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Resident
Vitals Log
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Incident Reports

LIC 624 — Report unusual incidents and injuries. Notify DSS within 24 hours for reportable incidents. Submit written report within 7 days.

LIC 624 on DSS
⚠ NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND RESPONSIBLE PERSONS BY NEXT WORKING DAY. Submit written report within 7 days of occurrence. Retain copy in client's file.

Progress Notes

Narrative notes for residents

Elimination Log

Bowel & bladder tracking with Bristol and hydration reference scales

Admission Agreements

Facility-specific agreement templates — upload once, fill per resident, send for e-signature

Visitor Log

Front-desk visitor sign-in and sign-out

Death Reports

LIC 624A — Report every client death regardless of cause or location. Notify licensing by next working day. Submit within 7 days.

LIC 624A on DSS
⚠ LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED. Notify licensing agency by next working day. Submit written report within 7 days.

Admission Form Checklist

Resident

AI Intake Scanner

Upload a discharge summary, facesheet, physician report, or any admission paperwork. Supports PDF and images (JPG, PNG). The AI will extract all information and fill the resident profile.

Click to upload or drag and drop
PDF, JPG, PNG — discharge papers, hospital facesheet, POLST, physician report
Resident
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
IDENTIFICATION AND EMERGENCY INFORMATION
This information is required under the H & S Code and the regulations of the Department to be maintained on every person admitted to a community care facility, to be readily available to the person in charge, but not accessible to unauthorized persons. All information must be kept current. See other side for additional information required for residential facilities for children.
A. ALL FACILITIES [EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700]
1.
NAME OF CLIENT OR CHILD
SOCIAL SECURITY NUMBER (OPTIONAL)
DATE OF BIRTH
AGE
SEX
2. RESPONSIBLE PERSON OR PLACEMENT AGENCY
NAME
ADDRESS
TELEPHONE
3. NAME OF NEAREST RELATIVE (OPTIONAL)
NAME
RELATIONSHIP
ADDRESS
TELEPHONE
4.
DATE ADMITTED TO FACILITY
ADDRESS PRIOR TO ADMISSION
5. DATE LEFT
FORWARDING ADDRESS
6. REASONS FOR LEAVING FACILITY
7. PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANY
NAME
ADDRESS
TELEPHONE
8. OTHER PERSONS TO BE NOTIFIED IN EMERGENCY
NAME
ADDRESS
TELEPHONE
a. PHYSICIAN
b. MENTAL HEALTH PROVIDER, IF ANY
c. DENTIST
d. RELATIVE(S)
e. FRIEND(S)
9. EMERGENCY HOSPITALIZATION PLAN
NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
MEDICAL PLAN
MEDICAL PLAN IDENTIFICATION NUMBER
NAME OF DENTAL PLAN (IF ANY)
DENTAL PLAN NUMBER (IF ANY)
10. OTHER REQUIRED INFORMATION
a. AMBULATORY STATUS
b. RELIGIOUS PREFERENCE
11. COMMENTS
SIGNATURE OF RESIDENT
SIGNATURE OF PERSON COMPLETING FORM
TITLE
DATE
LIC 601 (8/08) Personal   Page 1 of 2
Section B (Residential Facilities for Children) is on Page 2 and is not applicable for Residential Care Facilities for the Elderly. This form is LIC 601 (8/08) Personal Page 1 of 2.
Resident
View on DSS
California Health & Human Services Agency
California Department of Social Services
MEDICAL ASSESSMENT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
LIC 602A (4/25) (CONFIDENTIAL) Page 1 of 9
NOTE TO LICENSED MEDICAL PROFESSIONAL: The person/patient named below is either a prospective resident or resident of a Residential Care Facility for the Elderly (RCFE) licensed by the Department of Social Services. The licensee is required to provide primarily non-medical care and supervision to meet the needs of that person/patient. The information that you provide about this person/patient is required by law to assist in determining whether the person/patient is appropriate for care in this non-medical facility [California Code of Regulations (CCR), Title 22, Section 87458, Medical Assessment]. THESE FACILITIES CANNOT PROVIDE SKILLED NURSING CARE.

This form is provided as a courtesy to prospective residents/residents and licensees.

(Please attach separate pages if needed.)
I. FACILITY INFORMATION (To be completed by the licensee/designee)
NAME OF FACILITY/FACILITY CONTACT PERSON
PHONE NUMBER
E-MAIL ADDRESS
ADDRESS
CITY
ZIP CODE
II. PROSPECTIVE RESIDENT/RESIDENT INFORMATION (To be completed by the prospective resident/resident or prospective resident's/resident's legal representative)
NAME
DATE OF BIRTH
AGE
ADDRESS
CITY
ZIP CODE
III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (To be completed by prospective resident/resident or prospective resident's/resident's legal representative)
I hereby authorize release of medical information in this report to the facility named above.
I acknowledge that by providing my electronic signature for this form, I agree my electronic signature is the legal binding equivalent to my handwritten signature. I hereby confirm that my electronic signature represents my execution of authentication of this form, and my intent to be bound by it.
SIGNATURE OF PROSPECTIVE RESIDENT/RESIDENT OR PROSPECTIVE RESIDENT'S/RESIDENT'S LEGAL REPRESENTATIVE
DATE
LIC 602A (4/25) (CONFIDENTIAL) Page 1 of 9
Page 2 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 2 of 9
IV. PROSPECTIVE RESIDENT/RESIDENT INFORMATION (To be completed by the licensed medical professional)
DATE OF EXAM
GENDER
HEIGHT
WEIGHT
BLOOD PRESSURE
DIAGNOSIS/DIAGNOSES
a. Please indicate the prospective resident's/resident's diagnosis/diagnoses:
b. Treatment/medication (type and dosage)/equipment:
c. Can prospective resident/resident manage own treatment/medication/equipment?      
If no, describe what assistance is needed:
DEFINITIONS

Mild Cognitive Impairment (MCI): Refers to cognitive abilities that are in a "conditional state" between normal aging and dementia.

Major Neurocognitive Disorder (major NCD): Refers to substantially decreased cognitive or mental function due to a medical disease other than a psychiatric illness. Major NCD includes Alzheimer's disease and related disorders diagnosed by a licensed medical professional acting within their scope of practice. Related disorders considered to be major NCDs include, but are not limited to, vascular dementia, Lewy body dementia, Parkinson's disease, and frontotemporal dementia. Major NCDs cause impairment that is sufficient enough to interfere with independence in daily activities and may result in changes that include, but are not limited to, increased tendency to wander and decreased hazard awareness and ability to communicate.

COGNITIVE CONDITIONS
a. Does prospective resident/resident have any cognitive conditions?      
If yes, please indicate cognitive condition(s):
b. Treatment/medication (type and dosage)/equipment:
c. Can prospective resident/resident manage own treatment/medication/equipment?      
If no, describe what assistance is needed:
RESULTS OF EXAM FOR COMMUNICABLE TUBERCULOSIS (TB)
DATE TB TEST GIVEN
DATE TB TEST READ
TYPE OF TB TEST
RESULTS OF TB TEST
Action taken (if positive):
LIC 602A (4/25) (CONFIDENTIAL) Page 2 of 9
Page 3 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 3 of 9
RESULTS OF EXAM FOR INFECTIOUS DISEASES
a. Does prospective resident/resident have any infectious diseases?      
If yes, please indicate infectious disease(s):
b. Treatment/medication (type and dosage)/equipment:
c. Can prospective resident/resident manage own treatment/medication/equipment?      
If no, describe what assistance is needed:
RESULTS OF EXAM FOR CONTAGIOUS DISEASES
a. Does prospective resident/resident have any contagious diseases?      
If yes, please indicate contagious disease(s):
b. Treatment/medication (type and dosage)/equipment:
c. Can prospective resident/resident manage own treatment/medication/equipment?      
If no, describe what assistance is needed:
RESULTS OF EXAM FOR OTHER MEDICAL CONDITIONS
a. Does prospective resident/resident have any other medical conditions?      
If yes, please indicate other medical condition(s):
b. Treatment/medication (type and dosage)/equipment:
c. Can prospective resident/resident manage own treatment/medication/equipment?      
If no, describe what assistance is needed:
LIC 602A (4/25) (CONFIDENTIAL) Page 3 of 9
Page 4 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 4 of 9
ALLERGIES
a. Does prospective resident/resident have any allergies (e.g., seasonal, food, medication, dander)?      
If yes, please indicate allergy(ies):
b. Treatment/medication (type and dosage)/equipment:
c. Can prospective resident/resident manage own treatment/medication/equipment?      
If no, describe what assistance is needed:
1. OVERALL PHYSICAL HEALTH
PHYSICAL HEALTH STATUS YES NO ASSISTIVE DEVICE (If applicable) EXPLAIN
COMMENTS:
LIC 602A (4/25) (CONFIDENTIAL) Page 4 of 9
Page 5 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 5 of 9
2. CAPACITY FOR SELF-CARE
YES NO EXPLAIN
COMMENTS:
3. OVERALL MENTAL HEALTH
MENTAL HEALTH STATUS YES NO EXPLAIN
COMMENTS:
LIC 602A (4/25) (CONFIDENTIAL) Page 5 of 9
Page 6 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 6 of 9
4. BEHAVIORAL EXPRESSIONS*
YES NO EXPLAIN

* "Behavioral expression" means behavior or behaviors displayed by a resident that may result in harm to self or others including, but not limited to, unsafe wandering, or elopement, expressions of frustration, disorientation, hallucinations, or lacking in hazard awareness or impulse control. Behavioral expression may be due to boredom, fear, overstimulation, perceived threat, fatigue, physical discomfort, pain, "Major Neurocognitive Disorder (major NCD)", or other causes including, but not limited to, medication interactions and/or illnesses such as urinary tract infections.

** "Unsafe wandering" occurs when a resident at risk enters an area that is physically hazardous or contains items that are potential safety hazards. For example, unsafe wandering may occur when a resident enters another resident's room when doing so may lead to an altercation or contact with hazardous items.

***"Elopement" occurs when a resident who is at risk of harm due to their cognitive condition leaves the facility unsupervised, or while in the licensee's care, leaves another safe location unsupervised.

