How to Fill Out the LIC 625: California Appraisal/Needs and Services Plan

To fill out the LIC 625, California’s Appraisal/Needs and Services Plan for Residential Care Facilities for the Elderly, you complete a four-page form that pairs a background appraisal of the resident with a structured care plan, then collect signatures from the licensee, a qualified consultant, and the resident or their authorized representative. The current version (revised October 2024) is a free PDF from the California Department of Social Services, listed under the I–L alphabetical section of its forms page.¹

The form must be completed before admitting a new resident, updated at least once every 12 months, and revised any time a significant change occurs.² The resident (or their responsible person) must be involved in developing the appraisal, not just handed a finished document to sign.³

Start With the Medical Assessment (LIC 602A)

You cannot complete the LIC 625 in isolation. Before you begin, obtain a current LIC 602A, the medical assessment signed by a licensed medical professional within the past year.⁴ It supplies clinical findings the facility cannot generate on its own: diagnoses, tuberculosis and infectious disease screening results, prescribed medications, ambulatory status, cognitive conditions, and behavioral concerns.

Read the LIC 602A carefully and pull the relevant details forward into your background narrative and needs table. If the physician notes a dietary restriction, a medication that must be centrally stored, or a cognitive diagnosis such as major neurocognitive disorder, those findings should drive matching entries later in the LIC 625. The medical assessment also helps confirm the resident fits within the facility’s scope, since an RCFE provides primarily non-medical care and cannot deliver skilled nursing.

Page 1: Identifying Information and Background

The top of page one collects the resident’s name, date of birth, age, sex, address, and phone number, along with the facility’s name and license number and the name of any person or agency that referred the resident. Mark whether this is an initial admission or an update, and enter the date.

Below the header sits a narrative field labeled “Background Information.” Write a specific description covering the resident’s medical history, emotional and behavioral concerns, physical problems, functional limitations, functional capabilities, ability to handle personal cash and simple homemaking tasks, and personal likes and dislikes. This draws directly on the pre-admission interview, which under California regulations must cover the prospective resident’s desires about admission, their background, service needs, and any medical or functional limitations.³

Skip the generalities. Licensing analysts read this section, and vague entries like “generally healthy” draw scrutiny. Address every area the regulation lists for the functional capabilities evaluation: bathing, dressing and grooming, toileting, transferring in and out of a bed or chair, continence, eating, vision, hearing, speech, walking, dietary limitations, medical history, and medication needs.⁵ Note where the resident has no limitation as well as where they do. Write the concrete facts: uses a walker, moderate hearing loss in the left ear, needs reminders to take prescribed medication.

Pages 2–4: The Needs and Services Table

The core of the form is a multi-page table with five columns: Needs, Objective/Plan, Time Frame, Person(s) Responsible for Implementation, and Method of Evaluating Progress. Needs are grouped into five categories.

Emotional needs, such as anxiety about the transition to facility living or grief from the loss of a spouse.
Socialization needs, including difficulty adjusting socially or maintaining relationships with other residents or staff.
Mental needs, covering difficulty with intellectual functioning, including problems making decisions about daily activities.
Physical and health needs, such as mobility limitations, chronic pain, incontinence, or poor health habits.
Functioning skills, meaning difficulty developing or using independent living skills like dressing, bathing, managing money, or preparing simple meals.

For each category where the resident has an identified need, fill every column. The regulation is explicit about what a complete plan must contain: objectives tied to the resident’s specific problems or unmet needs, a time frame for reaching each objective, identification of the individuals or agencies responsible for carrying out each part of the plan, and a method for evaluating progress.³

Be concrete. An objective like “improve socialization” is too soft for a licensing review. Write something like “Resident will participate in at least two group activities per week within 30 days of admission,” and name the staff member or activity coordinator responsible. For evaluation, specify how you will track progress: weekly notes, monthly check-ins with the resident, or consultation with the resident’s physician.

Where the appraisal reveals service needs beyond the facility’s general program, the licensee must bring in a physician, social worker, or other consultant to help develop the written plan of action.⁶ That consultant then signs the form.

Signatures on the Final Page

Three signatures are required for a valid LIC 625.

The licensee signs and dates the form, declaring that the resident is compatible with the facility’s program and other residents, that the facility can provide the care described in the plan, and that to the licensee’s knowledge the resident does not require skilled nursing care. If more than one licensee holds the license, each signs.

An authorized representative, facility social worker, physician, or other appropriate consultant signs to confirm they have reviewed and agree with the assessment and believe the facility can provide the needed services.

