TransparencyResidential Provider Forms
Vendors of residential services must comply with ACRC Vendor Agreements and Title 17 Regulations. Service providers must have a Resident file for each resident, a Personnel file for each employee and a Residential Facility file for the home itself.
The forms below have been developed in coordination between Alta California Regional Center (ACRC), Community Care Licensing (CCL), and/or residential providers; they are provided for your benefit and ease of meeting the documentation requirements per vendorization and regulations. The forms are separated by Resident File, Personnel File, and Facility File. Each section has a Table of Contents that is to be used as a means of setting up your files as well as a self-auditing tool. The Tables of Contents will include Licensing forms (LIC forms) that are not located on ACRC’s website; those forms can be accessed through Community Care Licensing’s website.
If there are any questions or concerns regarding the ACRC forms or documentation requirements, please contact your ACRC Facility Liaison or your ACRC Community Services Specialist.
Resident File
Resident Chart Table of Contents
Recent Photo and Physical Description
Residential Services Provider (RSP) Review of Client Progress on IPP Objective
Client Rights
Individual Consultant Log Form
On-Going Notes
Behavior Consultation Log
HCBS Final Rules Signature
Special Incident Report
Centrally Stored Medication and Destruction
Resident Personal Property and Valuables
PRN Administration Record
Medication Reason for Use
Medication Administration Record (MAR)
Weight Record
Seizure Record
Physician Visit
Medication Transfer
Grievance Procedure
Dental Visit
Consultation Hours Log
Personnel File
Personnel Table of Contents
On Site Orientation and On the Job Training Checklist
Facility File
Facility File Table of Contents
Weekly Staff Schedule
Weekly Resident Accountability
Looking at Service Quality Provider Handbook
Monthly Fire Drill Record
Behavior Consultation Guidelines and Forms
Behavior Consultation Quarterly Progress Update Report
Individual Emergency Intervention Plan
Functional Assessment and Behavior Intervention Plan
Additional Resources
P&I Reimbursement Policy
ACRC Personal and Incidental Funds Instruction Manual
Please see: CCL – Forms and Publications to locate the following required forms: LIC 405, LIC 601, LIC 602 or LIC 602A, LIC 621, LIC 622