california department of social services physician's report

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What You Need to Know About California’s Form 602a for Residential Care Facilities

According to recent data,  7 out of 10 people will require assisted living care at some point during their lifetime. In California, residential care communities often offer amenities  and services such as meals, housekeeping, and round-the-clock caregiving assistance. However, it’s not as simple as finding a community, paying, and moving in.

For seniors in California seeking to relocate to a residential care community, completing the 602a form is a crucial step required by state law to be admitted. Unfortunately, not all seniors or their families are aware of this requirement. 

This guide addresses the ins and outs of California’s 602a form, from what it is to how it must be completed and how family members can help. Additionally, it addresses common questions seniors and their families may have about residential care facilities for the elderly in California.

• What Is a Residential Care Facility for the Elderly?

In California, a residential care facility for the elderly (RCFE) is a state-licensed facility that provides nonmedical daily living care, supervision and memory care in a residential setting based on specific licensing qualifications. According to state policy, at least  75% of residents of an RCFE must be aged 60 or older, and varying levels of care and supervision must be provided.  

In RCFEs, seniors receive assistance with activities of daily living that they would otherwise not be able to perform on their own. Communities can vary widely both in the scope of care and amenities provided. Some offer resort-style living on expansive grounds, while others exist in large single-family homes.

In California, RCFEs are licensed by the Department of Social Services, Community Care Licensing Division . A specific Senior Care Licensing Program exists within the division that licenses and monitors all RCFEs and continuing care retirement communities.

• What Is the California Form 602a?

Form 602a, formally known as the Physician’s Report for Community Care Facilities , is a crucial report that RCFEs use to get a bigger picture of a senior’s specific care needs. RCFEs in the state must ensure that residents meet their admission criteria and that the community is equipped to provide the necessary care. This form allows a facility’s admissions team to know exactly what a potential resident may need.  

California’s 602a form contains pertinent medical information, including:

• Facility information:  This includes basic identifiers, such as the facility’s name, address, phone number and license number.
• Senior’s identifying information: This includes the senior’s name, address, phone number, Social Security number, next of kin and the name of the person responsible for their finances.
• Senior’s diagnostic information for any medical conditions:  This includes a list of medical conditions, age, height, weight and whether the physician believes the individual may require skilled nursing care.
• Tuberculosis information:  Prior to admission, seniors must not have an active tuberculosis (TB) diagnosis. The physician must complete a TB skin test or chest X-ray to ensure there is no active infection.
• Medications and treatments:  This dictates treatments and medications, as well as doses of prescribed medications.
• Ambulatory status:  This describes how independently mobile a senior is, including whether they can independently transfer to and from a bed and if they are considered nonambulatory or bedridden, for the purpose of a fire clearance.
• Physical health status:  This describes how a physician rates the senior’s general physical health, including evaluations of impairments and assistive devices required.
• Mental health status:  This describes how a physician rates a senior’s mental health and whether they can communicate and follow directions or if they present as confused or depressed.
• Capacity for self-care: This describes a senior’s ability to complete activities of daily living, including the ability to groom and feed themselves, leave the facility unassisted or take and manage their own medications.  

After undergoing an evaluation in which their abilities and overall health are assessed, seniors are required to have this form filled out by a physician. The results allow facilities to understand the level of care the senior may need. If the applicant qualifies based on what the facility is licensed to provide, then they may be admitted. Those who require more assistance than an RCFE can give may need admission into a medical facility, such as a skilled nursing facility .

How Do You Complete the 602a Form?

Because the 602a form must be completed by a physician, you don’t need to fill it out. However, you do need to request that the form be completed by a doctor. This can take time to be filled out and returned, so it’s good practice to start the process as soon as possible. 

Ideally, a senior’s primary physician will complete this form, though if they are in a skilled nursing community or a hospital, it’s acceptable to have the attending physician fill it out.

To begin, follow the normal process for scheduling an appointment with your or your senior loved one’s primary care provider. While scheduling, make sure it’s noted that the purpose of the appointment is to complete the 602a form. This way, the office can accommodate the lengthier appointment and examination process.

How Can I Help My Loved One Complete the California Form 602a?

If you are a caregiver or family member of a senior loved one, your primary role in this process is to be an advocate. Here are some ways to offer support:

• Schedule the appointment for your senior loved one.
• Attend the appointment with them.
• Talk to the physician if you have any concerns about your loved one’s health and wellness that may be relevant to the form. Your insight may prove valuable.
• Reiterate to the doctor that the 602a form needs to be completed as thoroughly and accurately as possible.
• After the appointment, follow up with the doctor’s office to see if the form has been completed yet.
• Once the form has been completed, you can review it to ensure it’s been filled out correctly.
• Later, touch base with the RCFE to ensure they have the form.
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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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Form LIC 602A. Physician's Report For Residential Care Facilities For The Elderly (RCFE)

The LIC 602A form, also known as the Physician's Report for Residential Care Facilities for the Elderly (RCFE), is a vital document required by the California Department of Social Services' Community Care Licensing. This form serves the purpose of gathering comprehensive medical information about elderly individuals who are seeking admission to residential care facilities.

The LIC 602A form consists of multiple sections that are crucial for assessing an individual's health condition. These sections include fields such as patient identification, medical conditions, medications, cognitive status, physical limitations, and behavioral issues. Each field plays a significant role in providing a detailed overview of the person's health status and specific care requirements.

The parties involved in completing the LIC 602A form are the physician or healthcare provider responsible for evaluating the individual's health condition and the residential care facility where the person intends to reside. Collaborating closely during the form filling process is essential to ensure accuracy and provide up-to-date information.

When filling out the LIC 602A form, various data points are required. This includes personal information of the individual, medical history, current medications, diagnoses, treatment plans, and any relevant laboratory or diagnostic test results. Additionally, attaching supporting documents such as medical records, test reports, or assessments completed by other healthcare professionals may be necessary.

Application examples and use cases for the LIC 602A form include:

Admission to Residential Care Facility: The form is used when an elderly individual wishes to move into a residential care facility. It helps the facility staff assess the person's health condition and determine whether they can provide appropriate care.

Care Planning: The LIC 602A form assists in developing personalized care plans for residents based on their medical needs and limitations. It allows facility staff to understand the level of care required and tailor services accordingly.

Related forms or alternative options to the LIC 602A form may include:

Physician's Report - Skilled Nursing Facilities (SNF): This alternative form is used for individuals requiring a higher level of medical care and seeking admission to a skilled nursing facility.

Physician's Report - Community Care Facilities (CCF): This alternative form is used for individuals who require care in community-based facilities, such as adult residential facilities or group homes.

Once completed, the LIC 602A form is typically submitted directly to the residential care facility where the individual intends to reside. It is essential to fill out all relevant sections accurately and legibly. The facility securely stores the completed form as part of the resident's medical records, ensuring ongoing care planning and documentation.

Overall, the LIC 602A form is a crucial document for evaluating the health condition of elderly individuals seeking admission to residential care facilities. By providing detailed medical information, this form enables facility staff to understand residents' needs and create appropriate care plans. Accurate completion and submission of the form facilitate effective communication between healthcare providers and residential care facilities, ensuring high-quality care for the elderly .

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Physician's Report For Residential Care Facilities For The Elderly (RCFE (LIC 602A)

Department of social services.

This government document is issued by Department of Social Services for use in California

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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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