Review for an Assisted Living Facility



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Application for Plan Review
for an Assisted Living Facility


Form 3705

September 2014


Service Code

324200100



LTC Review Fees

1. Facility/Project Information

Facility Name

     

Physical Address — Street

City

State

ZIP

County

     

     

     

     

     

Facility/Project Contact Person

Contact Person’s Title

     

     

Facility/Project Contact Person’s Telephone Number

Fax Number

Internet Address

(     )      


(     )      

     

Mailing Address (if different from physical address) — Street or P.O. Box

City

State

ZIP

     

     

     

     

Project Cost Estimate

Is the facility to be completely fire sprinklered?

$      

 Yes  No

2. Applicant Information

Owner or Owner’s Contact Person

Title

Telephone Number

     

     

(     )      

Internet Address

Fax Number

     

(     )      

Address (if different than facility)

City


State

ZIP

     

     

     

     

Architect Firm

Telephone Number

     

(     )      

Name of Architect

Texas Registration Number

     

     

Project Manager

Title

     

     

Internet Address

Fax Number

     

(     )      

Mailing Address

City

State

ZIP

     

     

     


     

Engineering Firm

Telephone Number

     

(     )      

Name of Engineer

Texas Registration Number

     

     

Project Manager

Title

     

     

Internet Address

Fax Number

     

(     )      

Mailing Address

City

State

ZIP

     

     

     

     

3. Type of Application (check all that apply)

 Initial — New Construction  Initial — Relocation (New Construction)


No. of Beds:

     

(for fee purposes)

 Addition of Wing/Building/Area Describe:

     




Number of beds before project:

     




 Laundry  Kitchen  Living/Dining  Other:

     




Number of beds after project:

     




Other details/description:      

Have plans been previously submitted for this project? Yes  No

If Yes, when?

     




By whom?

     







4. Type of Facility (check all that apply)

 Type A Assisted Living Facility
 Small (16 beds or less)  Large (17 beds or more)

 Single-story
 Multi-story; Total no. of floors:


     

Alzheimer’s NOT applicable in Type A Assisted Living

 Type B Assisted Living Facility
 Small (16 beds or less)  Large (17 beds or more)


 Single-story
 Multi-story; Total no. of floors:


     

 Alzheimer’s Certified
Capacity:       beds


5. Fees

Fee Enclosed [see Texas Administrative Code (TAC), Title 40, Part 1, Ch. 92, §92.4(e)]

Remitter Name (who signed check)

Telephone Number

$      

Check Number:      

     

(     )      















































Instructions for Completing Form 3705

Application for Plan Review for an Assisted Living Facility

PROCEDURE

Complete this form to apply for optional plan review services for an assisted living facility.



Note: This application is for a plan review by the Texas Health and Human Services Commission (HHSC). A separate application is required for licensure. This plan review does not satisfy the requirements for a plan review by the Texas Department of Licensing and Regulation (TDLR) for accessibility.

Mail attached payment coupon with fee to:



Texas Health and Human Services Commission
Regulatory Services
P.O. Box 149055, Mail Code E-411
Austin, TX 78714-9055


Submit application and plans to:

Texas Health and Human Services Commission Phone: 512-438-2371
Long Term Care Regulatory Fax: 512-438-4623
Architectural Unit
Facility Enrollment, Mail Code E-250

701 West 51st Street

Austin, TX 78751


1. Facility/Project Information

  • Facility Name — Enter the full name of the facility.

  • Physical Address — Enter the address of the facility, including the city, state, ZIP code and county where the facility is physically located.

  • Facility/Project Contact Person — Full name of the person in charge of the building project.

  • Contact Person’s Title — Provide the facility/project contact person’s title.

  • Facility/Project Contact Person’s Telephone Number — Provide the telephone number, including area code.

  • Fax Number — Provide the facility/project contact person’s fax number, including area code.

  • Internet Address — Provide the Internet address or email address of the facility/project contact person.

  • Mailing Address — Provide the facility/project contact person’s mailing address, including city, state and ZIP code (if different from the physical address).

  • Project Cost Estimate — Provide the estimated cost of the project in dollars. (Note: Not required if unavailable.)

  • Is the facility to be completely fire sprinklered? — Check Yes or No.

2. Applicant Information

  • Owner or Owner’s Contact Person — Provide the full name of the owner’s representative.

  • Title — Provide the title of the owner’s representative.

  • Telephone Number — Provide the owner’s representative’s telephone number, including area code.

  • Internet Address — Provide the Internet address or email address of the owner’s representative.
  • Fax Number — Provide the owner’s representative’s fax number, including area code.


  • Address — Provide the address for the owner’s representative, including city, state and ZIP code (if different from the facility address).

  • Architect Firm — Provide the name of the firm or individual who produced the construction documents.

  • Telephone Number — Provide the architectural firm’s telephone number, including area code.

  • Name of Architect — Provide the full name of the architect whose seal is affixed to the drawings.

  • Texas Registration Number — Provide the architect’s registration number with the Texas Board of
    Architectural Examiners.

