Form LIC 401 at a glance
What it is: LIC 401 is the Monthly Operating Statement of the California Department of Social Services Community Care Licensing Division.
Who signs: The applicant or licensee is required to sign this form attesting to the financial 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).
What to bring and attach to Form LIC 401
In addition, an LIC 401a, Supplemental Financial Information, Part II must be submitted.
A profit and loss statement is to be submitted for other business operations.
A filled-in Form LIC 401 example: a licensed care home files its monthly statement
How to fill out Form LIC 401, box by box
Reporting period, facility name, facility address and application or license number
Include the required information to identify the 1) reporting period of the information, 2) facility name, 3) facility address and 4) application or license number.
Estimated Actual
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.
SSI, 3rd party voluntary contributions and private pay revenue
Report the SSI monthly rate, the number of clients/residents and the total monthly revenue.
Report all 3rd party voluntary contributions received on behalf of all SSI recipients.
Report average monthly rate for private pay clients/residents, the number of private pay clients/residents and the total monthly revenue.
Other revenues related to the facility
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.
Total Revenue and Worksheet attached?
Total Revenue: add lines 1 through 5 and any attached. Worksheet attached? YES NO.
Care and services
Line 7, Food Costs: costs for food products, and meals for clients, residents and staff.
Line 9, Laundry and Dry Cleaning: costs for laundry and dry cleaning.
Line 10, Personal Hygiene Items: costs for personal hygiene items provided for the clients and residents.
Line 12, Newspapers, Magazines, Cable TV: costs for newspapers, magazines, cable TV, etc.
Line 14, Client Transportation: costs for transporting clients/residents to and from medical appointments, recreational activities, and other allowable transportation costs.
Line 15, Total Care & Services: add lines 7 through 14.
General administration
Line 16, Salaries and Wages: staff salaries and wages (verified to staffing report).
Line 17, Payroll Taxes and Employee Benefits: federal and state payroll taxes and the cost of employee benefits including worker's compensation insurance incurred by the facility.
Line 19, Telephone: include all costs for telephone communications (phones, FAX, pagers, etc.).
Line 21, Advertising: costs for business related advertising.
Line 22, Fees for licenses and memberships: costs for business licenses, membership fees and professional fees.
Line 23, Contract Labor: all contract to labor.
Line 24, Insurance (Liability and Fire): costs for all other insurance (public liability, property damage, auto, surety bond, etc.).
Line 26, Total General Administration: add lines 16 through 25.
Physical plant
Line 27, Rent, Lease, Mortgage Payments and Homeowners Association Fees: cost to rent, lease or mortgage payments on the facility.
Line 29, Gas: costs for natural or propane gas used in the facility.
Line 30, Electricity: costs for electricity consumed at the facility.
Line 31, Water: costs for water, including bottled water.
Line 32, Garbage: costs for disposal of garbage.
Line 33, Repair & Maintenance (Building): costs for building repair and maintenance.
Line 34, Repair & Maintenance (Furniture & Equipment): costs for furniture and equipment repair and maintenance.
Line 35, Other (specify): all other expenses.
Line 36, Total Physical Plant: add lines 27 through 35.
Total Operating Costs and Net Profit (Loss)
Line 37, Total Operating Costs: add lines 15, 26, and 36.
Line 38, Net Profit (Loss): subtract line 37 from 6.
Preparer, applicant or licensee signature and date
Fill in PREPARED BY, TITLE and DATE, and sign at APPLICANT/LICENSEE SIGNATURE.
Sign under: "I declare under penalty of perjury that the foregoing and any attachments are true and correct."
The name of the preparer is to be printed in the space provided.
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.
More rules for Form LIC 401
A separate LIC 401 is to be submitted for each CCLD licensed/pending license operation.
Information reported on this document is subject to verification. Therefore, additional documentation may be requested to support some or all of the items reported.
If your situation is different
For individuals as sole proprietors
For individuals as sole proprietors, Part I of the LIC 401a must also be completed.
For general partners
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.
Sources
[1] Form LIC 401 (3/01), Monthly Operating Statement, California Department of Social Services Community Care Licensing Division (the Official source link on this page).