LIC 500 — Personnel Report
LIC 500 is the California CDSS form titled "Personnel Report". Tells Community Care Licensing who works at the facility and in what role.
Official PDF
The current LIC 500 is published by the California Department of Social Services. We link to the live source rather than hosting a copy, so you always get the latest revision.
Open LIC 500 on cdss.ca.govWho completes it and when
The facility prepares this form and files the completed original in the appropriate record.
At licensure and whenever facility personnel change.
How to complete LIC 500
- 1Download the current revision of the form directly from CDSS so you are not working from an outdated copy.
- 2Fill in facility and resident identifying information exactly as it appears in your licensing and resident records.
- 3Complete every section — evaluators read blanks as missing documentation.
- 4Obtain the required signatures and dates before filing.
- 5File the completed form in the resident or facility record. At licensure and whenever facility personnel change.
Mistakes evaluators flag
- Using an old revision of the form after CDSS published an update.
- Sections left blank with no explanation.
- Signature or date lines missed on the final page.
Questions about LIC 500
When is LIC 500 used?
At licensure and whenever facility personnel change.
Is LIC 500 required for an RCFE?
LIC 500 is not required for every RCFE resident or facility. It applies in the situations described in the form instructions.
Fill this form from data you already have
- Resident, staff, and facility details populate the form fields automatically.
- Track which forms are on file, which are missing, and which are about to expire.
- Incident reports draft the LIC 624 narrative and finalize an immutable PDF.
Related personnel forms
RCFE OS is not affiliated with the California Department of Social Services. This guide is operational information for licensees, not legal advice. Always follow the current form instructions and guidance from your licensing analyst.