Form LIC 604 at a glance
What it is: The Admission Agreement Guide for Residential Facilities is a form of the California Department of Social Services Community Care Licensing.
Who signs: Under 17. PARTIES TO THIS AGREEMENT, the Client/Resident or Authorized Representative and the Licensee/Administrator sign with a Date.
All community care facilities are required to have written admission agreement between the facility and each client/resident (or authorized representative) who is received for services pursuant to applicable sections of the California Code of Regulations, Title 22, Division 6.
A filled-in Form LIC 604 example: a facility completes the guide for a resident
How to fill out Form LIC 604, box by box
1. FACILITY INFORMATION
Under 1. FACILITY INFORMATION, fill in the Name of Facility, Type of Facility, Address, City, State, Zip Code and Telephone.
2. BASIC SERVICES
Under 2. BASIC SERVICES, enter the Name of Client/Resident, Social Security No. (Optional) and Birthdate.
Social Security No. is optional.
1) BASIC GENERAL SERVICES: (a) Lodging: single room double room. (b) Food Services: a. three nutritious meals daily and between meals nourishment or snack. b. Special diets if prescribed by a doctor. (c) Laundry service. (d) Cleaning of the client's/resident's room. (e) Comfortable and suitable bed including fresh linen weekly or more often, if required. (f) Plan, arrange and/or provide for transportation to medical and dental appointments. (g) A planned activity program including arrangement for utilization of available community resources. (h) Notification to family and other appropriate person/agency of client's resident's needs. 2) BASIC PERSONAL SERVICES: (a) Continuous observation, care and supervision, as required. (b) Assistance with bathing and personal needs, as required. (c) Assistance in meeting necessary medical and dental needs. (d) Assistance, as needed, with taking prescribed medications in accordance with physician's instructions unless prohibited by law or regulations. (e) Bedside care for minor temporary illnesses. (f) Maintenance or supervision of client/resident cash resources or property, if necessary.
B. The monthly rate for basic services is $_________________or the SSI/SSP established rate or a government funded rate of $___________________.
Basic services are paid in advance or in arrears.
3. OPTIONAL SERVICES
Under 3. OPTIONAL SERVICES, list each optional service with its Time/Intervals for Providing Service, its Rate for Providing Services and its Pay Schedule.
Total monthly rate for optional services is $. Optional services are paid in advance or in arrears.
The basic monthly rate does not include additional charges for optional services provided by the facility. There is no obligation to purchase any of these services.
4. TOTAL MONTHLY RATE (BASIC & OPTIONAL SERVICES)
Enter the total monthly rate for basic and optional services under 4. TOTAL MONTHLY RATE (BASIC & OPTIONAL SERVICES).
More rules for Form LIC 604
5. EVICTION PROCEDURES: ADULT RESIDENTIAL CARE FACILITY. The licensee/administrator of the facility may, upon thirty (30) days written notice to the client/resident, evict the client/resident for one or more of the following reasons: 1) Nonpayment of the rate for basic services within ten days of the due date; 2) Failure of the client/resident to comply with state or local law after receiving written notice of the alleged violation; 3) Failure of the client/resident to comply with the following written general policies of the facility which are for the purpose of making if possible for clients/residents to live together; 4) Inability of the licensee to meet the client's/resident's needs. Based upon a reassessment of the client's/resident's needs, conducted pursuant to applicable regulations, the licensee/administrator of the facility and the person who performs the assessment determine that the facility is not appropriate for the client/resident and the client/resident has been given the opportunity to relocate. 5) Change of use of the facility.
In an adult residential care facility, the licensee/administrator of the facility may, upon obtaining prior and/or documented telephone approval from the licensing agency, evict the client/resident upon three (3) days written notice to quit.
In an adult residential care facility, the licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the client/resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself/herself or to others in the facility.
In an adult residential care facility, a written report of any eviction shall be sent to the licensing agency within five (5) days.
13. Name of Client/Resident or Authorized Representative will: Pay the basic monthly rate in advance or in arrears. Will or will not purchase the optional services listed.
Provide two weeks notice of intent to move from the facility unless the client's/resident's physical condition prevents this being done.
15. The client's/resident's funding source* is private source, SSI/SSP established rate or government funded. (Response is optional). *Admission agreements and any attachments shall be completed and signed in duplicate. *One copy to be retained by the residential facility. *One copy to be given to the resident or resident's responsible person.
Write the visiting policy for the facility under 6. FACILITY VISITING POLICY.
Write the refund policy for the facility under 10. REFUND POLICY.
If rates are increased, the client/resident or authorized representative will be given at least 30 days written notice of the change. However, clients/residents whose care is funded at rates prescribed by government funded programs may have the basic rate change effective on the operative date of any rate change made in that program without notice.
The total monthly rate set forth in the admission agreement will be prorated on a daily basis upon the client's/resident's admission to or departure from the facility during the month.
If client/resident leave the facility temporarily, the holding rate for his/her room is the same as Item 2 or____________per day.
The licensee will not be responsible for any cash resources, valuables or personal property brought into the facility unless these items are delivered to the licensee/administrator for safeguarding.
Common questions about Form LIC 604
Who signs it?
The signature of the Client/Resident or Authorized Representative indicates that he/she has read, or had read and explained to him/her, the provisions of this agreement voluntarily.
When is this form not the right one?
This is a guide only and is not to be used as an admission agreement.
Sources
[1] Form LIC 604 (10/05), Admission Agreement Guide for Residential Facilities, California Department of Social Services (the Official source link on this page).