COMMUNITY PARTICIPATION APPLICATION

A. GENERAL INFORMATION ----- The Applicant hereby submits this application for Participation in the Care2bid program. Completion of said Application does not guarantee in any way Participation. Participation may only be granted upon successful completion of the following application and onsite survey.


Name of Assisted Living Community


Address of Assisted Living Community


City


State


Zip Code


AZ DHS License #


Manager's Name


Manager's Email


Manager's Phone Number


Manager's Fax Number


Number of Licensed Units


Year Licensed



B: STATEMENTS ----- Any Applicant for Participation who knowingly or willfully makes or causes to be made a false statement or representation on this statement, will be disqualified from any and all potential involvement with Care2bid and its affiliates. Each Applicant shall respond to the following questions. If the answer to any of the following questions is yes, please explain in the space provided below or attach a statement explaining the issue and the current status. Has the Applicant ever directly or indirectly had an ownership interest in an entity licensed by the Arizona Department of Health Services that:


1. Has been the subject of a decertification action?


If you responded yes to the above please explain:


2. Has ceased to operate such an entity as a result of a delicensure action or involuntary termination?


If you responded yes to the above please explain:


3. Has been the subject of a substantiated case of patient abuse or neglect involving material failure to provide adequate protection or services for the Resident in order to prevent such abuse or neglect?


If you responded yes to the above please explain:


4. Has been cited for serious or willful violations of rules and regulations governing the operation of said health care community?


If you responded yes to the above please explain:


5. Has the Applicant ever been found in violation of any local, state or federal statute, regulation, ordinance or other law by reason of that individual’s relationship to an Assisted Living Residence?


If you responded yes to the above please explain:



C: SUSTAINABILITY STANDARDS

1. I (We), the Applicant have sufficient personal knowledge and information to affirm that the ownership entity governing the Assisted Living Residence for which I (we) seek Participation is in sound fiscal condition and is maintaining sufficient cash flows and reserves to operate and maintain the Assisted Living Residence and all Resident service expenses at this time and upon commencement of Participation.


2. I (We), the Applicant affirm that the Assisted Living Residence for which Participation is sought meets all applicable local, state, and federal statutes, regulations, ordinances or other laws including, but not limited to, the federal Americans with Disabilities Act and the Fair Housing Amendments Act, the Arizona State Building Code, fire safety regulations, and other regulations affecting the health, safety or welfare of Residents and staff.


D: SIGNATURES

Full Name
Date MM/DD/YYYY







Verification