DSHS Form 06-168 "Adult Family Home (Afh) Change in Licensed Bed Capacity - Increase (Residential Care Services)" - Washington

What Is DSHS Form 06-168?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 06-168 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 06-168 "Adult Family Home (Afh) Change in Licensed Bed Capacity - Increase (Residential Care Services)" - Washington

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RESIDENTIAL CARE SERVICES (RCS)
Adult Family Home (AFH) Change in
Licensed Bed Capacity - Increase
Please type or print clearly. Fill out the form completely by answering all questions and following all instructions. Please
refer to
WAC 388-76-10030
and
RCW
70.128.066. It is the responsibility of the licensee to submit a complete form and
fee. Please contact
baau@dshs.wa.gov
if you have questions about this form. This form may be photocopied.
AFH NAME
AFH LICENSE NUMBER
AFH ADDRESS
COUNTY
NAME AND TITLE OF CONTACT PERSON (PROVIDER, ENTITY REPRESENTATIVE, RESIDENT MANAGER)
PHONE NUMBER
CURRENT LICENSED CAPACITY
PROPOSED LICENSED CAPACITY
EMAIL ADDRESS
Does your home have a septic system?
Yes
No
If yes, please include documentation showing the capacity supported by the septic system. This capacity should be
shown in number of individuals, not number of bedrooms.
Are you requesting to increase the home’s capacity to seven or eight beds?
Yes
No
If no, skip to the next section for all applicants.
If yes, please also include the following documents. Please label all documents:
An application fee of $485. Make your check or money order payable to Washington State Treasurer. Mail this form
and the fee to: ALTSA, PO BOX 45600, OLYMPIA WA 98504-5600. Please be sure to write the adult family
home license number on your check. Forms submitted without the fee will not be processed. This fee is
nonrefundable.
An attestation that this increase will not adversely affect the health, safety, or quality of life of current residents in the
home; and
A copy of the notification provided to residents and their representatives of the capacity increase.
A copy of the last six months of power, sewer, water, and sanitation bills for the adult family home.
A copy of the permit for the sprinkler system.
Check here if your home does not have a sprinkler system because your license is limited to serving only
residents who are independent with evacuation. Note that this limit must be on your license in order to meet this
requirement.
Please note that in order to increase to seven or eight beds you must meet all of the requirements found in
RCW
70.128.066. (See Page 2.)
All Applicants
Once your form has been submitted and verified, a licensor will contact you to schedule an inspection to verify the home
can sufficiently meet the capacity increase. You will be required to pay an additional bed fee based on the number of
beds added and the time until your annual licensing fee is due. This will be collected after your inspection but before your
capacity increase is approved. To estimate the amount due, see the formula on page 2.
Remember, the capacity increase is not in effect until you receive a revised license and letter from the
department verifying that the capacity increase is approved.
By signing this form, you are stating that you have read the requirements and understand what you need to do in order to
receive your requested capacity increase.
SIGNATURE
DATE
PRINT NAME
For ALTSA Fiscal Use Only
For ALTSA / RCS Use Only
Page 1 of 2
AFH CHANGE IN LICENSED BED CAPACITY – INCREASE
DSHS 06-168 (REV. 04/2022)
RESIDENTIAL CARE SERVICES (RCS)
Adult Family Home (AFH) Change in
Licensed Bed Capacity - Increase
Please type or print clearly. Fill out the form completely by answering all questions and following all instructions. Please
refer to
WAC 388-76-10030
and
RCW
70.128.066. It is the responsibility of the licensee to submit a complete form and
fee. Please contact
baau@dshs.wa.gov
if you have questions about this form. This form may be photocopied.
AFH NAME
AFH LICENSE NUMBER
AFH ADDRESS
COUNTY
NAME AND TITLE OF CONTACT PERSON (PROVIDER, ENTITY REPRESENTATIVE, RESIDENT MANAGER)
PHONE NUMBER
CURRENT LICENSED CAPACITY
PROPOSED LICENSED CAPACITY
EMAIL ADDRESS
Does your home have a septic system?
