CA Community Care Licensing Forms and Checklists

California community care licensing forms fall into a predictable set of categories filed with the Community Care Licensing Division (CCLD) of the Department of Social Services: an application packet at startup, background check and health forms for everyone in the facility, resident rights paperwork at admission, and incident reports for the life of the license.¹ Miss one form from the initial packet and CCLD returns the whole thing, so the full list matters before you start.

Start With the LIC 281 Checklist

The LIC 281 is the master instruction sheet. It lists every form your application needs, organized into Section A (licensing forms) and Section B (supplemental documents such as articles of incorporation, job descriptions, personnel policies, and a program description). The instructions are strict: your non-refundable application fee plus all Section A and Section B documents must arrive together as a single packet, in the order the booklet sets out, with original signatures.²

Section A forms vary by facility type. The LIC 281 includes a matrix showing which forms apply to group homes, adult residential facilities, residential care facilities for the elderly (RCFEs), adult day programs, foster family agencies, and other categories. The core forms below apply across most license types; check the matrix for exceptions before you file.²

Application and Identity Forms

The LIC 200 is the main application, required for every facility type. It captures the proposed facility type, maximum resident count, and whether you are applying as an individual, partnership, corporation, nonprofit, county agency, or LLC. It also asks you to acknowledge compliance responsibilities under the Health and Safety Code, local zoning, building codes, and fire safety rules.³

Three identity forms accompany it:

LIC 215 (Applicant Information) collects personal and business background on each applicant or corporate officer.
LIC 308 (Designation of Administrative Responsibility) names the day-to-day administrator and confirms they meet qualification requirements.
LIC 309 (Administrative Organization) is required for partnerships, corporations, and LLCs. It maps the organizational structure and identifies all partners, officers, or members with management authority.

Financial Documentation: The LIC 400 Series

CCLD verifies that you can afford to run the facility before it issues a license. Most residential facility types need several of these together:

LIC 400 (Affidavit Regarding Client Cash Resources) declares how you will handle residents’ personal funds.
LIC 401 (Monthly Operating Statement) projects expected monthly income and expenses.
LIC 401a (Supplemental Financial Information) adds detail beyond the operating statement.
LIC 402 (Surety Bond) protects resident personal funds held by the facility. Required for most residential license types.
LIC 403 (Balance Sheet) shows assets and liabilities.
LIC 404 (Financial Information Release and Verification) authorizes CCLD to verify what you submitted.⁴

Foster family agencies and adoption agencies skip the surety bond and client cash affidavit. The LIC 281 matrix spells out the exact combination for each license category.²

Background Check Forms

Health and Safety Code Section 1522 requires a criminal record clearance or exemption for every person who will have contact with residents: the licensee, the administrator, all employees, and any adult living on the premises. Fingerprints go through the Live Scan system, which transmits electronically to both the California Department of Justice and the FBI.⁵

Two forms drive this:

LIC 9163 (Request for Live Scan Service) is the transmittal form at the Live Scan site. It comes pre-populated with CCLD’s Originating Response Indicator (ORI) number so results route to the licensing division.
LIC 508 (Criminal Record Statement) is a sworn declaration, signed under penalty of perjury, in which each person subject to the check discloses prior convictions.⁶

No one may work in, reside in, or volunteer at the facility until their clearance is in hand. CCLD processes clearances through its Guardian system.⁷ If someone with an existing clearance transfers from another state-licensed facility, the licensee can request a transfer using LIC 9182 instead of repeating the fingerprint process.⁶

Health Screening Forms

Staff and residents both need medical documentation on file:

LIC 503 (Health Screening Report – Facility Personnel) documents that each employee has been screened for communicable diseases and is physically able to perform their duties.
LIC 602 (Physician’s Report for Community Care Facilities) is the physician’s assessment of an incoming resident’s condition, used to confirm the facility can meet the person’s care needs.
LIC 602A (Medical Assessment for Residential Care Facilities for the Elderly) is the RCFE-specific version of the physician’s report.⁸

These are not one-time filings. Updated staff screenings and fresh physician reports for new admissions stay mandatory for the life of the license.

Resident Rights and Personal Property

Two forms protect residents at and after admission.

