Skip to content
Sevana
Book a demo

Forms library

LIC 9242: Entrance Checklist, Residential Care Facilities for the Elderly

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

When it is due
No due date.The Licensing Program Analyst (LPA) gives it to the licensee or designee "upon entrance to the facility" [1]. RCFE inspections are unannounced: HSC § 1569.33(e) says the department "shall conduct annual unannounced inspections of all residential care facilities for the elderly" [2].
Who fills it out
The form does not say.The LPA provides it. The top asks for the facility name, license number, inspection dates and time, facility phone and email, LPA name, and administrator or designee [1].
Where it is kept
The home need not keep it.The form says it "does not need to be retained in the facility file at the conclusion of the inspection" [1]. CDSS's list of records an RCFE keeps (LIC 311F, 4/05) does not name it [7].
How long to keep
The form gives no period.It says the checklist need not be retained [1]. This page does not cover how long the records on the checklist must be kept.

LIC 9242 is the California Department of Social Services (CDSS) Entrance Checklist for Residential Care Facilities for the Elderly (RCFEs). The form says: "Upon entrance to the facility, the Licensing Program Analyst (LPA) provides this checklist to the licensee or their designee to help facilitate the inspection" [1]. It lists 26 numbered items the analyst asks the home to show, in three groups, with four blank lines for more [1]. The home does not need to keep it after the inspection, the form says [1].

Who fills it out

The form does not say who writes in the header lines [1]. The analyst provides the checklist [1]. The header asks for [1]:

  • facility name and license number
  • inspection date, "to" date and inspection time
  • facility phone number and email
  • LPA name
  • administrator or designee

Two items have a blank to fill: item 22 ("Personnel files for_____ staff") and item 25 ("Resident records for _____ residents"). Items 27 to 30 are blank lines under "MISCELLANEOUS" [1].

When it is due

The form sets no due date. The analyst provides it on entrance, at the start of the inspection [1].

The home does not choose the day. HSC § 1569.33(a): "Every licensed residential care facility for the elderly shall be subject to unannounced inspections by the department" [2]. Subdivision (e): "On and after January 1, 2019, the department shall conduct annual unannounced inspections of all residential care facilities for the elderly" [2].

Our inspections page shows how often small RCFEs are cited.

Where it is kept

The home need not keep it. The form says: "This checklist does not need to be retained in the facility file at the conclusion of the inspection" [1]. The PDF is public on CDSS's forms list [3], so a home can read it before a visit.

How long to keep it. The form gives no period. It says the checklist need not be retained [1]. CDSS's RCFE records list (LIC 311F) does not name LIC 9242 [7].

What the checklist asks for

The note on the form: "Asterisk (*) indicates other verifying documents may be substituted for form." Three items carry an asterisk: LIC 500, LIC 610E and PUB 475 [1].

A. Requested upon entrance [1]

  1. Register of Residents: current census, number of non-ambulatory or bedridden persons, number of persons on hospice
  2. Personnel Report (LIC 500*)
  3. Emergency and Disaster Plan for RCFEs (LIC 610E*)
  4. Documentation of quarterly emergency drills

LIC 9020A, a CDSS register form for RCFEs, has its own page.

B. Requested, or observed, during the physical plant inspection [1]

  1. License
  2. Licensing reports (last 12 months)
  3. Posting of Personal Rights
  4. Posting of Nondiscrimination Notice
  5. Posting of Complaint Information (PUB 475*)
  6. Posting of Long-Term Care Ombudsman poster
  7. Activity schedule (facilities licensed for seven or more only)
  8. Meal menu: weekly menus for 16 or more persons in care; a sample menu on file for fewer than 16
  9. Centrally stored medications
  10. Resident and Family Council Meeting Notice (if applicable)
  11. Stipulated Decision and Order (D&O) or Accusation (if applicable)

C. Requested at the end of the physical plant inspection [1]

  1. Plan of Operation, including the dementia plan (if applicable), admission policies, and the Plan for Incidental Medical and Dental Care
  2. Copy of liability insurance
  3. Copy of surety bond (if applicable)
  4. For homes caring for residents with dementia: facility advertisements and marketing or promotional material
  5. Annual fire inspection or certification of the fire system
  6. Current admission or intake packet: admission agreement with addendums, client handbook (if applicable), personal rights
  7. Staff records: the administrator's file; on-the-job training verification, including dementia-specific training (if applicable); personnel files for a stated number of staff, with health screenings, criminal record clearance, proof of training and proof of first aid training
  8. Personal and Incidental (P&I) records (if applicable)
  9. Centrally stored medication and destruction logs
  10. Resident records for a stated number of residents
  11. Theft and Loss Policy

Where some items come from.

