a lien enforced against it?
Yes No
h. Had a notice of eviction due to
payment problems?
Yes No
d. Had financial assets frozen?
Yes No
i. Had a garnishment or attachment of
wages or income?
Yes No
e. Had a contract to receive public or private monies not renewed or terminated prior to its expiration?
Yes
No
55. FOR FAMILY HOME APPLICANTS ONLY:
A.
I have sufficient resources to meet Rule 400.1404(4). The department defines “sufficient resources as follows:
Original applicants have financial assets available to provide for the operation of the home for a period of at least three months.
Renewal applicants have financial assets available to provide for the operation of the home for a period of at least 30 days.
These resources are from: (check all that apply)
Applicant/Joint Applicants employment outside of adult foster care
Non-Applicant/Joint Non-Applicant spouse’s income
Savings or available cash
Funding contracts/Intent to contract statement
Adult foster care income
Other, specify
Please attach an explanation of all items checked. You may be required to provide verification and/or documentation of the financial
information provided.
B.
I do not have sufficient resources at this time to meet Rule 400.1404(4). You may submit additional information for consideration.
Section VII – CERTIFICATION AND SIGNATURES
BCAL-569-I (Rev. 1-14) Previous edition obsolete. MS Word Page 4 of 4
I have read 1979 PA 218, and the Administrative Rules regulating the operation of Adult Foster Care facilities. If granted a
license I will comply with the Act and these Rules.
In order to permit a proper determination of conformity with the rules, I give permission to the Department of Human
Services to make all necessary and reasonable investigations of my activities, proposed standards of care, and to make an
on-site inspection of the proposed facility.
I am aware of the legal provisions of Section 13 and Section 31 of 1979 PA 218, respectively, that operating an adult foster
care facility without a license or to violate this Act is subject to criminal penalties, punishable by imprisonment or a
substantial fine or both.
I certify that I will assess the good moral character of the employees of this home/facility, as required by PA 218. I certify
that if I or any employee, volunteer, or household member of the facility who is on parole or probation or convicted of a
felony will be reported to the Department.
I also certify that any information I give in respect to any investigation by the department will be, to the best of my ability,
true and correct.
I give permission to the Michigan Department of Human Services to contact persons, including those I give as references,
in order to determine if I am in compliance with the Act and the Rules.
56. Applicant Name (print or type)
57. Applicant Signature
58. Date
59. Joint Applicant Name (print or type)
60. Joint Applicant Signature
61. Date
AN APPLICATION FEE (which is non-refundable and non-transferable), payable by check or money order ONLY, to the STATE OF
MICHIGAN, is to be sent in accordance with the Application Instructions. The fees are:
ORIGINAL
RENEWAL
ORIGINAL
RENEWAL
Family Home 1 – 6 $ 65.00 $25.00 Large Group Home 13 – 20 $170.00 $100.00
Small Group Home 1 – 6 $105.00 $25.00 Congregate Facility 21+ $220.00 $150.00
Small Group Home 7 – 12 $135.00 $60.00
Department of Human Services (DHS) will not discriminate against any individual or
group because of race, religion, age, national origin, color, height, weight, marital
status, sex, sexual orientation, gender identity or expression, political beliefs or
disability. If you need help with reading, writing, hearing, etc., under the Americans
with Disabilities Act, you are invited to make your needs known to a DHS office in
your area.
