California Department of Social Services

The LIC 9240 form is an entrance checklist specifically designed for Small Family Homes in California. This checklist is utilized during the admission process for individuals or families seeking entry into a Small Family Home. It ensures that all necessary steps and requirements are met to provide a safe and nurturing environment for residents. The checklist covers areas such as background checks, home assessments, licensing compliance, safety protocols, and initial care plans.

The LIC 9241 form serves as an entrance checklist used by Adult Care Facilities in California. This checklist is employed during the admission process for adults seeking entry into an Adult Care Facility. It ensures that all necessary procedures and requirements are met to provide a safe and supportive environment for residents. The checklist covers areas such as intake assessments, medical evaluations, consent forms, service planning, and initial orientation.

The LIC 9264 Form 1-2 is used to calculate and collect the annual provider fee from facilities regulated by the California Department of Social Services. This form assists in determining the appropriate fee amount based on factors such as the facility type, size, services provided, and any applicable exemptions or adjustments. It helps ensure that facilities contribute their fair share towards supporting the regulatory processes and infrastructure.

The LIC 9270 Form 7-1 is used to report monthly care fees for Continuing Care Retirement Communities (CCRCs) regulated by the California Department of Social Services. This form captures information regarding the fees charged to residents for various levels of care provided within the CCRC. It ensures accurate documentation and reporting of fee structures, facilitating transparency and clarity for both residents and regulatory purposes. By completing this form, CCRC operators fulfill their obligations to report and communicate monthly care fees to residents and regulatory authorities.

The LIC 9242 form is an entrance checklist specifically tailored for Residential Care Facilities for the Elderly (RCFEs) in California. This checklist is utilized during the admission process for older adults seeking entry into an RCFE. It ensures that all necessary steps and requirements are met to provide a safe and comfortable living environment for elderly residents. The checklist covers areas such as background checks, medical evaluations, care plans, safety protocols, and initial orientation.

The LIC 9265 Form 5-1 is used to report and document long-term debt that was incurred in a prior year by facilities regulated by the California Department of Social Services. This form captures details such as the nature of the debt, the amount owed, the terms of repayment, and any relevant supporting documentation. It helps ensure accurate record-keeping and disclosure of outstanding long-term debts, providing transparency and accountability in financial reporting.

The LIC 9271 Form 9-1 is used to calculate the refund reserve amount for facilities regulated by the California Department of Social Services. This form considers factors such as the type of facility, the agreements with residents, and applicable regulations to determine the appropriate refund reserve amount that needs to be set aside. It ensures that facilities have sufficient reserves to meet refund obligations to residents upon termination of their agreements.

The LIC 9272 form is an Annual Report Checklist used by entities regulated by the California Department of Social Services. This checklist ensures that all necessary information and documentation are included in the annual report submitted to the department. It covers various aspects such as financial statements, program activities, compliance with regulations, policies and procedures, staffing, training, and any other relevant information required by the department.

The LIC 9273 form is a Continuing Care Retirement Community (CCRC) Disclosure Statement required by the California Department of Social Services. This statement aims to provide prospective residents with essential information about CCRCs before making decisions regarding residency. It includes details about services offered, fees and charges, contractual agreements, refund policies, resident rights and responsibilities, facility operations, and any other pertinent information.

The LIC 9274 form is a Key Indicators Report used by facilities regulated by the California Department of Social Services. This report provides key performance indicators related to the facility's operations, service delivery, and compliance with regulations. It typically includes data on occupancy rates, staffing levels, incident reports, health and safety inspections, program outcomes, and any other relevant metrics specified by the department.