California LIC forms for RCFEs

Basic resident identification and emergency contact record kept on file at the facility.

Facility appraisal of the resident's functional capabilities and service needs.

Statutory RCFE admission agreement between the facility and the resident.

Facility disclosure worksheet for prospective residents and families.

Statement of resident personal rights for privately operated RCFEs.

Inventory of resident personal property and valuables held at the facility.

The Needs and Services Plan documenting the resident's care requirements.

Advance consent for emergency medical treatment in RCFEs.

Notification of the facility's telecommunications device policy.

Assessment of the resident's functional capabilities.

Preplacement appraisal of the resident completed before admission.

Statement of resident personal rights for publicly operated RCFEs.

Physician-completed medical assessment required for every RCFE admission.

Resident authorization to release medical information.

Record of centrally stored medications and their destruction.

Official monthly medication administration record for each resident.

Report of an unusual incident or injury involving a resident.

Report submitted to CCL upon the death of a resident.

Client death report used across residential facility types.

Facility-wide emergency and disaster plan template for RCFEs.

Record of group activities offered by the facility.

Roster of residents currently in the facility.

CCL entrance checklist used at RCFE inspections.

Floor plan and yard sketch of the licensed facility.

CDSS checklist of the records an RCFE must keep on site.

Checklist for reviewing the facility's earthquake preparedness.

TB and health screening report for facility personnel.

Disclosure of out-of-state residency and criminal history for background clearance.

Report of the people working at the licensed facility.

Individual personnel record kept in each employee's file.

Live Scan request form used for criminal record clearance.

Notice of employee rights under Community Care Licensing background check rules.

Application for an RCFE administrator certificate.

The license application filed with Community Care Licensing.

Background and qualification information for each license applicant.

Designation of who is responsible for facility operations.

Description of the facility's administrative and ownership structure.

Affidavit about the facility's handling of resident cash resources.

Statement identifying the board members of a corporate licensee.