Frequently Asked Questions

LIC 200 - Application for a Community Care Facility or Residential Care Facility for the Elderly License.

This is the Application Form that a prospective RCFE Licensee must complete as part of the process to obtain a license to operate an RCFE. This form requires information about facility location, organization type, facility ownership, property ownership, as well as information about what type of facility the applicant wishes to open (i.e. type of clients served, total number of residents, and whether the clients will be ambulatory, non-ambulatory, etc.).  

After licensure, this form is used to request an increase in capacity, request a change of ownership, or request approval to provide additional services. 
 

If CARR has a scanned LIC 200 for an individual facility, it will be shown as a document icon, identified as LIC200.

To view:  http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC200.pdf

The LIC 203, or more properly LIC 203A, is the License itself.  This document is the evidence from the state that the facility is licensed to provide care and supervision for the stated capacity of the facility, and to provide such additional services as may be stipulated on the document.  The License will be updated by CCL, from time to time, as the facility becomes approved for more or fewer services, changed name, or when there is a change in Licensee.  

CARR refers to this document as "LIC 203",  for ease of standardizing the file names for the scanned documents. 

The LIC 215 – Applicant Information. 

This form is one of the items in the Application package that must be completed and submitted to CCLD as part of the Application process. The form is not a public document, as it contains detailed personal information about the prospective Licensee (i.e. education, work experience, references and financial information).  According to Title 22, CCLD  looks for 'satisfactory evidence that the applicant is of reputable and responsible character'. [Title 22, §87155].

To the best of CARR's understanding this document is retained in CCLD's Confidential File for a specific facility.  

To view:  http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC215.pdf

Licensed facilities are required to have an authorized person continuously present at the facility during operational hours (24/7) to represent the facility and to accept licensing reports. This form is used to designate an authorized person to act in the absence of the Licensee.  The authorized person is required to meet all the qualifications of a licensed administrator as set forth in Title 22 (§ 87405).

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC308.pdf

If a facility's Licensee is a legal entity (corporation, public agency, limited liability corporation, limited liability partnership), the form is required as part of the application process.   

If CARR has a scanned Administrative Organization document in its database for a facility, it will be found as a document icon, identified as MISC-LIC309ORG.

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC309.pdf

Facilities handling residents' cash resources must be bonded for not less than $1,000.  This provision does not apply, however, if the facility handles amounts less than $50 per person or $500 for all persons per month.  Facilities may also choose not to handle residents' cash resources.  Bonding requirements are stipulated in Title 22, §87216.

To view:  http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC400.pdf

The LIC 401 is a form the applicant completes, estimating its monthly expenses and revenues.  The document is used by CCLD to a) verify a facility's operating budget is reasonable, and b) as the basis for the facility to pledge three-months' assets necessary to carry the facility through its first three months of operation.  

if CARR has scanned LIC 401s for any individual facility, the document will be displayed as a document icon, identified as LIC 401.  

  • Food Budget: On this form, you can see how much the Licensee has estimated for food.  Take that monthly number, divide by the number of residents the facility is licensed for.  You now have the monthly food budget for 1 resident.   Divide that number by 3 to estimate the amount per meal the Licensee plans on spending on your resident.

  • Profit:  You can also evaluate the amount of profit the Licensee is projecting by looking at the last line on the LIC 401.

  • In 95% of the files, the only LIC 401 in the file is the one the Licensee submitted with his application.  Annual updates of the LIC 401 are not required, nor collected by CCL.   

 

In most cases, the figures provided by a facility are estimates (actuals are only available if the Licensee operates another facility prior to the opening of the current one under consideration).  

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC401.pdf

This form, the LIC 402 - Surety Bond,  is required if a facility chooses to handle residents' cash resources (as reported on Form LIC 400).  It states the name of the bonding company and specific terms of the agreement.  Examples of when a bond is needed are: (1) The Licensee/facility employee cashes a resident's check and returns the money to the client; (2) The Licensee/facility employee keeps a resident's money in a safe place (including a financial institution) and controls its distribution.

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC402.pdf

The LIC 500 form - Personnel Report - Roster of Current Personnel, is intended to record the current roster of all facility personnel, other adults residing in the facility including backup persons and volunteers. 

The purpose of this using this form during the application phase, is to ensure that the facility is adequately planning for the staff coverage necessary to operate the facility in compliance with the regulations. This form lists all planned employee positions, and the days and hours staff are scheduled for duty.  During the application process, many facilities have not yet hired the staff they need, so the placeholder for positions and the designated employee is listed as "to be hired".

