Ariz. Admin. Code § 6-6-1104.03

Current through Register Vol. 30, No. 49, December 6, 2024

Section R6-6-1104.03 - Contents of a Complete Application Package - Initial License

An initial application package is complete when the Division has all of the following information:

1. From the license applicant, a completed application form as prescribed in R6-6-1101(A) which contains the following information:

a. Personally identifying information, as follows:

i. Name and gender,

ii. Date and place of birth,

iii. Social security number,

iv. Ethnicity and religious preference,

v. Current and previous address,

vi. Dates resided at previous address,

vii. Length of Arizona residency,

viii. Current marital status and marital history, and

ix. Any other names by which the license applicant has been known.

b. Personally identifying information on the license applicant's household members, as follows:

i. Name,

ii. Gender,

iii Date of birth,

iv. Relationship to license applicant, and

v. Length of time living in the home.

c. Personally identifying information on the license applicant's children who do not live with the license applicant, including emancipated children, as follows:

i. Name;

ii. Current address;

iii. Date of birth; and

iv. Occupation or school, if currently attending.

d. Any current or prior licenses or certificates held by the license applicant to provide care to a child or adult, as follows;

i. Type of license or certificate;

ii. Date of each license and certificate;

iii. State in which each license or certificate was issued;

iv. Any license or certificate which was revoked, denied, voluntarily surrendered, or suspended and the circumstances; and

v. Name of any other agency with which the license applicant is currently licensed or certified to provide services to children or adults.

e. A description of the license applicant's home, as follows:

i. The name of the school district in which the license applicant's home is located;

ii. Identification and description of any swimming pool, spa, fish pond, or other body of water; and

iii. Number of bedrooms.

f. Information about the license applicant, as follows:

i. Educational background;

ii. Employment history;

iii. Previous experience in providing room and board for any person;

iv. Any contact with CPS or APS and the circumstances;

v. Any arrest and the circumstances;

vi. Any history of mental illness or treatment for a mental illness or emotional disorder including hospitalization for alcohol, drug, or mental health issues and the circumstances;

vii. If currently or previously employed by the Department of Economic Security or the Division, position, title, name of the supervisor, and name of the program;

viii. The reason for wanting to provide care to an adult;

ix. Gender, age, characteristics, and special needs of the individual the license applicant would prefer to take into the home;

x. Any experience caring for individuals who have special needs;

xi. Discipline techniques used or believed appropriate; and

xii. Anticipated changes in the license applicant's family in the next 12 months.

g. Information about the license applicant's household member, as follows:

i. Any contact with CPS or APS by anyone currently or formerly residing with the license applicant and the circumstances;

ii. Any arrests and the circumstances;

iii. Any history of mental illness or treatment for a mental illness or emotional disorder including hospitalization for alcohol, drug, or mental health issues and the circumstances;

iv. If currently or previously employed by the Department of Economic Security or the Division, position, title, name of the supervisor, and name of the program;

v. Any experience caring for individuals with special needs; and

vi. Discipline techniques used or believed appropriate.

h. Reference information for the license applicant, as follows:

i. Three references who can attest to the license applicant's character and skill; and

ii. If the license applicant is working or has worked with children or adults with developmental disabilities, one employment reference;

i. List of any individuals who live on the property on which the license applicant's home is located, but not in the license applicant's home.

2. From the license applicant, the following documents listed on the application form:

a. A completed declaration of criminal history for the license applicant and each adult household member on a Division form with the following information:

i. Name,

ii. Social security number,

iii. Date of birth,

iv. Address,

v. A declaration of whether the individual has committed any of the crimes listed in A.R.S. § 36-594(3) and R6-6-1118, and

vi. Dated signature.

b. Documentation showing that the license applicant and each adult household member have been fingerprinted;

c. Documentation showing that the license applicant has a current driver's license, and current vehicle liability insurance as prescribed in R6-6-1112(A);

d. A completed monthly budget on a Division form showing the license applicant's monthly income, and monthly expenses, and the circumstances for any declaration of bankruptcy;

e. A physician's statement for the license applicant and each adult household member as prescribed in R6-6-1101(L);

f. Documentation of current immunizations for each child living in the license applicant's home as prescribed in R6-6-1101(E)(5);

g. Documentation that the license applicant has completed training as prescribed in R6-6-1105(A).

3. From sources other than the applicant, the documents listed on the application form, as follows:

a. Three letters of reference for the license applicant as prescribed in R6-6-1101(G);

b. If the license applicant works with children or adults with developmental disabilities, one employment letter of reference as prescribed in R6-6-1101(H);

c. Documentation that the license applicant and each adult household member have had a criminal history check as prescribed in R6-6-1101(B);

d. Documentation showing that the license applicant's home has passed:

i. A fire inspection as prescribed in R6-6-1111(E), and

ii. A health and safety inspection as prescribed in R6-6-1111(D).

e. Documentation that vehicles used for transporting individuals with developmental disabilities have passed a Division safety inspection to meet the safety requirements in R6-6-1112(B); and

f. Documentation that the CPS/APS Central Registry has been checked as prescribed in R6-6-1101(C).

Ariz. Admin. Code § R6-6-1104.03

Adopted effective February 1, 1998 (Supp. 98-1).