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

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A person seeking
				to obtain licensure as an AFC caregiver shall submit the following to the
				Department:
1. A completed application using the
				application form designated LCS-9, which is available on the Department's forms page
				at
http://www.nj.gov/health/forms
, which
				contains the following information, as applicable:
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";