Admin CDSS LIC 311C - Client Records CDSS On-line Forms and Publications
A. LIC 603 Preplacement Appraisal Information
B. LIC 625 Appraisal Needs and Services Plan updated at least annually and as frequently as necessary to ensure its accuracy. (LIC 625) or equivalent Regional Center Individual Performance Plan (IPP)
C. LIC 602 Physicians Report. Medical assessment including TB test results; ambulatory status; record of illnesses and medical care provided; evidence or periodic medical examination and care; and record of changes in physical, mental emotional and social functioning of residents. The assessment shall not be more than one year old when obtained.
D. LIC 604 Admission Agreement Guide. Current admission agreement with authorized signatures, or equivalent
placement agency admission agreement.
E. LIC 601 Identification and Emergency Information
F. P&I - LIC 405 Record of Client’s/Resident’s Safeguarded Cash Resources, including supporting receipts of expenditures and LIC 621 Client/Resident Personal Property and Valuables , a record of each client’s personal property and/or valuables entrusted to the facility.
G. A demand trust account for each client's cash resources if not kept in the facility.
H. LIC 625 Appraisal/Needs and Services Plan. Evidence of consultation from a dietitian, physician, social worker, psychologist, or any other consultation in determining if client needs can be met by facility or in modifying needs and services plan of client, when general facility program fails to meet an individual client’s needs.
I. LIC 622 Centrally Stored Medications and Destruction Record
J. (Do not use) LIC 624 Unusual Incident/Injury Report. Use SDRC SIR instead., as instructed here.
K. LIC 624A Death Report
L. LIC 9020 Register of Facility Clients/Residents
M. LIC 613 Personal Rights Forms
N. LIC 9172 Functional Capability Assessment
O. LIC 627C Consent for Medical Treatment
P. Certification from Regional Center for DD clients
Q. Mental Health Assessment, if needed
R. Restricted Health Condition Care Plan, if needed
S. LIC 9158 Telecommunications Device Notification form
1. LIC 602 Physician's Report For Community Care Facilities
2. LIC 605A Release of Client/Resident Medical Information