Minnesota : DHS
 
 
      
 


License Details

Basic license details.
Minnesota Community Based Services License status: Active
3200 LABORE RD STE 104
Vadnais Heights, MN 55110
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(651) 431-6882
Ramsey County

License number: 1070559
License holder: Commissioner of Department of Human Services
License Holder Entity Identification Number(s): 4286619
License status: Active
Type of service: Home and Community Based Services
Initial effective date: January 1, 2014
Last renewed or updated on: January 1, 2024
Next renewal due: December 31, 2024


Licensed to provide

Basic Support Services:
Respite care, in home or out-of-home
Individualized home supports

Intervention Support Services:
Positive supports
Specialist services
Crisis respite, in-home or out-of-home

In-Home Support Services:
In-home family support
Independent living skills training
Semi-independent living skills
Individualized home supports with training
Individualized home supports with family training

Residential Supports and Services:
Foster Care services or supported living services
Supported living services in a SLF
Residential services in an ICF/DD
Community residential services
Family residential services

Day Services:
Day training and habilitation
Prevocational
Structured day
Day support services

Employment Services:
Employment development services
Employment exploration services
Employment support services

Restrictions: None


Satellite Locations

Satellite License Number: 1070560 (Home and Community Based Services - Community Residential Setting)
MSOCS Woodcrest
1898 HURON AVE
Saint Paul, MN 55113

Satellite License Number: 1070562 (Home and Community Based Services - Community Residential Setting)
MSOCS Stephen Road
1399 Stephen Road
Cloquet, MN 55720

Satellite License Number: 1070564 (Home and Community Based Services - Community Residential Setting)
MSOCS Lakeland I
1021 Lakeland Drive NE
Willmar, MN 56201

Satellite License Number: 1070565 (Home and Community Based Services - Community Residential Setting)
MSOCS 3rd Street
1011 3rd St SE
Faribault, MN 55021

Satellite License Number: 1070566 (Home and Community Based Services - Community Residential Setting)
MSOCS Park Avenue
2307 Park Ave NW
Faribault, MN 55021

Satellite License Number: 1070569 (Home and Community Based Services - Community Residential Setting)
MSOCS Highland
300 Highland Ave
Northfield, MN 55057

Satellite License Number: 1070574 (Home and Community Based Services - Community Residential Setting)
MSOCS Lakeland II
913 Lakeland Drive NE
Willmar, MN 56201

Satellite License Number: 1070576 (Home and Community Based Services - Community Residential Setting)
MSOCS Richfield
6637 4th Avenue S
Richfield, MN 55423

Satellite License Number: 1070577 (Home and Community Based Services - Community Residential Setting)
MSOCS Arbor Way
900 Arbor Way
Sauk Rapids, MN 56379

Satellite License Number: 1070578 (Home and Community Based Services - Community Residential Setting)
MSOCS Lewiston
1375 310TH ST E
Northfield, MN 55057

Satellite License Number: 1070579 (Home and Community Based Services - Community Residential Setting)
MSOCS 89th Crescent
5422 89th Crescent N
Brooklyn Park, MN 55443

Satellite License Number: 1070580 (Home and Community Based Services - Community Residential Setting)
MSOCS Chippewa Acres
5035 140th Ave NE
Raymond, MN 56282

Satellite License Number: 1070585 (Home and Community Based Services - Community Residential Setting)
MSOCS Crystal
1101 Crystal lake Road W
Burnsville, MN 55337

Satellite License Number: 1070592 (Home and Community Based Services - Community Residential Setting)
MSOCS Anoka Burns
5361 189th Ave NW
Ramsey, MN 55303

Satellite License Number: 1070593 (Home and Community Based Services - Community Residential Setting)
MSOCS Jefferson
1904 Jefferson Road
Northfield, MN 55057

Satellite License Number: 1070594 (Home and Community Based Services - Community Residential Setting)
MSOCS Allen Path
54 Allen Path
Faribault, MN 55021

Satellite License Number: 1070595 (Home and Community Based Services - Community Residential Setting)
MSOCS Maplewood
121 Maplewood Dr
Randall, MN 56475

Satellite License Number: 1070596 (Home and Community Based Services - Community Residential Setting)
MSOCS Pillager Creek
118 E 2nd St
Pillager, MN 56473

