ࡱ> HJEFG@ u/bjbj (cuu*CF$\l\l\lPlmE:pBs(jsjsjsu5w<qxC>ҩf$RѲuyt"uyyjsjs|||y^jsjs|y||iPIjsp 0 h\loyj~D0E7UyU$IUIl|yyyBGd$|"GSTATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS APPLICATION FOR A CONTINUING CARE RETIREMENT COMMUNITY LICENSE (FIRST-TIME (FINAL) APPLICANT) S.C. Code Ann. 37-11-10 through 37-11-140 (Supp. 1997) Date submitted: FORMTEXT      1.Name of Facility FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      City/State/Zip FORMTEXT      Telephone No. FORMTEXT      Fax No. FORMTEXT      2.Name of Operator FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      Telephone No. FORMTEXT      Fax No. FORMTEXT      3.The operator is Partnership FORMCHECKBOX Limited Partnership FORMCHECKBOX (Check One)Corporation FORMCHECKBOX Other FORMCHECKBOX Specify:  FORMTEXT      4.Chief Executive Officer FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      City/State/Zip FORMTEXT      Telephone No. FORMTEXT      Fax No. FORMTEXT      5.Name of affiliated parent or subsidiary corporation or partnership  FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      Telephone No. FORMTEXT      Fax No. FORMTEXT      6.Owner s Name (Indicate if individual, partnership, corporation, unincorporated association, etc.)  FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      Telephone No. FORMTEXT      Fax No. FORMTEXT      7.Name of person to contact in case of inquiries  FORMTEXT      Position within facility FORMTEXT      Street Address FORMTEXT      Mailing Address FORMTEXT      Telephone No. FORMTEXT      Fax No. FORMTEXT       PLEASE NOTE:ALL EXHIBITS LISTED BELOW MUST BE ATTACHED. IF THE EXHIBIT(S) ARE NOT APPLICABLE OR AVAILABLE, ATTACH AN EXPLANATION IN PLACE OF THE REQUIRED EXHIBIT (S) STATING THE REASON (S) THEY ARE NOT APPLICABLE OR AVAILABLE.8a.(Attach as Exhibit A-1) Names, addresses and telephone and fax numbers of partners or members if the operator is a partnership or other unincorporated association.8b.(Attach as Exhibit A-2) Names, addresses and telephone and fax numbers of stockholders holding at least a five percent interest if the operator is a corporation.8c.(Attach as Exhibit B) Names, addresses, and telephone numbers of the officers, directors, trustees, managing or general partners, any person having a five percent or greater equity or beneficial interest in the continuing care retirement community, and any person who is or will be managing the facility daily, and a description of this persons interests in or occupations with the operator.8d.With respect to any person in items 1, 2, 4, 6, 8 (a), 8 (b) and 8 (c) please provide:i. (Attach as Exhibit C-1) A description of the business experience of the person, if any, in the operation or management of similar facilities;ii. (Attach as Exhibit C-2) The name and address of any professional service firm, association, trust, partnership, or corporation in which this person has, or which has in this person, a five percent or greater interest and is providing or in the future shall provide goods, leases, or services to the facility or to residents of the facility, of an aggregate value of $5,000 within any year, including a description of the goods, leases, or services and their probable or anticipated cost to the facility, operator, or residents, or a statement that this cost presently cannot be estimated;iii. (Attach as Exhibit C-3) A description of any matter in which the person has been convicted of a felony or pleaded nolo contendere to a felony charge, or held liable or enjoined in a civil action by final judgment, if the felony or civil action involved fraud, embezzlement, fraudulent conversion, or misappropriation of property, or is subject to a currently effective injunctive or restrictive court order or within the past five years, had a state or federal license or permit suspended or revoked as a result of an action brought by a governmental agency or department.9.(Attach as Exhibit D) A copy of any current document as it pertains to the legal organization of the operator, such as copies of articles of incorporation, with all amendments thereto, if the operator is a corporation; copies of all instruments by which the trust is declared if the operator is a trust; copies of articles of partnership or association and all other organization papers if the operator is organized under another form. In the event the operator is not the legal title holder to this property upon which the facility is or is to be constructed, the above documents shall be submitted for both the operator and the legal title holder.10.(Attach as Exhibit E) An organizational chart describing the relationship between the applicant and its affiliates, indicating the state of domicile of the entity and the primary business of each.11.(Attach as Exhibit F-1) A statement concerning any litigation, orders, judgments or decrees which might affect the facility.12.(Attach as Exhibit F-2) A statement concerning any adjudication of bankruptcy during the last five years against the operator, its predecessor, parent or subsidiary company and any principal owning more than five percent of the interests in the facility at the time of the filing of this application. (NOTE: This requirement does not extend to limited partners or those whose interests are solely those of investor.)13.