Submit the completed form to the relevant licensing authority via email, fax, or post. Ensure that all required fields are accurately filled. Email: licensing@ca.gov, Fax: (123) 456-7890, Mail: California Department of Social Services, Community Care Licensing Division, 744 P Street, MS 9-14-47, Sacramento, CA 95814.

The form does not have specific dates but must be updated as necessary upon admission or changes in the client's or resident's condition.

The purpose of this form is to assess and plan for the needs and services required by clients or residents in community care facilities. This comprehensive document ensures that all individual needs, whether social, emotional, mental, or physical/health, are thoroughly identified and addressed. Properly completing this form helps in creating a detailed care plan, thereby improving the quality of care and support provided to individuals.

• 1. CLIENT'S/RESIDENT'S NAME: Enter the full name of the client or resident here.
• 2. DATE OF BIRTH: Provide the exact date of birth of the client or resident.
• 3. AGE: Mention the age at the time of filling out the form.
• 4. FACILITY NAME: Insert the name of the facility where the client or resident is placed.
• 5. ADDRESS: Indicate the complete address of the facility.
• 6. SEX: Select either male or female gender of the client.
• 7. DATE: Mention the current date when the form is being filled.
• 8. TYPE OF NEEDS AND SERVICES PLAN: Specify whether this is an admission or update plan.
• 9. REFERRING AGENCY: Provide details of the agency or person referring the client.
• 10. LICENSING REGULATIONS: Explain which regulations require the appraisal to be completed.
• 11. BACKGROUND INFORMATION: Briefly describe the client’s medical, emotional, and functional history.
• 12. OBJECTIVES AND PLANS: List down objectives/plans for socialization, emotional, mental, and physical/health needs.
• 13. METHOD OF EVALUATING PROGRESS: Describe the method to evaluate the progress of the service plan.
• 14. PERSON RESPONSIBLE: Identify persons responsible for implementing the plan.

Failure to submit this form can result in a lack of comprehensive care plans for clients or residents, leading to unmet needs.

• Inadequate Care: Clients or residents may not receive the necessary services and support.
• Regulatory Non-Compliance: Non-submission may lead to violations of licensing regulations.
• Miscommunication: Lack of proper documentation can result in miscommunication among staff and caregivers.

• 1. New Admissions: Complete the form during the admission of a new client or resident.
• 2. Updates: Use this form to update the care plan if there is a change in the client’s condition.
• 3. Regulatory Requirements: Submit the form to comply with licensing regulations.
• 4. Care Plan Review: Review and document the progress in meeting the client’s needs.
• 5. Inter-agency Coordination: Facilitate communication and planning between different care agencies.