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California's Form 602a for Residential Care Facilities

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What Is LIC 602 Form?

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Form LIC 602 Instructions

Form lic602 physician's report for community care facilities - california.

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  • California Department of Social Services

Form LIC 602, Physician's Report for Community Care Facilities, is a document completed by a health care professional (physician) to determine whether the resident or the applicant for admission to a Community Care Facility is appropriate for continued care in this facility or admission. Community Care Facilities are licensed to provide round-the-clock non-medical residential care to adults and children in need of assistance.

The latest version of the Form 602 LIC was issued by the California Department of Social Services (CDSS) on July 1, 2022 , with all previous editions obsolete. A fillable version of the form is available for download below .

In California, it is possible to apply for residential care to receive personal services, supervision, rehabilitative therapy, medication, and more. This document is completed by the patient's primary physician or the attending physician . Most health care professionals are familiar with this document; however, it is recommended to have the form filled out by the primary care physician who possesses in-depth knowledge of the potential resident. A comprehensive physician's report is the most important part of the resident assessment process that must be updated should any significant change in the patient's condition take place.

  • Facility Information. This section must be filled out by the licensee/designee (usually, the employee of the Community Care Facility). Provide the name of the facility, its telephone number, address, the licensee's name, telephone number, and facility license number.
  • Resident/Client Information. It is completed by the resident/representative/licensee. Write down the name of the resident/client, the telephone number and the address, the social security number, and the information on the next of kin and the person responsible for the resident's/client's finances.
  • Patient's Diagnosis. The physician has to fill out this section of the form. Indicate the diagnosis, age, height, weight, and sex of the resident. Write down the results of the tuberculosis examination and mention any infectious/contagious diseases or allergies the resident/client has and if this individual is currently treated/receives any medication. State the ambulatory status of resident/client selecting one of the given options - ambulatory, nonambulatory, bedridden. Describe the patient's physical and mental health status and assess this individual's capacity for self-care. List medication that can be given to the resident/client and any prescribed medications this individual is currently taking. After that, sign and date the form, also providing your address and telephone number.

Additionally, the document must be signed and dated by the individual's authorized representative who agrees to release the medical information contained in this report relating to the physical examination of the patient.

Form LIC 602A, Physician's Report for Residential Care Facilities for the Elderly (RCFE) , is a related form used specifically to obtain residential care for the elderly residents or prospective residents of care facilities. Just like LIC Form 602, it needs to contain patient's information, authorization for release of medical information, and patient's diagnosis (primary and secondary diagnosis, description of known diseases, allergies, and other conditions, physical health and mental condition status, ambulatory status, etc.) certified by the health care professional.

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California Department of Social Services – Forms/Brochures

Centrally Stored Medication & Destruction Record

Client/Resident Personal Property & Valuables

Physician’s Report for Community Care Facilites

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Physician's Report for Residential Care Facilities for the Elderly (Rcfe)

Physician's Report for Residential Care Facilities for the Elderly (Rcfe)

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)

I. FACILITY INFORMATION (To be completed by the licensee/designee) 1. NAME OF FACILITY 2. TELEPHONE ( ) 3. ADDRESS CITY ZIP CODE

4. LICENSEE’S NAME 5. TELEPHONE 6. FACILITY LICENSE NUMBER ( ) II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person) 1. NAME 2. BIRTH DATE 3. AGE

III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (To be completed by resident/resident's legal representative) I hereby authorize release of medical information in this report to the facility named above. 1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE

2. ADDRESS 3. DATE

IV. PATIENT'S DIAGNOSIS (To be completed by the physician)

NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a residential care facility for the elderly licensed by the Department of Social Services. The license requires the facility to provide primarily non-medical care and supervision to meet the needs of that person. THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provide about this person is required by law to assist in determining whether the person is appropriate for care in this non-medical facility. It is important that all questions be answered. (Please attach separate pages if needed.) 1. DATE OF EXAM 2. SEX 3. HEIGHT 4. WEIGHT 5. BLOOD PRESSURE

