Activities of daily living (ADLs) are everyday routines generally involving functional mobility and personal care. Examples include bathing, dressing, toileting and self-feeding.
Frequently Asked Questions
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.
This only means CCL has to initiate the complaint investigation - not complete it and report findings to the complainant - with 10 days.
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:
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.