Alberta Granger Unit Manager Assisted Living Unit Bureau of Long Term Care Services Assisted Living Unit, Mail Stop #30 2727 Mahan Drive Tallahassee, FL 32308 (850) 487-2515 / SC 277-2515 (850) 922-1984 / SC 292-1984 Fax Adult Family Care Home The Adult Family Care Home is a residential home designed to provide personal care services to individuals requiring assistance. The provider must live in the home and offers personal services for up to 5 residents. More detailed program information on adult family care homes can be found at the Department of Elder Affairs' Florida Affordable Assisted Living Website.

Statute/Rule Authority

• Chapter 408, Part II, Florida Statutes (PDF) / (HTML)
• Chapter 429, Part II, Florida Statutes (PDF)/ (HTML)
• Chapter 58A-14, Florida Administrative Code (PDF) / (HTML)

Survey Guidelines

• Adult Family Care Home Survey Tags
  • ASPEN Regulation Set

Adult Family Care Home Application Package

• Application Information and Instructions
• Application Packet Fees
• AFCH Checklist
• AFCH License Application (AHCA Form 3180-1022)
• Health Care Licensing Application
• Health Care Licensing Addendum
• Voluntary Board Member Affidavit
• Affidavit of Compliance --Level 2 Background Screening for Covered Employees (AHCA 3100-0007)
• Affidavit of Compliance with Background Screening Requirement (AHCA 3100-0008)
• AFCH Statement of Income and Expense (AHCA Form 3180-1017)
• Dept. Of Health - Notice (Note: Applies to initial and renewal applications)

Community Residential Homes

• Important Notice; AFCH Zoning Requirements
• Chapter 419, Florida Statutes
• Community Residential Home Affidavit of Compliance
• AFCH Local Zoning Form (AHCA Form 3180-1021)
• Homes licensed by the Agency for Health Care Administration--visit the AHCA website at http://www.floridahealthfinder.gov
• Homes licensed by the Department of Children and Families--visit the DCF website at http://www.dcf.state.fl.us/districts/ to locate the Community Residential Home licensing staff in the appropriate district.
• Homes licensed by the Agency for Persons with Disabilities--visit the APD website at http://apd.myflorida.com/area/ to locate the APD staff in the appropriate district.

Background Screening Package

• Instructions
*note: Adult Family Care Home (AFCH) Background Screening Affidavit of Compliance (Attachment)
• Background Screening Website--Contact the ALF unit for a valid FBI fingerprint card.
• Level 1 Criminal History Request Form (AHCA Form 3110-0002) *Note--Download from Background Screening Website

Adult Family Care Home Renewal Application Package

• Renewal Application Information and Instructions
• Checklist
• Application (AHCA Form 3180-1022)
• Health Care Licensing Application
• Health Care Licensing Addendum
• Dept. Of Health - Notice (Note: Applies to initial and renewal applications)
• Affidavit of Compliance --Level 2 Background Screening for Covered Employees (AHCA 3100-0007)
• Affidavit of Compliance with Background Screening Requirement (AHCA 3100-0008)

Background Screening Package (Renewal)

• Renewal Instructions
*note: Adult Family Care Home (AFCH) Background Screening Affidavit of Compliance (Attachment)
• Background Screening Website--Contact the ALF unit for a valid FBI fingerprint card.
• Level 1 Criminal History Request Form (AHCA Form 3110-0002) *Note--Download from Background Screening Website

Resident Health Assessment

• Resident Health Assessment for Adult Family Care Homes (AHCA Form 3110-1023 AFCH-1110 01/08)