Fill in a Valid Lic 625 Template

The Lic 625 form is an important document used in the state of California for assessing the needs of clients or residents in community care facilities. This form facilitates the development of a customized needs and services plan, ensuring that individual requirements are adequately identified and addressed. Completion of the Lic 625 is essential for maintaining compliance with licensing regulations, particularly during client placement.

For more information on how to properly fill out the Lic 625 form, please click the button below.

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Understanding the LIC 625 form is essential for anyone involved in the care of individuals placed in various residential settings, particularly in California. This form, developed by the California Department of Social Services, plays a critical role in assessing and documenting the specific needs and service plans of clients or residents. It includes vital information such as the client's or resident's name, date of birth, age, and sex, as well as details about their medical history and personal preferences. The necessity for this assessment arises from licensing regulations aimed at ensuring that every individual receives proper support tailored to their unique circumstances. The form is initiated either upon admission or during updates and takes input from various sources, such as referral agencies, physicians, and social workers. Such collaboration is crucial, especially when addressing any potentially dangerous tendencies of the client. A detailed needs and services plan is created alongside the resident or their representative to outline objectives and responsibilities for care. This ensures a comprehensive approach to their well-being and adjustment in the facility. Through careful evaluations and updates, the LIC 625 form not only helps caregivers track progress but also fosters a sense of security and understanding for those they support.

Lic 625 Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY				CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
						COMMUNITY CARE LICENSING
APPRAISAL/NEEDS AND SERVICES PLAN


CLIENT’S/RESIDENT’S NAME	DATE OF BIRTH	AGE	SEX		DATE
			MALE	FEMALE

FACILITY NAME	ADDRESS				CHECK TYPE OF NEEDS AND SERVICES PLAN:
						ADMISSION	UPDATE

PERSON(S) OR AGENCY(IES) REFERRING CLIENT/RESIDENT FOR PLACEMENT			FACILITY LICENSE NUMBER		TELEPHONE NUMBER
					(	)

Licensing regulations require that an appraisal of needs be completed for specific clients/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for admission shall jointly develop a needs and services plan with the client/resident and/or client’s/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Additionally, the law requires that the referral agency/person inform the licensee of any dangerous tendencies of the client/resident.

NOTE: For Residential Care Facilities for the Elderly, this form is not required at the time of admission but must be completed if it is determined that an elderly resident’s needs have not been met.

BACKGROUND INFORMATION: Brief description of client’s/resident’s medical history/ emotional, behavioral, and physical problems; functional limitations; physical and mental; functional capabilities; ability to handle personal cash resources and perform simple homemaking tasks; client’s/resident’s likes and dislikes.

LIC 625 (6/12) CONFIDENTIAL

PAGE 1 OF 4

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

SOCIALIZATION — Difficulty in adjustig socially and unable to maintain reasonable personal relationships

EMOTIONAL — Difficulty in adjusting emotionally

LIC 625 (6/12) CONFIDENTIAL

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

MENTAL — Difficulty with intellectual functioning including inability to make decisions regarding daily living.

PHYSICAL/HEALTH — Difficulties with physical development and poor health habits regarding body functions.

LIC 625 (6/12) CONFIDENTIAL

PAGE 3 OF 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVCIES AGENCY	CALIFORNIA DEPARTMENT OF	SOCIAL SERVICES
	COMMUNITY	CARE LICENSING

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

FUNCTIONING SKILLS — Difficulty in developing and/or using independent functioning skills.

We believe this person is compatible with the facility program and with other clients/residents in the facility, and that I/we can provide the care as specified in the above objective(s) and plan(s).

TO THE BEST OF MY KNOWLEDGE THIS CLIENT/RESIDENT DOES NOT NEED SKILLED NURSING CARE.