Satellite License Number: 1070597 (Home and Community Based Services - Community Residential Setting)
MSOCS Scandia
15565 220th Street
Scandia, MN 55073

Satellite License Number: 1070598 (Home and Community Based Services - Community Residential Setting)
MSOCS 32nd Avenue
300 32ND AVE SW
Owatonna, MN 55060

Satellite License Number: 1070600 (Home and Community Based Services - Community Residential Setting)
MSOCS Ableman
23450 Falls Ave
Warsaw, MN 55087

Satellite License Number: 1070602 (Home and Community Based Services - Community Residential Setting)
MSOCS 8th Avenue
2020 8th Avenue NE
Owatonna, MN 55060

Satellite License Number: 1070603 (Home and Community Based Services - Community Residential Setting)
MSOCS 7th Avenue
813 7th Ave SW
Faribault, MN 55021

Satellite License Number: 1070605 (Home and Community Based Services - Community Residential Setting)
MSOCS Forest Lake
22500 Iverson Ave
Forest Lake, MN 55025

Satellite License Number: 1070609 (Home and Community Based Services - Community Residential Setting)
CAS Pine City
12433 LOON DR
Pine City, MN 55063

Satellite License Number: 1070610 (Home and Community Based Services - Community Residential Setting)
CSS Dakota Crisis
300 TIMBERLAND DR
Burnsville, MN 55337

Satellite License Number: 1070611 (Home and Community Based Services - Community Residential Setting)
MSOCS Cass Lake
16421 65th Ave NW
Cass Lake, MN 56633

Satellite License Number: 1070613 (Home and Community Based Services - Community Residential Setting)
MSOCS Forestview
12936 Kingwood Dr
Baxter, MN 56425

Satellite License Number: 1070618 (Home and Community Based Services - Community Residential Setting)
MSOCS Shady Grove
2001 11th St SW
Austin, MN 55912

Satellite License Number: 1070619 (Home and Community Based Services - Community Residential Setting)
CSS Hermantown Crisis
5223 Maple Grove Road
Hermantown, MN 55811

Satellite License Number: 1070620 (Home and Community Based Services - Community Residential Setting)
MSOCS West Concord
406 6th Street
West Concord, MN 55985

Satellite License Number: 1070622 (Home and Community Based Services - Community Residential Setting)
MSOCS Moorhead
820 63rd Ave N
Moorhead, MN 56560

Satellite License Number: 1070623 (Home and Community Based Services - Community Residential Setting)
MSOCS Alexandria
123 Bethesda St NW
Alexandria, MN 56308

Satellite License Number: 1070624 (Home and Community Based Services - Community Residential Setting)
MSOCS Sumerset
5405 Highway 63 South
Rochester, MN 55904

Satellite License Number: 1070625 (Home and Community Based Services - Community Residential Setting)
MSOCS Mahnomen
2559 140th Ave
Mahnomen, MN 56557

Satellite License Number: 1070626 (Home and Community Based Services - Community Residential Setting)
MSOCS Windfield
10900 Russell Ave S
Bloomington, MN 55431

Satellite License Number: 1070629 (Home and Community Based Services - Community Residential Setting)
MSOCS Ham Lake
17635 Jefferson St Northeast
Ham Lake, MN 55304

Satellite License Number: 1070631 (Home and Community Based Services - Community Residential Setting)
MSOCS Northland Park
12418 43rd Ave SW
Pillager, MN 56473

Satellite License Number: 1070632 (Home and Community Based Services - Community Residential Setting)
MSOCS Hillcrest
2415 Hillcrest Drive
Brainerd, MN 56401

Satellite License Number: 1070633 (Home and Community Based Services - Community Residential Setting)
MSOCS Biwabik
101 Old Hwy 4
Biwabik, MN 55708

Satellite License Number: 1070634 (Home and Community Based Services - Community Residential Setting)
CSS Region 10 Crisis
106 NW 1st Avenue
Kasson, MN 55944

Satellite License Number: 1070635 (Home and Community Based Services - Community Residential Setting)
MSOCS Windsor Place
1309 Windsor Place
Faribault, MN 55021

Satellite License Number: 1070638 (Home and Community Based Services - Community Residential Setting)
MSOCS Westfield
16839 750th Street
Hayfield, MN 55940

Satellite License Number: 1070639 (Home and Community Based Services - Community Residential Setting)
MSOCS Knotting Hill
4342 Knotting Hill Lane NW
Rochester, MN 55901

