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 Modifications include the removal of outdated information to improve the sequencing of information and official form designation (DOH-5259) now referred to as the Statement of Administrator Qualifications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
 
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

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