Lic 9172 - Functional Capability Assessment

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FUNCTIONAL CAPABILITY ASSESSMENT
Licensees of Adult Residential and Social Rehabilitation Facilities must obtain the following information prior to
placement. The Licensee can obtain this assessment information from the applicant or his/her authorized
representative. Adult Day Care Facilities and Adult Day Support Centers may use this form to identify the
functional ability of the applicant as required. The licensee must maintain this information in the client’s file as a
part of the Needs and Services Plan.
Note: Residential Care Facilities for the Elderly may use this form to assess the person’s functional capabilities as
required in Section 87584 of the regulations.
CLIENT’S NAME
DATE OF BIRTH
AGE
SEX
I I
MALE
I I
FEMALE
Check the box that most appropriately describes clients
Check the box that most appropriately describes clients
ability:
ability:
BATHING:
REPOSITIONING:
I I
I I
Does not bathe or shower self.
Unable to reposition.
I I
I I
Needs help with bathing or showering.
Repositions from side to side.
I I
I I
Bathes or showers without help.
Repositions from front to back and
back to front.
DRESSING:
I I
WHEELCHAIR:
Does not dress self.
I I
I I
Unable to sit without support.
Needs help with dressing.
I I
I I
Sits without support.
Dresses self completely.
I I
Uses wheelchair.
TOILETING:
I I
Needs help moving wheelchair.
I I
Not toilet trained.
I I
Moves wheelchair by self.
I I
Needs help toileting.
I I
VISION:
Uses toilet by self.
I I
Severe vision problem.
TRANSFERRING:
I I
Mild/moderate vision problem.
I I
Unable to move in and out of a bed or
I I
Wears glasses to correct vision problem.
chair.
I I
No vision problem.
I I
Needs help to transfer.
I I
Is able to move in and out of a bed or
HEARING:
I I
chair.
Severe hearing loss.
I I
Mild/moderate hearing loss.
CONTINENCE:
I I
Wears hearing aid(s).
I I
No bowel and/or bladder control.
I I
No hearing loss.
I I
Some bowel and/or bladder control.
I I
Use of assistive devices, such as a
COMMUNICATION:
I I
catheter.
Does not express verbally.
I I
I I
Complete bowel and/or bladder control.
Expresses by facial expressions or
gestures.
EATING:
I I
Expresses by sounds or movements.
I I
Does not feed self.
I I
Expresses self verbally.
I I
Feeds self with help from another
person.
WALKING:
I I
I I
Feeds self completely.
Does not walk.
I I
Walks with support.
GROOMING:
I I
Uses walker.
I I
Does not tend to own personal hygiene.
I I
Walks well alone.
I I
Needs help with personal hygiene
tasks.
I I
Handles own personal hygiene.
(over)
LIC 9172 (8/01)

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