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The Lic 603 form is a crucial document utilized within California's residential care facilities, specifically focusing on the appraisal of an applicant's needs prior to admission. This comprehensive form gathers detailed information about an individual's health status, mental condition, social factors, and the services they might require upon their arrival at the facility. It encourages collaboration, allowing relatives, social agencies, and healthcare professionals to assist applicants in completing it. Key areas assessed in the form include the applicant's overall health, physical disabilities, and mental condition, along with a health history detailing medications and past medical events. It also includes critical inquiries regarding tuberculosis and ambulatory status, which helps facilities understand mobility needs. Additional sections on functional capabilities and specific services required play a vital role in ensuring that the facility can provide appropriate care tailored to each applicant’s unique situation. Overall, the Lic 603 form serves not only as a gathering tool but also helps to chart a path for supportive care once the individual transitions into the residential facility.

Lic 603 Example

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

PREPLACEMENT APPRAISAL INFORMATION

Admission - Residential Care Facilities

NOTE: This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospital or physician may assist the applicant in completing this form.) This form is not a substitute for the Physician’s Report (LIC 602).

APPLICANT’S NAME

AGE

HEALTH (Describe overall health condition including any dietary limitations)

PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech)

MENTAL CONDITION (Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))

HEALTH HISTORY (List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years)

SOCIAL FACTORS (Describe likes and dislikes, interests and activities)

BED STATUS

OUT OF BED ALL DAY

IN BED ALL OR MOST OF THE TIME IN BED PART OF THE TIME

COMMENT:

TUBERCULOSIS INFORMATION

ANY HISTORY OF TUBERCULOSIS IN APPLICANT’S FAMILY?

DATE OF TB TEST

POSITIVE

 

 

 

YES

NO

 

NEGATIVE

 

 

 

ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?

ACTION TAKEN (IF POSITIVE)

 

YES

NO

 

 

 

 

 

 

GIVE DETAILS

 

 

 

LIC 603 (9/99)

(Over)

AMBULATORY STATUS (this person is ambulatory nonambulatory)

Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device. An ambulatory person must be able to do the following:

YES NO

Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.

Mentally and physically able to follow signals and instructions for evacuation.

Able to use evacuation routes including stairs if necessary.

Able to evacuate reasonably quickly (e.g., walk directly the route without hesitation).

FUNCTIONAL CAPABILITIES (Check all items below)

YES

NO

 

 

 

Active, requires no personal help of any kind - able to go up and down stairs easily

 

Active, but has difficulty climbing or descending stairs

 

 

Uses brace or crutch

 

 

Feeble or slow

 

 

Uses walker. If Yes, can get in and out unassisted?

Yes

No

Uses wheelchair. If Yes, can get in and out unassisted?

Yes

No

Requires grab bars in bathroom

Other: (Describe)

_______________________________________________________________________________________________________________

SERVICES NEEDED (Check items and explain)

YES NO

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■ ■

■ ■

■ ■

■ ■

■ ■

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Help in transferring in and out of bed and dressing________________________________________________________________________

_______________________________________________________________________________________________________________

Help with bathing, hair care, personal hygiene ___________________________________________________________________________

Does client desire and is client capable of doing own personal laundry and other household tasks (specify) ___________________________

Help with moving about the facility ____________________________________________________________________________________

_______________________________________________________________________________________________________________

Help with eating (need for adaptive devices or assistance from another person) _________________________________________________

_______________________________________________________________________________________________________________

Special diet/observation of food intake _________________________________________________________________________________

_______________________________________________________________________________________________________________

Toileting, including assistance equipment, or assistance of another person_____________________________________________________

Continence, bowel or bladder control. Are assistive devices such as a catheter required? _________________________________________

Help with medication _______________________________________________________________________________________________

_______________________________________________________________________________________________________________

Needs special observation/night supervision (due to confusion, forgetfulness, wandering) _________________________________________

Help in managing own cash resources _________________________________________________________________________________

Help in participating in activity programs ________________________________________________________________________________

_______________________________________________________________________________________________________________

Special medical attention ___________________________________________________________________________________________

_______________________________________________________________________________________________________________

Assistance in incidental health and medical care _________________________________________________________________________

_______________________________________________________________________________________________________________

Other “Services Needed” not identified above ___________________________________________________________________________

_______________________________________________________________________________________________________________

Is there any additional information which would assist the facility in determining applicant’s suitability for admission?

Yes

No

If Yes, please attach comments on separate sheet.

 

 

To the best of my knowledge; I (the above person) do not need skilled nursing care.