COMMENTS:
LIC 602A (4/25) (CONFIDENTIAL) Page 6 of 9
Page 7 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 7 of 9
5. ACCESS TO ITEMS
YES NO EXPLAIN
Would the prospective resident's/resident's or other resident's safety be at risk if the resident had access to the following items:
a. Personal care and hygiene items
b. Disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents.
c. Nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies.
Does the prospective resident/resident require supervision by the licensee when in proximity to or when there is use of:
a. Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices.
b. Fishponds, wading pools, hot tubs, swimming pools, or similar large bodies of water.
c. Birdbaths, fountains, or similar smaller decorative water features.
COMMENTS:
LIC 602A (4/25) (CONFIDENTIAL) Page 7 of 9
Page 8 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 8 of 9
6. MEDICATION MANAGEMENT
YES NO N/A EXPLAIN
COMMENTS:
AMBULATORY STATUS:
a. 1. The prospective resident/resident is able to independently transfer to and from bed:      
2. For purposes of a fire clearance, this prospective resident/resident is considered:

Nonambulatory: The prospective resident/resident is unable to leave a building unassisted under emergency conditions. This includes, but is not limited to, a prospective resident/resident who depends upon mechanical aids such as crutches, walkers, and wheelchairs. It also includes a prospective resident/resident who is unable, or likely to be unable, to respond physically or mentally to a sensory signal approved by the State Fire Marshal, or an oral instruction relating to fire or other dangers, and if unassisted, to take appropriate action relating to such danger.

Note: A prospective resident/resident who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be considered non-ambulatory for the purposes of a fire clearance.

Bedridden: For the purpose of a fire clearance, this means a prospective resident/resident who requires assistance with turning or repositioning in bed.

b. If prospective resident/resident is nonambulatory, this status is based upon:
LIC 602A (4/25) (CONFIDENTIAL) Page 8 of 9
Page 9 of 9
California Health & Human Services Agency · California Department of Social Services
LIC 602A (4/25) (CONFIDENTIAL) Page 9 of 9
c. If a prospective resident/resident is bedridden, check one or more of the following and describe the nature of the illness, surgery or other cause:
NOTE: An illness or recovery is considered temporary if it will last 14 days or less.
d. If a prospective resident/resident is bedridden, how long is bedridden status expected to persist?
1. Number of days
2. Estimated date illness or recovery is expected to end
3. If illness or recovery is permanent, please explain:
e. Is prospective resident/resident receiving hospice care?      
If yes, specify the terminal illness:
COMMENTS:
V. LICENSED MEDICAL PROFESSIONAL INFORMATION
LICENSED MEDICAL PROFESSIONAL NAME AND ADDRESS (PRINT)
PHONE NUMBER
E-MAIL ADDRESS
LENGTH OF TIME YOU HAVE PROVIDED CARE TO PROSPECTIVE RESIDENT/RESIDENT
LICENSED MEDICAL PROFESSIONAL SIGNATURE
I acknowledge that by providing my electronic signature for this form, I agree my electronic signature is the legal binding equivalent to my handwritten signature. I hereby confirm that my electronic signature represents my execution of authentication of this form, and my intent to be bound by it.
DATE
LIC 602A (4/25) (CONFIDENTIAL) Page 9 of 9
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
PREPLACEMENT APPRAISAL INFORMATION
Admission - Residential Care Facilities
NOTE: This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospital or physician may assist the applicant in completing this form.) This form is not a substitute for the Physician's Report (LIC 602).
APPLICANT'S NAME
AGE
HEALTH
(Describe overall health condition including any dietary limitations)
PHYSICAL DISABILITIES
(Describe any physical limitations including vision, hearing or speech)
MENTAL CONDITION
(Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))
HEALTH HISTORY
(List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years)
SOCIAL FACTORS
(Describe likes and dislikes, interests and activities)
BED STATUS
TUBERCULOSIS INFORMATION
ANY HISTORY OF TUBERCULOSIS IN APPLICANT'S FAMILY?
DATE OF TB TEST
ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?
ACTION TAKEN (IF POSITIVE)
GIVE DETAILS
LIC 603 (9/99) — Page 2
AMBULATORY STATUS (this person is      )
Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device. An ambulatory person must be able to do the following:
YES NO
Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.
Mentally and physically able to follow signals and instructions for evacuation.
Able to use evacuation routes including stairs if necessary.
Able to evacuate reasonably quickly (e.g., walk directly the route without hesitation).
FUNCTIONAL CAPABILITIES (Check all items below)
YES NO
Active, requires no personal help of any kind - able to go up and down stairs easily
Active, but has difficulty climbing or descending stairs
Uses brace or crutch
Feeble or slow
Uses walker. If Yes, can get in and out unassisted?
Uses wheelchair. If Yes, can get in and out unassisted?
Requires grab bars in bathroom
Other: (Describe)
SERVICES NEEDED (Check items and explain)
YES NO
Help in transferring in and out of bed and dressing
Help with bathing, hair care, personal hygiene
Does client desire and is client capable of doing own personal laundry and other household tasks (specify)
Help with moving about the facility
Help with eating (need for adaptive devices or assistance from another person)
Special diet/observation of food intake
Toileting, including assistance equipment, or assistance of another person
Continence, bowel or bladder control. Are assistive devices such as a catheter required?
Help with medication
Needs special observation/night supervision (due to confusion, forgetfulness, wandering)
Help in managing own cash resources
Help in participating in activity programs
Special medical attention
Assistance in incidental health and medical care
Other “Services Needed” not identified above
Is there any additional information which would assist the facility in determining applicant's suitability for admission?      
If Yes, please attach comments on separate sheet.
To the best of my knowledge; I (the above person) do not need skilled nursing care.
SIGNATURE
Click to sign
APPLICANT (CLIENT) OR AUTHORIZED REPRESENTATIVE
DATE COMPLETED
SIGNATURE
Click to sign
LICENSEE OR DESIGNATED REPRESENTATIVE
DATE COMPLETED
LIC 603 (9/99)
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
RESIDENT APPRAISAL
Residential Care Facilities For The Elderly
NOTE: This information may be obtained from the Prospective Resident, or his/her responsible person. This form is not a substitute for the Physician's Report (LIC 602).
APPLICANT'S NAME
AGE
HEALTH
(Describe overall health condition including any dietary limitations)
PHYSICAL DISABILITIES
(Describe any physical limitations including vision, hearing or speech)
MENTAL CONDITION
(Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))
HEALTH HISTORY
(List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years)
SOCIAL FACTORS
(Describe likes and dislikes, interests and activities)
BED STATUS
(An exception must be obtained to admit or retain a resident who will be temporarily bedridden more than 14 days. Permanently bedridden residents are prohibited).
TUBERCULOSIS INFORMATION
ANY HISTORY OF TUBERCULOSIS IN APPLICANT'S FAMILY?
DATE OF TB TEST/TYPE OF TEST
ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?
ACTION TAKEN (IF POSITIVE)
GIVE DETAILS
LIC 603A (7/99) — Page 2
AMBULATORY STATUS (this person is      )
Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device other than a cane. An ambulatory person must be able to do the following:
YES NO
Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.
Mentally and physically able to follow signals and instructions for evacuation.
Able to use evacuation routes including stairs if necessary.
Able to evacuate reasonably quickly (e.g., walk directly the route without hesitation).
FUNCTIONAL CAPABILITIES (Check all items below)
YES NO
Active, requires no personal help of any kind - able to go up and down stairs easily
Active, but has difficulty climbing or descending stairs
Uses brace or crutch
Frail or slow
Uses walker. If Yes, can get in and out unassisted?
Uses wheelchair. If Yes, can get in and out unassisted?
Requires grab bars in bathroom
Other: (Describe)
SERVICES NEEDED (Check items and explain)
YES NO
Help in transferring in and out of bed/turning in bed or chair (specify)
Help with bathing
Help with dressing, hair care, and personal hygiene (specify)
Does prospective resident desire and is he/she capable of doing own personal laundry and other household tasks? (specify)
Help with moving about the facility
Help with eating (need for adaptive devices or assistance from another person)
Special diet/observation of food intake
Toileting, including assistance equipment, or assistance of another person (specify)
Continence, bowel or bladder control. Are assistive devices such as a catheter required?
Help with medication
Needs special observation/night supervision (due to confusion, forgetfulness, wandering)
Help in managing own cash resources
Help in participating in activity programs
Special medical attention
Assistance in incidental health and medical care
Other “Services Needed” not identified above
Is there any additional information which would assist the facility in determining applicant's suitability for admission?      
If Yes, please attach comments on separate sheet.
TO THE BEST OF MY KNOWLEDGE, I/THE ABOVE PERSON DO/DOES NOT NEED SKILLED NURSING CARE.
SIGNATURE
Click to sign
SIGNATURE OF APPLICANT OR RESPONSIBLE PERSON
DATE COMPLETED
SIGNATURE
Click to sign
SIGNATURE OF LICENSEE OR DESIGNATED REPRESENTATIVE
DATE COMPLETED
LIC 603A (7/99)
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
APPRAISAL/NEEDS AND SERVICES PLAN
CLIENT'S/RESIDENT'S NAME
DATE OF BIRTH
AGE
DATE
SEX
CHECK TYPE OF NEEDS AND SERVICES PLAN
FACILITY NAME
FACILITY LICENSE NUMBER
TELEPHONE NUMBER
ADDRESS
PERSON(S) OR AGENCY(IES) REFERRING CLIENT/RESIDENT FOR PLACEMENT
Licensing regulations require that an appraisal of needs be completed for specific clients/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for admission shall jointly develop a needs and services plan with the client/resident and/or client’s/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Additionally, the law requires that the referral agency/person inform the licensee of any dangerous tendencies of the client/resident.
NOTE: For Residential Care Facilities for the Elderly, this form is not required at the time of admission but must be completed if it is determined that an elderly resident’s needs have not been met.
BACKGROUND INFORMATION
Brief description of client’s/resident’s medical history/ emotional, behavioral, and physical problems; functional limitations; physical and mental; functional capabilities; ability to handle personal cash resources and perform simple homemaking tasks; client’s/resident’s likes and dislikes.
LIC 625 (6/12)   CONFIDENTIAL   PAGE 1 OF 4
Page 2 of 4
NEEDS OBJECTIVE/PLAN TIME FRAME PERSON(S) RESPONSIBLE FOR IMPLEMENTATION METHOD OF EVALUATING PROGRESS
EMOTIONAL — Difficulty in adjusting emotionally
SOCIALIZATION — Difficulty in adjusting socially and unable to maintain reasonable personal relationships
LIC 625 (6/12)   CONFIDENTIAL   PAGE 2 OF 4
Page 3 of 4
NEEDS OBJECTIVE/PLAN TIME FRAME PERSON(S) RESPONSIBLE FOR IMPLEMENTATION METHOD OF EVALUATING PROGRESS
MENTAL — Difficulty with intellectual functioning including inability to make decisions regarding daily living.
PHYSICAL/HEALTH — Difficulties with physical development and poor health habits regarding body functions.
LIC 625 (6/12)   CONFIDENTIAL   PAGE 3 OF 4
Page 4 of 4
NEEDS OBJECTIVE/PLAN TIME FRAME PERSON(S) RESPONSIBLE FOR IMPLEMENTATION METHOD OF EVALUATING PROGRESS
FUNCTIONING SKILLS — Difficulty in developing and/or using independent functioning skills.
We believe this person is compatible with the facility program and with other clients/residents in the facility, and that I/we can provide the care as specified in the above objective(s) and plan(s).
TO THE BEST OF MY KNOWLEDGE THIS CLIENT/RESIDENT DOES NOT NEED SKILLED NURSING CARE.
LICENSEE(S) SIGNATURE
Click to sign
DATE
CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S)/FACILITY SOCIAL WORKER/PHYSICIAN/OTHER APPROPRIATE CONSULTANT SIGNATURE
Click to sign
DATE
I have reviewed and agree with the above assessment and believe the licensee(s) other person(s)/agency can provide the needed services for this client/resident
I/We have participated in and agree to release this assessment to the licensee(s) with the condition that it will be held confidential.
CLIENT’S/RESIDENT’S OR CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S) SIGNATURE
Click to sign
DATE
LIC 625 (6/12)   CONFIDENTIAL   PAGE 4 OF 4
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
CLIENT/RESIDENT PERSONAL PROPERTY AND VALUABLES
Facilities must safeguard client's/resident's personal property/valuables entrusted to the facility. Licensee/Administrator is responsible for maintaining a record of personal property/valuables entrusted to and removed from the facility. Under “Number”, enter the quantity of items entrusted. Under “Description”, describe the item (marking articles by names or numbers may aid identification.). Under “Location”, enter where items are stored. Licensee/Administrator and client/resident must sign each entry. Explain why, if client/resident does not sign. Provide a copy to the client/resident and maintain a copy in client's/resident's file. As property/valuable is removed, explain the reason for removal, enter the removal date, and ensure form is signed by all required persons specified above.
The reverse side of this form may be completed and retained in Residential Care Facilities for the Elderly to meet the notice requirements of Health and Safety Code Section 1569.153(k).
NAME OF CLIENT/RESIDENT
SOCIAL SECURITY NO.
A. PERSONAL PROPERTY/VALUABLES ENTRUSTED TO FACILITY
Number Description Date Location Signature of Client/Resident (or if “None” explain) Signature of Licensee/Administrator
B. PERSONAL PROPERTY/VALUABLES REMOVED
Number Description Date Location Signature of Client/Resident (or if “None” explain) Signature of Licensee/Administrator
LIC 621 (4/99) (CONFIDENTIAL)
Reverse Side — Residential Care Facilities For The Elderly Only
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY ONLY.
Section 1569.152 of the Health and Safety Code:
1569.152. (a) A residential care facility for the elderly, as defined in Section 1569.2, which fails to make reasonable efforts to safeguard resident property shall reimburse a resident for or replace stolen or lost resident property at its then current value. The facility shall be presumed to have made reasonable efforts to safeguard resident property if the facility has shown clear and convincing evidence of its efforts to meet each of the requirements specified in Section 1569.153. The presumption shall be a rebuttable presumption, and the resident or the resident's representative may pursue this matter in any court of competent jurisdiction.
(b) A civil penalty shall be levied if the residential care facility for the elderly has no program in place or if the facility has not shown clear and convincing evidence of its efforts to meet all of the requirements set forth in Section 1569.153. The State Department of Social Services shall issue a deficiency in the event that the manner in which the policies have been implemented is inadequate or the individual facility situation warrants additional theft and loss protections.
(c) The department shall not determine that a facility's program is inadequate based solely on the occasional occurrence of theft or loss in a facility.
SEC. 3. Section 1569.153 of the Health and Safety Code:
1569.153. A theft and loss program shall be implemented by the residential care facilities for the elderly within 90 days after January 1, 1989. The program shall include all of the following:

