How CCLD Analysts Evaluate LIC 602A Forms During RCFE Inspections
| The Role of LIC 602A in RCFE Regulation | Explains legal purpose and licensing relevance of the 602A form. |
| How LPAs Conduct Evaluations | Describes inspection process and document comparison methods. |
| What LPAs Look for in Detail | Lists key areas of review such as diagnoses, ADLs, and cognition. |
| CARE Tools: Inspection Consistency | Outlines how CARE Tools standardize regulatory reviews. |
| Frequent Problems Found During Reviews | Summarizes common compliance issues and citation triggers. |
| How Facilities Can Stay Compliant | Gives practical steps for maintaining ongoing compliance. |
| Pre-Inspection Self-Check | Provides a quick checklist before LPA visits. |
| Conclusion | Summarizes the importance of accurate and aligned documentation. |
The LIC 602A medical assessment form is an essential compliance document for all Residential Care Facilities for the Elderly (RCFE) in California. It verifies that residents are medically suitable for non-medical care and that each facility operates within its licensed scope. This report outlines how Licensing Program Analysts (LPAs) from the Community Care Licensing Division (CCLD) evaluate the LIC 602A during inspections, what issues they focus on, and how facilities can maintain compliance.
The Role of LIC 602A in RCFE Regulation
Legal Foundation
Under Title 22 §87458, a medical evaluation is required for every resident prior to admission. The assessment must be performed by a licensed practitioner within the past year and retained in the resident’s file. The form includes tuberculosis screening, diagnoses, prescribed medications, physical limitations, and behavioral findings.
Standard Form vs. Alternatives
Although RCFEs may create an alternative document, most use the state-issued LIC 602A. It meets every Title 22 requirement and reminds providers that RCFEs deliver non-medical care only and cannot provide skilled nursing services.
Ambulatory Status and Fire Clearance
The form also defines whether a resident is ambulatory, non-ambulatory, or bedridden. If a resident is bedridden, the RCFE must notify the fire authority and maintain an updated fire clearance. LPAs routinely confirm that documentation and on-site evacuation plans match.
How LPAs Conduct Evaluations
Comparing the 602A with Appraisals
Before admission, every RCFE completes a Pre-Admission Appraisal describing the resident’s physical and cognitive capabilities. LPAs cross-check the 602A with this appraisal to identify discrepancies—such as differences in mobility or care needs—that could indicate documentation errors.
Medication Management Review
When the 602A shows a resident cannot manage medications independently, the RCFE must ensure secure central storage and accurate Medication Administration Records (MARs). LPAs check that the listed drugs, doses, and notes match between documents.
Infection Control and TB Screening
Each 602A includes tuberculosis testing information. Missing or outdated TB results are viewed as recordkeeping failures and may lead to citations under §87458.
What LPAs Look for in Detail
Diagnoses and Medical History
Inspectors confirm that all diagnoses and vital information (height, weight, and current conditions) are documented. These data points must align with the resident’s care plan and dietary instructions.
Functional Status and ADLs
The LIC 602A outlines how well residents can perform activities of daily living (ADLs) such as bathing, dressing, eating, and walking. LPAs use this information to determine whether staffing and support levels are adequate.
Cognitive and Behavioral Findings
Cognitive assessments include Mild Cognitive Impairment (MCI) and Major Neurocognitive Disorders (Major NCD). Behavioral expressions—wandering, disorientation, or decreased awareness of danger—are critical for determining supervision needs.
Ambulatory and Non-Ambulatory Status
LPAs ensure the listed mobility status matches the resident’s actual condition. Any inconsistency may affect fire-safety requirements or licensed capacity.
CARE Tools: Ensuring Consistency in Inspections
What CARE Tools Are
The CCLD uses CARE Tools to create uniformity in inspections statewide. These tools help analysts evaluate records, medication management, and safety practices in a consistent and measurable way.
Connection Between CARE Tools and LIC 602A
Data from the 602A feeds into multiple CARE Tool domains—Resident Records, Medication Management, and Disaster Preparedness. LPAs expect the form’s information to align with written policies and observed practices.
Frequent Problems Found During Reviews
Missing or Expired Forms
Outdated 602As or missing signatures are among the most common compliance failures. LPAs interpret them as evidence of poor record maintenance.
Incorrect Mobility Classification
Listing a non-ambulatory resident as ambulatory—or failing to report a bedridden resident to the fire authority—constitutes a serious violation of Title 22.
Medication Record Discrepancies
When the 602A medication list doesn’t match the MAR or storage inventory, it signals gaps in medication oversight.
How Facilities Can Stay Compliant
Use the Most Recent Form
The current version of LIC 602A (April 2025) reflects all new Title 22 updates. Always use this form to avoid missing fields or outdated requirements.
Align Documentation Across Systems
The 602A, Appraisal, Care Plan, and MAR must all tell the same story about a resident’s needs and the facility’s response. Any mismatch can trigger a citation.
Keep Records Up to Date
Review mobility and cognitive information regularly, and notify relevant authorities when statuses change. Maintain TB and infection-control documentation without gaps.
Pre-Inspection Self-Check
Verify that every 602A is current and signed.
Match medications listed in 602A with MAR and actual supply.
Ensure all mobility statuses align with fire-clearance documentation.
Review behavioral sections and confirm related risk policies exist.
Conclusion
The LIC 602A is not just paperwork—it’s the framework connecting medical assessments, safety standards, and regulatory compliance. LPAs use it to evaluate whether an RCFE can provide safe, lawful, and appropriate care. When 602A data aligns with appraisals, care plans, and medication records, facilities strengthen both compliance and resident well-being.
Sources
Title 22, California Code of Regulations, Division 6, Chapter 8 – Residential Care Facilities for the Elderly (RCFE):
Sections §87457 (Pre-Admission Appraisal), §87458 (Medical Assessment), §87463 (Reappraisal), §87465 (Incidental Medical and Dental Care), §87506 (Resident Records), §87606 (Fire Clearance for Bedridden Residents), and §87615–§87616 (Prohibited Health Conditions).Official LIC 602A Form – Physician’s Report for Community Care Facilities (version 04/25), issued by the California Department of Social Services (CDSS).
Evaluator Manual – Residential Care Facilities for the Elderly (RCFE), Community Care Licensing Division (CCLD), California Department of Social Services.
CCLD Compliance and Regulatory Enforcement (CARE Tools) — statewide inspection framework used by Licensing Program Analysts (LPAs) during RCFE evaluations.
CDSS Policy Guides and Provider Information Notices (PINs) — guidance on medical documentation, mobility classification, and medication management procedures.
California Department of Public Health (CDPH) — Tuberculosis testing and reporting requirements for residential care facilities.
