Form LIC 9020 at a glance
What it is: Register of Facility Clients/Residents, California Department of Social Services, Community Care Licensing Division.
Where and when to file: The licensee shall ensure that a current register of all clients/residents in the facility is maintained.
The licensee shall ensure that a current register of all clients/residents in the facility is maintained.
A filled-in Form LIC 9020 example: a licensee records one resident
How to fill out Form LIC 9020, box by box
Facility name, facility number, licensee name and date
In Facility Name, enter the name used to designate the single facility under application.
In Facility Number, enter the facility number assigned by the California Department of Social Services.
In 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.
In Date/Update, enter the date information is being initially recorded or updated.
Client/Resident name
In Client/Resident Name, enter the client/resident legal name.
Ambulatory status
Under Ambulatory Status, check the appropriate box that indicates the client/resident mobility status.
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.
For the purposes of a fire clearance, 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.
For the purposes of a fire clearance, 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.
For the purposes of a fire clearance, Bedridden means a person who is unable to independently turn or reposition in bed.
Restricted health conditions
Restricted Health Conditions applies to facilities governed by California Code of Regulations, Title 22, Sections 80071(a)(1)(D) and 82071(a)(4) only.
List client/resident restricted health condition(s) in the space provided.
Physician
In Physician, enter the name, address, and telephone number of the client/resident attending physician.
Responsible person
In 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.
More rules for Form LIC 9020
Type or print clearly.
Sources
[1] Form LIC 9020 (5/17), Register of Facility Clients/Residents, California Department of Social Services (the Official source link on this page).