(a) Establishment and posting of the facility's policy regarding theft and investigative procedures.

(b) Orientation to the policies and procedures for all employees within 90 days of employment.

(c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery of the loss or theft and, upon request, the documented theft and loss record for the past 12 months shall be made available to the State Department of Social Services, law enforcement agencies and to the office of the State Long-Term Care Ombudsman in response to a specific complaint. The documentation shall include, but not be limited to, the following:

(1) A description of the article.

(2) Its estimated value.

(3) The date and time the theft or loss was discovered.

(4) If determinable, the date and time the loss or theft occurred.

(5) The action taken.

(d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident's behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident's representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident's family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident's family, or a responsible party may list those items which are not subject to addition or deletion from the inventory such as personal clothing or laundry, which are subject to frequent removal from the facility.

(e) Inventory and surrender of the resident's personal effects and valuables upon discharge to the resident or authorized representative in exchange for a signed receipt.

(f) Inventory and surrender of personal effects and valuables following the death of a resident to the authorized representative in exchange for a signed receipt. Immediate written notice to the public administrator of the county upon the death of a resident whose heirs are unable or unwilling to claim the property as specified in Chapter 20 (commencing with Section 1140) of Division 3 of the Probate Code.

(g) Documentation, at least semiannually, of the facility's efforts to control theft and loss, including the review of theft and loss documentation and investigative procedures and results of the investigation by the administrator and, when feasible, the resident council.

(h) Establishment of a method of marking, to the extent feasible, personal property items for identification purposes upon admission and, as added to the property inventory list, including engraving of dentures and tagging of other prosthetic devices.

(i) Reports to the local law enforcement agency within 36 hours when the administrator of the facility has reason to believe resident property with a then current value of one hundred dollars ($100) or more has been stolen. Copies of those reports for the preceding 12 months shall be made available to the State Department of Social Services and law enforcement agencies.

(j) Maintenance of a secured area for residents' property which is available for safekeeping of resident property upon the request of the resident or the resident's responsible party. Provide a lock for the resident's bedside drawer or cabinet upon request of and at the expense of the resident, the resident's family, or authorized representative. The facility administrator shall have access to the locked areas upon request.

(k) A copy of this section and Sections 1569.152, 1569.153 and 1569.154 is provided by a facility to all of the residents and their responsible parties, and available upon request, to all of the facility's prospective residents and their responsible parties.

(l) Notification to all current residents and all new residents, upon admission, of the facility's policies and procedures relating to the facility's theft and loss prevention program.

(m) Only those residential units in which there are no unrelated residents and where the unit can be secured by the resident or residents are exempt from the requirements of this section.

Section 1569.154 of the Health and Safety Code:
1569.154. No provision of a contract of admission, which includes all documents which a resident or his or her representative is required to sign at the time of, or as a condition of, admission to a residential care facility for the elderly, shall require or imply a lesser standard of responsibility for the personal property of residents than is required by law.
I have received a copy of Health and Safety Code Sections: 1569.152, 1569.153, and 1569.154 and am acquainted with the facilities personal property safeguard procedures.
CLIENT/RESIDENT/RESPONSIBLE PERSON SIGNATURE
Click to sign
TITLE
DATE
LICENSEE OR DESIGNATED REPRESENTATIVE
Click to sign
DATE COMPLETED
Resident
View on DSS
State of California — Health and Human Services Agency
Department of Social Services
Community Care Licensing
CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD
I. CENTRALLY STORED MEDICATION
INSTRUCTIONS: Centrally stored medications shall be kept in a safe and locked place that is not accessible to any person(s) except authorized individuals. Medication records on each client/resident shall be maintained for at least one year.
NAME (LAST FIRST MIDDLE)
ADMISSION DATE
ATTENDING PHYSICIAN
ADMINISTRATOR
FACILITY NAME
FACILITY NUMBER
MEDICATION NAME STRENGTH/
QUANTITY		 INSTRUCTIONS
CONTROL/CUSTODY		 EXPIRATION
DATE		 DATE
FILLED		 DATE
STARTED		 PRESCRIBING
PHYSICIAN		 PRESCRIPTION
NUMBER		 NO. OF
REFILLS		 NAME OF
PHARMACY
LIC 622 (3/99) (CONFIDENTIAL)
II. MEDICATION DESTRUCTION RECORD
INSTRUCTIONS: Prescription drugs not taken with the client/resident upon termination of services or otherwise disposed of shall be destroyed in the facility by the Administrator or Designated Representative and witnessed by one other adult who is not a client/resident. All facilities except Residential Care Facilities for the Elderly (RCFEs) shall retain destruction records for at least one year. RCFEs shall retain records for at least three years.
MEDICATION NAME STRENGTH/
QUANTITY		 INSTRUCTIONS
CONTROL/CUSTODY		 EXPIRATION
DATE		 DATE
FILLED		 DATE
STARTED		 PRESCRIBING
PHYSICIAN		 PRESCRIPTION
NUMBER		 DISPOSAL
DATE		 NAME OF
PHARMACY		 NO. OF
REFILLS
SIGNATURE OF ADMINISTRATOR OR DESIGNATED REPRESENTATIVE
Click to sign
SIGNATURE OF WITNESS ADULT NON-CLIENT
Click to sign
LIC 622 (3/99) (CONFIDENTIAL)
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
RELEASE OF CLIENT/RESIDENT MEDICAL INFORMATION
To
(PHYSICIAN, CLINIC, HOSPITAL, HOSPICE, HOME HEALTH AGENCY, ATTENDING NURSE, PSYCHOLOGIST, COUNSELOR, THERAPIST, ETC.)
Date:
(ADDRESS)
I hereby authorize you to release any and all medical or confidential information contained in the record of:
(NAME OF PERSON)
to
(NAME AND ADDRESS OF FACILITY, PERSON OR AGENCY REQUESTING INFORMATION)
THIS AUTHORIZATION SHALL EXPIRE ON:
(DATE)
CLIENT OR AUTHORIZED REPRESENTATIVE
(CLIENT OR AUTHORIZED REPRESENTATIVE)
RELATIONSHIP TO PERSON ON WHOM INFORMATION IS REQUESTED
(RELATIONSHIP TO PERSON ON WHOM INFORMATION IS REQUESTED)
ADDRESS
(ADDRESS)
NOTE:

1. The person who authorized this release may revoke this authorization at any time.

2. The person who authorized this release has a right to receive a copy of the release.

3. This information is required to conform to CCR Title 22 regulations, to ensure a continuum of care to the resident, client or child. Licensees should maintain a copy of this form in the facility records.

