S.D. Admin. R. tit. 44, art. 44:23, ch. 44:23:01, app A
RESIDENTIAL LIVING CENTER
REGISTRATION FORM
SDCL 34-12-32 and ARSD chapter 44:23:01 require a residential living center which provides residential services to two or more elderly or disabled persons to register annually with the state department of health. The undersigned hereby registers the residential living center described on this form.
Name of Center __________________________________________________________________________
Address ________________________________________________________________________________
(Street)
(City) (Zip Code)
Mailing Address (if different)_______________________________________________________________
County__________________________________________________ Telephone______________________
Owner(s) Name __________________________________________________________________________
Owner(s) Address ________________________________________________________________________
Operator(s) Name (if other than owner) _______________________________________________________
Check below the one which applies:
[] Sole Proprietorship ? Partnership
[] Not-for-profit corporation ? For-profit corporation
[] Political Subdivision ? Other ______________
Number of residential units in the Center: ______________________________________________
Resident capacity of the Center: ______________________________________________________
Number of residents currently residing in the Center: _____________________________________
Number of residents disabled: _______________________________________________________
Number of residents elderly: ________________________________________________________
Residential services offered or furnished (Check all that apply):
[] Room
[] Meals
[] Assistance with eating, bathing, and dressing
[] Assistance with personal and household chores
[] Organized social and recreational activities
[] Transportation services
[] Assistance with the self-administration of medications
[] Monitoring of nutrition or health
[] Protective supervision
[] Other_________________________________________________________
[] Other_________________________________________________________
I verify the information contained in this registration form is true and complete.
Signed___________________________________________________________ ____________________
Owner, operator, or other individual authorized to act on behalf of center Date
Submit on or before April 15, 1992, and January 1 every year thereafter to:
South Dakota Department of Health
Licensure and Certification Program
523 East Capitol Avenue
Pierre, SD 57501-3182
(form issued 3-92)
S.D. Admin. R. tit. 44, art. 44:23, ch. 44:23:01, app A