A Report on Community Residential Care for the Elderly

...- ..... GEORGE DEUKMEJIAN. Governor STATE OF CALIFORNIA {J COMMISSION ON CALIFORNIA STATE GOVERNMENT ORGANIZATION AND ECONOMY .'/ , v . 1303 J Street. Suite 270. (916) 445-2125 ~J: ~~ Sacramento 95814 Chllfman NATHAN SHAPELL Vlce-Ch."man HA'G G. MARD'KIAN ALFRED E. ALOUIST MARY ANNE CHALKER ALBERT GERSTEN RICHARO E. GULBRANSON MIL TDN MARKS Senalor GWEN MOORE A:ssemolywoman GEORGE E. PARAS ABRAHAM SP'EGEL BARBARA S. STONE RICHARD R. TERZIAN PHILLIP O. WYMAN Assemolyman JEANNINE L ENGLISH Executive Dirtlctor //////////////////////////////////////////////////////////////////////////// THE LITTLE HOOVER COMMISSION'S REPORT ON COMMUNITY RESIDENTIAL CARE =- FOR THE ELDERLY //////////////////////////////////////////////////////////////////////////// JANUARY 1989 GEORGE DEUKMEJIAN, Governor STATE OF CALIFORNIA COMMISSION ON CALIFORNIA STATE GOVERNMENT ORGANIZATION AND ECONOMY 1303 J Sireet. Suite 270, (916) 445-2125 Sacramento 95814 Chalfman NATHAN SHAPELL January 5, 1989 Vlce-Chalfman HAIG G. MARDIKIAN ALFRED E. ALQUIST Senator MARY ANNE CHALKER ALBERT GERSTEN The Honorable George Deukmejian RICHARDE.GULBRANSON Governor of California MILTON MARKS Senator GWEN MOORE The Honorable David Roberti The Honorable Kenneth L. Maddy Assemblywoman President pro Tempore of the Senate Senate Minority Floor Leader GEORGE E. PARAS ABRAHAM SPIEGEL and Members of the Senate BARBARA S. STONE The Honorable Willie L. Brown, Jr. The Honorable Ross Johnson RICHARD R. TERZIAN Speaker of the Assembly Assembly Minority Floor Leader PHILLIP D. WYMAN Assemblyman and the Members of the Assembly JEANNINE L. ENGLISH Executive Director Dear Governor and Members of the Legislature: Recently, media from allover the country converged on Sacramento when police unearthed the bodies of seven elderly people, apparently killed for their social security checks by the operator of an unlicensed residential care facility. Government official s, news commentators, and people on the streets were shocked: How could this have happened? The Little Hoover Commission, however, was not stunned. Five years ago, this Commission investigated the care that society provides for the elderly in residential homes, and produced a grim and ugly picture of negle ct, abuse and inadequate government controls. Our scathing report recommended numerous changes designed to protect vulnerable elderly Californians. Today, our Commission is back with the results of a review begun early this year of conditions in residential care facilities. The outcome is only marginally less bleak while the findings regarding the State's role as protector of society's weakest members is every bit as blistering as it was five years ago. Sacramento's board and care death house is, of course, a sensational case that we can all hope is unique. But our Commission's fear is that many other such tragedies await discovery because the Sacramento house reflects so many of the statewide problems with residential care facilities. For instance, the Sacramento board and care facility was unlicensed, but continued to receive referrals from government social workers. One of the biggest threats to the protection of the elderly is unlicensed facilities where the State plays no role in monitoring the quality of care. Nationally, it is estimated that one in six residential care faoilities is unlicensed. (ThiS lenernead not prtnted at taxpayer s expense) -2- Yet California has no aggressive strategy to eliminate these operations that prey on senior citizens. Because of the backlogged, time-consuming licensing process, many operators find it fiscally advantageous to begin their businesses with no license. The State's response, once an unlicensed facility is discovered, is to speed the application process for the operator. To date, there are no regulations to impose the $200-a-day fines written into law at the urgings of the Little Hoover Commission in 1985. In short, not only are there no effective punishments for unlicensed facilities, the State, through its policies and actions, actually provides incentives for these renegade operators. Had the facility in Sacramento been licensed, would anyone have noticed substandard care or abuse, or done anything about it? Statistically, across the State overworked ombudsmen are only able to visit 40 percent of the board and care facilities. In the small portion that they oversee, they find on an annual basis about 550 cases of confirmed abuse. When one also considers the unknown number of unreported cases, we have a frightening concept of the lives of senior citizens who are no longer at home with loved ones. When ombudsmen report abuse and violations of regulations, they find a frustrating, uneven and lethargic response from the State. Fines that are pa1try--$25 and $50 a day--compared to those levied on other care=" institutions are frequently waived or never collected. There is no clear coordination between the State's oversight function and local prosecution efforts. And the State makes no effort to let local referral agencies know the licensing and violation status of facilities in their area. Clearly, the system is in need of a drastic overhaul. The Little Hoover Commission; in the attached report, makes specific and detailed recommendations. Some of the changes are technical in nature, such as altering fire code requirements and waiving locked-facility regulations. But others, such as the following, are clear-cut, broad institutional changes: 1. A well-coordinated campaign to find and eliminate unlicensed facilities should be a top priority. Homes like the one in Sacramento must be stamped out of existence. 2. The State should make a strong effort to enforce existing laws regarding care and to crack down on violations in a timely, uniform and convincing manner. This means higher fines and more consistent prosecution of violators. 3. Those who are actually providing the care for the elderly need to be trained and certified to ensure that they are capable of meeting the needs of senior citizens. Creating a professional career ladder, reaching from the bottom aide to the top administrator, will do much to enhance the quality of care in residential facilities. -3- It is past time to put a stop to the inhumane treatment of people as they near the end of their lives. We urge your most energetic cooperation in adopting the recommendations of the Little Hoover Commission to remedy this horrifying situation. Richard Gulbranson Senator Milton Marks Assemblywoman Gwen Moore George Paras Abraham Spiegel Barbara Stone Richard Terzian Assemblyman Phillip Wyman TABLE OF CONTENTS Chapter Executive Summary i I. INTRODUCTION 1 Scope 1 Methodology 1 II. BACKGROUND 3 Profile of Residential Facilities for the Elderly 3 Role and Responsibilities of the Department of 4 Social Services/Community Care Licensing Role and Responsibilities of the California 5 Department of Aging The Evolution of Community Residential Care 6 Demographics 7 Fiscal Impact 8 The Continuum of Long-Term Care 9 III. STUDY FINDINGS 10 Finding #1 - Abuse and Neglect of Residents Are 10 Ongoing Problems Finding #2 - Performance ,by the Department's 13 Community Care Licensing Division Often is Characterized as Arbitrary and Slow Finding #3 - The Department's Enforcement Program 15 Suffers from Underutilization of Penalties, Fines and Relationships with Local Law Enforcement Agencies Finding #4 - Unlicensed Facilities Are Undeterred by 19 Current Enforcement Efforts Finding #5 - Case Management Services Are Not 21 Systematically Available to Older Californians Finding #6 - State Fire Regulations Do Not Recognize 23 Residential Facilities as a Special Case Finding #7 Small Facilities Lack the Special 24 Oversight They Need to Function in the Residential Care Network Finding #8 - Quality Is a Low Priority in California's 25 Residential Care Regulatory Program Finding #9 - Emergency Relocation Procedures Are 30 Not Standardized and Are Underfunded Finding #10 - The Cost of Providing Residential Care 31 Are Not Documented by the State Finding #11 - Private Funding Mechanisms Are Too New 33 and Untried to Relieve the Public Sector's Financial Burden IV. CONCLUSIONS AND RECOMMENDATIONS 35 Conclusions 35 Recommendations 36 EXHIBITS 44 1 EXECUTIVE SUMMARY Ours is a rapidly aging society. The United States population over 80 years old will grow from 2.9 million in 1980 to 7.9 million in 2020. In California, the aging of the population is accelerating more rapidly than in the nation at large. Over the next 20 years, Californians aged 80 and over will increase by 138 percent. Issues affecting the aged will, therefore, be more acute sooner in California than in most other states. Thus, unless problems such as abuse and neglect in residential facilities are corrected soon, they will affect greater and greater numbers of California's elderly. Despite many improvements made over the last five years, California's system of residential care for the elderly is still not adequate, even in licensed facilities. Nationwide, between 500,000 and 1,000,000 cases of elder abuse are reported annually. This represents as many as one in every 25 persons over the age of 60. Thus, approximately 150,000 Californians may be victims of elder abuse. During the first quarter of 1987-88, ombudsmen throughout the State received 237 reports of abuse in residential facilities for the elderly. They investigated 226 of those reports and confirmed that abuse had occurred in 137 cases. Given the likelihood that the first reports in this new reporting system would under count actual incidents, the reports demonstrate that abuse is a very real problem. The Commission's study revealed that performance by the Department of Social Services' (DSS) Community Care Licensing Division is often arbitrary and slow. At both hearings held over the course of this study, the Commission heard testimony regarding the Department's arbitrary, inconsistent and delayed implementation and enforcement of licensing laws and regulations. Applications for licensure are severely backlogged, and the Department's computer system does not appear adequate to overcome performance weaknesses. The study determined that the Department of Social Services' Enforcement Program suffers from underutilization of penalties and fines and a lack of coordination with local law enforcement. Fines for licensing violations in residential care facilities range from $25 to $50 per day. This is significantly less than fines for similar violations in skilled nursing facilities which range from $100 to $10,000 per incident. In addition, of the fines that are assessed by the Department of Social Services, only half are actually collected. Moreover, the Department is not required to involve local law enforcement in cases of abuse and neglect within set time limits. Thus, coordination between DSS and local law enforcement agencies on which the Department must rely to prosecute cases, varies dramatically. Without consistently enforcing the civil sanctions and effectively utilizing all law enforcement resources, the protection mechanisms established to insure the safety of elderly residents will continue to be ineffective. The Commission believes that the continued operation of unlicensed facilities poses a .serious threat to the safety and well-being of residents. The facility owner who starts operations without a license faces no significant penalty for do ing so. Indeed, in light of potential revenue losses resulting from delays in license application processing, facility ii owners actually have an economic incentive not to seek licensure. The Commission believes that investigating and prosecuting unlicensed facilities is difficult. However, it is imperative since currently unprotected residents are suffering because of the lax enforcement of laws. In our 1983 report, the Commission found that residents are rarely visited by outsiders and that case management services were available for the developmentally and mentally disabled but not for the elderly. Case management begins with an assessment of an individual's functional abilities, using a standardized assessment instrument. The assessment becomes the basis for a decision to place an older person in a particular facility. Case management also includes ongoing visitation to monitor the individual's health status and overall well-being.Five years later, except for those elderly certifiably frail enough to be at risk of placement in nursing homes, case management services comparable to those provided for other vulnerable populations still are not available to older Californians on a systematic basis. In addition, the Commission found that residential facilities for the elderly are caught from both sides by State fire regulations. On the one hand, they face slow and fragmented enforcement of fire codes that delay licensing or make continued operation difficult. On the other hand, these facilities often are plagued by rigid interpretation of the codes that force them to make costly changes that alter the noninstitutional setting in residential facilities. Without appropriate recognition of residential facilities as a special situation, the supply of residential care homes for the elderly may be greatly limited. Additionally, the Commission's study determined that small facilities, licensed to serve six or fewer residents, lack the special oversight they need to function in the residential care network. One of the particular problems faced by licensees operating family setting residences is isolation. There is a great unmet need for respite care for administrators of family setting residences. Furthermore, Licensing is particularly ill-suited as the sole regulatory program for family setting residences. The loss of direct interaction with social workers resulting from the Community Care Act of 1973 exacerbates the potential for adverse effects from isolation that characterizes family setting residences. Moreover, the Commission determined that quality is a low priority in California's Residential Care Regulatory Program. Licensing alone does not constitute a system of controls that could ever prescribe and monitor quality of care in the thousands of residential care facilities throughout the State. Factors contributing to the public sector's lack of control over the quality of care in residential facilities include the State's lack of ability to offer performance incentives, lack of training, failure to assess the care needs of the residents, regulations that discourage specialization, lack of requirements for English-speaking capability and lack of adequate consumer education. Without the prescription of controls, quality of care in residential facilities will be inconsistent and, in many cases, inadequate. 111 The study also determined that there is no State level policy on or protocol for emergency relocation of community care residents, but local government is generally expected to support this activity in times of crisis. Because relocation procedures are not provided by the State, orchestrating a transfer becomes the responsibility of local authorities. However, the current county level emergency response capability is no match for the incidence of elder abuse and abandonment in residential care facilities. Furthermore, the cost of providing residential care is not adequately documented. However, the Commission found that during the first half of the current decade, real spending on programs for seniors rose six percent while the over-60 population increased by 25 percent. Although approximately one-fourth of the residents are SSI/SSP recipients, the California Association of Residential Care Homes (CARCH) believes that many small homes cannot afford to accept SSI/SSP clients. CARCH estimates that the actual monthly cost per client is nearly double the current rate of $678. The State needs to know how much it costs to provide regulated levels of service in residential care facilities so that rates paid by the State to purchase those levels will assure that adequate service is available to those who qualify. The Commission study also revealed that private funding mechanisms have not been established to relieve the public sector's financial burden. Finally, for middle-income children, the cost of maintaining an elderly parent in a residential care setting becomes increasingly burdensome. Currently, only about two percent of long-term care costs in California are paid for by private insurance. Furthermore, many policies available at present cover only skilled nursing care. Long-term care plans similar to IRAs for investment-minded consumers are currently under consideration by the federal government but are likely to be expensive due to inflation of health-related costs. The Commission's report presents 10 recommendations to improve the quality of life for California's citizens that live in residential care facilities. 