a) Applications for a license to operate a Community-Based Residential Rehabilitation Care Center Model shall be in writing on forms provided by the Department. The application shall be made under oath and shall contain the following:

1. 1) Proof of a Certificate of Need to establish and operate a Community-Based Residential Rehabilitation Center Model issued by the Health Facilities Planning Board under the Illinois Health Facilities Planning Act;
2. 2) The name of the proposed Model;
3. 3) The address of the proposed Model;
4. 4) A precise description of the site of the proposed Model;
5. 5) The number of residences;
6. 6) The number of beds per residence;
7. 7) The number of non-resident participants;
8. 8) The name and address of the registered agent or other individual authorized to receive Service of Process for the Model licensee;

9. 9) The name, address and Illinois license numbers of the following persons:

   1. A) Medical Director,
   2. B) Supervisor of medical services, and
   3. C) Program Coordinator/Director;
10. 10) The Model's admission protocol and transfer criteria as required by Section 220.1700;
11. 11) Information regarding any conviction of the owner or operator of the proposed Model of a felony or of any other crime under the laws of any state or of the United States arising out of or in connection with the operation of a health care facility; and
12. 12) Information regarding any encumbrance on a health care license issued in Illinois or any other state to the owner or operator of the proposed Model.

e) An application for license renewal shall be filed with the Department 90 to 120 days prior to the expiration of the license, on forms provided by the Department.

1. 1) The renewal application shall comply with the requirements of subsections (a) and (b) of this Section; and
2. 2) Upon receipt and review of a complete application for license renewal, the Department may conduct a survey. The Department shall renew the license in accordance with subsection (d) of this Section.

f) The Department may issue a provisional license to any Community-Based Residential Rehabilitation Center Model that does not substantially comply with the provisions of the Act and this Part:

1. 1) A provisional license may be issued only if the Department finds that:

   1. A) The Model has undertaken changes and corrections which upon completion will render the Model in substantial compliance with the Act and this Part; and
   2. B) The health and safety of the participants in the Model will be protected during the period for which the provisional license is issued. (Section 30(c) of the Act)

2. 2) The Department shall advise the applicant or licensee of the conditions under which the provisional license is issued, including:

   1. A) The manner in which the Model fails to comply with the provisions of the Act and this Part;
   2. B) The changes and corrections that shall be completed;
   3. C) The time within which the necessary changes and corrections shall be completed (Section 30(c) of the Act); and
   4. D) The interim actions that are necessary to protect the health and safety of the participants.