California LIC 601: Completing Sections A and B, Filing, and Retention

The California LIC 601 form is the identification and emergency information record that licensed community care facilities keep for each person in their care, and you fill it out by completing Section A for every client, adding Section B if the client is a child in a residential placement, and handing the finished form to the facility administrator for the client’s on-site record. A blank copy is available from the California Department of Social Services at cdss.ca.gov. The form stays at the facility rather than going to a state office, but it has to be complete before or at the time of admission.

Who Uses This Form

The LIC 601 is required for all licensed community care facilities except child care centers and family child care homes.¹ That covers adult residential facilities, group homes, residential facilities for children, small family homes, foster family homes, social rehabilitation facilities, and similar placements licensed by the Community Care Licensing Division. Child care centers and family child care homes use the LIC 700 instead.

The underlying requirement comes from the California Health and Safety Code and is implemented through Title 22 of the California Code of Regulations. Section 80070 of Title 22 requires each facility to keep a separate, complete, and current record for every client, and the LIC 601 is how most facilities meet the identification and emergency-contact piece of that rule.²

How to Complete Section A

Section A applies to every facility that uses the form. It captures what staff and emergency responders need to act quickly.

Client name, date of birth, and admission date. Use the full legal name exactly as it appears on the birth certificate or legal identification. The admission date is the date the person entered the facility, not the date you are filling out the form.
Authorized representative. Name, address, and phone number of the parent, guardian, conservator, or other person legally responsible for the client. This is the first person the facility calls in an emergency.
Emergency contacts. Names, addresses, and phone numbers of people to notify if the authorized representative cannot be reached. List at least one or two alternates so staff are not stuck with a single unreachable number.
Physician and dentist. Name, address, and phone number for the client’s primary doctor and dentist. Section 80070 expects specialists and mental health providers to be part of the client record as well.²
Emergency hospitalization plan. The hospital the client should be taken to and its address, plus the medical insurance plan name and ID number, and the dental plan name and number if one exists.¹

Write legibly and match the entries to any supporting legal documents. A mismatched name or birth date can slow medical treatment and create problems during licensing inspections. When a field genuinely does not apply, write “N/A” rather than leaving it blank so the licensing analyst knows the question was answered, not skipped.

How to Complete Section B for Children in Residential Placement

Section B is an add-on only for residential facilities serving children. It covers custody, visitation, and other details unique to minors in out-of-home placements.¹

Alternate contact. Name, contact information, and relationship to the child for someone to reach if the authorized representative is unavailable.
Parent information. Names, addresses, and phone numbers of the child’s biological or legal parents, and a parent’s domestic partner if known, even when they are not the authorized representative.
Court status and custody orders. Note the child’s court status and attach copies of any custody orders or agreements with the parents or legal custodians. The attachment is optional for small family homes and foster family homes.
Prior living arrangement. Who the child was living with before admission, with relationship, address, and phone number.
Visitation restrictions. Any court-ordered or authorized-representative-ordered restrictions. Name each person who is not allowed to visit, along with their relationship, and note any restrictions on family residence visits.
Persons authorized to remove the child. Everyone allowed to take the child off the premises, their relationship to the child, and any conditions.
Telephone access. Whether the child may make and receive confidential phone calls. If not, specify the restrictions and whether they come from a court order.

Check every visitation and removal entry against the actual court orders before signing. Errors in this section can put a child at risk and can expose the facility and the authorized representative to serious consequences.

Where the Completed Form Goes

The LIC 601 is not mailed to the Department of Social Services. Give the completed form to the facility administrator or director, who files it in the client’s individual record on site. The form must be kept on the premises and readily available to the person in charge at all times, while remaining inaccessible to unauthorized people.¹

The information on the form is confidential. The licensee and employees cannot reveal it to unauthorized people, with the main routine exception being disclosure to the licensing agency during inspections.² Staff can share relevant details with hospital or emergency personnel during a genuine medical emergency so the client gets proper treatment.

Keeping the Form Current and How Long to Retain It

A completed LIC 601 is not a one-time document. Any time a phone number changes, a new doctor is assigned, insurance coverage switches, or a custody order is modified, the authorized representative needs to give the facility updated information. The regulations require each client record to stay “complete and current,” and an outdated emergency contact form fails that standard.²

Many directors schedule an annual review and ask families to verify every contact and medical detail. Even so, the duty to flag changes as they happen sits with the authorized representative, not with the facility’s yearly check-in. If staff cannot reach anyone during an emergency because the information is stale, the fallout lands on both the family and the operator.

After a client leaves, the record does not disappear. California regulations require facilities to retain records for a minimum of three years after services end.³

What Happens If the Form Is Missing or Wrong

A facility that fails to maintain complete and current client records faces real consequences. Under California Health and Safety Code Section 1548, a community care facility that does not correct a cited deficiency within the time allowed faces a civil penalty of $100 per day per violation. If the same deficiency is cited again as a repeat violation, the penalty becomes an immediate $250 per repeat violation plus $100 per day until corrected.⁴

Repeated record-keeping failures can also lead to probation or revocation of a facility’s license. For the family member or representative filling out the form, the practical risk is more immediate: if the information on the LIC 601 is wrong or missing when it matters most, the facility may not be able to reach the right doctor or authorize the right medical treatment in time.

1
California Department of Social Services. LIC 601 – Identification and Emergency Information
2
California Department of Social Services. General Licensing Requirements – Section 80070 Client Records
3
Cornell Law Institute. California Code of Regulations Title 22 101221 – Childs Records
4
California Legislative Information. California Code Health and Safety Code 1548 – Offenses