1. Certify residential care facility administrators with specific education and training requirements. 2. Authorize and fund counties, at their option, to license small residential care facilities and provide placement counseling and assistance. 3. Identify new revenue sources from which to increase funding for residential care for the elderly. 4. Improve effectiveness of monitoring and law enforcement. 5. Launch a well-coordinated campaign to detect and eliminate unlicensed facilities. 6. Strengthen current law and regulations pertaining to resident protections. lV 7. Develop protocols for emergency services coordination. 8. Develop a waiver application procedure for requesting permission to operate a locked facility for special conditions such as Alzheimers disease. 9. Upgrade the Department of Social Services' management information capabilities. 10. Develop fire safety regulations specific to residential care facilities. I. INTRODUCTION In 1983, the Commission on California State Government Organization and Economy, also known as the Little Hoover Commission, completed studies of both the nursing home and residential care industries. Since that time, significant progress has occurred in many areas of concern to the Commission. For example, the Long-Term Care Ombudsman program has been expanded to bring more volunteers into residential facilities for the elderly so that residents are now less isolated. But in certain crucial areas--such as investigation and closure of unlicensed facilities--progress is undetectable. Ours is a rapidly aging society. Unless problems such as abuse and neglect in residential facilities are corrected soon, they will affect greater and greater numbers of California's elderly and disabled citizens. For this reason, the Commission has chosen to review the current status of the safety and well-being of individuals residing in residential facilities for the elderly. This report includes a detailed description of California's existing system of community residential care for the elderly in particular, as well as a description of the evolution of community residential care in general. Pertinent legislation and roles of the Department of Social ~ Services/Community Care Licensing, the Long-Term Care Ombudsman program, and other agencies are discussed. The report also profiles Carifornia' s residential facilities for the elderly and describes in some detail the context in which they function, including such factors as funding, the continuum of long-term care, and demographics. The report takes a comprehensive view of quality of care, reviewing the following specific areas: o Prevention of abuse and neglect; o Enforcement of existing laws and regulations; o Performance of, and appropriate role for, the Department of Social Services/Community Care Licensing; o Efforts to deter the operation of unlicensed facilities; o State fire regulations and administration; o Placement process; o Need for case management services; and o Adequacy of funding. Methodology The Commission contracted with Marquart Policy Analysis Associates to assist in the preparation of this study. The initial phase of the study consisted of a literature search (a review of existing documents and analyses), with particular emphasis on changes in the residential care system since the Commission's 1983 report. The Commission held two public hearings: one on February 26, 1988 in Santa Ana and the second on April 29, 1988 in San Francisco (the witnesses are identified in Exhibit A). -2- Various public officials and industry representatives were interviewed over the course of the study. In addition, the Commission convened an Advisory Committee representing the agencies concerned with service delivery and quality of caregiving provided by residential facilities for the elderly (Exhibit B lists members of the Advisory Committee). The Advisory Committee met four times as a whole and 'a number of times as subcommittees and working groups, discussing issues and problems extensively and preparing papers on most of the topics covered in this report. While the Commission has given consideration to the ideas and concerns of all members of the Advisory Committee, the final report is a product of the Commission and mayor may not be consistent with the viewpoint of individual members of the Advisory Committee. -3- I I. BACKGROUND Profile of Residential Facilities for the Elderly A residential facility for the elderly (RFE) is a group housing arrangement chosen voluntarily by the residents who typically are over 60 years of age, although persons under 60 who have compatible needs may also be included. An RFE provides "nonmedical care and supervision" to residents. They are intended for residents who do not need the medical care or intensive supervision required in nursing homes. RFEs are governed by Health and Safety Code Chapter 3.3, Section 1569 et. ~ (Residential Facilities for the Elderly Act). The law requires that at least the following basic services must be made available in all such facilities: o Assisting with activities of daily living, as defined in the Health and Safety Code, in combinations which meet the needs of residents. o Helping residents gain access to appropriate supportive services in the community. o Being aware of the residents' general whereabouts, although residents may travel independently in the community. o Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. o Encouraging the residents to develop and maintain functional ability through participation in planned activities. Examples of activities with which residential facilities may assist residents include housework; laundry; money management; dressing; eating; grooming; arranging for transportation; telephoning; arranging for recreation, medical, dental, and other health services in the community; supervision and storage of medications. Under State law, residential facilities for the elderly are required to be licensed by the Community Care Licensing (CCL) Division of the Department of Social Services (DSS). As of September 1987, there were 3,675 licensed facilities operating in California, with a capacity to serve 78,817 residents. An unknown number of facilities operate without a license. The size of the facilities ranges from homes licensed for six or fewer to much larger facilities of 500 or more residents. About 67 percent of elderly residents live in the small homes. About 30 percent depend ssr/ssp entirely on for income [CSSP:lO]. -4- Role and Responsibilities of the Department of Social Services/Community Care Licensing The State Department of Social Services is mandated by Chapter 3 of the Health and Safety Code (SEC. 1500, et. ~) to license all facilities providing nonmedical, out-of-home residential or day care through its Community Care Licensing Division. CCL has 15 district offices throughout the State. In 1986-87, their caseload consisted of approximately 53, 000 day and residential care facilities (including foster care homes, which are licensed by county welfare departments). The license issued to residential facility owners is a basic permit to operate a corrnnunity care facility. If at any time the facility fails to meet minimum standards of health and safety, the Department may terminate the license. Facilities are inspected at least twice a year by licensing analysts, who generally have achieved an bachelor's degree as a job prerequisite. The residential facilities for the elderly caseload, if an analyst were limited strictly to these facilities, is 55. This compares with a case load of 83 for adult residential facilities. As of July 1, 1988, the Department had 283 analysts on staff and planned to add 60 more positions based on work volume. The Department's basic responsibilities include: o Approving or denying' initial and renewal applications for facility licensure; o Securing criminal record clearances on applicants, owners, staff, and non-client adult residents of facilities; o Investigating complaints against facilities; o Developing and enforcing regulations to protect client health, safety and human rights; o Visiting and evaluating all licensed facilities on a regular schedule (Exhibit C, Licensing Form 860-A, is used to evaluate compliance with laws and regulations); o Preventing the clustering of facilities in single neighborhoods by applying overconcentration standards to applications; o Providing information to the public on inspections, deficiencies, and plans of correction; and o Pursuing enforcement actions, including civil penalties and revocation and closure actions against facilities found in violation of law or regulations. -5- Role and Responsibilities of the California Department of Aging The California Department of Aging (CDA) is the single State agency responsible for administering programs funded under the federal Older Americans Act. Through area agencies on aging, the Department oversees programs that provide services to almost 4 million older Californians. In addition, the Legislature has delegated to CDA the responsibility for developing and implementing a comprehensive range of noninstitutional long-term care services for both older and functionally impaired adults. Services administered by the Department of Aging include social and nutrition services, senior employment programs, long-term care services, and staff training. Pursuant to Chapter 1637 /Statutes of 1984 [AB 2226 (Felando)], the principal emphasis of the Department of Aging is on long-term care, reflecting the State's policy to help older Californians live as independently as possible for as long as possible by preventing unnecessary institutionalization. The 1984 legislation gave CDA primary responsibility for overall policy coordination and direction of community based long-term care. CDA now administers several community based long-term care programs, including adult day health care, the multipurpose senior services program (MSSP), and Linkages. CDA's Long-Term Care Ombudsman program is closely involved with residential facilities. The Ombudsman program has the authority for and responsibility of receiving, investigating, and resolving complaints made by or on behalf of residents in long-term care facilities, including RFEs. Besides residential facilities for the elderly, the Ombudsman monitors skilled nursing, intermediate care, and adult day health care facilities. The State Ombudsman office, with a staff of eight, directs and technically assists 35 local Ombudsman programs that monitor clients in long-term care facilities. The State Ombudsman office also trains and certifies volunteers. . As of July 1987, there were 103 full-time equivalent paid staff and approximately 820 trained and certified volunteers in local ombudsman programs. The goals of the Ombudsman program are as follows: o To assist residents to assert their civil and human rights; o To ensure that quality of care includes considerations of quality of life; o To provide appropriate referrals to agencies; and o To inform the appropriate agencies of substandard conditions and important issues in long-term care facilities. The Ombudsman program functions as an advocate for individual clients, working to resolve whatever problems residents may have within a particular facility. AB 3662.required the State Long-Term Care Ombudsman to establish a 24-hour, toll-free telephone hotline to encourage reports of crises in long-term health or community care f~cilities. The hotline number (1-800-231-4024) is required to be posted conspicuously in a place easily accessible to residents. Chapter 769/Statutes of 1986 [AB 3988 (Papan)] established a new reporting system whereby abuse in long-term care -6- facilities is reported to the local Ombudsman program which, to the extent resources are available, is responsible for investigation and substantiation. In addition to the functions mentioned above, the Ombudsman program also does the following: o Advises the public of any inspection reports, statements of deficiency, and plans of correction for any long-term care facility within its service area; o Establishes and assists in the development and maintenance of resident and family councils; o Sponsors other community involvement in long-term care facilities; o Provides community education and training to facilities and the general public about long-term care in general and residents' rights issues in particular; o Hi tnesses Durable Powers of Attorney for Health Care Agreements in long-term care facilities; o IHtnesses certain transfers of property in long-term care facilities; and o Attends Citation Review Conferences. The Ombudsman program has considerable ground to cover: nearly 9,000 facilities in all, of which approximately 3,500 are residential facilities for the elderly. During the fiscal year ending June 30, 1987, the Ombudsman prbgram referred 1,185 complaints to Community Care Licensing. During the same period, 38 percent of licensed residential facilities had an ombudsman assigned to make regular visits. The Evolution of Community Residential Care In 1973, the California Community Care Licensing Act was passed to establish a statewide system of community care for the elderly and other dependent clients. The Act required the Department of Social Services to develop new regulations for licensing nonmedical, out-of-home care, in part as an alternative to state hospital care for those persons who did not require institutionalization but who were unable to care for themselves entirely on their own. Prior to the passage of this legislation, social workers in the Department of Mental Health's field offices recruited, trained, and certified family care homes. The homes were recruited on an as-needed basis and "certified" by Department of Mental Health social workers. In this system, social workers--relying 9n a "trained eye" and their understanding of the individual clients' needs and preferences--placed the primary emphasis on family caregivers' personal qualities. It was a subjective form of -7- certification, seen as a process of cultivating humanitarian motives (Thompson]. By contrast, the current system is based on the Department's monitoring role as licenser of residential facilities and tends to stress the business relationship of the licensee to the client. A license is a property right. While objective rather than subjective monitoring of minimum standards of care is appropriate, many observers point out an attendant loss of social workers' trained eyes and ears to monitor individual clients. Issued in December 1983. the Little Hoover Commission's first report on community residential care detailed the numerous problems still existing in the long-term care continuum and evaluated the impact of the State's move to license residential facilities to meet minimum health and safety standards rather than continuing the family care home model. The report led to legislative hearings focused on the specific problems of community residential care for the elderly. A task force was organized by the California Association of Homes for the Aging (CAHA) to examine the results of the investigations and to develop recommendations for legislation. The result of this process was Chapter 1127/Statutes of 1985 [SB 185 (Mello)], which established a separate licensing act for these facilities: the Residential Facilities for the Elderly Act. This legislation required training of both licensing and caregiver staff and mandated the development of three levels of