Frequently Asked Questions? - FAQs arranged in alphabetical order

Activities of daily living (ADLs) are everyday routines generally involving functional mobility and personal care.  Examples include bathing, dressing, toileting and self-feeding.

Title 22 (§ 87405 & 87406)

All facilities must have a certified administrator.  The RCFE administrator is the individual designated by the Licensee to oversee the management of the facility.  The administrator must have sufficient freedom from other responsibilities (i.e. caregiving) and be on the premises a sufficient number of hours to permit adequate attention to the management of the facility. 

Title 22 states "that CCLD can require the administrator to devote additional hours  to their responsibilities in the facility if substantiated by written documentation" and CCLD "reserves the right to revoke the license of the facility for an administrator's failure to comply with regulations."

If you are concerned with the performance of an administrator, it is appropriate to document your concerns and to contact CCLD.

According to Title 22, administrators must possess the following qualifications: (1) Knowledge of providing appropriate care and supervision, (2) Knowledge of and ability to conform to applicable laws and regulations, (3) Ability to maintain financial and other records, (4) Ability to direct the work of others, (5) Good character and a reputation for personal integrity, (6) Be at least 21 years old, (7) Have a high school diploma or GED for 1-6 bed facilities; 15 college credits and one year's experience for 16-49 bed facilities; two years of college and three years experience for 50+bed facilities.

To become certified as an administrator, individuals must receive 40-hours of  training from an accredited vendor, pass a test administered by CCLD, receive a criminal record clearance from the Department of Justice and pay a $100 processing fee.

Administrator certificates must be renewed every two years.  To maintain the certification, administrators must receive at least 20 hours of continuing education annually and pay $100 processing fee upon request for renewal.  Title 22 also requires that appropriate documentation be maintained demonstrating an administrator's certificate is valid and current (Title 22 §87412).

Proof of an administrator's qualifications and training is not available in the public file, however the consumer can verify whether an Administrator's Certificate is current by viewing the "List of Active Certificates"  on CCLD's website.   With limited available resources to independently evaluate the qualifications of those responsible for facility operations, it would be useful to interview the Administrator during the facility tour. 

The admissions process is the critical point at which you, the consumer, can identify if the facility you have chosen will be able to meet all of the resident's needs and expectations.  Prior to accepting a resident, the regulations stipulate that a facility must evaluate the appropriateness of the resident for the facility.  This evaluation typically consists of an interview, a pre-admissions appraisal, a medical assessment, and presentation of the Admissions Agreement (Title 22 § 87456).  Presented here is what you can expect from each of these events.

If at any point a facility conveys a sense of urgency, for example "Act now or your spot may be taken", it is important for consumers to be aware that in many cases facilities are operating below capacity and this sentiment could simply be a part of their marketing strategy.

Consumers can view the entire admissions process as YOUR chance to evaluate the appropriateness of the facility for the resident. 

You can expect the following from the facility:

(1) An interview with the Licensee/Administrator (§87457)

According to Title 22, during this interview, sufficient information must be provided regarding the facility and its services such that all persons involved in the placement can make an informed decision regarding admission.  Topics for discussion include the prospective resident's desires, expectations, their personal and medical background, and any specific resident needs.  Topics should be discussed in detail and in reference to how the facility anticipates achieving the care requested and required by this resident.

(2) A pre-admission appraisal (§ 87457)

The LIC 603 created by CCL and is used by facilities to document the appraisal.  This form can be used as a tool to assist you in your interview of the facility.  By reviewing these questions ahead of time, you will be prepared to ask the facility more specifically how it plans to address the resident's needs. 

Furthermore, Title 22 requires that if the initial appraisal (or any reappraisal) identifies a service need which is not being met by the general program of the facility, the facility must then obtain advice from a physician, social worker or other appropriate consultant to determine if the needs can be met by the facility, and then they must create a plan outlining the specifics of how those needs will be accommodated should the individual become/remain a resident.  The plan is required to include time frames, objectives, responsible parties, and methods for evaluating progress.  It is imperative that this plan be documented and signed by both parties and a copy maintained in and outside the resident's file to avoid confusion when/if concerns arise. 

Facilities are not required to accept every resident.  It is their responsibility to accept and retain only those residents whose needs can be met.

(3) The request for a recent medical assessment (Title 22 § 87458)

The form LIC 602A, is known as the Physician's Report.  This assessment must be completed and signed by a physician.  It is important to reiterate that RCFEs are non-medical facilities.  The staff employed by RCFEs are not required to have any medical experience aside from general training requirements (Title 22 § 87411).  If you feel the resident may need medical support, even intermittently, you will want to investigate the following:

  • the medical experience of the caregivers employed by the facility
  • the medical experience and critical thinking skills of the administrator/licensee
  • the availability of an RN or LVN (either one employed by the facility or available for consult)
  • and/or you might want to verify whether a higher level of care might not be more appropriate, in that it may provide more experience, more oversight, and more attention to certain conditions and changes in status.
(4) Presentation of the Admissions Agreement

Community Care Licensing offers LIC 604A for facilities to use as their Admissions Agreement.  Based on CARR's review of the files, many smaller facilities use this standard form.  Larger, corporate-owned facilities tend to use their own Admissions Agreement crafted by an attorney. 

Admission Agreement Summary (Title 22 § 87507)

1) Facility and Licensee Contact Information

2) Resident Information

  • Providing your Social Security Number is voluntary

  • Providing information pertaining to financial status, property ownership and (life) insurance information are not required per regulation

3) Basic Services

  • A detailed list and description of what constitutes the basic services provided by the facility must be in the admissions agreement (To see what is required to be provided at a minimum see Title 22 § 87464)

  • The monthly private pay rate for basic services must be stated in the admissions agreement

  • The monthly SSI/SSP rate for basic services must be stated in the admissions agreement and cannot be in excess of the SSI/SSP rate.  Per CCLD's Evaluator Manual (§ 87464): It is a violation of law for a licensee to purposely obtain an SSI/SSP beneficiary's personal and incidental needs allowance to pay for basic services.  CARR is unsure about what is acceptable with regard to requiring family members to pay additional expenses for SSI/SSP residents.  Title 22 § 87464 states that voluntary payments are allowed.  Should this issue arise, CARR recommends contacting Community Care Licensing for guidance.

4) Optional Items and Services

  • Those services not included under basic services, but are available to residents should they choose to receive them must be listed in the admissions agreement alongside the costs associated with each optional item or service.  The resident must agree to purchases these services at an extra charge in the admission agreement.

  • Typical optional items/services include incontinence products, cosmetology services, special food services or products (such as kosher food), etc.

  • Verify the facility's policy on notifying resident's and/or their responsible party should these services become necessary and the policy on arranging payment.

  • Verify the facility's policy on implementing these services should they be desired and the policy on arranging payment

  • Facility's are allowed to post these services in an accessible location if they are not included in the admissions agreement; therefore verifying policies regarding implementation of services and fees is helpful

5) Policies on Rate Changes

  • Facilities must provide 60 days written notice to resident of any basic rate change
  • For SSI/SSP rate changes, residents must be notified as soon as facility is notified.

6) Refund Conditions

7) Eviction Procedures (Title 22 § 87224)

As with any contract, read it entirely and be mindful of:

  • Hidden fees (levels of care or itemized services when additional assistance becomes necessary)
  • Pre-admission fees (non-refundable)
  • Terms of agreement tucked inside residential Handbooks that must be signed and dated.

If you have questions concerning the provisions, contact Community Care Licensing or have your attorney review the document for you.  

Title 22 § 87611 & § 87612

Here are the general requirements facilities must abide by when they accept and/or retain a resident with any of the following allowable health conditions: Oxygen administration, colostomy/ileostomy, IPPB, Contractures, Healing Wounds (bedsores - Stage I & II).

The facility must complete and maintain a current, written record of care for each resident that has one or more of these conditions.  This record must include, at a minimum, the following:

(1) Documentation from the physician that includes type of condition, stability of condition,  method of intervention, resident's ability to perform procedure and the appropriately skilled professional who will assist should resident require assistance with procedure.

(2) The names, address and telephone number of vendors (if any) and all appropriately skilled professionals providing services.

(3) Emergency contacts.

You, as the resident, or responsible party may wish to request a copy of this updated information.

In addition to this written record, the facility is also required per Title 22 § 87611 & 87613 to ensure:

(1) That facility staff have the knowledge and ability to recognize and respond to problems related to health conditions and must contact the physician, appropriately skilled professional, and/or vendor as necessary.

(2) The facility must monitor the ability of the resident to provide self care for these health conditions and document any change in that ability. 

Though not in the regulations, communicating changes in status to other relevant parties (physicians, responsible parties, CCLD if necessary, etc.) would be ideal.

(3) The facility must ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met.

Remember, these are non-medical facilities.  Be aware of the facilities' policies, procedures, outsourcing and histories as they pertain to residents' medical needs to solicit the most appropriate care for your resident.

The regulations go on to say that the duty established by this section does not infringe on the right of a resident to receive or reject medical care or services. 

Should this circumstance arise, be sure it is the resident's intent to refuse services, and not any idleness of the facility, that resulted in foregone medical attention or care.

Additionally, if a facility has had any of the following within the last two years, the Department must approve the facility's acceptance or retention of a resident with the above mentioned health conditions - A probationary license, administrative action, non-compliance conference,or notice of deficiency involving direct care that required correction within 24 hours.

According to Title 22, §87101(a)(6) an "ambulatory person" ". . . 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."

Facility licenses reflect the number of ambulatory and non-ambulatory residents a facility is authorized to serve at any one time.  Additionally, some facilities may have rooms that only ambulatory residents may occupy,  pursuant to the facility's Fire Marshal Clearance

Title 22, §87157 CCLD issues a license to an applicant once the following conditions have been met:

1) A review by an LPA is conducted which includes an on-site survey of the proposed premises and a determination of the qualifications of the applicant.

2) A passing fire clearance has been secured from the State Fire Marshal.

3) A determination that the applicant and facility comply with all provisions in the Health and Safety Code and regulations in Title 22.

According to Title 22 a skilled professional (aka a licensed professional (Title 22 §87101(l)(2), or medical professional (Title 22, §87101(m)(1)) refers to a person licensed in California to provide medical care or therapy, or to perform necessary medical procedures, each acting within their individual scope of practice. This includes:

  • Physicians/surgeons/physician's assistants,
  • RNs/LVNs/Nurse practitioners,
  • Physical/occupational/respiratory therapists,
  • Psychiatric technicians, etc.

RCFEs are non-medical facilities and are not required to have appropriately skilled professionals on-staff.  However, there are stipulations in the regulations that certain types of care can only be provided by appropriately skilled professionals (i.e. administering medications, injections, oxygen, etc.) if the resident is unable to provide the care himself.  

CARR advocates that consumers closely review a resident's current and potential care needs in conjunction with what types of care the RCFE can provide, consistent with Title 22 regulations. 

According to Title 22,§87101(b)(2) "Basic Services" ". . . means those services required to be provided by the facility in order to obtain and maintain a license and include, in such combinations as may meet the needs of the residents and be applicable to the type of facility to be operated, the following: safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care."

A facility's Admissions Agreement must include Basic Services.

Title 22 (§87464)

RCFEs are required to provide §87464(f): safe and healthful living accommodations and services, regular observation of the resident's physical and mental condition, three meals per day plus snacks, personal assistance with ADLs, medication management, social and recreational activities, transportation, housekeeping and maintenance.

"The services provided by the facility shall be conducted so as to continued and promote, to the extent possible, independence and self-direction for all persons accepted for care.  Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility an in the community."

Basic services must be provided to obtain and retain an RCFE license.

Title 22 (§87608)

Bed rails ". . . that extend from the head, half the length of the bed, and used only for assistance with mobility shall be allowed." (§87608(5)(A).

"A written order from a physician indicating the need for the postural support (in this case, bed rails) shall be maintained in the resident's record.  The licensing agency shall be authorized to require other additional documentation if needed to verify the order." (§87608, (3). 

"Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care, and have a hospice care plan that specifies the need for full bed rails."  §87608(5)(B)

Bed rails may not be used as a restraint, for the convenience of staff, or to substitute for staff. 

Title 22 §87606 & H&S Code §1569.72(b)(1) :  Bedridden means any of the following:

(1) A resident who requires ". . . assistance in turning and repositioning in bed", and is unable to leave a building unassisted under emergency conditions.

(2) A resident who is ". . . unable to independently transfer to and from bed. . ." and is unable to leave a building unassisted under emergency conditions.

Title 22, §87606 

(e) & (H&S Code 1569.72(e):   ". . . a bedridden resident may be retained in an RCFE in excess of 14 days if all of the following requirements are satisfied:

"(1) The facility notifies [CCLD] in writing regarding the temporary illness or recovery from surgery.

"(2) The facility submits to [CCLD], with notification, a physician and surgeon's written statement  that the resident's illness or recovery is of a temporary nature.  The statement shall contain an estimated date upon which the illness or recovery will end or upon which the resident will no longer be confined to a bed.