AUTHORITY: 1979 PA 218
COMPLETION: Mandatory
NON-COMPLETION: License issuance will be denied
BCAL 569-C (Rev. 1-14) Previous edition obsolete. MS Word Page 1 of 3
ADULT FOSTER CARE LICENSE
FOR DHS USE ONLY – Cashier Code: 40
LIMITED LIABILITY COMPANY, GOVERNMENTAL
License Number:
ORGANIZATION and CORPORATE APPLICATION
Paid Amount:
Michigan Department of Human Services
Cashier:
Bureau of Children and Adult Licensing
SECTION I – FACILITY INFORMATION
1. Facility Name
2. Application Type
3. License Number
Original Renewal Amended
4. Facility Street Address
5. City/Village
6. Township
7. State
8. Zip Code
9. County
10. Zoning Authority
11. Telephone Number
12. Fax Number
13. New Construction
Township City/Village ( ) ( ) Yes No
14. Proposed Capacity
15. I would prefer:
16. Ages
17. Currently Certified As A Specialized Program or Requesting
Males Females Both
Certification
Yes No
18. Program Type(s)
19. Water System
20. Sewer System
Mentally Ill
Developmentally Disabled
Aged
Alzheimer’s
Wheelchair Accessible
Physically Handicapped
Traumatic Brain Injured
Public
Private
Public
Private
21. Facility Type
Small Group 1-6 Small Group 7-12 Large Group 13-20 Congregate 21 or more – EXISTING ONLY
SECTION II – APPLICANT/LICENSEE INFORMATION
E-mail address
22. Corporate/Limited Liability company/Governmental Organization Name
23. Telephone Number
24. Fax Number
( ) ( )
25. Street Address 26. City State Zip Code
27. Mailing Address, if different (i.e. P.O. Box)
City
State
Zip Code
28. Date Incorporated/Organized
29. Federal ID Number
30.
31.
For Profit
Non Profit
Government
Non Government
SECTION III – RESPONSIBLE AGENCY INFORMATION (If Applicable) Attach Additional sheets, as necessary
32. Agency Name and Address
33. Name of Contact Person
34. Telephone Number
( )
( )
( )
( )
SECTION IV – LICENSEE DESIGNEE AND ADMINISTRATOR (Person responsible for the daily operation of the facility)
(Licensing Record Clearance form required to be completed by Licensee Designee or Administrator.)
35. Print Name of Licensee Designee
36. Date of
Birth
37. Social Security
Number
38. Print Name of the Administrator
39. Date of
Birth
40. Social Security
Number
41. Describe any conviction of corporate officers, company members, business owners, directors, licensee designee, administrator and non-
employee adult members of the household. Do not include minor traffic violations.
✔
BCAL 569-C (Rev. 1-14) Previous edition obsolete. MS Word Page 2 of 3
42. Does the Corporation/Limited Liability Company/Governmental Organization now, or has it ever, operated an adult foster care facility,
children’s foster care facility, children’s day care facility, child caring institution, adult or child camp, or child placing agency?
If “yes” please see Item 44. YES NO
43. Has the Corporation/Limited Liability Company/Governmental Organization ever been denied a license to operate an adult foster care
facility, children’s foster care facility, child or adult camp, child day care facility, child caring institution or child placing agency?
If “yes” please see Item 44. YES NO
44. If your response is YES to either item 42 or 43, complete the following information. Include all current and previous licensed programs
and denied licenses. Attach additional sheets, if necessary.
Name of Licensing/Certifying Agency
Type of Care
License Number
Application Date
Open
Closed
45. Provide the following information for all persons who live in the facility, including relatives, roomers and boarders, and live-in staff. DO
NOT include adult foster care residents. Attach additional sheets, if necessary.
Name (Last, First, Middle)
Position or Relationship
Date of Birth
46. Directions for reaching facility.
SECTION V – OWNERSHIP INFORMATION
47. Identify all ownership interest in the business. Attach additional sheets, if necessary.
Name
Street Address (city, state and zip)
48. Ownership of Facility to be licensed
Own
Rent/Lease
Buying
49. Identify all ownership interest in the property. Attach additional sheets, if necessary.
Name
Street Address (city, state and zip)
BCAL 569-C (Rev. 1-14) Previous edition obsolete. MS Word Page 3 of 3
SECTION VI – FINANCIAL INFORMATION
All questions must be answered by a member of the licensee company or board
Attach an explanation for each “YES” response:
50. HAS TO CORPORATION/LIMITED LIABILITY COMPANY/GOVERNMENTAL ORGANIZATION EVER:
a. Filed for bankruptcy?
YES
NO
f. Had a default judgment against it?
YES
NO
b. Had a seizure of assets?
YES
NO
g. Had a repossession or foreclosure?
YES
NO
c. Had a lien enforced against it?
YES NO
h. Had a notice of eviction due to payment
problems?
YES NO
d. Had its financial assets frozen?
