12-003.02A
Licensee
Responsibilities: The licensee must submit a written application
to the Department. The licensee may construct an application or obtain an
application form from the Department. The application must include:
1. Full name of the facility to be licensed,
street and mailing address, telephone number, and facsimile number, if
any;
2. Type of facility to be
licensed;
3. Name of the
administrator;
4. Name(s) and
address(es) of the facility owner(s);
5. Ownership type;
6. Mailing address(es) of the
owner(s);
7. Preferred mailing
address for receipt of official notices from the Department;
8. List of names and addresses of all persons
in control of the facility. The list must include all individual owners,
partners, limited liability company members, parent companies, and members of
boards of directors owning or managing the operations and any other persons
with financial interests or investments in the facility. In the case of
publicly held corporations, the individual owners listed must include any
stockholders who own 5% or more of the company's stock;
9. Legal name of the individual or business
organization (government, corporation, partnership, limited liability company,
or other type) to whom the license should be issued and a statement that the
individual or organization accepts the legal responsibility for compliance with
175 NAC 12;
10. Applicant's federal
employer identification number, if not an individual;
11. Applicant's social security number if the
applicant is an individual. (To ensure social security numbers are not part of
public records and are used only for administrative purposes, applicants may
submit social security numbers in a separate document.);
12. Number of beds;
13. Signature(s) of:
a. The owner, if the applicant is an
individual or partnership;
b. Two
of its members, if the applicant is a limited liability company;
c. Two of its officers, if the applicant is a
corporation; or
d. The head of the
governmental unit having jurisdiction over the facility to be licensed, if the
applicant is a governmental unit;
14. Occupancy certificates issued by the
State Fire Marshal or delegated authority dated within the 18 months prior to
the license expiration date;
15.
Required licensure fee specified in 175 NAC 12-004.10; and
16. If applicable, the disclosure information
required by the Alzheimer's Special Care Disclosure Act. The following
information must be submitted:
a. The
Alzheimer's special care unit's written statement of its overall philosophy and
mission which reflects the needs of residents afflicted with Alzheimer's
disease, dementia, or a related disorder;
b. The process and criteria for placement in,
transfer to, or discharge from the unit;
c. The process used for assessment and
establishment of the plan of care and its implementation, including the method
by which the plan of care evolves and is responsible to changes in
condition;
d. Staff training and
continuing education practices;
e.
The physical environment and design features appropriate to support the
functioning of cognitively impaired adult residents;
f. The frequency and types of resident
activities;
g. The involvement of
families and the availability of family support programs; and
h. The costs of care and any additional
fees.
12-003.02B
Department
Responsibilities: The Department will:
1. Send a notice of expiration and an
application for renewal to the licensee's preferred mailing address not later
than 30 days prior to the expiration date. The licensure renewal notice
specifies:
a. Date of expiration;
b. Fee for renewal;
c. License number; and
d. Name and address of the
facility;
2. Issue a
renewal license when it determines that the licensee has submitted a completed
renewal application;
3. Send to
each licensee that fails to renew its license a second notice, which is the
final notice and specifies that:
a. The
licensee failed to pay its renewal fees or submit an application, or
both;
b. The license has
expired;
c. The Department will
suspend action for 30 days following the date of expiration;
d. Upon receipt of the renewal fee and
completed renewal application, the Department will issue the renewal license;
and
e. Upon failure to receive the
renewal fee and completed renewal application, the license will be lapsed;
and
4. Place the
facility license on lapsed status for nonpayment of fees if the licensee fails
to renew the license. During this time, the facility may not operate. The
license remains in lapsed status until it is reinstated.