DEPARTMENT OF HEALTH

 

 

 

 

REGISTRATION FORM FOR

RESIDENTIAL LIVING CENTER

 

 

Chapter 44:23:01

 

APPENDIX A

 

SEE: § 44:23:01:03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 18 SDR 162, effective April 6, 1992.

RESIDENTIAL LIVING CENTER

REGISTRATION FORM

 

SDCL 34-12-32 and ARSD chapter 44:23:01 require a residential living center which provides residential services to two or more elderly or disabled persons to register annually with the state department of health.  The undersigned hereby registers the residential living center described on this form.

 

I.             NAME AND LOCATION OF CENTER

                Name of Center __________________________________________________________________________

                Address ________________________________________________________________________________

                                                                (Street)                                   (City)                                      (Zip Code)

                Mailing Address (if different)_______________________________________________________________

                County__________________________________________________ Telephone______________________

 

II.            CONTROL OF CENTER

                Owner(s) Name __________________________________________________________________________

                Owner(s) Address ________________________________________________________________________

                Operator(s) Name (if other than owner) _______________________________________________________

                Check below the one which applies:

                             Sole Proprietorship                                                           Partnership

                             Not-for-profit corporation                                              For-profit corporation

                             Political Subdivision                                                         Other ______________

 

III.          CENTER CAPACITY AND SERVICES

                Number of residential units in the Center:  ______________________________________________

                Resident capacity of the Center: ______________________________________________________

                Number of residents currently residing in the Center:  _____________________________________

                Number of residents disabled:  _______________________________________________________

                Number of residents elderly:  ________________________________________________________

                Residential services offered or furnished (Check all that apply):

 

                             Room

                             Meals

                             Assistance with eating, bathing, and dressing

                             Assistance with personal and household chores

                             Organized social and recreational activities

                             Transportation services

                             Assistance with the self-administration of medications

                             Monitoring of nutrition or health

                             Protective supervision

                             Other_________________________________________________________

                             Other_________________________________________________________

 

VI.          REGISTRANT

                I verify the information contained in this registration form is true and complete.

 

                Signed___________________________________________________________          ____________________

                                Owner, operator, or other individual authorized to act on behalf of center                       Date

 

Submit on or before April 15, 1992, and January 1 every year thereafter to:

 

South Dakota Department of Health

Licensure and Certification Program

523 East Capitol Avenue

Pierre, SD  57501-3182

 

(form issued 3-92)