YES NO
i. Had a garnishment/attachment of
wages/income?
YES NO
e. Had a contract to receive public monies not renewed or terminated prior to its expiration?
YES
NO
51. HAS ANY OFFICER OF THIS CORPORATION/LIMITED CORPORATION/GOVERNMENTAL ORGANIZATION EVER BEEN AN
OFFICER/PARTNER OF ANOTHER CORPORATION/LIMITED LIABILITY CORPORATION/GOVERNMENTAL ORGANIZATION OR
PARTNERSHIP THAT:
a. Filed bankruptcy?
YES
NO
b. Had a contract to receive public monies not renewed or terminated prior to its expiration?
YES
NO
c. Has been subject to a government seizure of assets?
YES
NO
SECTION VII – CERTIFICATION AND SIGNATURES
I have a read 1979 PA 218, as amended, and the administrative rules regulating the operation of adult foster care facilities. If granted a
license, I will comply with the Act and these rules.
In order to permit a proper determination of conformity with the rules, I give permission to the Michigan Department of Human Services to
make a necessary and reasonable investigation of my activities and proposed standards of care and to make an on-site inspection of the
facility.
I am aware of the legal provisions of Section 13 and Section 31 of 1979 PA 218, as amended, respectively, that operating an adult foster
care facility without a license or to violate this Act is subject to criminal penalties punishable by imprisonment or a substantial fine, or both.
I certify that I will assess the good moral character of the employees of this home/facility, as required by PA 218. I certify that if I or any
employee, volunteer, or household member of the facility who is on parole or probation or convicted of a felony, I shall report such
information to the Department.
I also certify that any information I give in respect to any investigation conducted by the Department will be, to the best of my ability, true and
correct.
I give permission to the Michigan Department of Human Services to contact persons, including those I give as references, in order to
determine if I am in compliance with the Act and the Rules.
52. Signature of a member of the licensee company or board
53. Date
Note: May not be signed by the licensee designee unless also a member of the licensee company or board.
54. AN APPLICATION FEE (which is non-refundable and non-transferable), payable by check or money order ONLY, to the STATE OF
MICHIGAN, is to be sent in accordance with the Application Instructions. The fees are:
ORIGINAL RENEWAL ORIGINAL RENEWAL
Small Group Home 1-6
$105.00
$25.00
Large Group Home 13-20
$170.00
$100.00
Small Group Home 7-12
$135.00
$60.00
Congregate Facility 21 +
$220.00
$150.00
Department of Human Services (DHS) will not discriminate against any individual or group
because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual
orientation, gender identity or expression, political beliefs or disability. If you need help with
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to
make your needs known to a DHS office in your area.
AUTHORITY: 1979 PA 218
COMPLETION: Mandatory
NON-COMPLETION: License issuance will be denied
BCAL-1326A (Rev. 11-13) Previous edition obsolete. MS Word 1
AFC
/HFA
LICENSING RECORD CLEARANCE REQUEST
INSTRUCTIONS
The purposes
of t
his form
are
:
1
.
Verify the address of a family home applicant with Secretary of State records.
2.
Produce a Bureau of Children and Adult Licensing (BCAL) files check for a cur
rent or previous licensee status of the
applicant in any county of the state.
3
.
Produce a Department of State Police check regarding the possible existence of a conviction record.
Instructions for processing:
The Licensing Record Clearance (BCAL-1326A) must be taken with you at the time the FBI
fingerprint is conducted. Note: The TCN# will be filled in by the Fingerprint Specialist and must be completed prior to
submitting the form.
Fingerprint check of Adult Foster Care and Home for the Aged license applicants and others as required by licensing statues.
You may select a fingerprint vendor at www.michigan.gov/msp/0,1607,7-123-1589_1878_8311-237662--,00.html
The existence of a conviction record does not necessarily disqualify an applicant for licensure, or an individual from
employment or residents in an adult foster care facility. However, it does provide BCAL with information which will be carefully
evaluated by licensing staff. A failure on the part of an applicant to provide BCAL with accurate and truthful information
and the authorization requested on this form may be sufficient cause to deny issuance of a license.
• I am aware that Michigan Department of State Police Records will be checked for information regarding criminal
convictions.
