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About Us
DisasterCAREHub
Disaster Plans
Resources
Facilities
Contact Us
Request a Demo
Resources
Agencies
Thank You To Our Partners & Resources.
AAA – Area Agencies on Aging
Disaster Preparedness
Disease Prevention & Health Promotion Program
Family Caregiver Support
Older Californians Nutrition Program
Supportive Services
ADRC – Aging and Disability Resource Connection
CAL GROWs – Growing a Resilient and Outstanding Workforce, CDA’s Direct Care Workforce Program
CFE – CalFresh Expansion Program
CFHL – CalFresh Healthy Living (formerly known as SNAP-ED)
CBAS – Community-Based Adult Services
CRC – Caregiver Resource Centers
DAHFP – Dignity at Home Fall Prevention Program
Digital Inclusion – Bridging the Digital Divide
HICAP – Health Insurance Counseling and Advocacy Program
Legal Services
LTCOP – Long-Term Care Ombudsman Program
MSSP – Multipurpose Senior Services Program
OLTCPR – The Office of the Long-Term-Care Patient Representative
SCSEP – Senior Community Service Employment Program
LIC Forms
Check out Required California Forms for Your RCFE or ARF.
LIC 01A (6/23) – Resource Family Application
LIC 01C (7/16) – Resource Family Application-Confidential
LIC 03 (7/23) – Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only
LIC 05A (8/21) – Resource Family Approval Certificate
LIC 08 (2/24) – Intensive Services Foster Care Unit (ISFC) Written Assessment of Risk and Compatibility
LIC 12 (8/21) – Resource Family Approval Document Alternative Plan (DAP)
LIC 122 (1/08) – Release Of Information
LIC 165 (8/07) – Board Of Directors Statement
LIC 185 (5/99) – Contact Sheet
LIC 192 (7/03) – Notification Of Initial Application Denial
LIC 195 (8/19) – Notice Of Operation In Violation Of Law
LIC 200 (2/24) – Application For A Community Care Facility or Residential Care Facility For The Elderly License
LIC 200TM (6/18) – Temporary Manager Application For Provisional License
LIC 201F (2/01) – Annual License Fee Notice – County
LIC 215 (12/22) – Applicant Information
LIC 215TM (11/18) – Temporary Manager Candidate List Application Information
LIC 216TM (11/18) – Temporary Manager Appointment Applicant Information
LIC 281 (6/24) – Application Instructions for A Facility License
LIC 281E (2/24) Application And Supporting documentation Checklist Short – Term Residential Therapeutic Program
LIC 300A (10/23) – Removal Confirmation – Exemption Needed
LIC 300B (11/23) – Removal Confirmation – Denial
LIC 300C (9/03) – Removal Confirmation – Rescinded
LIC 300D (9/03) – Removal Confirmation – Non-Exemptible
LIC 300E (12/03) – Removal Confirmation – County
LIC 301 (8/99) – Reference Request
LIC 301E (10/22) – Reference Request – Exemption
LIC 306 (3/01) – Reporting Requirements By Licensees To The State Department Of Social Services
LIC 308 (11/02) – Designation Of Facility Responsibility
LIC 309 (6/01) (PUBLIC) – Administrative Organization
LIC 311B (4/05) – Records To Be Maintained By The Facility – Group Homes
LIC 311C (4/05) – Records To Be Maintained At The Facility – Adult Residential
LIC 311F (4/05) – Records To Be Maintained At The Facility – Residential Care Facility For The Elderly
LIC 313 (12/01) – Evidence Of Program Consultant
LIC 400 (1/99) – Affidavit Regarding Client/Resident Cash Resources
LIC 401 (3/01) – Monthly Operating Statement
LIC 401A (3/99) – Supplemental Financial Information
LIC 402 (8/04) – Surety Bond
LIC 403 (7/11) – Balance Sheet
LIC 403A (9/11) – Balance Sheet Supplemental Schedule
LIC 404 (7/99) – Financial Information Release And Verification
LIC 405 (8/01) – Record Of Client’s/Resident’s Safeguarded Cash Resources
LIC 406 (5/13) – Client/Resident Cash Sheet
LIC 420 (4/99) – Budget Information
LIC 421A (3/24) – Civil Penalty Assessment (Unlicensed Facility)
LIC 421BG (5/19) – Civil Penalty Assessment – Caregiver Background Check
LIC 421D (ASC) (6/17) – Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (ASC)
LIC 421D (CRP) (6/17) – Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (CRP)
LIC 421FC (7/17) – Civil Penalty Assessment – Failure To Correct And Repeat Violations
LIC 421IM (7/17) – Civil Penalty Assessment – Immediate $500 And Repeat Violations
LIC 422 (9/11) – Notice Of Civil Penalties Due
