Form 1123, Review of Assisted Living Facility Type C

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Effective Date: 9/2011


Updated: 9/2011


To document compliance with Type C Assisted Living Facility licensure renewal review.


When to Prepare

The regulatory surveyor completes Form 1123 when the provider is no longer participating in the Adult Foster Care program and has a current Type C Assisted Living Facility license renewal application in process.

Number of Copies

One original and one copy.


File the original in the facility file. Mail a copy of the form to the Licensing and Credentialing Section.

Detailed Instructions

Identifying Information - Enter the facility name, facility address, telephone number; facility identification (ID) number, the license expiration date and the facility census.

Provider Qualifications - Check Yes or No to indicate whether the applicant/provider meets or does not meet the qualification or the qualification does not apply for each of the 12 items. Note: In Item 4, observe the caregiver for infection, disease, malady or illness. Consider whether the consumers express concerns about being exposed to colds or other infections. Ask consumers that can be interviewed if their needs are being met. In Item 5, ask consumers if they have experienced or observed problems with visitors or other consumers.

Home Requirements - Check Yes or No to indicate whether the home meets or does not meet the requirements for each of the 27 items. The home must be in compliance with all items before renewal of the license will be granted. Note: In Item 25, the provider must develop house rules, including smoking policies, and share the rules with each consumer. The provider is not required to post the rules.

List of all consumers in the household - Enter the names of all consumers in the household and their relationship to the applicant/provider (for example, family members, private-pay client, HHSC client).

Note: If the home has more than four consumers, the provider must obtain a Type A or Type B Assisted Living Facility license.

Recommendation - Check the appropriate box if the home IS recommended or NOT recommended.

Printed Name — Surveyor - Surveyor prints his/her name.

Signature — Surveyor and Date - Surveyor signs and dates the form.