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Home My WebLink AboutLetter (request for hazards identification) - 08/26/2013 ` � �$I� Vin�ant� S-� E _ . __ _.�, ; r d �� ' � DIVISION OF QUALITY ASSURANCE � .. _.,��+ ; , j � ' AUG 2 8 2013 � NORTHEASTERN REGIONAL OFFICE ; Scott Walker � 1325 SOUTH BROADWAY ; Govemor ! DE PERE WI 54115 ' - - � � - ' ' Telephone: 920-983-3200 Kltty Rhoades " " - ��—"" -�� ---' State of Wisconsin FAX: 920-983-3201 Secretary Department of Health Services dhs.wisconsin.gov August 26, 2013 � Pamela R. Ubrig, Oshkosh City Clerk k� PO Box 1130 Oshkosh, WI 54903-1130 Re: Request for Hazards Identification � Dear Ms. Ubrig: 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. Sincer ly, C� ; �. / ; � � Kathleen D. Lyons Assisted Living Regional Director Division of Quality Assurance Enclosure ; � � Wisconsin.gov � # - . � DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Quality Assurance DQA-290(Rev.OS/08) 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 Services)shall request that the Planning Commission or Agency send to the Department within 30 davs 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 Pamela R. Ubrig,Oshkosh City Clerk 8/26/13 Address 215 Church St., PO Box 1130 City,State,Zip Code Oshkosh, WI 54903-1130 Name-Proposed CBRF Century Oaks House 3 Facility Address 1804 Vinland St. City,State and Zip Code Oshkosh, WI 54901 Name-Prospective Licensee Century Oaks Prospective Licensee Address PO Box 421 City,State and Zip Code Neenah, WI 54956 IDENTIFY THE GENERAL TYPES OF DISABILITY CATEGORIES THIS PROGRAM WILL SERVE Advanced Aged Traumatic Brain Injury Irreversible Dementia/Alzheimer's Developmentally Disabled Emotionally Disturbed/Mental Illness Physically Disabled Terminally Ill Number of Residents 43 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 SIGN -PersOn Conducting Investigation Date Signed G q- -z 3 A r if ifferent from Addressee � . OQA-290(Rev. 10-06) 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? 2. Is there an unguarded body of water nearby? 3. Is the proposed facility located on floodplain? a. flood way, or b. flood fringe? What is the regional (or 100 year) flood elevation? MAN-MADE HAZARDS 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? 3. Are there any obnoxious odors from any source? 4. Is the proposed facility located by or on a heavily used highway or major thoroughfare? PROBLEMS WITH SUPPORT SERVICES 1. Are local police and fire department services accessible in case of an emergency? 2. Are health care facilities accessible for both normal and emergency services? 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); b. Places of employment, including sheltered workshops (where applicable); or, c. Other commonly used facilities such as parks, recreational centers, libraries, etc.? COMMENTS: /�a� -i^'�a�. �J'a�Z�S � �- � /�ec✓ �ac:�� s a�i a�..�- �'p U. S. �i�,'y�,�� S�S � �. /��o� �✓C�.,, �a� /`e�or� f��c c�a�. ace�:�a��Q T�n o?Q/d In��a7�s Gn adgaf.e d-� /d /da l��:c�vs �g. a�•y .