"(3) [CCLD] determines that the health and safety of the resident is adequately protected in that facility and that transfer to a higher level of care is not necessary.

Title 22,§87606(b) & H&S Code 1569.72(f):  "Notwithstanding the length of stay of a bedridden resident, every facility admitting or retaining a bedridden resident shall, within 48 hours of the resident's admission or retention in the facility, notify the local fire authority with jurisdiction in the bedridden resident's location of the length of time the resident will retain his/her bedridden status in the facility."

"CCLD"  and "CCL" denote Community Care Licensing Division, the state agency residing within Department of Social Services, responsible for licensing and regulating Residential Care Facilities for the Elderly (RCFEs). This website uses the terms interchangeably, except when the terms are used as part of a quoted Title 22 regulation. 

Title 22, §87101(c)(2), defines "capacity" as the ". . . maximum number of persons authorized to be provided services at any one time in any licensed facility."

If a facility wishes to change its capacity, it must request a Change in Capacity from CCLD, via a LIC 200.  One approved for additional residents, the state issues to the Licensee a new license reflecting the change.  The Capacity a facility is licensed for appears on each License (LIC 203).  Providing care to more residents than stated on the License is a violation of Title 22, §87204(a).

 

 

As defined by Title 22, §87101(c)(2), capacity of a facility refers to the ". . .maximum number of persons authorized to be provided services at any one time in any licensed facility."   A facility's capacity is printed on its license.  A facility's capacity is determined during the licensing process, and is based on the competency of the Licensee, the physical features of the facility, and the number of staff available, and the stipulations, if any, on the Fire Marshal Clearance. Any facility wishing to serve more than the number of persons authorized on their license must first receive approval from Community Care Licensing.  When the capacity increases, a new license should be issued. 

Title 22, §87101(c)(3):  "Care and supervision" means those activities which if provided shall require the facility to be licensed.  It includes assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents.  "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the resident:

  • Assistance in dressing, grooming, bathing and other personal hygiene;
  • Assistance with taking medication, as specified in regulation §87465;
  • Central storing and distribution of medications;
  • Arrangement of and assistance with medical and dental care. (This may include transportation.);
  • Maintenance of house rules for the protection of residents;
  • Supervision of resident schedules and activities;
  • Maintenance and supervision of resident monies or property;
  • Monitoring food intake or special diets."

A licensed facility is responsible for ensuring "care and supervision" is available/provided to all residents at all times.

Title 22 §87623

The facility shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances:

(1) If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation.  Insertion and irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders.  This includes changing the bag and tubing.

(2) Privacy is maintained when care is provided.

(3) Facility ensures that waste materials are disposed of properly (See §87303).

Additionally, the bag may be emptied by facility staff who receive instruction from an appropriately skilled professional.  If this is the case, the facility is required to maintain written documentation from the appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed.  The staff's performance must be evaluated by the professional at least annually but as often as necessary.

Title 22, §87761

Whenever a deficiency is noted during an inspection, CCL is required by law to issue a penalty notice (commonly called a citation). The Licensee is then on notice to correct the deficiency within a specified amount of time.   If a cited deficiency is not corrected within the specified amount of time , then a Civil Penalty (monetary damages) may be issued. Licensees are required to pay civil penalties; they range from $50 to $150 per day per violation.

Notwithstanding the above requirement, Civil Penalty  issues immediately under the following circumstances: 

  • $100/day for failure to obtain a Criminal Record Clearance or criminal record exemption on individuals working, residing or volunteering in the facility.  Subsequent violations within 12-month period will result in a $100/violation per day penalty for a maximum of 30 days.
  • $150/day for any deficiency resulting in sickness, injury or death of a client.
  • $150/violation for one day for a facility that violates the same regulation subsection within a 12-month period.  A penalty of $50/day, per cited violation, shall be assessed until the deficiency is corrected.  If cited again for same regulation subsection within a 12-month period, then $1,000 per cited violation for one day should be assessed, with $100/day, per cited violation until deficiency is corrected.

Regulations mention that "if necessary, a site visit shall be conducted immediately or within 5 working days to confirm that the deficiency has been corrected".

Title 22 §87621

The facility shall be permitted to accept or retain a resident who has a colostomy or ileostomy under the following circumstances:

(1) The resident is mentally and physically capable of providing all routine care for his/her ostomy; and the physician has documented that the ostomy is completely healed; OR

(2) If assistance in the care of the ostomy is provided by an appropriately skilled professional.

(3) Privacy is afforded when care is provided.

(4) The used bags are discarded appropriately.

Additionally, the bag and adhesive may be changed by facility staff who have been instructed by the appropriately skilled professional.  The facility must maintain written documentation provided by the appropriately skilled professional,  outlining the instruction of the procedures delegated, and the names of the facility staff who have been instructed.  The appropriately skilled professional shall review the procedures and techniques no less than twice a month.

(Title 22, §87755)

"Upon receipt of a complaint, . . . the department shall make a preliminary review and . . . an onsite inspection within 10 days after receiving the complaint except where the visit would adversely affect the licensing investigation or the investigation of other agencies, including, but not limited to, law enforcement agencies . . ."

This only means CCL has to initiate the complaint investigation - not complete it and report findings to the complainant  - with 10 days. 

Complaint investigations are reported on LIC 9099s.

Title 22, §87101(c)(11):   "Conservator" means a person appointed by the Superior Court pursuant to Probate Code section 1800 et. seq. or Welfare and Institutions Code §5350, to care for the person, or estate, or person and estate, of an adult."

". . . No Licensee or employee of a facility shall . . . (1) accept appointment as guardian or conservator of the person and/or estate of any resident. . .* " (Title 22, §87217(d)(1). 

*Except as provided in agreements with continuing care facilities.

Title 22 §87626

Contractures are the shortening of the muscle or joint resulting from and/or exacerbated by (among other things) inactivity.

Title 22 §87626(a)(1) ". . . the Licensee shall be permitted to accept or retain a resident who has contractures under the following circumstances:

(1) If the contractures do not severely affect functional ability and the resident is able to care for the contractures by him/herself (i.e. perform physical therapy exercises independently) ; or

(2) If the contractures do not severely affect functional ability and care and/or supervision is provided by an appropriately skilled professional (i.e, a skilled professional is responsible for assisting in the performance of exercises).

If a resident is experiencing contractures at the time of placement, it is important you discuss with the facility the resident's expectations regarding exercises and physical activity, and assess the facility's ability to meet the requirements, and your expectations. Facilities maintaining a limited activity program, or having inexperienced staff may cause contractures to worsen,  leading to decreased mobility, decreased quality-of-life, possible bedridden status, and perhaps make care in a skilled nursing home more immediate.  Here again, vigilance and communication are key. 

A Criminal Record Clearance, Title 22, §87101 (c)(18) ". . .means an individual has a California clearance [through the California Department of Justice] and a FBI clearance."  All Licensees, employees, volunteers and individuals (other than residents) residing in the facility must be fingerprinted and cleared before having a presence in a Residential Care Facility for the Elderly (RCFE).

Title 22, Section 87465 (a)(6)(D):  "Incidental Medical and Dental Care Services," provides the state's requirements and guidance for crushing medications.  

There are only two reasons, per the regulations, when a medication can be crushed:  to enhance swallowing, or to disguise the taste.   Crushing a medication cannot be done to trick or deceive a resident into taking a medication s/he would otherwise refuse. 

Prior to any crushing of a resident's medications,  the facility administrator must consult with a pharmacist and the physician.  The consultation can be done verbally or in writing, but either way, must be documented; documentation becomes part of the resident's permanent medical record.  Documentation required includes:

a.  dose

b.  instructions when and how often the medication will be given.

c.  the names of the doctor and pharmacist, along with their business names and the date of the conversation

d.  a written statement that the medication can 'be safely crushed without losing potency,"  

e.  identification of the foods and liquids the crushed medications can be mixed with, and

f.  instructions for crushing and mixing medication. 

g.  a consent form giving authorization for the medication to be crushed signed by either: 

i.  The resident if s/he isn't conserved.  If the resident cannot sign his name, his mark must be witnessed by a person who is not the license nor an employee of the facility. 

ii.  The resident's conservator when the conservator has authority to make decisions on this issue. 

Many medications (i.e. slow release, extended release, enteric coated, gels) cannot be crushed, and may be very dangerous for the resident if they are:  the resident will receive too much of the dose too quickly.   For that reason, a doctor’s order is needed before any medication can be crushed, then dosed, to a resident.   

The facility cannot unilaterally decide to crush and dose a medication for your resident.  If you are uncertain about why your resident is receiving crushed medications, ask to see the documentation specified above by Title 22.  If the facility doesn't have the documentation, file a complaint with CCL. 

Medications, after crushing, can be mixed with a small amount of applesauce, yogurt, pudding or mashed potatoes –  the doctor or the pharmacist will give guidance on an appropriate carrier at the time the crushed-medication order is received.

Caution 1:  Crushing medications cannot be used as a method to trick or deceive the resident into taking a drug or medication that he has, or would otherwise refuse to take.

Caution 2:  Crushing medications without a doctor's order could lead to adverse effects on the resident - including death.  

If your resident has swallowing difficulties,  notify the resident's doctor at the time the medication is being prescribed, as many medications are available in alternate forms (patches, suppositories, liquids, inhalers).  

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation.   

The date CARR last reviewed the public file on any specific facility in CARR's database, is featured prominently on the Facility Search profile results - directly under the facility phone number in a large gray box.  When the file is next reviewed, the new date of CARR's review will be posted.  The data CARR presents for that facility existed in the file on that date.  We do not scan all documents in the public file; rather we scan those that have the highest volume of information required by the consumer in order to make a placement decision. 

During CARR's research, many files were found to be incomplete and outdated.  If you are concerned that the specific facility you are considering is missing documentation that you would find helpful in making your placement decision, upon question, CARR will be pleased to reevaluate the file at CCLD for you Contact Us.  You can also contact CCLD directly to inquire about file access and updates. 

If you have public documents about an RCFE, and would like to see them posted, please Contact UsIf they meet our requirements, we will post them for you. 

According to Title 22, §87101(d)(2), "deficiency" ". . . means any failure to comply with any provision of the Residential Care Facilities Act for the Elderly and regulations adopted by the Department pursuant to the Act."

Title 22, §87758

A Type A violation is considered the most serious type of deficiency.  It is described as a deficiency that "poses an immediate or substantial threat to the health, safety and/or rights of the residents if not corrected".  Examples cited in Title 22  "include, but are not limited to", the following issues:

  • Criminal record clearances
  • Fire clearances
  • Night supervision
  • Food service, storage and preparation
  • Limitations on number, types and/or ambulatory status of residents
  • Telephone service
  • Health conditions of residents (bedridden, prohibited conditions, communicable diseases)
  • Resident rights
  • Safety of accommodations
  • Use of restraints 
  • Medical and dental care of residents
  • Medication
  • Water temperature
  • Hygiene accommodations (bathrooms, etc)
  • Relocation orders

During CARR's file review and review of the regulations, we've noticed that facilities receiving a Type A citation receive no other consequence than to create and adhere to a plan of correction. 

Title 22 authorizes LPAs to issue a penalty of $50 per day (maximum up to $150), per cited violation only if the violation is not corrected by the date specified in the plan of correction.  Based on CARR's file review, this practice is rare.  Very often there was no documentation of any follow-up visits to verify if the corrections had taken place.  More common, the file contained a faxed transmittal or mailed-in letter of self-certifying through receipts, photographs or letters of promise that the corrections had been made. CCLD also provides a LIC 9098 allowing a Licensee to self-certify that corrections have been made; with a self-certification in hand, the LPA is saved a return trip to the facility to validate the correction has been made. 

Of the Type A citations listed above, it appears violations of criminal record clearances most consistently resulted in civil penalties ($100/day).  For all other common Type A citations, civil penalties were rarely, if ever assessed.

CARR suggests consumers be watchful for repeated citations for violation of the same regulation - from one inspection to the next.  These patterns should be discussed to your satisfaction with the Licensee if you are considering the facility for placement of your resident. 

Title 22, §87101(d)(4) defines "dementia" to mean ". . . the loss of intellectual function (such as thinking, remembering, reasoning, exercising judgment and making decisions) and other cognitive functions, sufficient to interfere with an individual's ability to perform activities of daily living or to carry out social or occupational activities.  Dementia is not a disease itself, but rather a group of symptoms that may accompany certain conditions or diseases, including Alzheimer's Disease.  Symptoms may include changes in personality, mood and/or behavior.  Dementia is irreversible when caused by disease or injury, but may be reversible when caused by depression, drugs, alcohol, or hormone/vitamin imbalances."

 

 There is a regulatory difference between Licensees providing care of residents with dementia (Title 22, Section 87705), and Licensees who "advertise, promote, or otherwise hold themselves out as providing special care, programming and/or environments for residents with dementia (Title 22, Section 87706).  Also, not all facilities are approved by the state to provide dementia care;  CARR's review of 354 files revealed that Licenses (LIC 203) issued by CCLD frequently do not state whether a facility provides Dementia care.  If it is unclear from the License whether Dementia care is provided, the consumer should ask for clarification. 

