Forms library
California RCFE forms
One page for each state form a California RCFE keeps, with a link to the official PDF on cdss.ca.gov.
Admission and the resident file
- LIC 602A
Medical Assessment for Residential Care Facilities for the Elderly
The medical assessment a licensed medical professional signs before admission
- LIC 603A
Resident Appraisal
The appraisal you complete before a resident moves in
- LIC 9172
Functional Capability Assessment
The checklist of what a new resident can do for themselves
- LIC 625
Appraisal/Needs and Services Plan
A CDSS form you may use for the plan of action when a resident's need is not being met
- LIC 604A
Admission Agreement For Residential Care Facilities For The Elderly
The CDSS guide for the admission agreement you sign with each resident
- LIC 613C-2
Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly
The personal rights a resident signs at admission
- LIC 601
Identification and Emergency Information
The form with a resident's contacts, doctor, hospital and emergency details
- LIC 627C
Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities
The signed consent for emergency medical or dental care
- PUB 325
Your Right to Make Decisions About Medical Treatment
The brochure on medical care decisions that you give each resident on admission
- LIC 9020A
Register of Facility Residents - Residential Care Facilities for the Elderly
The register of every resident currently in your home
- LIC 605A
Release of Client/Resident Medical Information
The resident's written OK for a doctor or clinic to release records
- LIC 9158
Telecommunications Device Notification
The telephone equipment notice that goes with each admission agreement
Medication, incident reports and safety plans
- LIC 622
Centrally Stored Medication and Destruction Record
The record of medications you keep in one locked place and of any you destroy
- LIC 624
Unusual Incident/Injury Report
The report you file after a serious injury or an unusual incident
- LIC 624A
Death Report
The report you file when a resident dies
- SOC 341
Report of Suspected Dependent Adult/Elder Abuse
The report you file when you suspect abuse of a resident
- LIC 610E
Emergency and Disaster Plan for Residential Care Facilities for the Elderly
The disaster plan form for RCFEs and what the law requires in it
- LIC 9282
Residential Infection Control Plan
The CDSS form for an RCFE's written infection control plan
Resident money and belongings
- LIC 621
Client/Resident Personal Property and Valuables
The form for belongings and valuables a resident hands to the home
- LIC 9059
Personal Property Procedures
The CDSS guidelines form for how a home handles resident property, theft and loss
- LIC 9060
Resident Theft and Loss Record
The record for lost or stolen resident property worth $25 or more
- LIC 405
Record of Client's/Resident's Safeguarded Cash Resources
The ledger for resident money your home holds
Staff and background checks
- LIC 500
Personnel Report
The roster of staff, volunteers and other adults in the home, with duty hours
- LIC 501
Personnel Record
The employment application a staff member fills out
- LIC 503
Health Screening Report - Facility Personnel
The health screening and TB result for each staff member
- LIC 9163
Request for Live Scan Service - Community Care Licensing
The Live Scan form a person takes to be fingerprinted
- LIC 9182
Criminal Background Clearance Transfer Request
The request to move a staff member's active background clearance
- SOC 341A
Statement Acknowledging Requirement To Report Suspected Abuse Of Dependent Adults And Elders
The mandated reporter statement a new employee signs
Postings, records and inspections
- PUB 475
RCFE Complaint Poster
The state complaint poster that goes in the main entryway
- PUB 474
Rights of Resident Councils
The notice of resident council rights that you post in the home
- LIC 311F
Records To Be Maintained At The Facility - Residential Care Facility For The Elderly
CDSS's 2005 list of the records an RCFE keeps, and what has changed since then
- LIC 9242
Entrance Checklist, Residential Care Facilities for the Elderly
The checklist the licensing analyst hands you at an inspection
- LIC 809
Facility Evaluation Report
The report the licensing analyst leaves after a visit, with any deficiencies and due dates