Frequently Asked Questions? - UNDERSTANDING STATE REGULATION

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.

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.

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:

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.  

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

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

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

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, §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, §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 §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:

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. 

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. "