HomeMy WebLinkAboutCBRF Identification of Hazards Request - 10/17/08L-EPARTMENT OF HEALTH AND FAMILY SERVICES
Division of Disability and Elder Services
DDE-290 (Rev. 6-04)
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STATE OF WISCONSIN
CBRF IDENTIFICATION OF HAZARDS REQUEST
This is a request for identification and description of the type and extent of any specific hazards that may affect the health and safety of
the residents of a proposed Community Living Arrangement. This request is being made in compliance with s. 50.03(4)(a)(3), Wis
Stats, for Community Based Residential Facilities (CBRF) which states that:
The Department (of Health and Family Services) shall request that the Planning Commission or Agency send to the Department within
30 days a description of any specific hazards which may affect the health and safety of the residents of the Community Based
Residential Facility. No license may be granted to a Community Based Residential Facility until the 30-day period has expired or until
the Department receives the response of the Planning Commission or Agency, whichever is sooner.
Receipt of this form also serves as notification that a Community Living Arrangement, as defined in s. 46.03(22), Wis Stats, is being
proposed in your community. Completion of this form is not mandatory. Return this form to the address on the accompanying letter.
Name -Planning Commission or Agency Date Sent
CITY OF OSHKOSH 10/3/08
r~uuiwa
215 CHURCH AVENUE, PO BOX 1130
City, State, Zip Code
OSHKOSH, WI 54903
Name -Proposed CBRF
BELLA VISTA MANOR
Facility Address
631 HAZEL STREET
City, State and Zip Code
OSHKOSH, WI 54901
Name -Prospective Licensee
BELLA VISTA-CRL LLC
Prospective Licensee Address
875 N MICHIGAN AVENUE, STE 3740
City, State and Zip Code
CHICAGO, II, 60611
IDENTIFY THE GENERAL TYPES OF DISABILITY CATEGORIES THIS PROGRAM WILL SERVE
ADVANCED AGED, IRREVERSIBLE DEMENTIA/ALZHEIMER'S
Number of Residents
36
TO BE COMPLETED BY THE PLANNING COMMISSION OR AGENCY
Identify and describe any specific hazards that may affect the health and safety of resident of this proposed facility. See
the reverse side for a list of possible hazards with space for comments. Attach additional pages if necessary.
® A, Hazards identified (identify on reverse side)
^ B. NO hazards identified
^ C. NO hazard investigation conducted
RE -
if Different from Addressee
e Signed
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DDE-290 (Rev. 6-04)
EXAMPLES OF POTENTIAL HAZARDS
This is not a complete list but a guide to the kind of information that may apply.
Indicate any additional hazards not on this list.
NATURAL HAZARDS
1. Is there an open pit or quarry near the proposed facility? NCR
2. Is there an unguarded body of water nearby? S~ES~ e`>/~s~ ~~y
3. Is the proposed facility located on floodplain? y~Y
a. flood way, or
b. flood fringe?
What is the regional (or 100 year) flood elevation?
MAN-MADE HAZARDS
/ i
,'s ee~+ss~X'.cf~/y ~'~/-to +k~ ~~s ~rw,;l~: ~
1. Is the quality of air in the neighborhood of the proposed facility adversely affected by pollution? ~,
2. Is there a level of noise pollution being generated from any particular sources in the
surrounding area which could negatively affect the health or safety of the residents? a/c,.
3. Are there any obnoxious odors from any source? n/~,
4. Is the proposed facility located- by or on a heavily used highway or major thoroughfare? IVY
PROBLEMS WITH SUPPORT SERVICES
1. Are local police and fire department services accessible in case of an emergency? Yom,.
2. Are health care facilities accessible for both normal and emergency services? YES.
3. Are there any hazards which a resident of the proposed facility would encounter go to or from:
a. Elementary and secondary schools, or adult vocational schools (where applicable); it/o..
b. Places of employment, including sheltered workshops (where applicable); or, /lJo.
c. Other commonly used facilities such as parks, recreational centers, libraries, etc.?~/@.
COMMENTS:
Jim Doyle
Governor
Karen E. Timberlake
Secretary
State of Wisconsin
Department of Health Services
DIVISION OF QUALITY ASSURANCE
NORTHERN REGIONAL OFFICE
2187 NORTH STEVENS STREET, SUITE C
RHINELANDER WI 54501
Telephone: 715-365-2800
FAX: 715-365-2815
dhfs.wisconsin.gov
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October 3, 2008
City of Oshkosh
PO Box 1130
Oshkosh, WI 54903
Re: Request for Hazards Identification
Dear Sir or Madam:
o c T - s zoos
COMMUNITY DEVELOPMENT
This Agency has received an application for initial licensure as a Community Living
Arrangement at the premises identified on the enclosed Form 290.
Section 48.63(3) and s.50.03(a)(3), Wisconsin Statutes, specify that "Within ten working days
after receipt of an application for initial licensure (of a community living arrangement)...the
Department shall request that the planning`commission or agency send to the Department, within
30 days, a description of any specific hazards which may affect the health and safety of the
residents of the community living arrangement. No license may be granted until the 30-day
period has expired or until the Department receives the response of the planning commission or
agency, whichever is sooner."
Please forward this form to the appropriate municipal agency so that any possible hazards to the
residents of this proposed facility might be identified. Full consideration will be given to
identify hazards prior to issuing a license if the completed form is returned within 30 days of the
postmark date.
Thank you for your cooperation with this request.
Sincerely,
~~ti ~~
Susan Murphy
Assisted Living Regional Director
Division of Quality Assurance
Enclosure
cc: Northern Regional Office
Wisconsin.gov