Lic 625 PDF Details

If you are looking for professional development opportunities, the Lic 625 form is a great place to start. This form allows you to list your education and experience, as well as highlight any special skills or qualifications you may have. By completing the Lic 625 form, you can let potential employers know about your qualifications and showcase your strengths.

In the listing, there is some information about the lic 625. You can browse it just before filling in the gaps.

QuestionAnswer
Form NameLic 625
Form Length4 pages
Fillable?Yes
Fillable fields43
Avg. time to fill out9 min 40 sec
Other namesneeds services plan, 625 needs, lic services online, california lic 625

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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