SIGNATURE

DATE COMPLETED

APPLICANT (CLIENT) OR AUTHORIZED REPRESENTATIVE

SIGNATURE

DATE COMPLETED

LICENSEE OR DESIGNATED REPRESENTATIVE

DATE COMPLETED

File Breakdown

Fact Name Details
Purpose The LIC 603 form is used for gathering preplacement appraisal information for admission to residential care facilities in California.
Completing the Form This form can be filled out by the applicant or an authorized representative, such as a relative or healthcare provider.
Not a Substitute The LIC 603 is not a substitute for the Physician’s Report, known as LIC 602.
Health Assessment Applicants must provide detailed information about their overall health, including any dietary or physical limitations.
Tuberculosis History The form requires information regarding any tuberculosis history in the applicant’s family and details about recent exposure.
Ambulatory Status A section of the form assesses whether the applicant is ambulatory or non-ambulatory, ensuring appropriate measures for evacuation are noted.
Functional Capabilities The form includes check boxes for various functional capabilities to identify the applicant’s level of assistance needed.
Services Needed Applicants must specify the type of assistance or services they require, ranging from help with daily activities to medication management.
Additional Information There is an option to provide further information that could help facilities assess the applicant’s suitability for admission.
Signature Requirement Both the applicant (or authorized representative) and the facility’s licensee must sign and date the form for it to be valid.

Guide to Using Lic 603

Completing the Lic 603 form requires careful attention to the details about the applicant's health, social factors, and needs. This information is essential for facilities to assess suitability for admission. Follow these steps to accurately fill out the form.

  1. Begin with the applicant's name and age at the top of the form.
  2. In the Health section, describe the applicant's overall health condition, including any dietary limitations.
  3. For the Physical Disabilities section, detail any physical limitations such as vision, hearing, or speech issues.
  4. In the Mental Condition section, specify any symptoms such as confusion or forgetfulness, as well as social participation.
  5. Provide a Health History that lists current medications, major illnesses, surgeries, and any hospitalizations within the last five years.
  6. Under Social Factors, describe the applicant's likes, dislikes, interests, and activities.
  7. Indicate the Bed Status by checking one of the three options: Out of Bed All Day, In Bed All or Most of the Time, or In Bed Part of the Time.
  8. Complete the Tuberculosis Information section, noting any history of tuberculosis, the date of the TB test, and any recent exposure.
  9. Mark the applicant's Ambulatory Status as either ambulatory or nonambulatory and confirm related capabilities.
  10. In the Functional Capabilities section, check all items that apply regarding the applicant's activity level and needs for assistance.
  11. Address the Services Needed by checking the relevant services and providing explanations where necessary.
  12. If applicable, indicate whether additional information exists by checking Yes or No, and attach comments on a separate sheet, if required.
  13. Have the applicant or an authorized representative sign and date the form.
  14. Finally, the licensee or designated representative must also sign and date the form.

Get Answers on Lic 603

What is the purpose of the Lic 603 form?

The Lic 603 form, also known as the Preplacement Appraisal Information for Admission to Residential Care Facilities, is designed to assess the health and social needs of individuals seeking admission to care facilities in California. It gathers detailed information about the applicant's overall health, physical and mental capabilities, and any specific services they may require. This evaluation assists in determining the suitability of the applicant for the facility.

Who can complete the Lic 603 form?

The Lic 603 form can be completed by the applicant themselves or an authorized representative. This may include family members, social agency officials, hospital staff, or physicians. It is important that the information provided is accurate and comprehensive, as it directly impacts the admission process.

What information is required on the Lic 603 form?

The form requires various details including:

  1. Applicant's name and age
  2. Overall health condition and dietary limitations
  3. Any physical disabilities related to vision, hearing, or speech
  4. Mental health status, including symptoms of confusion or forgetfulness
  5. Health history, including medications and any major illnesses or hospitalizations
  6. Social factors such as likes, dislikes, and interests
  7. Bed status and ambulatory capabilities
  8. Specific services needed

Is the Lic 603 form a substitute for the Physician’s Report (LIC 602)?

No, the Lic 603 form is not a substitute for the Physician’s Report (LIC 602). The Lic 603 focuses on comprehensive information regarding the applicant's condition and needs, whereas the LIC 602 requires detailed medical evaluation from a physician. Both forms are essential for the admission process.

What does ambulatory status mean on the Lic 603 form?