Satellite License Number: 1070640 (Home and Community Based Services - Community Residential Setting)
MSOCS Fir
2440 Sterling Heights
Fergus Falls, MN 56537

Satellite License Number: 1070641 (Home and Community Based Services - Community Residential Setting)
MSOCS Gustavus
229 W Gustavus Ave
Fergus Falls, MN 56537

Satellite License Number: 1070642 (Home and Community Based Services - Community Residential Setting)
MSOCS Ridge Place
4301 Ridge Circle
Big Lake, MN 55309

Satellite License Number: 1070646 (Home and Community Based Services - Community Residential Setting)
MSOCS Park Rapids
911 PINE ST
Park Rapids, MN 56470

Satellite License Number: 1070647 (Home and Community Based Services - Community Residential Setting)
MSOCS Bemidji
810 CLAUSEN AVE SW
Bemidji, MN 56601

Satellite License Number: 1070648 (Home and Community Based Services - Community Residential Setting)
MSOCS White Bear Lake
5103 LONG AVE
Saint Paul, MN 55110

Satellite License Number: 1070649 (Home and Community Based Services - Community Residential Setting)
MSOCS Akeley Crossing
23653 Co Rd 25
Akeley, MN 56433

Satellite License Number: 1070650 (Home and Community Based Services - Community Residential Setting)
MSOCS Akeley Road
23655 Cty Rd 25
Akeley, MN 56433

Satellite License Number: 1070651 (Home and Community Based Services - Community Residential Setting)
MSOCS Pike Lake
5675 Birchway Rd
Duluth, MN 55811

Satellite License Number: 1070653 (Home and Community Based Services - Community Residential Setting)
MSOCS Christensen
1546 CHRISTENSEN AVE
Saint Paul, MN 55118

Satellite License Number: 1070655 (Home and Community Based Services - Community Residential Setting)
MSOCS Crestview
2406 Woodcrest Dr
Mounds View, MN 55112

Satellite License Number: 1070656 (Home and Community Based Services - Community Residential Setting)
MLB East Central
245 10TH AVE SW
Cambridge, MN 55008

Satellite License Number: 1070657 (Home and Community Based Services - Community Residential Setting)
MSOCS South Stevens
7532 Stevens Ave S
Richfield, MN 55423

Satellite License Number: 1070658 (Home and Community Based Services - Community Residential Setting)
MSOCS Little Brook
6332 Virginia Ave N
Brooklyn Park, MN 55428

Satellite License Number: 1070659 (Home and Community Based Services - Community Residential Setting)
MSOCS Pine Island
611 Co Rd 13 SW
Pine Island, MN 55963

Satellite License Number: 1070660 (Home and Community Based Services - Community Residential Setting)
MSOCS Pickeral Lake
20124 Pickeral Lake Road
Brainerd, MN 56401

Satellite License Number: 1070661 (Home and Community Based Services - Community Residential Setting)
MSOCS Grand Rapids
1939 NW 7th St
Grand Rapids, MN 55744

Satellite License Number: 1070662 (Home and Community Based Services - Community Residential Setting)
MSOCS Parkview
1311 2ND ST NW
Austin, MN 55912

Satellite License Number: 1070667 (Home and Community Based Services - Day Services Facility)
MSOCS Faribault Community Resources FCR
201 LYNDALE AVE S
Faribault, MN 55021

Satellite License Number: 1070670 (Home and Community Based Services - Day Services Facility)
MSOCS West Metro Community Resources (WMCR)
7667 EQUITABLE DR
Eden Prairie, MN 55344

Satellite License Number: 1070672 (Home and Community Based Services - Day Services Facility)
MSOCS North Metro Community Resources (NMCR)
9237 E RIVER RD NW
Coon Rapids, MN 55433

Satellite License Number: 1070675 (Home and Community Based Services - Day Services Facility)
MSOCS Owatonna Community resources (OCR)
900 30TH PL NW
Owatonna, MN 55060

Satellite License Number: 1070682 (Home and Community Based Services - Day Services Facility)
MSOCS Solstice Community Resources (SCR)
660 W 92ND ST
Bloomington, MN 55420

Satellite License Number: 1075476 (Home and Community Based Services - Community Residential Setting)
MLB Stratton Lake
25024 Lincoln Dr NE
Isanti, MN 55040

