Form Lic 9020a - Register Of Facility Residents - Residential Care Facilities For The Elderly

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
REGISTER OF FACILITY RESIDENTS -
RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
FACILITY NAME:
FACILITY NUMBER:
LICENSEE NAME
DATE/UPDATE
ROOM
RESIDENT NAME AND
AMBULATORY STATUS
PHYSICIAN
REPRESENTATIVE
IDENTIFIER
LANGUAGE READ
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
BEDRIDDEN
I
PHONE:
PHONE:
OTHER __________
(
)
(
)
NAME:
NAME:
I
AMBULATORY
ADDRESS:
ADDRESS:
I
NON-AMBULATORY
LANGUAGE(S) READ
I
ENGLISH
I
I
BEDRIDDEN
OTHER __________
PHONE:
PHONE:
(
)
(
)
Page______ of ______
LIC 9020A (6/17) (CONFIDENTIAL)

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