In the intricate web of administrative paperwork that undergirds the operation of community care facilities in California, the LIC 601 form plays a crucial role. Crafted by the State of California Health and Human Services Agency and enforced by the Community Care Licensing Division of the California Department of Social Services, this form is a cornerstone document that ensures all individuals admitted to a community care facility have their identification and emergency information meticulously documented and kept up-to-date. It’s designed not just as a bureaucratic requirement but as a safeguard, ensuring that in any emergency, critical information is at the fingertips of those who need it, yet securely out of reach from those without authorization. On its pages, the form encompasses a wide scope of personal details, ranging from basic identification data, contact information for responsible parties, financial responsibility, to emergency medical plans, and even personal preferences and restrictions. Its existence underscores a delicate balance: the need for thorough documentation against the imperative of privacy and personal security. Whether for children or adults, the LIC 601 is more than just paper; it's a testament to a system's dedication to care, accountability, and preparedness.
| Question | Answer |
|---|---|
| Form Name | Lic 601 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | human lic 601, lic 600, lic 601, lic 601 rcfe |
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
IDENTIFICATION AND EMERGENCY INFORMATION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
This information is required under the H & S Code and the regulations of the Department to be maintained on every person admitted to a community care facility, to be readily available to the person in charge, but not accessible to unauthorized persons. All information must be kept current. See other side for additional information required for residential facilities for children.
A. ALL FACILITIES |
[EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700] |
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NAME OF CLIENT OR CHILD |
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SOCIAL SECURITY NUMBER (OPTIONAL) |
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DATE OF BIRTH |
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AGE |
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SEX |
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2. |
RESPONSIBLE PERSON OR PLACEMENT AGENCY |
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ADDRESS |
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TELEPHONE |
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3. |
NAME OF NEAREST RELATIVE (OPTIONAL) |
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RELATIONSHIP |
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ADDRESS |
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TELEPHONE |
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4. |
DATE ADMITTED TO FACILITY |
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ADDRESS PRIOR TO ADMISSION |
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5. |
DATE LEFT |
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FORWARDING ADDRESS |
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6. |
REASONS FOR LEAVING FACILITY |
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7. |
PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANY |
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NAME |
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ADDRESS |
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TELEPHONE |
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8. |
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OTHER PERSONS TO BE NOTIFIED IN EMERGENCY |
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NAME |
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a. |
PHYSICIAN |
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b. |
MENTAL HEALTH PROVIDER, IF ANY |
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c. |
DENTIST |
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d. |
RELATIVE(S) |
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e. |
FRIEND(S) |
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9. |
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EMERGENCY HOSPITALIZATION PLAN |
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NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY |
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ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY |
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MEDICAL PLAN |
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MEDICAL PLAN IDENTIFICATION NUMBER |
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NAME OF DENTAL PLAN (IF ANY) |
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DENTAL PLAN NUMBER (IF ANY) |
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10. |
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OTHER REQUIRED INFORMATION |
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a.AMBULATORY STATUS
b. RELIGIOUS PREFERENCE |
NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR, IF ANY |
TELEPHONE |
( )
11. COMMENTS
SIGNATURE OF RESIDENT
SIGNATURE OF PERSON COMPLETING FORM
TITLE
DATE
LIC 601 (8/08) Personal |
Page 1 of 2 |
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B.RESIDENTIAL FACILITIES FOR CHILDREN
(Additional information is required by regulation for residential facilities for children.)
1.NAME OF CHILD
2. NAME AND ADDRESS OF PERSON TO CONTACT, IF AUTHORIZED REPRESENTATIVE IS NOT AVAILABLE |
SPECIFY RELATIONSHIP |
TELEPHONE NUMBER |
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3. NAME AND ADDRESS OF PARENT(S)/PARENT’S DOMESTIC PARTNER, IF KNOWN |
TELEPHONE NUMBER |
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4.CHILD’S COURT STATUS (ATTACH CUSTODY ORDERS AND AGREEMENTS WITH PARENT(S), OR PERSON(S) HAVING LEGAL CUSTODY. NOTE: OPTIONAL FOR SMALL FAMILY AND FOSTER FAMILY HOMES)
5. |
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PERSON(S) WITH WHOM CHILD HAS BEEN LIVING (IF KNOWN) |
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NAME AND RELATIONSHIP |
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ADDRESS |
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TELEPHONE |
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6. |
VISITATION RESTRICTIONS (BY COURT ORDER OR AUTHORIZED REPRESENTATIVE) |
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PERSON(S) NOT AUTHORIZED TO VISIT CHILD |
PERSON(S) NOT AUTHORIZED TO VISIT CHILD |
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NAME |
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RELATIONSHIP |
NAME |
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RELATIONSHIP |
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7. |
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FAMILY RESIDENCE VISITATION RESTRICTIONS |
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SPECIFY, IF ANY |
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8. |
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ALL PERSONS AUTHORIZED TO REMOVE CHILD FROM HOME |
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NAME
RELATIONSHIP
SPECIFY CONDITIONS
9. |
TELEPHONE ACCESS |
MAKE AND RECEIVE CONFIDENTIAL CALLS
■ YES |
■ NO (BY COURT ORDER) |
IF NO, SPECIFY RESTRICTIONS
10.COMMENTS
LIC 601 (8/08) Personal |
Page 2 of 2 |