Satellite License Number: 1075743 (Home and Community Based Services - Community Residential Setting)
MLB Broberg Lake
675 336th Ave NE
Cambridge, MN 55008

Satellite License Number: 1075744 (Home and Community Based Services - Community Residential Setting)
MSOCS Bloomington House
9741 Queen Rd
Bloomington, MN 55431

Satellite License Number: 1076438 (Home and Community Based Services - Community Residential Setting)
MSOCS Rose Garden
20512 University Ave NE
East Bethel, MN 55011

Satellite License Number: 1076773 (Home and Community Based Services - Community Residential Setting)
MSOCS DeCatur
6300 DECATUR AVE N
Brooklyn Park, MN 55428

Satellite License Number: 1079445 (Home and Community Based Services - Community Residential Setting)
MSOCS Concord
40821 FAHRION RD
North Branch, MN 55056

Satellite License Number: 1079598 (Home and Community Based Services - Community Residential Setting)
MSOCS Loyola Site
23963 LOYOLA ST NE
Stacy, MN 55079

Satellite License Number: 1079670 (Home and Community Based Services - Community Residential Setting)
MSOCS Jennifer
5668 W ARROWHEAD RD
Hermantown, MN 55811

Satellite License Number: 1079847 (Home and Community Based Services - Community Residential Setting)
MSOCS TMP
18046 EVENER WAY
Eden Prairie, MN 55346

Satellite License Number: 1080042 (Home and Community Based Services - Day Services Facility)
MSOCS Willmar Area Vocational and Employment Services (aka WAVES)
2200 23RD ST NE STE 2050
Willmar, MN 56201

Satellite License Number: 1080227 (Home and Community Based Services - Community Residential Setting)
MSOCS Eagle Pointe #310
2550 VOYAGEUR PKWY APT 310
Hastings, MN 55033

Satellite License Number: 1080425 (Home and Community Based Services - Day Services Facility)
MSOCS NuVisions
1004 1ST ST S
Willmar, MN 56201

Satellite License Number: 1081596 (Home and Community Based Services - Community Residential Setting)
MSOCS Parkside
215 ERBLANG AVE
Faribault, MN 55021

Satellite License Number: 1082032 (Home and Community Based Services - Community Residential Setting)
MSOCS ILEX
12097 ILEX ST NW
Coon Rapids, MN 55448

Satellite License Number: 1083089 (Home and Community Based Services - Community Residential Setting)
MSOCS Wakeman
713 DALE ST SW
Hutchinson, MN 55350

Satellite License Number: 1083317 (Home and Community Based Services - Day Services Facility)
MSOCS Vocational Opportunities & Individualized Community Employment
8053 INDUSTRIAL PARK RD
Baxter, MN 56425

Satellite License Number: 1084878 (Home and Community Based Services - Community Residential Setting)
MSOCS Edge of 17
2304 14TH ST SW
Austin, MN 55912

Satellite License Number: 1085448 (Home and Community Based Services - Community Residential Setting)
MSOCS Rochester
448 17TH ST SW
Rochester, MN 55902

Satellite License Number: 1086323 (Home and Community Based Services - Community Residential Setting)
MSOCS Redwood Falls
205 Baker Dr
Redwood Falls, MN 56283

Satellite License Number: 1086655 (Home and Community Based Services - Community Residential Setting)
MSOCS Morristown
400 2nd St SW
Morristown, MN 55052

Satellite License Number: 1087705 (Home and Community Based Services - Community Residential Setting)
MSOCS Kasson
1101 1ST AVE NE
Kasson, MN 55944

Satellite License Number: 1089919 (Home and Community Based Services - Community Residential Setting)
MSOCS Austin
1000 12TH ST SW
Austin, MN 55912

Satellite License Number: 1090681 (Home and Community Based Services - Community Residential Setting)
MSOCS Blaine
12949 KENYON ST NE
Blaine, MN 55449

Satellite License Number: 1090726 (Home and Community Based Services - Day Services Facility)
MSOCS Virginia Community Resources VCR
230 1st St S
Virginia, MN 55792

Satellite License Number: 1091529 (Home and Community Based Services - Community Residential Setting)
MSOCS Shumway
1805 SHUMWAY AVE
Faribault, MN 55021

