Texas Department of Aging and Disability Services

Form 3681-A October 2012

Assisted Living/Residential Care (AL/RC), Out-of-Home Respite (OHR) and Adult Foster Care (AFC)

Community Services Contract Application Addendum A

1. Legal Name of Entity 3. Facility Physical Address (Street, City, State, ZIP) 4. Assisted Living Facility License No. 6. Licensed Capacity 5. Size of Assisted Living Facility (check one) 2. Doing Business As (DBA), if applicable

Small (16 or fewer beds)

7. Nursing Facility License No.

Large (17 or more beds) A

Other (specify): B C

8. Type of Assisted Living Facility License (check one)

I. Assisted Living/Residential Care Non-Apartment

Check the program(s) and enter the number of beds you wish to offer for each program.

Program Community Care for Aged and Disabled (CCAD) Community Based Alternatives (CBA) Community Based Alternatives Out-of-Home Respite (CBA-OHR)

No. of Beds

II. Assisted Living/Residential Care Personal Care 3

Check the program(s) and enter the number of beds you wish to offer for each program.

Program Community Based Alternatives (CBA)

No. of Beds

III. Assisted Living/Residential Care Assisted Living Apartment

1. Check the program(s) and enter the number of beds you wish to offer for each program. 2. Complete the Square Footage Calculation for Assisted Living Apartments table in this section.

Program Community Based Alternatives (CBA) Community Based Alternatives Out-of-Home Respite (CBA-OHR)

No. of Beds

Form 3681-A Page 2 / 10-2012 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable

III. Assisted Living/Residential Care Assisted Living Apartment (continued)

Square Footage Calculation for Assisted Living Apartments A. Identifying Information Apt. No. Address B. Private Space Area C. Area Width D. Area Length E. Private Space Square Footage (C x D)

1. Living 2. Bedroom

Program

CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage

(Sum E1-E4) E. Private Space Square Footage (C x D)

A. Identifying Information Apt. No. Address

B. Private Space Area

C. Area Width

D. Area Length

1. Living 2. Bedroom

Program

CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage

(Sum E1-E4) E. Private Space Square Footage (C x D)

A. Identifying Information Apt. No. Address

B. Private Space Area

C. Area Width

D. Area Length

1. Living 2. Bedroom

Program

CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage

(Sum E1-E4) E. Private Space Square Footage (C x D)

A. Identifying Information Apt. No. Address

B. Private Space Area

C. Area Width

D. Area Length

1. Living 2. Bedroom

Program

CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage

(Sum E1-E4)

Form 3681-A Page 3 / 10-2012 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable

IV. Assisted Living/Residential Care Residential Care Apartment

Check the program(s) and enter the number of beds you wish to offer for each program.

Program Community Care for Aged and Disabled (CCAD) Community Based Alternatives (CBA) Community Based Alternatives Out-of-Home Respite (CBA-OHR)

No. of Beds

Square Footage Calculation for Residential Care Apartments A. Identifying Information Apt. No. Address B. Private Space Area C. Area Width D. Area Length E. Private Space Square Footage (C x D)

1. Bedroom 2. Bathroom

Program

CCAD CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage (Sum E1-E4) G. Private Space Square Footage per Resident (F 2) H. Allocated Common Area Square Footage (See footnote below.) I. Total Square Footage per Resident (G + H)
E. Private Space Square Footage (C x D)

A. Identifying Information Apt. No. Address

B. Private Space Area

C. Area Width

D. Area Length

1. Bedroom 2. Bathroom

Program

CCAD CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage (Sum E1-E4) G. Private Space Square Footage per Resident (F 2) H. Allocated Common Area Square Footage (See footnote below.) I. Total Square Footage per Resident (G + H)
Footnote: If the private space square footage per resident (G) is less than 350 square feet, complete the Allocated Common Area Calculation table in this section and enter the result here.