LICENSEE(S) SIGNATURE

DATE

I have reviewed and agree with the above assessment and believe the licensee(s) other person(s)/agency can provide the needed services for this client/resident

CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S)/FACILITY SOCIAL WORKER/PHYSICIAN/OTHER APPROPRIATE CONSULTANT SIGNATURE	DATE

I/We have participated in and agree to release this assessment to the licensee(s) with the condition that it will be held confidential.

CLIENT’S/RESIDENT’S OR CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S) SIGNATURE

DATE

LIC 625 (6/12) CONFIDENTAIL

PAGE 4 OF 4

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File Breakdown

Fact Name	Description
Purpose of the Form	The LIC 625 form is used to complete an appraisal of individual needs for residents in community care facilities. It helps develop a tailored service plan that addresses specific needs.
Applicable Regulations	This form is governed by California regulations for Community Care Licensing, specifically addressing the requirements for needs and services plans for clients in care facilities.
Referral Requirements	Referral agencies must inform the licensee about any dangerous tendencies of the client/resident, ensuring a safe placement process.
Use for Elderly Residents	While the form is not required at the time of admission for Residential Care Facilities for the Elderly, it must be completed if it is determined that the resident's needs are unmet after admission.

Guide to Using Lic 625

Completing the Lic 625 form is an essential step in the process of developing a tailored needs and services plan for individuals in care facilities. By accurately filling out this form, staff can ensure that each client's unique requirements are identified and addressed promptly. Here’s how to navigate the form.

Client/Resident Information: Starting at the top of the form, fill in the client’s or resident’s full name, date of birth, age, and sex. Indicate if they are male or female.
Facility Information: Next, provide the name and address of the facility. Ensure that you check the appropriate box to indicate whether this is an admission or an update of a needs and services plan.
Referral Information: Include the names of the person(s) or agency(ies) referring the client for placement. Be sure to enter the facility license number and the contact telephone number.
Background Information: Offer a brief description of the client’s medical history, emotional and behavioral issues, physical problems, and any functional limitations. This section should also note the client’s capabilities regarding personal tasks and their likes and dislikes.
Needs Objectives/Plans: In the designated areas, specify the objectives related to the client’s socialization, emotional well-being, mental health, physical health, and functioning skills. List the time frame for each objective, the person responsible for implementation, and the method of evaluating progress.
Compatibility Assessment: Indicate whether the person is compatible with the facility program and other residents. Include a statement confirming that the client does not require skilled nursing care.
Signatures: Finally, secure the necessary signatures. The licensee should sign and date the form, followed by the client’s or their authorized representative’s signature. Ensure that the confidentiality of the assessment is noted and agreed upon.

Get Answers on Lic 625

What is the purpose of the Lic 625 form?

The Lic 625 form is designed to assess the needs of clients or residents in various care facilities in California. It identifies individual needs and helps create a tailored service plan. By completing this form, facilities can ensure they meet the specific requirements and preferences of each resident.

Who must complete the Lic 625 form?

The staff person responsible for admission at the facility is required to complete the Lic 625 form. This process should involve collaboration with the client or resident, their authorized representative, or other relevant professionals, such as a physician or social worker. Additionally, referral agencies must inform the facility about any dangerous tendencies related to the client or resident.

When is the Lic 625 form required?

The form is required at the time of admission for most clients or residents. However, if a resident in a Residential Care Facility for the Elderly is found to have unmet needs after admission, the Lic 625 form must be completed to document and address those needs.

What kind of information is included in the Lic 625 form?

The Lic 625 form collects a variety of important information, including:

Client or resident's medical history and any emotional, behavioral, or physical problems.
Functional limitations and capabilities.
Client or resident's preferences, including likes and dislikes.
Details on socialization, emotional health, mental functioning, and physical health.

How is the progress of the client's service plan evaluated?

The Lic 625 form outlines methods for evaluating the progress of the client's needs and services plan. This includes identifying responsible persons for implementation and establishing time frames for objectives. Regular assessments should be conducted to ensure the plan remains effective and responsive to the client or resident's evolving needs.