6. TUBERCULOSIS (TB) TEST a. Date TB Test Given b. Date TB Test Read c. Type of TB Test d. Please Check if TB Test is: ■ Negative ■ Positive e. Results: mm ______f. Action Taken (if positive): ______

______g. Chest X-ray Results: ______h. Please Check One of the Following: ■ Active TB Disease ■ Latent TB Infection ■ No Evidence of TB Infection or Disease

LIC 602A (8/11) (CONFIDENTIAL) PAGE 1 OF 6 7. PRIMARY DIAGNOSIS: a. Treatment/medication (type and dosage)/equipment:

b. Can patient manage own treatment/medication/equipment? ■ Yes ■ No c. If not, what type of medical supervision is needed?

8. SECONDARY DIAGNOSIS(ES): a. Treatment/medication (type and dosage)/equipment:

9. CHECK IF APPLICABLE TO 7 OR 8 ABOVE: ■ Mild Cognitive Impairment: Refers to people whose cognitive abilities are in a “conditional state” between normal aging and dementia. ■ Dementia: The loss of intellectual function (such as thinking, remembering, reasoning, exercising judgement and making decisions) and other cognitive functions, sufficient to interfere with an individual’s ability to perform activities of daily living or to carry out social or occupational activities. 10. CONTAGIOUS/INFECTIOUS DISEASE: a. Treatment/medication (type and dosage)/equipment:

LIC 602A (8/11) (CONFIDENTIAL) PAGE 2 OF 6 11. ALLERGIES: a. Treatment/medication (type and dosage)/equipment:

12. OTHER CONDITIONS: a. Treatment/medication (type and dosage)/equipment:

13. PHYSICAL HEALTH STATUS ASSISTIVE DEVICE YES NO (If applicable) EXPLAIN a. Auditory Impairment b. Visual Impairment c. Wears Dentures d. Wears Prosthesis e. Special Diet f. Substance Abuse Problem g. Use of Alcohol h. Use of Cigarettes i. Bowel Impairment j. Bladder Impairment k. Motor Impairment/Paralysis l. Requires Continuous Bed Care m. History of Skin Condition or Breakdown

LIC 602A (8/11) (CONFIDENTIAL) PAGE 3 OF 6 14. MENTAL CONDITION YES NO EXPLAIN a. Confused/Disoriented b. Inappropriate Behavior c. Aggressive Behavior d. Wandering Behavior e. Sundowning Behavior f. Able to Follow Instructions g. Depressed h. Suicidal/Self-Abuse i. Able to Communicate Needs j. At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items k. Able to Leave Facility Unassisted 15. CAPACITY FOR SELF-CARE YES NO EXPLAIN a. Able to Bathe Self b. Able to Dress/Groom Self c. Able to Feed Self d. Able to Care for Own Toileting Needs e. Able to Manage Own Cash Resources 16. MEDICATION MANAGEMENT YES NO EXPLAIN a. Able to Administer Own Prescription Medications b. Able to Administer Own Injections c. Able to Perform Own Glucose Testing d. Able to Administer Own PRN Medications e. Able to Administer Own Oxygen f. Able to Store Own Medications

LIC 602A (8/11) (CONFIDENTIAL) PAGE 4 OF 6 17. AMBULATORY STATUS:

a. 1. This person is able to independently transfer to and from bed: ■ Ye s ■ No

2. For purposes of a fire clearance, this person is considered: ■ Ambulatory ■ Nonambulatory ■ Bedridden

Nonambulatory: A person who is unable to leave a building unassisted under emergency conditions. It includes any person who is unable, or likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating to fire danger, and/or a person who depend upon mechanical aids such as crutches, walkers, and wheelchairs. Note: A person who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be considered non-ambulatory for the purposes of a fire clearance.