Ambulatory status indicates whether a person can move without assistance. An applicant is considered ambulatory if they can walk unassisted or with minimal assistance, follow evacuation signals, and evacuate quickly in case of an emergency. The form requires details on the applicant’s ability to perform these tasks.

What happens if an applicant has a history of tuberculosis?

If there is a history of tuberculosis (TB) in the applicant's family or recent exposure, it must be disclosed on the form. The applicant should provide specific details regarding TB tests, including results and any actions taken if the test is positive. This information is crucial for maintaining the health and safety of all residents in the facility.

What if additional information is needed for the Lic 603 form?

If there is further information that could help the facility determine the applicant's suitability for admission, it must be noted on the form. It’s advisable to attach any relevant comments on a separate sheet. Providing comprehensive information increases the chances of a successful admission process.

Common mistakes

Completing the Lic 603 form correctly is crucial for ensuring a smooth transition into residential care facilities. However, there are several common mistakes that people often make when filling it out. These oversights can lead to delays in processing applications or even result in the denial of admission. It is essential to be aware of these pitfalls to avoid unnecessary complications.

One frequent mistake is failing to provide comprehensive health information. It's important to thoroughly describe the applicant's overall health, including any dietary limitations and physical or mental conditions. Inadequate details can lead to misunderstandings about the applicant's needs, potentially jeopardizing their health and safety.

Another common error involves neglecting to list all prescribed medications. Applicants may omit important medications or forget to mention major illnesses, surgeries, or accidents. Clarity in this section is vital; missing medications can result in serious consequences, particularly for individuals with complex health needs.

People often underestimate the significance of the tuberculosis information section. Applicants may forget to indicate prior exposure to tuberculosis or fail to report positive TB test results. This oversight can pose a risk not only to the applicant but also to other residents in the facility.

In addition, some individuals make the mistake of leaving out vital details regarding their ambulatory status. Accurate categorization, whether ambulatory or non-ambulatory, is crucial for the facility to accommodate the applicant’s needs. Misrepresenting this information could hinder appropriate care during emergencies.

When reporting functional capabilities, many people simply check "Yes" or "No" without providing necessary context. Describing how the applicant can navigate daily activities, including mobility and personal care, helps caregivers understand the support required. Generic responses won't provide the insight needed to ensure the applicant's well-being.

Services needed often go unaddressed. Applicants may check boxes but fail to elaborate on the type of assistance required. The "Services Needed" section should be filled out with specific, detailed explanations so care providers can deliver tailor-made support.

Lastly, it is crucial to answer the question about additional information genuinely. Many skip this step or respond with "No" without considering that they might have information beneficial to the caregiving facility. Sharing relevant details can significantly influence the suitability assessment for admission.

By being mindful of these common pitfalls when filling out the Lic 603 form, applicants and their representatives can help facilitate a smoother application process and ensure that the necessary care and support are in place from the start.

Documents used along the form

The Lic 603 form is a crucial document in the admission process for residential care facilities in California, gathering essential health and social information about the applicant. In addition to this form, several other documents often complement the application process. Understanding each of these forms can facilitate smoother admissions and better care for residents.

  • Physician’s Report (LIC 602): This document provides a comprehensive medical evaluation of the applicant's health. It is essential for confirming any medical conditions, medications, and necessary treatments, serving as a necessary complement to the Lic 603.
  • Preplacement Appraisal (LIC 604): This form assesses the applicant’s overall support needs and compatibility with available services. It helps providers understand how best to accommodate and support the individual's requirements.
  • Authorization for Release of Information (LIC 805): This authorization gives permission for caretakers to access the applicant's past medical records. It streamlines the process of obtaining essential health information that may inform the care plan.
  • Medication Administration Record (MAR): This record details all prescribed and over-the-counter medications that the applicant currently takes. It is crucial for staff to manage and monitor the medication regimen effectively.
  • Advance Health Care Directive: This legal document allows applicants to specify their preferences for medical treatment or designate someone to make decisions on their behalf. It ensures that the resident’s wishes are respected in health care decisions.
  • Consent for Treatment: This consent form is needed for medical procedures or treatments that the applicant may receive while in the care facility. It ensures that necessary legal permissions are in place to avoid liability issues.
  • Behavioral Health Assessment: Often required for applicants with mental health considerations, this document provides insights into the applicant's psychological state and any specific needs they may have regarding mental health care.
  • Personal Care Agreement: This agreement outlines the specific personal care services to be provided to the resident. It serves as a contractual understanding between the facility and the resident or their representatives.

Each of these documents plays an integral role in creating a comprehensive view of the applicant's needs and ensuring that they receive appropriate care. Together, they contribute to a more effective and empathetic approach to the admission process, supporting both the resident and the facility staff.

