Form LIC9020a "Register of Facility Residents - Residential Care Facilities for the Elderly" - California

What Is Form LIC9020a?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form LIC9020a by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC9020a "Register of Facility Residents - Residential Care Facilities for the Elderly" - California

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
REGISTER OF FACILITY RESIDENTS -
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
FACILITY NAME:
FACILITY NUMBER:
LICENSEE NAME
DATE/UPDATE
ROOM
RESIDENT NAME AND
AMBULATORY STATUS
PHYSICIAN
REPRESENTATIVE
IDENTIFIER
LANGUAGE READ
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
I
BEDRIDDEN
OTHER __________
PHONE:
PHONE:
(
)
(
)
Page______ of ______
LIC 9020A (6/17) (CONFIDENTIAL)
STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
REGISTER OF FACILITY RESIDENTS -
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
FACILITY NAME:
FACILITY NUMBER:
LICENSEE NAME
DATE/UPDATE
ROOM
RESIDENT NAME AND
AMBULATORY STATUS
PHYSICIAN
REPRESENTATIVE
IDENTIFIER
LANGUAGE READ
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
I
BEDRIDDEN
OTHER __________
PHONE:
PHONE:
(
)
(
)
Page______ of ______
LIC 9020A (6/17) (CONFIDENTIAL)
INSTRUCTIONS FOR REGISTER OF FACILITY RESIDENTS
Type or print clearly. The licensee shall ensure that a current register of all residents in the facility is
maintained.
1. Facility Name: Enter the name used by to designate the single facility under application.
2. Facility Number: Enter facility number assigned by the California Department of Social Services.
3. Licensee Name: Enter the name of the licensee. “Licensee” means the individual, firm,
partnership, corporation, association or county having the authority and responsibility for the
operation of a licensed facility.
4. Date/Update: Enter the date information is being initially recorded or updated.
5. Room Identifier: Enter information that identifies the resident room, such as room number.
6. Resident Name and Language Read: Enter resident legal name. Enter language(s) read by
resident in the spaces provided.
7. Ambulatory Status: Check appropriate box that indicates the resident mobility status. These
definitions are for the purposes of a fire clearance.
I
Ambulatory: Means a person who is capable of demonstrating the mental competence and
physical ability to leave a building without assistance of any other person or without the use of
any mechanical aid in case of an emergency.
Non-ambulatory: Means a person who is unable to leave a building unassisted under
I
emergency conditions. It includes any person who is unable or likely to be unable, to physically
and mentally respond to a sensory signal approved by the State Fire Marshal, or an oral
instruction relating to fire danger, and person who depend upon mechanical aids such as
crutches, walkers, and wheelchairs. A person who is unable to independently transfer to
and from bed, but who does not need assistance to turn or reposition in bed, shall be
considered non-ambulatory for fire safety requirements.
Bedridden: Means a person who is unable to independently turn or reposition in bed.
I
8. Physician: Enter the name, address, and telephone number of the resident attending physician.
9. Representative: Enter the name, address, and telephone number of the person who has
authority to act on behalf of the resident. “Representative” is defined in California Code of
Regulations, Title 22, Section 87101(r)(3).
Page ______ of ______
LIC 9020A (6/17) CONFIDENTIAL
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