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COMMUNITY CARE LICENSING DIVISION REGISTER OF …

STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY care LICENSING DIVISIONREGISTER OF FACILITY CLIENTS/RESIDENTSFACILITY NAME:FACILITY NUMBER:LICENSEE NAMEDATE/UPDATENAME:NAME:ADDRESS:ADDRESS :PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )Page_____ of _____LIC 9020 (8/11) (CONFIDENTIAL)RESPONSIBLE PERSONPHYSICIAN AMBULATORY STATUSRESTRICTED CONDITION(S)(If applicable)CLIENT/RESIDENTNAMEROOMIDENTI FIER(If applicable)AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN INSTRUCTIONS FOR REGISTER OF FACILITY

lic 9020 (8/11) (confidential) page_____ of _____ physician responsible person ambulatory status restricted condition(s) (if applicable) client/resident name room identifier (if applicable) ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden ambulatory non-ambulatory bedridden

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Transcription of COMMUNITY CARE LICENSING DIVISION REGISTER OF …

1 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYCALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY care LICENSING DIVISIONREGISTER OF FACILITY CLIENTS/RESIDENTSFACILITY NAME:FACILITY NUMBER:LICENSEE NAMEDATE/UPDATENAME:NAME:ADDRESS:ADDRESS :PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )NAME:NAME:ADDRESS:ADDRESS:PHONE:PHONE:( )( )Page_____ of _____LIC 9020 (8/11) (CONFIDENTIAL)RESPONSIBLE PERSONPHYSICIAN AMBULATORY STATUSRESTRICTED CONDITION(S)(If applicable)CLIENT/RESIDENTNAMEROOMIDENTI FIER(If applicable)AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN AMBULATORY NON-AMBULATORY BEDRIDDEN INSTRUCTIONS FOR REGISTER OF FACILITY CLIENT/RESIDENTSType or print clearly.

2 The licensee shall ensure that a current REGISTER of all clients/residents in thefacility is Name: Enter the name used by to designate the single facility under Name: Enter the name of the Licensee. Licensee means the individual, firm,partnership, corporation, association or county having the authority and responsibility for theoperation of a licensed : Enter the date information is being initially recorded or Identifier: Applicable to Residential care for the Elderly only. Enter information thatidentifies the resident room, such as room Name: Enter client/resident legal Status: Check appropriate box that indicates the client/resident mobility definitions are for the purposes of a fire clearance.

3 Ambulatory: Means a person who is capable of demonstrating the mental competence andphysical ability to leave a building without assistance of any other person or without the use ofany mechanical aid in case of an emergency. Non-ambulatory: Means a person who is unable to leave a building unassisted underemergency conditions. It includes any person who is unable or likely to be unable, to physicallyand mentally respond to a sensory signal approved by the State Fire Marshal, or an oralinstruction relating to fire danger, and person who depend upon mechanical aids such ascrutches, walkers, and wheelchairs.

4 A person who is unable to independently transfer toand from bed, but who does not need assistance to turn or reposition in bed, shall beconsidered non-ambulatory for fire safety requirements. Bedridden: Means a person who is unable to independently turn or reposition in Health Conditions means those conditions required by sections 80071(a)(1)(D) and 82071(a)(4), and only applies to facilities governed by these : Enter the name, address, and telephone number of the client/resident Person: Enter the name, address, and telephone number of the person responsiblefor the client/resident. Responsible Person means that individual or individuals, including arelative, health care surrogate decision maker, or placement agency, who assists the resident inplacement or assume varying degrees of responsibility for the resident s 9020 (8/11) CONFIDENTIALPage _____ of _____


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