• I certify that the information I have given on the form is, to the best of my ability, true and correct.
• The Department may perform this check at any time while I am licensed or associated with a licensed facility.
• I understand the personal information and fingerprints submitted by live scan are used to search against criminal
identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI). I hereby
authorize the release of any records to the person or agency listed above. I further understand MSP and the FBI may also
retain the submitted information and fingerprints as permitted by the Federal Privacy Act of 1974 (5 USC § 552a(b)) for
routine uses beyond the principal purpose listed above. Routine uses include, but are not limited to, disclosures to:
governmental authorities responsible for civil or criminal law enforcement, counterintelligence, national security, or public
safety.
• 28 CFR §16.34- Procedure to obtain change, correction or updating of identification records.
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect
and wishes changes, corrections or updating of the alleged deficiency, he/she should make application directly to the
agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the
accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division,
ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the
agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an
official communication directly from the agency which contributed the original information, the FBI CJIS Division will make
any changes necessary in accordance with the information supplied by that agency.
**DISCLAIMER: ALL FINGERPRINTS PROCESSED WITH INCORRECT FINGERPRINT CODES OR USE OF THE
WRONG LICENSE RECORD CLEARANCE REQUEST FORM ARE THE RESPONSIBILITY OF THE INDIVIDUAL. MSP
WILL CHARGE FOR SECOND REQUESTS DUE TO INCORRECT FINGERPRINT CODES.
AUTHORITY: 1978 PA 368
Department of Human Services (DHS) will not discriminate against any
individual or group because of race, religion, age, national origin, color,
height, weight, marital status, sex, sexual orientation, gender identity or
expression, political beliefs or disability. If you need help with reading,
writing, hearing, etc., under the Americans with Disabilities Act, you are
invited to make your needs known to a DHS office in your area.
1979 PA 218
COMPLETION Required
CONSEQUENCE: Licensure may be denied.
BCAL-1326A (Rev. 11-13) Previous edition obsolete. MS Word 2
AFC
/HFA
LICENSING RECORD CLEARANCE REQUEST
STATE OF MICHIGAN
Department of Human Services
Bureau
of Children and Adult Licensing
DIRECTIONS FOR COMPLETING FORM:
LIVESCAN FINGERPRINT REQUEST
•
Please read the accompanying instructions before completing this form.
• Please type or print CLEARLY so that the information provided can be read.
• Mail completed form to BCAL Central Office or address noted in box below.
Fingerprint Specialist
section only.
TCN# ______________________________
(MUST BE FILLED IN PRIOR TO RETURNING)
Date Fingerprinted: __________________
Type of Picture I.D. presented:
___________________________________
SECTION I: REQUESTOR INFORMATION
Department of Human Services
Bureau of Children and Adult Licensing
201 North Washington Square
P.O. Box 30650
Lansing, MI
48909
FCL (Adult Foster Care) Agency ID: 86871E
Licensing Consultant (if known)
HAL (Homes for the Aged) Agency ID: 86872L
Licensee/Applicant Name Name of Facility County BCAL License Number (If assigned)
License/Application Type (check all that apply):
AFC Group Home
Home for the Aged
AFC Family Home
The Person Being Cleared Is (CHECK ONLY ONE PER FORM):
Authorized Representative (HFA only)
Applicant/Co-Applicant
Licensee/Licensee Designee
AFC Administrator (Responsible for daily operation of group home)
Responsible Person (AFC Family Homes Only)
Adult Member of Household (specify relationship to licensee):
Other (describe):
SECTION II: CLEARANCE INFORMATION (To be completed by applicant or other person to be cleared – If more than
one person is named on the application, each is to complete a BCAL-1326A). PRINT CLEARLY.
NAME (Last, First, Middle Jr., II, etc.) GENDER BIRTH DATE SOCIAL SECURITY NUMBER
MARITAL STATUS SGL ALSO KNOWN AS (Aliases, Maiden Name, Previous Married Name(s))
MAR DIV WID
ADDRESS (Street Number and Name) MICHIGAN DRIVERS LICENSE OR STATE ID NUMBER
CITY COUNTY STATE ZIP CODE PHONE NUMBER RACE HEIGHT WEIGHT
OTHER STATES RESIDED IN DURING PAST 5 YEARS:
Have You Ever Been Convicted Of A Crime, Felony Or Misdemeanor?
