California Department of Social Services Monthly Operating Statement
This file is the Monthly Operating Statement (LIC 401) required by the California Department of Social Services for care facilities. It details the operating revenues and costs for a specific reporting month. Applicants and licensees must submit this form as part of their compliance.
Edit, Download, and Sign the California Department of Social Services Monthly Operating Statement
Form
eSign
Add Annotation
Share Form
How do I fill this out?
To fill out this form, you'll need to provide detailed financial information about the care facility for a specific month. Ensure you include all required revenues and costs, and verify the accuracy of the data. Sign and date the form upon completion.
How to fill out the California Department of Social Services Monthly Operating Statement?
1
Identify the reporting period, facility name, address, and license number.
2
Report all sources of operating revenues like SSI revenue and private payments.
3
List all operating costs including food, supplies, and administrative expenses.
4
Calculate the total operating costs and net profit or loss.
5
Sign and date the form to certify the accuracy of the provided information.
Who needs the California Department of Social Services Monthly Operating Statement?
1
Care facility operators who need to report their monthly financial activities.
2
Applicants for a care facility license who must provide financial estimates.
3
Accountants managing the finances of care facilities.
4
Regulatory compliance officers ensuring accurate financial reporting.
5
Business owners monitoring the profit and loss of their care facilities.
How PrintFriendly Works
At PrintFriendly.com, you can edit, sign, share, and download the California Department of Social Services Monthly Operating Statement along with hundreds of thousands of other documents. Our platform helps you seamlessly edit PDFs and other documents online. You can edit our large library of pre-existing files and upload your own documents. Managing PDFs has never been easier.
Edit your California Department of Social Services Monthly Operating Statement online.
On PrintFriendly, you can easily edit this PDF file. Open the file on the platform and use the editing tools to modify any field. Once completed, you can download the edited version directly.
Add your legally-binding signature.
With PrintFriendly, signing this PDF is a breeze. Open the file, use the signature tool to add your digital signature, and place it on the designated signature field. Save and download the signed document instantly.
Share your form instantly.
Sharing this PDF on PrintFriendly is simple. Open the document, click on the share button, and choose your preferred method like email or a direct link. Share the completed form securely and efficiently.
How do I edit the California Department of Social Services Monthly Operating Statement online?
On PrintFriendly, you can easily edit this PDF file. Open the file on the platform and use the editing tools to modify any field. Once completed, you can download the edited version directly.
1
Upload the PDF file to PrintFriendly.
2
Open the document in the PDF editor.
3
Click on the fields that need editing and enter the new information.
4
Review the changes for accuracy.
5
Save and download the edited PDF.
What are the instructions for submitting this form?
Submit the completed LIC 401 form via mail to the California Department of Social Services at the address provided in the instructions. You can also fax it to the number indicated on the form or submit online if an electronic submission form is available. Ensure all sections are accurately filled, signed, and dated. Verify the instructions on the reverse side of the form for updated submission details.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates provided for the submission of this form for 2024 or 2025. Ensure timely submission as part of compliance requirements.
What is the purpose of this form?
The Monthly Operating Statement (LIC 401) serves a critical function in the financial accountability of care facilities. It provides a detailed breakdown of all revenues and operating costs incurred over a month, thereby offering a clear picture of the facility’s financial health. By mandating this form, the California Department of Social Services ensures transparency and fiscal responsibility among care facilities. Filling out the LIC 401 form accurately is not just a regulatory requirement but also a valuable practice for facility management. It helps the operators track financial performance, identify areas where costs can be managed better, and demonstrate financial stability to stakeholders and regulators. This form is an integral part of the compliance process for existing and newly applying facilities. As a monthly snapshot of financial activities, the LIC 401 allows facilities to make informed decisions based on actual data. It helps in planning budgets, managing resources efficiently, and maintaining overall financial health. Compliance with this requirement underscores a facility’s commitment to high standards of care and operational excellence.
Tell me about this form and its components and fields line-by-line.
- 1. Facility Information: Includes facility name, address, and license number.
- 2. Program Revenues: Captures various revenue sources such as SSI revenue, voluntary contributions, and private pay.
- 3. Other Revenues: Includes any additional revenues related to the facility like interest income or insurance reimbursements.
- 4. Operating Costs - Care and Services: Detailed costs for food, household supplies, personal hygiene, and other client services.
- 5. Operating Costs - General Administration: Includes salaries, benefits, office supplies, and other administrative expenses.
- 6. Operating Costs - Physical Plant: Captures costs for rent, utilities, repairs, and maintenance of the facility.
- 7. Net Profit (Loss): Calculates the financial outcome by subtracting total operating costs from total revenues.
- 8. Signature Block: Requires the name of the preparer, title, and signatures of the applicant or licensee.
What happens if I fail to submit this form?
Failure to submit the Monthly Operating Statement can lead to regulatory non-compliance.
- Penalties: Non-submission can result in fines or other penalties.
- License Revocation: Repeated failure may lead to the suspension or revocation of the operating license.
- Operational Disruption: The facility may face interruptions in operations due to non-compliance issues.
How do I know when to use this form?
- 1. Monthly Reporting: Submit this form monthly to comply with financial reporting requirements.
- 2. License Application: Include estimated financials when applying for a new care facility license.
- 3. Operational Monitoring: Use the form to track and monitor the financial health of the facility.
Frequently Asked Question
How do I fill out the Monthly Operating Statement on PrintFriendly?
Open the PDF in the editor, click on the fields to enter information, and save the completed form.
Can I edit the Monthly Operating Statement after uploading?
Yes, you can use PrintFriendly's editing tools to modify any field in the PDF.
How do I add a signature to the Monthly Operating Statement?
Use the signature tool in the PrintFriendly editor to add your digital signature.
Can I share the completed form directly from PrintFriendly?
Yes, you can share the form via email or a direct link using the share button.
Do I need special software to fill out the form on PrintFriendly?
No, PrintFriendly provides all the tools you need to fill out, edit, and save the form online.
Is there a way to verify the accuracy of my entries?
Yes, review your entries before saving to ensure all information is accurate.
Can I save a partially completed form and finish it later?
Yes, you can save your progress and return to complete the form at any time.
How do I print the completed Monthly Operating Statement?
Download the completed PDF and use your printer to create a hard copy.
What if I make a mistake while filling out the form?
You can easily correct mistakes using the editing tools in PrintFriendly.
Can I fill out the form on a mobile device?
Yes, PrintFriendly is compatible with mobile devices for on-the-go form filling.
Related Documents - Monthly Operating Statement
Supplemental Financial Information Form California Department of Social Services
This form is used by sole proprietors, general partners, and licensees to report supplemental financial information for the California Department of Social Services. It includes sections for personal income, personal expenses, and other financial details. Completing this form accurately is essential for compliance with licensing regulations.
Preplacement Appraisal Information - California Residential Care Facilities
This form is required by the California Department of Social Services for admission to residential care facilities. It gathers applicant information including health, physical and mental condition, social factors, and needed services. The form helps determine the applicant's suitability for admission.
California Department of Social Services Personnel Record
This form is used by employees of the California Department of Social Services to provide personal and employment information. It includes fields for personal details, employment history, and educational background. This form helps maintain accurate records of employees.
California Department of Social Services Personnel Record Form
This form is used by the California Department of Social Services to keep a record of employee details. It includes personal information, employment history, education, and references. This is mandated for compliance and verification purposes.