The resident signs to confirm they participated in and agree to the assessment. If the resident lacks capacity to sign, their authorized representative or conservator signs on their behalf. This signature also authorizes the facility to hold the assessment under a confidentiality condition. A form signed only by the licensee, without the resident’s involvement or signature, is incomplete.

Within two weeks of admission, the facility must also coordinate a meeting with the resident, their representative if any, relevant staff, and any home health providers to prepare a written record of the care the resident will receive.⁷ The LIC 625 serves as that written record when a needs and services plan is involved.

Check Against Acceptance and Retention Limits

The LIC 625 is not just paperwork. Its findings determine whether the facility can legally accept the resident. An RCFE may accept residents who need help with medication, those receiving outside medical care, people with behavioral concerns, and even residents who are bedridden if hospice or other specific conditions are met. But a facility cannot accept or keep someone with active communicable tuberculosis or someone who requires around-the-clock skilled nursing or intermediate care.⁸ If the appraisal shows needs that exceed what the RCFE can provide, the facility must decline admission or help the resident transition to appropriate care.

When to Update the Form

The LIC 625 must be updated in writing at least every 12 months, or sooner whenever a significant change in the resident’s condition occurs, whichever comes first. These updates are called reappraisals.² The annual review also satisfies the Health and Safety Code Section 1569.80 requirement to meet with the resident and relevant participants to review and revise the written care record.⁷

Significant changes that require an immediate reappraisal include physical trauma such as a heart attack, stroke, or serious fall; noticeable cognitive decline in memory, reasoning, judgment, or decision-making; new or worsening behaviors that could cause harm, such as unsafe wandering, elopement attempts, hallucinations, or loss of impulse control; a major mental or social event like the death of a loved one; illness or injury that substantially changes the resident’s health care or dietary needs; and any change in whether the resident’s access to certain personal items could endanger themselves or others.²

When a behavioral concern triggers a reappraisal, the documentation must go beyond noting the behavior. Describe what happened, identify events occurring just before it (interactions, environmental changes, possible signs of new illness or pain), and spell out the least restrictive intervention the facility will use to manage it.²

Where the Form Lives After You Finish It

Keep the completed LIC 625 in the resident’s individual record at the facility or in a central administrative location readily available to staff.⁹ The resident’s record must also hold the pre-admission appraisal documentation, functional capabilities evaluation, mental condition assessment, social factors documentation, and every reappraisal.

Records are confidential. The licensee and employees may share information only with the resident’s written consent or that of their designated representative, with one major exception: licensing agency staff can inspect, audit, and copy any resident record on demand during normal business hours.⁹ Analysts will check that the services being delivered match what the LIC 625 documents.

What Incomplete Forms Cost

Missing or incomplete LIC 625 forms are licensing violations. For a first-time deficiency that remains uncorrected after the facility has been given time to fix it, the Department of Social Services assesses a civil penalty of $100 per day. A repeat notice for the same violation carries an immediate $250 penalty plus $100 per day until corrected. Serious violations that cause resident injury, involve fire clearance problems, involve absence of required supervision, or reflect refusal to allow licensing staff entry trigger an immediate $500 penalty plus the daily $100 charge.¹⁰ A third citation within 12 months brings an immediate $1,000 penalty per violation.¹¹

Record-keeping deficiencies rarely lead to license revocation on their own, but they surface alongside other problems, and a pattern of incomplete appraisals tells analysts the facility may not be delivering the care it claims to provide.

1
California Department of Social Services. Forms and Publications (I-L)
2
Legal Information Institute. California Code of Regulations Title 22 Section 87463 – Reappraisals
3
Justia Law. California Code of Regulations Title 22 Section 87457 – Pre-Admission Appraisal
4
Legal Information Institute. California Code of Regulations Title 22 Section 87458 – Medical Assessment
5
Legal Information Institute. California Code of Regulations Title 22 Section 87459 – Functional Capabilities
6
California Department of Social Services. Records to Be Maintained at the Facility – Residential Care Facility for the Elderly
7
California Legislative Information. California Health and Safety Code Section 1569.80
8
Legal Information Institute. California Code of Regulations Title 22 Section 87455 – Acceptance and Retention Limitations
9
Legal Information Institute. California Code of Regulations Title 22 Section 87506 – Resident Records
10
California Legislative Information. California Health and Safety Code Section 1569.49
11
California Department of Social Services. Civil Penalty Assessment