care within residential facilities. In 1987, SB 50 (Mello) was introduced to implement and fund the three levels of care referenced in SB 185 of 1985. The bill called for three levels of care to be established; defined the three levels of care; required that services be designated for the appropriate levels of care; prohibited facilities from accepting or retaining residents who require intermediate care or skilled nursing services; placed limits on health services to be provided to residents; provided authority to the Department of Social Services to establish criteria to approve licensed facilities' abili ty to provide Level II and Level III services; and provided for supplemental SSI/SSP payments for Levels II and III. Due to the State's uncertain fiscal condition, the Governor advised the Legislature that SB 50 would not be signed, however, the provisions of the three levels of care have been implemented by the Department of Social Services. SB 50 was seen by providers and related agency representatives as a step toward bringing SSI/SSP reimbursement closer to the true costs of residential caregiving. The levels of care would have provided a means for maintaining residents for a longer time in the residential setting, thus reducing the need for placement in skilled nursing facilities. Demographics Health care during the twentieth century, which began with an average U.S. life expectancy of 47 years, emphasized "cure" rather than "care" [JECCUS:59]. The, significance of the care is increasingly important, however, as citizens live greatly lengthened but often impaired lives. -8- The U.S. population over 80 years old will grow from 2.9 million in 1980 to 7.9 million in 2020 [Rich:149]--an increase of nearly 175 percent in only 40 years. In California, the aging of the population is accelerating more rapidly than in the nation at large. Compared with the national average, California has fewer people under 18 and more people between the ages of 25 and 44 ("baby boomers"). In fact, California has a higher percentage of people in this age group (33.5 percent) than all but five other states [UCSH] . Moreover, in California between 1985 and 1990, those aged· 65 to 74 will increase by 16 percent while those 75 and over will increase by 19 percent [CDA, 1986, App C:2]. Between 1980 and 2000, Californians aged 80 and over will increase by 94 percent and those 85 and over will increase by 138 percent [UCSH:5]. Problems affecting the aged will therefore be more acute, sooner, in California than in most other states. Demographics become even more significant in light of the California Department of Aging's 1985 estimate that 15.4 percent of those over 65 need personal care or mobility assistance. California's po1icymakers also must bear in mind, according to the University of California's Academic Geriatric Resource Program, that the elderly will have more limited economic resources as the aged population becomes more ethnically diverse and predominantly female. Fiscal Impact As the U.S. population ages, limits to federal funding represent a growing concern. The maximum Social Security tax has increased more than 10,000 percent to date from the inception of Social Security in 1936. Moreover, in 1936 there were 46 workers for each retiree. Now, there are only three workers per retiree and, by 2020, there will be only two [Henderson, 40]. In California, for those elderly who find themselves in the position of seeking aid and assistance, myriad programs and services are mandated. In its 1988-89 Perspectives and Issues, the Legislative Analyst's Office devoted a section to State programs for older Californians, noting that 17 State agencies administer 39 separate programs which include income support, employment services, health services, social services, discounts, and nutrition. From a management and consumer standpoint, the complexity of services and of establishing eligibility for them creates something of a maze. The cost to the State for these programs in 1987-88 was approximately $1.8 billion, with an additional $1.6 billion contributed by the federal government. Estimated expenditures for the 1988-89 fiscal year are about $2 billion for the State and $1. 7 billion for the federal government (Exhibit D provides detail). Counties have come under increasing pressure to provide a broad array of services to the elderly, particularly in program areas such as Adult Protective Service$. Since the enactment of mandatory abuse reporting laws in 1982, the demand for Adult Protective Services has increased by 64 percent without a commensurate increase in funding. -9- The Continuum of Long-Term Care Care and services for older Californians have been developing in piecemeal fashion over the last several years. While it is often termed a continuum, long-term care actually consists of generally unconnected programs which are provided by many agencies--17 State agencies, to be exact, administering 39 separate programs. Local government and the private sector are also involved in providing an array of services. Services offered within the long-term care continuum include adult day care, hospice care, home health care, multipurpose senior services programs, skilled nursing facilities, transportation services, preventive health care and nutrition programs (see Exhibit E for a complete list of services in the continuum) . Residential care for the elderly falls in the middle of the "continuum." Theoretically, residential care clients are too vulnerable or frail or lonely to live independently in their own homes, but they do not need the intensive medical care and attention provided by a skilled nursing facility. Residential care facilities provide an appropriate alternative which, at its best, allows older Californians to maintain a sense of independence within a home setting. -10- III. STUDY FINDINGS Despite many improvements made over the last five years, California's system of residential care for the elderly is still not adequate, even in licensed facilities. This is due primarily to insufficient training for caregivers, lack of certification for administrators, mediocre performance by the Department of Social Services, continued operation of unlicensed facilities, insufficient legal protection for residents, inconsistent enforcement of existing laws, and an inadequate SSI/SSP reimbursement structure. Additional factors include insufficient availability of placement assistance, failure to monitor clients, management information systems inadequate to support the Department's Licensing program, problems in the interpretation of State fire regulations, failure of the private sector to share the growing burden of long-term care funding, and lack of consumer awareness of the many issues relevant to quality of care in residential facilities. FINDING 111 - Abuse and Neglect of Residents Are Ongoing Problems The problems of abuse and neglect that were detailed in the Commission's 1983 report continue to plague elderly Californians living in residential care facilities. During February 1988, the Commission gained first-hand knowledge of the neglectful and demoralizing conditions that exist in some facilities by conducting surprise visits to several facilities in Orange County. During the visits, Commission members found residents who were not being fed regularly or receiving an adequate diet, residents suffering from severe bed sores, and residents whose doors were locked from the outside to prevent them from leaving the confines of their rooms. One of the f~cilities had been cited within the prior 90 days for having a resident insufficiently clothed in a bare room, exposed, dirty, smelly, in bed, and unable to respond. The resident was unable to move or clear flies out of her open mouth. The testimony of Orange County's Deputy Coroner points to the potential end result of such abuse and neglect: In 1987, we had 97 board and care deaths in Orange County. Based on the kind of care that they ought to be getting at board and care homes, we shouldn't have that many deaths in board and care homes. They should die in convalescent hospitals or acute care hospitals, not board and care. The Department of Social Services compiled a "Characteristics Survey" on dependent adult and elder abuse based on all cases reported to County Welfare Departments during a one-month period from February 15, 1987 through March 16, 1987. For the 340 cases of elder abuse reported, the study showed that, of the 93 cases among adults not living in their own homes, 30 reported incidents, or 32.3 percent, involved community care facility residents. [HWA:1988] -11- Nationwide, according to an estimate by a Congressional Committee on Aging, between 500,000 and 1,000,000 cases of elder abuse are reported annually. This number represents as many as one in every 25 persons over the age of 60. Thus, approximately 150,000 Californians may be victims of elder abuse [CSSA:1987]. Adding to the problem is the victim's reluctance to bring the abuse to the attention of service agencies, frequently due to the victim's absolute dependence on the abuser for basic needs. The elderly, of all age groups, are least likely to report abuse. Table 111-1 details the first quarterly reports from the newly established elder abuse reporting program administered by the State Long-Term Care Ombudsman. Table III-1 CASES OF ABUSE IN RESIDENTIAL FACILITIES FOR THE ELDERLY REPORTED TO LONG-TERM CARE OMBUDSMAN Summary of Data for First Quarter of Fiscal Year 1987-88 (July - September 1987) Number of Cases Investi- Abuse Cases Reports Age Reported gated Confirmed Dismissed Unfounded 18-59 37 29 17 9 6 60-64 35 35 19 12 1 65+ 165 162 101 43 13 Totals - 23 - 7 -22-6 - 13 - 7 - 64 20 Percentages 100% 95.4% 57.8% 27.0% 8.4% Source: Department of Social Services, Elder Abuse Reporting Unit As Table 111-1 illustrates, of the 165 cases of elder abuse reported, 101 cases were confirmed. Annualizing the cases reported in the first three-month period means approximately 950 cases will have been reported during any twelve-month period, of which 550 will have been confirmed. While the Long-Term Care Ombudsman program is seen as the primary statewide effort to prevent abuse and neglect in residential facilities, ombudsmen are able to visit less than 40 percent of the facilities and depend primarily on a volunteer staff covering residential facilities as only one category of long-term care facilities. The State Ombudsman estimates that 60 percent of abuse and neglect complaints are made to volunteer ombudsmen when they are visiting in a facility. It is. the presence of an ombudsman that most often gives a resident the opportunity to voice a complaint. Since 60 percent of the facilities remain unvisited, it is not unreasonable to infer that the -12- initial reports documented in Table 111-1 undercount the actual incidents of abuse. The prepared testimony of the State Ombudsman included the following statistics in Table 111-2, documenting complaints received from residents during the 12-month period ending June 30, 1987 (prior to enactment of the mandatory reporting law): Table III-2 COMPLAINTS OF ABUSE IN RESIDENTIAL FACILITIES FOR THE ELDERLY NUMBER AND PERCENT BY TYPE 1986-87 Number Percent ~ Physical Abuse 712 5.8 Quality of Care 1,886 15.4 Staffing 537 4.4 Resident Rights 1,815 14.9' Diet 859 7.0 Financial 1,028 8.4 Activities Program 382 3.1 Physical Plant 853 7.0 Facility Administration 667 5.5 Regulatory Agency 143 1.2 Medical Care 746 6.1 Transfers 541 4.4 Legal 425 3.5 Pharmacy 251 2.1 Placement 730 6.0 Social Services 297 2.4 Other' 342 2.8 Total 12,214 100.0% Source: California Department of Aging, Long-Term Care Ombudsman Program While the number of complaints (12,214) is alarming, representatives of the California Association of Health Facilities (CAHF) testified at the Commission's San Francisco hearing in April 1988 that each local Ombudsman program has developed its own guidelines and that significant confusion surrounds the categories of "abuse" set out in Table 111-2. For example, an Ombudsman may report as a case of "diet abuse," a complaint from a resident that she does not like the food or that the agency's dilatory tactics fit the description of "regulatory agency abuse." Nonetheless, the frequency of reported and confirmed abuse and neglect of residents in California's residential facilities for the elderly is cause for serious concern. Furthermore, the evidence suggests that the problem is more widespread than is now documented. Required abuse reporting and improvements in report handling are beginning to yield better information about the actual dimensions of this problem. Having good data promotes -13- greater understanding of the nature and extent of abuse and neglect but cannot alone determine how to design and implement an appropriate governmental response. Until the capacity to respond is created, an unknown number of older Californians will continue to be abused and neglected by the very people who are responsible for providing their care. FINDING #2 Performance by the Department's Community Care Licensing Division Often Is Characterized as Arbitrary and Slow The Commission has heard considerable testimony regarding the Department's arbitrary, inconsistent, and delayed implementation and enforcement of licensing laws and regulations. Applications for licensure are severely backlogged, and the Department's computer system does not appear adequate to allow the Licensing Division to overcome its weaknesses. According to the testimony of a representative of the Orange County Ombudsman Office: We had an ombudsman who went in the field and found seven residents in a facility, and the facility was licensed for six; she told the owner that she was going to be reporting this ..•• When the ombudsman went to follow up a couple of months later, she found that [the licensee] had received an extension from Licensing •.. and was, for some period of time, going to be allowed to have seven residents in her facility. This [is] very difficult to explain to other owners, and it makes it very difficult for us to have any clout as well. Local ombudsmen also report that the Department has closed facilities for little apparent cause--facilities where the deficiencies cited are not serious and where, in the opinion of ombudsmen, residents receive acceptable care. At the other extreme, the Commission has been apprised of cases involving failure to close facilities where serious deficiencies had not been corrected despite repeated notifications to licensees and where those deficiencies were considered serious enough to jeopardize the safety and well-being of residents. Another performance problem in the Department's Licensing Division is that turnaround time for processing applications for licensure is extensive and is cited as contributing to the frequency with which potential licensees start operations before they have obtained a valid license. One factor delaying application processing is the requirement that fingerprints of all caregiving staff in the facility be checked for convictions. This process alone, undertaken by the Attorney General's Office, takes at least 30 days. The Licensing Division's "Monthly Work Volume Report" tracks the number of applications received each month and the various dispositions of applications, but it does not indicate any time limit after which application processing is considered overdue. The figures for the first quarter of 1988 reveal that close to five times as many applications are carried over each month as are received. The figures in Tables 111-3 and 111-4 indicate a high volume backlog. Yet, the Department persists in claiming that its ~icensing Division is adequately funded. -14- Table III-3 STATUS OF RFE LICENSURE APPLICATIONS JANUARY-MARCH 1988 January February March Carried 524 470 470 Received 89 104 101 Adjusted -22 -28 -5 Approved -93 -61 -76 Denied -4 -5 -4 Withdrawn -24 -10 -14 Continuing -47-0 -47-0 -472 Source: Department of Social Services, Community Care Licensing Table III-4 RESIDENTIAL FACILITIES FOR THE ELDERLY AVERAGE MONTHLY NUMBER OF PENDING APPLICATIONS 1987 Under 90 Days 474 Over 90 Days, Within CCL Control 15 Over 90 Days, Outside CCL Control 197 Average Monthly Pending Applications -686 Source: Department of Social Services, Community Care Licensing As Table 111-3 illustrates, in February, the Department received 104 applications for RFE licensure alone, while only 61 were approved. For each of the three months, at least 470 were carried over. Table 111-4 illustrates that the average number of applications pending per month is 686. These figures illustrate the need for the Department to address the backlog problem. Chapter 154/Statutes of 1984 [AB 3474 (Wyman)], effective July 1, 1985, required the Department of Social Services to establish an automated information system on community care licensees and former licensees. While this has been accomplished, the Department's data processing capability does not allow it to collect or compile data flexibly to give managers the capability to focus on performance weaknesses. This became evident to the Commission when the Department was unable to provide statistical information in summary form. The Commission requested the Department to provide the following summary information: number of -15- licensed beds by facility size and client population category, number of licensing enforcement actions by facility size, statistics on abuse citations and civil penalties, unlicensed facility investigation actions, and data on the timeliness of completed investigations. The Director of Social Services responded: ••• [M]ost of the statistical information that you requested is either not maintained in the detail requested or is unavailable. To obtain the specific information you requested would require considerable time for each licensing office to manually compile data by review of facility files and licensing office logs • ••• Information concerning turnaround time for processing applications and for conducting investigations of abuse or unlicensed operation is not available at this time. Such information is only available by reviewing facility files or district office logs • ... Information on citations of abuse can only be obtained by reviewing facility files maintained in each district office . . • • Number of licensed beds for client groups is only available by manually counting from the computer list ..