Lic 625 PDF Details

The LIC 625 form, issued by the State of California’s Health and Human Services Agency through the Department of Social Services Community Care Licensing, serves an essential function in the landscape of community care and residential facilities. This form is a critical document for ensuring that individuals entering these facilities receive care tailored to their unique needs. It encompasses a comprehensive appraisal and needs and service plan, detailing the client or resident’s personal information, including name, date of birth, sex, and other essential data, along with the facility's details. It is meticulously designed to capture a wide spectrum of information including, but not limited to, emotional, behavioral, and physical problems; functional limitations; likes and dislikes; as well as the client's or resident's capacities in handling personal finances and performing basic homemaking tasks. The process of completing this form is collaborative, requiring inputs from multiple stakeholders including the client or resident, their authorized representative, and professionals like physicians and social workers. This ensures the development of a highly personalized service plan aiming to address the individual’s specific needs. Moreover, this form acts as a medium for the referral agency or person to inform the facility of any potential risks associated with the client’s or resident's tendencies. While not initially required at admission in residential care facilities for the elderly, its completion becomes necessary if it's determined that an elderly resident's needs are unmet, highlighting the form's adaptability and importance in continuous care assessment.

QuestionAnswer
Form NameLic 625
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameslic 625 appraisal, california 625, needs services plan, lic625 ccld

Form Preview Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

 

 

 

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

 

 

 

 

 

 

COMMUNITY CARE LICENSING

APPRAISAL/NEEDS AND SERVICES PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT’S/RESIDENT’S NAME

 

DATE OF BIRTH

AGE

SEX

 

DATE

 

 

 

 

 

 

MALE

FEMALE

 

 

 

 

 

 

 

 

 

 

FACILITY NAME

 

ADDRESS

 

 

 

CHECK TYPE OF NEEDS AND SERVICES PLAN:

 

 

 

 

 

 

 

ADMISSION

UPDATE

 

 

 

 

 

 

 

 

PERSON(S) OR AGENCY(IES) REFERRING CLIENT/RESIDENT FOR PLACEMENT

 

 

FACILITY LICENSE NUMBER

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

Licensing regulations require that an appraisal of needs be completed for specific clients/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for admission shall jointly develop a needs and services plan with the client/resident and/or client’s/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Additionally, the law requires that the referral agency/person inform the licensee of any dangerous tendencies of the client/resident.

NOTE: For Residential Care Facilities for the Elderly, this form is not required at the time of admission but must be completed if it is determined that an elderly resident’s needs have not been met.

BACKGROUND INFORMATION: Brief description of client’s/resident’s medical history/ emotional, behavioral, and physical problems; functional limitations; physical and mental; functional capabilities; ability to handle personal cash resources and perform simple homemaking tasks; client’s/resident’s likes and dislikes.

LIC 625 (6/12) CONFIDENTIAL

PAGE 1 OF 4

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

 

 

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

SOCIALIZATION — Difficulty in adjustig socially and unable to maintain reasonable personal relationships

EMOTIONAL — Difficulty in adjusting emotionally

LIC 625 (6/12) CONFIDENTIAL

PAGE 2 OF 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

 

 

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

MENTAL — Difficulty with intellectual functioning including inability to make decisions regarding daily living.

PHYSICAL/HEALTH — Difficulties with physical development and poor health habits regarding body functions.

LIC 625 (6/12) CONFIDENTIAL

PAGE 3 OF 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVCIES AGENCY

CALIFORNIA DEPARTMENT OF

SOCIAL SERVICES

 

COMMUNITY

CARE LICENSING

 

 

 

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

FUNCTIONING SKILLS — Difficulty in developing and/or using independent functioning skills.

We believe this person is compatible with the facility program and with other clients/residents in the facility, and that I/we can provide the care as specified in the above objective(s) and plan(s).

TO THE BEST OF MY KNOWLEDGE THIS CLIENT/RESIDENT DOES NOT NEED SKILLED NURSING CARE.

LICENSEE(S) SIGNATURE

DATE

I have reviewed and agree with the above assessment and believe the licensee(s) other person(s)/agency can provide the needed services for this client/resident

CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S)/FACILITY SOCIAL WORKER/PHYSICIAN/OTHER APPROPRIATE CONSULTANT SIGNATURE

DATE

 

 

I/We have participated in and agree to release this assessment to the licensee(s) with the condition that it will be held confidential.

CLIENT’S/RESIDENT’S OR CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S) SIGNATURE

DATE

LIC 625 (6/12) CONFIDENTAIL

PAGE 4 OF 4

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Step 1: At first, choose the orange "Get form now" button.

Step 2: When you enter the california lic 625 editing page, you'll see lots of the options you can take with regards to your file within the top menu.

In order to complete the document, provide the data the program will require you to for each of the following segments:

step 1 to writing ca lic 625

Indicate the information in SOCIALIZATION Difficulty in, and EMOTIONAL Difficulty in adjusting.

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You should be asked for some valuable details so you can complete the MENTAL Difficulty with, and PHYSICALHEALTH Difficulties with part.

part 3 to filling out ca lic 625

The PHYSICALHEALTH Difficulties with, LIC, CONFIDENTIAL, and PAGE OF field has to be applied to write down the rights or responsibilities of both parties.

part 4 to completing ca lic 625

Finalize by checking all of these sections and filling out the pertinent information: FUNCTIONING SKILLS Difficulty in.

ca lic 625 FUNCTIONING SKILLS Difficulty in blanks to fill

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