How to Complete the California LIC 401 Monthly Operating Statement

The California LIC 401 Monthly Operating Statement is the one-page financial snapshot every community care facility applicant or licensee files with the California Department of Social Services to show monthly revenue, operating costs, and net profit or loss. You complete it by filling in a header, five revenue lines, three sections of operating costs totaling thirty lines, and a signed summary, then submit it with the companion LIC 401a as part of your full license application packet. One form per facility, signed in original ink, with actual figures if the facility is already running or estimates if it is not yet open.¹

Who Files the LIC 401

The form is listed as item A7 in the CDSS facility license application instructions and is required from applicants and licensees operating as sole proprietors, partnerships, corporations, or LLCs.² It covers Residential Care Facilities for the Elderly, Adult Residential Facilities, Social Rehabilitation Facilities, Adult Day Programs, RCF-CI facilities, Group Homes, Community Treatment Facilities, Transitional Housing Placement Programs, Foster Family Agencies, and Adoption Agencies.

Small Family Homes are the single exception. They do not have to submit a LIC 401.² If you hold or are applying for licenses on more than one facility, each facility needs its own separate form.

What to Gather Before You Start

Pull your financial records together first. The licensing agency verifies the numbers you report, so guessing invites a returned packet.

Your facility license number, or your application number if you are applying for the first time.
The current monthly SSI rate and the number of SSI clients you serve or expect to serve.
The average monthly private-pay rate and the number of private-pay residents.
Your lease, rental agreement, or mortgage statement. The rent figure you enter must match it.²
Payroll records, which are checked against your staffing report (Form LIC 500).
Utility bills, insurance policies, and vendor invoices for gas, electricity, water, garbage, liability insurance, and maintenance.

One rule shapes everything else on the form. If your facility is already operating, every figure must be actual. Only facilities that have not yet opened may use estimates. The top of the form asks you to indicate which you are reporting.¹

Header

The header asks for the reporting month and year, the full facility name, the facility address, and your license or application number.¹ Use the facility name exactly as it appears on your license or application. A mismatch here can get your entire packet returned.

Revenue Lines 1 Through 6

The top of the form covers Operating Revenues across five lines plus a total.¹

Line 1, SSI Revenue. Enter the monthly SSI rate, the number of SSI clients, and the product of the two.
Line 2, Voluntary Third-Party Contributions. All voluntary payments received on behalf of SSI recipients from outside parties.
Line 3, Private Revenue. Enter the average monthly private-pay rate, the number of private-pay residents, and the total.
Lines 4 and 5, Other Revenue. Report each additional source of facility-related income on its own, such as interest income, subleases, insurance reimbursements, or proceeds from selling assets. If you have more than two, attach a worksheet and put the combined total on line 5.
Line 6, Total Revenue. Add lines 1 through 5 plus any attached worksheet amounts.

Watch the client count. The total residents reflected across your SSI and private-pay lines must match the capacity you are requesting on your application. A 15-bed RCFE application whose revenue section accounts for eight residents will be flagged.²

Operating Costs Lines 7 Through 36

Operating costs fill most of the form and sit in three groups. Each group has its own subtotal, and the three subtotals feed the summary at the bottom.

Care and Services (Lines 7–15)

These lines are the direct cost of caring for residents.¹

Line 7, Food Costs. All food and meal expenses for clients, residents, and staff.
Line 8, Household Supplies. Cleaning supplies, excluding laundry and dry cleaning.
Line 9, Laundry and Dry Cleaning.
Line 10, Personal Hygiene Items provided to clients and residents.
Line 11, Recreational Activities.
Line 12, Newspapers, Magazines, Cable TV.
Line 13, Medical and First Aid, including medical supplies and any non-reimbursable medical costs.
Line 14, Client Transportation to and from medical appointments, activities, and other approved destinations.
Line 15, Total Care and Services. Add lines 7 through 14.

