Skip to content
Sevana
Book a demo

Forms library

LIC 601: Identification and Emergency Information

By Sevana Care · Checked against cdss.ca.gov and Title 22 on

When it is due
Neither the form nor § 87506 gives a number of days [1][3].The form says "All information must be kept current" [1]. Section 87506(a) asks for a "separate, complete, and current record" for each resident [3].
Who fills it out
Neither the form nor § 87506 says which person in the home completes it [1][3].The form has a signature box for the resident, one for the "person completing form," a title and a date [1].
Where it is kept
Section 87506(a) requires a record for each resident, in the facility or at a central administrative location readily available to facility and licensing staff [3].CDSS's list, dated 4/05, puts "Identification and Emergency Information (LIC 601)" under "Residents Records" [2]. The form says the information must be "readily available to the person in charge, but not accessible to unauthorized persons" [1].
How long to keep
Section 87506(e) sets a minimum of three years after service to the resident ends for original records [3].Section 87506 does not name LIC 601 [3].

LIC 601 is the California Department of Social Services (CDSS) Identification and Emergency Information form [1]. CDSS lists it in the records an RCFE keeps, under "Residents Records" [2]. Its header calls the information "required under the H & S Code and the regulations of the Department" for "every person admitted to a community care facility" [1]. Title 22 § 87506(b) lists what each resident's record must contain, such as contacts, physician, dentist and ambulatory status, and names no form [3]. Section 87102, the Chapter 8 list of forms, does not include LIC 601 [7].

Who fills it out

The form does not say who in the home completes it. Its last row has a box for the "Signature of resident" and a box for the "Signature of person completing form," with a title and a date [1].

Section 87506(a) says: "The licensee shall ensure that a separate, complete, and current record is maintained for each resident" [3].

When it is due

No number of days. Neither the form nor § 87506 gives a deadline for completing it [1][3].

It must stay current. The form says "All information must be kept current" [1]. Section 87506(a) asks for a "complete, and current" record [3].

It records the end of the stay. Items 4 and 5 ask for the date admitted, the date left and a forwarding address [1]. Section 87506(b)(4) lists "Dates of admission and discharge" among the record's contents [3].

Where it is kept

Section 87506(a) requires a record for each resident, in the facility or at a central administrative location readily available to facility staff and to licensing agency staff [3]. CDSS's list puts "Identification and Emergency Information (LIC 601)" under "Residents Records" and says these records "must be kept in the facility complete and current, and readily available for review" [2]. That list is dated 4/05. The current rule, § 87506(a), also allows a central administrative location.

The form adds its own handling line. The information must be "readily available to the person in charge, but not accessible to unauthorized persons" [1].

Licensing staff may inspect it. Section 87506(d): "All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours" [3]. Licensing representatives "shall not remove" some current records for current residents "unless the same information is otherwise readily available in another document or format." Those records include [3]:

  • religious preference and the name and address of a clergyman or religious advisor
  • the name, address and telephone number of responsible persons
  • the resident's physician and dentist
  • ambulatory status
  • a continuing record of illness, injury, or medical or dental care "when it affects the resident's ability to function, or services needed"
  • current medications
  • "Any other records containing current emergency or health-related information for current residents"

How long to keep it. Section 87506(e): "Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident" [3]. Section 87506 does not name LIC 601 [3].

Resident records are confidential. The licensee is responsible for storing them and safeguarding what they contain [3].

What the record must show

What the form asks. Page 1, section A, is headed "ALL FACILITIES." It asks for these, in this order [1]:

  1. The client's name, Social Security number (marked "OPTIONAL"), birth date, age and sex.
  2. The responsible person or placement agency, with address and telephone.
  3. The nearest relative (marked "OPTIONAL"), with relationship, address and telephone.
  4. The date admitted and the address before admission.
  5. The date left and the forwarding address.
  6. The reasons for leaving the facility.
  7. The people responsible for financial affairs, payment for care, or the legal guardian, if any.
  8. Others to notify in an emergency: physician, mental health provider, dentist, relatives and friends.
  9. The emergency hospitalization plan: hospital name and address, medical plan and number, dental plan and number.
  10. Other required information: ambulatory status, religious preference, and the name, address and telephone of a clergyman or religious advisor.
  11. Comments.

