LIC 603 (6/22)_PREPLACEMENT APPRAISAL INFORMATION

PREPLACEMENT APPRAISAL INFORMATION
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING
Admission - Residential Care Facilities

NOTE: This information may be obtained from the applicant, or his/her authorized representative. (Relatives, social agency, hospitalor physician may assist the applicant in completing this form This form is not a substitute for the Physician's Report (LIC 602
RESIDENT'S NAME

First NameMiddle NameLast NameSuffix
AGE
HEALTH (Describe overall health condition including any dietary limitations)
PHYSICAL DISABILITIES (Describe any physical limitations including vision, hearing or speech)
MENTAL CONDITION (Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))
HEALTH HISTORY (List currently prescribed medications and major illnesses, surgery, accidents; specify whether hospitalized and length of hospitalization in last 5 years)
See LIC_602 and med list
SOCIAL FACTORS (Describe likes and dislikes, interests and activities)
Likes to
BACKGROUND INFORMATION Calculation
BED STATUS
COMMENT
TUBERCULOSIS INFORMATION
ANY HISTORY OF TUBERCULOSIS IN APPLICANT'S FAMILY?
DATE OF TB TEST

MonthDayYear
Date
TB TEST results
ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?
ACTION TAKEN (IF POSITIVE)
GIVE DETAILS
AMBULATORY STATUS - this person is:

Ambulatory means able to demonstrate the mental and physical ability to leave a building without the assistance of a person or the use of a mechanical device.An ambulatory person must be able to do the following:

Rows	YES	NO
Able to walk without any physical assistance (e.g., walker, crutches, other person), or able to walk with a cane.
Mentally and physically able to follow signals and instructions for evacuation.
Able to use evacuation routes including stairs if necessary
Able to evacuate reasonably quickly

FUNCTIONAL CAPABILITIES

(Check all items below)
Active, requires no personal help of any kind - able to go up and down stairs easily
Active, but has difficulty climbing or descending stairs
Uses brace or crutch
Feeble or slow
Uses walker?
If Yes, can get in and out unassisted?
Uses wheelchair?
If Yes, can get in and out unassisted?
Requires grab bars in bathroom
Other: Functional Capabilities (Describe)

Other
SERVICES NEEDED

(Check items and explain)

Rows	YES	NO	If YES, Specify
Help in transferring in and out of bed and dressing
Help with bathing, hair care, personal hygiene
Does client desire and is client capable of doing own personal laundry and other household tasks (specify)
Help with moving about the facility
Help with eating (need for adaptive devices or assistance from another person)
Special diet/observation of food intake
Toileting, including assistance equipment, or assistance of another person
Continence, bowel or bladder control. Are assistive devices such as a catheter required?
Help with medication
Needs special observation/night supervision (due to confusion, forgetfulness, wandering
Help in managing own cash resources
Help in participating in activity programs
Special medical attention
Assistance in incidental health and medical care
Other “Services Needed” not identified above

Is there any additional information which would assist the facility in determining applicant's suitability for admission?
If Yes, please upload comments on separate sheet.
File Upload attachment of comments

Cancelof
To the best of my knowledge; I (the above person) do not need skilled nursing care.

(Check items and explain)
Name of Residents (RP)

First NameLast Name
LICENSEE OR DESIGNATED REPRESENTATIVE
Email of LICENSEE OR AUTHORIZED REPRESENTATIVE
example@example.com
SIGNATURE of Licensee or Authorized Rep
SIGNATURE of Resident or RP
Date Completed

MonthDayYear
Date
File Upload (s) supporting documentation

Cancelof
Should be Empty:

PREPLACEMENT APPRAISAL INFORMATION

TUBERCULOSIS INFORMATION

FUNCTIONAL CAPABILITIES

SERVICES NEEDED

To the best of my knowledge; I (the above person) do not need skilled nursing care.