Yes
No
If yes, please include documentation showing the capacity supported by the septic system. This capacity should be
shown in number of individuals, not number of bedrooms.
Are you requesting to increase the home’s capacity to seven or eight beds?
Yes
No
If no, skip to the next section for all applicants.
If yes, please also include the following documents. Please label all documents:
An application fee of $485. Make your check or money order payable to Washington State Treasurer. Mail this form
and the fee to: ALTSA, PO BOX 45600, OLYMPIA WA 98504-5600. Please be sure to write the adult family
home license number on your check. Forms submitted without the fee will not be processed. This fee is
nonrefundable.
An attestation that this increase will not adversely affect the health, safety, or quality of life of current residents in the
home; and
A copy of the notification provided to residents and their representatives of the capacity increase.
A copy of the last six months of power, sewer, water, and sanitation bills for the adult family home.
A copy of the permit for the sprinkler system.
Check here if your home does not have a sprinkler system because your license is limited to serving only
residents who are independent with evacuation. Note that this limit must be on your license in order to meet this
requirement.
Please note that in order to increase to seven or eight beds you must meet all of the requirements found in
RCW
70.128.066. (See Page 2.)
All Applicants
Once your form has been submitted and verified, a licensor will contact you to schedule an inspection to verify the home
can sufficiently meet the capacity increase. You will be required to pay an additional bed fee based on the number of
beds added and the time until your annual licensing fee is due. This will be collected after your inspection but before your
capacity increase is approved. To estimate the amount due, see the formula on page 2.
Remember, the capacity increase is not in effect until you receive a revised license and letter from the
department verifying that the capacity increase is approved.
By signing this form, you are stating that you have read the requirements and understand what you need to do in order to
receive your requested capacity increase.
SIGNATURE
DATE
PRINT NAME
For ALTSA Fiscal Use Only
For ALTSA / RCS Use Only
Page 1 of 2
AFH CHANGE IN LICENSED BED CAPACITY – INCREASE
DSHS 06-168 (REV. 04/2022)
Calculate the additional bed fee:
Once you have completed the inspection and a licensor makes a recommendation to increase your bed capacity, you will
need to submit payment for each additional bed in order to receive your capacity increase. You can estimate the amount
owed for the additional licensed beds, which is based on the time until your next annual fee is due, using this formula:
months until the anniversary date x
increased beds x $18.75 (monthly bed fee) =
Any part of a month should be rounded up. Example: If your anniversary date is three (3) months and one (1) day from
now, you would round up to four (4) months. You will be contacted with the amount owed after the inspection and
recommendation are complete, and your capacity increase will not be approved until payment is received.
For capacity increases to seven or eight beds:
RCW 70.128.066
requires providers who wish to increase their capacity to seven or eight beds to:
Demonstrate financial solvency and management experience for the home and the ability to meet other relevant
safety, health, and operating standards pertaining to the operation of an adult family home, including the ability to
meet the needs of all current and prospective residents and ways to mitigate the potential impact of vehicular traffic
related to the operation of the home.
Have held the license for the adult family home for which they are requesting the capacity increase for at least 24
months.
Have been licensed for six residents for at least 12 months prior to applying to increase to seven or eight beds.
Have received at least two full inspections and have received no enforcement actions during the period of the last two
inspections.
Submit an attestation that an increase in the number of beds will not adversely affect the health, safety, or quality of
life of the current residents in the home.
Demonstrate the ability to comply with the emergency evacuation standards established in rule.
Have a residential sprinkler system in place.
Have paid any fees associated with licensure or additional inspections.
Provide at least sixty days’ notice in writing at the time of application to all residents and their representatives in a
manner or language that they understand that the home has applied for a license capacity increase to admit up to
seven or eight residents before admitting the seventh resident. (Capacity increases to seven or eight will not be
approved less than sixty days from the date the application is received.)
Page 2 of 2
AFH CHANGE IN LICENSED BED CAPACITY – INCREASE
DSHS 06-168 (REV. 04/2022)
Page of 2