Form LIC 602. Physician's Report For Community Care Facilities

Form LIC 602, officially titled Physician’s Report for Community Care Facilities, is a mandatory medical evaluation form required by the California Department of Social Services (CDSS). It is used to assess whether an individual is suitable for admission to a Community Care Facility (CCF), such as an assisted living home, residential care facility, or rehabilitation center.

The form must be completed by a licensed physician and provides detailed medical information about the resident or applicant. It ensures that the facility can meet the individual’s health and supervision needs while maintaining compliance with California Community Care Licensing regulations.

What the LIC 602 Form Includes

The LIC 602 form consists of multiple sections that capture key health and personal data:

• Facility and resident information: names, addresses, contact details, and licensing data.

• Medical diagnosis: primary and secondary conditions, treatment history, and length of care.

• Tuberculosis (TB) test results and other infectious disease screenings.

• Physical health status: includes details on ambulation, use of assistive devices, diet, allergies, and chronic conditions.

• Mental health assessment: evaluates confusion, depression, communication ability, and capacity to follow instructions.

• Capacity for self-care: covers bathing, dressing, mobility, medication management, and financial independence.

• Medication section: lists current prescriptions and approved over-the-counter drugs.

• Physician’s certification and signature confirming the individual’s fitness for community care.

Who Needs LIC 602

This form is required for:

• Individuals applying for admission to a licensed community care or assisted living facility in California.

• Existing residents undergoing periodic health reassessment.

• Facilities needing medical documentation for regulatory compliance or fire clearance (ambulatory status verification).

Why It’s Important

The LIC 602 form ensures residents receive appropriate non-medical care and supervision without exceeding the facility’s scope of service. It helps administrators determine whether a person requires skilled nursing care or can safely reside in a non-medical setting.

Accurate completion of this form supports:

• Safe placement decisions

• Compliance with Title 22 regulations

• Eligibility verification for state or insurance programs

How to Use

The completed LIC 602 form is submitted to the Community Care Licensing Division (CCLD) or the facility’s administrator. It must be signed by both the physician and the resident or authorized representative. A copy is retained in the patient’s record for ongoing care coordination.

You can download a fillable LIC 602 PDF, print it, or fill it out online on our site to simplify the admission process to community care facilities.