Common mistakes

Filling out the Lic 625 form can be a straightforward task, but many individuals encounter pitfalls that can jeopardize the purpose of the form. One of the most common mistakes is providing incomplete or inaccurate background information. This section is crucial as it details the client’s or resident’s medical history, emotional and behavioral challenges, and functional limitations. Omitting significant information or misreporting details can lead to inappropriate care plans and, consequently, poor outcomes for the resident. Every piece of information matters, and a comprehensive overview is necessary to tailor the needs and services plan effectively.

Another frequent error occurs when individuals fail to specify the type of needs and services plan being requested. The form allows for different checkboxes to identify whether the plan is for admission or an update. Confusing these options can complicate the admission process or delay necessary services. Clearly indicating the intended purpose from the outset helps staff develop the right strategies based on current needs. It streamlines communication between the referral agency, facility, and other involved parties.

A third mistake is neglecting to include a detailed plan for evaluating progress. The form requires a method for assessing how well the needs and services plan is being implemented. Without a clear evaluation method, it becomes difficult to monitor the resident’s development and adjust the care plan accordingly. This oversight may hinder the ability to adapt strategies that could better support the client’s needs, leading to stagnation in their progress and potential setbacks in their care.

Lastly, signatories of the Lic 625 form must be careful to ensure that all required signatures are obtained. This includes not only the licensee’s signature but also that of the client’s authorized representative, physician, or social worker as necessary. Skipping this step can result in administrative delays and legal issues regarding the authorization of care. Securing all relevant approvals is essential for compliance and ensures that the plan is valid and enforceable.

Documents used along the form

The Lic 625 form is a crucial document used by residential care facilities in California to evaluate the needs of clients or residents. Alongside this form, several other documents are often utilized to create a comprehensive understanding of a resident's requirements and to ensure their well-being. Below is a list of additional forms commonly associated with the Lic 625.

Licensing Application (LIC 200): This form is used to apply for a license to operate a community care facility. It includes details about the facility, ownership, and management structure, and is essential for compliance with state regulations.
Health Screening Report (LIC 503): Required for all clients, this report documents a resident’s health history and current medical status. It aids in determining the appropriate care needed and identifies any special health requirements.
Individual Service Plan (ISP): This document outlines the specific services and interventions required for the client’s care. The ISP is crafted collaboratively by care staff, the client, and their family to meet individual needs effectively.
Incident Report (LIC 624): This form is used to document any significant events or incidents affecting a resident’s health or safety. It serves to maintain a record of occurrences that may require further review or action to ensure the safety of all residents.

These documents collectively help in managing the care and support of residents in community care facilities. By using the Lic 625 form alongside these additional forms, care providers can develop tailored approaches to address the unique needs of each individual, ensuring a higher standard of care and support.

Similar forms

The Lic 625 form serves a specific purpose in the assessment and planning of care for clients in residential facilities. Several other forms share similarities with the Lic 625 in their intent to gather information about individuals and their needs. The following documents provide comparable functions:

Individual Service Plan (ISP): This document outlines the services and support an individual requires based on their unique needs. Like the Lic 625, it involves input from multiple stakeholders, including social workers and healthcare providers.
Comprehensive Assessment: Often required for various institutions, a comprehensive assessment collates detailed information about an individual's medical, psychological, and social history. This document, akin to the Lic 625, is essential for developing a tailored care plan.
Client Assessment Form: Used in many healthcare settings, this form collects data about a client's needs, preferences, and history. Similar to the Lic 625, it facilitates the creation of a care plan that addresses specific requirements.
Needs Assessment Document: This document identifies the needs of individuals in care facilities and assists in forming actionable plans. It serves as a planning tool, much like the Lic 625, emphasizing the importance of individualized care.
Intake Assessment Form: Commonly utilized upon admission, this form gathers initial information about a client’s background, health, and preferences. It is comparable to the Lic 625, as both documents are aimed at understanding clients better to provide appropriate care.

