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The Lic 625 form plays a crucial role in ensuring that individuals placed in various community care settings receive appropriate and tailored services to meet their unique needs. Specifically designed for use in California, this form assists in creating a Needs and Services Plan that is fundamental for each client or resident. The form begins with essential information, including the client’s name, date of birth, age, sex, and the facility details, setting the stage for a comprehensive assessment of personal needs. A licensed facility must conduct an appraisal to identify the individual requirements of a resident and collaboratively develop a service plan with various stakeholders, including family members and professionals. Furthermore, it is essential for referral agencies to disclose any potentially dangerous tendencies of a client prior to placement, ensuring safety and suitability. While the form is not required at the initial admission for Residential Care Facilities for the Elderly, it must be completed if it becomes evident that a resident’s needs are not being adequately met. The form encompasses a range of factors, such as medical history, functional capabilities, emotional well-being, and socialization skills, which guide the creation of a personalized care plan. By establishing clear objectives, timelines, and responsible parties, the LIC 625 form serves not only as a documentation tool but also as a means to evaluate progress in meeting the client's needs effectively.

Lic 625 Example

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

 

 

 

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

 

 

 

 

 

 

COMMUNITY CARE LICENSING

APPRAISAL/NEEDS AND SERVICES PLAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT’S/RESIDENT’S NAME

 

DATE OF BIRTH

AGE

SEX

 

DATE

 

 

 

 

 

 

MALE

FEMALE

 

 

 

 

 

 

 

 

 

 

FACILITY NAME

 

ADDRESS

 

 

 

CHECK TYPE OF NEEDS AND SERVICES PLAN:

 

 

 

 

 

 

 

ADMISSION

UPDATE

 

 

 

 

 

 

 

 

PERSON(S) OR AGENCY(IES) REFERRING CLIENT/RESIDENT FOR PLACEMENT

 

 

FACILITY LICENSE NUMBER

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

Licensing regulations require that an appraisal of needs be completed for specific clients/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for admission shall jointly develop a needs and services plan with the client/resident and/or client’s/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Additionally, the law requires that the referral agency/person inform the licensee of any dangerous tendencies of the client/resident.

NOTE: For Residential Care Facilities for the Elderly, this form is not required at the time of admission but must be completed if it is determined that an elderly resident’s needs have not been met.

BACKGROUND INFORMATION: Brief description of client’s/resident’s medical history/ emotional, behavioral, and physical problems; functional limitations; physical and mental; functional capabilities; ability to handle personal cash resources and perform simple homemaking tasks; client’s/resident’s likes and dislikes.

LIC 625 (6/12) CONFIDENTIAL

PAGE 1 OF 4

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

 

 

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

SOCIALIZATION — Difficulty in adjustig socially and unable to maintain reasonable personal relationships

EMOTIONAL — Difficulty in adjusting emotionally

LIC 625 (6/12) CONFIDENTIAL

PAGE 2 OF 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

 

COMMUNITY CARE LICENSING

 

 

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

MENTAL — Difficulty with intellectual functioning including inability to make decisions regarding daily living.

PHYSICAL/HEALTH — Difficulties with physical development and poor health habits regarding body functions.

LIC 625 (6/12) CONFIDENTIAL

PAGE 3 OF 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVCIES AGENCY

CALIFORNIA DEPARTMENT OF

SOCIAL SERVICES

 

COMMUNITY

CARE LICENSING

 

 

 

NEEDS

OBJECTIVE/PLAN

TIME FRAME

PERSON(S) RESPONSIBLE

FOR IMPLEMENTATION

METHOD OF

EVALUATING PROGRESS

FUNCTIONING SKILLS — Difficulty in developing and/or using independent functioning skills.

We believe this person is compatible with the facility program and with other clients/residents in the facility, and that I/we can provide the care as specified in the above objective(s) and plan(s).

TO THE BEST OF MY KNOWLEDGE THIS CLIENT/RESIDENT DOES NOT NEED SKILLED NURSING CARE.