LIC 422A (10/11) – Civil Penalty Ledger
LIC 424 (1/03) – Record Of Client’s Cash Resources For Change Of Licensee
LIC 500 (11/03) – Personnel Report
LIC 501 (3/99) – CCL/Personnel Record
LIC 503 (6/24) – Health Screening Report – Facility Personnel
LIC 507 (1/00) – Facilities Staff Work Schedule
LIC 508 O-O-S (9/23) – Out-Of-State Disclosure
LIC 508D (10/23) – Out-Of-State Disclosure And Criminal Record Statement
LIC 601 (8/08) – Identification And Emergency Information
LIC 602 (7/22) – Physician’s Report For Community Care Facilities
LIC 602A (8/11) – Physician’s Report For Residential Care Facilities For The Elderly (RCFE)
LIC 603 (6/22) – Preplacement Appraisal Information
LIC 603A (7/99) – Resident Appraisal
LIC 604 (10/05) – Admission Agreement Guide For Residential Facilities
LIC 604A (2/05) – Admission Agreement For Residential Care Facilities For The Elderly
LIC 605A (7/22) – Release Of Client/Resident Medical Information
LIC 606 (8/18) – Residential Care Facility For The Elderly Disclosure Worksheet
LIC 610D (12/21) – Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities
LIC 610E (3/19) – Emergency Disaster Plan For Residential Care Facilities For The Elderly
LIC 613 (12/02) – Personal Rights Adult Residential Care Facilities
LIC 613C (1/19) – Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly
LIC 613C-2 (1/19) – Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly
LIC 621 (4/99) – Client/Resident Personal Property And Valuables
LIC 622 (9/19) – Centrally Stored Medication And Destruction Record
LIC 622A (6/17) – Medication Administration Record (MAR)
LIC 622B (5/17) – Psychotropic Medication Administration Record (MAR)
LIC 623 (5/01) – Group Planned Activities
LIC 624 (4/99) – Unusual Incident/Injury Report
LIC 624A (7/99) – Death Report
LIC 624 LE (12/22) – Law Enforcement Contact Report
LIC 625 (10/24) – Appraisal/Needs and Services Plan
LIC 627C (4/00) – Consent For Emergency Medical Treatment – Adult And Elderly Residential Facilities
LIC 809 (9/23) – Facility Evaluation Report
LIC 811 (8/06) – Confidential Names
LIC 812 (8/06) – Detail Supportive Information
LIC 813 (5/24) – Facility Photography Report
LIC 855 (9/00) – Declaration
LIC 856A (3/21) – Complaint Intake Notification
LIC 856B (3/21) – Complaint Determination Notification – Substantiated
LIC 856C (3/21) – Complaint Determination Notification – Unsubstantiated
LIC 856D (3/21) – Complaint Determination Notification – Unfounded
LIC 858 (10/99) – Client/Resident Records Review (Residential)
LIC 859 (8/06) – Review of Staff/Volunteer
LIC 907 (5/00) – Transmittal For Processing
LIC 957 (10/99) – Complaint Control Log
LIC 972 (5/00) – Individual Waiver/Exception Log
LIC 986A (10/99) – Notice Of Revocation Action
LIC 989 (11/02) – Information Request
LIC 989A (3/17) – Non-Confidential Records Request Form
LIC 995D (5/03) – Family Child Care Home Explanation Of Removal/Exclusions And Reinstatement
LIC 995F (10/09) – Caregiver Background Check Information
LIC 999 (3/99) – Facility Sketch (Floor Plan)
LIC 9015 (9/00) – Legal Case Transmittal
LIC 9020 (5/17) – Register Of Facility Clients/Residents
LIC 9020A (6/17) – Register Of Facility Residents – Residential Care Facilities For The Elderly
LIC 9031 (11/99) – Notice Of Temporary Suspension Order Of License
LIC 9052 (1/22) – Notice Employee Rights
LIC 9054 (3/99) – Local Fire Inspection Authority Information
LIC 9058 (3/22) – Applicant/Licensee Rights
LIC 9059 (5/99) – Personal Property Procedures
LIC 9060 (2/00) – Resident Theft And Loss Record
LIC 9092 (2/11) – Fire Pre-Inspection/Consultation Request
LIC 9095 (6/99) – Evaluation Of Teacher Qualifications
LIC 9096 (2/00) – Evaluation Of Director Qualifications
LIC 9098 (4/09) – Proof Of Correction(s)
LIC 9099 (12/16) – Complaint Investigation Report
LIC 9102TA (2/19) – Advisory Notes – Technical Assistance
LIC 9102TV (2/19) – Advisory Notes – Technical Violation
LIC 9106 (11/19) – Group Home Program Statement General Instructions
LIC 9106A (9/24) – Short-Term Residential Therapeutic Program
LIC 9111 (12/99) – Noncompliance Conference Summary
LIC 9112 (9/21) – Facility Compliance Plan
LIC 9119 (10/22) – Facility Inspection Checklist Group Homes