NO
YES (If yes, explain)
Type, Location, and Date of Conviction(s)
My signature certifies that I have reviewed the instruction page.
Signature Of Person To Be Cleared Date
SECTION III: CENTRAL RECORDS CLEARANCE (BCAL Use Only)
SECTION IV: CONVICTION CLEARANCE
PREVIOUS LICENSE? INITIALS/CLEARANCE DATE
For BCAL Use Only
NO
ACTIVE
CLOSED
LICENSE NUMBER
DISCIPLINARY ACTION?
YES
SECRETARY OF STATE DISCREPANCY?
(For family home applicants only)
INITIALS/CLEARANCE DATE
NO
YES
If you have multiple individuals in the home that will require additional forms, please print additional copies of this form before filling it out.
BCAL-3704-AFC (Rev. 4-14) Previous edition obsolete. MS Word
MEDICAL CLEARANCE REQUEST – ADULT FOSTER CARE AND HOMES FOR THE AGED
Michigan Department of Human Services
Bureau of Children and Adult Licensing
APPLICANT/LICENSEE INFORMATION
Facility/Home Name
License Number
Facility/Home Address (Street Number and Name)
City
State
Zip Code
Licensing Consultant (Name, Address, Phone)
License Application Type
PLEASE
MAIL TO
Department of Human Services
Bureau of Children and Adult Licensing
201 North Washington Square
P.O. Box 30650
Lansing, MI 48909
Adult Foster Care (24-Hour Care)
Home for the Aged (24-Hour Care)
PATIENT INFORMATION (To be Completed by Patient) (Please Print or Type)
Name (Last, First, Middle, Jr., II, etc.)
Date of Birth
Social Security Number
Telephone Number
Address (Street Number and Name)
City
State
Zip Code
RELEASE OF INFORMATION (To be Completed by Patient)
I authorize the release of medical information concerning me
to the facility/home listed above and to the Michigan
Department of Human Services, Bureau of Children and
Adult Licensing, for the purpose of determining my suitability
to provide or be associated with the care of dependent
adults.
Date
Patient’s Signature
Physician’s Name (Please PRINT or TYPE)
MEDICAL INFORMATION (To be Completed by Physician)
• This individual is, or will be, employed in a dependent adult care setting.
• It is necessary to establish that those providing care are in such physical and mental condition and health as not to adversely
affect the health or safety of a dependent adult and the quality and manner of his/her care.
• To assist us in this determination, you are being asked to answer the following.
Has this Person Been Tested for T.B.?
Date Tested
Test Type
Results
No
Yes
If Yes
Skin Test
X-Ray
Positive (Explain in Comments)
Negative
How would you describe the patient’s general physical/mental condition and health? (Use Comments section for explanations)
No physical/mental condition or health problem exists that would limit the ability to work with or around dependent adults.
Physical/mental condition or health problem exists that would not limit the ability to work with or around dependent adults. Explain in
Comments if reasonable accommodation may be needed.
Physical/mental condition or health problem exists which would affect the ability to work with or around dependent adults, with or
without reasonable accommodation.
Comments (Please use back of this form if additional space is needed.)
Would you like to be contacted by the licensing consultant regarding your recommendation?
Yes
No
Licensed Physician or his/her designee Signature
Signature Date
Telephone Number
Examination Date
Address (Street Number and Name)
City
State
Zip Code
AUTHORITY: 1973 PA 116
1979 PA 218
RESPONSE: Voluntary
PENALTY: Application for licensure may be denied.
Department of Human Services (DHS) will not discriminate against any
individual or group because of race, sex, religion, age, national origin, color,
height, weight, marital status, political beliefs or disability. If you need help
with reading, writing, hearing, etc., under the Americans with Disabilities Act,
you are invited to make your needs known to a DHS office in your area.
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L RE: ADULT FOSTER CARE APPLICATION GROUP HOME (Michigan)

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Completed 16 June 2021

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