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LIC 602A: California RCFE Medical Assessment

Residential care facilities for the elderly (RCFEs, California's licensed assisted living) must have a signed medical assessment on file before accepting a resident, and this courtesy form covers what Title 22, section 87458 requires. Clinicians meet it when a patient is moving into an RCFE or the facility needs an updated assessment. The licensee uses it to decide whether its non-medical care can meet the person's needs.

Who completes it

The facility completes Section I, and the prospective resident or their legal representative completes Sections II and III, including the release. A licensed medical professional acting within the scope of their practice, such as a physician, nurse practitioner or physician assistant, completes the Section IV assessment and the Section V signature block.

How to fill it in

I. Facility Information (to be completed by the licensee/designee)

The facility enters its name, contact person, phone, email and address. Use this block to confirm which RCFE is asking and where the finished assessment goes. The form notes that you may attach separate pages wherever you need more space.

II. Prospective Resident/Resident Information and III. Authorization for Release of Medical Information

The prospective resident or their legal representative enters name, date of birth, age and address, then signs and dates the release authorizing you to share the report with the facility named in Section I. The release includes an acknowledgment that an electronic signature is legally binding. Confirm it is signed before you send the completed form.

IV. Prospective Resident/Resident Information: exam, diagnoses and cognitive conditions

Record the exam date, gender, height, weight and blood pressure. List diagnoses with treatment, medication (type and dosage) and equipment, and say whether the person can manage their own treatment; if not, describe the help needed. The cognitive conditions block uses the printed definitions of mild cognitive impairment and major neurocognitive disorder, which includes Alzheimer's disease, vascular, Lewy body and frontotemporal dementia and Parkinson's disease.

Results of exam for tuberculosis, infectious, contagious and other medical conditions; allergies

For tuberculosis, enter the dates the test was given and read, the test type, the result and any action taken if positive. Then answer Yes or No for infectious diseases, contagious diseases, other medical conditions and allergies. For each Yes, name the condition, give treatment, medication and equipment, and state whether the person can manage it on their own.

1. Overall Physical Health and 2. Capacity for Self-Care

Rate overall physical health as good, fair or poor, then answer Yes or No, with any assistive device, for hearing and vision loss, dentures, prosthesis, special diet, substance, alcohol and nicotine use, bowel and bladder incontinence, motor impairment, need for help repositioning and transferring, and skin breakdown history. Self-care items cover bathing, dressing, feeding, toileting, managing cash, communicating, following directions and leaving the facility unsupervised given the person's cognition.

3. Overall Mental Health and 4. Behavioral Expressions

Rate overall mental health, then mark depression, suicidal ideation, self-abuse or other concerns. The behavioral expressions grid asks about disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, expressions of frustration and hallucinations. Footnotes define each term; for example, elopement means a person at risk because of their cognitive condition leaving the facility unsupervised. Explain each Yes and add comments.

5. Access to Items and 6. Medication Management

Say whether the person's or other residents' safety would be at risk if the person had access to personal care items, cleaning solutions, sharp objects and similar hazards, or to supplements, alcohol, cigarettes and other potentially toxic substances. Indicate whether supervision is needed near stoves and heaters, pools and hot tubs, or decorative water features. Then mark whether the person can self-administer prescriptions, injections, PRN medications and oxygen, do glucose testing and store their own medications.

Ambulatory Status

State whether the person transfers to and from bed independently and classify them as ambulatory, nonambulatory or bedridden for fire clearance, using the printed definitions. For nonambulatory status, say whether it rests on a physical condition, a mental condition or both. For bedridden status, give the cause, the expected duration in days or an end date, or explain if permanent. Finally, note whether the person receives hospice care and, if so, the terminal illness.

V. Licensed Medical Professional Information

Print your name and address, add phone and email, and state how long you have provided care to the person. Sign and date the form. The block includes an acknowledgment that an electronic signature is the legally binding equivalent of a handwritten one, so an e-signed form is acceptable.

Common mistakes

  • Filling out an outdated Physician's Report version instead of the updated LIC 602A, which CDSS released to match the dementia care regulations effective January 1, 2025.
  • Leaving the tuberculosis results incomplete; Title 22 requires examination results for communicable tuberculosis, and the form asks for test dates, type, result and any action taken.
  • Marking a resident nonambulatory without saying whether the status rests on a physical condition, a mental condition or both, as the regulation requires.
  • Answering No to self-management of a treatment or medication without describing the assistance needed, which each condition block asks for.
  • Skipping the bedridden duration questions, which the facility needs because an illness or recovery lasting 14 days or less is treated as temporary.
  • Relying on an assessment made more than a year before the person's acceptance, which does not meet Title 22, section 87458.

Submitting and payment

How to submit it
Send the completed form to the facility contact named in Section I; the licensee keeps it in the resident's record. The assessment must have been made within the year before the person is accepted, and the facility must obtain an updated one when the Department requires it.
Who pays
Neither the form nor the CDSS notice announcing it sets a fee or billing code for completing the assessment.

Good to know

  • The form was formerly titled Physician's Report for Residential Care Facilities for the Elderly. CDSS updated it for the dementia care regulations that took effect January 1, 2025; the current revision is 4/26.
  • The note to the clinician stresses that RCFEs provide primarily non-medical care and supervision and cannot provide skilled nursing care, so the assessment speaks to whether the setting is appropriate.
  • Ambulatory status feeds the facility's fire clearance: a person who cannot transfer to and from bed independently counts as nonambulatory, and one who needs help turning or repositioning in bed counts as bedridden.
  • CDSS calls it a courtesy form: the regulation requires a medical assessment with specified content, and this template is built to cover it. Both the resident's and the clinician's signature blocks accept electronic signatures.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Assessment for Residential Care Facilities for the Elderly

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can complete the LIC 602A?

Any licensed medical professional acting within the scope of their practice. The 2025 update removed references to a physician so that other licensed professionals, such as nurse practitioners and physician assistants, can complete it. Title 22 section 87458 likewise requires the medical assessment to be signed by a licensed medical professional acting within scope.

How recent must an RCFE medical assessment be?

Under Title 22 section 87458, the assessment must have been made within the last year before the person is accepted as a resident, and the facility must obtain an updated assessment when the Department requires it. Separately, the facility updates its own appraisal of the resident at least every 12 months or when the resident's condition changes significantly.

What does bedridden mean on the LIC 602A?

For fire clearance purposes, bedridden means the person needs help turning or repositioning in bed. If you mark bedridden, check the cause (illness, recovery from surgery or other), give the expected duration in days or an estimated end date, or explain if it is permanent. The form treats an illness or recovery lasting 14 days or less as temporary.

Is the LIC 602A the same as the old Physician's Report?

It keeps the LIC 602A number but replaces the Physician's Report for Residential Care Facilities for the Elderly. Provider Information Notice 25-05-ASC lists the changes: updated definitions of mild cognitive impairment and major neurocognitive disorder, separate sections for cognitive, infectious, contagious and other conditions, and new fields on behavioral expressions, access to items, medication management and ambulatory status.