  • Items 7 to 9: § 87468(c) says licensees "shall prominently post personal rights, nondiscrimination notice, and complaint information" [4].
  • Item 10: WIC § 9718 says: "Every long-term care facility, as defined in subdivision (b) of Section 9701, shall post in a conspicuous location a notice of the name, address, and phone number of the office and the nearest approved organization, and a brief description of the services provided by the office and the approved organization. The form of the notice shall be approved by the office" [5]. WIC § 9701(b)(2) lists "Any residential care facility for the elderly" as a long-term care facility [6].
  • Items 11 and 12: LIC 311F lists notices of planned activities for homes of seven or more, menus written at least one week in advance for 16 or more, and a sample menu for fewer than 16 [7].
  • Item 14: HSC § 1569.157(f)(2) asks a home of 16 or more with a council to post meeting information [8]. The item names family councils too. HSC § 1569.158(d) says a family council "shall be provided with adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters" [11].

Questions

Is LIC 9242 a rule?

The form says its purpose is "to help facilitate the inspection" [1]. HSC § 1569.33 sets the inspections and names no checklist [2]. CDSS's Provider Information Notice (PIN) 23-01-ASC says of its CARE Tools that they "do not impose any new requirements on licensees and providers, and only help facilitate inspections" and that analysts inspect "for compliance with all licensing statutes and regulations applicable to ASC facilities including those not listed in the tools." That PIN does not name LIC 9242 [9].

Does the home have to give the analyst every item?

The form does not say what follows if an item is missing. It calls its lists "ITEMS & INFORMATION REQUESTED FROM THE FACILITY" [1].

What does the asterisk mean?

The form says an asterisk "indicates other verifying documents may be substituted for form" [1]. It does not say which documents.

Is LIC 9242 only for RCFEs?

Yes, by its title. CDSS has separate entrance checklists for other kinds of care facility. For adult care facilities it is LIC 9241 [3].

When did CDSS start using it?

The form is dated 9/19 [1]. PIN 19-19-ASC (August 30, 2019) announced new inspection tools for RCFEs from fall 2019. It does not name LIC 9242 [10].

How Sevana Care keeps this record

Required postings mean a regular walk around the building. The inspection checklist in Sevana Care has a section for them. Its items cover the license, personal rights, the PUB 475 poster, licensing reports, planned activities, resident council rights and space for a family council board. You mark an item checked, and the row shows how many days are left until the next check, or how many days it is overdue. We don't fill in or print the LIC 9242. See the Required postings section under Inspections in the sample home.

More in Postings, records and inspections

  • LIC 311F: CDSS's 2005 list of the records an RCFE keeps, and what has changed since then

Sources

  1. CDSS, LIC 9242 (9/19), Entrance Checklist Residential Care Facilities For The Elderly (PDF)
  2. California Health and Safety Code § 1569.33 (leginfo)
  3. CDSS, Forms and Publications (I-L)
  4. California Code of Regulations, Title 22, § 87468, Personal Rights of Residents (Westlaw)
  5. California Welfare and Institutions Code § 9718 (leginfo)
  6. California Welfare and Institutions Code § 9701 (leginfo)
  7. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  8. California Health and Safety Code § 1569.157 (leginfo)
  9. CDSS, PIN 23-01-ASC, Annual Inspections Using the Compliance and Regulatory Enforcement (CARE) Tools (PDF)
  10. CDSS, PIN 19-19-ASC, Statewide New Inspection Tool Launch in Residential Care Facilities for the Elderly (PDF)
  11. California Health and Safety Code § 1569.158 (leginfo)