•. Clearly, if the Department is not able to produce information in response to a request from the Commission, it is unable as well to produce such information for its own internal use in evaluating="its performance. It cannot identify bottlenecks so that problems can be resolved quickly, before poor performance by Licensing personnel contributes to degradation of the health and safety of residents. The Commission's position in 1983 was that the Department should be able to target its monitoring and enforcement resources to problem facilities and vulnerable residents. More data are now available to the Department for this purpose--dependent adult abuse reports, for examp1e--but the Department still has not adopted a strategy of preventive monitoring based on systematic data analysis, nor are its management information systems equal to such a strategy. FINDING 113 The Department's Enforcement Program Suffers from Underutilization of Penalties, Fines and Relationships with Local Law Enforcement Agencies Fines for licensing violations in residential care facilities are much less than fines for similar violations in skilled nursing facilities. Of the fines that are assessed by the Department of Social Services (DSS), only half are actually collected. Moreover, the Department is not required to involve local law enforcement in cases of abuse and neglect within set time limits. Thus, coordination between DSS and local law enforcement agencies, on which the Department must rely to prosecute cases, varies dramatically. Without consistently enforcing the civil sanctions and effectively utilizing all law enforcement resources, the protection mechanisms established to insure the safety of elderly residents will continue to be ineffective. -16- When Licensing analysts find a deficiency, they normally schedule a plan of correction visit within 30 days to determine whether the deficiency was corrected (exceptions are made for a few kinds of deficiencies for which corrections can be demonstrated through correspondence). If the deficiency is not corrected, a civil penalty (fine) is imposed unless the problem is corrected by the time of the next visit. At the next visit, if the deficiency still is not corrected, the fine is determined to have been running from the date of the previous visit. The analyst eventually makes another follow-up visit to document the correction. Because a license, once granted, is a property right conferring significant due process protections, licensees may seek administrative review or may go to court to dispute the Department's assessments. The Commission was told informally that, when an analyst has imposed a fine, licensees sometimes phone a district office licensing supervisor or send a letter to request reduction or elimination of a fine. Reportedly, such requests are informally granted. This practice clearly undermines enforcement. Licensing fines--$25 per day for less serious violations and $50 per day for the more serious ones--are so low as to be treated simply as a cost of doing business, especially in the larger facilities. No dollar distinction is made in fines per day whether the facility is small or large--that is, whether failure to correct the violation is affecting five residents or 100 residents. Fines for licensing violations in residential care facilities are much lower than fines for licensing violations in skilled nursing facilities. ~ Skilled nursing facility fines, by contrast, are based on both facility size and the seriousness of the infraction. The least serious category of civil penalty is a "B" citation, which carries a penalty of from $100 to $1,000 per incident. "A" and "AA" citations, which carry penalties ranging from $1,000 to $10,000, are based on the probability that death or serious physical hartn to a patient may result, or may have resulted, from the incident. The Commission believes that penalties of $50 per day are inadequate to deter serious violations. Moreover, methods used to collect fines once they have been assessed have resulted in a very poor collection rate. While it would seem to be an easy matter for Community Care Licensing to collect fines since it has the authority to deny the renewal of licenses when fines remain unpaid, in practice it is the Department's view that its fining structure would be perfect only if the Department collected no fines, because the Department uses the threat of fines to induce compliance. As noted, the Department is authorized to refuse renewal of a license if the facility has an outstanding civil penalty but rarely takes this action, because the facility may continue to operate anyway until a hearing has taken place before an administrative law judge. Representing yet another enforcement challenge, the administrative hearing process routinely takes from six to nine months to complete. According to the Department, the time and expense involved can easily outweigh the collections objective. -17- Though licensees are required to put up bonds during the licensing process, these are surety bonds only, intended to cover any mishandling of residents' funds, but not to pay civil penalties. The provider community has observed that the Department is not serious about collecting fines and is content to keep churning out notices without trying to collect the money. Currently, civil penalties collected represent roughly half of civil penalties assessed and, for the most part, are paid voluntarily. The Department relies on small claims court as its only recourse when fines go unpaid. Many small claims courts, however, have asked the Department to stop using them on a routine basis as a collections vehicle. Licensing analysts are not trained as collection agents, nor can they afford to spend their time on collections activity at the expense of fulfilling regulatory duties. During the course of our study, the Department centralized the collections function in Sacramento. The Department now has begun filing pages of civil penalty notices at one time in small claims court in Sacramento. The Department also has begun to collect unpaid fines through income tax returns--an approach coordinated with the Franchise Tax Board. The Department's emphasis on rectifying unsafe and deficient conditions is laudable. On the other hand, the force of a monetary penalty can be an effective tool to ensure compliance and to deter unwanted behavior. Unless it enforces regulations uniformly, however, the Department undermines its own mission and leaves itself open to charges of capriciousness. The Department needs clear triggering mechanisms to involve local law enforcement agencies in abuse investigations and prosecutions on a timely basis. Currently, there is no requirement in law that these transactions occur within a specified time. A pattern of delayed investigations and prosecutions fails to promote licensees' compliance with the law. A representative of the Orange County Ombudsman Office testified, for example, about a licensee: [He was] cited for no qualified staff on premises, facility over-capacity, residents retained and admitted requiring higher levels of care, myriad careproviders without health screening and/or fingerprinting, no resident records available, inadequate and spoiled food, personnel records constantly unavailable, and illegal use of restraints. During the latter half of 1987, this licensee was also cited for having the water turned off, the exits blocked, ill residents, the home needing repair, phone disconnected, cockroaches in the food, and required medication not available. Although we were informed over a year ago that this home was being handled by Social Services' Legal Department, this licensee continued operating until, at her discretion a few months ago, she moved from her facility one day prior to a scheduled interview initiated as a result of our request to the Orange County Register newspaper to investigate c9nditions in this home. We felt that was the only way we were going to get her closed down. She is currently operating unlicensed. -18- The cooperation of local law enforcement agencies on whom the Department must rely to prosecute cases varies dramatically. The working relationships between the district licensing office and the City and County of Los Angeles exemplify the ideal. The testimony of the Deputy District Attorney for Los Angeles County provided the Commission with the following statistics: Accounting for the fiscal year between July 1, 1986 to June 30, 1987, my section has handled another 60 matters--22 of those matters concerned residential care facilities. Criminal charges have been filed in six of those cases. During that period of time none of the criminal cases was completed. From July 1987 to the present, we have obtained convictions in three of those six cases. The cases involved operating residential care facilities without being licensed. In one instance, which the City Attorney has referred to, we jointly prosecuted with the City Attorney .an unlicensed residential care facility and collectively in that case obtained a jail sentence. In another instance, two defendants were convicted of operating an unlicensed care facility and received a probationary term of 190 hours of community service on condition not to operate a community care facility. In that instance, also, they were ordered effectively out of the business. Three cases are still pending. The Deputy-in-Charge, Nursing Home and Dependent Care, Office of the District Attorney, Los Angeles County, has completed a comprehensive analysis of the sections of the California Health and Safety Code which pertain to residential facilities. His observations, appended in Exhibit H, include recommended code changes which would facilitate successful prosecution. The Department recently has become more aggressive in completing administrative actions. During calendar year 1987, the Department revoked 329 community care licenses. Seven years previously, Licensing revoked only 10 licenses in one year. Of the 329 licenses revoked in 1987, 57 were residential facility licenses [CARCH:1988]. Law enforcement personnel, Ombudsmen, Adult Protective Services workers, and Licensing staff receive differing types and amounts of training and sensitization regarding interviewing elderly or dependent adult victims of abuse. Chapter 637/Statutes of 1987 [SB 526 (Mello)] authorized the Attorney General's Bureau of Medi-Cal Fraud to train State, district, health and social services personnel, and Ombudsman staff and volunteers to evaluate and document criminal abuse. This training supports coordination and systematic information-sharing among enforcement agencies. Given the responsibility of monitoring residential care facilities to insure that minimum standards of health and safety are met, the Department of Social Services clearly has a very difficult job to do. The degree of difficulty, in fact, demands that the Licensing Division effectively utilize enforcemen~ resources, including penalties and fines, and establish routine working relationships with local law enforcement agencies that produce prosecutions and convictions of residential facility owners whose negligence or abuse harms the residents in their charge. -19- FINDING f/4 Unlicensed Facilities Are Undeterred by Current Enforcement Efforts The continued operation of unlicensed residential facilities for the elderly poses a threat to the safety and well-being of affected residents. Facility owners who choose to start operating without a license, perhaps as an economic decision in light of the significant costs associated with delays in licensure application processing, have no economic incentive to seek licensure unless the consequences of doing so are even more costly than waiting for approval. To date, the Department has done little to detect unlicensed facilities. That the Department does not keep centralized records of unlicensed facility investigations and case dispositions is indicative of the low priority assigned to unlicensed facilities. Another indication of the Department's inattention to this matter is the failure to produce periodically updated lists of licensed facilities for distribution to discharge planners. The Department is not obligated statutorily to produce or distribute such reports. The Department's position is that the burden is on the individual discharge planner to call Licensing and inquire about individual facilities. In effect, discharge planners are not able to check licensing status efficiently before making placements, despite Chapter 1096/Statutes of 1985 [AB 17 (Wright)], which required placement agencies to place persons in licensed facilities only and makes placement of clients in unlicensed facilities a misdemeanor. Assembly Concurrent Resolution 133 directed the Department of Social Services, assisted by the Department of Consumer Affairs, to develop recommendations for telephone directory listings of licensed residential care facilities in the yellow pages and to convey these recommendations to representatives of all telephone companies in California. A check on the approximately 50 residential care homes listed in the January 1988 Sacramento Yellow Pages, however, showed that only one facility advertises itself as "state licensed," although the license number for that facility does not appear in the ad (see Exhibit H). Unlicensed facilities pose potential dangers for residents. The Los Angeles City Attorney testified that during the course of a recent investigation, a multiagency task force found: three elderly persons literally tied to their beds. One woman was found tied to the bed with bonds across the upper portion of her body and her feet were tied to the bed. In another bedroom, a woman had her nightgown tied to the bed and her feet were bound. The last elderly female was found in a rear bedroom tied at the torso and ankles. All were in a health condition that was in dire need of skilled nursing maintenance and care. ObViously, in