(LIC 603)_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(Specify extent of any symptoms of confusion, forgetfulness: participation in social activities (i.e., active or withdrawn))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
BED STATUS

OUT OF BED ALL DAYIN BED ALL OR MOST OF THE TIMEIN BED PART OF THE TIME
COMMENT
TUBERCULOSIS INFORMATION
ANY HISTORY OF TUBERCULOSIS IN APPLICANT'S FAMILY?

YESNO
DATE OF TB TEST

MonthDayYear
Date
TB TEST results

PositiveNegative
ANY RECENT EXPOSURE TO ANYONE WITH TUBERCULOSIS?

YESNO
ACTION TAKEN (IF POSITIVE)
GIVE DETAILS
AMBULATORY STATUS - this person is:*

ambulatorynonambulatory

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:

	YES	NO
Able to walk without any physical assistance
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

YESNO
Active, but has difficulty climbing or descending stairs

YESNO
Uses brace or crutch

YESNO
Feeble or slow

YESNO
Uses walker?

YESNO
If Yes, can get in and out unassisted?

YESNO
Uses wheelchair?

YESNO
If Yes, can get in and out unassisted?

YESNO
Requires grab bars in bathroom

YESNO
Other: Functional Capabilities (Describe)

YESNOOther
SERVICES NEEDED

(Check items and explain)

	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?

YesNo
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*

Clear
SIGNATURE of Resident or RP

Clear
Date Completed*

MonthDayYear
Date
Date Completed

MonthDayYear
Date
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.