Register Facility Clients Residents Form PDF Details

In the realm of health and human services, meticulous record-keeping stands as a cornerstone for ensuring the welfare and safety of facility clients or residents. The State of California, through its Health and Human Services Agency and the California Department of Social Services' Community Care Licensing Division, mandates the utilization of the Register of Facility Clients/Residents form. This essential document serves as a comprehensive record, detailing crucial information about individuals residing in various care facilities. The form encapsulates facility and licensee identification, including the name and number of the facility as well as the name of the licensee responsible for operations. It entails a systematic approach to logging updates, room identifiers applicable specifically to residential care for the elderly, and the residents' or clients' full legal names. A critical aspect of this form is the classification of clients’ or residents' ambulatory status—categorizing them as ambulatory, non-ambulatory, or bedridden, pivotal for emergency responses and fire safety protocols. It further requires documentation of any restricted health conditions, alongside the details of the attending physician and a responsible person for each resident. This responsible individual might be a family member, a health surrogate, or a placement agency, signifying someone who either assists in placement or undertakes varying levels of accountability for the resident’s well-being. The form, identified as LIC 9020 (8/11) and marked confidential, is a testament to the structured and thorough approach adopted by the state to safeguard the health and safety of individuals under facility care, underscoring the importance of clear, precise, and up-to-date records.

QuestionAnswer
Form NameRegister Facility Clients Residents Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesregister of facility clients residents, lic 9020, register of facility clients residents form, lic 9020a 6 17

Form Preview Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING DIVISION

REGISTER OF FACILITY CLIENTS/RESIDENTS

FACILITY NAME:

FACILITY NUMBER:

LICENSEE NAME

DATE/UPDATE

ROOM

CLIENT/RESIDENT

AMBULATORY STATUS

 

 

 

 

 

 

IDENTIFIER

NAME

RESTRICTED CONDITION(S)

 

 

PHYSICIAN

RESPONSIBLE PERSON

(If applicable)

 

(If applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

NAME:

 

 

 

 

AMBULATORY

■

 

 

 

 

 

 

 

 

 

ADDRESS:

ADDRESS:

 

 

 

 

 

 

 

NON-AMBULATORY

■

 

 

 

 

 

 

 

 

BEDRIDDEN

■

 

 

 

 

 

 

 

 

PHONE:

PHONE:

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

NAME:

 

 

 

 

AMBULATORY

■

 

 

 

 

 

 

 

 

 

ADDRESS:

ADDRESS:

 

 

 

 

 

 

 

NON-AMBULATORY

■

 

 

 

 

 

 

 

 

BEDRIDDEN

■

 

 

 

 

 

 

 

 

PHONE:

PHONE:

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

NAME:

 

 

 

 

AMBULATORY

■

 

 

 

 

 

 

 

 

 

ADDRESS:

ADDRESS:

 

 

 

 

 

 

 

NON-AMBULATORY

■

 

 

 

 

 

 

 

 

BEDRIDDEN

■

 

 

 

 

 

 

 

PHONE:

PHONE:

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

NAME:

 

 

 

 

AMBULATORY

■

 

 

 

 

 

 

 

 

 

ADDRESS:

ADDRESS:

 

 

 

 

 

 

 

NON-AMBULATORY

■

 

 

 

 

 

 

 

 

BEDRIDDEN

■

 

 

 

 

 

 

 

 

PHONE:

PHONE:

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

NAME:

 

 

 

 

AMBULATORY

■

 

 

 

 

 

 

 

 

 

ADDRESS:

ADDRESS:

 

 

 

 

 

 

 

NON-AMBULATORY

■

 

 

 

 

 

 

 

 

BEDRIDDEN

■

 

 

 

 

 

 

 

 

PHONE:

PHONE:

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME:

 

NAME:

 

 

 

 

AMBULATORY

■

 

 

 

 

 

 

 

 

 

ADDRESS:

ADDRESS:

 

 

 

 

 

 

 

NON-AMBULATORY

■

 

 

 

 

 

 

 

 

BEDRIDDEN

■

 

 

 

 

 

 

 

 

PHONE:

PHONE:

 

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIC 9020 (8/11) (CONFIDENTIAL)

Page______ of ______

INSTRUCTIONS FOR REGISTER OF FACILITY CLIENT/RESIDENTS

Type or print clearly. the licensee shall ensure that a current register of all clients/residents in the facility is maintained.

1.Facility Name: Enter the name used by to designate the single facility under application.

2.Facility Number:

3.Licensee Name: Enter the name of the Licensee. “Licensee” means the individual, firm, partnership, corporation, association or county having the authority and responsibility for the operation of a licensed facility.

4.Date/Update: Enter the date information is being initially recorded or updated.

5.Room Identifier: Applicable to Residential Care for the Elderly only. Enter information that identifies the resident room, such as room number.

6.Client/Resident Name: Enter client/resident legal name.

7.Ambulatory Status: Check appropriate box that indicates the client/resident mobility status. These definitions are for the purposes of a fire clearance.

■Ambulatory: Means a person who is capable of demonstrating the mental competence and physical ability to leave a building without assistance of any other person or without the use of any mechanical aid in case of an emergency.

■Non-ambulatory: Means a person who is unable to leave a building unassisted under emergency conditions. It includes any person who is unable or likely to be unable, to physically and mentally respond to a sensory signal approved by the State Fire Marshal, or an oral instruction relating to fire danger, and person who depend upon mechanical aids such as crutches, walkers, and wheelchairs. A person who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be considered non-ambulatory for fire safety requirements.

■Bedridden: Means a person who is unable to independently turn or reposition in bed.

Restricted Health Conditions means those conditions required by sections 80071(a)(1)(D) and 82071(a)(4), and only applies to facilities governed by these sections.

8.Physician: Enter the name, address, and telephone number of the client/resident attending physician.

9.Responsible Person: Enter the name, address, and telephone number of the person responsible for the client/resident. “Responsible Person” means that individual or individuals, including a relative, health care surrogate decision maker, or placement agency, who assists the resident in placement or assume varying degrees of responsibility for the resident’s well-being.

LIC 9020 (8/11) CONFIDENTIAL

Page ______ of ______

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1. Begin filling out the register of facility clients residents form with a number of major fields. Get all the information you need and ensure there is nothing overlooked!

9020 lic conclusion process outlined (portion 1)

2. The third part is usually to complete the next few blanks: PHONE, NAME, ADDRESS, PHONE, NAME, ADDRESS, PHONE, NAME, ADDRESS, NONAMBULATORY, BEDRIDDEN, PHONE, NAME, AMBULATORY, and ADDRESS.

Writing section 2 in 9020 lic

3. Completing PHONE, NONAMBULATORY, BEDRIDDEN, PHONE, LIC CONFIDENTIAL, and Page of is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

9020 lic writing process shown (portion 3)

Concerning PHONE and BEDRIDDEN, ensure that you don't make any mistakes in this current part. These two could be the most important ones in the document.

4. Your next subsection requires your details in the following areas: Ambulatory Means a person who is, Nonambulatory Means a person who, Bedridden Means a person who is, Restricted Health Conditions means, Physician Enter the name address, physician, and Responsible Person Enter the name. Be sure to give all needed info to move onward.

Physician Enter the name address, Nonambulatory Means a person who, and Responsible Person Enter the name of 9020 lic

5. To finish your document, this particular segment requires several extra blank fields. Filling in LIC CONFIDENTIAL, and Page of will certainly conclude everything and you'll certainly be done very quickly!

The best ways to fill in 9020 lic portion 5

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