The state once required Dementia waivers before Licensees could care for residents with dementia; Dementia Waivers are no longer required.  

 

Title 22 §87628 & 87629

Diabetes is an on-going medical condition and without proper management can result in serious medical complications.  RCFEs are licensed as non-medical facilities and are not required to have on staff a licensed skilled professional.  Therefore, the consumer should know what is legally allowed within the RCFE setting  regarding diabetes care, and compare that to the current and potential needs of the resident.

Facilities are allowed to accept or retain a resident who has diabetes if:

(1) the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication (which includes both oral and injections)

(2) or if the resident has the medication administered by an appropriately skilled professional.

If the resident is able to manage her condition independently, then there is no need to read further.  If the resident requires assistance in managing her diabetes and there is a skilled professional (i.e. an RN) on-staff available 24/7 to assist, then you will want to be sure there is good communication between yourself/the resident, the skilled professional and other staff members.  If the resident requires assistance in managing her diabetes, and there is not a skilled professional on staff and readily available, then review the remainder of this FAQ to review that placement in such a facility will meet the resident's specific needs.

Injections

Regarding injections, unless they are a licensed skilled professional, staff cannot mix medication, fill a syringe, nor can they administer injections. 

Facilities are charged with the responsibility of ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility. 

Facilities must also ensure that syringes and needles are disposed of properly (per California Code of Regulations, Title 8, §5193 & Title 22 § 87303(f)(2). 

Managing diabetes is not simply medication management; proper diet and sufficient physical activity are important as well.  Title 22, §87628 states that the facility is responsible for providing modified diets as prescribed by a resident's physician. Discuss with the facility its ability  to consistently accommodate dietary needs.  Deviations from established/pre-approved menus are known to occur in some facilities.  Equally important: double-check that the physical activities scheduled on the facility's activities calendar are sufficient and actually take place.

Contact the LPA assigned to the facility if you have concerns regarding your diabetic resident; in many cases, facility personnel are unclear as to what they are allowed and not allowed, to do.   

If you experience unlicensed personnel performing functions reserved for skilled professionals, report the incident to CCLD immediately.  LPAs are required to issue a notice of deficiency to the facility immediately, citing Regulations §87629(a) and (b)(1),  and §87465 (a)(6),  per CCLD's Evaluators Manual.

Title 22, §87101(d)(9), a "Do-Not-Resuscitate" or DNR Form ". . . means the pre-hospital do-not-resuscitate forms developed by the California Emergency Medical Services Authority. . ."  [and others.]  "These forms, when properly completed by the resident or (in certain instances) a resident's Health Care Surrogate Decision Maker and, by a physician, alert pre-hospital emergency medical services personnel to the resident's wish to forego resuscitative measures in the event of the resident's cardiac or respiratory arrest."

Review the resident's file to validate the resident's signed DNR is in the file, and verify the facility knows its responsibility to immediately provide the DNR to emergency responders

Title 22 §87465

The regulations read:

"When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility."

CCLD (or the Department) makes Form LIC 622 available to facilities on its website.  This form is designated as The Centrally Stored Medication and Destruction Record.

Most larger facilities have 'corporate' policies and procedures in place to record centrally stored medications.  Some smaller facilities have them in place as well.  However, there is no explicit declaration in the facility's public file as to whether or not they record such information, or if they meet the criteria requiring central storage.

Assuming that precise information regarding a resident's medications is being recorded is not valid.  In CARR's experience, we have seen documentation of facilities using shoe boxes as storage units, with post-it notes serving as official documentation for the next shift, or other insufficient techniques.  We have also seen incomplete and inconsistent use of LIC 622s.   Asking questions and being vigilant with regard to a facilities' centrally stored medication policies and procedures is consumers best way to obtain confidence in how the facility manages medications.

As defined by Title 22, §87101(e)(1), an "egress alert device" means ". . . a wrist band or other device which may be worn by a resident or carried on a resident's person, which triggers a visual or auditory alarm when the resident leaves the facility building or grounds."

Title 22 §87756

Reasons for Evaluations

  • All RCFEs subject to unannounced visits by CCLD.
  • CCLD shall visit an RCFE at least once every 5 years.
  • Special circumstances (i.e. probationary license, etc) may require more frequent visits.
  • CCLD is required to visit facilities as often as necessary to ensure quality care is provided.
  • CCLD shall conduct annual unannounced visits to no less than 20% of facilities.
  • Visits for complaint investigations are different than visits for facility evaluations. 

Facility evaluations are reported on LIC 809s.

Reasons for Deficiencies

A deficiency is defined by Title 22 as "any failure to comply with any provision of the act governing RCFEs and any other applicable regulations". 

If a deficiency is found during an evaluation, LPAs are required to issue a notice of deficiency.  However, if the deficiency is deemed minor and is corrected during the visit a notice of deficiency need not be issued according to Title 22. 

If a deficiency is noted, the LPA must meet with the person in charge of the facility and discuss the noted deficiencies and together they must develop a plan for correcting each deficiency.  The plan of correction must then be included on the notice of deficiency.  The notice is then signed by both parties and should then be posted in a conspicuous location in the facility.

Viewing deficiencies

Copies of all notices of deficiencies are kept at the facility (as well as at CCLD in the facility's individual file). 

Every RCFE must:

Title 22, §87101(e)(6) "exception" ". . .means a variance from a specific regulation based on the unique need or circumstances of a specific resident or staff person."  An exception cannot be transferred or applied to any other individual.  Requests for exceptions are made to CCLD by the Licensee.

A licensee must give 30 days written notice delivered in person or via mail to the resident and/or resident's responsible party.  Three (3) day evictions (aka expedited evictions) are possible with approval from the Department.  Approval for an expedited eviction will only be granted if the Department finds good cause.  Good cause exists if the facility can prove the resident is engaging in behaviors threatening to the well-being of other residents.

Title 22 87224: A facility may evict a resident for 1 or more of the following reasons:

1)      Non-payment of the rate for basic services within 10 days of due date.  Basic services at a minimum are defined in Title 22, §87464 (LINK) and services considered basic by the facility are to be specified in the signed admissions agreement.  If a resident becomes a recipient of SSI/SSP during their stay, the facility cannot evict the resident for a change in the resident's income status and must continue to provide basic services as stated in the admissions agreement to the resident at the SSI/SSP basic rate.  (For Fee Schedule SEE SSI (LINK) (family not make up difference FAQ:)

2)      Failure of a resident to comply with state or local law after a written notice of the alleged violation has been issued from the appropriate authorities. The violation must be deemed as one that affects the well-being of other residents.  For example, a driving violation would not be grounds for eviction unless the resident was responsible for driving other residents.

3)      Failure of a resident to comply with the written policies of the facility.  These policies must be contained in the signed admissions agreement.  Said policies must be in place for the purpose of making communal living possible.

4)      If a resident is deemed through a reappraisal to be no longer appropriate for the facility. While the licensee can conduct the reappraisal (§87463), they must bring any significant changes in a resident's condition to the attention of the resident's physician, family and responsible party and must arrange a meeting to include all parties. It has been noted that some facilities attempt to misuse this section as an opportunity to dump a difficult or high-needs resident.  If the facility should have reasonably predicted the resident's current condition during the admissions process and admitted them in spite of, than the facility remains responsible for providing the necessary care.  For example, if the resident is admitted with a diagnosis of dementia and begins to wander, it is the facility's responsibility to properly address this behavior.  They cannot seek the remedy of eviction since this is not a change in condition but rather a behavior that should have been anticipated by the licensee given the resident's diagnosis of dementia. 

Should a reappraisal determine that the resident has a developed a prohibited health condition (link) then the facility may request a waiver to retain the resident or the resident will need to be moved to a higher level of care. 

Note to consumer:  LPAs are not medical professionals and are, therefore, limited in their ability to determine whether or not a facility is truly qualified for a waiver that expands the scope of care of a facility.  CARR recommends families discuss with a trusted physician or nurse, the specific requirements and attention necessary to ensure the health of a medically-compromised resident living in a non-medical environment.  Additionally, families’ continued vigilance is paramount in all circumstances surrounding changes in conditions.

5)      A change in the use of the facility.

Eviction notices must include:

  • Reasons for the eviction, specific facts, dates, places, witnesses and circumstances
  •  Information about resources to assist in locating alternative housing and care options (i.e. public & private placement agencies & care managers)
  •  Information about a resident's rights to file a complaint with the Department regarding the eviction alongside contact information for State & Local Long-term Care Ombudsman offices (LINK)

Contesting an Eviction

  • Residents have the right to file a complaint regarding evictions.  Residents and/or their families can contact the local Community Care Licensing Office.  The Department is mandated to investigate a complaint within 10 days.  Click here for a list of Program Offices  and contact information.  
  • Should a resident remain after the effective date of the eviction, then the facility must file an unlawful detainer action with the superior court and get a written judgment signed by a judge to have the resident evicted.  Only a sheriff or sheriff's deputy is authorized to physically evict a resident.  A licensee is not authorized to take any physical action to remove the resident and/or their belongings from the facility or deny them access.
  • During the 30 days and after (should the resident remain) it is still the facility's responsibility to provide uninterrupted care and services to the resident.

More information on enforcement of these polices can be found in CANHR's archive

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation. 

Title 22 Section 87209 - Program Flexibility

Under this section of Title 22, a Licensee can submit a request for a written exception to retain a resident who has a prohibited or restricted health condition, and would otherwise have to move to a higher level of care.

Per Title 22, §87101(f)(2), "Federal Bureau of Investigation (FBI) clearance" ". . . means an individual has no felony or misdemeanor convictions reported by the Federal Bureau of Investigation.  The individual may also have been arrested with no criminal conviction, convicted of a minor traffic offense or adjudicated as a juvenile."

Receiving an FBI clearance is a component of receiving a Criminal Record Clearance, required for Licensees, employees, volunteers, and other individuals (who are not residents) residing in the facility, prior to having a presence in the facility.

Reasons for Evaluations

  • All RCFEs subject to unannounced visits by CCLD.
  • CCLD shall visit an RCFE at least once every 5 years.
  • Special circumstances (i.e. probationary license, etc) may require more frequent visits.
  • CCLD is required to visit facilities as often as necessary to ensure quality care is provided.
  • CCLD shall conduct annual unannounced visits to no less than 20% of facilities.
  • Visits for complaint investigations are different than visits for facility evaluations. 

Facility evaluations are reported on LIC 809s.

Reasons for Deficiencies

A deficiency is defined by Title 22 as "any failure to comply with any provision of the act governing RCFEs and any other applicable regulations". 

If a deficiency is found during an evaluation, LPAs are required to issue a notice of deficiency.  However, if the deficiency is deemed minor and is corrected during the visit a notice of deficiency need not be issued according to Title 22. 

If a deficiency is noted, the LPA must meet with the person in charge of the facility and discuss the noted deficiencies and together they must develop a plan for correcting each deficiency.  The plan of correction must then be included on the notice of deficiency.  The notice is then signed by both parties and should then be posted in a conspicuous location in the facility.

Viewing deficiencies

Copies of all notices of deficiencies are kept at the facility (as well as at CCLD in the facility's individual file). 

Every RCFE must:

(Title 22, §87202)

  • Prior to accepting any residents, the licensee must notify CCLD and obtain an appropriate fire clearance for the clients the RCFE plans to serve.
  • All facilities must maintain an appropriate fire clearance approved by the fire department having jurisdiction over the area the facility is located in.   

The request (STD 850) for Fire Marshal Clearance (FMC) is forwarded to the local Fire Marshal Office, or Fire Protection Jurisdiction.  The agency then schedules a tour of the facility, and notes any approvals or special conditions on the body of the STD 850.  The completed document is signed by the agency and returned to CCLD for its action.  Fire clearances are required for non-ambulatory, hospice and bedridden resident acceptance and retention. 
 

Title 22, §87101(h)(1), defines "healing wounds include cuts, stage one and two dermal ulcers [bedsores] as diagnosed by a physician, and incisions that are being treated by an appropriate skilled professional with the affected area returning to its normal state."

Healing wounds are sometimes referred to as 'decubitus ulcers," "pressure sores," or "bed sores."

Use:    Third party caregivers or skilled medical professionals hired through Home Healthcare (HHC) agencies can be used in an RCFE.  These individuals can be hired either a) by the RCFE to provide the skilled medical professional services necessary to meet the resident’s incidental medical needs, or b) by the resident’s family or responsible party to augment care and services being provided by the facility. 

Medicare Certification:  Home health care (HHC) agencies offer a variety of skilled medical services, and most are not required by the state to be licensed.  However if use of HHC individuals is expected to be paid by Medicare, it is important to select a Medicare-certified HHC agency, as services rendered by a non-Medicare certified agency will not be reimbursed.  

Facility-Provided Home Health Services:    Typically, the resident’s care plan prepared by the Licensee will stipulate the requirement for use of a home health aide to provide injections, wound care, or other specialized care that the Licensee is unable by regulation to provide. 

