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.
| Question | Answer |
|---|---|
| Form Name | Lic 401 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | lic 401a form, lic 401 monthly operating statement, 401 statement, lic 401 example |