Prevention. Promotion. Protection.

Assisted Living Downloads

ALL of the following items MUST BE COMPLETED AND INCLUDED in your application packet before being accepted by Assisted Living Licensing for review.

Please make copies for your records of all items before submitting.

  • Completed application form, signed and notarized
  • Application fee
  • List of Services Provided
  • Disaster Preparedness Plan
  • Emergency Evacuation Plan/Diagram
  • Staff Plan
  • Restraint Policy
  • If you have a private water supply, you must submit a water quality report completed by municipal authorities
  • If you have a private sewage system, you must submit documentation that the appropriate State or Municipal authorities have approved your waste system.
  • If planning to serve 6 or more consumers, you must also include copies of all permits or approvals required by State or local government agencies for assisted living homes including, but not limited to:
      • Fire Code Permit
      • Current Building Code Permit
      • Sanitation and Environmental Permit/Approval
      • Business License

Administrator & Designee Paperwork
(Each must have the following)

  • Name-Check Criminal Background Investigation from the State Troopers (for all persons living in the home age 16 and older)
  • Signed Sworn Statement indicating you have not been convicted of a crime listed in 7 AAC 75.215(b) (for all persons living in the home age 16 and over)
  • Submit fingerprint cards for State and FBI fingerprint background investigation check (for all persons living in the home age 16 and over).
  • Fingerprint processing fee per person: $59.00 check made out to Dept. of Public Safety
  • Three character references and two employment references (No Relatives)
  • Proof of current CPR certification
  • Proof of current First Aide certification
  • Proof of current negative TB test

Attendance at an Assisted Living Home Administration Orientation is MANDATORY. Orientations are held quarterly. If completed, please bring your application packet to Orientation. There will be specific time set aside at Orientation to review completed application packets. If you live outside of the Anchorage/Mat-Su area, please contact us to review Orientation options.

If you are mailing applications to the office, only completed application packets will be accepted. If packets are not complete, they will be mailed back. Please mail to the following address when complete:

Certification & Licensing
Assisted Living Licensing, Ste. 232
619 E. Ship Creek Ave
Anchorage, AK 99501

Once your application is reviewed and accepted, you will be contacted by a Licensing Inspector to schedule an appointment for a physical inspection of your home.

Applications

For your convenience, these downloads are available in MSWord and PDF formats. To download your free version of Abobe Acrobat, please click here.

 

Forms

 

Checklists

 

Examples

 

For more information, please contact us.