Adult Care Facility and Assisted Living Common Application

The Bureau of Licensure and Certification is responsible for the review and consideration of all requests to obtain licensure and certification of adult care facilities throughout New York State (NYS). The application review process involves assessment of several components involving the applicant's legal, financial and character and competence standing. Details of the proposed project (i.e., new construction or renovation of a currently licensed facility) are also considered. The Bureau works closely with the appropriate Regional Office to ensure that the proposed operator/applicant has the capacity to provide the necessary care and services in a safe and healthy environment to residents of NYS. New or revised Operating Certificates are issued to applicants whose projects have been approved by the Bureau. Operating Certificates are renewed periodically as scheduled.

Adult Care Facility Common Application

• Schedule 1 – General Information (PDF)
• Schedule 2 – Personal Qualifying Information (PDF)
• Schedule 3 – Legal Information (PDF)
• Schedule 4 – Financial Information (PDF)
• Schedule 5 – Architectural Information (PDF)
• Schedule 6 – Program Information (Regional Office) (PDF)
• Schedule 7A – Limited Change of Ownership Notice (PDF)
• Schedule 7B – ACF Notification of Business Conversion (PDF)
• Schedule 7C – Bed Capacity Increase (PDF)
• Schedule 7D – Application to Operate a Day Program for Non-Residents (PDF)
• Schedule 7E – Decertification of Bed Capacity (PDF)
• Schedule 8 – Request for Approval of Operator in Good Standing (PDF)

Model Residency Agreements

• Adult Home Residency Agreement Checklist (DOCX)
• Enriched Housing Program Residency Agreement Checklist (DOCX)
• Adult Home Model Admission Agreement (PDF)
• Enriched Housing Program Model Admission Agreement (PDF)
• Assisted Living Program Addendum to Admission Agreement (PDF)
• Enriched Housing Program Model Residency Agreement (PDF)
• Special Needs Assisted Living Residence Model Addendum (PDF)
• Enhanced Assisted Living Residence Model Addendum (PDF)
• Adult Home Model Residency Agreement (PDF)

Additional Information

• Adult Care Facility Operating Certificate Renewal Process (PDF)
• Notification to Operate a Temporary Residential Services/Respite Program (DOH-5241) (PDF)
  • Model Temporary Residential Care Addendum to Admission/Residency Agreement (PDF)
• Adult Care Facility New York State Electronic Certificate of Need Companion Guide (PDF)
• Architectural Submission Guide (PDF)
• Questions and Answers Adult Care Facility Common Application
• Training Power Point (PDF)
• Special Needs Assisted Living Plan Overview and Requirements (PDF)