Similar forms

  • LIC 602 - Physician’s Report: Similar to the LIC 603, this form gathers critical health information, but it is specifically designed to be completed by a physician. It focuses on the medical history and physical condition of the applicant, which includes an assessment of medical needs and treatment plans.

  • LIC 625 - Emergency Information: This document serves to identify important contacts and medical information in case of an emergency. Like the LIC 603, it emphasizes the individual's needs and health status, ensuring that caregivers have vital information readily available.

  • LIC 500 - Application for a License: This application form is utilized when a facility applies for licensure. The LIC 500 requests information about the facility's ability to meet the care needs of residents, similar to how the LIC 603 assesses an applicant's suitability for the facility.

  • LIC 610 - Assessment or Individualized Program Plan: This document focuses on the specific needs and preferences of the individual in care. Like the LIC 603, it requires detailed information about the applicant's personal circumstances, enabling tailored care and support planning.

  • LIC 924 - Continuing Care Disclosure Statement: This document outlines the terms and services provided, helping potential residents understand their rights and responsibilities. It shares the LIC 603's goal of ensuring that individuals have a clear understanding of what to expect in terms of care and resources.

  • LIC 203 - Fire Clearance Request: While primarily focused on safety and compliance, this form ensures that facilities meet the necessary health and safety standards to accommodate residents. This aligns with the LIC 603's determination of the applicant's health and mobility capabilities within the facility.

Dos and Don'ts

When filling out the Lic 603 form, it is important to follow certain guidelines to ensure accuracy and clarity. Here is a list of things you should and shouldn't do:

  • Do provide complete and honest information about the applicant’s health and background.
  • Do ensure that all sections are filled out to the best of your knowledge.
  • Do use clear and simple language to describe any health conditions or needs.
  • Do seek assistance if necessary from qualified individuals who know the applicant well.
  • Do attach any additional information that may be relevant to the applicant’s admission.
  • Don't leave any sections blank unless specifically instructed to do so.
  • Don't provide vague descriptions; detail is important for accurate assessments.
  • Don't exaggerate or understate health conditions to misrepresent the applicant's needs.
  • Don't ignore the need for signatures; all parties must sign where required.
  • Don't submit the form without reviewing it for errors or incomplete sections.

Misconceptions

When dealing with the LIC 603 form, confusion often arises due to various misconceptions. Here are seven common misunderstandings clarified:

  1. The LIC 603 form can replace the Physician’s Report (LIC 602).

    This is not accurate. The LIC 603 is meant to gather information about an applicant for residential care but does not substitute for the Physician’s Report, which includes specific medical evaluations.

  2. The form can only be filled out by the applicant themselves.

    In reality, the form can be completed by an authorized representative, such as family members or healthcare providers, who can assist in providing accurate information.

  3. All questions on the LIC 603 must be answered.

    This is a misconception. While it’s beneficial to complete as many fields as possible, some may be left unanswered if the information is not relevant or available.

  4. Answering “No” in health sections means there are no concerns.

    It is crucial to understand that a “No” response does not mean there are no health concerns. It is essential to provide detailed descriptions wherever applicable to convey a complete picture of the applicant's health.

  5. The form only assesses physical health.

    The LIC 603 takes into account health, physical disabilities, mental condition, and social factors. It aims for a holistic view of an applicant's needs.

  6. It is unnecessary to document social factors.

    This is a misunderstanding. Social factors, such as the applicant's likes and dislikes, significantly impact their adjustment and care in a facility, making this information vital.

  7. Submitting the LIC 603 guarantees admission to a facility.

    The form serves to assess suitability for admission but does not guarantee it. Admission ultimately depends on the facility's specific policies and availability of suitable resources.

Key takeaways

When filling out the Lic 603 form, it's essential to keep the following key takeaways in mind:

  • Accurate Health Information: Provide a detailed description of the applicant's overall health condition, including any dietary restrictions and physical disabilities. This information helps to assess the suitability for residential care.
  • Identify Services Needed: Clearly check all applicable services the applicant requires, such as help with bathing, mobility, and medication management. This ensures that the facility can meet the individual's needs.
  • Ambulatory Status: Specify whether the applicant is ambulatory or non-ambulatory. Define the individual's capability to evacuate the building independently, as this is crucial for safety assessments.
  • Additional Information: Respond to the question about any additional information that may assist in determining the applicant's suitability. If applicable, attach comments on a separate sheet to provide further details.