Satellite License Number: 1093468 (Home and Community Based Services - Day Services Facility)
MSOCS Community Resources of Southern Minnesota CRSM
1810 COMMERCE DR
North Mankato, MN 56003

Satellite License Number: 1095136 (Home and Community Based Services - Day Services Facility)
MSOCS Cambridge Community Resources CCR
140 BUCHANAN ST N STE 178
Cambridge, MN 55008

Satellite License Number: 1095901 (Home and Community Based Services - Community Residential Setting)
MLB Donnelly
20345 DONNELLY AVE
Farmington, MN 55024

Satellite License Number: 1096994 (Home and Community Based Services - Community Residential Setting)
MSOCS Afton
14829 70TH ST S
Hastings, MN 55033

Satellite License Number: 1099530 (Home and Community Based Services - Day Services Facility)
MSOCS Northern Vocational Opportunities
707 HIGHWAY 33 S STE 8
Cloquet, MN 55720

Satellite License Number: 1100462 (Home and Community Based Services - Day Services Facility)
MSOCS North Shore Community Options
2822 PIEDMONT AVE
Duluth, MN 55811

Satellite License Number: 1100565 (Home and Community Based Services - Community Residential Setting)
MSOCS Little Crow
709 DALE ST SW
Hutchinson, MN 55350

Satellite License Number: 1103783 (Home and Community Based Services - Day Services Facility)
MSOCS East Metro Community Resources Roseville
360 LARPENTEUR AVE W
Roseville, MN 55113

Satellite License Number: 1104284 (Home and Community Based Services - Community Residential Setting)
MSOCS Portage Lake
22593 PORTAGE LN
Deerwood, MN 56444

Satellite License Number: 1106949 (Home and Community Based Services - Community Residential Setting)
MSOCS Harrow
20355 HARROW AVE N
Forest Lake, MN 55025

Satellite License Number: 1107072 (Home and Community Based Services - Day Services Facility)
West Metro Community Resources Golden Valley
701 DECATUR AVE N
Golden Valley, MN 55427

Satellite License Number: 1107939 (Home and Community Based Services - Community Residential Setting)
MSOCS Hickory Trail
17772 JOHNSON RD
Brainerd, MN 56401

Satellite License Number: 1108529 (Home and Community Based Services - Community Residential Setting)
MSOCS Center City
35226 PARK TRL
Center City, MN 55012

Satellite License Number: 1110612 (Home and Community Based Services - Community Residential Setting)
MSOCS Blooming Prairie
3771 HIGHWAY 30 E
Blooming Prairie, MN 55917

Satellite License Number: 1115222 (Home and Community Based Services - Community Residential Setting)
MSOCS Stony Lake
8620 257TH AVE NW
Zimmerman, MN 55398

Satellite License Number: 1122587 (Home and Community Based Services - Community Residential Setting)
Minnesota Community Based Services
38555 9TH AVE
North Branch, MN 55056



Additional information
Certification: Adult Mental Health Certification - Community Residential Setting - Site Specific

Note: For additional information relating to providers who are licensed by an authority other than the Minnesota Department of Human Services, please contact the licensing authority directly. A directory of county agencies is online.