Resident-Provided Home Health Services:  There are times when family members (or responsible parties) of the resident elect to have additional care, assistance and supervision provided for their residents.  The resident may receive Home Healthcare services directly, and apart from any care and supervision provided by the facility. 

In these instances, the family or other responsible party would independently arrange for the service, interview the caregiver, arrange for payment, and would be responsible for coordinating with the Licensee, this 3rd party’s presence in the facility, including Criminal Background Checks (see below).

Criminal Background Checks:   Title 22, Section 87411 exempts “licensed or certified medical professionals from criminal background check requirements.  Thus a privately paid personal assistant who is also a licensed medical professional is exempt.  In addition, a privately paid personal assistant who has a current certification as a Certified Nursing Assistant and/or a Certified Home Health Aide is exempt.”  The operative word here is “certified.”    

What You Should Know: 

 

Consumers should ask to see evidence of a home health aide’s certification if the agency or the individual represents they are “certified.”  The licensee must keep a copy of the  person’s current license or certification on file in the facility.

Some RCFEs may have Home Health Agencies that they regularly use.  The Licensee or Administrator may tell you that you have to use ‘their’ home health agency.  That is not true.  You and your resident have the choice of which home health agency you use. 

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation.. 

The home page of the Hospice Foundation of America describes Hospice as a ". . . special concept of care designed to provide comfort, pain relief and support to residents and their families when a life-limiting illness no longer responds to cure-oriented treatments. This type of care neither prolongs life nor hastens death, but rather has the goal to improve the quality of a resident's last days (or months) by offering comfort and dignity." Source: http://www.hospicefoundation.org

RCFEs caring for residents receiving hospice services must meet specific qualifications as stipulated in Title 22, §87633. Providing Hospice Care.

Title 22 §87633

If a hospice waiver has been granted by CCLD to the facility, the hospice waiver document (usually a letter on CCLD letterhead) should be posted prominently in the facility near the facility's license.  The number of hospice residents permitted in the facility at any one time will be included on the waiver.   The facility's responsibilities to hospice residents are individually discussed.

Selecting a Hospice Agency

The right to select a hospice agency is reserved to the resident and his/her responsible party.  A facility may suggest a particular hospice agency, and may even hold a hospice agency license itself, but under no circumstances is the resident required to contract with the agency suggested by the RCFE.  CONSUMERS ARE ALLOWED TO USE ANY HOSPICE AGENCY THEY CHOOSE.  Further, and per Title 22, the contract for hospice services is between the resident and the hospice agency, not between the facility and the hospice agency.  However, the facility is responsible for ensuring that the hospice care plan developed for the resident complies with the requirements of Title 22, and that all the resident's care needs are being met at all times (regardless of the specific responsibility of the facility or the hospice agency).

All contracted hospice agencies must be both licensed by the state and certified by the Medicare program.

Hospice Care Plans

A written hospice care plan must be developed for each terminally ill resident by that resident's hospice agency, and agreed to by the Licensee and the resident (or the resident's responsible party), prior to the initiation of hospice services in the facility for that resident.  All hospice care plans must be fully implemented by the facility and by the hospice agency.   It is the facility's responsibility to ensure that the plan is current, accurately matches the services being provided and that the resident's needs are being met AT ALL TIMES.

The plan, which shall be maintained in the facility for each hospice resident, must include the following:

(1) The name and contact information (including 24-hour emergency phone number) of the hospice agency and the resident's physician;

(2) Designation of the resident's primary contact person at the hospice agency, and primary and alternate caregivers at the facility

(3) A full description of services to be provided by hospice agency (including type and frequency of services)

(4) A full description of services that are the responsibility of the facility (including storage and handling of medication, the maintenance and use of medical supplies and equipment, etc.). "The plan shall neither require nor recommend that facility personnel other than a skilled professionals preform any procedures that must legally be provided by an appropriately skilled professional" (Title 22 § 87633).  This includes the administration of medications.   For procedures related to the appropriate assistance with medications as performed by facility staff see Medication Management.

(5) Identification of the training needed, which staff members need this training, and who will provide the training regarding the facility's responsibilities to the hospice resident. 

General training topics include turning and repositioning the resident, incontinence care, skin breakdown, hydration, etc.  Additionally, it is the facility's responsibility to ensure that all staff are knowledgeable about each individual resident's anticipated dying process so as to adequately meet the care plan requirements. 

The hospice agency is required to provide training to facility staff regarding the specific needs (current and on-going) of the individual resident under their care.

(6) A description of all hospice services to be provided or arranged in the facility, by persons other than the facility or hospice agency (i.e. clergy, resident's family and friends).


CCLD may require, at any time, a revision of the hospice care plan if the plan is not fully implemented or if it determines that a revision is necessary to protect the health and safety of the resident.

Medications

As a resident's dependency and frailty increases, his ability to self-administer medications will  likely diminish.  By regulation, facility staff are only allowed to assist in self-administration of medications.  If a resident requires someone else to administer medications, that someone  must be a skilled medical professional. 


Once self-administration is no longer possible, two options remain:

(1) A skilled medical professional can administer medications to the resident.  As hospice agency nurses do not remain at the facility 24/7, but rather make rounds to a number of facilities on a given day, it is important to establish in the care plan who else will be available to administer medications.  If the facility has a skilled medical professional on-staff, then that authorized person may administer. 

(2) Another option is that the hospice agency train a resident’s family member(s) or friend(s) how to properly administer medications.  Such designations must be documented in the hospice care plan.  If a skilled medical professional is not available, nor an authorized family or friend, medications may not be administered by facility staff, or any other paid aide or personal attendant, and the resident will need to be placed into a higher level of care.  Please note also that Title 22 specifies that fellow residents may not be considered a “friend” or “relative” who is able to administer medications.

Additional notes: (1) Morphine pumps are allowed in RCFEs but must be administered by the resident or appropriately skilled professional, and its use must be documented in the hospice care plan.  (2) Nasogastric tubes (aka feeding tubes) and serious infections are not allowed in RCFEs.


Restricted Health Conditions (§ 87612)

Title 22 states that a facility does not need the approval of CCLD to care for a hospice resident with a restricted health condition provided the resident is currently receiving hospice care and the restricted health condition is addressed in the hospice care plan.  Also see Restricted Health Conditions.

Hospital Beds and Bed Rails

Hospital beds and full bed rails are permissible if the hospice care nurse indicates they are necessary in the hospice care plan.  Otherwise, half bed rails that are used only to assist a resident with mobility are allowed within the RCFE setting. Written authorization from a physician is required to be maintained in the residents file if half bed rails are to be used for any reason for any resident. (§ 87608)

Fire Clearance

If a hospice resident becomes bedridden, the facility may accept and/or retain the resident provided they notify the local fire authority within 48 hours of the estimated length of time the resident will be bedridden.

Records

Facilities are required to maintain the following hospice care records:  

  • An accurate hospice care plan
  • A record of all hospice-related staff training provided
  • A record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility 

Other documentation includes:

  • The resident’s (or resident’s Health Care Surrogate Decision Maker’s) written request for retention and hospice services in the facility, as well as any Advance Health Care Directive, Request to Forego Resuscitative measures, and/or Do-Not-Resuscitate Form.
  • Contact info of hospice agency and emergency contacts
  • A copy of the written certification statement of the resident’s terminal illness from the director or physician of the hospice agency, and the resident’s individual physician (if they have one)
  • If the hospice resident shares a room with another, a statement signed by the resident’s roommate that she is aware of the resident’s condition, and voluntarily agrees to grant access to shared living spaces to the hospice agency, caregivers, friends, family and others.  (The roommate may verbally, or in writing withdraw the agreement at any time and alternative arrangements must be made to accommodate the needs of the hospice resident.)

 

 

 

Pursuant to Title 22, §87101(f)(1), a  "facility hospice care waiver"  means ". . . a waiver from the limitation on retention of residents who require more care and supervision than other residents and residents who are bedridden other than for temporary illness."  This ". . . waiver granted by [CCLD] will permit the retention in a facility of a designated maximum number of terminally ill residents who are receiving hospice services from a hospice agency."   The ". . . waiver will apply only to those residents who are receiving hospice care in compliance with a hospice care plan meeting the requirements. . ."  of Title 22, §87633.

Hospice waivers are frequently posted near the facility license.  A facility's license should also accurately reflect the number of state-approved hospice waivers.

Title 22 §87625

Facilities are permitted to accept or retain residents who have a manageable bowel and/or bladder incontinence condition provided the condition can be managed with any of the following:

(1) Self care by the resident

(2) A structured bowel/bladder retraining program designed by an appropriately skilled professional that assists the resident in restoring a normal pattern of continence

(3) A program of scheduled toileting at regular intervals

(4) The use of incontinent care products

If a facility chooses to provide care for a resident with an incontinence issue, they are responsible for ensuring all of the following:

(1) Residents that would benefit from scheduled toileting are assisted an/or reminded to go to the bathroom at regular intervals rather than being diapered.    

Diapering should be used as a convenience and comfort for the residents, NOT for the convenience and comfort of the facility staff.  

(2) Residents that are incontinent are checked  during those periods of time when they are known to be incontinent, including during the night.  

(3) Residents that are incontinent must be kept clean and dry and the facility must remain free of odors from incontinence.

(4) Bowel and/or bladder programs are designed by an appropriately skilled professional with training and experience in care of elderly persons with bowel and/or bladder dysfunction and with experience in the development of retraining programs for restoration of normal patterns of continence.  

(5) The appropriate skilled professional who developed the incontinence program for the facility provides training to facility staff responsible for implementing the program and must re-assess residents' conditions and evaluate the effectiveness of the current program. 

(6) Privacy is always afforded when care is provided.

(7) Facilities and their staff are never allowed to withhold fluids to control a resident's incontinence nor are they allowed to catheterize an incontinent resident for the convenience of staff.

While not mentioned in Title 22, another important issue here is the facility's policy on charging for incontinence care and supplies.  These are policies seen by CARR within local RCFEs:

  • Some facilities include incontinence care and supplies in the monthly rate.

  • Some consider incontinence care as part of standard care provided, and include it in the monthly rate but charge for supplies; some give residents/their families the option provide their own disposable briefs. 

  • Still other facilities consider incontinence care an additional service, and charge residents for care based on the level of assistance needed, as well as charging for the supplies.

Ask facilities about their individual policies, and also read the admissions agreement carefully to be prepared if incontinence issues arise, or if they become more severe.  Familiarize yourself with the experience and oversight of the staff by an appropriately skilled professional regarding incontinence care.  During CARR's review of the public files, and based on our field experience, many accidents, injuries and conflicts have  occurred during times when the resident was being assisted with toileting, and/or from lack of attention to incontinence needs.  Proper technique, critical thinking skills, and compassion are necessary to ensure safe and dignified incontinence care for the resident.  Also explore the willingness, experience of the staff, and the staffing levels of a facility to see if your resident will receive the attention s/he requires.

Community Care Licensing (CCLD) is required to inspect each Residential Care Facility for the Elderly (RCFE) at least once every 5 years (Title 22, §87756 (d)). CCLD is also obligated to visit (unannounced) approximately 20% of the facilities within its jurisdiction, annually (Title 22, §87756(c)); for the San Diego area that translates into approximately 141 facilities/year.  Other reasons for unannounced visits may include, but are not limited to, the following: 

  1. A Licensee is on probation, 
  2. An accusation against a Licensee is pending (i.e. a complaint has been reported)*,
  3. When the terms of a compliance plan require an annual evaluation (i.e a visit is necessary to verify compliance on a deficiency issue), 
  4. When the facility requires an annual visit as a condition of receiving federal financial participation, and 
  5. To ensure a person who has been ordered out of an RCFE, is no longer at the facility.

The Inspection report is called Facility Evaluation Report (Form LIC 809).  The LIC 809 is the "primary paperwork used to document the level of facility compliance" (§3-3010 - Evaluator's Manual 10RM-12, August 2010).  The Facility Evaluation Report is a Public Document  available in the public file.  

Facility searches on this site display LIC 809s available in the public file for individual RCFEs, at the time of CARR's review.  Previewing these evaluations will offer insight into the challenges faced by particular facilities.   When reviewing a facility's public file, note how frequently (or infrequently) the facility has been evaluated.  Fewer visits by the state is not a direct indication of fewer deficiencies, or a higher level of compliance.

*Complaints are recorded on LIC 9099s.  If CARR has scans of this public document, or unofficial excerpts (LIC 9099F) available, they will be found under the Facility Search, by individual facility name. 

By Title 22, Licensees are not required to carry any type of insurance (liability, fire, theft, auto, or other) to be licensed RCFE in the state of California.  As a matter of good business practice, many do, but there is no state mandated requirement for a Licensee to carry any type of insurance coverage.

If the Licensee will be taking your resident to appointments (doctor, dentist, church) in the Licensee's personal or business automobile, a prudent consumer will ask for evidence of current automobile coverage.  Proof of Insurance certificates provided by the insurer to the driver - these cards are required to be kept in the vehicle itself. 

