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LIC 604A: Admission Agreement For Residential Care Facilities For The Elderly
By Sevana Care · Checked against cdss.ca.gov and Title 22 on
- When it is due
- No later than seven days following admission [3].The form reads differently: its signature section says "upon admission" [1].
- Who fills it out
- The licensee completes the agreement with each resident or the resident's representative [3].The resident or representative signs and dates it, and so does the licensee or the licensee's designated representative [3].
LIC 604A is the California Department of Social Services (CDSS) form that guides an RCFE's admission agreement. The form says: "You may use these instructions and the following form as a guide to create an admission agreement for your facility, or you may modify and use this form" [1]. Title 22 § 87507, "Admission Agreements", is the rule, and it names no form for the agreement itself. It says the licensee "shall complete an individual written admission agreement" with "each resident or the resident's representative, if any" [3]. CDSS lists the form in the records an RCFE keeps [2].
Who fills it out
The licensee completes the agreement with each resident or the resident's representative [3]. The resident or representative signs and dates it, and so does the licensee or the licensee's designated representative [3]. The form has a signature block for the resident, the resident's responsible person or conservator (if applicable) and the licensee or facility representative, each with a date [1].
The licensee gives a copy of the signed and dated current agreement, and of every later signed and dated modification, to the resident or representative "immediately upon signing" [3].
When it is due
Signed within seven days of admission. Title 22 § 87507(c): agreements "shall be signed and dated ... no later than seven days following admission". Attachments must be signed and dated the same way [3]. The form says "Telecommunications Device Form (LIC 9158), must be attached to each agreement" [1].
The form reads differently. Its signature section says the agreement must be dated and signed "upon admission" [1]. The form is dated 2/05, and § 87507 has been amended since then, in 2008, 2017 and 2025 [1][3].
Changes. Modifications are signed and dated [3]. The agreement must state "the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes" [3]. Section 87507(d) says the rule on keeping the signed agreement in the resident's file "does not apply to rate increases which have specific notification requirements" in Health and Safety Code § 1569.655 [3].
Where it is kept
In the resident's file. "The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications" [3]. The form says the same [1]. The resident record also lists "the admission agreement and pre-admission appraisal" [5]. CDSS's list puts LIC 604A under "Residents Records" [2].
A blank copy is available to the public. On request, the licensee provides blank copies of the most current approved agreement, modifications and attachments immediately, and may charge fees at cost for copying or mailing. The licensee posts a complete copy, or notice that it is available, where the public can see it in the home [3].
How long to keep it: at least three years after service ends. Title 22 § 87506(e): original records or photographic reproductions "shall be retained for a minimum of three (3) years following termination of service to the resident" [5]. Section 87506(b)(15) puts the admission agreement in the resident's record [5]. Section 87506 does not mention LIC 604A by name [5].
What the record must show
Section 87507(g) says the agreement must specify [3]:
- the basic services to be made available, and the additional items and services available
- payment provisions: rates, who pays, the due date, billing and payment procedures, and an itemized monthly statement
- the conditions for changing rates
- refund conditions
- the Department's authority to examine residents' records
- the visiting and communication policy
- general facility policies, including policies on firearms
- notice that the grievance procedure is available, and the resident's right to contact the Department of Social Services or the long-term care ombudsman
- the rules for involuntary transfer or eviction, and other conditions for ending the agreement
Section 87507(h) lists what the agreement must not contain, including waivers of facility responsibility for residents' health, safety or property [3]. The text must be in black type of at least 12-point on plain white paper, one side only, in "words with common and everyday meanings" [3].
The licensee must also attach a copy of the applicable resident's rights to every admission agreement, and include information on reporting suspected or known elder and dependent abuse (§ 87507(l)) [3]. The agreement "shall not require advance notice for its termination upon the death of the resident" (§ 87507(i)) [3].
