LIC 604A — Admission Agreement for Residential Care Facilities for the Elderly
LIC 604A is the statutory admission agreement between an RCFE and its resident. It is the contract that defines services, rates, refunds, rights, and the conditions under which a resident may be asked to leave.
Official PDF
The current LIC 604A 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 604A on cdss.ca.govWho completes it and when
The facility prepares it; the resident or their legal representative signs it.
Signed at admission; updated when material terms change.
How to complete LIC 604A
- 1Complete the facility identification, rate, and services sections with the actual amounts the resident will pay.
- 2Attach the current fee schedule and any optional-service pricing you reference in the agreement.
- 3Walk the resident or representative through rate-increase notice, refund, and eviction provisions before signing.
- 4Have all parties sign and date, and give the resident a signed copy the same day.
- 5Amend in writing whenever rates or services change materially, and keep every version in the file.
Mistakes evaluators flag
- Rate blanks left empty or filled in with a number that does not match what is billed.
- No signed copy given to the resident.
- Amendments made verbally rather than as a written, signed change.
Questions about LIC 604A
Does the resident get a copy of the admission agreement?
Yes. The resident or their representative should receive a fully signed copy, and the facility keeps the original in the resident record.
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 admission 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.