By Title 22, RCFEs are not required to carry any type of insurance either as a condition to being licensed, or after licensure. Facilities have 100% discretion as to whether they carry any type of insurance: liability, fire, auto or theft protection for resident's property. 

Property owners having mortgages on their property are generally required by their lender to carry Risk of Loss coverage for Fire, earthquake, flood and other acts of God.  The consumer is encouraged to ask to see proof of current policy coverage if you concerns about the risks the facility owner is insured against. 

Whether to carry liability insurance is no longer left to the discretion of the licensee.  Effective 7/1/2015 there is a law requiring every RCFE in the state to carry liability insurance compliant with the statute, Health and Safety Code 1569.618 (c).  

Because this is a new requirement, CARR recommends that consumers ask the licensee to produce proof of insurance to be assured the facility has the coverage required under the new law:  $1,000,000 per occurrence, and $3,000,000 in aggregate.  

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation..

LIC 200 - Application for a Community Care Facility or Residential Care Facility for the Elderly License.

This is the Application Form that a prospective RCFE Licensee must complete as part of the process to obtain a license to operate an RCFE. This form requires information about facility location, organization type, facility ownership, property ownership, as well as information about what type of facility the applicant wishes to open (i.e. type of clients served, total number of residents, and whether the clients will be ambulatory, non-ambulatory, etc.).  

After licensure, this form is used to request an increase in capacity, request a change of ownership, or request approval to provide additional services. 
 

If CARR has a scanned LIC 200 for an individual facility, it will be shown as a document icon, identified as LIC200.

To view:  http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC200.pdf

The LIC 203, or more properly LIC 203A, is the License itself.  This document is the evidence from the state that the facility is licensed to provide care and supervision for the stated capacity of the facility, and to provide such additional services as may be stipulated on the document.  The License will be updated by CCL, from time to time, as the facility becomes approved for more or fewer services, changed name, or when there is a change in Licensee.  

CARR refers to this document as "LIC 203",  for ease of standardizing the file names for the scanned documents. 

The LIC 215 – Applicant Information. 

This form is one of the items in the Application package that must be completed and submitted to CCLD as part of the Application process. The form is not a public document, as it contains detailed personal information about the prospective Licensee (i.e. education, work experience, references and financial information).  According to Title 22, CCLD  looks for 'satisfactory evidence that the applicant is of reputable and responsible character'. [Title 22, §87155].

To the best of CARR's understanding this document is retained in CCLD's Confidential File for a specific facility.  

To view:  http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC215.pdf

Licensed facilities are required to have an authorized person continuously present at the facility during operational hours (24/7) to represent the facility and to accept licensing reports. This form is used to designate an authorized person to act in the absence of the Licensee.  The authorized person is required to meet all the qualifications of a licensed administrator as set forth in Title 22 (§ 87405).

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC308.pdf

If a facility's Licensee is a legal entity (corporation, public agency, limited liability corporation, limited liability partnership), the form is required as part of the application process.   

If CARR has a scanned Administrative Organization document in its database for a facility, it will be found as a document icon, identified as MISC-LIC309ORG.

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC309.pdf

Facilities handling residents' cash resources must be bonded for not less than $1,000.  This provision does not apply, however, if the facility handles amounts less than $50 per person or $500 for all persons per month.  Facilities may also choose not to handle residents' cash resources.  Bonding requirements are stipulated in Title 22, §87216.

To view:  http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC400.pdf

The LIC 401 is a form the applicant completes, estimating its monthly expenses and revenues.  The document is used by CCLD to a) verify a facility's operating budget is reasonable, and b) as the basis for the facility to pledge three-months' assets necessary to carry the facility through its first three months of operation.  

if CARR has scanned LIC 401s for any individual facility, the document will be displayed as a document icon, identified as LIC 401.  

  • Food Budget: On this form, you can see how much the Licensee has estimated for food.  Take that monthly number, divide by the number of residents the facility is licensed for.  You now have the monthly food budget for 1 resident.   Divide that number by 3 to estimate the amount per meal the Licensee plans on spending on your resident.

  • Profit:  You can also evaluate the amount of profit the Licensee is projecting by looking at the last line on the LIC 401.

  • In 95% of the files, the only LIC 401 in the file is the one the Licensee submitted with his application.  Annual updates of the LIC 401 are not required, nor collected by CCL.   

 

In most cases, the figures provided by a facility are estimates (actuals are only available if the Licensee operates another facility prior to the opening of the current one under consideration).  

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC401.pdf

This form, the LIC 402 - Surety Bond,  is required if a facility chooses to handle residents' cash resources (as reported on Form LIC 400).  It states the name of the bonding company and specific terms of the agreement.  Examples of when a bond is needed are: (1) The Licensee/facility employee cashes a resident's check and returns the money to the client; (2) The Licensee/facility employee keeps a resident's money in a safe place (including a financial institution) and controls its distribution.

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC402.pdf

The LIC 500 form - Personnel Report - Roster of Current Personnel, is intended to record the current roster of all facility personnel, other adults residing in the facility including backup persons and volunteers. 

The purpose of this using this form during the application phase, is to ensure that the facility is adequately planning for the staff coverage necessary to operate the facility in compliance with the regulations. This form lists all planned employee positions, and the days and hours staff are scheduled for duty.  During the application process, many facilities have not yet hired the staff they need, so the placeholder for positions and the designated employee is listed as "to be hired".

CARR's review of the facility files found the LIC 500s are rarely updated following the original date of licensing; 75% of all files reviewed in 2009 contained incomplete reports (Master's Thesis, Murphy,C. 2010).  

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC500.pdf

The LIC501 form is only completed if the administrator is not the Licensee.  It lists the administrator's work experience, education and references for CCLD to review during the application process.  If the administrator is the Licensee, this same information is gathered on the LIC 215 form.   These forms and, therefore, the information on the qualifications of those individuals operating RCFEs, are not considered public documents.

View the document: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC501.pdf

The LIC 503 is required as part of the application process, and is used to verify the health (general well-being, lack of communicable diseases, etc.) of the Licensee and/or administrator, if they are different people.  It is also used within facilities during the hiring process for staff. It requires completion and signature by a physician

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC503.pdf

State law (Health & Safety Code §1569.17) requires that persons associated with licensed facilities be fingerprinted and disclose any convictions. The LIC 508 or LIC 508D, completed during the application and hiring process, asks for any criminal history of Licensees and facility employees.

Criminal Record Clearance requirement for all RCFEs.

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC508.PDF

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC508D.PDF

Each facility is required to have an annually updated emergency disaster plan. This form should be found prominently posted in every facility near a telephone (a copy is also maintained at CCLD in the facility's file).  This form contains important items such as (1) staff task assignments during an emergency, (2) emergency contact information and exit information, (3) temporary relocation sites and (4) transportation arrangements.  

Prudent consumers may want to confirm the feasibility of the proposed plan. Will the relocation sites truly be able and available to accommodate the resident during a disaster? Is the staffing adequate at all times to evacuate the type of residents served by the facility? Is the transportation reliable and promptly available? 

 

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC610E.PDF

This document is available to RCFEs if they centrally store their medications.

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC622.PDF

The LIC 809 or Facility Evaluation Report is the key record of the state's inspection of an RCFE.  The Licensing Program Analyst (LPA) uses this document during site visits to record the compliance of a facility.  

This document can be viewed in conjunction with Compliant Investigation Reports (LIC 9099s) to better inform the consumer about a facility's performance.  Consumers can view these public documents on CARR's website by using the Facility Search, or by filing a request with Community Care Licensing Division (CCLD).

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC809.pdf

Before a facility can accept residents,  CCL must obtain a fire clearance for the facility from the local fire inspection authority having jurisdiction in the area the facility is located.  CCL submits the request for an inspection to the cognizant Fire Marshal's office.  The purpose of the inspection is to verify that the physical features of the facility can safely provide for the capacity and ambulatory status of the residents the facility wishes to care for, and also notifies which rooms are approved for non-ambulatory residents. Fire clearances are required prior to obtaining certain types of waivers. 

On this site, if CARR has the Fire Marshal Clearance for a particular facility, it will appear in the Facility Search as an icon identified as  FMC. 

To view the actual document, visit the link below:

http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC9054.pdf

The LIC 9099 or Facility Complaint Report is another key record to be used as evidence of the state's oversight of RCFEs.  Any person can file a complaint with CCLD against a particular Licensee or facility.  CCLD is obliged to initiate investigation of a complaint within 10 working days after the date of complaint filing.

For each specific complaint filed with CCLD, CCLD must make a finding;

  • a complaint can be substantiated,
  • determined inconclusive, or
  • can be deemed unfounded.  

An LPA will find a complaint 'substantiated' if corroborating evidence can be found for the allegation.  If there is conflicting or ambiguous information surrounding a complaint, the complaint is frequently inconclusive.  When little to no corroborating evidence, or when evidence is counter to an allegation, the frequent finding for a complaint is unfounded.  

Substantiated complaints generally include violations of Title 22 regulations, and deficiencies are usually cited as part of the final complaint findings.  

This document can be viewed in conjunction with Facility Evaluation Reports (LIC 809s) to better inform the consumer about a facility's performance.  Consumers can view these public documents on CARR's website by using the Facility Search option or by filing a request with Community Care Licensing Division (CCLD).

To view the form: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC9099.PDF

The LIC 999 - Facility Sketch, provides a sketch of all indoor and outdoor space used by residents. It offers specifics such as room dimensions and purpose (i.e. staff rooms, rooms approved for non-ambulatory residents, etc.), utility shut-off locations, and exit routes. This form is supplied to CCL during the application process and maintained in CCL's facility's file.

If the facility is later remodeled as to room configurations or use, or if the facility is expanded to add square footage, a reviewed LIC 999 is required by the CCL. 

To view: http://www.dss.cahwnet.gov/cdssweb/entres/forms/English/LIC999.PDF

LICENSE

Title 22, §87101 (l)(1) and H&SC §1569.2(g) defines  "license" to ". . . mean a basic permit to operate a residential care facility for the elderly."

The license should be posted prominently in every facility, demonstrating Community Care Licensing's (CCLD's) care parameters approved by the state. 

LICENSEE

Title 22, §87101 (l)(3) " 'Licensee' means the individual, firm, partnership, corporation, association, or county having the authority and responsibility for the operation of a licensed facility." 

The Licensee's name appears on each License. 

The Licensee is the individual, partnership or corporation that has the authority and responsibility for the operation of the licensed RCFE.  To become a Licensee, the individual or 'legal entity' must attend the mandatory orientations, and successfully complete the application process.  The License to operate an RCFE is issued in the name of the Licensee. 

According to the regulations, the Licensee may, or may not, act as the administrator of the RCFE.  It is very common in smaller facilities (1-6 bed facilities), for the Licensee to also act as the Administrator.  In larger facilities, an Administrator is usual hired by the Licensee.  The individual serving as the Administrator of an RCFE must meet the educational and experience requirements of Title 22. 

Licensing Program Analysts, or LPAs,  are the employees of Community Care Licensing Division (CCLD)  responsible for licensing, evaluating, and investigating Residential Care Facilities for the Elderly (RCFEs).  They conduct site visits and, in the presence of deficiencies, have the authority to issue citations and civil penalties.

A full description of their duties is available at : http://www.ccld.ca.gov/Res/pdf/LPA-Residential.pdf

Title 22, §87101(s)(2) states that  "'may' means permissive."

 

 Nothing in Title 22  authorizes caregivers to directly administer medications; this task is reserved for appropriately skilled professionals.  Most facilities do not retain appropriately skilled professionals, since Title 22 does not require it.  Therefore, it is imperative consumers clarify with facilities what the facility means when it advertises "Medication Management Services";  does the facility have a nurse on staff to oversee the handling of both prescription and non-prescription drugs?

To directly administer medications (per CARR's recent discussions with CCLD's Sacramento office), is to place the medication in a resident's mouth or, in the case of injections, to fill a syringe and/or inject a resident with medication.  Unlicensed (not appropriately skilled professional) caregivers are not allowed to administer medications.  They are allowed to prepare medications (i.e. dispense and pour).  This preparation is what is meant by "assist with self-administration" in the regulations.  Facilities that provide assistance with medications are responsible for accurately logging dosage and maintaining medical records, and for prompt communications with resident's physician.     

When considering placement, the consumer should consider the ability of the resident  to self-administer medications.  Matching the resident's ability to the competency and capabilities of the facility is critical to be avoid medication errors.

Provided here is Title 22's (§ 87455 & § 87465) guidance and requirements for medication assistance. 

(§87455}

RCFEs are allowed to accept or retain:

  • Persons capable of administering their own medications,
  • Persons who because of forgetfulness or physical limitations need only be reminded or to be assisted to take medication usually prescribed for self-administration,
  • Persons receiving needed medical care from a visiting nurse.

(§87465)

1) Staff designated by the licensee may assist persons with self-administration as needed.  Assistance shall be limited to the following:

  • Medications usually prescribed for self-administration which have been authorized by the person's physician.
  • Medications during an illness determined by a physician to be temporary or minor.
  • Assistance required because of tremor, failing eyesight, and similar conditions.
  • Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's rights to refuse medications.

