LIC 624 — Unusual Incident/Injury Report
LIC 624 is California's Unusual Incident / Injury Report. RCFEs use it to report qualifying incidents — falls with injury, elopement, aggression, hospitalization, abuse allegations, and similar events — to Community Care Licensing.
Official PDF
The current LIC 624 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 624 on cdss.ca.govWho completes it and when
The administrator or designated staff member, using facts gathered from staff who witnessed or responded to the incident.
Within statutory reporting timeframes after any qualifying incident.
How to complete LIC 624
- 1Stabilize the resident and handle the emergency first; documentation follows care.
- 2Gather the facts while they are fresh: who, what, when, where, who witnessed it, and what was done.
- 3Complete the facility, resident, and incident sections, keeping the narrative factual and free of speculation or blame.
- 4Document every notification made — physician, responsible party, licensing, law enforcement or ombudsman where applicable — with names and times.
- 5Report within the required timeframe, then complete the follow-up section once the outcome and corrective action are known.
- 6Keep the submitted report, follow-up, and any supporting records together in the resident's file.
Mistakes evaluators flag
- A narrative that draws conclusions ('the resident was confused and careless') instead of describing observed facts.
- Notification times left blank, which makes the reporting timeline impossible to prove.
- The follow-up section never completed after the resident returned from the hospital.
- Reporting late because the incident was written up at the end of the shift instead of when it occurred.
Questions about LIC 624
What incidents require a LIC 624?
It is used for unusual incidents and injuries involving residents — for example injuries requiring medical treatment, elopement, aggression between residents, and other events your licensing program requires to be reported. Check the form instructions and your licensing analyst for the current reportable list.
How fast does LIC 624 have to be submitted?
Qualifying incidents are reported within the statutory timeframe, which begins when the incident occurs or is discovered — not when the paperwork is finished. Serious events also require immediate telephone notification.
What is the difference between LIC 624 and LIC 624A?
LIC 624 reports unusual incidents and injuries. LIC 624A is the death report used when a resident dies.
Can LIC 624 be filled out digitally?
Yes. Facilities commonly complete the official PDF on a computer and print or transmit it. RCFE OS pre-fills the official form from the incident record and produces a flattened final PDF.
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 incident & reporting 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.