LICENSEE(S) SIGNATURE

DATE

I have reviewed and agree with the above assessment and believe the licensee(s) other person(s)/agency can provide the needed services for this client/resident

CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S)/FACILITY SOCIAL WORKER/PHYSICIAN/OTHER APPROPRIATE CONSULTANT SIGNATURE

DATE

 

 

I/We have participated in and agree to release this assessment to the licensee(s) with the condition that it will be held confidential.

CLIENT’S/RESIDENT’S OR CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S) SIGNATURE

DATE

LIC 625 (6/12) CONFIDENTAIL

PAGE 4 OF 4

Get Lic 625 PDF Form

Form Characteristics

Fact Name Description
Purpose of LIC 625 This form is used to assess a client’s or resident’s individual needs and develop a personalized services plan to meet those needs.
Referral Process The referral agency or person is responsible for notifying the facility of any dangerous tendencies a client/resident may have before admission.
Applicable Regulations California Health and Safety Code governs the requirements for the appraisal and needs assessment for residents in care facilities.
Requirements for Elderly Residents While LIC 625 is not needed at admission for elderly residents, it must be completed if their needs are not being met post-admission.

Guidelines on Utilizing Lic 625

Filling out the Lic 625 form is an important step in ensuring that the needs of a client or resident are properly assessed and planned for. This form is crucial for creating personalized service plans and should be completed thoughtfully. The following steps will guide you through filling out the form effectively.

  1. Obtain the Form: Start by downloading or printing the Lic 625 form from the appropriate California Department of Social Services website.
  2. Client/Resident Information: Fill in the client's/resident's name, date of birth, age, and sex in the designated fields.
  3. Facility Information: Enter the facility name and address where the client/resident will be placed.
  4. Select the Type of Needs Plan: Check either admission or update as the type of needs and services plan being completed.
  5. Referral Information: Indicate the person(s) or agency(ies) referring the client/resident for placement. Include their contact information, such as telephone number and facility license number.
  6. Medical and Background Information: Provide a brief overview of the client’s/resident’s medical history and emotional, behavioral, and physical problems. Include details about their functional limitations and capabilities, as well as their likes and dislikes.
  7. Needs Objective/Plan: For each identified need (socialization, emotional, mental, physical/health, functioning skills), specify the needs, objectives, time frame, responsible persons, and methods for evaluating progress.
  8. Licensee's Acknowledgment: The licensee should sign and date the form, indicating their belief that they can meet the client’s/resident's needs without skilled nursing care.
  9. Authorized Representative’s Acknowledgment: The client’s/resident’s authorized representative, facility social worker, physician, or other consultant must review and sign the form, agreeing with the assessment.
  10. Confidentiality Agreement: Ensure that the final signature confirms that the assessment will be held confidential.

Once the form is completed and all required signatures are obtained, it should be submitted to the appropriate licensing authority for review and to ensure compliance with state regulations. Proper documentation plays a critical role in the care and support of the client or resident.

What You Should Know About This Form

What is the purpose of the Lic 625 form?

The Lic 625 form is used to evaluate the individual needs of clients or residents applying for placement in certain care facilities. The primary goal is to create a personalized service plan that addresses medical, emotional, and physical needs. It helps caregivers understand how best to support each individual, ensuring they receive appropriate services for their well-being.

Who is responsible for completing the Lic 625 form?

The form should be completed by a responsible staff member at the facility, usually in collaboration with the client or resident and their authorized representative. This may include a physician, social worker, or other appropriate consultants. It is essential for those involved to provide accurate information to ensure the client’s needs are fully understood and met.

What information is collected on the Lic 625 form?

The Lic 625 form collects various types of information including basic personal details, medical history, emotional and behavioral challenges, and functional capabilities. It also addresses how well the client can manage personal finances and perform daily tasks. Each of these components helps to identify specific needs and develop an effective service plan.

Is the Lic 625 form necessary for all admissions to care facilities?

No, the Lic 625 form is not required for all admissions. For Residential Care Facilities for the Elderly, it must be completed only if staff determine that an elderly resident's needs are not being met. However, it is crucial for identifying and planning for necessary services following admission if issues arise.

How does the facility evaluate the progress of the service plan?

