AGING AND DISABILITY SERVICES ADMINISTRATION
July 5, 2002
AASA: AFH #2002-023
SUBJECT: REVISED CAREGIVER EXPERIENCE ATTESTATION (CEA) FORM
FOR RESIDENT MANAGERS/ENTITY REPRESENTATIVES
Dear Adult Family Home Provider:
This letter replaces AASA: AFH #2002-008, dated March 15, 2002.
RCW 70.128.120 requires adult family home (AFH) licensees to obtain proper references from resident managers and entity representatives prior to employment. A proper reference will verify that, after the age of eighteen, the individual obtained 320 hours of successful, direct caregiving to vulnerable adults. This experience needs to occur in a licensed or contracted setting prior to operating or managing an AFH.
The department continues to require a structured attestation form to secure notarized references to verify the 320 hours of caregiving experience. More than one reference may be necessary to document the required 320 hours. One form must be completed for each reference given. This form must be completed by a person who has directly supervised the potential resident manager and entity representative during the hours of caregiving. These are: a former supervisor, a co-worker, a client/resident , or a family member of a client/resident in that setting. Please note that Aging and Disability Services Administration (AASA) and Division of Developmental Disability (DDD) Case Managers cannot serve as references for this purpose.
The potential resident manager and entity representative is responsible
to ensure that:
a) The form is completed by a prior supervisor (see paragraph 2, above);
and
b) The person completing the form has it notarized and returns it to the
AFH licensee.
The completed form(s) shall be retained with other documents of qualifications in the individual's personnel file kept on the premises of the licensed AFH and must be available for review by department licensing staff.
The AFH Caregiving Experience Attestation (CEA) Form B for Resident Managers and Entity Representatives is enclosed. This form has been revised; please discard any existing copies and begin using the enclosed copy immediately. You may duplicate this form as needed.
The revised form reads "CEA Form B - June 2002" at the bottom
left of each page. It will be your responsibility to provide the resident
manager and entity representative as many copies of the form as necessary
to document the required caregiving hours. This form can also be accessed
at http://www.aasa.dshs.wa.gov/professional/default.htm#rc;
scroll down the page until you see the "Adult Family Homes" heading,
then select from the list of bulleted items.
If you have any questions, please contact your RCS Field Manager.
Sincerely,
Patricia K. Lashway, Director
Residential Care Services
