STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
RESIDENT APPRAISAL
Residential Care Facilities For The Elderly
NOTE: This information may be obtained from the Prospective Resident, or his/her responsible person. This form is not a substitute for the
Physician’s Report (LIC 602).
APPLICANT’S NAME 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(Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))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)
SOCIAL FACTORS (Describe likes and dislikes, interests and activities)
BED STATUS (An exception must be obtained to admit or retain a resident who will be temporarily bedridden more than 14 days. Permanently
bedridden residents are prohibited).
TUBERCULOSIS INFORMATION
COMMENT:
OUT OF BED ALL DAY IN BED MOST OF THE TIME
IN BED PART OF THE TIME IN BED ALL OF THE TIME
ANY HISTORY OF TUBERCULOSIS IN APPLICANT’S FAMILY?
YES NO
DATE OF TB TEST/TYPE OF TEST
POSITIVE
NEGATIVE
ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?
YES NO
ACTION TAKEN (IF POSITIVE)
GIVE DETAILS
LIC 603A (7/99)
(Over)
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AMBULATORY STATUS (this person is ambulatory nonambulatory)
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
other than a cane. An ambulatory person must be able to do the following:
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 (e.g., walk directly the route without hesitation).
FUNCTIONAL CAPABILITIES (Check all items below)
YES NO
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
Frail or slow
Uses walker. If Yes, can get in and out unassisted? Yes No
Uses wheelchair. If Yes, can get in and out unassisted? Yes No
Requires grab bars in bathroom
Other: (Describe)
SERVICES NEEDED (Check items and explain)
YES NO
Help in transferring in and out of bed/turning in bed or chair (specify) _________________________________________________________
Help with bathing__________________________________________________________________________________________________
Help with dressing, hair care, and personal hygiene (specify) _______________________________________________________________
Does prospective resident desire and is he/she 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 (specify) _____________________________________________
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?
Yes No
If Yes, please attach comments on separate sheet.
TO THE BEST OF MY KNOWLEDGE, I/THE ABOVE PERSON DO/DOES NOT NEED SKILLED NURSING CARE.
SIGNATURE OF APPLICANT OR RESPONSIBLE PERSON DATE COMPLETED
SIGNATURE OF LICENSEE OR DESIGNATED REPRESENTATIVE DATE COMPLETED