2) Staff shall be permitted to assist if:

  • the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or non-prescription PRN ("as needed") medication.
  • the resident's physician has stated in writing that the resident is unable to determine his/her own need for PRN medications but can communicate his/her symptoms clearly. Provided there is written direction from the physician, on a prescription blank, specifying all administering information; the medication is given according to the physician's directions; a record of each dose is maintained in the resident's record (including the date and time given, the dosage, and the resident's response).
  • the resident is unable to determine his/her own need for PRN medications, and is unable to communicate symptoms clearly.  Provided staff contact the resident's physician prior to each dose, describe resident's symptoms, and receive direction to assist the resident in self-administering that dose of medication; the date and time of each contact with the physician, the physicians directions, are documented and maintained in resident's record; the date and time the PRN med was taken, dosage, and resident's response recorded.

3) For every PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank maintained in the residents file and a label on medication (both containing specific symptoms to indicate need, exact dosage, minimum number of hours between dosage and maximum number of doses allowed in 24-hour period).

In conversations between CCLD's Duty Worker, and CARR in May 2011, to administer PRN ("as needed") medications, a physician must be contacted prior to each dosage.  Medications administered daily must be given according to the physician's directions which must be reflected on the prescription bottle and in the resident's file (§87465 (c)(2)).  Records of daily medications must be maintained as  well. 

 

There is not a specific regulation stating that RCFEs must centrally store all resident medications. 

According to Title 22 (§87465), "medications shall be centrally stored under the following circumstances: 

1)   Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom the medication is prescribed.

2) The medication requires refrigeration and the resident has no private refrigerator.  Such medication may not be stored in the kitchen refrigerator.  It must be kept in a safe and locked refrigerator that is not accessible to persons other than employees responsible for the supervision of centrally stored medication.

3)  A physician, the administrator, or CCLD determines that because of potential dangers related to the medication itself, or due to the physical arrangements of the facility and the condition or the habits of other persons in the facility the medication must be centrally stored to ensure the safety of residents.

4)  If a facility does centrally store its medication, the following requirements shall be actively in place:

a) The medications are kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored medication. 

b) Each and every container shall be maintained in compliance with state and federal laws, be labeled and carry all of the following information:

  • The name of the resident for whom it is prescribed.

  • The name of the prescribing physician (While not required, the physician's phone number is not a bad idea).

  • The name, strength, and quantity of the drug.

  • The date filled.

  • The prescription number and the name of the issuing pharmacy.

  • The instructions, if any, regarding control and custody of the medication.

  • The expiration date and number of refills.

c) Each resident's medications shall be stored in its originally-received container.  No medications shall be transferred between containers, and no persons other than the dispensing pharmacist shall alter a prescription label."

(Please note that while most bottles issued by a pharmacy currently will have all of the above information printed on the label, CARR is informing you of these details should you encounter issues with storage and labeling of medications.)

To verify that all of these safeguards are in place at the facility you are considering, consumers can inquire about the following:

  • Their policy and procedures regarding medications/centrally stored medications;

  • Ask to see their storage units;

  • Possibly ask to preview a sample of their record keeping; (FYI:They might need to redact confidential information prior to your review)

  • Ask about the training and experience of those responsible for administering medications.

  • Review the facility's file for cited deficiencies, or grievances regarding medications (LIC 809s and/or LIC 9099s)

  • And most importantly, follow-up on all of these items consistently while in residence at a facility.  Consider it a good way to avoid the possibility of a medication error.

Morphine is typically prescribed to individuals experiencing chronic or severe pain or those who are terminally ill.   In assisted living facilities, residents prescribed morphine are most often times receiving hospice services.  The intended use of morphine at the end-of-life is to maintain an appropriate level of comfort for the resident. 

Morphine can be administered in many forms.  The same rules that apply to administering other medications in the assisted living setting, apply to morphine.  Most notable is the requirement that residents must be able to self-administer medications or, if unable, medications must be administered by a skilled medical professional only.  For terminally ill residents, self-administration is often times not an option and, as pain can be unpredictable, the absence of an on-site skilled medical professional presents a challenge.  (Hospice nurses do visit residents, but are not available at the facility 24/7 to meet unscheduled needs.)

To address this, Title 22 (§ 87633) allows family members or friends (NOT receiving monetary or any other form of compensation for their services) to administer medications (including morphine) to hospice residents who are unable to self-administer, as long as the following criteria are met:

  • It is written in the hospice care plan.
  • The family  members have been trained by the hospice agency in proper administration.
  • It is recorded in the plan,  that if the family or friend is not available and/or fails to arrive at the appointed time, that a licensed health professional will be made available to attend to the residents needs and administer the medication.

A few other notes on morphine/medications:

Morphine pumps are permissible if:

  • The facility has received a Hospice Care Waiver

  • The hospice resident, hospice health care professional, or other appropriately skilled professional is administering the medication

  • The procedure is specified in the Hospice Care Plan

For medications that need to be pre-drawn into an individual syringe or oral dosing unit, the following shall apply:

  • Only a registered nurse may pre-draw the medication for later administration
  • The pre-drawn medication in the individual syringe or oral dosing unit must be labeled and properly stored
  • Medications may be set up in advance for a period not to exceed 24 hours

When administering lethal medications such as morphine, residents should be closely monitored.  More information about hospice care and morphine may be found here.  

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation. 

Anyone can submit an application to CCLD to open an RCFE.

Title 22 stipulates that CCLD needs "evidence satisfactory to the department that the applicant is of reputable and responsible character" (§87155) and that the applicant must meet  and comply with all application requirements (i.e. completed application, attendance at Orientation and other Component reviews,  payment of Licensing fees, etc).

Title 22, §87415

The Licensee must designate the following number of people to assist in caring for residents in the event of an emergency between the hours of 10 pm and 6 am:

  • For facilities with 16 or fewer residents, one employee must be on the premise but need not be awake.
  • For facilities with 16 to 100 residents, a total of two employees must be available.  At least one person shall be on the premises and awakeAnother employee shall be on call, and be capable of responding within 10 minutes.
  • For facilities with 101 to 200, a total of three employees must be available.  One employee must be on the premise and awakeAnother employee on the premise but on call.  And still another, on call and capable of responding within 10 minutes.
  • For every additional 100 residents (or fraction thereof), an additional employee must be on the premise and awake.
  • In facilities that require a signal system (Title 22, §87303), at least one employee must be located to enable an immediate response to the signal.  If the signal system is visual only, this employee must be awake.

According to Title 22, §87101(n)(2), a non-ambulatory person "means a person who is unable to leave a building unassisted under emergency conditions.  It includes, but is not limited to, those persons who depend upon mechanical aids such as crutches, walkers and wheelchairs.  It also includes persons who are unable, or likely to be unable, to respond physically or mentally to an oral instruction relating to fire danger and, unassisted, take appropriate action relating to such danger."   

Residents with dementia, and bedridden residents are considered non-ambulatory.  A facility's license reflects the number of ambulatory and non-ambulatory residents a facility  may serve at any one time.  Additionally, some facility rooms may not be cleared to house non-ambulatory residents per the Fire Marshal.

Title 22 §87618

A facility may accept or retain a resident who requires the use of oxygen GAS if:

(1) the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself *; OR

(2) intermittent oxygen administration is performed by an appropriately skilled professional.

*The facility is responsible for continuously monitoring the resident's ongoing ability to operate the equipment in accordance with the physician's orders.

Since a licensed professional is not required per regulation to be onsite 24/7 in an RCFE, in some cases the ability of a facility to guarantee intermittent administration and assistance by a skilled professional may be difficult. 

The regulations do, however, require that the facility staff have knowledge of, and the ability to operate the oxygen equipment.  But they are not allowed to assist the resident, per the regulations; only an appropriate skilled professional is allowed to provide this assistance. 

In addition to the administration of oxygen, Title 22 includes the following requirements as they pertain to the oxygen equipment:

(1) The facility shall submit a written report to the local fire jurisdiction notifying them oxygen is in use at the facility.

(2) "No Smoking-Oxygen in Use" signs shall be posted in appropriate areas.

(3) Smoking shall be prohibited where oxygen is in use.

(4) Oxygen tanks that are not portable must be secured in a stand or to a wall.

(5) Plastic tubing from the nasal canula or mask to the oxygen shall be long enough to allow movement by the resident but not constitute a hazard to the resident or others.

(There are special conditions if oxygen tubing exceeds 7 feet in length. Refer to Title 22 or contact CARR if you require detailed information.)

(6) Oxygen from a portable source shall be used by residents when they are outside their rooms.

(7) Equipment shall be operable.

(8) Equipment shall be removed when no longer in use.

(9) Room size should be appropriate to accommodate all equipment.

A facility may accept or retain a resident who requires the use of LIQUID oxygen if:

(1) The licensee obtains prior approval from the licensing agency; AND

(2) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself.

 The regulations do not speak to a resident remaining in an RCFE if he requires assistance with liquid oxygen.  Even if a licensed skilled professional is available to assist,  it is not clear that the regulations allow this type of assistance.  If this could be an issue for your resident, contact CCLD for regulatory clarification. 

Assisted living services in California are almost entirely private pay.  Though, there is some governmental assistance available for seniors meeting certain eligibility criteria.  Below you will find brief descriptions regarding payment options & links to additional information.

Personal Resource Options Include:
  • Personal Income/Savings/Assets
  • Reverse Mortgages:  Reverse Mortgages are a special type of home loan that lets homeowners (62 and older) convert the equity in their home into cash. 

Free information is available from the U.S Department of Housing & Urban Development at or by calling The National Council on Aging at (800) 510-0301.  Here the phone is answered by individuals offering counseling on reverse mortgages, providing answers to the following questions:

  • The pros & cons of reverse mortgages
  • The cost associated
  • Other options that may be available

This document contains a thorough overview of long-term care insurance and answers the most pertinent questions you need to get your research started:

  • What is LTC & who can benefit from it?

  • How to choose a qualified agent?

  • Questions to ask before purchase.

  • Rules that apply to agents, benefits & policies, etc.

  • In California only 3 categories of LTC insurance are sold, here they are listed and described.

  • Additional resources - Including HICAP, the Health Insurance Counseling & Advocacy Program  This organization provides free counseling on LTC insurance & Medicare & Medicare Supplement Policies.  Consumers should call 1(800) 434-0222 to find the local HICAP project operating in their community.

Government Assistance Options Include:

  • Veterans Benefits:  For free information, call The Department of Veteran Affairs at 1-800-827-1000] California Regional Offices.    Another good resource appears to be VeteranAid.  
  • Supplemental Security Income (SSI):   Supplemental Security Income, also known as SSI, is a benefit paid to qualifying blind, disabled, or 65+ year old individuals having fewer than $2,000 in assets.  As of 2011, the monthly rate for RCFEs from SSI funds is $982/month.  The maximum SSI a qualifying elder can receive is $1,100. (SEE ALSO SSI FAQ)

Not all RCFEs accept SSI clients.  However, after admission, a facility cannot evict a resident for non-payment should the resident's wealth diminish and they be approved for SSI.  The resident must be retained and cared for at the lower SSI rate making the original rate contained in the Admissions Agreement void.  

  • The Assisted Living Waiver Pilot Program (ALW):  Under the ALW program, Medicaid pays for services in assisted living for eligible seniors at a tiered reimbursement rate.  While SSI is used to cover the cost of room & board.  The program is currently only available in the following counties- Sacramento, San Joaquin, Los Angeles, Sonoma, Fresno, San Bernardino and Riverside Counties.  The number of waiver slots available in each county is limited.  Individuals applying must be deemed nursing home eligible.  For here more on this program,  or contact the state office directly at (916) 552-9105.

  • Medicare:  Medicare does not cover services in assisted living facilities.

Notes in italics represent the views and/or experience of CARR regarding this topic.

Title 22 §87608.

The following regulations pertain to postural supports:

(1) Supports shall be limited to devices used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of a bed, a chair, etc.  Included here are physician-prescribed orthopedic devices (braces or casts) used for support of a weakened body part or correction of body parts.

(2) Supports shall be fastened or tied in a manner that permits quick release by the resident.

(3) A written order from a physician indicating the need for the support shall be maintained in the resident's record, and if necessary CCLD may require additional documentation to verify the order.

(4) If the use of the support changes the ambulatory status of a resident to non-ambulatory, the licensee shall ensure that the appropriate fire clearance has been secured prior to the use of the support.

(5) Under no circumstances shall postural supports include tying, depriving or limiting the used of a resident's hands or feet.

(6) Bed rails that extend from the head half the length of the bed and are used only for assistance with mobility shall be allowed.

(7) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and who have a hospice care plan that specifies the need for full bed rails.

Title 22, §87217(d)(1)-(4)

"No Licensee or employee shall*:

(1) accept appointment as a guardian or conservator of the person and/or estate of any resident,

(2) accept any general or special power of attorney for any resident,

(3) become substitute payee for any payments made to any resident [unless involving Social Security monies & licensee is representative payee], or

(4) become the joint tenant on any account specified in §87217(h) with a resident. 

