LIC 624A — Death Report
LIC 624A is the death report submitted to Community Care Licensing when a resident of the facility dies. It records the circumstances, the parties notified, and the disposition.
Official PDF
The current LIC 624A 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 624A on cdss.ca.govWho completes it and when
The administrator or designated staff member.
Within 24 hours of a resident's death.
How to complete LIC 624A
- 1Notify the physician, responsible party, and licensing as required — the phone notification comes before the paperwork.
- 2Record the date, time, and location of death, and who was present or discovered it.
- 3Describe the circumstances factually, including any preceding illness, fall, or hospitalization.
- 4Document each notification with name, relationship or agency, and the time contacted.
- 5Submit within the required timeframe and file a copy with the resident's closed record.
Mistakes evaluators flag
- Waiting for the death certificate before reporting.
- Notification log left blank because calls were made from personal phones and never written down.
- Property release to family never reconciled against the LIC 621 inventory.
Questions about LIC 624A
How quickly must a resident death be reported?
Resident deaths are reported to Community Care Licensing within the timeframe stated in the form instructions — commonly within 24 hours — with immediate telephone notification for unexpected deaths.
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.