Form Lic 9020 - Register Of Facility Clients/residents Page 2
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1
2INSTRUCTIONS FOR REGISTER OF FACILITY CLIENTS/RESIDENTS
Type or print clearly. The licensee shall ensure that a current register of all clients/residents in the
facility is maintained.
1. Facility Name: Enter the name used by to designate the single facility under application.
2. Facility Number: Enter facility number assigned by the California Department of Social Services.
3. Licensee Name: Enter the name of the licensee. “Licensee” means the individual, firm,
partnership, corporation, association or county having the authority and responsibility for the
operation of a licensed facility.
4. Date/Update: Enter the date information is being initially recorded or updated.
5. Client/Resident Name: Enter client/resident legal name.
6. Ambulatory Status: Check appropriate box that indicates the client/resident mobility status.
These definitions are for the purposes of a fire clearance.
Ambulatory: Means a person who is capable of demonstrating the mental competence and
physical ability to leave a building without assistance of any other person or without the use of
any mechanical aid in case of an emergency.
Non-ambulatory: Means a person who is unable to leave a building unassisted under
emergency conditions. It includes any person who is unable or likely to be unable, to physically
and mentally respond to a sensory signal approved by the State Fire Marshal, or an oral
instruction relating to fire danger, and person who depend upon mechanical aids such as
crutches, walkers, and wheelchairs. A person who is unable to independently transfer to
and from bed, but who does not need assistance to turn or reposition in bed, shall be
considered non-ambulatory for fire safety requirements.
Bedridden: Means a person who is unable to independently turn or reposition in bed.
7. Restricted Health Conditions: Applicable to facilities governed by California Code of
Regulations, Title 22, Sections 80071(a)(1)(D) and 82071(a)(4) only. List client/resident restricted
health condition(s) in the space provided.
8. Physician: Enter the name, address, and telephone number of the client/resident attending
physician.
9. Responsible Person: Enter the name, address, and telephone number of the person responsible
for the client/resident. “Responsible Person” means that individual or individuals, including a
relative, health care surrogate decision maker, or placement agency, who assists the resident in
placement or assume varying degrees of responsibility for the resident’s well-being.
Page ______ of ______
LIC 9020 (5/17) CONFIDENTIAL
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