For families & physicians
Official California RCFE admission forms.
The forms below are the current California Department of Social Services (CDSS) forms required for admission to a Residential Care Facility for the Elderly under Title 22. Download, complete, and return to our office — we'll walk through each one with you.
Family & resident
Completed by the family or resident
- LIC 601Official CDSS form
Identification and Emergency Information
Resident identity, emergency contacts, and key medical alerts.
- LIC 603Official CDSS form
Pre-Placement Appraisal Information
Information about the prospective resident used during placement appraisal.
- LIC 605AOfficial CDSS form
Resident's Record of Cash Resources, Personal Property and Valuables
Inventory of cash, valuables, and personal property brought into the facility.
- LIC 627Official CDSS form
Consent for Medical Treatment
Authorization for the facility to obtain emergency medical treatment when needed.
Physician
Completed by the resident's physician
- LIC 602Official CDSS form
Physician's Report for Residential Care Facilities for the Elderly
Completed by the resident's physician prior to admission. Required by Title 22.
- LIC 9172Official CDSS form
Resident or Client / Conservator / Family Authorization
Authorization for release of medical information and care coordination.
At admission
Reviewed and signed with our office
- LIC 621Official CDSS form
Admission Agreement Checklist
Used alongside our admission agreement. Reviewed together at signing.
- LIC 604AOfficial CDSS form
Personal Rights — Residential Care Facilities for the Elderly
California Title 22 personal rights statement. Signed at admission.
- LIC 613COfficial CDSS form
Personal Rights — RCFE (Acknowledgment)
Acknowledgment of receipt of personal rights, signed by resident or representative.
- LIC 9158Official CDSS form
Telecommunications Device Notification
Notification regarding access to telecommunications devices in the facility.
- LIC 9182Official CDSS form
Resident's Personal Property Theft and Loss Program
Notice and acknowledgment for the property protection program.
Returning completed forms
You can return completed forms in whichever way is easiest — in person at our home, by secure email, or by mail. We are happy to walk through any form with you over the phone or in person; nothing about admission should feel confusing or rushed.
Email: Admin@NorthLakeVillas.com
Phone: (626) 398-8668
In person / mail: 2851 Lake Ave., Altadena, CA 91001