(Attach as Exhibit G) A statement as to the operators affiliation with a religious, charitable, or other nonprofit organization, the extent of the affiliation, if any, the extent to which the affiliate organization is responsible for the financial and contractual obligations of the operator, and the provision of the Federal Internal Revenue Code, if any, under which the operator or affiliate is exempt from the payment of income tax.14.(Attach as Exhibit H) Documents pertaining to the location and description of the physical property of the facility, existing or proposed, and to the extent proposed, the estimated completion date, whether construction has begun, and the contingencies subject to which construction may be deferred.15.(Attach as Exhibit I) A statement as to the health and financial conditions required for a person to be accepted as a resident and to continue as a resident once accepted, including the effect of a change in the health or financial condition of a person between the date of entering a contract for continuing care and the date or initial occupancy of a living unit by that person.16.(Attach as Exhibit J) A copy of your current and/or proposed continuing care contract(s) and any current and/or proposed binding reservation agreement for the furnishing of continuing care or for taking reservations for continuing care. Please submit both your current contract and the proposed contract conforming to R.28-600 N. If, in your opinion, you will not be able to submit a copy of your proposed contract at the time you will be filing the application with the Department, please notify the Department as soon as possible of the anticipated delay and the reasons for such delay.17.(Attach as Exhibit K) Description of the services provided or proposed to be provided pursuant to contracts for continuing care at the facility, including the extent to which medical care is furnished, and a clear statement of which services are included for specified basic fees for continuing care and which services are made available at or by the facility at extra charge.18.(Attach as Exhibit L) A description of all fees required of resident, including the entrance fee and/or periodic charges, if any. The description must include:a.(Attach as Exhibit L-1) A statement of the fees charged if the resident marries while at the facility and a statement of the terms concerning the entry of a spouse to the facility and the consequences if the spouse does not meet the requirements for entry;b.(Attach as Exhibit L-2) A statement as to the circumstances under which the resident is permitted to remain in the facility if he has financial difficulties;c.(Attach as Exhibit L-3) A description of the terms and conditions under which a contract for continuing care at the facility may be canceled by the operator or by the resident, and the conditions, if any, under which all or a portion of the entrance fee is refunded if the contract is canceled by the operator or by the resident or if the resident dies before or following occupancy of a living unit;d.(Attach as Exhibit L-4) A description of the conditions under which a living unit occupied by a resident may be made available by the facility to a different or new resident;e.(Attach as Exhibit L-5) A description of the manner by which the operator may adjust periodic charges or other recurring fees and the limitations on these adjustments, if any. If the facility is already in operation or if the operator or manager operates one or more similar continuing care locations in this State, tables must be included showing the frequency and average dollar amount of each increase in periodic charges, or other recurring fees at each facility or location for the previous five years, or for all of the years in operation if less than five years. (See Section 37-11-30(B)(6)(e).)19.(Attach as Exhibit M) Anticipated and/or actual number of residents of your facility that are or will be provided services pursuant to a continuing care contract. The number of living units constructed and the current number of residents of the facility that are provided services by the operator pursuant to the contract for continuing care; the number of reservation agreements and/or the number of people on the waiting list; and, if applicable, a current occupancy status of a nursing home, community residential care facility or a similar facility or accommodation.20.(Attach as Exhibit N) A statement as to whether your facility has a complaint system to resolve complaint by residents. If the facility has a complaint system, please attach the description of the system. If the facility has presently no complaint system, please attach the description of the proposed system. Please consult Section 37-11-60 of the State Continuing Care Retirement Community Act and regulation R.28-600 Y as to the minimum standards for the complaint system. (NOTE: Pursuant to R.28-600 E (2)(f), a complaint system must be in effect prior to issuance of an interim license.)21.(Attach as Exhibit O) A copy your current or proposed entrance fee escrow agreement, if applicable. Please consult SC Code Ann. 37-11-90 and SC Code Regs. 28-600 R.22.(Attach as Exhibit P) A copy of a reservation agreement if the operator is taking reservations for continuing care; and a copy of the escrow agreement for such deposits.23.(Attach as Exhibit Q) A representative sample of advertisement for your facility.24.