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LIC 624A: Death Report
By Sevana Care · Checked against cdss.ca.gov and Title 22 on
- When it is due
- A written report to licensing and to the person responsible for the resident within seven days of the death [2].The rule says "seven days" and does not say business days [2]. The form's own header also says to notify licensing, the placement agency and responsible persons "by next working day" [1].
- Who fills it out
- The licensee must send the report to licensing [2].The form has a "Report submitted by" line and a "Report reviewed/approved by" line, each with a name, title and date [1].
LIC 624A is the California Department of Social Services (CDSS) Death Report. Its header reads: "Licensee must report the death of a client of any cause, regardless of where the death occurred" [1]. In an RCFE, Title 22 § 87211(a)(1) requires a written report to licensing and to the person responsible for the resident within seven days of a resident's death from any cause [2]. CDSS lists LIC 624A as the Death Report in the records an RCFE keeps [3].
Who fills it out
The licensee must send the report to licensing: "Each licensee shall furnish to the licensing agency such reports as the Department may require" [2]. The form has a "Report submitted by" line and a "Report reviewed/approved by" line, each with a name, title and date [1].
The rule covers the "death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility" [2].
The form is a general Community Care Licensing Division form. Its header reads "California Department of Social Services, Community Care Licensing Division," it says "client," and it never names RCFEs [1].
The report goes to the licensing agency and to the person responsible for the resident [2]. The form's header also says to notify the licensing agency, the placement agency and responsible persons, "if any" [1]. The bottom of the form has lines to record who was told: licensing, Adult/Child Protective Services, the long-term care ombudsman, the parent, guardian or conservator, law enforcement, and the placement agency, each with a name and phone number [1].
When it is due
Written report: seven days. Send it to licensing and to the person responsible for the resident within seven days of the death [2]. The rule says "seven days" and does not say business days [2].
The form's own header also says to notify the licensing agency, the placement agency and responsible persons "by next working day," and to submit the written report within 7 days of occurrence [1]. Title 22 § 87211 gives RCFEs the seven-day written report for a death [2].
Coroner's report. The form's cause-of-death line reads "if coroner report made, send copy within 30 days" [1]. The form does not say who receives the copy [1].
Suspected abuse of an elder or dependent adult is a separate clock. Title 22 § 87211(b) and (c) send you to Welfare and Institutions Code § 15630(b)(1) [2]. The SOC 341 page covers that report.
Where it is kept
The form says "Retain copy of report in client's file" [1]. CDSS lists the Death Report, with the unusual incident/injury report, under "Residents Records," records that "must be kept in the facility complete and current, and readily available for review" [3].
Title 22 § 87506 requires a record for each resident, kept "in the facility or in a central administrative location readily available to facility staff and to licensing agency staff" [4]. Records are kept for a minimum of three years after service to the resident ends [4]. The section does not list death reports by name [4].
What the record must show
- The contents. § 87211(a)(1) lists what it must contain: the resident's name, age, sex and date of admission; the date and nature of the event; the attending physician's name, findings and treatment, if any; and what happened to the case [2].
- The form's fields [1]:
- the facility name, file number and address
- the client's name, date of birth, sex and date of admission
- the date, time and place of death
- the immediate cause of death
- the conditions before or contributing to the death
- the immediate action taken, including persons contacted
- whether medical treatment was necessary and its nature
- the names of the attending physician and the mortician
- Who was notified. The bottom of the form asks who was told, with name and phone number [1].
- The dates. The date and time of death and the date of each signature are on the form [1]. The seven days run from the death [2].
Other forms with "624" in the number
From the CDSS forms list [5]:
- LIC 624 (4/99), Unusual Incident/Injury Report: the form CDSS lists beside LIC 624A in the RCFE records list [5][3].
- LIC 624B (8/08), Unusual Incident/Injury Report - Family Child Care Home: for family child care homes [7].
- LIC 624 LE (12/22), Law Enforcement Contact Report: for incidents where law enforcement contacts a child in a group home or similar children's program. Its check boxes list group homes, short-term residential therapeutic programs, community treatment facilities and similar programs, not RCFEs [8].
Questions
Do RCFEs use LIC 624A?
CDSS lists "Death Report (LIC 624A)" in its records list for residential care facilities for the elderly [3]. Title 22 § 87211 sets the report's contents and its seven-day deadline and does not name the form [2].
Is a death reported on LIC 624 or LIC 624A?
None of the sources here says which of the two forms to use for a death. The LIC 624A header reads: "LICENSEE MUST REPORT THE DEATH OF A CLIENT OF ANY CAUSE, REGARDLESS OF WHERE THE DEATH OCCURRED" [1]. The CDSS records list names both forms in one item, for a "report of unusual incident, event, serious injury requiring medical attention, or death, while the resident is under facility supervision" [3]. That wording is narrower than the rule, which covers a death wherever it occurred [2]. Title 22 § 87211(a)(1)(A) puts a death in the same seven-day written report as the other three events [2]. The LIC 624 page covers the incident report.
Does the death have to happen in the home?
No. § 87211(a)(1)(A) covers a death "regardless of where the death occurred," and lists a day program, a hospital, travel to or from a hospital, and a visit away from the facility [2]. The form says the same in its header [1].
Is the deadline different from LIC 624?
No. § 87211(a)(1) gives a death, a serious injury, the use of an Automated External Defibrillator and an incident that threatens a resident's welfare, safety or health the same seven days [2]. The two forms print the same header instructions: notify by next working day, submit the written report within 7 days [1][6].
How Sevana Care keeps this record
Who has to hear about a death, and by when? You log it once in Sevana Care, and the checklist lists who to tell: licensing and the responsible person, plus the placement agency if one placed the resident. The seven-day written report shows its due time, ticks when marked sent and flags Overdue once the deadline passes. Filing the LIC 624A stays with you; keep your filed copy on the resident's record. The Incidents tab in the sample home shows it.
More in Medication, incident reports and safety plans
Sources
- CDSS, LIC 624A (7/99), Death Report (PDF)
- California Code of Regulations, Title 22, § 87211, Reporting Requirements (Westlaw)
- 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, § 87506, Resident Records (Westlaw)
- CDSS, Forms and Publications (I-L)
- CDSS, LIC 624 (4/99), Unusual Incident/Injury Report (PDF)
- CDSS, LIC 624B (8/08), Unusual Incident/Injury Report - Family Child Care Home (PDF)
- CDSS, LIC 624 LE (12/22), Law Enforcement Contact Report (PDF)