The LIC 613 (Personal Rights) must be reviewed and signed by each resident or their conservator at admission and kept in the resident’s file. It lists every right guaranteed under Title 22, including dignified treatment, safe accommodations, the right to leave the facility at any time, and the right to file complaints with the licensing agency. A signed copy goes to the resident, and the facility must also post these rights in an area accessible to the public.⁹

The LIC 621 (Client/Resident Personal Property and Valuables) inventories a resident’s possessions from admission onward, protecting both the resident and the facility.¹⁰

Incident Reporting Forms and Deadlines

Once you are licensed, certain events trigger mandatory reports. Title 22, Section 80061 sets the deadlines: an initial report to the licensing agency by the next business day, followed by a written report within seven calendar days.¹¹

LIC 624 (Unusual Incident/Injury Report) covers any event that threatens a resident’s physical or emotional health or safety, including serious injuries and unauthorized absences.
LIC 624A (Death Report) is filed separately for a resident death.
LIC 306 (Reporting Requirements by Licensees) covers operational changes CCLD must be notified about, such as a change of administrator or a modification to licensed capacity.⁸

The seven-day written deadline is firm. Repeated failures to report become their own category of deficiency at your next evaluation.

Deficiencies and Plans of Correction

When CCLD inspects and finds a violation of Title 22 or the Health and Safety Code, it issues a deficiency on the Facility Evaluation Report. Type A violations pose a direct and immediate risk to residents’ health, safety, or personal rights. Type B violations are problems that could become a risk if left uncorrected, or recordkeeping failures that affect resident care.¹²

For community care licensees, the deficiency notice doubles as a Penalty Notice. Failing to correct cited deficiencies by the deadline triggers civil penalty assessments. If you disagree with a penalty, you have 10 days from receipt of the Penalty Notice to request a formal review in writing.¹²

You are expected to write a specific Plan of Correction for each violation on the right side of the evaluation form, opposite the citation. Notify the licensing agency once corrections are complete. Vague plans and missed deadlines are where facilities get into escalating trouble.

Renewal

Your license does not last forever. Renewal requires a renewal application and payment of the renewal fee before the license expires. CCLD is not obligated to remind you, so track your expiration date independently. Operating with an expired license is a violation and can trigger enforcement. Contact your regional licensing office well before expiration to request the renewal application and confirm any updated documentation requirements, since forms and fees can change between cycles.

Federal Records That Run Alongside

CCLD forms cover state licensing. Two federal record sets apply on top and catch operators off guard.

Facilities with employees must maintain OSHA injury and illness logs. Each recordable workplace injury or illness is entered on the OSHA 300 Log and a 301 Incident Report within seven calendar days, and the OSHA 300-A summary is completed at year-end.¹³ In settings with needlestick risk or exposure to infectious material, those injuries are treated as privacy concern cases and recorded without the employee’s name on the log.

If your facility qualifies as a HIPAA-covered entity because it transmits health information electronically for billing or other transactions, you must also maintain written authorization forms for any disclosure of protected health information that falls outside treatment, payment, or healthcare operations. Authorizations must include an expiration date and a clear statement of the resident’s right to revoke consent.¹⁴

1
California Department of Social Services. Community Care Licensing – About Us
2
California Department of Social Services. Application Instructions for a Facility License (LIC 281)
3
California Department of Social Services. Application for a Community Care Facility or Residential Care Facility for the Elderly License (LIC 200)
4
California Department of Social Services. Financial Information Release and Verification (LIC 404)
5
California Legislative Information. California Health and Safety Code 1522
6
Cornell Law School. California Code of Regulations Title 22, 87355 – Criminal Record Clearance
7
California Department of Social Services. Guardian
8
California Department of Social Services. Forms and Publications (I-L)
9
California Department of Social Services. Personal Rights Adult Community Care Facility (LIC 613)
10
California Department of Social Services. Client/Resident Personal Property and Valuables (LIC 621)
11
Cornell Law School. California Code of Regulations Title 22, 80061 – Reporting Requirements
12
California Department of Social Services. Facility Evaluation Report
13
Occupational Safety and Health Administration. 1904.29 – Forms
14
U.S. Department of Health and Human Services. Summary of the HIPAA Privacy Rule