DAL 18-03: Statement of Administrator Qualifications for Adult Care Facilities
February 23, 2018
DAL 18-03 Statement of Administrator Qualifications for Adult Care Facilities
Dear Administrator:
The purpose of this letter is to inform Adult Care Facility Operators that the Department of Health Statement of Administrator Qualifications – for Adult Residential Care Facilities (DSS-3233) has been revised. Modifications include the removal of outdated information to improve the sequencing of information and official form designation (DOH-5259) now referred to as the Statement of Administrator Qualifications for Adult Care Facilities.
The DOH-5259 form is available as an attachment to this letter and is posted on the Department of Health's website under ACF forms at the following link: https://www.health.ny.gov/facilities/adult_care/forms.htm
Please be reminded that the Statement of Administrator Qualifications for Adult Care Facilities (DOH-5259) must be completed in its entirety, and submitted to your Regional Office for approval prior to appointing an Adult Home Administrator.
Patricia Hasan Capital District Regional Office 875 Central Avenue Albany, NY 12206 (518) 408-5287 |
John VanDyke Central New York Regional Office 217 South Salina Street, 4th floor Syracuse, NY 13202 (315) 477-8472 |
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Bobbie Barrington Metropolitan Area Regional Office 90 Church Street, 15th Floor New York, NY 10007 (212) 417-4440 |
Norine Nickason Western Regional Office 335 East Main Street, 1st Floor Rochester, NY 14604 (585) 423-8185 |
If you have any questions regarding the DOH-5259 form, please contact my office at (518) 408-1133 for further clarification.
Sincerely,
Valerie A. Deetz,
Director
Division of ACF/Assisted Living Surveillance
cc:
B. Barringon
P. Hasan
N. Nickason
J. Pinto
J. Van Dyke