(Attach as Exhibit R) A copy of all necessary permits, licenses and certifications received or applied for and their status at the time the application is submitted to the Department. This includes copies of any DHEC licenses the applicant holds or a list of licenses applied for together with the brief description of nursing, medical or other health related facilities or services you operate or provide to your residents. Please state specifically whether the DHEC licenses you have are community based or restricted.25.(Attach as Exhibit S) A copy of any agreements with the providers for the provision of nursing care, health care, or other health-related services.26.(Attach as Exhibit T) A statement as to whether or not your facility or any component thereof is eligible for Medicare and/or Medicaid. In case the facility is not eligible for Medicare and/or Medicaid, insert also the following statement in your disclosure statement: This facility is currently not eligible for Medicare and Medicaid (insert whichever is applicable). In case a resident exhausts his available financial resources prior to or following admission into our nursing home or assisted living accommodations, the resident might have no choice but to apply for admission to a facility that is eligible for these payments. (In case you currently have a discretionary fund to assist residents who deplete their financial resources, please add the following paragraph:) The discretionary funds available to the management may be used to supplement the entire cost of care or a part of it. However, the application of these funds is entirely within the discretion of the management and the presence of these funds is no guarantee for a continuing stay in this facility following the depletion of your own financial resources.27.(Attach as Exhibit U) A copy of any residents guide, policy manual, or other material of similar application. (NOTE: Should these materials be too bulky, you may submit them under separate cover.)28.(Attach as Exhibit V) An affidavit by the person who prepared the original feasibility study that there has been no material adverse change in status with regard to the feasibility study, such statement generally dated not more than 12 months from the date of filing the application for a final license. Should a material adverse change exist at the time of the submission, then sufficient information acceptable to the Department and the feasibility consultant shall be submitted together with the proposed remedy;29.(Attach as Exhibit W) If instead of a feasibility study a substitute was submitted with an application for a preliminary license, then the feasibility study and the opinion letter shall be submitted with an application for a final license. However, operators of proposed facilities that are not planned to exceed 25 units and that will not collect entrance fees, do not have to submit a feasibility study with the application.30.(Attach as Exhibit X) Proof that the applicant has received written commitments for construction financing and for permanent long-term financing when the construction has been completed.31.(Attach as Exhibit Y) A statement concerning the anticipated role of any publicly funded benefit or insurance program in the financing of care.32.(ATTACH IN A SEPARATE BINDER) A copy of a disclosure statement conforming in all respects to Section 37-11-60 and regulation R.28-600 O. This Exhibit shall be accompanied by an affidavit by the operator that prospective residents will or are receiving this disclosure statement.33.(ATTACH IN SEPARATE BINDERS)a.Two (2) certified financial statements of the operator. 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PLEASE NOTE:IF THE FISCAL YEAR ENDED MORE THAN ONE HUNDRED TWENTY DAYS BEFORE THE DATE OF FILING, PLEASE SUBMIT YOUR PREVIOUS CERTIFIED FINANCIAL STATEMENT TOGETHER WITH AN UNCERTIFIED STATEMENT FROM THE PERIOD BETWEEN THE DATE THE FISCAL YEAR ENDED AND A DATE NOT MORE THAN NINETY DAYS BEFORE THE DATE THE APPLICATION IS FILED.b.A projected annual budget of the facility for one year.c.If the facility had in the past two years a feasibility study made, please submit a copy of the study.d.A statement of financial responsibility as required in Section 28-600 S of the State Continuing Care Retirement Community Act. 34.A check for $2000 made payable to the South Carolina Department of Consumer Affairs.35.Any additional information that you may think is material, may be attached and labeled as Addendum 1, 2, etc.36.The undersigned attest that the information submitted herein is true and accurate. ____________________________________ Signature ____________________________________ Title ____________________________________ Signature ____________________________________ Title SWORN AND SUBSCRIBED to before me this ______ day of ____________, ______. ___________________________________ Notary Public for _____________________ My Commission Expires: _______________ PLEASE NOTE: THE APPLICATION FORM SHALL BE SIGNED BY THE CHIEF EXECUTIVE OFFICER OF THE FACILITY AND BY THE PERSON WHO PREPARED THE APPLICATION. PLEASE READ VERY CAREFULLY REGULATION R.28-600 I (ALL LICENSE APPLICATIONS, FORM) APPLICATIONS NOT FOLLOWING THE GUIDELINES OF THE REGULATION SHALL BE RETURNED TO THE OPERATOR. 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