NAC435.515. Provisional certificate: Submission and contents of application.

An application for a provisional certificate must be submitted to the Division and to each regional center in which the applicant wishes to provide supported living arrangement services, on a form furnished by the Division, and must include, without limitation:

     1. For a provider of supported living arrangement services who is a natural person:

     (a) Three or more letters of reference;

     (b) A statement which is signed by the provider and which states that the provider agrees to maintain the confidentiality of any person who receives supported living arrangement services;

     (c) Proof that the applicant has successfully completed a course in cardiopulmonary resuscitation according to the guidelines of the American Red Cross or American Heart Association;

     (d) Proof that the applicant is currently certified in standard first aid through a course from:

          (1) The American Red Cross;

          (2) The American Heart Association; or

          (3) An equivalent course in standard first aid, if the applicant submits proof that such course meets or exceeds the requirements of the American Red Cross or the American Heart Association;

     (e) Written verification, on a form prescribed by the Division, stating that the fingerprints of the applicant were taken and directly forwarded electronically or by another means to the Central Repository for Nevada Records of Criminal History and that the applicant has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation for a report on the applicant’s background and to such other law enforcement agencies as the Division deems necessary;

     (f) A copy of the social security card of the applicant;

     (g) Proof that the applicant has sufficient working capital to ensure that the applicant would be financially capable of providing supported living arrangement services for a period of at least 3 months; and

     (h) Any other information required by the Division.

     2. For a provider of supported living arrangement services that is an organization consisting of a partnership, firm, corporation, association, state or local government or agency thereof:

     (a) A copy of the business license of the organization;

     (b) A copy of the bylaws, articles of incorporation, articles of association, articles of organization, partnership agreement, constitution and any other substantially equivalent documents of the organization, and any amendments thereto;

     (c) A list of the members of the governing body of the organization;

     (d) If the applicant is an association or a corporation:

          (1) The name, title and principal business address of each officer and member of its governing body;

          (2) The signature of the chief executive officer or an authorized representative; and

          (3) If the applicant is a corporation, the name and address of each person holding more than 10 percent of its stock;

     (e) Proof that at least one supervisor, administrator or manager of the provider satisfies the same or similar criteria of a qualified mental retardation professional set forth in 42 C.F.R. § 483.430;

     (f) For each member of the governing body:

          (1) Three or more letters of reference; and

          (2) Written verification, on a form prescribed by the Division, stating that the fingerprints of the member of the governing body were taken and directly forwarded electronically or by another means to the Central Repository for Nevada Records of Criminal History and that the member of the governing body has given written permission to the law enforcement agency or other authorized entity taking the fingerprints to submit the fingerprints to the Central Repository for submission to the Federal Bureau of Investigation for a report on the member’s background and to such other law enforcement agencies as the Division deems necessary;

     (g) Proof that the applicant has sufficient working capital to ensure that the provider is financially capable of providing supported living arrangement services for a period of at least 3 months;

     (h) Copies of any policies and procedures of the organization relating to the provision of supported living arrangement services; and

     (i) Such other information as may be required by the Division.

     [Men. Hygiene & Men. Retardation Div., Residences § 4 subsecs. 1 & 2, eff. 2-5-82]—(NAC A by Div. of Men. Health & Dev. Services by R071-06, 11-13-2006)