Progress is evaluated through ongoing assessments of the client's needs and objectives outlined in the service plan. The responsible staff will regularly review and adjust the plan, ensuring it remains effective and responsive to any changes in the client's situation. This process helps determine whether the objectives are being successfully met and if additional support is needed.

Common mistakes

Filling out the Lic 625 form is a crucial step in ensuring that clients receive the appropriate care and services they need. However, mistakes can happen, and some common errors can cause significant issues down the line. Awareness of these pitfalls can help a lot.

One common mistake is leaving information blank. Some sections of the form, like medical history and functional capabilities, are essential for developing a suitable service plan. Omissions can lead to misunderstandings about a client's needs, resulting in inadequate care. Ensure that every relevant box is checked and that detailed information is provided.

Another frequent error is inaccurately assessing the client's needs. The form includes areas detailing emotional, physical, and mental health challenges. It's vital to be honest and thorough in this assessment. If there's uncertainty about a client's condition, consulting with a healthcare professional or social worker can provide clarity. The aim is to create a comprehensive picture to guide care.

People often overlook the requirement to update the form promptly. If a client’s needs change, failure to update the Lic 625 can hinder the ability to provide proper services. Regular reviews and revisions must be a part of your process, ensuring that information remains current and accessible.

Another key mistake is neglecting to include all stakeholders in the process. The form emphasizes collaboration among the client, their representatives, and service providers. Involving all relevant parties ensures a well-rounded understanding of the client's needs and capabilities. This collaborative approach can lead to more effective and personalized care solutions.

Misunderstanding the evaluation methods is also a concern. The form asks for ways to assess progress toward objectives. If these methods are unclear, progress can be misjudged, which can affect the effectiveness of the service plan. Define specific, measurable actions for evaluating each need, making it easier to track progress over time.

Lastly, people sometimes forget the importance of signatures. Each section of the form requires appropriate signatures confirming that the information is accurate and that there’s agreement on the care plan. Missing a signature may lead to delays or questions about consent, so always triple-check that every necessary party has signed off.

By avoiding these mistakes, you can help ensure that the Lic 625 form is filled out correctly, thus providing clients with the care they truly deserve. Remember, thoroughness and clarity are key.

Documents used along the form

The Lic 625 form plays a crucial role in the admission and assessment process for clients in care facilities in California. It is often accompanied by various other documents that assist in outlining the client's needs, consent, and the facility's obligations. Below is a list of additional forms and documents frequently used with the Lic 625 form.

  • LIC 610: This is the Application for a Community Care Facility License. It provides essential information about the facility, including its ownership and operational plans.
  • LIC 624: This form serves as a Personal Rights statement for clients/residents. It details the rights entitled to individuals in care facilities, ensuring their dignity and respect are upheld.
  • LIC 602: The Admission Agreement outlines the terms of residence for a client, including services provided, fees, and rights and responsibilities of both parties.
  • LIC 9280: This document is a Health Screening form that must be completed to assess the physical health of a prospective client before admission.
  • SOC 341: This is a Child’s Needs and Services Plan. For residential facilities serving children, this plan identifies specific needs and goals for the child’s development.
  • LIC 700: Emergency Procedures for clients in care facilities, detailing the measures in place to address emergencies and ensure client safety.
  • LIC 808: The Caregiver Reference form. This provides background check information on current or potential staff within the facility.
  • LIC 859: The Individual Plan of Care, which outlines specialized care objectives tailored to meet the particular needs of each client.
  • CDSS-19: This document is a Community Care Licensing Division report that summarizes compliance with regulations and any findings from inspections.
  • APD 06-05: This is a policy instruction related to the assessment and planning for clients with specific developmental disabilities, ensuring needs are met comprehensively.

The above documents collectively contribute to a comprehensive understanding of the client’s needs and the operational framework of care facilities. Proper completion and use of these forms facilitate effective communication among all parties involved, ultimately enhancing the quality of care provided.

Similar forms

  • LIC 622 - Emergency Care and Disaster Plan: Similar to the Lic 625 form, the LIC 622 outlines an individual’s emergency care needs and strategies to address those in case of disaster. Both forms prioritize safety and individualized attention based on specific client needs.

