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LIC 613C-2: Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly

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

When it is due
The rights and the nondiscrimination notice are given "at the time the admission agreement is signed" [3].The form is a signed acknowledgment with no filing deadline [1]. Posting the rights, the notice and the complaint information is a separate rule [3].
Who fills it out
Title 22 requires that the resident and the resident's representative be personally advised of the rights and the nondiscrimination notice and given a copy, and the licensee has each of them sign a copy [3].The last page has lines for the resident and, if applicable, the resident's representative to sign and date [1].
Where it is kept
The signed copy "shall be included in the resident's record" [3].The form says: "A signed copy of these rights and nondiscrimination notice shall be retained in the resident's file maintained by the licensee" [1].
How long to keep
Title 22 § 87506(e) says original resident records "shall be retained for a minimum of three (3) years following termination of service to the resident" [5].The list of what a resident's record contains in § 87506(b) does not name the signed rights [5].

LIC 613C-2 is the California Department of Social Services (CDSS) form "Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly" [1][2]. It lists the personal rights of residents, carries the nondiscrimination notice, and ends with a page the resident and their representative sign [1]. Title 22 § 87468, headed "Personal Rights of Residents," has you advise each resident and their representative of these rights and give them a copy when the admission agreement is signed, put the signed copy in the resident's record, and post the rights [3]. Homes licensed to a city, county or other government entity use a different CDSS form, LIC 613C [2][3].

Who fills it out

Title 22 requires that the resident and the resident's representative be personally advised of the rights and given a copy [3]. The licensee also has to "have each resident and the resident's representative sign a copy of these rights" [3].

Which version applies to whom. Title 22 § 87468(a) defines the two kinds of home [3]:

  • A "privately operated facility" is an RCFE "licensed to an individual, firm, partnership, association, or corporation."
  • A "publicly operated facility" is an RCFE "licensed to a city, county, or other government entity."

CDSS lists LIC 613C-2 (3/25) for privately operated RCFEs and LIC 613C (1/19) for publicly operated RCFEs [2].

The last page of LIC 613C-2 has lines for the facility name and address, the resident's name, the name and title of the resident's representative (if applicable), and a signature and date for the resident and for the representative [1]. The facility name also goes in the nondiscrimination notice [1].

When it is due

Admission. The rights and the nondiscrimination notice are given "at the time the admission agreement is signed" [3]. The form says the same [1].

Posting. Licensees "shall prominently post" the personal rights, the nondiscrimination notice and complaint information "in areas accessible to residents, representatives, and the public" [3]. The posting is in English and in any other language in which at least five percent of the residents can only read that language [3]. The complaint information goes on the RCFE Complaint Poster (PUB 475) or a poster with the same content, 20 by 26 inches, in the main entryway [3].

You can use LIC 613C-2 as the copy you give and the copy the resident signs [1][3].

Where it is kept

The signed copy "shall be included in the resident's record" [3]. The form says the same: "A signed copy of these rights and nondiscrimination notice shall be retained in the resident's file maintained by the licensee" [1].

How long to keep it. Title 22 § 87506(e) says original resident records "shall be retained for a minimum of three (3) years following termination of service to the resident" [5]. The list of what a resident's record contains in § 87506(b) does not name the signed rights [5].

What the record must show

The signed copy [1][3]:

  • the facility's name and address, and the resident's name
  • the representative's name and title, if there is a representative
  • a signature and a date for the resident and, if applicable, for the representative
  • the sentence they sign: "I/we have been personally advised of, and have received a copy of, the personal rights and nondiscrimination notice described on this form"

The notice itself [1][3]:

  • The nondiscrimination notice must read "[Name of facility] does not discriminate and does not permit discrimination ..." and give the State Long-Term Care Ombudsman contact. The form prints 1-800-231-4024.
  • The form's first page has a blank for "The local Long-Term Care Ombudsman's Office telephone number."

Questions

Is the form itself required?

The form says it "is provided as a courtesy to licensees" [1]. Title 22 § 87468 requires the advice, the copy, the signed copy in the record, the notice wording and the posting [3].

Is LIC 613 the same as LIC 613C-2?

No. CDSS lists LIC 613 (12/02) as "Personal Rights Adult Residential Care Facilities" and LIC 613C-2 (3/25) as "Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly" [2]. The list also has LIC 613A for child care centers, LIC 613B for children's residential facilities and LIC 613C for publicly operated RCFEs [2].

What is the difference between LIC 613C and LIC 613C-2?

CDSS lists LIC 613C (1/19) as "Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly" and LIC 613C-2 (3/25) as the same title for "Privately Operated" facilities [2]. LIC 311F, the CDSS records list dated 4/05, names "Personal Rights (LIC 613C)" as the evidence that a resident received the rights [6]. LIC 311F is dated before the 1/19 and 3/25 revisions and does not mention LIC 613C-2 [6].

Is there a Spanish version?

CDSS lists LIC 613C-2 (3/25) on its Spanish forms page [7].

How Sevana Care keeps this record

Is the personal rights form signed? Each resident's documents have a place for the personal rights acknowledgment. Photograph or upload the signed copy and it shows On file instead of Missing. The inspection checklist also has a posting item for personal rights, the nondiscrimination statement and complaint information. After you mark it checked, the row counts the days left until the next check. We don't write the notice. See it in the sample home.

More in Admission and the resident file

  • LIC 602A: The medical assessment a licensed medical professional signs before admission
  • LIC 603A: The appraisal you complete before a resident moves in
  • 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 601: The form with a resident's contacts, doctor, hospital and emergency details

Sources

  1. CDSS, LIC 613C-2 (3/25), Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly (PDF)
  2. CDSS, Forms and Publications (I-L)
  3. California Code of Regulations, Title 22, § 87468, Personal Rights of Residents (Westlaw)
  4. CDSS, LIC 613C (1/19), Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly (PDF)
  5. California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
  6. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  7. CDSS, Spanish forms and publications