LIC 9172 — Functional Capability Assessment
LIC 9172 is the California CDSS form titled "Functional Capability Assessment". Documents functional capabilities that inform the Needs and Services Plan.
Official PDF
The current LIC 9172 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 9172 on cdss.ca.govWho completes it and when
The facility prepares this form and files the completed original in the appropriate record.
Completed at admission and reviewed as needed.
How to complete LIC 9172
- 1Download the current revision of the form directly from CDSS so you are not working from an outdated copy.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. Completed at admission and reviewed as needed.
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 9172
When is LIC 9172 used?
Completed at admission and reviewed as needed.
Is LIC 9172 required for an RCFE?
LIC 9172 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.