*except as provided in approved continuing care agreements.

Under Title 22, §87101(p)3), PRN (pro re nata) medication ". . . means any non-prescription or prescription medication which is to be taken 'as needed'."   This prescribing protocol ('as needed') contrasts with other prescribing protocols, i.e every 12 hours, or three times a day, with meals.

On this website, CARR has provided relevant information found in the public file on licensed facilities in San Diego and Imperial Counties.  CARR collected this information from the public files housed at Community Care Licensing Division (CCLD).  These files are physically available at the state's offices for all to view.  

If you choose to review a file at CCLD  you will first have to submit, either in person, or over the phone, a California Public Records Act (CPRA) Request, specifically requesting a file by facility name.  Under the CPRA, they must respond to your request within 10 days.

Each file at CCL has two components:  A Public File and a Confidential File.  The state will only provide you the Public File, not the Confidential File.  In the PUBLIC FILE, there are two sections: the application section (the left side of the file) and the compliance section (the right side of the file).  

APPLICATION SECTION: 

The documents supplied in this section are windows into the operation and business of the facility.  Documents in this section include the contact information of all Licensees (whether individuals or business entities), the License, Delegation, bonding status, the fire marshal clearance for the building and their authorized capacity, the expected operating costs and revenue of the facility, promised staffing levels, etc.  

  • For many facilities in CARR's facility database, most of these documents are provided as of the last time the file was reviewed.  For other facilities, our database is not nearly as complete.  As file surveillance continues, CARR's database will expand to include many of these documents. 

COMPLIANCE SECTION: 

The documents in this section serve as the record of the communication between CCLD and the facility/Licensee.  The two most important document types are the LIC 809- Facility Evaluations,  and the LIC 9099 - Complaint Investigations.  Also included in this section are Communication Logs, Civil Penalty Assessments and Invoices, any other correspondence and Long-term Care Ombudsman evaluations.

  • CARR considers the LIC809 and LIC9099 documents to be the most important among those in its document database.  These documents are the windows you have regarding how well the Licensee complies with the regulations.  From these documents you can infer quality-of-care based on the types and frequency of deficiencies cited.  If you don't have time to read any other documents about a facility, please read the LIC809s and LIC9099s for the facility you are interested in. 

If you need more information regarding certain documents in the file, please take a look at the Understanding California's Oversight & Regulation section and/or Understanding CCLDs Forms in our FAQ section or contact us

Moving from one's home into the care of others is a very complex transition. And while a welcoming smile, glossy brochure and 20-minute tour of featured amenities may give you and your loved one the reassurance you need to embark on this difficult transition, what you really need to make this transition safely and successfully, is the facts.

Familiarizing yourself with a facility's history through review of the public file, or the documents from the public file offered on this site, can help bring into focus the entire picture. Of particular interest to any consumer is a detailed review of the inspection (LIC 809) reports, and the complaint documents (LIC 9099).  

A facility's file suggests a facility's weaknesses, strengths, any reoccurring challenges, a Licensees' level of responsibility, and the overall oversight of the facility.  

Title 22, §87101(r)(5) defines a "Residential Care Facility for the Elderly" (RCFE), as ". . . a housing arrangement chosen voluntarily by the resident, the resident's guardian, conservator or other responsible person; where 75% of the residents are sixty years of age or older and where varying levels of care and supervision are provided, as agreed to at time of admission or as determined necessary at subsequent times of reappraisal.  Any younger residents must have needs compatible with other residents.

This site distinguishes between an RCFE and Assisted Living, and an RCFE and a Skilled Nursing Facility

Title 22 (§ 87507) only mandates refunds in two (2) situations:

1)      The Department orders the relocation of a resident.  In this case, the resident is relieved of any advance notice requirements contained in the admissions agreement.

2)      Upon the death of a resident, the agreement between the facility and the resident is terminated and relatives are not liable for any payment beyond that due at the date of death, unless agreed to in writing or ordered by a court.

Title 22 includes no other provisions for refunds or advanced notice requirements for residents or families.  Refund policies (outside of the above) are at the discretion of the facility and will be stated in the admissions agreement.  Therefore, it is imperative you familiarize yourself with a facility's policy regarding events that may prompt a resident's departure from the facility:

  •  Personal decision to move
  •  Sickness/Injury/Higher level of care
  •  Depleted Resources

If the terms set forth in the admissions agreement are not agreeable to you, search for a facility that has more reasonable policies or see if there is room for negotiation (and get all agreements in writing, no verbal assurances).  For example, is the required notification for moving 30 days or 60 days?  Is there the option for a reduced payment or per diem rate should the resident need to relocate temporarily?  How soon must you remove the resident's personal effects after death to avoid being charged?

While consumers always have the right to ask for a refund and to file a complaint against a facility they believe is taking advantage, the policy that is contained in the signed admissions agreement is binding.

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation. 

Title 22, §87101(r)(6) defines "responsible person" as the ". . . individual or individuals, including a relative, health care surrogate decision maker or placement agency, who assist the resident in placement, or assume varying degrees of responsibility for the resident's well-being."

Definition:  Merriam-Webster’s online dictionary defines “restraints” to mean the “action of keeping someone or something under control,” or “a measure or condition that keeps someone or something under control or within limits.

Personal Rights:  Restraint of a resident violates a resident’s Personal Rights, Title 22, Section 87572: 

a)    a resident is to be free from corporal or unusual punishment, humiliation, intimidation, mental abuse, or other actions of a punitive nature. . .” ,

b)   a resident is to be able to leave or depart the facility at any time and not to be locked into any room, building, or on facility premises by day or night.  This does not prohibit the establishment of house rules, such as the locking of doors at night, for the protection or residents; not does it prohibit, with permission of the licensing agency, the barring of windows against intruders.

Many things in an assisted living facility can be used to restrict the movement, motion and activity of residents:  postural supports (braces, soft ties intended to keep a resident upright, casts), bed-rails, geri-chairs, sliding trays, locks on doors, wooden bars in sliding doors, and drugs.

Postural Supports allowed by Title 22 ( Section 87608(a)(1) include “ . . . appliances or devices such as braces, spring release trays, or soft ties . . .used to achieve proper body position and balance, to improve a resident’s mobility and independent functioning, or to position, rather than restrict” a resident’s movement.

Postural supports require a) “quick release” by the resident and b) a written order from a doctor prior to use. 

Postural supports may not be used to tie, limit or deprive a resident of the use of her hands or feet.

Bed-Rails are allowed by Title 22, a postural support under Section 87608(5)(a); they may be used for mobility aids only.  Bed-rails that extend from the “. . .head half the length of the bed, and used only for assistance with mobility shall be allowed.”   Full bed-rails are prohibited except for residents receiving hospice care, with a care plan that specifies the need for full bed-rails.  Bed-rails are not to be used as a restraint to keep a resident in bed during the night, or to facilitate an understaffed facility. 

Geri-chairs with sliding trays:    Geri-chairs are standard in many facilities;  they allow the resident to be positioned in an upright position with the tray pushed close to the body thereby facilitating independent feeding and ease of swallowing.   However, CARR has seen these chairs be misused by laying the person back in the chair to a quasi-supine position incapacitating an individual from getting out of the chair – they are essentially ‘pinned’ into the chair. 

Locked Doors:    At no time may a resident be locked in or locked out of his room.   If a door has a lock on the inside, the lock must be a single-action so the resident can quickly get out. 

Blocked Sliding Doors:   Another form of restraint or restriction of a resident’s movements occurs when the Licensee has blocked the exit door to the outside.   Rooms are approved for non-ambulatory when the room has an exit to the outside, for example: a French door, a sliding door on a track, or a regular door.  CARR has seen documentation where furniture, storage boxes has blocked the exit, or where a stick has been placed in a sliding door track preventing the door from being used as an exit.  Blocked exits are considered a form of restraint.  Blocked exits are also a violation of Title 22, Section 87307(d)(6). 

Psychoactive Drugs:     California Advocates for Nursing Home Reform (CANHR) is a leading advocate of minimizing or eliminating the use of psychoactive drugs on residents of skilled nursing facilities and in residential care facilities for the elderly.  According to CANHR there are four types of psychoactive drugs:  antipsychotics (Zypreza, Haldol); anti-anxiety drugs (Ativan, Valium);  anti-depressants (Prozac and Zoloft);  sedatives and hypnotics (Halcion/Restoril).   The subject of misuse and overuse of these drugs is huge; suffice it to say here that if your resident is taking these drugs,  your resident is susceptible to the drugs being used as a chemical restraint. 

Risks of Restraints:  The risks of a resident being restrained include physical and emotional distress.  Physical manifestation can include decubitus ulcers (bedsores), bruising, incontinence, constipation; emotional manifestations include emotional distress, intimidation, anger, isolation, and loss of personal dignity.  The long-term effects of being on psychoactive drugs are myriad, and in many cases, exacerbate existing medical conditions, hastening death.

Why would a facility use restraints on a resident?    Facilities are frequently understaffed; Title 22, Section 87411 requires that ‘facility personnel shall at all times be sufficient in numbers, . . . and competent to provide services necessary to meet resident needs.”  That said, facilities generally staff lean, therefore it may be to the benefit of the facility to periodically restrain residents, particularly those tending to be wanderers, those who may be disruptive,  or those who may be aggressive. 

Consumers are asked to be ever watchful and vigilant and be on guard for a resident in, or under restraint.  Be watchful not only for your resident, but for others in the facility as well.

Resource:  The Ombudsman Services of Northern California publishes a helpful on-line guide “RCFE Regulation Reference Guide”  http://rcfe.lsnc.net/restraints/ that provides general guidance what is allowed and what isn’t allowed regarding restraint of residents.

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation. 

Title 22 (§87612)(a)

"The Licensee may provide care for residents who have any of the below-listed restricted health conditions, or who require any of the below-listed health services."  [Each below-listed condition has additional requirements associated with it, in order for facilities to be able to provide that specific type of care.]

1) Administration of Oxygen (§87618)

2) Catheter Care (§87623)

3) Colostomy/ileostomy Care (§87621)

4) Contractures (§87626)

5) Diabetes (§87628)

6) Enemas, suppositories, and /or fecal impaction removal (§87622)

7) Incontinence of bowel and/or bladder (§87625)

8) Injections (§87629)

9) Intermittent Positive Pressure Breathing Machine (§87619)

10) Stage 1 & 2 pressure sores (dermal ulcers) (§87631(a)(3))

11) Wound care (§87631)

Title 22, §87217(a) et.al.

Licensees are not ". . .required to handle residents' cash resources.  [However, if it is deemed and documented through an appraisal, that] a resident is incapable of handling his own cash resources, his cash resource must be safeguarded in accordance with the regulations. . .".    If the Licensee elects to safeguard a resident's cash resources, the Licensee does so pursuant to the stipulations of Title 22, §87217, paraphrased and summarized below:

  • Accurate records shall be kept and adequate safeguards maintained  (§87217(c)
  • Receipts for articles or cash must be given.  (§87217(b)
  • There is to be no commingling with facility funds. [This does not prohibit the Licensee from providing advances or loans to residents from facility money.]  (§87217(e)
  • No facility shall make expenditures from these resources for basic services. [There is an exception with regard to Social Security monies if Licensee is representative payee].  (§87217(f)
  • "No Licensee or employee shall (a) accept appointment as a guardian or conservator of the person and/or estate of any resident, (b) accept any general or special power of attorney for any resident, (c) become substitute payee for any payments made to any resident [unless involving Social Security monies & licensee is representative payee], or (d) become the joint tenant on any account with a resident.*" (§87217(d). 
  • Cash resources entrusted to the Licensee and  kept on the facility premises shall be locked and secured. (§87217(h)
  • Cash resources not kept at the facility must be immediately upon admission be deposited into a bank account separate from the personal and business accounts of the licensee provided that the account title clearly notes that it is residents' money and the resident has access to the money upon demand to the licensee.  (§87217(h)
  • All monetary gifts and any gift exceeding an estimated value of $100, which are given to the licensee by or on behalf of a resident shall be recorded (this does not include friends or relatives of deceased residents).  (§87217(k)
  • Any Licensee who is entrusted to safeguard resident cash resources shall file or have on file with the licensing agency a copy of a surety bond issued by a company to the State of California as principal. (§87216(a)

If a resident needs assistance from a facility with her finances, verify that the RCFE under consideration is bonded and that the amount is sufficient to adequately safeguard the money of the resident.  CCLD verifies that the bond held is sufficient , however there is no substitute for performing your own due diligence. 

*Except as provided in approved agreements with continuing care facilities.

According to Title 22 a skilled professional (aka a licensed professional (Title 22 §87101(l)(2), or medical professional (Title 22, §87101(m)(1)) refers to a person licensed in California to provide medical care or therapy or to perform necessary medical procedures.  This includes:

  • Physicians/surgeons/physician's assistants;
  • RNs/LVNs/Nurse practitioners;
  • Physical/occupational/respiratory therapists;
  • Psychiatric technicians, etc. 

Each must operate within his/her scope of practice.

