LIC 613 — Personal Rights — Adult Community Care Facilities
LIC 613 is the California CDSS form titled "Personal Rights — Adult Community Care Facilities". Records that the client was advised of, and received a copy of, their Title 22 personal rights.
Quick facts
- Who fills it out
- The facility prepares this form and files the completed original in the appropriate record.
- When it's used
- Reviewed and signed by the client and/or representative at admission.
- Official revision
- LIC 613 (12/02) · source checked 2026-08-20
- Required?
- Situational
Official PDF
The current LIC 613 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 613 on cdss.ca.govHow to complete LIC 613
- 1Download the current revision of the form directly from CDSS so you are not working from an outdated copy.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. Reviewed and signed by the client and/or representative at admission.
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 613
When is LIC 613 used?
Reviewed and signed by the client and/or representative at admission.
Is LIC 613 required for an RCFE?
LIC 613 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 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.