a case of a fire, we could have had a very terrible disaster. In order to ,execute the warrant, forced entry at that location was necessary. The investigators had to kick in the door which attests to the hazard that elderly residents were living under. Additionally, there was no nursing staff present at the location. As a result of -20- this investigation, all three locations were closed and the elderly residents were immediately removed. My office filed criminal charges stemming from two of the locations and the Los Angeles District Attorney's Office filed charges on the third location. The operator was sentenced to 90 days in jail after she pleaded to operating an unlicensed facility and endangering an adult. A dramatic illustration that an unlicensed facility can pose a serious threat to residents was uncovered in November of this year, when the bodies of seven elderly residents were unearthed in the yard of a facility in Sacramento. The owner/operator of the home has been charged with murder of the residents and forgery of their social security and benefit checks. According to news reports, one social worker referred 19 people to the facility because the owner accepted people who were hard to place, stating that "she [the owner of the facility] was the best the system had to offer." A representative of the Ombudsman program also testified to abuse and neglect in unlicensed facilities: We had an unlicensed facility that was brought to our attention by Community Care Licensing. There was a woman in the facility that they asked the Ombudsman to assist in removing. The facility knew the Ombudsman was coming. When the Ombudsman got there, the resident was in a room that had nothing in it but two beds, and a door was cracked open just enough to let a little bit of light in. The=--woman was filthy dirty, her clothes were dirty, her hair was matted, there were boxes filled with newspaper stacked around the room, there was rancid butter and food particles on her bedside. She was able to get the woman out of the facility and into a licensed home where her hair had to be cut off, and when they went to move the boxes, there were maggots found underneath the boxes. This home still has residents. The Commission's 1983 report recommended that a citation system be created for unlicensed facilities. In fact, since 1985, the Department has had authority to levy a fine of $200 per day against facilities operating without a license, but formulation of the regulations that would put this system into operation is still "in process." Given the demonstrated potential for harm to residents in facilities operating outside the law, it is difficult to understand why the system is not yet in effect. Representatives of DSS have stated that they work with an unlicensed facility to become licensed once it has been discovered. Many of the providers on the Advisory Committee see the situation as one in which there was not only no penalty for operating as an unlicensed facility but, in fact, a benefit: an unlicensed facility can operate and make money without going to the expense of compliance with regulations. Once the unlicensed facility is discovered, DSS speeds up the licensing process during which time the facility remains open without penalty. A representative of Bay Area Advocates for Nursing Home Reform testified at the Commission's San Francisco hearing that, after visiting what was clearly a residential facility in San Francisco and being shown a hotel license, she phoned Community Care Licensing to report the facility as -21- unlicensed and was told that the Department "couldn't do anything." Though Chapter 1096/Statutes of 1985 [AB 17 (Wright)] requires placement agencies to report suspected unlicensed facilities to Community Care Licensing, the system cannot function as intended unless aggressive enforcement of laws against operating a residential facility without a license is the routine follow-up to such reports. Means to identify unlicensed facilities exist but are not being used. For example, computer tapes listing more than three SSI/SSP residents at the same address could be run against lists of licensed facilities. Also, home health care providers could be required to report unlicensed facilities. Investigating and prosecuting unlicensed facilities is difficult. But unprotected residents are paying the penalty for lax enforcement of laws against unlicensed facilities. FINDING tis Case Management Services Are Not Systematically Available to Older Californians In its 1983 report, the Commission found that residential facilities for the elderly were rarely visited by outsiders but that case management services were available to varying extents for the developmentally and mentally disabled. Five years later, case management services comparable to those provided for other vulnerable client populations still are not available to the elderly on a systematic basis. Two recently issued reports--one prepared by the Administration, the other by the Legislature--raise the issue of the lack of case management services available to the elderly in California. The Health and Welfare Agency's (HWA's) report to the Legislature, A Study of California's Publicly Funded Long-Term Care Programs, noted that "upwards of 50 percent of the identified needs of the elderly and disabled clients can be met with" case management artd personal care services. [HWA:1988] California's most comprehensive case management and personal care services program for the elderly is the multipurpose senior services program (MSSP), which served 7,900 clients in 1986-87. As the HWA report observed: It is not that the service system does not exist, although there is a question of statewideness for some elements of the system--particularly in the availability of case management services--the issue is rather one of how to better link services together in a more systematic and coordinated way. [HWA:1988] The Senate Subcommittee on Aging and Senate Office of Research jointly issued in September 1988 their report, Conservatorship of the Elderly. The report recommends State licensure of "conservatorship and case management agencies" as a means of preventing unnecessary conservatorship by making case management services for seniors more widely available. Comprehensive case. management begins with an assessment of an individual's functional abilities. Having obtained information regarding a person's degree of functional impairment and resulting needs for personal assistance and health care, the case manager then works with the client to determine -22- his or her preferences, availability of financial resources, and availability of friends and family members to help make decisions and to provide supportive services such as transportation, assistance with shopping, or recreation. Ideally, the assessment process would be the basis for the decision to place an older person in a particular facility. A representative of the Ombudsman program in San Francisco testified at the Commission's April 1988 hearing regarding the critical need for case management: The trouble with the elderly in residential care statewide is there is not yet any comprehensive case management system available to those elderly. Consequently, once they're placed, they are forgotten and visited by an occasional Ombudsman and once every six months by a Licensing evaluator .••• Where there is case management of clients in residential care, a lot of the daily problems are better monitored and conflict resolutions can occur almost immediately. This witness's sentiments are representative of those heard over and over by the Commission, both in the hearings and at the Advisory Committee meetings. Another witness, a social worker with San Francisco General Hospital, pleaded: ••• an individual [case manager is needed] to follow each individual client so they can advocate for the client, so that they can relocate the client if they're in a bad cft"cumstance, so that they can help educate the administrator, not just about the general needs of the client, but the specific needs of this client and how to help this particular client. The need for increased case management for the elderly has long been an expressed concern, and State government has undertaken several efforts to provide it. 'Among the programs currently administered by the Department of Aging are: o The multipurpose senior services program (MSSP) , which operates under a Medicaid waiver to provide social and health services case management to Medi-Ca1 eligible seniors who are certifiable for placement in an intermediate care facility (ICF) or skilled nursing facility (SNF). o The Linkages program, which provides information and referral, assessment, and networking of services. This program has a more broadly defined client population and more preventive focus than MSSP, but its continued existence is uncertain. II o IISEED proj ects are trying to develop integrated intake and assessment models for multiple interagency long-term care programs, including those providing case management services. These programs rep~esent piecemeal measures, rather than a statewide system of mUltiple levels of case management services to tie together all the existing elements of the long-term care network for seniors and disabled adults. Private pay case management is available in metropolitan areas, -23- but the combination of public and private services at this pOint still does not add up to case management's being systematically available for seniors. Increased availability of case management services would ensure more frequent resident monitoring by case workers who have been trained to evaluate the health status and general well-being of the residents and to assess the quality of care offered in each facility. Lack of case management is a missing link that has prevented RFEs from being integrated into California's continuum of long-term care. FINDING 116 State Fire Regulations Do Not Recognize Residential Facilities as a Special Case Residential facilities for the elderly are caught from both sides by State fire regulations. On the one hand, they face slow and fragmented enforcement of fire codes that delay licensing or make continued operation difficult. On the other hand, these facilities often are plagued by rigid interpretation of the codes that force them to make costly changes that alter the noninstitutional setting in residential facilities. Because State fire regulations are interpreted individually by the approximately 1,200 fire districts and departments in California, provider associations note many inconsistencies in the way regulations are applied. In fact, inconsistencies have occurred in the same jurisdiction from one inspection to the next; what causes particular hardships for providers is to receive an opinion during construction that is later reversed. ~ The State Fire Marshal does not have authority over local fire jurisdictions. The State Fire Marshal can advise, but local fire districts and departments are responsible for enforcing their own, sometimes higher, standards. Current State fire regulations lack an intermediate designation for community residential care facilities. Residential care facilities of more than six beds fall into the "I" (Institution) rather than the "R" (Residence) classification, which undermines the goals of community residential care. For example, the wide doorways and halls required for the "I" classification result in the institutional look of a hospital or nursing home. The inclusion of residents who use three- or four-pronged canes ("quad canes") or walkers in the fire code definition of "nonambulatory" results in unwarranted hardship for residents who are excluded from or required to leave the facility of their choice because the structural modifications required by the fire codes to provide for nonambulatory residents on other than ground floors are prohibitively expensive, even though these residents are capable of vacating the premises in case of fire. This problem is particularly acute in a community like San Francisco, where most residences have only a garage on the ground floor so that, in effect, all residents live on the second story. Effective January 1, 1988, responsibility for tracking fire clearances for residential care facilities shifted from the State Fire Marshal's Office to the Department of .Social Services. As a result, many of these facilities no longer receive annual fire inspections, and the fire safety of their residents may be compromised. Previously, the Department of Social Services looked to the State Fire Marshal's Office to follow up on fire -24- clearances for all residential facilities, regardless of jurisdiction. Since the State Fire Marshal's Office sought a fire clearance for each facility in the State each year, all residents were assured of annual attention to fire safety. Many local jurisdictions, however, do not require fire clearances after the original fire clearance is obtained, except when structural changes to the facility are made. Moreover, since the Department has no authority over local fire jurisdictions or history of a working relationship, the districts have no incentive to be prompt in processing fire clearances. FINDING 117 Small Facilities Lack the Special Oversight They Need to Function in the Residential Care Network Small facilities are those licensed to serve six or fewer residents. These are the facilities commonly referred to as "board and care homes." The Commission's 1983 report outlined the importance of, as well as the problems unique to, the community care "subsystem" comprised of small facilities: Throughout the period of this study, the Commission has received comments from diverse sources on the special set of problems that is associated with small community care facilities.... The "family setting" of the small facilities represents a tradition in therapeutic environments. • . . It is desirable now and will remain desirable for the foreseeable future to keep community residential care decentralized """and to utilize the family care setting.... The large number of facilities available, the scattered site distribution of these facilities, and the diversity in levels of care available are all characteristics of the "small facilities subsystem ..