Licensed Facilities Renewal Application for Residential Care, Assisted Living and Nursing Facilities: Part 1 Facility information — 1. Current license expiration date: / / 2. Type of facility: Residential Care (RCF) Assisted Living (ALF) Nursing Facility (NF) Intensive Intervention Memory Care Community (5 or fewer Residents with special needs) 3. Licensing fee: RCF/ALF/NF fee paid Memory care fee paid 4. Type of action: Facility name change Renewal Increase / Decrease in Licensed Units Capacity Projected date: / / 5. Facility information (attach a screen print of the confirmed Secretary of State registration page): Name of facility (include business as” or DBA name registered with the Oregon Secretary of State): “doing Phone: - - Fax: - - Street address: City/State/ZIP: County: Mailing address (if different): City/State/ZIP: Administrator: Email: Start date: / / Director of Nursing: Medical Director: Licensed maximum capacity: New capacity: Current census: Licensed number of units: New Memory care number of beds: Is property owned by applicant (licensee)? Yes No (provide owner contact information below) Name: Phone: - - Address:
Licensed Facilities Renewal Application for Residential Care, Assisted Living and Nursing Facilities: Part 1 — Facility information 1. Current license expiration date: / / 2. Type of facility: Residential Care (RCF) Intensive Intervention Community (5 or fewer Residents with special needs) Assisted Living (ALF) Nursing Facility (NF) Memory Care 3. Licensing fee: RCF/ALF/NF fee paid Memory care fee paid 4. Type of action: Renewal Facility name change Increase / Decrease in Licensed Units Capacity Projected date: / / 5. Facility information (attach a screen print of the confirmed Secretary of State registration page): Name of facility (include “doing business as” or DBA name registered with the Oregon Secretary of State): Phone: - - Fax: - - Street address: City/State/ZIP: County: Mailing address (if different): City/State/ZIP: Administrator: Email: Start date: / / Director of Nursing: Medical Director: Licensed maximum capacity: New capacity: Current census: Licensed number of units: New Memory care number of beds: Is property owned by applicant (licensee)? Yes No (provide owner contact information below) Name: Phone: - - Address:
APDR-0570R.docx