New Jersey Administrative Code
Title 8 - HEALTH
Chapter 43B - STANDARDS FOR LICENSURE OF ADULT FAMILY CARE CAREGIVERS AND SPONSOR AGENCIES
Subchapter 2 - LICENSING PROCEDURES FOR AFC CAREGIVERS AND AFC SPONSOR AGENCIES
Section 8:43B-2.1 - Licensing of AFC caregiver

i. The words "Application for a long-term care facility license";

ii. The type of application, date of application, date of check or money order, check or money order number, and amount of the check or money order;

iii. The official name of the facility and employer identification number (EIN) at which the person will practice as an AFC caregiver, site address, including the county and mailing address, including the county, if different, telephone number, email address, name and license number of administrator, if applicable, emergency contact name, telephone number, and email address;

iv. The owner/corporate name (licensed operator) and EIN number, the DBA, if applicable, address, including the county, telephone and fax number, and email address;

v. The management company, if applicable, address, including the county, telephone and fax number, and email address, along with the name and title of a contact person of the facility at which the person will practice as an AFC caregiver;

vi. The official name of the facility (provider name) and EIN number, primary type of facility--either adult family caregiver or adult family care sponsor agency, and the quantity of all beds/slots at the location;

vii. The type of ownership: for-profit or non-profit, and whether it is a corporation, proprietorship, limited liability corporation, partnership, limited partnership, religious affiliation, or other;

viii. The building ownership; whether wholly owned by a licensed operator identified at (a)1iv above, or leased and, if leased, identify the owner of the building and submit a copy of the lease;

ix. The name, title, and address of the individual or current registered agent upon whom orders may be served (must be a New Jersey resident);

x. The name, title, address, Social Security number or EIN number, and the percentage of ownership of each and every owner, officer, partner, stockholder, or corporate officer of the facility, which must add up to 100 percent;

xi. The counties served by the facility;

xii. Whether any person identified in this application has ever had an interest, directly or indirectly, in any application for a health care facility in New Jersey or any other state, that was denied or revoked;

xiii. Whether any of the principals have ownership, management, or operational interest in any other licensed health care facility in New Jersey or any other state;

xiv. Whether any principals, owners, operators, or managers of the facility have ever been found guilty of a criminal or administrative charge of resident/patient fraud, abuse, and/or neglect and whether any of these have ever been indicted for the same charge;

xv. Whether any principals, owners, operators, or managers of the facility have ever been indicted for or convicted of a felony crime;

xvi. With regard to (a)1xii, xiii, xiv, or xv above, identify the individual by name and provide details; and

xvii. A certification, with the certifier's name, title, signature, and date, which reads: "The applicant certifies that all information contained in this application and attachments is true and correct, to the best of his/her knowledge and belief, and that willful misrepresentation of these facts may make the applicant subject to civil penalties; that the application has been duly authorized by the governing body of the applicant; and that the facility has been and will be operated in accordance with applicable licensing requirements";

i. The Department shall not impose this fee more frequently than biennially, even if inspections occur more frequently;

ii. Failure to pay an inspection fee shall result in the denial of an initial license for new AFC caregivers and non-renewal of a license for existing AFC caregivers; and

iii. This fee is refundable if an application is denied prior to Department inspection of the premises at which the applicant would provide AFC caregiver services due to an applicant failing to meet the qualification standards at N.J.A.C. 8:43B-4.1 or being disqualified following a criminal record background check pursuant to N.J.A.C. 8:43B-3.