  • Project Manager — Provide the full name of the architectural project manager in charge of the project.

  • Title — Provide the architectural project manager’s title.

  • Internet Address — Provide the Internet address or email address of the architect in charge of the project.

  • Fax Number — Provide the architect’s fax number, including area code.

  • Mailing Address — Provide the mailing address, including city, state and ZIP code of the architect in charge of
    the project.

  • Engineering Firm — Provide the full name of the firm or individual who produced the construction documents.

Form 3705Instructions
Page 2/09-2014

  • Telephone Number — Provide the engineering firm’s telephone number, including area code.

  • Name of Engineer — Provide the full name of the engineer whose seal is affixed to the drawings.
  • Texas Registration Number — Provide the engineer’s Texas registration number with the Texas Board of Professional Engineers.


  • Project Manager — Provide the full name of the engineering project manager in charge of the project.

  • Title — Provide the engineering project manager’s title.

  • Internet Address — Provide the Internet address or email address of the engineer in charge of the project.

  • Fax Number — Provide the engineer’s fax number, including area code.

  • Mailing Address — Provide the mailing address, including city, state and ZIP code, of the engineer in charge of
    the project.

3. Type of Application

  • Check the appropriate boxes for the type of application being submitted.

  • “Initial” means new facility or the conversion of an existing building into a licensed facility.

  • “Initial — Relocation” means relocating an existing licensed facility.

  • “Addition of Wing/Building/Area” means making an addition to a licensed facility.

  • Provide a one-sentence description of the addition.

  • “Laundry” means construction of a new laundry or renovation of or addition to an existing laundry in a
    licensed facility.

  • “Kitchen” means construction of a new kitchen or renovation of or addition to an existing kitchen in a
    licensed facility.

  • “Living/Dining” means construction of new living or dining space or renovation of or addition to an existing dining or living space in a licensed facility.

  • Check the box for Other and enter a brief description of other items included in the project.

  • No. of Beds — Provide the number of proposed beds for this project (for calculation of the plan review fee).
  • Number of beds before project — Provide the licensed capacity (number of beds) before this project.


  • Number of beds after project — Provide the proposed licensed capacity (number of beds) after this project.

  • Have plans been previously submitted for this project? — Check Yes or No.

  • If Yes, provide the date of last submittal and the remitter’s name.

4. Type of Facility

  • Check the appropriate box for Type A or B facility.

  • Check the box for small or large facility.

  • Check the box for single-story or multi-story.

  • If multi-story, indicate the number of floors.

  • Indicate if an application has been made for Alzheimer’s certification.

  • Indicate the number of Alzheimer’s certified beds.

5. Fees

  • Compute the fee from 40 TAC §92.4(e) based on whether the facility is Type A or B, small or large, single-story or multi-story, and add the Alzheimer’s certification fee if applicable.

  • Check Number — Provide the check number from the fee check.

  • Remitter Name — Provide the full name of the person whose signature is on the fee check.

  • Telephone Number — Provide the remitter’s telephone number, including area code.



Form 3705 — Instructions
Page 3/09-2014

§92.4(e) License Fees

Facility Type


New or Conversion: Single-story

New or Conversion: Multiple-story

Addition or Remodeling

Alzheimer's Certification

Small

Type A

(4 to 16 beds based on

residential board and care

occupancy of the Life

Safety Code, Chapter
21-2 Slow)


$900

$1,100

2% of
construction cost

Minimum: $350

Maximum: 50% of

the plan review fee

for a new facility of

the same type



Not applicable

Large

Type A

(17 or more beds based on

residential board and care

of the Life Safety Code,

Chapter 21-3)


17-80 beds:

$1,100


17-80 beds:

$1,650


2% of

construction cost

Minimum: $400

Maximum: 50% of

the plan review fee

for a new facility of

the same type


Not applicable

81-120 beds:

$1,650


81-120 beds:

$2,150


121+ beds:

$14 per bed



121+ beds:

$18 per bed



Small

Type B

(4 to 16 beds based on

residential board and care

occupancy of the Life

Safety Code, Chapter
21-2 Impractical)


$1,100

$1,650

2% of
construction cost

Minimum: $350

Maximum: 50% of

the plan review fee

for a new facility of

the same type



$350

additional fee




Large

Type B

(17 or more beds based on

the health care occupancy

of the Life Safety Code,

Chapter 12)


17-80 beds:

$1,600

17-80 beds:

$2,100


2% of
construction cost

Minimum: $500

Maximum: 50% of

the plan review fee

for a new facility of

the same type



$550

additional fee



81-120 beds:

$2,150


81-120 beds:

$2,650


121+ beds:

$18 per bed



121+ beds:

$22 per bed










Payment Coupon for Facility Enrollment
Plan Review (324200100)


Facility Name and Address

     

     

     

     

     


Print Remitter’s Name (person signing check):

     

Make check or money order payable to:

Texas Health and Human Services Commission

Attach check or money order to this coupon and return to:

Texas Health and Human Services Commission
Regulatory Services
P.O. Box 149055, Mail Code E-411
Austin, TX 78714-9055



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