Lic 603 Form PDF Details

The process of admitting an individual to a residential care facility in California involves thorough and comprehensive assessments to ensure the best care and accommodation for the potential resident. One crucial step in this process is the completion of the LIC 603 form, a document required by the California Department of Social Services' Community Care Licensing division. This form serves as a preplacement appraisal, collecting detailed information about the applicant’s health condition, physical and mental capabilities, social factors, and specific care needs. In addition to capturing the applicant's overall health, including dietary limitations and physical disabilities, it delves into mental conditions, health history, and social preferences. Furthermore, it assesses the individual's functional capabilities, ambulatory status, and the necessity for diverse services ranging from personal hygiene assistance to specialized medical attention. The LIC 603 form also addresses tuberculosis exposure, bedding and ambulatory needs, and requires an account of any services the applicant might need, emphasizing the importance of a well-rounded evaluation to determine the suitability for admission into a care facility. Through such detailed assessments, the form aims to ensure that care facilities are well-prepared to meet the specific needs of each resident, thereby facilitating a better quality of care and living environment.

QuestionAnswer
Form NameLic 603 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespreplacement information online, california lic 603, lic 603, california 603

Form Preview Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

PREPLACEMENT APPRAISAL INFORMATION

Admission - Residential Care Facilities

NOTE: This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospital or physician may assist the applicant in completing this form.) This form is not a substitute for the Physician’s Report (LIC 602).

APPLICANT’S NAME

AGE

HEALTH (Describe overall health condition including any dietary limitations)

PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech)

MENTAL CONDITION (Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))

HEALTH HISTORY (List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years)

SOCIAL FACTORS (Describe likes and dislikes, interests and activities)

BED STATUS

■

■

■

OUT OF BED ALL DAY

IN BED ALL OR MOST OF THE TIME IN BED PART OF THE TIME

COMMENT:

TUBERCULOSIS INFORMATION

ANY HISTORY OF TUBERCULOSIS IN APPLICANT’S FAMILY?

DATE OF TB TEST

■ POSITIVE

 

 

 

■ YES

■ NO

 

■ NEGATIVE

 

 

 

ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?

ACTION TAKEN (IF POSITIVE)

 

■ YES

■ NO

 

 

 

 

 

 

GIVE DETAILS

 

 

 

LIC 603 (9/99)

(Over)

AMBULATORY STATUS (this person is ■ ambulatory ■ nonambulatory)

Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device. An ambulatory person must be able to do the following:

YES NO

■■ Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.

■■ Mentally and physically able to follow signals and instructions for evacuation.

■■ Able to use evacuation routes including stairs if necessary.

■■ Able to evacuate reasonably quickly (e.g., walk directly the route without hesitation).

FUNCTIONAL CAPABILITIES (Check all items below)

YES

NO

 

 

 

■

■

Active, requires no personal help of any kind - able to go up and down stairs easily

 

■

■

Active, but has difficulty climbing or descending stairs

 

 

■

■

Uses brace or crutch

 

 

■

■

Feeble or slow

 

 

■

■

Uses walker. If Yes, can get in and out unassisted?

■ Yes

■ No

■

■

Uses wheelchair. If Yes, can get in and out unassisted?

■ Yes

■ No

■■ Requires grab bars in bathroom

■■ Other: (Describe)

_______________________________________________________________________________________________________________

SERVICES NEEDED (Check items and explain)

YES NO

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

■ ■

Help in transferring in and out of bed and dressing________________________________________________________________________

_______________________________________________________________________________________________________________

Help with bathing, hair care, personal hygiene ___________________________________________________________________________

Does client desire and is client capable of doing own personal laundry and other household tasks (specify) ___________________________

Help with moving about the facility ____________________________________________________________________________________

_______________________________________________________________________________________________________________

Help with eating (need for adaptive devices or assistance from another person) _________________________________________________

_______________________________________________________________________________________________________________

Special diet/observation of food intake _________________________________________________________________________________

_______________________________________________________________________________________________________________

Toileting, including assistance equipment, or assistance of another person_____________________________________________________

Continence, bowel or bladder control. Are assistive devices such as a catheter required? _________________________________________

Help with medication _______________________________________________________________________________________________

_______________________________________________________________________________________________________________

Needs special observation/night supervision (due to confusion, forgetfulness, wandering) _________________________________________

Help in managing own cash resources _________________________________________________________________________________

Help in participating in activity programs ________________________________________________________________________________

_______________________________________________________________________________________________________________

Special medical attention ___________________________________________________________________________________________

_______________________________________________________________________________________________________________

Assistance in incidental health and medical care _________________________________________________________________________

_______________________________________________________________________________________________________________

Other “Services Needed” not identified above ___________________________________________________________________________

_______________________________________________________________________________________________________________

Is there any additional information which would assist the facility in determining applicant’s suitability for admission?

■ Yes

■ No

If Yes, please attach comments on separate sheet.

 

 

To the best of my knowledge; I (the above person) do not need skilled nursing care.

SIGNATURE

DATE COMPLETED

APPLICANT (CLIENT) OR AUTHORIZED REPRESENTATIVE

SIGNATURE

DATE COMPLETED

LICENSEE OR DESIGNATED REPRESENTATIVE

DATE COMPLETED

How to Edit Lic 603 Form Online for Free

With the goal of allowing it to be as easy to apply as possible, we designed this PDF editor. The process of creating the lic 603 form can be simple when you adhere to the next actions.

Step 1: Press the orange "Get Form Now" button on this page.

Step 2: At this point, you're on the form editing page. You can add text, edit present information, highlight particular words or phrases, insert crosses or checks, insert images, sign the form, erase unrequired fields, etc.

The next parts are inside the PDF form you will be completing.

california lic 603 spaces to fill out

Note the details in HEALTH HISTORY List currently, last years, SOCIAL FACTORS Describe likes and, BED STATUS, OUT OF BED ALL DAY, IN BED ALL OR MOST OF THE TIME, IN BED PART OF THE TIME, TUBERCULOSIS INFORMATION, COMMENT, ANY HISTORY OF TUBERCULOSIS IN, DATE OF TB TEST, YES, ANY RECENT EXPOSURE TO ANYONE WITH, ACTION TAKEN IF POSITIVE, and POSITIVE.

step 2 to filling out california lic 603

You have to write particular data in the area AMBULATORY STATUS this person is, ambulatory, nonambulatory, Ambulatory means able to, YES, Able to walk without any physical, FUNCTIONAL CAPABILITIES Check all, YES, Active requires no personal help, Active but has difficulty climbing, Uses brace or crutch, Feeble or slow, Uses walker If Yes can get in and, Uses wheelchair If Yes can get in, and Yes.

Finishing california lic 603 step 3

You will have to describe the rights and obligations of both parties in space YES, Help in transferring in and out of, Help with bathing hair care, Does client desire and is client, Help with moving about the, Help with eating need for, Special dietobservation of food, Toileting including assistance, Continence bowel or bladder, Help with medication, Needs special observationnight, Help in managing own cash, Help in participating in activity, Special medical attention, and Assistance in incidental health.

Entering details in california lic 603 part 4

Finalize by reading all of these areas and completing the appropriate data: Is there any additional, Yes, If Yes please attach comments on, To the best of my knowledge I the, SIGNATURE, APPLICANT CLIENT OR AUTHORIZED, SIGNATURE, LICENSEE OR DESIGNATED, DATE COMPLETED, DATE COMPLETED, and DATE COMPLETED.

Filling in california lic 603 step 5

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Step 4: Create duplicates of the file - it may help you keep clear of potential future complications. And don't get worried - we are not meant to reveal or view the information you have.

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