CARR's review of the facility files found the LIC 500s are rarely updated following the original date of licensing; 75% of all files reviewed in 2009 contained incomplete reports (Master's Thesis, Murphy,C. 2010).  

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC500.pdf

The LIC501 form is only completed if the administrator is not the Licensee.  It lists the administrator's work experience, education and references for CCLD to review during the application process.  If the administrator is the Licensee, this same information is gathered on the LIC 215 form.   These forms and, therefore, the information on the qualifications of those individuals operating RCFEs, are not considered public documents.

View the document: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC501.pdf

The LIC 503 is required as part of the application process, and is used to verify the health (general well-being, lack of communicable diseases, etc.) of the Licensee and/or administrator, if they are different people.  It is also used within facilities during the hiring process for staff. It requires completion and signature by a physician

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC503.pdf

State law (Health & Safety Code §1569.17) requires that persons associated with licensed facilities be fingerprinted and disclose any convictions. The LIC 508 or LIC 508D, completed during the application and hiring process, asks for any criminal history of Licensees and facility employees.

Criminal Record Clearance requirement for all RCFEs.

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC508.PDF

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC508D.PDF

Each facility is required to have an annually updated emergency disaster plan. This form should be found prominently posted in every facility near a telephone (a copy is also maintained at CCLD in the facility's file).  This form contains important items such as (1) staff task assignments during an emergency, (2) emergency contact information and exit information, (3) temporary relocation sites and (4) transportation arrangements.  

Prudent consumers may want to confirm the feasibility of the proposed plan. Will the relocation sites truly be able and available to accommodate the resident during a disaster? Is the staffing adequate at all times to evacuate the type of residents served by the facility? Is the transportation reliable and promptly available? 

 

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC610E.PDF

This document is available to RCFEs if they centrally store their medications.

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC622.PDF

The LIC 809 or Facility Evaluation Report is the key record of the state's inspection of an RCFE.  The Licensing Program Analyst (LPA) uses this document during site visits to record the compliance of a facility.  

This document can be viewed in conjunction with Compliant Investigation Reports (LIC 9099s) to better inform the consumer about a facility's performance.  Consumers can view these public documents on CARR's website by using the Facility Search, or by filing a request with Community Care Licensing Division (CCLD).

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC809.pdf

The LIC 999 - Facility Sketch, provides a sketch of all indoor and outdoor space used by residents. It offers specifics such as room dimensions and purpose (i.e. staff rooms, rooms approved for non-ambulatory residents, etc.), utility shut-off locations, and exit routes. This form is supplied to CCL during the application process and maintained in CCL's facility's file.

If the facility is later remodeled as to room configurations or use, or if the facility is expanded to add square footage, a reviewed LIC 999 is required by the CCL. 

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC999.PDF

Before a facility can accept residents,  CCL must obtain a fire clearance for the facility from the local fire inspection authority having jurisdiction in the area the facility is located.  CCL submits the request for an inspection to the cognizant Fire Marshal's office.  The purpose of the inspection is to verify that the physical features of the facility can safely provide for the capacity and ambulatory status of the residents the facility wishes to care for, and also notifies which rooms are approved for non-ambulatory residents. Fire clearances are required prior to obtaining certain types of waivers. 

On this site, if CARR has the Fire Marshal Clearance for a particular facility, it will appear in the Facility Search as an icon identified as  FMC. 

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC9054.pdf

The LIC 9099 or Facility Complaint Report is another key record to be used as evidence of the state's oversight of RCFEs.  Any person can file a complaint with CCLD against a particular Licensee or facility.  CCLD is obliged to initiate investigation of a complaint within 10 working days after the date of complaint filing.

For each specific complaint filed with CCLD, CCLD must make a finding;

  • a complaint can be substantiated,
  • determined inconclusive, or
  • can be deemed unfounded.  

An LPA will find a complaint 'substantiated' if corroborating evidence can be found for the allegation.  If there is conflicting or ambiguous information surrounding a complaint, the complaint is frequently inconclusive.  When little to no corroborating evidence, or when evidence is counter to an allegation, the frequent finding for a complaint is unfounded.  

Substantiated complaints generally include violations of Title 22 regulations, and deficiencies are usually cited as part of the final complaint findings.  

This document can be viewed in conjunction with Facility Evaluation Reports (LIC 809s) to better inform the consumer about a facility's performance.  Consumers can view these public documents on CARR's website by using the Facility Search option or by filing a request with Community Care Licensing Division (CCLD).

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC9099.PDF