•• " [CCSGOE:1983] One of the particular problems faced by licensees operating family setting residences, 'or board and care homes, is isolation. Burnout among caregivers is common, since in many instances the same caregiver is on duty 24 hours a day, day in and day out, 365 days a year. Conventional wisdom in the long-term care field--and, indeed, common sense--has it that burnout increases the likelihood that abuse of residents will occur. There is a great unmet need for respite care for administrators of family setting residences. Current regulations do not address this need, and the State's fiscal condition does not bode well for a change. Licensing is particularly ill-suited as the sole regulatory program for family setting residences. Prior to enactment of the Community Care Licensing Act of 1973, board and care home operators were recruited. Currently, they are "self-selected" exclusively. Prior to licensing, social workers met one-on-one with board and care home operators as often as once a week to explain the particular care needs of individuals who would soon be moving in, to counsel the operators on support services available to them, and to listen to descriptions of incidents involving the residents so as to offer advice on how to handle similar situations should they recur. The ~oss of these relationships exacerbates the potential for adverse effects from the isolation that characterizes family setting residences. -25- In large facilities run by professional administrators, quality of care is mediated not just by the Department of Social Services, but by the norms and standards inherent in professional training, by the interactions of professional staff with both the nonprofessional caregiving staff and with the residents, and by regular traffic through the facility of vendors and delivery people, visiting health professionals, church groups and service clubs, and friends and family members. Treating family setting residences as if the same apparatus used to regulate larger facilities will assure safe, high quality care in board and care homes is unrealistic. Furthermore, it deprives the residents in small facilities of the protections and quality assurances they deserve and rely on the State to provide. Virtually no progress has been made since the Commission's 1983 report toward the goals clearly identified at that time to identify family setting as a residential care specialty and to recognize the significant value of these residences for their ability to provide cost-effective care in all geographical locations. FINDING 118 Quality Is a Low Priority in California's Residential Care Regulatory Program Other than as a response to deinstitutionalization of State hospital patients, residential care in California has developed in a policy vacuum. Licensing alone cannot prescribe and monitor quality of care in the tens of thousands of residential care facilities throughout the state. Factors contributing to the public sector's lack of interest in providing control over the quality of care in residential facilities include the State's: (1) lack of incentives ability to offer quality of care, (2) lack of training and other qualifications requirements for either administrative or caregiving personnel in residential facilities, (3) failure to assess on a routine basis the care needs of the residents, (4) regulations that discourage specialization, (5) lack of requirements for English-speaking capability, and (6) lack of adequate consumer education. Lack of Performance Incentives The nursing home quality improvement program in Illinois--referred to as "QUIP"--demonstrates that upgrading quality of care is possible when facilities have positive financial incentives to strengthen caregiving performance. In addition, the placement process has been used to great advantage in Illinois to reward excellent facilities (those which go beyond minimum standards of caregiving). At present, there are virtually no such positive incentives for residential facilities in California to provide higher than minimum standards of caregiving: the State does not offer additional reimbursement for attaining higher than minimum standards of health and safety or for providing higher levels of care, nor does it make referrals of prospective residents to high performance facilities. In Illinois, skilled nursing facilities receive visits from "nurse-managers" who monitor individualized care plans prepared for patients and determine the number of stars earned by a particular facility. -26- The homes are rated on hundreds of criteria used to evaluate the individualized care plans, including the degree of involvement of family members with the residents and the extent to which the facilities help residents to become meaningfully engaged in the connnunity. The head of a provider group in Illinois has connnented that the QUIP program has led facilities away from a pattern of "paper compliance" and toward real concern about quality of care. Although some aspects of the program are not feasible for residential facilities (for example, Illinois used Medicaid savings generated by closer monitoring to reward star-earning facilities with higher cash reimbursement), the success of the program clearly points to the possibilities of enhanced morale, sense of purpose, and quality of care for residents when positive incentives for improvement are available. Licensing may be a necessary component in any quality assurance program but, by itself, it offers no positive incentives to residential care providers either to improve quality of care or to maintain high quality standards and conditions. Licensing alone also is not sufficiently "present" (other than once or twice a year for inspection visits), much less punitive, to deter the delivery of poor care or even to deter abuse and neglect. The lack of both positive and negative incentives constitutes a major weakness in California's residential care regulatory program. Lack of Training and Other Qualifications Requirements Administrators and licensees of residential facilities are required to take 20 hours per year of continuing education. No training requirements have been set for caregivers, however, despite the complexities inherent in meeting the comprehensive needs of residents. The caregiving skill gap is further exacerbated by the complete lack of formal education and experience requirements for administrators who are mandated to train the caregiving staff. The' industry is without recognized career paths, further contributing to quality of care problems. Quality in caregiving demands a complex set of skills and a broad knowledge base. For administrators there are six areas in which training and education are necessary to collectively constitute a "uniform core of knowledge" include: 1. Laws, regulations, policies, and procedural standards that impact the operations of residential care facilities for the elderly 2. Business operations 3. Management and supervision of staff 4. Psychosocial needs of elderly residents 5. Physical needs of elderly residents 6. Connnunity services available to seniors Previous proposals have reconnnended that administrators should receive a total of 20 hours of credit each year, 10 hours of which must be from areas 1, 2, and 3, and 19 hours from areas 4, 5, and 6. Exhibit I further breaks down each of the six main categories of the uniform core of knowledge into subcategories; it is worth reviewing if only to realize the breadth of information relevant to caregiving in residential facilities. -27- Administrators with fewer than 16 beds are not required to possess any academic qualifications whatsoever. For administrators of larger residential facilities, the existing academic and experience requirements, as shown below, are unlikely to promote high quality of care. Moreover, there is no formal means of verifying administrator qualifications as there would be if certification of administrators were required. Table III-5 EDUCATIONAL REQUIREMENTS FOR RFE ADMINISTRATORS College Education Years of Experience Medium Facility (16 - 49 Beds) 15 Units 1 Large Facility (50+ Beds) 2 Years 3-4 There is a glaring discrepancy between requirements for residential facility administrators and requirements for nursing home administrators. Nursing home requirements are based directly on a medical model and therefore on the needs of the most frail. But residential facility administrators have a comparable need to understand and effectively manage the "community-based health services model" that has become the norm in RFE caregiving. Other than training provided by administrators, the hands-on caregiving line staff are unlikely to be trained at all, nor are they required to be trained or to demonstrate caregiving skills to qualify for employment. Furthermore, training and education for either administrators or caregivers are not widely available. There is, however, at least one encouraging sign of progress: through the combined efforts of the Department of Aging, California State University/Chico, and CARCR, three hours per month of satellite TV programming targeted to residential facilities is being offered at 72 sites throughout California. Current regulations also lack specific standards for residential facility supervision. For example, other than at night and in facilities with more than 50 beds, no minimum staffing ratio of caregivers to residents has been established. There is no regulation to prevent one licensee/administrator from supervising multiple facilities where he or she avoids more stringent regulation because each facility is licensed for well under 50 beds, although the total number of beds for which this individual is responsible may exceed 50. Failure to Assess Care Needs Many residents in RFEs may require higher levels of care than current law and regulations al~ow to be provided in community care facilities. Indeed, the Department's own recent survey of the health status of elderly residents revealed a much older and more frail population than anticipated. -28- Federal reimbursement to hospitals is now based on diagnostically related groups (DRGs), tying reimbursement directly to a patient's diagnosis. If the cost for a particular patient exceeds the designated amount, the hospital must absorb the additional cost. This has led hospitals in some cases to release patients less fully recovered than previously--the "quicker and sicker" syndrome. Consequently, lower cost facilities--skilled nursing facilities and residential facilities--are now taking in clients with more serious health conditions than they did previously. By definition, residential facility clients are more vulnerable than the general population, and, understandably, they don't like to move. Thus, out of concern and affection for residents whose health is deteriorating, many facilities voluntarily enter a cycle of providing more care than current law allows to accommodate the wishes of residents and their families. Existing law and regulations envision a population of well elderly, but that vision does not correspond with what is actually occurring. A recent legislative proposal, Chapter 1127/Statutes of 1985 [SB 185 (Mello)], would have required resident assessments and care plans to assure that placement was appropriate. In effect, this approach would standardize the availability of health care services in residential facilities for the elderly. The Department of Social Services recently completed statewide training relative to care needs assessment. This training is designed to acquaint State licensing analysts with specific medical conditions that are or are not permitted within the scope of caregiving in a residential facility and to bring consistency to care needs evaluation. The Department's process stops short, however, of prescribing care or services for which the residents now have unmet needs. Regulations That Discourage Specialization As long-term care matures into a true continuum of options, the suppliers of care need to diversify to respond to special needs. To some extent, current law and regulations inhibit this process from taking place in residential care. Alzheimer's disease sufferers, for example, often become sufficiently "gravely disabled" to require protective supervision and may have conservators (legally authorized decision makers) appointed for them under provisions of either the Probate or Welfare and Institutions Code. Apart from their dementia in the early stages, some individuals are healthy and do not require skilled nursing care. Victims of Alzheimer's disease tend to wander away from home, however, then become disoriented and unable to find their way back. Their disorientation makes them fearful and sometimes suspicious of and combative with people who try to help them. Well elderly do nQt enjoy sharing residence with dementia patients, whose behavior can be disruptive, loud, and violent. Of special concern is the fact that dementia patients frequently are awake and restless throughout the night, depriving others in the house or facility of sleep. -29- Special training is available for teaching people how to manage the difficult problems associated with dementia and such staff are needed in facilities serving Alzheimer's disease patients. Because early dementia does not require skilled nursing care, residential care facilities, who specialize in serving dementia patients exclusively would be desirable. Patterns of behavior among victims of Alzheimer's disease and other dementias have led to including placement in a locked facility in the definition of "protective supervision" for such persons. This practice, however, is a violation of current community care facility regulations. Section 87144 of Title 22 of the California Administrative Code reads in pertinent part as follows: (a) Each resident shall have personal rights which include, but are not limited to, the following: (b) To leave or depart the Facility at any time and to not 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 of residents; nor does it prohibit, with permission of the licensing agency, the barring of windows against intruders. During the course of the Commission's study, we learned of a facility in San Diego licensed as a residential facility for the elderly. Licensed to accommodate 64 elderly persons, the facility was developed to serve primarily persons with Alzheimer's disease and other dementias. At the time the situation came to our attention, seven such persons resided in the facility, all of whom were conservatees under the Lanterman-Petris-Short (LPS) Act. The facility intends to restrict its admissions to LPS conservatees. The Department, however, has notified the licensee that the facility is operating in violation of Section 87l44(a)(6). The facility has applied for a waiver of this provision, pursuant to Section 87118, which provides that the use of alternative programs and procedures or the conduct of experimental projects shall not be prohibited by the Department's regulations, provided that (1) the alternatives are carried out with "provisions for safe and adequate services," and (2) the licensee requests and is granted a written waiver by the Department. At present, there are few options for the placement of persons who are gravely mentally disabled but who are otherwise healthy and do not require skilled nursing care. The lack of options reduces the "least restrictive alternative placement" goal in the LPS Act to merely an ideal. As we have seen, existing community care licensing regulations may occasionally have the unintended consequence of inhibiting or discouraging specialization which would expand the options for meeting the special needs of particular residential care clients. Lack of Requirements for English-speaking Capability It is imperative that each residential facility have a staff member available at all times who can communicate effectively in English; to understand Licensing regulations and requirements; to effectively -30- understand and communicate with residents and family members, Ombudsmen, Adult Protective Services workers, and State Licensing personnel; to comprehend medical and medication-related instructions; and, most importantly, to communicate effectively in case of medical and other kinds of emergencies. Currently, there is no requirement pertaining to Engl~sh-speaking capability. The Commission is supportive of the greatest possible variety of multicultural settings, recognizing the benefits to ethnically diverse residents. In no way should the finding of a need for English-speaking capability in a residential care facility for the elderly be construed as being at odds with this value. The issue arises strictly as a matter of protection for residents. Inadequate Consumer Education As a routine matter, there is no uniform process available to the public to help potential residents and family members locate high quality facilities. Recent unsuccessful legislation would have called upon the Department to publish a comprehensive brochure to include: ••• guidelines highlighting resident health and safety issues to be considered in the selection of a residential care facility for the elderly, locations of the licensing offices of the State Department of Social Services where facility records may be reviewed, types of local organizations which may have additional information on specific facilities, and a list of recommended inquiries to be made in the selection of a residential care facility for the elderly •.