How to Fill Out the California LIC 603 Preplacement Appraisal Form

The California LIC 603 form, titled Preplacement Appraisal Information, is a one-page intake document that residential care facilities complete for every prospective resident before admission. It captures the applicant’s health status, physical abilities, mental condition, daily care needs, and tuberculosis screening results so the facility can decide whether it has the staff and resources to care for that person.¹ Both the applicant (or an authorized representative) and the licensee sign it, and the completed form stays in the resident’s file permanently.

When LIC 603 Is Required

California Code of Regulations, Title 22, Section 87457 requires a written pre-admission appraisal before any resident moves into a residential care facility. The appraisal has to evaluate the prospective resident’s functional capabilities, mental condition, and social factors, then compare those needs against the facility’s admission criteria.² LIC 603 is the standard CDSS document designed to satisfy that requirement.

If the appraisal reveals a service need the facility’s general program does not cover, the facility must consult a physician, social worker, or other appropriate professional to decide whether it can realistically meet that need before accepting the applicant.² Skipping or half-completing this step is where facilities get into trouble during licensing inspections.

One boundary to flag before you start: LIC 603 is not a substitute for the Physician’s Report (Form LIC 602). The form itself says so. The two documents serve different purposes, and facilities typically need both in the resident’s file.¹

Where to Get the Form

LIC 603 is a free PDF download from the California Department of Social Services at cdss.ca.gov/cdssweb/entres/forms/English/LIC603.pdf.¹ The form notes that information can come from the applicant or an authorized representative, and that relatives, a social agency, a hospital, or a physician may help complete it. Before sitting down with the form, gather the applicant’s medical records, current medication list, TB screening results, and any behavioral or psychiatric documentation. You will need specifics, not generalities.

How to Fill Out Each Section

The form is organized into clearly labeled sections. Each one asks for a different dimension of the applicant’s condition and needs.

Identification, Health, and History

Start with the applicant’s name and age, then work through the health information:¹

Health: describe the applicant’s overall condition, including any dietary limitations. If the person follows a low-sodium, diabetic, or pureed diet, note it here.
Physical Disabilities: describe limitations including vision, hearing, or speech impairments.
Mental Condition: note symptoms of confusion or forgetfulness, and whether the applicant is socially active or withdrawn.
Health History: list currently prescribed medications and major illnesses, surgeries, or accidents. Specify any hospitalizations and the length of each hospitalization in the last five years.
Social Factors: describe likes, dislikes, interests, and activities. This helps the facility assess social compatibility with current residents.

Write in plain, specific terms. “Takes Metformin 500 mg twice daily for type 2 diabetes” is useful. “Has health issues” is not.

Bed Status and Tuberculosis Information

Bed Status asks you to pick one of three options: out of bed all day, in bed all or most of the time, or in bed part of the time. Check the one that most accurately reflects a typical day.¹

The Tuberculosis block requires several data points:

Whether the applicant has any family history of tuberculosis (yes or no)
Date of the most recent TB test and whether the result was positive or negative
Whether the applicant has had recent exposure to anyone with tuberculosis
If the test was positive, what action was taken

Have the TB screening results on hand before you begin. A missing or outdated TB test is one of the most common reasons a form sits incomplete.

Ambulatory Status

This section determines whether the applicant qualifies as ambulatory or nonambulatory. The form defines “ambulatory” as having the mental and physical ability to leave a building without help from another person or a mechanical device. Four yes-or-no questions test this:¹

Can the person walk without physical assistance (other than a cane)?
Can the person follow signals and instructions for evacuation?
Can the person use evacuation routes, including stairs if necessary?
Can the person evacuate reasonably quickly, walking the route without hesitation?

Ambulatory status affects which facilities can legally accept the resident and what fire-safety staffing ratios the facility needs to maintain. Answer honestly. Overstating mobility puts everyone at risk during an actual emergency.