Bedridden: For the purpose of a fire clearance, this means a person who requires assistance with turning or repositioning in bed.

b. If resident is nonambulatory, this status is based upon:

■ Physical Condition ■ Mental Condition ■ Both Physical and Mental Condition

c. If a resident is bedridden, check one or more of the following and describe the nature of the illness, surgery or other cause:

■ llness: ______

■ Recovery from Surgery: ______

■ Other: ______

NOTE: An illness or recovery is considered temporary if it will last 14 days or less.

d. If a resident is bedridden, how long is bedridden status expected to persist?

1. ______(number of days)

2. ______(estimated date illness or recovery is expected to end or when resident will no longer be confined to bed)

3. If illness or recovery is permanent, please explain: ______

LIC 602A (8/11) (CONFIDENTIAL) PAGE 5 OF 6 e. Is resident receiving hospice care?

■ No ■ Yes If yes, specify the terminal illness: ______

18. PHYSICAL HEALTH STATUS: ■ Good ■ Fair ■ Poor

19. COMMENTS:

20. PHYSICIAN'S NAME AND ADDRESS (PRINT)

21. TELEPHONE 22. LENGTH OF TIME RESIDENT HAS BEEN YOUR PATIENT ( ) 23. PHYSICIAN'S SIGNATURE 24. DATE

LIC 602A (8/11) (CONFIDENTIAL) PAGE 6 OF 6

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Physician's Report - Child Care Centers (LIC 701)

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  6. STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA

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COMMENTS

  1. PDF PHYSICIAN'S REPORT-CHILD CARE CENTERS

    state of california . health and human services agency california department of social services . community care licensing . physician's report—child care centers (child's pre-admission health evaluation) part a - parent's consent (to be completed by parent) (name of child) , born (birth date) is being studied for readiness to enter

  2. PDF LIC 602A

    state of california - health and human services agency california department of social services . physician's report for residential care facilities for the elderly (rcfe) i. facility information (to be completed by the licensee/designee) 1. name of facility 2. telephone ( ) 3. address . city . zip code . 4. licensee's name . 5. telephone ( ) 6.

  3. PDF Physician'S Report for Community Care Facilities

    STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING . PHYSICIAN'S REPORT FOR COMMUNITY CARE FACILITIES . For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). NOTE TO PHYSICIAN:

  4. PDF Physician's Report for RCFE

    STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE) IV. PATIENT'S DIAGNOSIS (To be completed by the physician) I. FACILITY INFORMATION (To be completed by the licensee/designee)

  5. PDF Physician'S Report for Community Care Facilities

    The determination of ambulatory or nonambulatory status of all other disabled persons placed after January 1, 1984, who are not developmentally disabled shall be made by the Director of Social Services, or his or her designated representative. LIC 602 (10/99) (OVER) I. PHYSICAL HEALTH STATUS: GOOD FAIR POOR. COMMENTS:

  6. PDF PHYSICIAN'S REPORT FOR COMMUNITY CARE FACILITIES

    state of california - health and human services agency california department of social services community care licensing physician's report for community care facilities for resident/client of, or applicants for admission to, community care facilities (ccf). ... physician's signature physician's name and address: telephone: date:

  7. What to Know about California's 602 Form

    Families can find the form on the California Department of Social Services website. A Place for Mom advisors also have the form handy for families who want to move a loved one into a California residential care facility for the elderly. The physician's report requires the following: A patient history. A patient physical examination.

  8. PDF Physicians Report

    state of california california department of social services health and human services agency community care licensing ... physician's report---child care centers (child's pre-admission health evaluation) part a - parent's consent (to be completed by parent) child's name: _____, born _____is being studied for readiness to enter ...

  9. Form LIC701 Physician's Report

    This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department. ... Form DL546A Physician's Health Report - California; Form LIC857 Children's Records Review (Child Care ...

  10. Form LIC602 Physician's Report for Community Care Facilities

    Download Fillable Form Lic602 In Pdf - The Latest Version Applicable For 2024. Fill Out The Physician's Report For Community Care Facilities - California Online And Print It Out For Free. Form Lic602 Is Often Used In Patient Evaluation, Physician Report Form, Long Term Care, Health Assessment Form, California Department Of Social Services, California Legal Forms, Legal And United ...