4. The above facility is licensed by the Department of Social Services (or its accredited agencies), and does not provide skilled nursing care.

LIC 605 A (5/00)
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
CONSENT FOR EMERGENCY MEDICAL TREATMENT
Adult and Elderly Residential Facilities
AS THE CLIENT, AUTHORIZED REPRESENTATIVE OR CONSERVATOR, I HEREBY GIVE CONSENT TO
FACILITY NAME
TO PROVIDE ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
NAME
. THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE INDIVIDUAL NAMED ABOVE.
CLIENT HAS THE FOLLOWING MEDICATION ALLERGIES:
DATE
CLIENT/AUTHORIZED REPRESENTATIVE/CONSERVATOR SIGNATURE
Click to sign
(CIRCLE APPROPRIATE TITLE)
HOME ADDRESS
HOME PHONE
WORK PHONE
LIC 627C (ENG/SP) (4/00) (CONFIDENTIAL)
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
Community Care Licensing
ADMISSION AGREEMENTS FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
GUIDE TO ADMISSION AGREEMENTS FOR RESIDENTIAL CARE FACILITY FOR THE ELDERLY
GENERAL INSTRUCTIONS

You may use these instructions and the following form as a guide to create an admission agreement for your facility, or you may modify and use this form. If you have questions, please contact your licensing office.

Definition:

An admission agreement contract includes all documents that a resident or responsible person must sign at the time of, or as a condition of, admission. It may not include any written attachment that contains prohibited provision(s).

Reference: Health & Safety (H&S) Code Sections 1569.154, 1569.880.

Language and Format:

The admission agreement must be:

  • Written in clear, easily understandable language, using words with common and everyday meaning.
  • Appropriately divided with each section suitably captioned.
  • Printed in black ink, 12-point type size, on plain white paper using only one side of the paper.

Reference: H&S Code Sections 1569.882.

Standard of Responsibility/Liability and Unlawful Provisions:

The admission agreement must not:

  • Require or imply a lesser standard of responsibility for the residents' personal property than is required by law.
    Reference: H&S Code Section 1569.154
  • Release you from responsibility for providing a safe and healthful facility, equipment, and accommodations.
    Reference: Title 22 California Code of Regulations (CCR) Section 87568
  • Include any provision of unlawful waivers of facility liability for the residents' health and safety or personal property.
    Reference: H&S Code Section 1569.883(a)
  • Include any provision that you know, or should know, is deceptive or unlawful.
    Reference: H&S Code Section 1569.883(b)
LIC 604A (2/05) (CONFIDENTIAL)
Posting, Copies, Retention:
  • You must retain the original admission agreement and any modifications in the resident's file.
    Reference: CCR Section 87568
  • You must provide a copy to the resident and responsible person, if any, or conservator.
    Reference: CCR Section 87568
  • You must make blank complete copies of the admission agreement immediately available to the public. You may charge the cost for copying and mailing. A complete copy of a blank admission agreement, or notice of its availability, must be placed in a conspicuous location accessible to public view in the facility.
    Reference: H&S Code Section 1569.881
  • A list of other services and charges available through the facility must be posted in a location accessible to residents.
    Reference: CCR Section 87568
Optional Services:

You may assess a separate charge for an item for service only if authorized by the admission agreement. If additional services are available through the facility to be purchased by the resident that were not available at the time the admission agreement was signed, a list of these services and charges shall be provided to the resident or the resident's responsible person. A statement acknowledging the acceptance or refusal to purchase the additional services shall be signed and dated by the resident or the resident's responsible person and attached to the admission agreement.

Reference: H&S Code Section 1569.884(c)

Preadmission Fees:

You may charge a single preadmission fee for non-SSI/SSP residents as long as you provide a written general statement describing costs associated with the fee and you state whether or not the fee is refundable. You may not charge a deposit against any possible damages by the resident. If the fee or some portion is refundable, the written statement must describe the conditions for refund.

Reference: H&S Code Section 1569.651

Dementia:

You must include a statement informing residents and/or responsible persons and conservators that environments, services and programs specific to dementia care are described in the facility's plan of operation and the plan is available for review upon request.

Reference: CCR Section 87725

Theft and Loss Program:

You do not need to notify a resident(s) of the policies and procedures concerning the facility's theft and loss prevention program, if the unit can be secured by the resident(s), and providing there are no unrelated residents sharing the unit.

Reference: H&S Code Section 1569.153(m)

Note: This admissions agreement is structured so that paragraphs titled "A" indicate specific requirement(s), while paragraphs titled "B", "C" and "D" offer possible methods of referring to the requirement in your admission agreement.
LIC 604A (2/05) (CONFIDENTIAL)
This admission agreement complies with the referenced sections of the Health and Safety Code and of the California Code of Regulations, Title 22, as of the date shown at the bottom of this form.
1. FACILITY INFORMATION
NAME OF FACILITY
FACILITY LICENSE NUMBER
TELEPHONE
ADDRESS
CITY
STATE   ZIP
A residential care facility for the elderly licensed by the California State Department of Social Services IS NOT ALLOWED TO PROVIDE 24-HOUR SKILLED NURSING CARE.
NAME OF LICENSEE
TELEPHONE
LICENSEE'S MAILING ADDRESS
CITY
STATE   ZIP
2. RESIDENT INFORMATION
NAME OF RESIDENT
SOCIAL SECURITY NO. (VOLUNTARY)
RESPONSIBLE PERSON
BIRTHDATE
DATE OF ADMISSION
ADDRESS
RELATIONSHIP
TELEPHONE
NOTE: "Responsible person" means that individual or individuals, including a relative, health care surrogate decision maker, or placement agency, who assist the resident in placement or assume varying degrees of responsibility for the resident's well-being.
Reference: CCR 87101
3. BASIC SERVICES

A. To ensure a safe and healthful living environment for all residents the following basic services must be available. The services actually provided will be those the resident wants and those the resident needs, based on the individual's pre-admission appraisal, and the needs and services plan. Subsequent resident appraisals may result in the need for additional basic services.

B. Basic services at a minimum include:

(1) Continuous care and supervision;
(2) Observation for changes in physical, mental, emotional, and social functioning; and
(3) Notification to resident's family, physician, and other appropriate person/agency of resident's needs.
(4) Lodging:
(5) Food Services:
(If additional space is needed, attach signed and dated sheet.)
(6) Helping gain access to supportive services as follows:
(If additional space is needed, attach signed and dated sheet.)
LIC 604A (2/05) (CONFIDENTIAL) Page 1
(If additional space is needed, attach signed and dated sheet.)
(If additional space is needed, attach signed and dated sheet.)
other personal care needs:
(If additional space is needed, attach signed and dated sheet.)

Additional basic services that the resident needs or wants, and that will be provided by the facility, include those checked below:

Reference: H&S Code Sections 1569.2, 1569.312, CCR Sections 87101(c), 87568, 87854, 87590, 87591
LIC 604A (2/05) (CONFIDENTIAL) Page 2
4. RATE FOR BASIC SERVICES
The monthly private pay rate for basic services as specified above is
$
The monthly SSI/SSP rate for all basic services as specified above is
$
Reference: H&S Code Sections 1569.312, 1569.884, CCR Section 87568
NOTICE TO SSI/SSP BENEFICIARIES AND THEIR RESPONSIBLE PERSONS: If the resident is a SSI/SSP recipient, then basic services shall be provided at the SSI/SSP rate at no additional charge to the resident. It is a violation of law for the licensee to purposely obtain an SSI/SSP beneficiary's personal and incidental needs allowance to pay for basic services, including care and supervision. To enable verification that this law is being properly observed, the State Department of Social Services recommends that residents voluntarily disclose in this admission agreement whether the rate paid to the facility includes SSI/SSP benefits.
Reference: Welfare & Institutions Code Sections 13920, 13921, CCR Section 87590, 87101
5. OPTIONAL ITEMS AND SERVICES

A. Optional Services are those services not included under basic services. You must state whether optional services are available, list the optional services, and identify their cost(s).

B. The following optional services are desired by the resident.

ITEM AND SERVICE TIME AND FREQUENCY FOR PROVIDING SERVICE RATE FOR ITEM OR SERVICE
(1)
(2)
(3)
(If additional space is needed, attach signed and dated sheet.) Reference: H&S Code Section 1569.884(c), CCR Section 87568.
6. THIRD PARTY SERVICES

A. The agreement must explain any third party service(s) available, within the facility, that are related to the resident's service plan.

OR
(Resident or Responsible Person's Initials)
Reference: H&S Code Section 1569.884(c).
LIC 604A (2/05) (CONFIDENTIAL) Page 3
7. PAYMENT PROVISIONS

A. The agreement must include a comprehensive description of billing and payment policies and procedures.

B. The billing and payment policies and procedures are:

(If additional space is needed, attach signed and dated sheet.)

C. The monthly costs are as follows:

1) Basic service rate
2) Costs for optional services
3) Third party service(s)
Total:

D.

1) Payment is due on:
2) Method of payment accepted:
3) Payment may be delivered to:
Reference: H&S Code Sections 1569.651(b), 1569.655(a), 1569.884(d), 1569.884(e), 1569.884(f), CCR Sections 87658, 87568, 87101, 87568
8. RATE CHANGE

A. The agreement must inform the resident of the conditions under which rates may be increased and provide no less than 60 days prior written notice to the resident or the resident's responsible person. The written notice must include the amount of the increase, the reason for the increase, and a general description of the additional costs. This does not apply to optional services provided under a separate fee-for-service arrangement with the resident. Written notice must be provided to the resident and the resident's representative, if any, within two business days of providing service at a new level of care that results in a rate increase. The notice must include a detailed explanation of the additional services provided at the new level of care, and must itemize the charges.