Public documents available for this license.
Licensing Actions and Maltreatment Investigation Memorandums
Documents below appear for four years from the date of posting
Document type Date issued Format
Maltreatment Investigative Memorandum 4/19/2024 HTML
Maltreatment Investigative Memorandum 3/27/2024 HTML
Maltreatment Investigative Memorandum 1/24/2024 HTML
Maltreatment Investigative Memorandum 10/27/2023 HTML
Maltreatment Investigative Memorandum 10/18/2023 HTML
Maltreatment Investigative Memorandum 10/13/2023 HTML
Maltreatment Investigative Memorandum 9/15/2023 HTML
Maltreatment Investigative Memorandum 8/18/2023 HTML
Maltreatment Investigative Memorandum 7/7/2023 HTML
Maltreatment Investigative Memorandum 5/24/2023 HTML
Maltreatment Investigative Memorandum 3/31/2023 HTML
Maltreatment Investigative Memorandum 3/1/2023 HTML
Correction Order 11/16/2022 HTML
Maltreatment Investigative Memorandum 11/2/2022 HTML
Maltreatment Investigative Memorandum 9/30/2022 HTML
Maltreatment Investigative Memorandum 7/1/2022 HTML
Maltreatment Investigative Memorandum 6/24/2022 HTML
Correction Order 6/24/2022 HTML
Maltreatment Investigative Memorandum 6/10/2022 HTML
Maltreatment Investigative Memorandum 6/8/2022 HTML
Correction Order 5/23/2022 HTML
Correction Order 5/11/2022 HTML
Maltreatment Investigative Memorandum 5/11/2022 HTML
Maltreatment Investigative Memorandum 4/20/2022 HTML
Maltreatment Investigative Memorandum 2/25/2022 HTML
Maltreatment Investigative Memorandum 1/26/2022 HTML
Maltreatment Investigative Memorandum 1/21/2022 HTML
Maltreatment Investigative Memorandum 1/7/2022 HTML
Maltreatment Investigative Memorandum 1/7/2022 HTML
Maltreatment Investigative Memorandum 12/22/2021 HTML
Maltreatment Investigative Memorandum 11/19/2021 HTML
Maltreatment Investigative Memorandum 10/6/2021 HTML
Maltreatment Investigative Memorandum 9/15/2021 HTML
Maltreatment Investigative Memorandum 9/3/2021 HTML
Maltreatment Investigative Memorandum 8/20/2021 HTML
Maltreatment Investigative Memorandum 8/6/2021 HTML
Maltreatment Investigative Memorandum 8/6/2021 HTML
Maltreatment Investigative Memorandum 5/12/2021 HTML
Maltreatment Investigative Memorandum 4/30/2021 HTML
Maltreatment Investigative Memorandum 4/16/2021 HTML
Maltreatment Investigative Memorandum 3/31/2021 HTML
Maltreatment Investigative Memorandum 3/3/2021 HTML
Correction Order 3/3/2021 HTML
Maltreatment Investigative Memorandum 2/12/2021 HTML
Fine Order 2/12/2021 HTML
Maltreatment Investigative Memorandum 2/12/2021 HTML
Maltreatment Investigative Memorandum 1/20/2021 HTML
Maltreatment Investigative Memorandum 12/30/2020 HTML
Maltreatment Investigative Memorandum 11/4/2020 HTML
Maltreatment Investigative Memorandum 9/11/2020 HTML
Maltreatment Investigative Memorandum 8/26/2020 HTML
Maltreatment Investigative Memorandum 7/31/2020 HTML
Maltreatment Investigative Memorandum 7/29/2020 HTML
Maltreatment Investigative Memorandum 7/10/2020 HTML
Maltreatment Investigative Memorandum 6/12/2020 HTML
Maltreatment Investigative Memorandum 5/13/2020 HTML


Human Services (DHS) licensing web page statement:

The information found on this web page is public information. Types of public information you will find on this website include:

  • Maltreatment investigation memorandum*
  • Licensing actions for license types other than family child foster care, including: conditional licenses, fines, revocations, indefinite suspensions, and temporary immediate suspensions (See the glossary of terms for an explanation of each type of licensing action.) Please note that licensing actions for family child foster care are public documents and available upon request from DHS.
  • Summary of reviews and investigations for family child care**
  • Decisions issued by DHS to appeals of violations cited on correction orders and conditional licenses
  • Final agency decisions for licensing actions
  • Correction Orders for license types other than family child care, child foster care, adult foster care, and family adult day service programs. Please note that correction orders are public documents and available upon request from DHS, the licensing county, or the licensing agency

*Maltreatment allegations involving a family child care or family child foster care program are conducted by the County in which the alleged incident occurred.

**Summary of reviews and investigations for all other provider types will be added in the future.

Determinations may be subject to appeal. Not all records related to the license are included on this web page. If you view information that you believe is not public, notify DHS Licensing Division immediately by calling (651) 431-6500.

Minnesota Department of Human Services website accessibility disclaimer: The Minnesota Department of Human Services has a policy of making the information on its websites accessible to people with disabilities. Pursuant to this commitment, DHS implements the provisions of the Americans with Disabilities Act and the Minnesota Human Rights Act. If you experience any difficulty accessing the content, call (651) 431-6500 or send an electronic mail message to DHS.LicensingDivision@state.mn.us to receive the subject matter in an alternative format. Indicate the nature of your accessibility problem, your preferred format, the license number of the facility, type and date of the document and your contact information so DHS can reach you with any questions in fulfilling your request.