  11. Forms and Publications (I-L)

    LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information. LIC 279 (2/23) - Application For A Family Child Care Home License. LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes. LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License.

  12. PDF Physician'S Report for Community Care Facilities

    California Health & Human Services Agency California Department of Social Services LIC 602 (7/22) Page 4 of 4 PLEASE LIST THE OVER-THE-COUNTER MEDICATION THAT CAN BE GIVEN TO THE CLIENT/ RESIDENT. AS NEEDED FOR THE FOLLOWING CONDITIONS: CONDITIONS OVER-THE-COUNTER MEDICATION(S) 1. Headache 2. Constipation 3. Diarrhea 4. Indigestion 5. Others ...

  13. PDF Physician'S Report for Community Care Facilities

    STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING PHYSICIAN'S REPORT FOR COMMUNITY CARE FACILITIES For Resident/Client Of, Or Applicants For Admission To, Community Care Facilities (CCF). NOTE TO PHYSICIAN: The person specified below is a resident/client of or an ...

  14. Physician's Report For Community Care Facilities (LIC 602)

    The purpose of the LIC 602 form is to collect information about an individual seeking admission or continued care in a residential care facility. The California Department of Social Services uses the form to determine whether the individual is appropriate for such care.

  15. What You Need To Know About the California Form 602

    Form 602 is issued by the California Department of Social Services. The form was established as a way to help senior communities better understand the needs of potential residents in terms of medical assistance, nutritional needs, mental and physical capabilities and other care requirements. The form cannot be filled by any family member.

  16. DSS Forms

    California Department of Social Services - Forms/Brochures. Centrally Stored Medication & Destruction Record. Client/Resident Personal Property & Valuables. Physician's Report for Community Care Facilites. Record of Client's/Resident's Safeguard Cash Resources. Learn more about our Transparency Policy and access to Public Information ...

  17. Physician's Report for Residential Care Facilities for the Elderly

    SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE. 2. ADDRESS 3. DATE. IV. PATIENT'S DIAGNOSIS (To be completed by the physician) NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a residential care facility for the elderly licensed by the Department of Social Services.

  18. Physician's Report For Residential Care Facilities For The ...

    Download Physician's Report For Residential Care Facilities For The Elderly (RCFE (LIC 602A) - Department of Social Services (California) form. Formalu Locations. United States. Browse By State Alabama AL Alaska AK Arizona AZ Arkansas AR California CA Colorado CO Connecticut CT

  19. PDF LIC 503 Health Screening Report

    All personnel, including applicant, licensee or employed staff of Residential Care Facilities for the Elderly, Community Care or Child Care Facilities must demonstrate that their health condition allows them to perform the type of work required. This health appraisal is to be. completed by or under the direction of a physician.

  20. PDF Residential Care Facilities for The Elderly

    State of California - Health and Human Services Agency California Department of Social Services PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED RESIDENTIAL CARE FACILITIES FOR THE ELDERLY LIC 613C-2 (1/19) Page 4 of 7 • To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the ...

  21. Physician's Report

    Download Physician's Report - Child Care Centers (LIC 701) - Department of Social Services (California) form. Formalu Locations. United States. Browse By State Alabama AL Alaska AK Arizona AZ Arkansas AR California CA Colorado CO Connecticut CT Delaware DE Florida FL Georgia GA

  22. Community Care Licensing

    Community Care Licensing Division 744 P Street, MS 8-17-17 Sacramento, CA 95814 Email: [email protected].

  23. Forms/Brochures

    For personal information access requests, send an email to CDSS' Public Inquiry and Response Unit [email protected] and/or call (916) 651-8848. They will direct you to your program representative.

  24. Home

    About CDSS. California Department of Social Services 744 P Street Sacramento, CA 95814 For public assistance case issues, inquiries, or complaints, e-mail our Public Inquiry and Response Unit at [email protected]. For assistance with Pandemic EBT, please call the P-EBT Helpline at 1-877-328-9677.