B. Written notice will be provided to the resident and the resident's representative, if any, within two business days of providing service at a new level of care that results in a rate increase. The notice will include a detailed explanation of the additional services provided at the new level of care, and will itemize the charges.

(Resident or Responsible Person's Initials)

C. Written notice of a general increase will be provided

days (60 or more), prior to the increase. (Resident or Responsible Person's Initials)
Reference: H&S Code Sections 1569.651, 1569.655, 1569.884, CCR Section 87568
LIC 604A (2/05) (CONFIDENTIAL) Page 4
9. REFUND POLICY

A. The agreement must indicate whether or not all, or any portion(s), of a payment will be refunded.

B. Refunds will be granted as follows:

(If additional space is needed, attach signed and dated sheet.)
C. If the resident leaves the facility temporarily, the holding rate for his/her room is $ per day. The total monthly rate set forth in the admission agreement be prorated on a daily basis upon the resident's admission to, or permanent departure from, the facility during the month.
Reference: H&S Code Section 1569.884, CCR Section 87568
10. TELEPHONE SERVICES

A. Telecommunications Device Form (LIC 9158), must be attached to each agreement.

B. The signed and dated form is attached. (Resident or Responsible Person's Initials)
Reference: H&S Code Section 1569.159, CCR Section 87568
11. HOUSE RULES/FACILITY POLICIES

A. The house rules must be for the purpose of making it possible for residents to live together. When referring to a resident's obligation to observe facility rules, you must ensure the rules are reasonable, and inform the resident of the procedure for suggesting rule changes.

B. The following house rules must be observed:

(If additional space is needed, attach signed and dated sheet.)

C. The procedure for suggesting rule changes is as follows:

(If additional space is needed, attach signed and dated sheet.)
Reference: H&S Code Section 1569.885(a), CCR Section 87568
12. FACILITY VISITING POLICY

A. The agreement must include the facility policy concerning family visits and communication. The policy must be designed to encourage regular family involvement with the resident. The policy must also provide ample opportunity for family participation in facility activities.

B. Facility visiting hours are . The policy concerning visits is:

C. The policy concerning other communication with residents is:

(If additional space is needed, attach signed and dated sheet.)
Reference: H&S Code Sections 1569.313, 1569.884(g), CCR Section 87568
LIC 604A (2/05) (CONFIDENTIAL) Page 5
13. THEFT AND LOSS PROGRAM

A. The licensee must notify residents, upon admission and in the admission agreement, of the written policies and procedures regarding the facility's theft and loss prevention program. A copy of the law that sets forth the requirements for this program (Health and Safety Code Sections 1569.152 through 1569.154) must be provided to all residents and their responsible persons; and, upon request, to all prospective residents and their responsible persons.

B. The policies and procedures relating to theft and loss prevention are as follows:

(If additional space is needed, attach signed and dated sheet.)
C. I accept or, I decline to have my personal items inventoried.
D. I received a copy of Health & Safety Code Sections 1569.152 through 1569.154. (Resident or Responsible Person's Initials)
Reference: H&S Code Sections 1569.152, 1569.153, 1569.154, CCR Section 87227.1
14. PERSONAL RIGHTS

A. The licensee must advise the resident or responsible person of, and provide a copy of, the resident's personal rights specified by law.

B. I have been advised of my personal rights listed in California Code of Regulations, Title 22, Section 87572. (Resident or Responsible Person's Initials)
C. Attached is a signed copy of the personal rights. (Resident or Responsible Person's Initials)
(Form LIC 613C may be used.)
Reference: H&S Code Section 1569.885(d), CCR Section 87572
15. GRIEVANCES/COMPLAINTS

A. The licensee must make a copy of the facility grievance procedure for resolution of a resident's complaints available to the resident or the resident's responsible person. The procedure must inform residents of their rights to contact the Department of Social Services, the long-term care ombudsman, or both, regarding grievances against the facility.

B.
I received notice that a copy of the facility grievance procedure for resolution of complaints is available to me, or my responsible person, and I was informed of my right to contact the Department of Social Services, the long-term care ombudsman, or both, regarding grievances against the facility.
(Resident or Responsible Person's Initials)

C. The Department of Social Services' address and telephone number are:

The Long-Term Care Ombudsman telephone number is:

Reference: H&S Code Sections 1569.885(b)-(c)
LIC 604A (2/05) (CONFIDENTIAL) Page 6
16. ADVANCE HEALTH CARE DIRECTIVE

A. The licensee must provide written information to residents upon admission about the resident's right to make decisions concerning medical care, including the right to accept or refuse treatment, and the right, under state law, to formulate an advance health care directive.

B. I received the brochure entitled "Your Right to Make Decisions About Medical Treatment" PUB 325, and a copy of California Code of Regulations, Title 22, Sections 87575.1(b) & (c). (Resident or Responsible Person's Initials)
Reference: H&S Code Section 1569.156(a)(3), CCR Section 87575.1
17. ACCESS TO RECORDS

A. The agreement must provide notification that the Department of Social Services has the authority to examine resident records as part of the facility evaluation.

B. I acknowledge that the Department of Social Services has the authority to examine my records as part of the facility evaluation. (Resident or Responsible Person's Initials)
Reference: CCR Section 87568
18. TERMINATION OF AGREEMENT

A. The agreement must indicate whether it will be automatically terminated by the death of the resident. The resident's relatives and/or responsible persons will not be liable for any payment beyond that due at the date of death, unless agreed to in writing, or ordered by the court.

OR,
(If additional space is needed, attach signed and dated sheet.)

C. I acknowledge that the Department of Social Services has authority to order my relocation for any of the following reasons:

(1) My health condition cannot be cared for within the limits of the license;

(2) I require inpatient care in a health facility;

(3) My mental or physical condition requires immediate transfer to protect my health and safety.

(Resident or Responsible Person's Initials)
Reference: H&S Code Sections 1569.54, 1569.193, 1569.884, CCR Section 87568
19. CONDITIONS FOR EVICTION

A. The agreement must specify that a written notice that includes specific facts concerning the date, place, witnesses, and circumstances for eviction will be provided to the resident. Specific conditions under which a resident may be evicted must be worded exactly as written in the applicable law or regulations.

B. Reasons for eviction are as follows:

"The licensee may, upon 30 days written notice to the resident, evict the resident for one or more of the following reasons:

(1) Nonpayment of the rate for basic services within 10 days of the due date.

(2) Failure of the resident to comply with state or local law after receiving written notice of the alleged violation.

(3) Failure of resident to comply with written general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.

(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87587, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.

(5) Change of use of the facility."

Reference: H&S Code Section 1569.886, CCR Section 87589

The licensee may give a 3-day written notice to evict, provided written approval is obtained from the Department of Social Services. The Department may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior that is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility.

Reference: H&S Code Section 1569.886, CCR Sections 87568, 87589
LIC 604A (2/05) (CONFIDENTIAL) Page 7
20. RELOCATION AND APPEAL NOTICE

A. The agreement must include an explanation of the resident's right to notice prior to an involuntary transfer, discharge, or eviction, the process by which the resident may appeal the decision, and a description of the relocation assistance offered by the facility.

B. Residents may appeal the decision as follows:

(If additional space is needed, attach signed and dated sheet.)

