Annual License Renewal

Section IV: Additional Documentation The following documents must be attached to this application:If applicant for licensure is a corporation, firm or association. Provide a copy of the Articles of Incorporation and names and telephone numbers of all members of the Board of Directors.Information relating to the number, experience, and training of the employees of the facility or program.Any promotional materials (in electronic or print format) which will be used to market the services offered by the facility.Documentation that the facility has been inspected by the local fire safety authority or the State Fire Marshal and determined to be in compliance with applicable statutes and rules.The facility’s current and approved comprehensive emergency management plan.A copy of the lease signed by the applicant and lessor, if the facility is located in a leased building or on leased property.Individuals or entities applying for licensure as a Comprehensive Transitional Education Program shall provide the number and location of the component centers or units which will compose the comprehensive transitional education program.Applicants for initial licensure shall attach the approved variance from local zoning officials (if one is required as described within Section V of this application). Some local governments may choose to provide the applicant with written verification that the home is in compliance with zoning requirements; in those instances, the applicant should attach a copy of such documentation to this application as well.A copy of the applicants written policy regarding sexual activity involving residents of the facility as required under Rule 65G-2.009, F.A.C.  A floor plan of the facility.Name(s) of any controlling entity of the applicant.Disclosure of any financial or ownership interest that the controlling entity of the applicant has held in the last 5 years in any entity licensed by the State of Florida to provide residential care which has closed voluntarily or involuntarily, has filed for bankruptcy, has had a license denied, suspended, or revoked, or has had an injunction issued against it by a regulatory agency. The applicant must disclose the reason each licensed entity was closed, and whether the closure was voluntary or involuntary. Copies of any known sanctions, fines, or recoupments related to the receipt or use of federal Facility Application Form – APD 2014-01 (April 1, 2014). Rule 65G-2.002 9 or state funds by all controlling entities of the applicant within the preceding twelve month period. These include the results of any investigations into Medicaid or Medicare fraud.Evidence of financial ability to operate the facility in accordance with Chapter 65G-2 for up to 60 days without dependence upon payment from the state or other third party fees from facility residents. Such evidence shall include bank account statements, pay stubs, documentation of a line of credit, or any other documents which would demonstrate the expected ability of the licensee to continue operations for that time period and under those conditions.