Keep in touch with what’s happening in California about assisted living and RCFE legislation and related items.
Frequently Asked Questions
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
- Long-Term Care Insurance: The following link will direct you to California’s Department of Insurance – Consumers: Long-Term Care Insurance (2008).
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.
Activities of daily living (ADLs) are everyday routines of individuals - tasks and behaviors that are necessary for functional mobility and personal care. Examples include bathing, dressing, toileting and self-feeding.
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 and in the community."
Basic services must be provided to obtain and retain an RCFE license.
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) and 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."
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 (ADLs) and the assumption of varying degrees of responsibility for the safety and well-being of residents. "Care and Supervision" includes 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.]
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 to discuss with the facility the resident's expectations regarding exercises and physical activity. Assess the facility's ability to meet the resident's requirements, and expectations. Facilities having a limited activity program, or having inexperienced staff may cause contractures to worsen.]
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..
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.
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)
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.
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.)
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."