Dos and Don'ts

When completing the Lic 625 form, it is crucial to follow specific guidelines to ensure accuracy and compliance. Below are five things to consider doing and not doing during this process.

Do provide accurate information. Ensure that all details about the client’s or resident’s medical history and personal preferences are correctly stated.
Do collaborate with involved parties. Jointly fill out the form with authorized representatives or professionals who understand the client’s needs.
Do maintain confidentiality. Safeguard personal information, ensuring it is used only as intended for care and service planning.
Do review the information. Before submission, verify that all parts of the form are complete and reflect the client's current condition.
Do familiarize yourself with the guidelines. Understanding the regulations surrounding the Licensing process can aid in filling out the form effectively.

Don’t omit essential details. Failing to include necessary medical or behavioral information could lead to inadequate care planning.
Don’t rush the process. Take the time needed to gather information and thoughtfully complete the form.
Don’t ignore instructions. Adhering to specific guidelines will help prevent delays or issues with the approval of the service plan.
Don’t submit without necessary signatures. Ensure that all required parties have signed the document as part of the review process.
Don’t assume previous forms suffice. Each submission should reflect the current status and needs of the client or resident, regardless of past documents.

Misconceptions

Understanding the Lic 625 form often comes with several misconceptions. Here’s a clarification of ten common misunderstandings surrounding this important document:

It must be completed before admission. Contrary to popular belief, the Lic 625 form is not required at the time of admission for all types of facilities. In the case of Residential Care Facilities for the Elderly, it is only necessary if an elder resident's needs are found to be unmet.
Anyone can fill out the form. This is incorrect. The form must be completed by staff responsible for admission in collaboration with the client or an authorized representative. This ensures an accurate assessment of the client’s needs.
The information collected is public. In fact, the data on the Lic 625 form is considered confidential. It should only be shared with the appropriate parties involved in the care of the client or resident.
It is optional for facilities to use it. Many assume the use of the Lic 625 form is at the facility’s discretion. However, licensing regulations mandate its completion for specific cases to ensure that client needs are adequately addressed.
Once the form is done, it does not need to be updated. This is a misconception. The Lic 625 form should be regularly updated to reflect any changes in the client’s needs and services.
The Lic 625 solely focuses on medical history. While medical history is important, the form covers various aspects, including emotional, behavioral, and functional capabilities of the resident.
There is no need for a social worker or physician to be involved. This is misleading. The collaboration of professionals, such as social workers and physicians, is crucial to develop a comprehensive needs and services plan.
It is a lengthy and complicated document. Though the form appears detailed, it is designed to gather essential information succinctly. Proper guidance can simplify the completion process.
The form determines placement suitability on its own. The Lic 625 helps assess needs, but placement decisions also require consideration of a facility's resources and capabilities to meet those needs.
Completion guarantees immediate assistance. Filling out the Lic 625 does not automatically initiate services. Caregivers must still actively implement the outlined needs and objectives in their care plans.

Clarifying these misconceptions helps ensure that individuals understand the critical role of the Lic 625 form in providing tailored care for residents in community care facilities.

Key takeaways

The Lic 625 form is essential for creating a tailored needs and services plan for clients or residents in community care facilities. Here are six key takeaways regarding its completion and usage:

Purpose of the Form: The Lic 625 form is used to assess the individual needs of a client or resident and develop a service plan to address those needs.
Completion Requirement: The form must be completed by staff at the time of admission for clients in specific circumstances, particularly when determining the individual’s care requirements.
Referral Information: It is vital that the referral agency or representative informs the licensee of any dangerous tendencies associated with the client or resident.
Comprehensive Assessment: The form includes sections to document medical history, emotional and behavioral issues, and functional capabilities, among other relevant details.
Implementation and Evaluation: The plan created must include specific objectives, responsible persons, time frames, and methods for evaluating progress.
Confidentiality: All information included in the form is confidential and requires the consent of the client or their authorized representative for release to the licensee.