How to Fill Out and Submit the California LIC 602 Physician’s Report

The California LIC 602A form is the medical assessment a licensed healthcare provider must complete before a senior moves into a Residential Care Facility for the Elderly. To use it, download the current version from the California Department of Social Services, take it to a physician, nurse practitioner, or physician assistant to fill in the clinical sections, and deliver the signed original to the facility administrator. The assessment has to have been performed within one year of admission, and the TB portion within three months.¹

Where to Download the Current Version

The current form is LIC 602A, revised April 2025, available as a free PDF from the CDSS forms page.² You can also pull it directly at cdss.ca.gov/cdssweb/entres/forms/English/LIC602A.pdf.³ Most RCFEs keep blank copies at the front desk and will hand one out during a tour. Print it before the doctor’s appointment so the provider can complete it in the exam room instead of finishing it later.

Who Can Sign the LIC 602A

The regulation requires the form to be signed by a licensed medical professional acting within the scope of their practice.¹ Physicians (MDs and DOs), nurse practitioners, and physician assistants all qualify. It doesn’t have to be the resident’s primary care doctor, but a provider who already knows the patient’s history will produce a more accurate assessment and is less likely to miss a medication or diagnosis.

What the Provider Fills In

The top of the form is identifying information: resident name, date of birth, and the facility name. Everything below that is clinical, and the answers directly shape whether the facility can accept the resident and what the care plan will look like.

Diagnoses, Medications, and Allergies

The provider lists every active diagnosis, primary and secondary, along with the treatment or medication for each, including type and dosage.³ For each diagnosis, the form asks whether the resident can manage their own treatment; if not, the provider describes what assistance is needed. A separate section covers seasonal, food, medication, and dander allergies with treatment details. The provider also indicates whether any medication needs to be stored centrally by the facility rather than kept in the resident’s room.¹

Tuberculosis Screening

The TB section records the date the test was given, the date it was read, the type of test, and the result. The test — a chest X-ray or a Mantoux tuberculin skin test measured in millimeters — must have been obtained no more than three months before placement. If it comes back positive, the provider documents the action taken. After admission, the Mantoux skin test is repeated annually, except for residents with a history of positive reactions, who get a clear chest X-ray instead.⁴

Cognitive Conditions and Behavioral Expressions

The provider notes whether the resident has any cognitive conditions and, if so, identifies the specific diagnosis. The form defines two categories on its own pages: Mild Cognitive Impairment (MCI), described as a conditional state between normal aging and dementia, and Major Neurocognitive Disorder, which covers Alzheimer’s disease, vascular dementia, Lewy body dementia, Parkinson’s disease, and frontotemporal dementia.³

Below the diagnosis, the form asks the provider to evaluate specific behaviors that could put the resident or others at risk: disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, expressions of frustration, and hallucinations. The facility uses these answers to decide whether it can safely accommodate the resident.

Ambulatory Status

This section classifies the resident as ambulatory, nonambulatory, or bedridden, and that classification decides which rooms, floors, and facilities can legally accept them. Under state regulation, a nonambulatory person is someone unable to leave a building unassisted during an emergency, which includes people who rely on crutches, walkers, or wheelchairs and people unable to respond to a fire alarm or follow oral instructions about danger.⁵ The provider also notes whether nonambulatory status is based on physical condition, mental condition, or both.¹

Bedridden status is more restrictive. A bedridden resident needs help turning or repositioning in bed, or cannot independently transfer to and from bed, and an RCFE generally cannot admit a bedridden person without a special fire clearance.⁶ A temporary illness of 14 days or less is an exception; past that, the facility must notify CDSS and provide a physician’s written estimate of when the bed confinement will end.

Physical Health and Capacity for Self-Care

The provider rates overall physical health as good, fair, or poor, then works through a checklist covering hearing loss, vision loss, dentures, prostheses, special diet needs, substance use, bowel and bladder incontinence, motor impairment, repositioning and transfer needs, and skin condition history.³ A separate self-care section evaluates daily activities like bathing, dressing, eating, and toileting, and whether the resident can leave the facility unsupervised. These answers feed straight into the care plan.

Timing: The One-Year and Three-Month Windows

The medical assessment must have been performed within one year before the facility accepts the resident.¹ The TB test has its own tighter deadline of three months before placement. Scheduling the whole assessment close to the move-in date is the cleanest way to satisfy both requirements in a single visit.

Submitting the Form to the Facility

Once the provider signs the form, the resident or family delivers the original to the facility administrator. Keep a photocopy for your own records — useful if you switch facilities later or if a question comes up about what was documented at admission. The administrator reviews the completed LIC 602A to confirm the resident’s needs fit within the facility’s license. RCFEs provide non-medical care and supervision; they are not licensed for skilled nursing.³ If the assessment shows the prospective resident needs 24-hour skilled nursing or intermediate care, the facility must deny admission.⁶ After acceptance, the form goes into the resident’s permanent file, where it becomes part of what state inspectors look at during audits.

When You’ll Need an Updated Assessment

The initial LIC 602A doesn’t last forever. CDSS can require an updated medical assessment at any time.¹ An update becomes necessary whenever the resident has a significant change in condition: a hospitalization, a new diagnosis, or a noticeable decline in mental or physical function.⁷ Many facilities also require annual updates as internal policy even when the Department has not asked for one.

Cost and Insurance

The form itself is free. The cost is the visit where the provider fills it out. Medicare Part B covers an annual wellness visit, but Medicare states plainly that the yearly wellness visit isn’t a physical exam, and routine physical exams are not a covered benefit.⁸ Whether insurance covers the appointment depends on how the provider codes it. A standard office visit or evaluation may be partially covered by Medicare or supplemental insurance; a form-completion service is sometimes treated as administrative and excluded. Call the billing office before the appointment and ask how they plan to code it. Some providers fold the form into a regular office visit at no extra charge; others charge a separate fee.

If the Facility Denies Admission

An RCFE can deny admission when the assessment shows needs that exceed what the facility is licensed to provide, most commonly 24-hour skilled nursing or bedridden status without the required fire clearance. A denial based on the LIC 602A is not final. You can get a second opinion from another provider if you believe the assessment overstated the resident’s needs, or look for a facility with a higher level of licensure. If a resident is already placed and the facility later decides their condition has changed enough to require relocation, the resident or their representative can request a review of the relocation decision through CDSS.⁹ That request has to be filed with the facility within three working days of receiving the written notice to relocate.

1
Cornell Law Institute. California Code of Regulations Title 22 Section 87458 – Medical Assessment
2
California Department of Social Services. Forms and Publications (I-L)
3
California Department of Social Services. LIC 602A – Medical Assessment for Residential Care Facilities for the Elderly
4
Cornell Law Institute. California Code of Regulations Title 22 Section 87894 – Resident Medical Assessments
5
Cornell Law Institute. California Code of Regulations Title 22 Section 87101 – Definitions
6
California Legislative Information. California Health and Safety Code HSC 1569.72
7
U.S. Department of Health and Human Services. Compendium of Residential Care and Assisted Living Regulations and Policy: California
8
Medicare.gov. Yearly Wellness Visits
9
California Department of Social Services. Title 22 Regulations – Residential Care Facilities