Form 3681-A Page 4 / 10-2012 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable

IV. Assisted Living/Residential Care Residential Care Apartment (continued)

Square Footage Calculation for Residential Care Apartments A. Identifying Information Apt. No. Address B. Private Space Area C. Area Width D. Area Length E. Private Space Square Footage (C x D)

1. Bedroom 2. Bathroom

Program

CCAD CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage (Sum E1-E4) G. Private Space Square Footage per Resident (F 2) H. Allocated Common Area Square Footage (See footnote below.) I. Total Square Footage per Resident (G + H)
E. Private Space Square Footage (C x D)

A. Identifying Information Apt. No. Address

B. Private Space Area

C. Area Width

D. Area Length

1. Bedroom 2. Bathroom

Program

CCAD CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage (Sum E1-E4) G. Private Space Square Footage per Resident (F 2) H. Allocated Common Area Square Footage (See footnote below.) I. Total Square Footage per Resident (G + H)
E. Private Space Square Footage (C x D)

A. Identifying Information Apt. No. Address

B. Private Space Area

C. Area Width

D. Area Length

1. Bedroom 2. Bathroom

Program

CCAD CBA

CBA-OHR

3. Kitchen 4. Storage
(within private space area)

F. Total Private Space Square Footage (Sum E1-E4) G. Private Space Square Footage per Resident (F 2) H. Allocated Common Area Square Footage (See footnote below.) I. Total Square Footage per Resident (G + H)
Footnote: If the private space square footage per resident (G) is less than 350 square feet, complete the Allocated Common Area Calculation table in this section and enter the result here.

Form 3681-A Page 5 / 10-2012 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable

IV. Assisted Living/Residential Care Residential Care Apartment (continued) Allocated Common Area Calculation
Address D. Area Square Feet (BxC)

A. Useable Area Description

B. Area Width

C. Area Length

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. E. Useable Common Area Square Footage (Sum of D 1-10) F. Licensed Capacity G. Allocated Common Area Square Footage per Resident (C+F)

Form 3681-A Page 6 / 10-2012 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable

V. Adult Foster Care

Check the program(s) and enter the number of beds you wish to offer for each program.

Program Community Care for Aged and Disabled (CCAD) Community Based Alternatives (CBA) Community Based Alternatives Out-of-Home Respite (CBA-OHR)

AFC Level (I, II or III) N/A

No. of Beds

Square Footage Calculation for AFC Bedrooms

A. Bedroom No. and Occupancy B. Program C. Bedroom Width D. Bedroom Length E. Bedroom Square Feet (CxD)

Bedroom No. Single (80 sq. ft) Double (120 sq. ft) Bedroom No. Single (80 sq. ft) Double (120 sq. ft) Bedroom No. Single (80 sq. ft) Double (120 sq. ft) Bedroom No. Single (80 sq. ft) Double (120 sq. ft) Bedroom No. Single (80 sq. ft) Double (120 sq. ft) Bedroom No. Single (80 sq. ft) Double (120 sq. ft) Bedroom No. Single (80 sq. ft) Double (120 sq. ft)

CCAD CBA

CBA-OHR

CCAD CBA

CBA-OHR

CCAD CBA

CBA-OHR

CCAD CBA

CBA-OHR

CCAD CBA

CBA-OHR

CCAD CBA

CBA-OHR

CCAD CBA

CBA-OHR

Form 3681-A Page 7 / 10-2012 1. Legal Name of Entity 2. Doing Business As (DBA), if applicable

VI. Other Out-of-Home Respite

Check the program(s)/setting(s) you wish to offer.

CBA Out-of-Home Respite Nursing Facility

VII. Certification I certify that all information provided in this application is true and correct. If applicable, I also certify that the bedrooms(s)/apartment(s) documented above have previously been approved under a DADS contract and were removed from a DADS contract on (enter date). I further certify that the bedroom(s)/apartment(s) have not been modified since they were under a DADS contract.

SignatureAuthorized Person Name of Authorized Person (please print or type) Title of Authorized Person (please print or type)

Date