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PROGRAMS (Adult Facility)

The forms below are requirements by Community Care Licensing for an Adult Facility.  They are grouped based on Administration, Consumer, and Staff records needed to be sustained by a facility.

Administrative Records

LIC308-Designation of Facility Respo
LIC402-Surety Bond
LIC610D-Emergency Disaster Plan
LIC9058-Applicant Licensee Rights
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Client Records

LIC405-Record of Client Cash Resourc
LIC601-Identification and Emergency
LIC602-Physican Report
LIC603-Preplacement Appraisal Inform
LIC604-Admission Agreement Guide
LIC613-Personal Rights for Adult Car
LIC621-Client Personal Property and
LIC622-Centrally Stored Medication a
LIC624-Unusual Incident Injury Repor
LIC624A-Death Report
LIC625-Appraisal Needs and Service P
LIC627C-Consent for Medical Treatmen
LIC9020-Register of Facility Clients
LIC9158-Telecommunications Device No
LIC9172-Functional Capability Assess
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Records to be Maintained at the Facility

LIC311C-Records to be Maintained at
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Personal Records

LIC500-Personnel Report
LIC501-Personnel Record
LIC503-Health Screening Report
LIC508-Criminal Record Statement
LIC9188-Criminal Record Exemption Tr
SOC341A-Acknowledging Requirement to
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