•• Consumer education is necessary to further complement the placement process. There will be rapidly accelerating needs for all of these services as the population of California becomes a more aged one. FINDING 119 Emergency Relocation Procedures Are Not Standardized and Are Underfunded There is no State-level policy on or protocol for emergency relocation of community care residents, but local government is more or less expected to support this activity in times of crisis. Local ombudsmen report scenes of chaos and trauma when conditions are so threatening to the well-being of residents that the Department determines particular facilities must be closed at once and the residents must be transferred. Because relocation procedures or guidelines are not provided by the State, orchestrating such a transfer becomes the responsibility of local ombudsmen and local placement authorities, usually a county's Adult Protective Services unit. Moreover, since many counties do not have Adult Protective Services on call at night or on the weekends, the safety of residents living in community care facilities may be jeopardized. Funding for Adult Protective Services is consolidated into "County Services Block Grant," whi~h also funds in-home supportive services (IHSS) case assessment, social work staff development (for all children and adult programs), and information and referral. In 1987-88, funding levels for this block grant were 24.7 percent behind the consumer price index since -31- 1983-84, with increases directed only to IHSS case load growth, making emergency response a desperately underfunded area of service delivery. At the Commission's San Francisco hearing, the State Ombudsman testified: Sometimes, there is no provision for emergency care and shelter for residents when the caretaker is taken ill or leaves the home. On several occasions during the last year, the Ombudsman Program Crisis Line has been contacted and asked for assistance because there was no caretaker in a facility--usually this has been at night or on' a weekend. Many counties have no Adult Protective Services workers on call and Licensing offices are closed. The current county-level emergency response capability is no match for the incidence of elder abuse and abandonment in residential care facilities. Lack of adequate funding precludes the availability of basic public safety personnel and programs in the evenings and on weekends. FINDING #10 - The Costs of Providing Residential Care Are Not Documented by the State In California, the Governor and the Legislature are under pressure from the growing senior population to expand long-term care services at a much faster rate than the constitutionally governed increase in the overall appropriations limit permits. During the first half of the current decade, real spending on programs for seniors rose by 6 percent. During the same time period, the over-60 population increased by 26 percent. California's appropriations limit (the "Gann limit") exacerbates state government's inability to respond to needs for long-term care because the costs of creating and sustaining that system would require that State spending exceed the limit (this situation is illustrated graphically in Exhibit F). As of September 1987, about 19,700--or 25 percent--of California's residential facility residents were SSI/SSP recipients [CSSP:lO]. Whether current SSI/SSP rates cover the costs of residential care is unknown. The California Association of Residential Care Homes (CARCH) believes that many small homes cannot afford to accept SSI/SSP clients. CARCH estimates the actual monthly cost per client is nearly double the current residential care rate of $678 (this rate reflects an increase which becomes effective January 1, 1989) and lobbied last year to increase the rate to $990 per month ($891 for room, board, care, and supervision and $99 for personal and incidental expenses). No increase was approved. The Commission does not fully accept CARCH's cost estimate of approximately $1,200 per resident per month, because that estimate includes the full mortgage payment for a six-bed, owner-operated residence. The Commission believes the mortgage payment paid by a resident operator cannot be legitimately viewed entirely as a cost of operating the facility. A recent legislative proposal (SB 50) would have established supplements to SSI/SSP payments ~o support higher levels of intensive nonmedical personal care or health-related services not presently available in residential facilities for the elderly. The proposed supplemental rate for the higher level of care was $220 per month. If implemented statewide, the -32- Legislative Analyst estimated the General Fund costs of this measure would have been approximately $22 - $25 million annually. Due to the projected fiscal impact of SB 50, the Governor advised the Legislature he would veto the bill. At the Commission's San Francisco hearing in April 1988, an owner/administrator of an 89-bed residential facility in Stanislaus County testified as follows: Rates for care should directly reflect the people of the State of California's desire to see their elderly cared for appropriately ..•• If you want excellent care, pay excellent rates. If you will accept lousy care, pay lousy rates. But please don't demand excellent care and not give providers the tool they need to provide it. The same logic asserts itself in the 1988-89 Perspectives and Issues report from the Legislative Analyst's Office. The Analyst discussed the difficulty of developing a coherent long-term care policy due to the aging of the population and the pressures the size of this group will create to increase expenditures for long-term care services. To meet the needs, long-term care expenditures would have to increase at a much greater rate than the rate of growth in the overall State appropriations limit. Such increases would have been unlikely in any case, but the passage of Proposition 98 in November 1988 (guaranteeing State spending on public schools as a constant percentage of total State spending) makes increased spending for long-term care impossible. The fiscal options identified by the Analyst do not hold great promise for enhanced quality of care in residential facilities. Those options are as follows: o Increase funding for long-term care services by (a) redirecting funding from other public programs to long-term care, and/or (b) expand the use of alternative sources of funding, such as federal funds or private health insurance. o Limit the level of services available to the population in need of long-term care. The second of these two options, limiting the level of services available to the long-term care population, is clearly not viable, either in terms of the associated human cost of potential abuse, neglect, or suffering or in terms of the need to meet at least minimum standards of health and safety that the State itself has already mandated. If the industry is correct in asserting that the SSI/SSP residential care rate is too low, it could mean that administrators are unable to hire well-trained caregivers because they cannot afford to pay more than minimum wage. Special dietary requirements may be so costly that residential facilities cannot accept SSI/SSP residents who need extraordinary foods or special preparation of meals. Amenities that would make old age more pleasant and comfortable, such as air conditioning, may not be feasible on a bare bones budget. The administrator of an owner-operated facility may not be able to afford time off. Not being able to get away on a regularly -33- scheduled basis from a demanding and stressful caregiving regimen contributes to the likelihood that a tired administrator will neglect, abandon, or abuse the residents. Part of the problem is that the State has not developed the capacity to estimate or measure the cost of providing residential care. Consequently, there is no source of information from within State government that can become a basis of comparison with the claims of provider groups. The resulting annual arguments over rates tend to obscure the issue, which is that residential care is a necessary component of· California's long-term care system. It is neither feasible nor desirable to care for the same client population in more expensive and restrictive intermediate care or skilled nursing facilities. The State needs to know how much it costs to provide regulated levels of service in residential care facilities so that the rates paid by the State to buy those levels of service will assure that services are available to those individuals who qualify. FINDING #11 - Private Funding Mechanisms Are Too New and Untried to Relieve the Public Sector's Financial Burden The demographic picture of an increasingly aged population clearly indicates the rapid acceleration in long-term care expenditures that Californians can expect to make, whether publicly or privately. For working, middle-income children, the cost of maintaining an elderly patent in a residential care setting becomes increasingly burdensome over time because payments for long-term care represent a continuing drain on their disposable income. Price increases may be impossible for them to meet. While many corporations offer generous benefits to their employees, elder care is still unusual in an employee benefit plan. A May 1988 survey of personnel 'managers found that a 67 percent majority felt that eldercare deserves attention, but few of those surveyed indicated they have considered offering eldercare as an employee benefit. Many corporations are only now offering to help pay child day care costs. There is little public awareness of the need for long-term care financial planning. Currently, only about two percent of long-term care costs in California are paid for from private insurance; and nationally, only a few hundred thousand people are covered by long-term care insurance. Furthermore, many policies available at the present time cover only skilled nursing care and private limited coverage. The California Legislature recently passed legislation prohibiting long-term care insurers from offering benefits for skilled nursing care only [Chapter 1328/Statutes of 1988 (SB 170/Mello)]. In addition, the National Association of Insurance Commissioners is proposing changes in its long term care policy that would eliminate many of the restrictions in coverage that make it difficult for policy holders to collect any benefits. These provisions include: (1) coverage for a minimum of 24 consecutive months; (2) no requirement of prior hospitalization; and (3) no cancellation on the basis of age or health of insured. -34- Long-term care plans similar to IRAs for investment-minded consumers are under consideration by the federal government, but such plans are likely to be expensive due to inflation of health-related costs. In short, funding available from private sources is dwarfed by the numbers of people needing services and by the costs of this care. Approximately 25 percent of all elderly residents in residential facilities are SSI/SSP recipients. The other 75 percent are private pay residents who may be exhausting their life savings or depending on support from relatives whose ability and willingness to continue paying may be both time-limited and price-sensitive. --------------------------- ----- --- --- -------------------------------------------------------------------------- -35- IV. CONCLUSIONS AND RECOMMENDATIONS Despite various improvements over the last five years, California's system of residential facilities for the elderly is not structured to guarantee that acceptable care will be provided. The Connnission' s findings are supported by estimates made by California's Long Term Care Ombudsmen. Ombudsmen for Stanislaus and San Joaquin Counties rated 10 percent of the facilities in their counties as good, 70 percent as mediocre, and 20 percent as substandard. In Sacramento County, Ombudsmen indicated that 20 percent were good or excellent, 30 percent were mediocre, and fully 50 percent were "substandard and unlivable". Licensing of residential facilities for the elderly stresses the business relationship of the licensee to the client. While the Department of Social Services' monitoring of compliance with minimum standards of care is necessary and desirable, current regulation neglects more client-centered elements of care necessary to ensure their well-being. Trained, concerned "eyes and ears" should be available to observe residents and conditions in residential facilities on a regular basis, to spot and address potential problems before they become unmanageable. The State must be able to offer positive incentives to licensees to upgrade the quality of care above minimum standards. Residential care, as a system, must provide informed, concerned placement counseling to prospective residents and their families. Limited case management and service coordination have long been accepted in California as necessary for developmentally disabled and mentally ill individuals residing in connnunity care facilities. Similar services are needed to ensure the well-being of elderly community care residents. Significant problems in residential care require significant State action. These problems include: insufficient training for caregivers, lack of certification of administrators, ineffective performance in several crucial areas by Community Care Licensing, the continued operation of unlicensed faci1i ties, inconsistent application of fire regulations, arbitrary enforcement of licensing laws and regulations, insufficient funds for emergency services, and an inadequate reimbursement structure for SSI/SSP recipients. The State must face the problem of who will pay for the care of the elderly as fewer taxpayers are available to support services for a larger and larger elderly population. The cost to society, families, and older Californians themselves will be overwhelming unless realistic financial planning and incentives to invest and save are developed and applied to the cost of long-term care. Provision of support must not and cannot be a concern solely of the government. Innovation must be forthcoming from the private sector to help the public sector address the crushing cost burden of long-term care. -36- RECOMMENDATI ONS The Little Hoover Commission recommends that the Governor and the Legislature take the following specific actions to address the problems identified in this study of California's residential facilities for the elderly. 1. Certify Residential Care Facility Administrators A. The Governor and the Legislature enact legislation to require certification of on-site administrative personnel in residential facilities for the elderly. One of the most direct paths to upgrading the quality of residential care is to specify education and training requirements for facility staff and to take steps to ensure that the necessary education and training will be available. Without education and training opportunities specific to administration of and caregiving in residential facilities, the establishment of career paths in residential care is not possible. Certification should be developed relative to the special needs of particular client populations and for specialized residential care functions. 13. The State agency responsible for this certification should be the Board of Examiners of Nursing Home Administrators (BENHA), expanded to become the Board of Examiners of Long-Term Care Administrators (BELTCA) . C. Certification should be a requirement of licensure for all new applicants and, following a three-year phase~in period,. for all renewals. D. Any new State funds made available to supplement reimbursement for SSI/SSP residents should follow only those residents in facilities operated, by administrators certified in a relevant specialty. E. Certified personnel should be required to pass qualifying examinations in competencies related to the residential care specialities for which they seek certification. The exams should be based on a core of knowledge to be established by BELTCA. F. The unique advantages of family setting residences (six beds or fewer) should be retained by tailoring certification for family setting administrators to require their participation in "self-help" programs that (1) provide respite care opportunities for participating administrators, ~nd (2) establish ongoing, structured processes to achieve resolution of problems unique to small facilities. Family setting administrators should receive continuing education credits for participation in BELTCA-approved self-help programs. G. The Governor and the Legislature enact legislation to upgrade current continuing education requirements by: o Specifying a minimum number of hours per year for each personnel classification in residential facilities (see Recommendation #6(c) regarding residential care personnel classifications); -37- o Requiring all personnel classifications to complete the specified number of hours of continuing education every year; and o Requiring administrators to maintain accurate and up-to-date records on continuing education credits earned by every staff person in the facility. H. The Governor and the Legislature enact legislation that would establish a recognizable career path for staff in residential care facilities to include the following: o Authorize creation of gerontology career programs specific to residential care at the community college level; o Mandate that the University of California and California State University and College systems require gerontology and social welfare students to include coursework in residential care as a degree requirement; and o Authorize and fund internship programs to recruit individuals training for careers in medicine, nursing, dentistry, dental hygiene, social work, or psychology to apply their specialized training for the benefit of residents in long-term care settings. 