LIC 9119 CTF (1/22) – Facility Inspection Checklist Community Treatment Facility
LIC 9119 EBSH (4/22) – Facility Inspection Checklist Enhanced Behavioral Supports Homes
LIC 9119 TrSCF (12/22) – Facility Inspection Checklist Transitional Shelter Care Facility
LIC 9119 YHPC (4/22) – Facility Inspection Checklist Youth Homelessness Prevention Center
LIC 9120A (2/20) – Licensed Facility Inspection Checklist Adult Care Facilities
LIC 9122A (7/20) – Facility Inspection Checklist Small Family Home
LIC 9123 (2/20) – Facility Inspection Checklist – Residential Care Facility For The Elderly
LIC 9128 (5/23) – Foster Family Agency Program Statement
LIC 9139 (3/23) – Renewal Of Continuing Education Course Approval – Administrator Certification Program
LIC 9140 (3/24) – Request For Course Approval – Administrator Certification Program
LIC 9140A (3/23) – Request to Add or Replace Instructor
LIC 9141 (6/23) – Vendor Application/Renewal – Administrator Certification Program
LIC 9142A (3/23) – Roster of Participants
LIC 9148 (9/00) – Earthquake Preparedness Checklist (EPC)
LIC 9158 (7/22) – Telecommunications Device Notification
LIC 9163 (7/24) – Request Live Scan Service – Community Care Licensing
LIC 9163B (11/22) – Request Live Scan Service – Long Term Care OMBUDSMAN
LIC 9165 (4/22) – Board Of Director Statement
LIC 9172 (8/01) – Functional Capability Assessment
LIC 9182 (11/23) – Criminal Background Clearance Transfer Request
LIC 9186 (2/01) – Client Death Report
LIC 9188 (11/23) – Criminal Record Exemption Transfer Request
LIC 9200 (9/11) – Pre-Licensing Facility Evaluation Checklist
LIC 9214 (5/23) – Application for Administration Certification – Administrator Certification Program
LIC 9216 (3/17) – Complaint And Type A Violation Log
LIC 9224 (8/08) – Acknowledgement Of Receipt Of Licensing Reports
LIC 9225 (4/10) – Pre-Placement Questionnaire
LIC 9229 (7/21) – Licensing Program Manager (LPM) Checklist For Complaint Review
LIC 9230 (7/21) – Licensing Program Analyst (LPA) Checklist For Complaint Review
LIC 9235 (10/22) – Facility Inspection Checklist Short – Term Residential Therapeutic Program
LIC 9236 (6/23) – Entrance Checklist Short – Term Residential Therapeutic Program
LIC 9237 (7/20) – Facility Inspection Checklist Transitional Housing Placement Program
LIC 9238 (5/23) – Entrance Checklist Transitional Housing Placement Program
LIC 9239 (5/23) – Entrance Checklist Group Home
LIC 9239 CTF (3/23) – Entrance Checklist Community Treatment Facility
LIC 9239 EBSH (3/23) – Entrance Checklist – Enhanced Behavioral Supports Homes
LIC 9239 TrSCF (3/23) – Entrance Checklist – Transitional Shelter Care Facility
LIC 9241 (2/20) – Entrance Checklist Adult Care Facilities
LIC 9242 (9/19) – Entrance Checklist Residential Care Facilities For The Elderly
LIC 9263 (8/23) – Form 1-1: Resident Population
LIC 9264 (3/21) – Form 1-2: Annual Provider Fee
LIC 9265 (6/21) – Form 5-1: Long-Term Debt Incurred In A Prior Year (Including Balloon Debt)
LIC 9266 (3/21) – Form 5-2: Long-Term Debt Incurred During Fiscal Year (Including Balloon Debt)
LIC 9267 (3/21) – Form 5-3: Calculation Of Long-Term Debt Reserve Amount
LIC 9268 (6/21) – Form 5-4: Calculation Of Net Operating Expenses
LIC 9269 (3/21) – Form 5-5: Annual Reserve Certification
LIC 9270 (9/22) – Form 7-1: Report On CCRC Monthly Care Fees
LIC 9271 (6/21) – Form 9-1: Calculation Of Refund Reserve Amount
LIC 9272 (11/21) – Annual Report Checklist
LIC 9273 (7/23) – Continuing Care Retirement Community Disclosure Statement
LIC 9274 (11/21) – Key Indicators Report
LIC 9275 (6/21) – External Water Sampler Self-Certification Form
L
IC 9277LUA (8/23) – Guardian Licensee User Access Form
LIC 9282 (6/23) – Residential Infection Control Plan – Adult Residential Facilities, Enhanced Behavioral Supports Homes, Community Crisis Homes, Residential Care Facilities for the Elderly, Residential Care Facilities for the Chronically Ill, and Social Rehabilitation Facilities
LIC 9283 (6/23) – Infection Control Plan – Adult Day Programs
Other Resources
Learn about other resources we offer to help your RCFE or ARF succeed.
Tools
RCFE Compliance Checklist
Click Here
Easy RCFE AB 3098 Compliance Webinar
Click Here
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