  • LIC 629 - Personal Rights: This document focuses on articulating the personal rights of residents, similar to how the Lic 625 identifies and addresses client needs and services. Both forms ensure the dignity and respect of residents are upheld.

  • LIC 627 - Staff Observation/Assessment: Like the Lic 625, this assessment form contains components geared toward understanding individual needs. Both documents are essential for developing tailored service plans that address the unique situations of clients.

  • LIC 600 - Application for Community Care Facility License: While the LIC 600 is used during the licensing process, it has a similar purpose of gathering information to align services with client needs. Both documents play a role in the overall care planning and compliance process.

  • LIC 9088 - Needs and Services Plan for Adult Clients: This form is also designed to create a comprehensive plan based on residents' specific needs, akin to the Lic 625. Both documents seek to enhance the well-being of clients through targeted services.

  • LIC 535 - Personal Care Agreement: This agreement outlines what care will be provided and aligns closely with the personalized focus of the Lic 625. Both documents emphasize the need for clear communication and understanding between clients and care providers.

Dos and Don'ts

When filling out the Lic 625 form, attention to detail is essential to ensure accurate processing of the needs assessment. Here are seven important dos and don’ts to keep in mind:

  • Do read all instructions carefully before you begin.
  • Do provide accurate personal information for the client, including correct name and date of birth.
  • Do be thorough in describing the client’s medical history and needs.
  • Do include details about any emotional, behavioral, or physical issues.
  • Don’t leave any sections blank; all areas must be addressed.
  • Don’t include subjective opinions; stick to factual information only.
  • Don’t forget to have all necessary parties sign the form before submission.

Following these guidelines can help facilitate a smoother process for everyone involved.

Misconceptions

  • Misconception 1: The LIC 625 form is only for elderly clients.

    • This form is used for various clients, not exclusively for the elderly. It is applicable to any individual requiring a needs assessment for placement in a community care facility.

  • Misconception 2: The form must be completed before admission.

    • The LIC 625 form is not always required at the time of admission. For residential care facilities for the elderly, it must be completed only if the resident’s needs are not met later on.

  • Misconception 3: Only medical professionals can fill out the LIC 625 form.

    • While medical professionals can provide valuable input, the form can also be completed by facility staff who are trained in assessing needs and services.

  • Misconception 4: The form is a one-time requirement.

    • Updates to the LIC 625 form may be necessary over time. As clients’ needs change, the form should be reviewed and revised to ensure accurate service planning.

  • Misconception 5: Clients have no say in their needs assessment.

    • Clients or their authorized representatives are actively involved in developing their personalized needs and services plan, ensuring that their preferences and requirements are considered.

  • Misconception 6: The information in the form can be shared freely.

    • The form and its contents are confidential. Disclosure of information requires consent from the client or authorized representative.

  • Misconception 7: Completing the form guarantees approval for placement.

    • Filling out the LIC 625 form does not ensure placement in a facility. It is part of assessing compatibility with the facility’s program and available services.

Key takeaways

When filling out and using the Lic 625 form, several important points must be considered to ensure compliance with regulations and the effective development of service plans.

  • The form is intended to assess the individual needs of clients or residents, which helps in creating an effective service plan.
  • This appraisal is required by licensing regulations for specific clients/residents before placing them in care facilities.
  • It should be completed with the participation of the client/resident or their authorized representative, ensuring collaboration in the process.
  • The form allows for the identification of medical history and various emotional, behavioral, and physical needs and capabilities.
  • It is crucial to document any dangerous tendencies reported by the referral agency or individual to ensure the safety of all residents.
  • For Residential Care Facilities for the Elderly, the form must be completed only if the resident's needs are determined to be unmet post-admission.
  • Specific sections outline social, emotional, mental, and physical health needs, as well as the development of functioning skills.
  • The signatures on the form confirm that all parties involved agree with the assessment and the ability of the facility to meet the identified needs.
  • Confidentiality is a critical aspect, and all assessment information should be treated with care to protect client/resident privacy.

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