The form has 21 numbered sections covering these topics and ends with the signature block [1]. It has no section on the itemized monthly statement in § 87507(g)(3)(H) or on firearms policies in § 87507(g)(8)(C), which was added with effect from 1-1-2025 [1][3]. The form says it complies with the referenced sections "as of the date shown at the bottom of this form" [1]. Its section references are older than today's numbering: it cites § 87568, which the history of § 87507 shows was renumbered to § 87507 in 2008 [1][3].
Another form with a similar number
The CDSS forms list also has LIC 604 (10/05), Admission Agreement Guide For Residential Facilities [4].
Questions
Do RCFEs use LIC 604A?
CDSS lists "Current admission agreement with authorized signatures, Admission Agreement Guide for RCFE (LIC 604A)" in its records list [2]. Section 87507 requires the written agreement and names no form for it [3]. The form calls itself a guide you may use or modify [1].
Why do the titles differ?
The CDSS forms list reads "Admission Agreement For Residential Care Facilities For The Elderly" [4]. The PDF's first page reads "Guide to Admission Agreements for Residential Care Facility for the Elderly", and the form page reads "Admission Agreements for Residential Care Facilities for the Elderly" [1]. LIC 311F reads "Admission Agreement Guide for RCFE" [2].
Does every agreement need LIC 9158 attached?
Yes. Health and Safety Code § 1569.159 has CDSS provide a form "which the residential care facility for the elderly shall attach to each resident admission agreement, notifying the resident that he or she is entitled to obtain services and equipment from the telephone company" [6]. The LIC 604A form says: "Telecommunications Device Form (LIC 9158), must be attached to each agreement" [1]. Section 87507(b) adds that the licensee completes and keeps in the resident's file a Telecommunications Device Notification form for each resident whose pre-admission appraisal or medical assessment indicates they are deaf, hearing-impaired or otherwise disabled [3].
What does § 87507 say about fees and refunds?
It says: "Any fee that is charged prior to or after admission, shall be clearly specified", and "Only one preadmission fee ... may be charged per resident admission" [3]. If a licensee charges a preadmission fee, it must give a written general statement "stating that the preadmission fee is refundable, and describing conditions for the refund" [3]. The form's paragraph reads: "state whether or not the fee is refundable" [1]. That wording does not match current Health and Safety Code § 1569.651(b) or § 87507(g)(3)(C)1, which both require a statement "stating that the preadmission fee is refundable" [7][3]. A licensee "shall not require any form of preadmission fee or deposit" from a recipient of the State Supplementary Program for the Aged, Blind and Disabled (SSP) [7], and § 87507(g)(3)(C)3 says the same [3]. A licensee also "shall not require, request, or accept any funds" from a resident or the resident's representative "that constitutes a deposit against any possible damages by the resident" [7]. Section 87507(g)(5) sets the refund conditions, including those for advance monthly fees and preadmission fees [3].
How Sevana Care keeps this record
Has the admission agreement been signed yet? Each resident's admission file in Sevana Care has a place for the signed agreement, and its page notes "Signed within 7 days of admission (§87507)". It starts as Missing and becomes On file once you add the signed copy. We don't write the agreement or the LIC 604A. Keep the signed original in the resident's file, as § 87507 requires. Open the sample home to see the screen, though uploads are off there.
More in Admission and the resident file
- LIC 9172: The checklist of what a new resident can do for themselves
- LIC 613C-2: The personal rights a resident signs at admission
- LIC 601: The form with a resident's contacts, doctor, hospital and emergency details
- 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
- CDSS, LIC 604A (2/05), Guide to Admission Agreements / Admission Agreements for Residential Care Facilities for the Elderly (PDF, 10 pages)
- CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
- California Code of Regulations, Title 22, § 87507, Admission Agreements (Westlaw)
- CDSS, Forms and Publications (I-L)
- California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
- California Health and Safety Code § 1569.159 (leginfo)
- California Health and Safety Code § 1569.651 (leginfo)