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Adult Family Home Caregiving Experience Attestation (CEA) Form A - dshs wa 2026
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Definition and Meaning
The Adult Family Home Caregiving Experience Attestation (CEA) Form A is a mandatory form for individuals seeking licensure to operate an Adult Family Home (AFH) in Washington state. This form is essential in verifying that the applicant has accumulated sufficient hands-on caregiving experience, specifically a minimum of 1,000 hours within the last 60 months, involving direct care of vulnerable adults. It substantiates that the applicant is suitably prepared to manage the daily caregiving responsibilities required in an AFH setting. The form is a critical component of the licensure application process and requires detailed completion to accurately reflect the applicant’s caregiving experience.
How to Use the Adult Family Home Caregiving Experience Attestation (CEA) Form A
To use the CEA Form A effectively, applicants must ensure that all sections of the form are accurately filled out. This includes providing personal information and detailing the caregiving experience which meets the required threshold. Applicants will need to indicate the types of care activities performed, the settings in which they worked, and the specific time frames of their caregiving roles. The form must be completed by the applicants themselves or by someone who can credibly attest to their experience. Once filled out, the form should be notarized to validate its authenticity before submission.
Steps to Complete the Adult Family Home Caregiving Experience Attestation (CEA) Form A
- Obtain the Form: Secure a copy of CEA Form A from the relevant state department or a verified online source specializing in Washington state forms.
- Personal Section: Enter personal details such as your name, address, and contact information in the designated fields.
- Experience Detailing: Accurately document your caregiving experience, including specific responsibilities, environments, and durations of care provided, ensuring it sums to at least 1,000 hours.
- Attestation: Identify a credible person (e.g., former employer, colleague) who can confirm your described experiences.
- Notarization: Have the completed form notarized to further uphold its validity.
- Submission: Submit the notarized form to the appropriate state licensing body, following their preferred method of submission.
Key Elements of the Adult Family Home Caregiving Experience Attestation (CEA) Form A
- Personal Information: This section captures the identity and contact information of the applicant.
- Caregiving Experience: Details of caregiving roles including job titles, locations, tasks performed, and the total hours worked.
- Verifier Information: Information about the person attesting to the applicant's experience, ensuring accountability and credibility of the provided data.
- Notarization: A segment for a notary public to confirm the authenticity of the information and the identity of the individuals completing the form.
Who Typically Uses the Adult Family Home Caregiving Experience Attestation (CEA) Form A
This form is primarily utilized by individuals seeking to establish or renew an Adult Family Home in Washington state. It caters to those at the forefront of providing care, such as homeowners or primary caregivers in the AFH environment. As it verifies caregiving experience, it is often used by applicants who must demonstrate their qualifications and readiness to manage an AFH, ensuring they meet the state’s legal and operational expectations for caregiving services.
State-Specific Rules for the Adult Family Home Caregiving Experience Attestation (CEA) Form A
Washington state mandates specific requirements for the CEA Form A to be valid:
- A notarized signature is essential for form submission.
- The stated 1,000 hours of caregiving experience must be recent, within the last five years.
- The form should be completed by or include an attestation from someone with direct knowledge of the applicant's experience.
- The form is considered part of the official application package for AFH licensure and must comply with all the Washington state Department of Social and Health Services (DSHS) guidelines.
Legal Use of the Adult Family Home Caregiving Experience Attestation (CEA) Form A
Legally, the CEA Form A serves to verify that applicants have the prerequisites to provide care in an Adult Family Home setting. The form’s proper completion and its notarization are mandatory to protect against fraudulent claims of caregiving experience. Submission of false information on the form can result in penalties including disqualification from licensure, financial penalties, or legal action. Applicants and attestors should ensure that all information is accurate and verifiable to maintain their legitimacy in operating or managing an AFH.
Examples of Using the Adult Family Home Caregiving Experience Attestation (CEA) Form A
To illustrate, consider an individual with experience in a nursing home setting who seeks to leverage their caregiving skills in an AFH. By documenting their experience caring for residents, detailing the types of assistance provided, and demonstrating their compliance with Washington state requirements, they can successfully submit the CEA Form A to advance their application. Another example might involve a caregiver working in a private home setting who needs to substantiate their diverse caregiving responsibilities to meet the state’s validation criteria through the form.
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What is the Copes program in Washington state?
The COPES program pays for long-term care in your home or in a community setting, like assisted living or an adult family home. COPES care can include help from a trained caregiver to shower, dress, eat, use the toilet, walk, change position in bed, and manage your medications.
How do I become an independent caregiver in Washington State?
Requirements For Becoming an In-Home Caregiver in Washington State Be 18 years old or older. Be authorized to work in the U.S. Provide a picture ID of yourself. Pass a criminal conviction background check. Complete Washington States caregiver training requirements.
How much is the LTC benefit in Washington state?
The WA Cares Fund is a public long-term care insurance program. All working Washingtonians contribute a small percentage of their income into the fund. Then when you need care, you can access your earned benefit of $36,500 (adjusted up to inflation) to pay for services.
How to get an adult family home license in Washington State?
To obtain a license from the DSHS, an individual must go through a thorough licensing process, which includes a background check, an inspection of the home, and a review of the proposed care plan. Its important to note that all staff members must also pass a background check.
What are the caregiver training requirements in Washington State?
Home Care Aides (HCAs) also known as Long Term Care Workers (LTCWs) need 75 hours of training with a state approved training program, and they must take a state certification exam.
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People also ask
Can a family member get paid to be a caregiver in Washington state?
Long-term care (LTC) insurance, ing to Washington state law, is an insurance policy, contract or rider that provides coverage for at least 12 consecutive months to an insured person if they experience a debilitating prolonged illness or disability.
What is Altsa in Washington State?
The Aging and Long-Term Support Administration (ALTSA) is responsible for Washington states nationally recognized system of long-term services and supports serving older adults and people with disabilities. This system includes: Home and community-based settings. Protections from abuse, neglect and exploitation.
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The attestor who completes the form must have personal knowledge of the direct caregiving experience achieved after age eighteen.
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