Functional Capabilities and Services Needed

The Functional Capabilities checklist asks you to check every item that applies: whether the applicant is fully active without help, has difficulty with stairs, uses a brace, crutch, walker, or wheelchair, is feeble or slow, or needs grab bars in the bathroom. If the applicant uses a walker or wheelchair, an additional question asks whether they can get in and out of it without assistance.¹

Services Needed is the longest checklist on the form and the one that matters most for the admission decision. Check and briefly explain each service the applicant requires:

Help transferring in and out of bed and dressing
Help with bathing, hair care, and personal hygiene
Whether the applicant can and wants to do their own laundry and household tasks
Help moving about the facility
Help with eating, including adaptive devices or direct assistance
Special diet or observation of food intake
Toileting assistance, including equipment such as a catheter
Continence support for bowel or bladder control
Help with medication
Special observation or night supervision due to confusion, forgetfulness, or wandering
Help managing cash resources
Help participating in activity programs
Special medical attention
Assistance with incidental health and medical care

Each checked item should carry a brief written explanation so staff understand the scope. “Help with medication” paired with “takes 12 daily prescriptions across 4 time intervals, cannot self-administer” tells the administrator far more than a bare checkmark.

Additional Information and the Skilled Nursing Declaration

The final content section asks whether there is any additional information that would help determine the applicant’s suitability for admission. If yes, attach comments on a separate sheet. Use this space for anything that does not fit the earlier checkboxes: behavioral triggers, preferred daily routines, religious or cultural considerations, specific fears.¹

The form includes a declaration stating: “To the best of my knowledge, I (the above person) do not need skilled nursing care.” Residential care facilities are not licensed to provide skilled nursing, so this declaration confirms the applicant falls within the facility’s legal scope. If skilled nursing is needed, a different type of facility and licensing framework applies.

Signatures and Where the Form Lives

Two signatures go at the bottom. The applicant or their authorized representative signs first, confirming the accuracy of the information. The licensee or designated representative signs next, indicating they have reviewed the appraisal and accept the resident for admission.¹

The completed LIC 603 becomes part of the resident’s permanent record kept on-site. Title 22, Section 87506 requires each resident’s file to include the pre-admission appraisal alongside medical assessments, medication records, the admission agreement, and other documentation.³ These records must be accessible for immediate review during unannounced licensing inspections.

Reappraisals After Admission

LIC 603 is not filed and forgotten. Title 22, Section 87463 requires facilities to update the pre-admission appraisal in writing at least once every 12 months, or sooner if the resident’s condition changes significantly.⁴

A “significant change” includes physical trauma such as a heart attack or stroke, cognitive decline affecting reasoning or judgment, behavioral changes that could result in harm, the loss of a loved one, or an illness that alters the resident’s healthcare or dietary needs.⁴ If the facility observes behavioral expressions that have caused or could cause harm, the reappraisal must document a description of the behavior, events that occurred just before it, and the least restrictive intervention planned to manage it. After each reappraisal, the facility should consult with any professionals providing specialized services to the resident so changes in condition are properly addressed.

What Happens If the Form Is Missing or Incomplete

A missing or incomplete LIC 603 is a deficiency that licensing evaluators flag during inspections. Under 22 CCR Section 101195, a serious deficiency that is not corrected by the deadline in the notice carries a penalty of $50 per day per violation, up to a maximum of $150 per day.⁵

California Health and Safety Code Section 1548 provides a separate enforcement mechanism: a civil penalty of $100 per day for each violation a facility fails to correct within the time specified in the notice.⁶ Beyond daily fines, repeated or severe deficiencies can lead to administrative action against the provider’s license. Keeping a complete, current LIC 603 for every resident is one of the simplest ways to avoid those consequences.

1
California Department of Social Services. LIC 603 – Preplacement Appraisal Information
2
Cornell Law Institute. California Code of Regulations Title 22 Section 87457 – Pre-Admission Appraisal
3
California Department of Social Services. Residential Care Facilities for the Elderly – RCFE Regulations
4
Cornell Law Institute. California Code of Regulations Title 22 Section 87463 – Reappraisals
5
Cornell Law Institute. California Code of Regulations Title 22 Section 101195 – Penalties
6
California Legislative Information. California Code Health and Safety Code 1548 – Offenses