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An Official
Pennsylvania
Government Website
Department of Human Services
BHSL Administrator Change Form
Online Administrator Change Form for Personal Care Homes (PCH) and Assisted Living Residences (ALR)
PCH/ALR Name
*
*
PCH/ALR License Number
*
*
County
*
Please select an option
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Previous Administrator
*
*
Date of Change
*
*
New Administrator Information
Administrator Name
*
*
Phone (XXX-XXX-XXXX)
*
*
Email
*
*
*
Does the new administrator meet all the regulatory requirements related to administrator training and qualifications?
*
Yes
No
Is the new administrator the staff person responsible for the general administration and management of the PCH/ALR?
*
Yes
No
