CA RCFE Forms and Documentation

California RCFEs (Residential Care Facilities for the Elderly) are licensed and controlled by California Department of Social Services (DSS). RCFEs are required to follow the licensing procedures and maintain documentation per state regulations. The documentation includes facility level documents, staff / employee documents, and resident (or client) level documents.

Carevium care management platform helps maintain the required documentation. Wherever the documents / forms are to be filled in or provided by other parties such as residents / responsible person, physician, etc., those documents can be scanned and uploaded to Carevium documents store as scanned electronic documents (in PDF format) for easy access and view.

Following are the key forms / documents to be used by residential care facilities providing board and care or assisted living services in California. Most of  the information included in this page is also applicable for assisted living communities in other states in US; however the exact format and content elements may vary depending on the respective state regulations.

Please see CA DSS document LIC 311F – documentation and records required under specific sections of Title 22, California Code of Regulations, MUST BE KEPT IN THE FACILITY, COMPLETE AND CURRENT, AND READILY AVAILABLE FOR REVIEW.

Resident Related Documents

LIC 601 – Resident Identification and Emergency Information. This resident profile record can be printed from Carevium care management application.

LIC 604A – Admission Agreement for Residential Care Facilities for the Elderly.

LIC 405 – Record of Client’s / Resident’s Safeguarded Cash Resources.

LIC 602A – Physician’s Report for RCFE. Scan and upload this completed form to Carevium.

LIC 603 – Pre-placement Appraisal Info. This report can be generated and maintained in Carevium, if you use the appraisal module.

LIC 603A – Resident Appraisal. This report can be generated and maintained in Carevium, if you use the appraisal module.

LIC 605A – Release of Client’s / Resident’s Medical Information. Scan and upload this completed form to Carevium.

LIC 613C – Personal Rights. Scan and upload this completed form to Carevium.

LIC 621 – Personal Property and Valuables.

LIC 622 – Centrally Stored Medication & Destruction Record.

LIC 624 – Unusual Incident / Injury Report.

LIC 624A – Death Report.

LIC 625 – Resident Appraisal and Service Plan.

LIC 627A – Consent to a Medical Examination. Scan and upload this completed form to Carevium.

LIC 627C – Consent for Emergency Medical Treatment. Scan and upload this completed form to Carevium.

LIC 9020 – Register of Facility Clients / Residents.

LIC 9158 – Telecom Device Notification form. If applicable, scan and upload this completed form to Carevium.

Employee Administration Related Documents

SOC 341A  – Statement Acknowledging Requirement to Report Suspected Abuse of a
Dependent Adult or Elder
. Scan and upload this completed form to Carevium.

LIC 500 – Personnel Report. This report / roster can be printed from Carevium, if you use the Staff Scheduling feature.

LIC 501 – Individual Employee Record (to be filled by employee). Scan and upload this completed form to Carevium.

LIC 503 – Health Screening Report. Scan and upload this completed form to Carevium.

LIC 508 – Criminal Record Statement. Scan and upload this completed form to Carevium.

Facility Administrative Records

LIC 203 – RCFE Facility License. Scan and upload this document to Carevium (facility level document storage).

LIC 610E – Emergency Disaster Plan. Scan and upload this document to Carevium (facility level document storage).

Disclaimer: Please note that the documentation requirements and related regulation might be changed  by the authorities. While we try to keep the above information updated, it should always be verified with the authorities. Also, note that the computer generated reports could be formatted differently when compared with the manual forms. You should validate the same against your requirements.