License Application Checklist for Adult Day Centers

Use this checklist to ensure you have completed and included the following items when
submitting your application materials. Retain a copy of all forms and materials submitted for
your records.

ADULT DAY CENTER APPLICATION REQUIREMENTS

License Application

Certificate of Compliance Minnesota Workers Compensation Law form

Organizational chart specify the organizational structure and authority within the
program
License application fee

Ownership Verification as applicable, submit documentation to verify the type of

business organization, such as a copy of the Articles of Organization, Articles of
Incorporation, etc
Signed and notarized Applicant Agreement, Acknowledgement and Verification
form
License Application Addendum

Policies and Procedures - all required policies and procedures identified in the
document titled Guidelines for Developing Policies and Procedures for Adult Day
Centers
Floor Plan identification of all space to be used, including dimensions and planned
use of each area

Meal and Snack Menus - sample menus for all meals and snacks served by the
program which comply with USDA nutritional requirements and approved by a
registered dietitian (Minnesota Rules, part 9555.9710, subpart 1, E)
Participants Records - sample forms to be maintained in the participants files
(Minnesota Rules, part 9555.9660; and Minnesota Statutes, sections 626.557,
subdivision 14, (b), and 245A.65, subdivision 2, (b))
Adult Day Program Center Director Personnel Requirements Form - for the center
director, a completed Adult Day Program Center Director Personnel Requirements
Form and documentation to verify qualification requirements (Minnesota Rules, part
9555.9680, subpart 1)
Summary of Staff Information Form identification of the applicant(s) and as
applicable, staff persons hired at the time of application

April 2013 Page 1

Katie Adult Day Center Policies and Procedures Manual 02-007.16

A Product of LeadingAge Minnesota October 2016
 Consultants - names of the required consultants, including a registered dietitian,
registered nurse, and registered physical therapist, and documentation to verify that the
consultants licensure, registration, or certification, meets the requirements under
Minnesota Rules, part 9555.9710
Monthly Plan for Diversified Daily Program Activities - monthly plan for diversified
activities designed to meet the needs and interests of the participants (Minnesota
Rules, part 9555.9710, subpart 6)
Record of Incidents - sample form to document all incidents involving participants
(Minnesota Rules, part 9555.9720, subpart 4)

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Adult Day Services Policies and Procedures Manual 02-007.16
A Product of LeadingAge Minnesota October 2016