This term does not include an uncertified caregiver, medication technician, administrator and/or Licensee, unless that individual also maintains a valid skilled professional license mentioned above.

Supplemental Security Income, also known as SSI, is a benefit paid to qualifying blind, disabled, or 65+ year old individuals having fewer than $2,000 in assets.  SSI monies (about $650 provided by the federal government; the remainder comes from state funds) can be used to pay for 24/7 care and supervision in an RCFE, however by law, the RCFE cannot charge more than the rate set by California for assisted living services.  As of 2011, the monthly rate for RCFEs from SSI funds is $982/month.  Since the maximum SSI a qualifying elder can receive is $1,100, the individual is left with #128 for personal items and discretionary spending.

Families note:  the RCFE cannot require that family members supplement the resident's monthly SSI payment to, nor can the Admissions Agreement be modified to include additional assistance by family members; RCFE owners can not receive a family supplement over and above the stipulated SSI amount for the resident's room, board and care. 

The fact is that few facilities accept residents who only receive SSI benefits because the rate is well below the normal monthly rate of $2,500 to $3,000 charged by RCFEs. To find out whether the assisted living facility takes SSI, the consumer has to call the candidate RCFE, asking whether they accept SSI clients.  There is no single place where a consumer can refer to that would advise which RCFEs accept  SSI clients.  

One source a consumer can look is the LIC 401, Monthly Operating Statement, completed by the RCFE application and submitted to the state as part of the license application package.  CARR regularly scans and posts the LIC 401 for individual facilities - so if it is available in the public record, it will likely be posted on this site.  The first part of the LIC 401 requires the licensee to account for his monthly revenue.  The first line in this section provides for SSI residents.  CARR has seen some licensees indicate that of a 6-bed intended occupancy, the licensee will calculate his total revenues based on having 1 or 2 SSI residents.  CARR is the first to acknowledge this source as unreliable, but if the licensee indicated a revenue stream coming from SSI clients, it may indicate the potential for the licensee to accept an SSI client.    

Information contained in this FAQ is based in part on research done by BA, CARR's spring SDSU intern.  Thanks BA.  

 

Title 22, Section 87101(d)(7) defines "direct care staff" to mean ". . . the Licensee, or those individuals employed by the Licensee, who provide direct care to the residents, including but not limited to, assistance with activities of daily living."

Caregivers are direct care staff.

Title 22, §87411

According to Title 22, facility personnel at all times must be sufficient in number and competency to provide services necessary to meet residents needs.  Additional staff should be employed as necessary to perform office work, cooking, housekeeping and facility maintenance.  For additional information, see FAQ Staffing in an RCFE.

All personnel who supervise and/or provide care to residents must be at least 18 years old, in good health as verified by a physician, must possess a current First Aid certificate, and must obtain a criminal record clearance from the Department of Justice. 

All staff who provide direct care to residents are required to receive at least 10 hours of initial training within the first 4 weeks of employment and must receive at least 4 hours of additional training annually.  The most popular training tools used in RCFEs are video instruction tapes/CDs and, at times, on-site trainings from persons knowledgeable on the specific subject(s).   

While proof of receiving the appropriate training is available on all employees in their personnel file, how much knowledge employees actually retain from videos/training is unknown.  Therefore, consumers may want to look for the following characteristics to assess the competency of the care staff:      (The following are mentioned in Title 22 as evidence of safe and effective job performance.)

(1) Familiarity with the aging process;

(2) The importance and techniques of personal care services and supervision;

(3) Respectful of Residents Rights;

(4) Knowledge of the psychosocial needs of the elderly (i.e. recreation, companionship);

(5) Knowledge necessary in order to recognize early signs of illness and the need for professional help (includes dementia);

(6) Knowledge of community resources;

(7) Ability to communicate with residents;

(8) Principles of good nutrition and sanitation;

(9) Knowledge of safely assisting with prescribed medications which are self-administered (Medication Management)

If you are concerned with the staffing level, or competency of staff in a particular RCFE, documenting your concerns and sharing the documentation with the LPA assigned to your facility may be helpful.

CCLD "may require a facility to provide additional staff whenever it determines through documentation that additional staff is required to provide adequate services" (Title 22, § 87411). 

Title 22, §87411

Title 22 does not mandate staffing requirements for residential care facilities; Title 22 states that "facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. 

The 'sufficient number' required is determined by the Licensee.  Aside from the Personnel Record (LIC 501) submitted during the application process, the public files at CCLD offer little information about a facility's staffing levels.

As residents' status changes, the balance of staffing levels may be impacted.   If you believe a resident's needs are being unfulfilled due to inappropriate staffing levels, contact the LPA assigned to your facility, or file a complaint with CCLD. 

According to Title 22 (§ 87412) personnel records, in all cases, shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.  If sharing this documentation with you is against the facility's policy or if they are reluctant to provide that information to you,  be aware that all personnel records must be made available to LPAs during normal business hours (§87412). Contacting the LPA assigned to the facility for assistance in this matter is appropriate.

Facilities are required to obtain a Hospice Care Waiver from the Department if they wish to retain clients receiving hospice care services (§ 87632).  Once granted, the waiver slot(s) can be applied to any future resident or residents needing hospice services without additional approval from the Department. 

Residents receiving hospice care services may eventually require “total care”.   Total care is defined as a condition where residents depend on others to perform all of their activities of daily living.  Under Title 22, total care is considered a prohibited health condition in assisted living facilities (LINK). 

Previously, to care for residents requiring total care, a facility would request a total care exception to allow a particular resident to be retained in the facility.  However, in response to facilities requests, the Department has streamlined the process and expanded its application by creating a Total Care Waiver.  Now, facilities may request a Total Care Waiver within their request for a Hospice Waiver.  And like the Hospice Waiver, once granted, the Total Care Waiver slot(s) can be applied to any future resident or residents needing total care without additional approval from the Department. [Consumers should note that while exceptions apply to specific individuals, waivers are applied facility-wide.]

The requirements for requesting a total care waiver are as follows (§ 87616):

1.  A facility must submit a plan for ensuring that the total care residents’ needs can be met.

2. The plan must also address how the facility will minimize this impact on the other residents.

3. The facility must provide documentation of the resident’s current health condition, including medical reports, etc. or retain the hospice care plan at the facility for Department review

To view the actual policy: (LINK http://www.ccld.ca.gov/res/pdf/10rcfe04.pdf).

Consumers should note all of the following: 

Once granted, Total Care Waivers expand the scope of care provided by an assisted living facility.  Without a waiver, total care residents would be required to move into a skilled nursing facility (aka nursing home) to be under the supervision of a medical team.  And while hospice nurses are to be involved in the care provided to total care residents, facilities remain the primary provider of care and supervision.

CARR reminds consumers that assisted living facilities are licensed as non-medical facilities.  Facilities are not mandated to maintain any patient-to-staff ratios nor are they required to employee nursing staff (even if granted a Total Care Waiver).  Additionally, the State inspects facilities only once every five years. Should a resident require total care, safety and quality of care can only be achieved through ongoing communications between all parties involved (facility staff, hospice, family members and resident) and extreme vigilance. 

Should you believe that a facility is failing to provide the care promised or is in need of additional staff, CARR recommends consumers document all events that will support such claims and to file a complaint with the Department.  CARR remains concerned about this expansion of resident care, as we have noted facilities with intolerable compliance histories who are not stripped of their hospice waivers. 

CARR questions the policy and procedures surrounding Total Care Waivers and has sought comment from the Department as of May 22, 2012.

Notes in italics represent the views and/or experiences of CARR regarding the topic and/or regulation.  

All personnel who assist residents with the self-administration of medications must receive the following training pursuant to Health & Safety Code 1569.69, and Title 22:(§87411): 

(1) For facilities with 16 or more residents: 8 hours of hands-on shadowing training and 8 hours of other training; or

(2) For facilities with 15 or fewer residents: 2 hours of hands-on shadowing training and 4 hours of other training.

(3)  In all facilities, personnel continuing to assist residents with the self-administration of their medication must complete four hours of training every 12 months.

After receiving the appropriate training, staff who assist residents with their medication should be competent in all of the following areas and must pass an examination demonstrating their comprehension of the subject matter, and competency:

a) The role, responsibilities and limitations of staff who assist residents with the self-administration of medication,

b) Terminology specific to medication assistance,

c) Different types of medication orders: prescription, over-the-counter, controlled,

d) Assistance procedures (in and out of the facility),

e) Medication documentation system used within the facility,

f) Proper storage, security, and disposal,

g) Process used for ordering medication, refills, and handling receipt of medications from the pharmacy,

h) Medication side effects, adverse reactions and errors,

Passing a test on medication management is an ambiguous accomplishment, as the test is not standardized within the industry, nor is it administered by a third party (i.e. CCLD or another regulatory/licensing board).  Upon completion of the test, no state or national accreditation is issued; a record of completion, however, should be maintained by the facility in their personnel records.

Facilities with 16 or more residents are required to have a pharmacist or nurse review their facility's medication management program and procedures at least twice a year.  Documentation of the review is mandated.  Facilities with 15 or fewer residents are not required to seek such guidance.

Title 22, §87101(t)(2), defines "transfer trauma" ". . . means the consequences of the stress and emotional shock caused by an abrupt, involuntary relocation of a resident from one facility to another."

Title 22, Section 87101(u)(1) defines "universal precautions" as ". . .  an approach to infection control that treats all human blood and body fluids [mucous, saliva, urine, etc.] as if they were infectious."

Title 22, §87101(v)1) a "vendor" means a CCLD-approved ". . . institution, association, individual(s), or other entity that assumes full responsibility or control over a [CCLD]-approved Initial Certification Training Program or a Continuing Education Training Program."

The Evaluator's Manual Transmittal No. 09RM-18, 3-4200, dated 11/2009 states that a "Type A: Immediate Health, Safety or Personal Rights Impact - are violations of the regulations, and the Health and Safety Code that, if not corrected, have a direct and immediate risk to the health, safety or personal rights of those in care."

Pursuant to Transmittal No 09RM-18 dated 11/2009, §3-4200, a "Type B: Potential Health, Safety or Personal Rights Impact - Violations of the regulations and the Health and Safety Code that, without correction, could become an immediate risk to the health, safety or personal rights of clients, or record keeping violation that would impact the care of clients and/or protection of their resources, or a violation that would impact those services required to meet clients' needs."

The Self-Assessment Guide, "Facility Evaluation Process" "Technical Support Program" (TSP 9/02) describes a Type C violation as one that does "not present an immediate or potential threat to the health, safety or personal rights of clients/residents in care and where the Licensee has maintained substantial compliance with regulations. "

Title 22, Division 6, Chapter 8, Section 87468 lists some of the rights residents retain when moving into an assisted living facility.  They are also enumerated in LIC 613C. 

Specifically Title 22 enumerates 18 resident rights including the right to have visitors, including the right to visit privately during reasonable hours, and without prior notice, provided that rights of other residents are not infringed upon.  A facility may not unilaterally restrict a resident’s telephone calls or visitors. 

Having friends, family, business associates and all others requested by the resident to visit is an important aspect of socialization and allowing the resident to remain connected, involved, and feel loved and cared for.  Failures in allowing a resident to have visitors is a violation of the resident’s personal rights, and worse – contributes to an elder’s isolation, depression, and loneliness.

Despite the clarity of Title 22 regarding the resident’s unequivocal right to receive visits by family, friends, ombudsman, advocacy representatives and all others the resident is willing to entertain, issues may arise through actions of a Public Guardian or Conservator.  Generally a Public Guardian or Conservator can restrict visitors to the conserved resident; the legal powers of the Public Guardian or conservator take precedence over Title 22 Section 87468.   

Assert your Rights:   As always, if you feel your resident’s right to have visitors and phone calls is being restricted, document the circumstances, document the facts, and make a prompt complaint to CCL via telephone call to the duty work, or in writing using the LIC802 form, or a letter documenting your allegations and supporting information. 

Notes in italics represent the views and/or experience of CARR regarding this topic and/or regulation.

Any staff may take the vital signs of a resident.  However, if the reading is to be used to determine the need for medication, the reading must be taken by an appropriately skilled professional.  

Title 22, §87101(v)(3), "'voluntary' means resulting from free will."  

Title 22, §87411

Volunteers may be used in RCFEs, but may not be included in the facility staffing plan.  They must be supervised and are not authorized to assist residents with activities of daily living.

A waiver, per Title 22, §87101(w)(1), allows for ". . . variance to a specific regulation based on a facility-wide need or circumstance which is not typically tied to a specific resident or staff persons. Requests for waivers are made to the licensing agency, in advance, by an applicant or Licensee. "

The most common waiver requested is a hospice waiver.  When a facility requests a hospice waiver, it is requesting permission to accept, or retain any resident, at any time in the future, who may require hospice services. The facility must submit a written request for a waiver. Typically, Community Care Licensing (CCL) will approve the waiver if the facility is determined, through a case management visit, to be in substantial compliance.

A waiver is in contrast to an "exception" , which is a variance from the regulations based on a unique need or circumstance of a specific resident or staff person. An exception cannot be transferred or applied to any other individual.