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Adult Care Facility Common Application - Schedule 2 - Personal Qualifying Information Adult Care Fac

Adult Care Facility Common Application - Schedule 2 - Personal Qualifying Information Adult Care Fac 2025

Adult Care Facility Common Application - Schedule 2 - Personal Qualifying Information Adult Care Fac Preview on Page 1

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The document outlines the instructions for completing Schedule 2 of the Adult Care Facility Common Application by the New York State Department of Health. It details the requirements for personal qualifying information, financial statements, and not-for-profit director statements necessary for individuals involved in the ownership or management of adult care facilities. The document specifies which forms need to be submitted based on the individual's role and ownership percentage, as well as instructions for out-of-state compliance reviews.

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How to use or fill out Adult Care Facility Common Application - Schedule 2 - Personal Qualifying Information Adult Care Fac

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Click ‘Get Form’ to open it in the editor.
Begin with Schedule 2A, where you will enter your personal identifying information. Fill in your last name, first name, middle initial, home address, and contact details.
Proceed to the Formal Education section. List the institutions you attended along with the degrees received and relevant dates.
In the Licenses Held section, provide details of any professional licenses you possess, including type and issuing institution.
Complete the Employment History section by detailing your past ten years of employment. Include employer names, addresses, positions held, and reasons for departure.
For Offices Held or Ownership in Health Care Facilities, disclose any affiliations with health care entities over the past decade.
Ensure all required fields are filled out completely. Review for accuracy before signing and notarizing the document as required.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Who regulates assisted living facilities in NYS?

The New York State Department of Health regulates the ALP, a Medicaid State Plan service that operates in facilities that are licensed as either an adult home or enriched housing program.

Are assisted living facilities federally regulated?

Each state has its own set of regulations and a designated regulatory body. For example, in California, the State Department of Social Services oversees assisted living regulations.

How do I file a complaint against an assisted living facility in NY?

Assisted Living Facility or Adult Home Complaint Agency: New York State Department of Health. Division: Assisted Living Facilities and Adult Homes. Phone Number: (866) 893-6772. Business Hours: Monday - Friday: 8:30 AM - 4:45 PM.

Who do assisted living facilities report to?

Assisted living facilities are regulated by individual state agencies, not the federal government. Typically, the state health or social services department oversees these facilities, sometimes called residential care settings.

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