C. The relocation assistance offered by the facility is as follows:

(If additional space is needed, attach signed and dated sheet.)
NOTE: When the Department orders relocation of a resident, due to a health condition that cannot be cared for within the limits of the license, the resident shall not be held responsible for meeting any advance notice requirement imposed by the licensee in the admission agreement. The licensee shall refund any money the resident would have been entitled had notice been given as required by the admission agreement.
Reference: H&S Code Section 1569.886, CCR Sections 87568, 87701.1
21. SIGNATURES
The signature of the resident and/or responsible person indicates that he/she has read, or had read and explained to him/her, the provisions of this agreement. The agreement must be dated and signed, acknowledging the contents, by the resident and/or responsible person if any, and the licensee, or designated representative upon admission.
Reference: H&S Code Section 1569.887(a), CCR Section 87568
RESIDENT:
DATE:
RESIDENT'S RESPONSIBLE PERSON OR CONSERVATOR: (IF APPLICABLE)
DATE:
LICENSEE/FACILITY REPRESENTATIVE:
DATE:
LIC 604A (2/05) (CONFIDENTIAL) Page 8
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
TELECOMMUNICATIONS DEVICE NOTIFICATION
ORIGINAL - Client/Client Representative COPY - Client/Resident File
FACILITY TYPE
NOTICE
Any deaf or hearing impaired, or otherwise impaired resident of any community care facility is entitled to equipment and service, pursuant to Section 2881 of the California Public Utilities Code, to improve the quality of their telecommunications. Any resident who has a declaration from a licensed professional or a qualified state or federal agency, that he or she is deaf or hearing impaired, or otherwise disabled should contact the California Telephone Access Program at 1-800-806-1191 and ask for assistance in obtaining this equipment and service.
This section shall not be construed to require, in any way, the licensee to provide a separate telephone line for any resident.
CLIENT/RESIDENT SIGNATURE
Click to sign
DATE
CONSERVATOR/RESPONSIBLE PERSON/AUTHORIZED REPRESENTATIVE SIGNATURE (IF ANY)
Click to sign
DATE
FACILITY NAME
FACILITY ADDRESS
FACILITY REPRESENTATIVE SIGNATURE
Click to sign
DATE
California Public Utilities Code
SECTION 2881 (a) and (c)
2881. (a) The commission shall design and implement a program to provide a telecommunications device capable of serving the needs of individuals who are deaf or hearing impaired, together with a single party line, at no charge additional to the basic exchange rate, to any subscriber who is certified as an individual who is deaf or hearing impaired by a licensed physician and surgeon, audiologist, or a qualified state or federal agency, as determined by the commission, and to any subscriber that is an organization representing individuals who are deaf or hearing impaired, as determined and specified by the commission pursuant to subdivision (e). A licensed hearing aid dispenser may certify the need of an individual to participate in the program if that individual has been previously fitted with an amplified device by the dispenser and the dispenser has the individual's hearing records on file prior to certification.
(c) The commission shall also design and implement a program whereby specialized or supplemental telephone communications equipment may be provided to subscribers who are certified to be disabled at no charge additional to the basic exchange rate. The certification, including a statement of visual or medical need for specialized telecommunications equipment, shall be provided by a licensed optometrist or physician and surgeon acting within the scope of practice of his or her license, or by a qualified state or federal agency as determined by the commission.
LIC 9158 (11/04)
Resident
View on DSS
State of California — Health and Human Services Agency
California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 1 OF 8
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION:
This form describes the personal rights of each person admitted to a privately operated Residential Care Facility for the Elderly (RCFE). This form also provides the complaint procedures for a resident and the resident’s responsible person.
The California Code of Regulations, Title 22, requires that a licensee personally advise any resident and the resident’s responsible person or conservator (if any) of the personal rights described on this form when a resident is admitted to a RCFE. The facility staff and the resident’s responsible person or conservator (if any) must explain these rights to the resident in a manner appropriate to the resident’s needs.
This personal rights form must be reviewed, completed, and signed and dated by each resident and responsible person or conservator (if any) upon admission to a RCFE. The licensee is required to provide the resident and responsible person or conservator (if any) with a complete written copy of these rights. The signed copy of these rights shall be retained in the resident’s file maintained by the licensee.
The licensee is also required to post these rights in a prominent area accessible to residents, residents’ responsible persons, and the public.
These personal rights must be posted in English. If five percent (5%) or more of the residents in a facility primarily read in another language, these personal rights must also be posted in that language.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 1 OF 8
Page 2 of 8 — Signature Page
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 2 OF 8
RESIDENT AND RESPONSIBLE PERSON OR CONSERVATOR (IF ANY):
Upon satisfactory and full disclosure of the personal rights described on this form, complete the following:
I/We have been personally advised and have received a copy of the personal rights in section 1569.269 of the Health and Safety Code and the personal rights in the California Code of Regulations, Title 22, section 87468 described on this form.
PRINT THE NAME OF THE FACILITY
PRINT THE ADDRESS OF THE FACILITY
PRINT THE NAME OF THE RESIDENT
SIGNATURE OF THE RESIDENT
Click to sign
DATE
SIGNATURE OF THE RESPONSIBLE PERSON OR CONSERVATOR, IF ANY
Click to sign
TITLE OF THE RESPONSIBLE PERSON OR CONSERVATOR, IF ANY
The resident and responsible person or conservator (if any) have the right to be informed of the appropriate licensing agency to contact regarding complaints, which is:
NAME
ADDRESS
CITY
ZIP CODE
AREA CODE/TELEPHONE NUMBER
To report known or suspected elder abuse, please contact the Statewide Ombudsman Toll Free 24-hour CRISIS line at 1-800-231-4024.
Local Ombudsman's Office Telephone Number:
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 2 OF 8
Page 3 of 8 — Health and Safety Code Section 1569.269 Rights (1-9)
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 3 OF 8
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: Each resident of a Residential Care Facility for the Elderly shall have all of the following rights, which are in Health and Safety Code section 1569.269:
(1)
To be accorded dignity in their personal relationships with staff, residents, and other persons.
(2)
To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
(3)
To confidential treatment of their records and personal information and to approve their release, except as authorized by law.
(4)
To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.
(5)
To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
(6)
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
(7)
To be served food of the quality and in the quantity necessary to meet their nutritional needs.
(8)
To make choices concerning their daily life in the facility.
(9)
To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding the care and services to be provided in accordance with Section 1569.80, and to involve persons of their choice in the planning process. The licensee shall provide necessary information and support to ensure that residents direct the process to the maximum extent possible, and are enabled to make informed decisions and choices.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 3 OF 8
Page 4 of 8 — Health and Safety Code Section 1569.269 Rights (10-17)
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 4 OF 8
(10)
To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
(11)
To present grievances and recommend changes in policies, procedures, and services to the staff of the facility, the facility’s management and governing authority, and to any other person without restraint, coercion, discrimination, reprisal, or other retaliatory actions. The licensee shall take prompt actions to respond to residents’ grievances.
(12)
To contact the State Department of Social Services, the long-term care ombudsman, or both, regarding grievances against the licensee. The licensee shall post the telephone numbers and addresses for the local offices of the State Department of Social Services and ombudsman program, in accordance with Section 9718 of the Welfare and Institutions Code, conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents.
(13)
To be fully informed, as evidenced by the resident’s written acknowledgement, prior to or at the time of admission, of all rules governing residents’ conduct and responsibilities. In accordance with Section 1569.885, all rules established by a licensee shall be reasonable and shall not violate any rights set forth in this chapter or in other applicable laws or regulations.
(14)
To receive in the admission agreement a comprehensive description of the method for evaluating residents’ service needs and the fee schedule for the items and services provided, and to receive written notice of any rate increases pursuant to Sections 1569.655 and 1569.884.
(15)
To be informed in writing at or before the time of admission of any resident retention limitations set by the state or licensee, including any limitations or restrictions on the licensee’s ability to meet residents’ needs.
(16)
To reasonable accommodation of individual needs and preferences in all aspects of life in the facility, except when the health or safety of the individual or other residents would be endangered.
(17)
To reasonable accommodation of resident preferences concerning room and roommate choices.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 4 OF 8
Page 5 of 8 — Health and Safety Code Section 1569.269 Rights (18-26)
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 5 OF 8
(18)
To written notice of any room changes at least 30 days in advance unless the request for a change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.
(19)
To share a room with the resident’s spouse, domestic partner, or a person of resident’s choice when both spouses, partners, or residents live in the same facility and consent to the arrangement.
(20)
To select their own physicians, pharmacies, privately paid personal assistants, hospice agency, and health care providers, in a manner that is consistent with the resident’s contract of admission or other rules of the facility, and in accordance with this act.
(21)
To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.
(22)
To be protected from involuntary transfers, discharges, and evictions in violation of state laws and regulations. Facilities shall not involuntarily transfer or evict residents for grounds other than those specifically enumerated under state law or regulations, and shall comply with enumerated eviction and relocation protections for residents. For purposes of this paragraph, ‘involuntary’ means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.
(23)
To move from a facility.
(24)
To consent to have relatives and other individuals of the resident’s choosing visit during reasonable hours, privately and without prior notice.
(25)
To receive written information on the right to establish an advanced health care directive and, pursuant to Section 1569.156, the licensee’s written policies on honoring those directives.
(26)
To be encouraged to maintain and develop their fullest potential for independent living through participation in activities that are designed and implemented for this purpose, in accordance with Section 87219 of Title 22 of the California Code of Regulations.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 5 OF 8
Page 6 of 8 — Health and Safety Code Section 1569.269 Rights (27-30)
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 6 OF 8
(27)
To organize and participate in a resident council that is established pursuant to Section 1569.157.
(28)
To protection of their property from theft or loss in accordance with Sections 1569.152, 1569.153, and 1569.154.
(29)
To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following: (A) Accept appointment as a guardian or conservator of the person or estate of a resident. (B) Become or act as a representative payee for any payments made to a resident, without the written and documented consent of the resident or the resident’s representative. (C) Serve as an agent for a resident under any general or special power of attorney. (D) Become or act as a joint tenant on any account with a resident. (E) Enter into a loan or promissory agreement or otherwise borrow money from a resident without a notarized written agreement outlining the terms of the repayment being given to the resident.
(30)
To keep, have access to, and use their own personal possessions, including toilet articles, and to keep and be allowed to spend their own money, unless limited by statute or regulation.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 6 OF 8
Page 7 of 8 — Title 22 CCR Section 87468 Rights (1-8)
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 7 OF 8
PERSONAL RIGHTS
IN PRIVATELY OPERATED
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
EXPLANATION: Each resident of a Residential Care Facility for the Elderly shall have personal rights which include, but are not limited to, the following rights in the California Code of Regulations, Title 22, section 87468:
(1)
To be accorded dignity in his/her personal relationships with staff, residents, and other persons.
(2)
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
(3)
To be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature, such as withholding of monetary allowances or interfering with daily living functions such as eating or sleeping patterns or elimination.
(4)
To be informed by the licensee of the provisions of law regarding complaints and of procedures to confidentially register complaints, including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency.
(5)
To have the freedom of attending religious services or activities of his/her choice and to have visits from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis.
(6)
To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit the establishment of house rules, such as the locking of doors at night, for the protection of residents; nor does it prohibit, with permission of the licensing agency, the barring of windows against intruders.
(7)
To visit the facility prior to residence along with his/her family and responsible persons.
(8)
To have his/her family or responsible persons regularly informed by the facility of activities related to his care or services including ongoing evaluations, as appropriate to the resident’s needs.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 7 OF 8
Page 8 of 8 — Title 22 CCR Section 87468 Rights (9-18)
State of California — Health and Human Services Agency · California Department of Social Services
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 8 OF 8
(9)
To have communications to the facility from his/her family and responsible persons answered promptly and appropriately.
(10)
To be informed of the facility’s policy concerning family visits and other communications with residents, as specified in Health and Safety Code section 1569.313.
(11)
To have his/her visitors, including ombudspersons and advocacy representatives permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
(12)
To wear his/her own clothes; to keep and use his/her own personal possessions, including his/her toilet articles; and to keep and be allowed to spend his/her own money.
(13)
To have access to individual storage space for private use.
(14)
To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls.
(15)
To mail and receive unopened correspondence in a prompt manner.
(16)
To receive or reject medical care, or other services.
(17)
To receive assistance in exercising the right to vote.
(18)
To move from the facility.
LIC 613C-2 (1/16) (CONFIDENTIAL) PAGE 8 OF 8
Resident
View on DSS
State of California · Health and Human Services Agency
Department of Social Services
PUB 325 (12/16)
Your Right To
Make Decisions
About Medical
Treatment
This brochure explains your right to make healthcare decisions and how you can plan now for your medical care if you are unable to speak for yourself in the future.
A federal law requires us to give you this information. We hope this information will help increase your control over your medical treatment.
WHO DECIDES ABOUT MY TREATMENT?
Your doctors will give you information and advice about treatment. You have the right to choose. You can say "Yes" to treatments you want. You can say "No" to any treatment that you don't want – even if the treatment might keep you alive longer.
HOW DO I KNOW WHAT I WANT?
Your doctor must tell you about your medical condition and about what different treatments and pain management alternatives can do for you. Many treatments have "side effects." Your doctor must offer you information about problems that medical treatment is likely to cause you.

