LIC 603, Preplacement Appraisal Information

What is LIC 603?

LIC 603, Preplacement Appraisal Information, is a form of the California Department of Social Services (CDSS), Community Care Licensing. The form is labelled "Admission - Residential Care Facilities". The blank on this page is the edition marked "LIC 603 (6/22)", the edition listed in the CDSS forms catalogue.

Who fills it in

The form says the information "may be obtained from the applicant, or his/her authorized representative", and that relatives, a social agency, a hospital or a physician may assist the applicant in completing it. It is not a substitute for the Physician's Report (LIC 602).

What it asks

• Health: overall health condition, including any dietary limitations.
• Physical disabilities: physical limitations, including vision, hearing or speech.
• Health history: currently prescribed medications and major illnesses, surgery and accidents, and any hospitalization and its length in the last 5 years.
• Functional capabilities and services needed, by checking items and explaining.
• Any additional information that would help the facility decide on admission, on a separate sheet if needed.
• A statement that the applicant does not need skilled nursing care, with signatures and the date completed from the applicant or authorized representative and from the licensee or designated representative.

Related forms

LIC 603A, Resident Appraisal, is a separate CDSS form for Residential Care Facilities for the Elderly. CDSS also notes that any modification to or substitution of a required department form must be approved by CDSS before agency use, so keep the form as issued.