STATE OF CALIFORNIA CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY COMMUNITY CARE LICENSING DIVISION
This information is required under the H & S Code and the regulations
of the Department to be maintained on every person admitted to a
community care facility, to be readily available to the person in charge,
but not accessible to unauthorized persons. All information must be
kept current. See other side for additional information required for
residential facilities for children.
IDENTIFICATION AND
EMERGENCY INFORMATION
A. ALL FACILITIES [EXCEPT CHILD CARE CENTER/FAMILY CHILD CARE HOME COMPLETES LIC 700]
1. NAME OF CLIENT OR CHILD SOCIAL SECURITY NUMBER (OPTIONAL) DATE OF BIRTH AGE SEX
2. RESPONSIBLE PERSON OR PLACEMENT AGENCY ADDRESS
TELEPHONE
( )
3. NAME OF NEAREST RELATIVE (OPTIONAL)
RELATIONSHIP ADDRESS
( )
4. DATE ADMITTED TO FACILITY ADDRESS PRIOR TO ADMISSION
5. DATE LEFT FORWARDING ADDRESS
6. REASONS FOR LEAVING FACILITY
7.
PERSON(S) RESPONSIBLE FOR FINANCIAL AFFAIRS, PAYMENT FOR CARE, LEGAL GUARDIAN, IF ANY
NAME ADDRESS TELEPHONE
( )
( )
( )
8.
OTHER PERSONS TO BE NOTIFIED IN EMERGENCY
NAME ADDRESS TELEPHONE
a. PHYSICIAN
( )
b. MENTAL HEALTH PROVIDER, IF ANY
( )
c. DENTIST
( )
d. RELATIVE(S)
( )
e. FRIEND(S)
( )
9.
EMERGENCY HOSPITALIZATION PLAN
NAME OF HOSPITAL TO BE TAKEN IN AN EMERGENCY ADDRESS OF HOSPITAL TO BE TAKEN IN AN EMERGENCY
MEDICAL PLAN MEDICAL PLAN IDENTIFICATION NUMBER
NAME OF DENTAL PLAN (IF ANY) DENTAL PLAN NUMBER (IF ANY)
10.
OTHER REQUIRED INFORMATION
b. RELIGIOUS PREFERENCE
NAME AND ADDRESS OF CLERGYMAN OR RELIGIOUS ADVISOR, IF ANY TELEPHONE
( )
11. COMMENTS
SIGNATURE OF RESIDENT SIGNATURE OF PERSON COMPLETING FORM TITLE DATE
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LIC 601 (8/08) Personal