Often, more than one treatment might help you – and people have different ideas about which is best. Your doctor can tell you which treatments are available to you, but your doctor can't choose for you. That choice is yours to make and depends on what is important to you.
CAN OTHER PEOPLE HELP WITH MY DECISIONS?
Yes. Patients often turn to their relatives and close friends for help in making medical decisions. These people can help you think about the choices you face. You can ask the doctors and nurses to talk with your relatives and friends. They can ask the doctors and nurses questions for you.
CAN I CHOOSE A RELATIVE OR FRIEND TO MAKE HEALTHCARE DECISIONS FOR ME?
Yes. You may tell your doctor that you want someone else to make healthcare decisions for you. Ask the doctor to list that person as your healthcare "surrogate" in your medical record. The surrogate's control over your medical decisions is effective only during treatment for your current illness or injury or, if you are in a medical facility, until you leave the facility.
WHAT IF I BECOME TOO SICK TO MAKE MY OWN HEALTHCARE DECISIONS?
If you haven't named a surrogate, your doctor will ask your closest available relative or friend to help decide what is best for you. Most of the time that works. But sometimes everyone doesn't agree about what to do. That's why it is helpful if you can say in advance what you want to happen if you can't speak for yourself.
DO I HAVE TO WAIT UNTIL I AM SICK TO EXPRESS MY WISHES ABOUT HEALTH CARE?
No. In fact, it is better to choose before you get very sick or have to go into a hospital, nursing home, or other healthcare facility. You can use an Advance Health Care Directive to say who you want to speak for you and what kind of treatments you want. These documents are called "advance" because you prepare one before healthcare decisions need to be made. They are called "directives" because they state who will speak on your behalf and what should be done.

In California, the part of an advance directive you can use to appoint an agent to make healthcare decisions is called a Power of Attorney For Health Care. The part where you can express what you want done is called an Individual Health Care Instruction.
WHO CAN MAKE AN ADVANCE DIRECTIVE?
You can if you are 18 years or older and are capable of making your own medical decisions. You do not need a lawyer.
WHO CAN I NAME AS MY AGENT?
You can choose an adult relative or any other person you trust to speak for you when medical decisions must be made.
WHEN DOES MY AGENT BEGIN MAKING MY MEDICAL DECISIONS?
Usually, a healthcare agent will make decisions only after you lose the ability to make them yourself. But, if you wish, you can state in the Power of Attorney for Health Care that you want the agent to begin making decisions immediately.
HOW DOES MY AGENT KNOW WHAT I WOULD WANT?
After you choose your agent, talk to that person about what you want. Sometimes treatment decisions are hard to make, and it truly helps if your agent knows what you want. You can also write your wishes down in your advance directive.
WHAT IF I DON'T WANT TO NAME AN AGENT?
You can still write out your wishes in your advance directive, without naming an agent. You can say that you want to have your life continued as long as possible. Or you can say that you would not want treatment to continue your life. Also, you can express your wishes about the use of pain relief or any other type of medical treatment.

Even if you have not filled out a written Individual Health Care Instruction, you can discuss your wishes with your doctor, and ask your doctor to list those wishes in your medical record. Or you can discuss your wishes with your family members or friends. But it will probably be easier to follow your wishes if you write them down.
WHAT IF I CHANGE MY MIND?
You can change or cancel your advance directive at any time as long as you can communicate your wishes. To change the person you want to make your healthcare decisions, you must sign a statement or tell the doctor in charge of your care.
WHAT HAPPENS WHEN SOMEONE ELSE MAKES DECISIONS ABOUT MY TREATMENT?
The same rules apply to anyone who makes healthcare decisions on your behalf – a healthcare agent, a surrogate whose name you gave to your doctor, or a person appointed by a court to make decisions for you. All are required to follow your Health Care Instructions or, if none, your general wishes about treatment, including stopping treatment. If your treatment wishes are not known, the surrogate must try to determine what is in your best interest.

The people providing your health care must follow the decisions of your agent or surrogate unless a requested treatment would be bad medical practice or ineffective in helping you. If this causes disagreement that cannot be worked out, the provider must make a reasonable effort to find another healthcare provider to take over your treatment.
WILL I STILL BE TREATED IF I DON'T MAKE AN ADVANCE DIRECTIVE?

Absolutely. You will still get medical treatment. We just want you to know that if you become too sick to make decisions, someone else will have to make them for you.

Remember that:

  • A POWER OF ATTORNEY FOR HEALTH CARE lets you name an agent to make decisions for you. Your agent can make most medical decisions – not just those about life sustaining treatment – when you can't speak for yourself. You can also let your agent make decisions earlier, if you wish.
  • YOU CAN CREATE AN INDIVIDUAL HEALTHCARE INSTRUCTION by writing down your wishes about health care or by talking with your doctor and asking the doctor to record your wishes in your medical file. If you know when you would or would not want certain types of treatment, an Instruction provides a good way to make your wishes clear to your doctor and to anyone else who may be involved in deciding about treatment on your behalf.
  • THESE TWO TYPES OF ADVANCE HEALTHCARE DIRECTIVES may be used together or separately.

To implement Public Law 101-508, the California Consortium on Patient Self-Determination prepared this brochure in 1991; it was revised in 2000 by the California Department of Health Services, with input from members of the consortium and other interested parties, to reflect changes in state law.

HOW CAN I GET MORE INFORMATION ABOUT MAKING AN ADVANCE DIRECTIVE?
Ask your doctor, nurse, social worker, or healthcare provider to get more information for you. You can have a lawyer write an advance directive for you, or you can complete an advance directive by filling in the blanks on a form.
STATE OF CALIFORNIA · HEALTH AND HUMAN SERVICES AGENCY · DEPARTMENT OF SOCIAL SERVICES   |   PUB 325 (12/16)
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY
RESIDENT FACESHEET — CONFIDENTIAL

RESIDENT FACESHEET

Facility Form
Demographics
Full Legal Name (Last, First, MI)
Preferred Name
Date of Birth
Age
Gender
Room
Admission Date
Care Level
DNR Status
Ambulatory Status
Insurance
Medical Information
Diagnoses
Allergies (Medications / Food / Environmental)
Current Medications
Physician & Pharmacy
Physician Name
Physician Phone
Pharmacy
Pharmacy Phone
Emergency Contact 1
Name
Relationship
Phone
Alternate Phone
Emergency Contact 2
Name
Relationship
Phone
Alternate Phone
Responsible Party / POA
Responsible Party / POA Name
Relationship
Phone
Billing Email
Hospital & Insurance
Hospital of Choice
Medi-Cal Number
Insurance ID / Member #
Preferences & Notes
Resident Facesheet — Confidential — For Facility Use Only
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY
RESIDENT EVACUATION / EXIT ROUTE PLAN

EXIT ROUTE PLAN

Facility Form
Facility Name
Resident Name
Room Number
Date Prepared
Primary Exit Route
Secondary Exit Route
Primary Assembly Area
Alternate Assembly Area
Ambulatory Status
Fire Clearance Classification
Special Evacuation Instructions

RACE — Rescue, Alarm, Contain, Evacuate

PASS — Pull, Aim, Squeeze, Sweep

Emergency Phone (Fire/Police)
Staff Responsible for This Resident

Administrator Signature

Resident Acknowledgment / Date
Exit Route Plan — Updated annually and upon any change in resident ambulatory status
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

NARRATIVE CHART / PROGRESS NOTES

Facility Form
Resident Name
Room
Date / Time Category Notes Staff Initials
Narrative Chart — Maintain in resident chart; entries are legal documents

Skin Assessment

Resident
More ▾

Skin Assessment

Body Diagram

B Bruise W Wound R Rash S Pressure Wound SK Skin Tear SC Scar T Tattoo/Birthmark E Edema

Front

Back

Markers

Nurse / Caregiver Signature
Date
Complete at admission and with each noted skin change. Retain in resident chart.
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

MEDICATION ADMINISTRATION LOG

Facility MAR Form
Resident Name
Room
Allergies
Month / Year
Medication / Dose / Route / Frequency MD Start Date 1–5 6–10 11–15 16–20 21–25 26–28 29–31 Notes

Staff Initials Key: Record initials in each cell for days administered. Leave blank if not scheduled. Use code H=Held, R=Refused.

Medication Administration Log — Facility form; retain per Title 22 record-keeping requirements
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

THEFT AND LOSS POLICY

H&SC §§1569.152–1569.154
Facility Name
Resident Name
Date Provided

Section A: This facility maintains written policies and procedures regarding the theft or loss of residents' personal property and cash resources. A copy of these policies is available upon request.

Section B: This facility is required by law (Health & Safety Code §1569.152) to report all suspected theft or loss of a resident's personal property or cash resources to the Department of Social Services within 24 hours of discovery.

Section C: Residents or their representatives have the right to file a complaint with the Community Care Licensing Division regarding theft or loss. The toll-free complaint hotline is 1-844-538-8766.

Section D: This facility has procedures in place for documenting and safeguarding residents' cash resources, personal property, and valuables. Residents are encouraged to use the facility's safekeeping services for valuable items.

I acknowledge that I have been provided a copy of this facility's Theft and Loss Policy as required by Health & Safety Code §§1569.152–1569.154.

