Memory Care Community Endorsement Application Instructions




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Memory Care Community



Endorsement Application Instructions

A community must be in compliance with the physical plant requirements for licensing and endorsement. To ensure your community is in compliance with these standards, contact Facilities Planning and Safety at 503-373-7201.

Note: A Memory Care Endorsement will not be approved until all requirements for the community’s license and endorsement has been met.

When an application must be submitted:

  • 60 days prior to anticipated opening of a new community;

  • 60 days prior to a change of ownership or management;

  • 45 days prior to license renewal include with facility license application.

1. Type of license and endorsement fee:

  • Indicate type of license of the endorsed community;

  • Include endorsement fee as indicated.

2. Type of Application:

  • Indicate what type of application.

3. Community information:

  • State the name of the community exactly as registered with the Secretary of State Corporation Division. Website: http://filinginoregon.com;

  • Provide name of administrator;

  • State the maximum endorsed capacity that a license is being requested for; and

  • Provide the current occupancy of the community (except for initial endorsement application).

4. Applicant Information:

  • Provide name of legal owning entity with the address and contact information;

5. Management/Operation information:

  • Provide name and contact information for the management company only if it is a different entity than the licensee.

6. Experience:

  • Describe the experience that the applicant has in overseeing the operations of a memory care community. If a consultant will be utilized, please provide that information.

  • If a managing company will be overseeing the operations, please include what experience they have in overseeing the operations of a memory care community.

To complete the Endorsement Application initial endorsement, change of ownership or management, the following must be included:

  • Memory care disclosure statement as required in OAR 411-057-0140 (4);

  • Policies and procedures as outlined in OAR 411-057-0140 (5);

  • Employee training curricula as outlined in table 1 referenced in OAR 411-057-0150;

  • Activities evaluation and sample calendar;

  • Floor plan of the community;

  • Copy of service or care planning tool;

  • Residency/Admission agreement; and

  • Copies of advertising brochures.









For SPD use only

Approval date:

     

License number:

     

License expiration date:

     










Memory Care Community Endorsement Application

1. License type Endorsement fee

 Residential care  $50 (1 — 16 capacity)

 Nursing facility  $75 (17 — 50 capacity)

 Assisted living  $100 (51 or more capacity)





2. Type of application

 Initial for new community

Projected opening date:

     /     /     







PR number:

     

 License renewal

 Change of ownership

 Change of operator/management

 Increase/decrease in capacity






3. Community information

Name of community:

     




(Doing Business As (DBA) name registered with Secretary of State)

Phone:

     

FAX:

     

E-mail:

     

Street address:

     

City, State, ZIP:

     

County:

     

Mailing address:

     

Administrator:

     

E-mail:

     

Maximum endorsed capacity:

     

Current occupancy:

     







4. Applicant information

 Owner (licensee)  Management

Name of legal owning entity:

     




(Exactly as registered with the Secretary of State)

Contact name:

     

Phone:

     

FAX:

     

E-mail:

     

Street address:

     

City, State, ZIP:

     




5. Management/Operator information

(Complete only if another entity other than the applicant will be overseeing the operations
of community)

Name of management company:

     

Contact name:

     

Phone:

     

FAX:

     

E-mail:

     

Street address:

     

City, State, ZIP:

     




6. Experience

Please describe applicant’s and/or management company’s experience in operating Memory
Care Communities. (Please attach additional page if needed.)

     

     

     

     

     

     

     

     




Applicant Signature

I, the undersigned, an authorized representative of the applicant declare to the best of my knowledge this information is true, correct and complete. By knowingly and willfully failing to fully disclose the information requested may result in denial of application.







     

(Name of authorized representative) (Date)







     

(Signature) (Date)

Send completed application to:
Office of Licensing and Regulatory Oversight

Attn: Licensing Specialist

PO Box 14530

Salem, OR 97309



Or to CBC.Team@dhsoha.state.or.us
If you have questions, email CBC.Team@dhsoha.state.or.us
Note: A Memory Care Endorsement will not be approved until all requirements for the community’s license and endorsement has been met.

SDS 940 (1/15)


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