General Administration (Lines 16–26)

Line 16, Salaries and Wages. These must be verifiable against your staffing report and must show at least minimum wage for every position.
Line 17, Payroll Taxes and Employee Benefits. Federal and state payroll taxes, workers’ compensation, and other benefits. The application instructions note that fringe benefits should normally run about 25 percent of salary costs. If you do not provide benefits, explain why on the form or an attachment.²
Lines 18 through 25 cover general transportation, telephone, office supplies, advertising, license and membership fees, contract labor, liability and fire insurance, and indirect overhead.
Line 26, Total General Administration. Add lines 16 through 25.

Physical Plant (Lines 27–36)

Line 27, Rent, Lease, Mortgage Payments, and HOA Fees. Must match your lease agreement or mortgage statement.
Line 28, Property Taxes.
Lines 29 through 32, Utilities. Gas, electricity, water, and garbage, each on its own line.
Lines 33 and 34, Repair and Maintenance, split between the building and furniture or equipment.
Line 35, Other. Any physical-plant cost not covered above. Specify what it is.
Line 36, Total Physical Plant. Add lines 27 through 35.

Summary, Signature, and Perjury Declaration

Two calculation lines close the form.¹

Line 37, Total Operating Costs. Add the subtotals from lines 15, 26, and 36.
Line 38, Net Profit or Loss. Subtract line 37 from line 6. A negative figure does not automatically disqualify you, but the licensing agency will look at whether your start-up funds can cover at least three months of operating costs.

Below the summary, print the preparer’s name and title, then sign and date. The signature block is a declaration under penalty of perjury that the information is true and correct, and the licensing agency requires an original ink signature. Photocopied signatures are rejected.²

Attach the LIC 401a

Every LIC 401 must come with a completed LIC 401a, the Supplemental Financial Information form.¹ Sole proprietors also complete Part I of the LIC 401a. In a partnership, each general partner files a separate LIC 401a in addition to the one filed for the partnership itself. Forgetting the supplemental form is one of the most common reasons packets come back as incomplete.

Where to Submit

The LIC 401 is not filed on its own. It goes to the CDSS Community Care Licensing Division office serving your area as part of the full application packet, with all Section A and Section B documents arranged in the order the application instructions specify.² CDSS runs separate regional offices for Adult and Senior Care, Child Care, and Children’s Residential programs, so check the Community Care Licensing page for the right mailing address for your program.³

If anything in the packet is incomplete, the licensing agency returns the whole packet, not just the problem form. Photocopy the full packet before you send it so you have a reference copy for any correction and resubmission.

What the Licensing Agency Looks For

The form exists so the state can decide whether your facility can sustain itself. For Residential Care Facilities for the Elderly, California regulations require start-up funds sufficient to cover a minimum of three months of operating costs, and any construction financing must already be in place.⁴ The agency may ask for bank statements, loan documents, or other records to verify the funds you report.

All information on the form is subject to verification, and the licensing agency may request additional documentation.¹ Salaries below minimum wage, rent that does not match your lease, inflated revenue projections, or a client count that does not match the capacity you are requesting will all draw scrutiny.

Mistakes That Get Packets Returned

Using estimated figures when the facility is already operating. Only facilities not yet open may estimate.
Client count on the revenue lines that does not match the capacity on the application.
Blank or unusually low line 17. Either show roughly 25 percent of wages for benefits or attach an explanation.²
Photocopied signature instead of original ink.
Omitting the LIC 401a.
Filing a single form for multiple facilities instead of one per facility.

Keep a Copy

Hold onto a copy of every LIC 401 you file along with the supporting bills, payroll records, and lease documents behind the numbers. Licensing Program Analysts routinely review archived financial documents during facility inspections and may ask you to reconcile a prior budget against current operations. The signature block’s perjury declaration means deliberately falsified figures carry legal exposure beyond any administrative action, so the version you file and the records you keep should tell the same story.

1
California Department of Social Services. Monthly Operating Statement LIC 401
2
California Department of Social Services. Application Instructions for A Facility License
3
California Department of Social Services. Community Care Licensing
4
California Department of Social Services. Article 3 Application Procedures Section 87218