RESIDENT / RESPONSIBLE PERSON SIGNATURE
TITLE / RELATIONSHIP
ADMINISTRATOR SIGNATURE / DATE
H&SC §§1569.152–1569.154 — Provide to resident and responsible party at admission
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

RESIDENT AND FAMILY COUNCIL RIGHTS

H&SC §§1569.157–1569.158
§1569.157 — Resident Council Rights

Residents of this facility have the right to organize and participate in a Resident Council. The Resident Council is an independent body of residents that may meet to discuss and address issues of concern to residents. The facility must:

  • Provide a meeting space for the Resident Council to meet privately without facility staff, unless invited.
  • Designate a staff member to assist the Resident Council when requested.
  • Respond in writing within 10 days to written concerns submitted by the Resident Council.
  • Post notices of Resident Council meetings in a place accessible to all residents.
  • Not interfere with the formation, maintenance, or participation in a Resident Council.
§1569.158 — Family Council Rights

The families and representatives of residents have the right to organize and participate in a Family Council. The Family Council is an independent body that may meet to discuss matters of concern to families. The facility must:

  • Provide a meeting space for the Family Council to meet privately without facility staff, unless invited.
  • Designate a staff member to assist the Family Council when requested.
  • Respond in writing within 10 days to written concerns submitted by the Family Council.
  • Post notices of Family Council meetings in a place accessible to residents and their families.
  • Not discourage or interfere with family participation in the Family Council.
Resident Name
Date Informed

I acknowledge that I have been informed of my rights regarding Resident and Family Councils as provided under Health & Safety Code §§1569.157–1569.158.

RESIDENT / REPRESENTATIVE SIGNATURE
STAFF SIGNATURE
DATE
H&SC §§1569.157–1569.158 — Provide at admission and post in common area
Resident
⚠️
PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST)
PHYSICIAN / NP / PA SIGNATURE IS REQUIRED — This form will not be valid without a physician signature. First follow these orders, then contact physician.
CALIFORNIA POLST COALITION
PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT

POLST

California POLST Form
Patient Name (Last, First, MI)
Date of Birth
Last 4 SSN
A — Cardiopulmonary Resuscitation (CPR)

If patient has no pulse and is not breathing:

B — Medical Interventions

If patient has a pulse and/or is breathing:

Additional Orders
C — Artificially Administered Nutrition

Always offer food and fluids by mouth if feasible and desired:

Surrogate / Authorized Representative
Surrogate Name
Relationship
Phone

Patient / Surrogate Signature

Date
⚠️ PHYSICIAN / NP / PA SIGNATURE REQUIRED
This form is not valid without a provider signature.

Physician / NP / PA Signature (Required)

License Number / Date
California POLST — Follows patient. Copy to chart, give copy to patient/surrogate. Review periodically or upon change of condition.
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

DISCHARGE PAPERS

Facility Form

📎 Click to upload hospital discharge summary (optional — manual entry below)

Patient Information
Patient Name
Discharge Date
Discharging Facility
Attending Physician
Physician Phone
Diagnoses at Discharge
Discharge Medications
Allergies
Discharge Condition
Ambulatory Status at Discharge
Follow-Up Instructions
TB Result
TB Test Date

Receiving Facility / Person

Staff Completing Form

Date
Discharge Papers — Provide copy to resident, receiving facility, and attending physician
Facility Form
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

NEIGHBORHOOD COMPLAINT PROCEDURES

Facility Form
Facility Contact Information
Administrator Name
Email
Phone
Facility Address

Neighbors and community members may direct complaints or concerns regarding facility operations to the administrator using the contact information above. All complaints will be reviewed and responded to within 10 business days. Complaints may also be directed to the Department of Social Services, Community Care Licensing Division, at 1-844-538-8766.


Administrator Signature

Effective Date
Post in a conspicuous location visible to visitors and neighbors
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

IDs AND INSURANCE INFORMATION

Facility Form
Photo ID
ID Type
ID Number
Issued By (State)
Expiration Date
Insurance Card
Plan / Carrier Name
Member ID
Group Number
Member Services Phone
Effective Date
Retain copy of all IDs and insurance cards in resident chart
Resident
RESIDENTIAL CARE FACILITY FOR THE ELDERLY

PICTURES OF BODY — PHOTOGRAPHIC RECORD

Facility Form
Resident Name
Date of Photos
Staff Name
📷

Click to Upload Photos

Supports JPG, PNG, HEIC — photograph all skin conditions, bruises, wounds, and notable marks at admission and with each change

Notes / Description of Photographs

Staff Signature

Date
Photographic record — store securely in resident chart; retain per facility policy

Patient Documents

Documents are synced to secure cloud storage and cached on this device.
Upload Document
Click to upload or drag and drop
PDF, JPG, PNG — any document up to 20MB

Staff Profiles

Caregiver Payroll

Total Weekly Hours
0.00 hours
Gross Pay
$0.00

Revenue & Financials

Facility Overview

Staff Scheduling

🔗 LIC 500 on DSS

DSS Inspection Walkthrough

RCFE Annual Licensing Visit — Comprehensive Walk-Through Checklist

…
1Administrative Documents

Have all of the following readily available and current:

2Exterior & Grounds
Front Yard
Side & Backyard
3Fire & Emergency Preparedness
Medical Equipment
4Resident Bedrooms
Each Resident Room
Shared Rooms
5Bathrooms
Every Bathroom
Water Temperature
6Kitchen & Food Service
Refrigerator
Pantry
Kitchen Safety
7Medication Audit
Medication Storage
Medication Records
8Resident Files

Check every resident file for the following:

9Personnel Files

Check every employee file for the following:

10Housekeeping & Maintenance
11Resident Rights & Quality of Care
12Staff Interview Readiness

Every caregiver should know:

13Top 20 Deficiencies to Double-Check

These are the most commonly cited violations — verify each one:

Staffing Checklist

Staff documentation and compliance checklist

Staff Member
Staff Member
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
PERSONNEL RECORD
LIC 501 (1/19)
EMPLOYEE NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER
DATE OF BIRTH
HOME ADDRESS
PHONE NUMBER
POSITION / TITLE
DATE OF HIRE
FACILITY NAME
FACILITY ADDRESS
FACILITY LICENSE NUMBER
FACILITY PHONE
CRIMINAL RECORD CLEARANCE / EXEMPTION
CLEARANCE DATE
CLEARANCE TYPE
EXEMPTION NUMBER (IF ANY)
EMPLOYEE SIGNATURE
ADMINISTRATOR / DESIGNEE SIGNATURE
DATE
Staff Member
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
FACILITY PERSONNEL RECORD
LIC 503 (8/03)
NAME OF EMPLOYEE (LAST, FIRST, MIDDLE)
POSITION / TITLE
DATE OF HIRE
DATE OF BIRTH
PHONE NUMBER
FACILITY NAME
FACILITY LICENSE NUMBER
FACILITY ADDRESS
HOME ADDRESS
TB TEST DATE
TB TEST RESULT
CPR CERTIFICATION DATE
CPR EXPIRATION DATE
EMPLOYEE SIGNATURE
ADMINISTRATOR SIGNATURE
DATE
Staff Member
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
CRIMINAL RECORD STATEMENT
LIC 9052 (11/16)
Pursuant to Sections 1522 and 1596.871 of the Health and Safety Code, the following individuals are required to obtain a criminal record clearance or criminal record exemption prior to employment or residence in a licensed community care facility.
FULL NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
GENDER
HOME ADDRESS
PHONE NUMBER
FACILITY NAME
FACILITY LICENSE NUMBER
CAPACITY IN WHICH EMPLOYED
CRIMINAL RECORD DECLARATION
I declare under penalty of perjury that I have read the above and that the information I have provided is true and correct.
APPLICANT / EMPLOYEE SIGNATURE
DATE
Staff Member
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
CRIMINAL RECORD EXEMPTION NOTIFICATION
LIC 508 (2/18)
NAME OF INDIVIDUAL (LAST, FIRST, MIDDLE)
DATE OF BIRTH
FACILITY NAME
FACILITY LICENSE NUMBER
EXEMPTION DATE
EXEMPTION TYPE
EXEMPTION NUMBER
POSITION / TITLE
NOTES
LICENSEE SIGNATURE
INDIVIDUAL SIGNATURE
DATE
Staff Member
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
APPLICANT ARREST NOTIFICATION
SOC 341A
APPLICANT / EMPLOYEE NAME
DATE OF BIRTH
NOTIFICATION DATE
FACILITY NAME
FACILITY LICENSE NUMBER
FACILITY ADDRESS
ARREST INFORMATION / CHARGES
ARREST DATE
ARRESTING AGENCY
ADMINISTRATOR SIGNATURE
APPLICANT / EMPLOYEE SIGNATURE
DATE
Staff Member
View on DSS
State of California · Health and Human Services Agency
California Department of Social Services
Community Care Licensing Division
PERSONNEL REPORT
LIC 9163 (8/18)
FACILITY NAME
FACILITY LICENSE NUMBER
FACILITY ADDRESS
ADMINISTRATOR NAME
REPORT DATE
EMPLOYEE INFORMATION
EMPLOYEE NAME (LAST, FIRST, MIDDLE)
POSITION / TITLE
DATE OF HIRE
DATE OF BIRTH
SOCIAL SECURITY NUMBER
STATUS
EFFECTIVE DATE OF CHANGE
REASON FOR CHANGE
ADMINISTRATOR / LICENSEE SIGNATURE
DATE

Admin Reports

Facility-level administrative documents required for DSS inspection

DSS License Dates

Original license dates and last DSS inspection dates for all facilities

Water Temperature Log

Title 22 requires hot water between 105°F and 120°F at the tap. Log temperatures regularly for DSS compliance.

MONTH
LOCATION
Safe (105–120°F) Low (<105°F) High (>120°F)

Fire Extinguisher Inspections

Annual professional inspections required by Title 19. Monthly visual checks required by Title 22. Both logged here.

Extinguisher Units —
TYPE
YEAR
UNIT

Disaster Drill Log

California RCFE requires disaster drills every 3 months

DSS Admin Renewal

Track administrator certification expiry dates across your facilities

Open DSS Portal

Title 22 Regulations

Official CA DSS Title 22 regulations for Residential Care Facilities for the Elderly (Jan 2025 revision) — reference copy

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Team & Access

Invite staff to CareNest. Each person gets their own login with access based on their role.

Active Team Members
Pending Invitations

Settings

Owner and Co-Owner access only.

Data Backup
Export all CareNest data to a JSON file as a backup. You can restore from this file if needed. Supabase cloud sync is your primary backup — use this for an extra local copy.
Last auto-save: —
App Information
Platform: CareNest RCFE Management
Supabase Project: —
Organization ID: —
Live Site: —
Terms version accepted: —
Terms of Service Privacy Policy
Late Entry — Dose Correction

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