Lic 401 Form PDF Details

The LIC 401 form is a vital document for care facilities operating within the California Department of Social Services, particularly under the Community Care Licensing Division. This comprehensive form, requiring diligent completion on a monthly basis, serves as an operating statement for the reporting period specified. It encompasses various essential aspects such as estimated and actual revenues, ranging from SSI revenue, voluntary third-party contributions, private revenue to other facility-related revenues. Additionally, it meticulously outlines operating costs, segregated into subcategories like care and services, general administration, and physical plant costs. These encapsulate expenses from food costs, household supplies, personal hygiene items, to more extensive costs like rent, utilities, and maintenance. Facilities must report both estimated and actual figures, offering a holistic view of their financial health. The necessity for accuracy is underscored by the requirement for the preparer's printed name and the applicant or licensee's signature, affirming the veracity of the information. This form not only fulfills regulatory compliance but also aids in the strategic management of the facility's resources, ensuring operational sustainability and the provision of quality care.

QuestionAnswer
Form NameLic 401 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslic 401a form, lic 401 monthly operating statement, 401 statement, lic 401 example

Form Preview Example

STATE OF CALIFORNIA–HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

MONTHLY OPERATING STATEMENT

 

IMPORTANT - Before completing,

 

 

 

 

 

FOR THE MONTH ENDING:___________________

 

see reverse for instructions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FACILITY NAME:

 

 

 

 

 

APP./LIC. NO.

 

 

 

 

 

 

 

FACILITY ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly

 

 

 

 

 

 

 

 

 

 

OPERATING REVENUES

 

 

Estimated

 

 

Ln #

PROGRAM REVENUES

 

 

 

Actual

Ln #

 

 

 

 

 

 

1.

SSI Revenue (Monthly SSI Rate) x (Number of SSI Clients) Rate $ _____________ x # _____________ = 1

$

 

2.

Voluntary 3rd Party Contributions

 

 

 

 

2

 

3.

Private Revenue

Number of Private Pay Residents # ______________

3

 

 

OTHER REVENUES RELATED TO THE FACILITY

 

 

 

 

4.

____________________________________________________________________________________

4

 

5.

____________________________________________________________________________________

5

 

6.

Total Revenue (add lines 1 through 5 and any attached). Worksheet attached?

YES NO

6

$

 

 

 

 

 

 

 

 

 

 

OPERATING COSTS

 

 

Estimated

 

Monthly

 

CARE AND SERVICES

 

 

 

Actual

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Food Costs

 

 

 

7

$

 

 

 

 

8.

Household Supplies

 

 

 

8

 

9.

Laundry and Dry Cleaning

 

 

 

9

 

10.

Personal Hygiene Items

 

 

 

10

 

11.

Recreational Activities

 

 

 

11

 

12.

Newspapers, Magazines, Cable TV

 

 

 

12

 

13.

Medical and First Aid

 

 

 

13

 

14.

Client Transportation

 

 

 

14

 

15.

Total Care & Services (add lines 7 through 14)

 

15

$

 

GENERAL ADMINISTRATION

 

 

 

 

 

 

16.

Salaries and Wages

 

 

 

16

 

17.

.............................................................................................................Payroll Taxes and Employee Benefits

 

 

 

17

 

18.

General Transportation

 

 

 

18

 

19.

Telephone

 

 

 

19

 

20.

Office Supplies

 

 

 

20

 

21.

Advertising

 

 

 

21

 

22.

Fees for licenses and memberships

 

 

 

22

 

 

 

 

 

23.

Contract Labor

 

 

 

23

 

 

 

 

 

24.

Insurance (Liability and Fire)

 

 

 

24

 

 

 

 

 

25.

Indirect Overhead

 

 

 

25

 

 

 

 

 

26.

Total General Administration (add lines 16 through 25)

 

 

26

 

 

$

 

PHYSICAL PLANT

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

Rent, Lease, Mortgage Payments and Homeowners Association Fees

 

27

 

28.

Property Taxes

 

 

 

28

 

29.

Gas

 

 

 

29

 

30.

Electricity

 

 

 

30

 

31.

Water

 

 

 

31

 

32.

Garbage

 

 

 

32

 

33.

Repair & Maintenance (Building)

 

 

 

33

 

34.

............................................................................................Repair & Maintenance (Furniture & Equipment)

 

34

 

35.

Other (specify)

 

 

 

35

 

36.

.......................................................................................Total Physical Plant (add lines 27 through 35)

 

36

$

37.

...........................................................................................Total Operating Costs (add lines 15, 26, and 36)

 

37

$

 

 

 

 

 

 

 

38.

