DAL 14-05: Revised ACF DSS Forms: 934, 2853, 2854, 2855 and 3027

July 18, 2014

DAL: DAL 14-05

SUBJECT: Revised ACF DSS Forms: 934, 2853, 2854, 2855 and 3027

Dear Administrator:

The purpose of this letter is to inform you that several Adult Care Facility Department of Social Services (DSS) Forms related to Adult Care Facilities (ACF) were revised to eliminate content that is no longer applicable, to standardize information contained in the forms and improve their overall appearance. The forms are referenced in the ACF regulations and therefore must continue to be identified as DSS forms. The following revised forms are attached:

  • DSS 934: Notice of Change Enriched Housing Apartment Certification for Residents Receiving Social Security Income (SSI). Corrected address to which forms are to be mailed. Eliminated sponsor type, county name, county code, capacity on operating certificate and number of residents being served.
  • DSS 2853: Statement Offering Personal Allowance Account. Eliminated reference to Home Relief (HR) recipients and replaced with current statutory language reflective of Safety Net Assistance (SNA) recipients. Additionally, included facility name and operating certificate number.
  • DSS 2854: Personal Allowance Ledger. Eliminated request for Social Security Number, clarified column titles and included facility name and operating certificate number.
  • DSS 2855: Personal Monthly Allowance Summary. Clarified column titles and included facility name and operating certificate number.
  • DSS 3027: Inventory of Resident Property. Changed orientation of document from portrait to landscape, included facility name, operating certificate number, the date items were returned to resident and provided column for resident initials.

The Division of ACF/Assisted Living Surveillance will continue to review and update existing forms and notify you of changes. If you have questions regarding the revised forms, please contact the Division of ACF/Assisted Living Surveillance at (518) 408-1133 for further clarification.

Sincerely,

Valerie A. Deetz, Director
Division of ACF and Assisted Living Surveillance

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