Form LIC405 "Record of Client's/Resident's Safeguarded Cash Resources" - California

What Is LIC 405 Form?

Form LIC 405, Record of Client's/Resident's Safeguarded Cash Resources, is a legal document needed to safeguard and maintain accounting records regarding the resident cash resources. Residents of the community care facilities may be incapable of handling their own resources, and the representatives of these facilities provide them with assistance. Form LIC 405 allows the facility to maintain an accurate and current account of resident cash resources with supporting receipts.

This form was released by the California Department of Social Services (CDSS), a component of the California Health and Human Services Agency (CHHS). The latest version of the form was issued on August 1, 2001, with all previous editions obsolete. You can download a fillable LIC 405 Form through the link below.

ADVERTISEMENT

California LIC 405 Instructions

The document provides a general understanding of the circumstances that surround handling resident cash resources and illustrates an accounting for resident cash resources. Record the following information in the LIC 405 Form:

  1. State the date of the transaction - the date that funds were received by the facility or purchases were made on behalf of the resident. This date must be written on the invoice or cash receipt.
  2. Describe the transaction. Enter the source of the money received and the goods purchased or service provided. You must adequately represent the transaction - this description has to match the description on the cash receipt or invoice.
  3. Record the amount of money received - earnings, cash gifts, tax credits, refunds, etc. Resident cash resources also include funds transferred from facilities where the individual previously resided and funds provided by relatives. Keep these funds at the facility or in a financial institution - either way, you must find a locked and secured location.
  4. Write down the amount of money spent or withdrawn on behalf of the resident. This includes money given directly to residents as a spending allowance.
  5. Calculate the balance of remaining funds after each transaction.
  6. Sign the form. This document requires signatures of the licensee and the resident or resident's representative. These signatures verify a cash transaction and confirm its accuracy.

All the purchases must be supported by receipts filed for each resident in chronological order. Resident records, including ledgers and bank records, have to be retained for a minimum of three years following the termination of community care services. Keep the receipts that support purchases for a resident with the resident's personal file.


Not the form you were looking for? Check out these related documents:

ADVERTISEMENT

Download Form LIC405 "Record of Client's/Resident's Safeguarded Cash Resources" - California

Download PDF

Fill PDF online

Rate (4.3 / 5) 52 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
INSTRUCTIONS:
1)
The date of the transaction shall be noted under Date.
RECORD OF CLIENT'S/RESIDENT'S
2)
Use a separate line for each transaction.
SAFEGUARDED CASH RESOURCES
3)
Supporting receipts for purchases shall be filed in order of dates
of purchases.
4)
The client's/resident's (or client's/resident's representative)
Client/resident: Your signature below indicates you have
received the following amount of money from the facility on
signature on this for m may ser ve as a receipt for cash
distribution to the client/resident. (Sec. 80026(h)(1)(A) and
the date indicated.
87227(g)(1)(A).
Facilities that handle client's/resident's cash resources must
5)
The facility representative’s signature is necessary to be able to
maintain accurate records of all money received and disbursed.
verify a cash transaction.
NAME OF CLIENT/RESIDENT:
FACILITY NUMBER:
YEAR
SIGNATURE FOR CASH TRANSACTIONS
AMOUNT
DESCRIPTION
AMOUNT
SPENT OR
FACILITY REPRESENTATIVE
CLIENT/RESIDENT
DATE
BALANCE
OR REPRESENTATIVE
RECEIVED
WITHDRAWN
LIC 405 (8/01)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
INSTRUCTIONS:
1)
The date of the transaction shall be noted under Date.
RECORD OF CLIENT'S/RESIDENT'S
2)
Use a separate line for each transaction.
SAFEGUARDED CASH RESOURCES
3)
Supporting receipts for purchases shall be filed in order of dates
of purchases.
4)
The client's/resident's (or client's/resident's representative)
Client/resident: Your signature below indicates you have
received the following amount of money from the facility on
signature on this for m may ser ve as a receipt for cash
distribution to the client/resident. (Sec. 80026(h)(1)(A) and
the date indicated.
87227(g)(1)(A).
Facilities that handle client's/resident's cash resources must
5)
The facility representative’s signature is necessary to be able to
maintain accurate records of all money received and disbursed.
verify a cash transaction.
NAME OF CLIENT/RESIDENT:
FACILITY NUMBER:
YEAR
SIGNATURE FOR CASH TRANSACTIONS
AMOUNT
DESCRIPTION
AMOUNT
SPENT OR
FACILITY REPRESENTATIVE
CLIENT/RESIDENT
DATE
BALANCE
OR REPRESENTATIVE
RECEIVED
WITHDRAWN
LIC 405 (8/01)