.......................................................................................................Net Profit (Loss) (subtract line 37 from 6)

 

38

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I declare under penalty of perjury that the foregoing and any attachments are true and correct.

PREPARED BY:

TITLE:

APPLICANT/LICENSEE SIGNATURE:

DATE:

LIC 401 (3/01)

MONTHLY OPERATING STATEMENT

GENERAL INFORMATION AND INSTRUCTIONS

GENERAL INFORMATION - Each applicant/licensee (sole proprietorship, partnership, corporation or limited liability company) must submit a LIC 401, OPERATING STATEMENT, for care facilities in operation or pending (to commence within the next twelve months). In addition, an LIC 401a, Supplemental Financial Information, Part II must be submitted. A separate LIC 401 is to be submitted for each CCLD licensed/pending license operation. A profit and loss statement is to be submitted for other business operations. For CCLD operations already licensed or other ongoing business operations the reported amounts are to be actual rather than estimated. For CCLD operations pending license or other pending business operations the reported amounts may be estimated.

FOR INDIVIDUALS AS SOLE PROPRIETORS - Part I of the LIC 401a must also be completed.

FOR GENERAL PARTNERS - In addition to the LIC 401a, Part II, for the partnership a separate Form LIC 401a must be completed for each general partner. Information reported on this document is subject to verification. Therefore, additional documentation may be requested to support some or all of the items reported.

INSTRUCTIONS Please include the required information at the top of this form to identify the 1) reporting period of the information,

2)facility name, 3) facility address and 4) application or license number.

REVENUES

Line # PROGRAM REVENUES

1.Report the SSI monthly rate, the number of clients/residents and the total monthly revenue.

2.Report all 3rd party voluntary contributions received on behalf of all SSI recipients.

3.Report average monthly rate for private pay clients/residents, the number of private pay clients/residents and the total

monthly revenue.

OTHER REVENUES

4-5. Report all other facility related revenues (i.e. interest income, subleases, insurance reimbursements, sale of assets) individually on lines 4 and 5. If more space is required attach a worksheet and indicate the total on line 5.

OPERATING COSTS

CARE AND SERVICES

7.Costs for food products, and meals for clients, residents and staff.

8.Costs for cleaning supplies (except laundry and dry cleaning).

9.Costs for laundry and dry cleaning.

10.Costs for personal hygiene items provided for the clients and residents.

11.Costs for recreational activities.

12.Costs for newspapers, magazines, cable TV, etc.

13.Costs for medical supplies, first aid, and any other non-reimbursable medical costs.

14.Costs for transporting clients/residents to and from medical appointments, recreational activities, and other allowable transportation costs.

GENERAL ADMINISTRATION

16.Staff salaries and wages (verified to staffing report).

17.Federal and state payroll taxes and the cost of employee benefits including worker’s compensation insurance incurred by the facility.

18.Direct transportation costs, (Include vehicle loan payments, maintenance and fuel).

19.Include all costs for telephone communications (phones, FAX, pagers, etc.).

20.Costs for office supplies and postage.

21.Costs for business related advertising.

22.Costs for business licenses, membership fees and professional fees.

23.All contract to labor.

24.Costs for all other insurance (public liability, property damage, auto, surety bond, etc.).

25.Costs/Expenses required for the support of a corporate or headquarter’s office.

PHYSICAL PLANT

27.Cost to rent, lease or mortgage payments on the facility.

28.Costs for real estate property taxes (average monthly cost).

29.Costs for natural or propane gas used in the facility.

30.Costs for electricity consumed at the facility.

31.Costs for water, including bottled water.

32.Costs for disposal of garbage.

33.Costs for building repair and maintenance.

34.Costs for furniture and equipment repair and maintenance.

35.All other expenses.

SIGNATURE BLOCK

The name of the preparer is to be printed in the space provided. The applicant or licensee is required to sign this form attesting to the financial information. Failure to sign, date and attest to the accuracy of the information reported on the Monthly Operating Statement (LIC 401) shall constitute non-compliance and the rejection of this report.

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Writing part 1 of 401 monthly

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Food Costs   Household Supplies, Rent Lease Mortgage Payments and, and Salaries and Wages   Payroll in 401 monthly

3. The following segment is typically pretty easy, Rent Lease Mortgage Payments and, Total Operating Costs add lines, Net Profit Loss subtract line, I declare under penalty of perjury, PREPARED BY, TITLE, APPLICANTLICENSEE SIGNATURE, DATE, and LIC - all these fields needs to be filled in here.

Step number 3 in filling out 401 monthly

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