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LIC 9158: Telecommunications Device Notification
By Sevana Care · Checked against cdss.ca.gov and Title 22 on
- When it is due
- The rule gives no number of days for this form [3].Health and Safety Code (HSC) § 1569.159 and the LIC 604A form say to attach it to each admission agreement [4][6]. Section 87507(b) adds that the licensee completes it and keeps it in the file for each resident whose pre-admission appraisal or medical assessment indicates the resident is deaf, hearing-impaired or otherwise disabled [3].
- Who fills it out
- The licensee completes it and keeps it in the resident's file [3].The form has three signature lines, each with a date: the resident, the conservator, responsible person or authorized representative if any, and a facility representative [1].
LIC 9158 is the California Department of Social Services (CDSS) Telecommunications Device Notification, a one-page notice [1]. It tells a resident who is deaf, hearing impaired or otherwise impaired that Public Utilities Code § 2881 entitles them to equipment and service to improve their telecommunications [1]. Under HSC § 1569.159, CDSS provides the form and the RCFE "shall attach" it to each resident admission agreement [4]. Section 87507(b) adds that the licensee completes the form and keeps it in the resident's file for a resident whose appraisal or medical assessment indicates a hearing or other disability [3].
Who fills it out
Section 87507(b): "The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form" [3]. It names the form as "LIC 9158, 11/04" [3]. The CDSS list and the PDF are dated 7/22 [2][1].
The form has three signature lines, each with a date [1]:
- the client or resident
- the conservator, responsible person or authorized representative, if any
- the facility representative
It also asks for the facility name and address [1]. At the top, it lists facility types with check boxes. One is "Residential Care Facility for the Elderly" [1].
When it is due
No number of days. Section 87507(b) gives none, and neither does the form [3][1].
The rule adds a completed copy in the file for some residents. Section 87507(b) applies to "each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c)" [3].
The statute and the LIC 604A form say each agreement. Under HSC § 1569.159, CDSS provides a form "which the residential care facility for the elderly shall attach to each resident admission agreement" [4]. The LIC 604A form says: "Telecommunications Device Form (LIC 9158), must be attached to each agreement" [6]. Its next line asks the resident or responsible person to initial that "The signed and dated form is attached" [6].
The admission agreement has its own date. Section 87507(c) requires the agreement to be signed "no later than seven days following admission" [3]. Section 87507(b) does not repeat that limit for LIC 9158 [3].
Updates. Neither the form nor § 87507(b) says when to repeat the notice [1][3].
Where it is kept
The form's header marks two copies: "ORIGINAL - Client/Client Representative" and "COPY - Client/Resident File" [1]. Section 87507(b) says the licensee maintains the form "in the resident's file" [3]. Section 87506(a) requires a separate, complete and current record for each resident, in the facility or at a central administrative location readily available to facility and licensing staff [7].
Section 87506(c): "All information and records obtained from or regarding residents shall be confidential" [7].
CDSS's list of records an RCFE keeps (LIC 311F, 4/05) does not name LIC 9158 [8].
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" [7]. Section 87506 does not name LIC 9158, and § 87507(b) gives no period [7][3].
What the record must show
What the form says. The notice covers [1]:
- Any "deaf or hearing impaired, or otherwise impaired resident of any community care facility is entitled to equipment and service, pursuant to Section 2881 of the California Public Utilities Code, to improve the quality of their telecommunications."
- A resident who has a declaration from a licensed professional or a qualified state or federal agency that they are deaf, hearing impaired or otherwise disabled should contact the California Telephone Access Program and ask for help getting the equipment and service. The form prints the program's number.
- "This section shall not be construed to require, in any way, the licensee to provide a separate telephone line for any resident."
- The text of Public Utilities Code § 2881(a) and (c), printed below the signature lines.
What the statute says the form must include. HSC § 1569.159 lists the words the form "shall include": a resident with a declaration "that he or she is hearing or speech impaired, or otherwise disabled should contact the local telephone company and ask for assistance in obtaining this equipment and service" [4]. The form says to contact the California Telephone Access Program instead [1]. Neither text says which one controls [4][1].
Which wording of § 2881 the form prints. The form's reprint of § 2881(a) says "deaf or hearing impaired" [1]. Section 2881(a) now says "deaf or hard of hearing" [5]. The section was last amended in 2025 [5]. None of the cited sources says when the wording changed.
The current § 2881 also lets a physician assistant or nurse practitioner certify a person's needs [5]. The form's reprint does not [1].
Questions
Does every resident need LIC 9158?
Yes. HSC § 1569.159 says the RCFE "shall attach" the form to each resident admission agreement [4]. The LIC 604A form says the same [6]. Section 87507(b) adds that the licensee completes the form and keeps it in the file for each resident whose appraisal or medical assessment indicates a hearing or other disability [3].
Why does § 87507(b) say 11/04 when the form says 7/22?
None of the cited sources says what changed between the two dates. Section 87507(b) names "LIC 9158, 11/04" [3]. The CDSS list shows "LIC 9158 (7/22) - Telecommunications Device Notification," and the PDF footer reads "LIC 9158 (7/22)" [2][1].
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 601: The form with a resident's contacts, doctor, hospital and emergency details
- LIC 627C: The signed consent for emergency medical or dental care
Sources
- CDSS, LIC 9158 (7/22), Telecommunications Device Notification (PDF)
- CDSS, Forms and Publications (I-L)
- California Code of Regulations, Title 22, § 87507, Admission Agreements (Westlaw)
- Health and Safety Code § 1569.159 (leginfo.legislature.ca.gov)
- Public Utilities Code § 2881 (leginfo.legislature.ca.gov)
- CDSS, LIC 604A (2/05), Admission Agreement Guide for Residential Care Facilities for the Elderly (PDF)
- California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
- CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
- CDSS, LIC 9158 MFHV (6/26), Telecommunications Device Notification - MFHV (PDF)