The California Department of Social Services (CDSS) governs Residential Care Facilities for the Elderly (RCFE) which encompasses Assisted Living, Memory Care, and Continuing Care Retirement Communities (CCRCs).
The following links are from the CDSS website and are used for RCFE purposes. You can locate the form you need and click the link to review, print, save,or fill out. If the link does not work, you can go directly to the CDSS website at www.CDSS.CA.GOV If a form isn’t included on this page, click the following link CDSS Forms Page to access ALL available forms from the CDSS website.
FORMS
- LIC107-fingerprint follow up request
- LIC122-Release of information
- LIC 311C (4/05) – Records To Be Maintained At The Facility – Adult Residential
- LIC 503 (3/99) – Health Screening Report – Facility Personnel
- LIC 508 (7/20) – Criminal Record Statement & Out-Of-State Disclosure
- LIC 601 (8/08) – Identification And Emergency Information
- LIC 602A (8/11) – Physician’s Report For Residential Care Facilities For The Elderly (RCFE)
- LIC 603 (9/99) – Pre Placement Appraisal Information
- LIC 603A (7/99) – Resident Appraisal
- LIC 604A (2/05) – Admission Agreement For Residential Care Facilities For The Elderly
- LIC 605A (5/00) – Release Of Client/Resident Medical Information
- LIC 606 (8/18) – Residential Care Facility For The Elderly Disclosure Worksheet
- 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 625 (11/19) – Appraisal/Needs and Services Plan
- LIC 627C (4/00) – Consent For Emergency Medical Treatment – Adult And Elderly Residential Facilities
Do you have questions? Confused about the different options?
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