HomeMy WebLinkAbout20100706.tiff Fax Mar 29 2010 09:31am P001/004
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Colorado Department
of Public Health
and Environment
To: Kim Ogle Phone#: 970-353-6100
Fax #: 970-304-6498
From: Alexa Nordic Phone#r 303-692-2813
CDPIRE, HFEMSI)—Licensing Section Fax #: 303-753-6214
Total pages including cover:
Subject: Triangle Cross Ranch 4
Please note the tentative approval by the Department of Public Health and Environment for Triangle Cross
Ranch to increase beds from 19 to 24.
Thanks,
Alexa
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Health Facilities&Emergency Medical Services Division(11FEMS)
Main(303)692-2800
4300 Cherry Creek Drive South
Denver,CO 80246
2010-0706
ze9,70,/,a0te,eite5-77-dY /2. 070
Fax Mar 29 2010 09:31am P002/004
HEALTH FACR.R1Fs AND Enjacmrcr
MEDICAL SERVICES In VISION
4300 Cherry Creek Drive South State Licensure Program J
Deaver,CO 80246
Voic&303.692-2800 Fait 303-753-6214 ASSISTED LIVING RESIDENCES
www.cdpbestate.co.tis/hafclasp Cr tar
andEmixornarar
ZONING DEPARTMENT
Sign off for Local Authorities
Written evidence of compliance with local zoning codes must be obtained prior to issuance of a sate license for
operation of a health facility. Contact the city or COMM*department in your area and have the director or designee
sign below. The original signed form must be returned to Health Facilities and Emergency Medical Services Division
(HFEMSD)as part of your application packet.
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF APPLICATION: I 11otl W
1 )Chant of Owoembip
l I New Seared Dak
I I!scram itSet: From_ [q To 2.4"
I J Chaege of Letatbo: From
To
SECTION B: TO BE COMPLETED BY THE APPLICANT
Current Name of Facility: TRIANGLE CROSS RANCH
Proposed Name of Facility(if applicable):
Address: 36045 COUNTY ROAD 51, GALETON, CO 80622
City County
No.of Licensed Beds Requested: 2't
Name of Person to Contact Si.t22RAnt CSlaM) Plane; flip) {— ?iy Fax: (ezO)t4S'#-5M(j
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY ZONING DEPARTMENT
Zoning Department having Jurisdiction: WELD COUNTY COLORADO PLANNING SERVICES
The above- am cility meets the requirements for zoning approval: [LK]YES [ ]NO SEE ATTACHED
(If"no"pl a on a separate attachment)
DOCUMENTS
Signature: Date: 2,i1.-2-010
Name ofPe son ntact: RIM OGLE Phone: ( 970) 353 610Qax:( 970) 304 6498
Address: P.O. BOX 758, GREELEY, CO 80631 EXTENSION 3540
SECTION D: FOR HFEMSD COMPLETION
Initial Notification to Zoning Department by !d(p x11 knit t on -'/12'7 L J C) (Date)
Effective Date of License: 7
Final Notification to Zoning Department by _on (Date)
Fax Mar 29 2010 Vat P003/00d
-- -. -� � nVCG r.VUJI UUJ
REALM FACU,tTIESAND EMERGENCt' .-- — —
MEDICpLSEawcEs DivestoN
4300 Cheery Creek Drive South State Lir ensure Program
Denver,CO 80246 [°u4�
Voices 303.692-2800 Fax:303-753-6214 ASSISTED LIVING RESIDENCES
waw.cdpbe.state.co.os/hehfd.aep Colorado t
af Atlic
and Environment •
BUILDING DEPARTMENT
Sign off for Local Authorities
Written evidence of compliance with local building codes must be obtained prior to issuance of a state license for
operation of a health facility. Conrad the city or county department in your area and have the director or designee
sign below. The original signed form must be returned to Health Facilities and Emergency Medical Services Division
(HFEMSA)as pan of your application packet
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF APPLICATION: )Infdal
I )Change of Ownership
I )New Secured Usk Silicotruwe la Reds: 7Rom__19 To s�I.4
[ I ChangeofLocatlua. From
To
SECTION B: TO BE COMPLETED BY THE APPLICANT
Name of Facility: TRIANGLE CROSS RANCH
Address: 36O45 COUNTY ROAD 51, GALETON CO 8O622
1 City County
No.of Licensed Beds Requested: 2rl
Name of Person to Contact: - .I.Z7S Sk1442 Phone: (8713)15tk- {Sax: (IV)4,54 -S3gA
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY BUILDING DEPARTMENT
Building Department having Jurisdiction: WELD COUNTY COLORADO PLANNING SERVICES
The above-named facility meets the requirements for building approval: [ J YES [ J NO SEE SEPARATE
(1f"no"please explain on a` peparate-cta chmeat.)
ATTACHMENT
Signature. =-/�� Date: 2 ^iZ.. 2..0 k0
Name of Person to Contact REN SWANSON Phone: (971)353-6100 Fax: (970) 3O4-6498
EXTENSION 3548
Address: PO BOX 758, GREELEY, CO 8O631
Fax Mar 29 2010 09:31am P004/004
HEALTH FACILITIES AND EMERGENCY •
MEDICAL SERVICES DIVISION
4300 Cherry Creek Drive South State Licensure Program
f
Denver,CO 80246 _
Voice:303-692-2800 Fax:303-753-6214 ASSISTED LIVING RESIDENCES
www,cdphe.state.co.us/hf/hfdasp ColoradoPublicriehrt
of andEnvixonmtnt
FIRE DEPARTMENT
Sign off for Local Authorities
Written evidence of compliance with local fire codes must be obtained prior to issuance of a state license for operation
of a health facility. Contact the city or county department in your area and have the director or designee sign below.
The original signed form must be returned to Health Facilities and Emergency Medical Services Division(HFEMSD)
as pan of your application packet
SECTION A: TO BE COMPLETED BY THE APPLICANT
PURPOSE OF APPLICATION_ I 1 Initial
1 I Change of Ownership
I I New Secured Unit
p4 Increase An Beds: From iq To a2
iii
1 1 Change of Location: From
To
SECTION B: TO BE COMPLETED BY THE APPLICANT
Name of Facility: ,
Address: Zi-
d ity County
No.of Licensed Beds Requested: 0.19'
Name of Person to Contact: SaZatlitts 4444) Phone: fix )tfS'ka2-(.QFax: (97O )454—531/2)
SECTION C: TO BE COMPLETED BY THE CITY/COUNTY FIRE DEPARTMENT
Fire Department having Jurisdiction:Galefc,l r re 'Pr e}o 6-.On <S r',C
The above-named facility meets the requirements for fire safety: DO YES [ J NO
(If"no"pl xplain o separate attachment)
Signatur eceo If Date: Pra-"'L S. o2C/C7
Name of Person to Contact: jam e+i jn 14- (E)-.;e-(1) Phone: (9)0)34,2)205 Fax:e970) '6q-•%≥I
s /' /
Address:_4 4P, 4.2 _ � S�f I 6okJi24 , & (�,, 2_
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