How to Complete California Form LIC 603: Preplacement Appraisal Information

The California LIC 603 form, officially the Preplacement Appraisal, is the intake document a Residential Care Facility for the Elderly (RCFE) must have on file before admitting a new resident. It records the applicant’s physical abilities, health history, mental condition, and social preferences so the facility can confirm it has the staff and resources to meet those needs. Without a completed LIC 603, admission cannot legally proceed.¹

Where to Get the Form

The LIC 603 is a free PDF on the California Department of Social Services website, under forms and publications.¹ Many RCFEs also hand a blank copy to families during an initial tour or intake meeting. The content is the same either way.

Who Provides the Information

The applicant is the primary source, but the form’s own instructions allow the information to come from the applicant or an authorized representative, with help from relatives, a social agency, a hospital, or a physician.¹ On the facility side, the licensee or a designated admissions employee must interview the prospective resident and any responsible person before admission.²

If the applicant can’t provide the information or sign, an authorized representative can act in their place. This is typically someone holding a durable power of attorney for health care or a court-appointed conservator. Even then, the regulation expects the prospective resident or their responsible person to be involved in developing the appraisal, so the facility should still speak with the applicant whenever possible.²

Filling Out Each Section

Personal Identification and Health Overview

Start with the applicant’s name, age, and a general description of health, including any dietary limitations. List physical disabilities such as vision, hearing, or speech impairments. A health-history section asks for current medications, major illnesses, surgeries, and accidents in the past five years, and whether any of those involved hospitalization.¹

Tuberculosis Information

Record whether there is a family history of tuberculosis, the date of any TB test, the result, and any recent exposure. If a test came back positive, describe what was done about it.¹

Ambulatory Status

Answer this section carefully. The form defines “ambulatory” as being able to leave a building without help from another person or a mechanical device. To qualify, the person must be able to walk independently or with only a cane, follow evacuation signals and instructions, use evacuation routes including stairs, and evacuate without hesitation.¹ Someone who depends on a walker or wheelchair is classified as nonambulatory, which limits placement to facilities licensed to accept nonambulatory residents. An inaccurate answer here is a fire-safety compliance problem, not just a paperwork error.

Functional Capabilities and Services Needed

These two sections use checklists. Check every item that applies, from “active, requires no personal help” through the use of a brace, walker, or wheelchair, and the need for grab bars in the bathroom. The services-needed checklist covers transferring in and out of bed, bathing, eating, toileting, continence management, medication, managing personal finances, participating in activity programs, night supervision, and any special medical attention.¹

Specificity matters. Checking “help with medication” without noting whether the person needs reminders, help opening containers, or full administration leaves the facility guessing. Use the spaces provided to add brief explanations.

Mental Condition and Social Factors

Describe the extent of any confusion or forgetfulness and whether the person is socially active or withdrawn. The social-factors section asks about likes, dislikes, interests, and preferred activities.¹ If the applicant wanders, has a history of nighttime agitation, or shows other behaviors that affect safety, say so plainly. Vague answers here are a common reason facilities later discover they cannot meet a resident’s needs.

Bed Status and Additional Comments

Indicate whether the person is out of bed all day, in bed most of the time, or in bed part of the time. A final open field invites additional comments on a separate sheet. Use it for context the checkboxes don’t capture.

The Separate Medical Assessment

The LIC 603 does not replace the Physician’s Report, which is submitted on form LIC 602/602A.¹ Before admission, the facility also needs a medical assessment signed by a licensed medical professional within the past year, covering diagnoses, a physical examination including screening for communicable tuberculosis, current prescribed medications, and information relevant to the preplacement appraisal.³

The LIC 602A also documents behavioral expressions such as unsafe wandering, elopement risk, disorientation, hallucinations, and lack of hazard awareness.⁴ Plan to have the medical assessment done before or alongside the LIC 603, since the facility needs both to decide on admission.

Signing and Certification

The bottom of the form carries this certification: “To the best of my knowledge, I (the above person) do not need skilled nursing care.” Two dated signatures are required, one from the applicant or authorized representative and one from the facility’s licensee or designated representative.¹ RCFEs are not licensed to provide skilled nursing care. If the applicant’s needs cross that line, the facility must decline admission.

What Happens After You Submit It

Hand the completed, signed form to the facility administrator, typically during a scheduled intake visit. The facility compares the appraisal and the medical assessment against the acceptance and retention criteria in its license.²

If the appraisal shows a need the facility’s general program doesn’t cover, the regulation requires the facility to consult a physician, social worker, or other appropriate consultant to determine whether the need can still be met. If it can, the facility and consultant develop a written plan with objectives and timeframes, steps for meeting those objectives, who is responsible for each step, and how progress will be measured. If a placement agency or consultant already completed a needs assessment, the facility must obtain it and fold it into its own appraisal.² If the facility decides it cannot meet the applicant’s needs, it must say so before move-in.

Reappraisals After Admission

The LIC 603 is not a one-time filing. California regulations require the preplacement appraisal to be updated in writing as frequently as necessary, or at least once every twelve months, whichever comes first.⁵ A reappraisal is also triggered by any significant change, which the regulation defines broadly:

Physical trauma such as a heart attack or stroke.
Changes in thinking, memory, reasoning, or decision-making.
Behavioral changes including unsafe wandering, elopement, hallucinations, lack of hazard awareness, or poor impulse control.
Mental or social trauma, such as the loss of a loved one.
Illness or injury that significantly changes health care or dietary needs.
Any change affecting whether the resident can safely access items in their living space.

These triggers cover most real-world situations families worry about, including a return from a hospital stay that leaves the resident with new medical needs or reduced mobility.⁵

Why Accuracy Matters

Beyond helping the facility place the resident correctly, accurate answers protect against financial consequences down the line. Under California Health and Safety Code Section 1569.49, an uncorrected cited deficiency carries a civil penalty of $100 per day. Violations that result in resident injury or illness, and fire-clearance violations (which include incorrect ambulatory-status documentation), trigger an immediate $500 penalty plus $100 per day.⁶ That is why the ambulatory section in particular deserves careful attention when you fill the form out the first time.

1
California Department of Social Services. LIC 603 – Preplacement Appraisal – Residential Care Facilities for the Elderly
2
Legal Information Institute. California Code of Regulations Title 22 Section 87457 – Pre-Admission Appraisal
3
Legal Information Institute. California Code of Regulations Title 22 Section 87458 – Medical Assessment
4
California Department of Social Services. LIC 602A – Medical Assessment for Residential Care Facilities for the Elderly
5
Legal Information Institute. California Code of Regulations Title 22 Section 87463 – Reappraisals
6
California Legislative Information. California Health and Safety Code HSC 1569.49