LIC 604A: Admission Agreement for Residential Care Facilities for the Elderly
LIC 604A is the admission agreement between an RCFE and its resident. It outlines the services provided, rates and fees, refund policies, resident rights, and the conditions under which a resident may be asked to leave the facility.
What Is LIC 604A?
LIC 604A, Admission Agreement for Residential Care Facilities for the Elderly, is the agreement between the facility and the resident that sets out the terms of the resident's stay.
The agreement covers important details such as the services provided, rates and fees, optional services, refunds, rate increases, and conditions related to leaving the facility. It gives both the facility and the resident a written understanding of what has been agreed upon.
For RCFE owners, the goal is simple: make sure the resident understands what they are paying for, what services they will receive, and the terms of their stay before the agreement is signed.
Official LIC 604A Form
The current LIC 604A published by the California Department of Social Services is available through the CDSS website. RCFE Connect links to the live source rather than hosting a copy, so you can refer to the official form.
Who Completes LIC 604A and When?
The facility prepares the admission agreement, while the resident or their legal representative reviews and signs it.
The agreement should be completed and signed as part of the admission process. If the terms of the agreement change, such as rates or services, the changes should be documented in writing and kept with the resident's records.
What Information Is Included on LIC 604A?
LIC 604A addresses important terms of the resident's agreement, including:
Facility and resident information
Services provided by the facility
Rates and fees
Optional services and their charges
Rate increases and related notices
Refund provisions
Conditions related to leaving the facility
Signatures and dates of the parties to the agreement
How to Complete LIC 604A
1. Complete the facility and resident information
Enter the required information for the facility and resident or their representative. Make sure the information is accurate and matches the resident's records.
2. Record the actual rates and services
Complete the rate and service sections using the actual amounts and services agreed upon with the resident. Avoid leaving applicable rate information blank.
3. Review fees and optional services
If the resident will pay for additional or optional services, make sure the applicable charges are clearly identified and consistent with what the facility will actually bill.
4. Explain the agreement before signing
Walk the resident or their representative through important provisions, including rate increases, refunds, and conditions related to leaving the facility. Give them an opportunity to review the agreement and ask questions.
5. Have all required parties sign and date
Make sure the appropriate parties sign and date the agreement. Provide the resident or their representative with a fully signed copy.
6. Keep the agreement updated
When rates, services, or other material terms change, document the change in writing and keep the updated agreement or amendment with the resident's records. Keep previous versions when they are part of the resident's file.
Common LIC 604A Mistakes to Avoid
A few common issues can create problems when reviewing an admission agreement:
Rate information left blank: Applicable rates should be completed rather than left empty.
Rates don't match what is billed: The amounts in the agreement should be consistent with the actual charges to the resident.
No signed copy provided: The resident or their representative should receive a fully signed copy.
Verbal changes only: Changes to rates or services should be documented in writing rather than relying on a verbal agreement.
Missing signatures or dates: Review the agreement before filing to make sure the required signatures and dates are present.
LIC 604A Quick Check
Before filing the admission agreement, check:
☐ Facility and resident information is complete and accurate
☐ Agreed-upon rates are clearly recorded
☐ Services and optional services are identified
☐ Applicable fees match what the facility will actually charge
☐ Refund and rate-increase provisions were reviewed
☐ Required parties have signed and dated the agreement
☐ Resident or representative received a signed copy
☐ Written amendments are maintained when terms change
Frequently Asked Questions
Does the resident get a copy of the admission agreement?
Yes. The resident or their representative should receive a fully signed copy of the admission agreement, while the facility keeps the original in the resident's record.
Who prepares LIC 604A?
The facility prepares the admission agreement for the resident or their representative to review and sign.
When should LIC 604A be completed?
It should be completed and signed as part of the admission process, before or at the time the resident enters into the agreement with the facility.
What happens if the rates or services change?
Changes should be documented in writing rather than made only through a verbal agreement. The facility should keep the updated documentation with the resident's records.
Why is LIC 604A important for RCFE owners?
It provides a written record of the terms agreed upon between the facility and resident, including the services, rates, fees, and other conditions of the resident's stay.
More California RCFE LIC Forms
LIC 604A is one of many forms used in California's residential care system.
RCFE Connect is building a practical library to help facility owners understand what different LIC forms are for, when they are used, and what to check when completing them.
More LIC form guides coming soon.
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