The rule uses the word "representative." Section 87506(b)(8) asks for the "name, address, and telephone number of the resident's representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency" [3]. The form's item 2 says "responsible person." Section 87101 says "Responsible Person" means "Representative" for purposes of the regulations [6].

Section 87506(b) says each resident's record "shall contain at least" these items. LIC 601 asks for several of them [3][1]:

  • Birthdate. Item 1 asks for the date of birth [1]. The rule lists "Birthdate" [3].
  • Admission and discharge dates. Items 4 and 5 [1].
  • The representative. Item 2 asks for the responsible person [1]. The rule asks for the representative's name, address and telephone number [3].
  • Physician and dentist to call in an emergency. Item 8 [1].
  • Ambulatory status. Item 10a [1].
  • Religious preference and the name and address of a clergyman or religious advisor, if any. Item 10b [1].

The Social Security number. The form prints "SOCIAL SECURITY NUMBER (OPTIONAL)" [1]. Section 87506(b)(2) lists "Social Security number" among the items the record contains [3]. Neither text says what a home does if a resident has no number or does not give it.

What the form leaves out. Section 87506(b) lists "legal name and preferred name, as indicated by the resident" and "Gender identity and preferred pronoun, as indicated by the resident" [3]. The 8/08 form has no field for either [1].

What the form adds. The form also asks for the emergency hospitalization plan, the people responsible for financial affairs and a nearest relative [1]. The rule says the record holds "at least" its listed items [3].

Page 2 is for children's homes. Page 2 is headed "B. RESIDENTIAL FACILITIES FOR CHILDREN." Page 1 says the other side holds "additional information required for residential facilities for children" [1].

Questions

Does an RCFE have to use LIC 601?

Section 87506(b) sets the contents of the record and names no form [3]. CDSS lists LIC 601 in the records an RCFE keeps [2], and a CDSS forms request for RCFEs, LIC 183B (10/03), also lists it [5]. Section 87102, the Chapter 8 list of forms, does not include LIC 601 [7].

Does LIC 601 replace the medical assessment, LIC 602A?

No source says so. CDSS lists them on separate lines under "Residents Records": the physician's report (LIC 602A), then "Identification and Emergency Information (LIC 601)" [2]. Section 87506(b)(10) puts the medical assessment report in the record as its own item [3].

Why does LIC 601 mention children's facilities?

Its header speaks of "every person admitted to a community care facility," and page 1 points to the other side for "additional information required for residential facilities for children." Page 2 is that section [1].

Is the Social Security number optional?

The form says "OPTIONAL" next to it [1]. Section 87506(b)(2) lists "Social Security number" in the record [3]. The sources do not reconcile the two.

How Sevana Care keeps this record

Contact details change, and the sheet behind them goes out of date. Each resident has a document file in Sevana Care, with a place for the LIC 601 that shows Missing until a copy is filed and On file after that. It counts toward a check that lists residents missing a required document. We leave filling out the LIC 601 to you. See it in a resident's Admission file in the sample home.

More in Admission and the resident file

  • LIC 9172: The checklist of what a new resident can do for themselves
  • LIC 625: A CDSS form you may use for the plan of action when a resident's need is not being met
  • LIC 613C-2: The personal rights a resident signs at admission
  • LIC 627C: The signed consent for emergency medical or dental care
  • PUB 325: The brochure on medical care decisions that you give each resident on admission

Sources

  1. CDSS, LIC 601 (8/08), Identification And Emergency Information (PDF)
  2. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  3. California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
  4. CDSS, Forms and Publications (I-L)
  5. CDSS, Notice of Form Change No. 04-064 (2/27/2004), with LIC 183B (10/03) Forms Request, Residential Care Facilities For The Elderly (PDF)
  6. California Code of Regulations, Title 22, § 87101, Definitions (Westlaw)
  7. California Code of Regulations, Title 22, § 87102, Descriptions of Forms (Westlaw)