2. Authorize and Fund Counties, at Their Option, to License Small Residential Care Facilities and Provide Placement Counseling and Assistance The Commission recommends that counties be offered the option of licensing small residential care facilities. One of the services offered by many counties in their Adult Protective Services CAPS) programs is "out-of-home care. " This service has disappeared from some county welfare departments due to undetfunding but, where it still exists, it frequently entails having APS social workers recruit local residential care facility administrators to provide temporary shelter for abused or neglected adults. Through this process, the APS social workers become familiar with the homes in their counties; this familiarity could be instrumental in helping prospective permanent residents and their families in selecting an appropriate facility. The larger counties, through agreements with the Department of Social Services, already are in the business of licensing foster family homes for children. Licensing small residential care facilities for adults would constitute an extension in their scope. Exercise of this option would give counties better control over conditions in these facilities and would give the facilities access to a source of regular referrals. 3. Identify New Revenue Sources from Which to Increase Funding for Residential Care for the Elderly A. The Commissio~ recommends that the Governor and the Legislature direct the Secretary of Health and Welfare and Director of Finance to identify potential new revenue sources from which funding for residential care for the elderly can be increased. State government -38- in California must confront the problem of who will pay for the care of the elderly when there are fewer younger taxpayers every year relative to the older population. The costs to society, families, and older Californians themselves will be catastrophic unless realistic financial planning and incentives for investment and savings are developed now. The Commission believes that the public sector alone cannot manage this burden. California needs a public-private partnership to ensure that elderly or dependent adults are cared for properly, now and in the future. The prospect of new costs in the millions of dollars caused the Administration to reject recent legislation that would have established supplemental SSI/SSP reimbursement for higher levels of care in RFEs. Yet, in its September 1988 report on long-term care, the Agency acknowledged that "additional resources and the expansion of program services to meet the needs of the State's growing frail elderly and disabled populations will be required." [HWA:1988] B. The Department of Personnel Administration should widely publicize and educate workers about its Dependent Care Assistance program, which allows State workers to pay for care for elderly dependents with tax-free portions of their salary. In addition, the Department should develop and propose other prototype elder care benefit plan options for workers. C. The Department of Personnel Administration should develop and propose a benefits plan available to all State employees which includes the option to purchase long-term care insurance and a financial incentive to exercise that option before age 50. 4. Improve Effectiveness of Monitoring and Law Enforcement The Commission found a number of flaws marring the effectiveness of State efforts to -enforce licensing laws and health and safety regulations pertaining to residential facilities, which the following recommendations are designed to eliminate: A. The Department of Social Services should assemble a task force including representatives of the Long-Term Care Ombudsman Program, Adult Protective Services, and the California Association of District Attorneys to: o Develop clear, concise definitions of elderly abuse and neglect; o Establish clear procedures and role definitions for all affected agencies to enable timely response to and substantiation of cases of abuse and neglect; o Train appropriate personnel from all affected agencies; and o Standardize prosecution procedures throughout the State, including time frames for completion of each phase of investigation and prosecution. -39- B. The Governor and the Legislature should enact legislation to make civil penalties for violation of licensing laws and regulations substantially more punitive. Department of Social Services should be required to evaluate the relative seriousness of various kinds and combinations of violations and recommend to the Legislature commensurate penalties. C. The Governor and the Legislature should amend Sections 1543 and 1569.43 of the Health and Safety Code to authorize all local prosecutors, rather than only district attorneys, to "independently" prosecute violations of law and regulations relative to residential facilities for the elderly. (Exhibit I provides additional code amendments needed to ensure that abuse and neglect of residents will be prosecuted more aggressively.) D. The Department of Social Services should work with the California District Attorneys' Association to develop a strategy to enforce current law which makes it a misdemeanor for discharge planners to place clients in unlicensed residential care facilities. This strategy should begin with the Department's publication of quarterly listings of the licensing status of all known facilities. E. The Medi-Cal Fraud Unit of the Attorney General's Office should be expanded to investigate abuse and neglect in RFE in addition to its current investigations of skilled nursing facilities. 5. Launch a Well-Coordinated Campaign to Detect and Eliminate Unlicensed Facilities Distressingly little effort is currently made to deter operation of unlicensed facilities. The Commission believes that effective deterrence is possible only through a State-and-Iocal partnership between licensing and law enforcement agencies that combines economic disincentives with stringent penalties for noncompliance with laws requiring licensure. To that end, the Commission offers the following recommendations: A. The Governor and the Legislature should enact legislation to substantially increase fines for operating residential care facilities without a license. Fines should be set on a per bed per day basis. B. The Governor and the Legislature should enact legislation to require the Department of Social Services to cooperate with local prosecutors to plan and publicize a six-month amnesty period for existing unlicensed facilities, during which time such facilities could apply for licensure without penalty. C. Post-amnesty, the Department and local prosecutors should pool resources to implement an aggressive and well-coordinated program to detect and eliminate unlicensed facilities. This program should include but not be limited to: o Checking tapes for three or more recipients living at the same address and making follow-up investigations; -40- o Checking yellow pages and other advertisements against records of licensed facilities; o Collecting maximum fines from administrators of confirmed unlicensed facilities; and o Creating a provisional license option for any unlicensed facility administrator whose application is not approved within 60 days, provided the applicant is making all reasonable efforts to satisfy requirements for licensure. 6. Strengthen Current Law and Regulations Pertaining to Resident Protections Existing law and regulations are insufficient to protect the rights and safety of residential facility residents. The Commission believes the following changes are needed to correct these weaknesses: A. Amend regulations to require that someone who speaks and understands English is on the premises at all times in every residential facility, regardless of size, such capability is essential to being prepared for emergency situations. B. Implement current law requiring the Department of Social Services to develop and train administrators to use a resident assessment instrument. C. Enact legislation to require the Department of Social Services to analyze resident assessments and, on the basis of such analysis, to define all levels and classifications of administrative and caregiving staff required to meet the identified needs of residents and to establish in regulations appropriate staffing ratios for all personnel classifications in residential facilities. D. As an interim measure prior to implementation of administrator certification, enact legislation to require the Department of Social Services to develop a written exam designed to test licensure applicants' knowledge of regulations and ability to administer the Department's resident assessment instrument. Require the Department to determine an acceptable level of performance on this exam to serve as a condition for licensure (including renewals). E. Enact legislation to require the Department of Social Services to publish a quarterly listing of licensed residential care facilities, alphabetically by Licensing district, and to distribute this listing to all long-term care ombudsman programs in each district and all subscribing placement agencies. This listing should include a report of facility-by-facility citations issued for life-threatening conditions and other serious violations. It should report any failure to renew licensure and all revocation and suspension actions taken by the Department in each district during that quarter. -41- F. Enact legislation to require all residential care facilities to include their license numbers in all advertising, including ads in the yellow pages of local telephone directories. G. Require the Department of Social Services to report to the Legislature during deliberations on the 1989 Budget Act on its progress in completing and distributing a consumer guidelines brochure for persons who are "shopping" for a residential facility. H. Enact legislation to require the Department to develop a written notice for the purpose of informing prospective residents that licensing analysts' inspection reports on all facilities are on file and available for public review in the nearest district office of Community Care Licensing. The Department should establish in regulations the requirement that all facility administrators provide this written notice and the address of the district office to all prospective residents. 7. Develop Protocols for Emergency Services Coordination Closing a residential facility, although drastic, is occasionally necessary due to threatening conditions in the facility or refusal of the licensee to comply with law and regulations. In this event, the residents suffer the hardship of often unwanted relocation. The importance of achieving this transition as smoothly as possible cannot be overstated, given that many residents in these circumstances are already weakened and traumatized by the poor care they have been receiving. The Department of Social Services relies heavily in these situations on assistance from local emergency services, such as county adult protective services and law enforcement agencies, which is appropriate because local agencies are more familiar with alternative facilities in the community and the availability of support services. It is clear, however, that local agencies need guidelines for meeting the needs of facility residents in times of crisis. The Commission recommends that the Governor and the Legislature enact legislation to require the Department of Social Services to develop written protocols for emergency services coordination specific to crises involving facility closure. These protocols should include: A. The Department's responsibilities to develop working relationships with local emergency service agencies; B. The roles of specific local emergency service agencies in the event a residential facility for the elderly must be closed and the residents transferred to other facilities in the community; and C. Step-by-step procedures that the Department and local emergency service agencies will follow in order to accomplish the transfer of residents with minimum confusion, including but not limited to assignment of responsibility for: o The development of written relocation plans which include the address and contact information for individual residents' future homes; and -42- o Contacting the residents' relatives or other persons to be notified of emergencies on the residents' behalf, as noted on admission agreements maintained by the facility administrator. 8. Develop a Waiver Application Procedure for Requesting Permission to Operate a Locked Facility The promise of "least restrictive alternative" is explicit in current law regarding care for the "gravely disabled," but it is not met by forcing individuals who need protection from their own tendency to wander to be placed in nursing homes or other facilities offering higher levels of care than they need. The Commission believes the unmet need for locked facilities at levels of care lower than skilled nursing could be filled at least partially by granting to residential care facilities that meet specified conditions a waiver of Section 87144 of Title 22 of the California Administrative Code, which ensures all residents' right to leave a community care facility at any time. We recommend that the conditions such facilities should be required to meet include, but not be limited to, the following: A. Accept only residents who require the protection of living in a locked facility; B. Develop each resident using a standardized assessment instrument to determine the resident's degree of functional impairment and, on the basis of the assessment, develop a written individualized care plan indicating the resident's need for placement in a locked facility; C. Train staff to provide care to the target client population. Staff must be present on the premises at all times; and D. Meet staffing ratios established by the Department of Social Services. These ratios should be appropriate for the particular client population. 9. Upgrade the Department of Social Services' Information Management Capabilities The existing management information system used to monitor residential facilities for the elderly is inadequate to enable the Department effectively to monitor approximately 3,500 residential facilities serving nearly 80,000 residents. Therefore, the Commission recommends that the Governor and the Legislature authorize the Department to modernize its computer equipment and information processing capabilities. SpeCifically, the Department must be able to perform certain analyses, including but not limited to compiling aggregations of: Types of violations, by facility size (number of beds); Enforcement actions, by types of violations; Enforcement actions, by facility size; Turnaround time for licensure applications; and Turnaround time for complaint investigations, including reports of abuse and neglect, and investigations of unlicensed facilities. -43- These types of analysis are necessary to enable the Department to target its enforcement resources to facilities that are statistically most likely either to pose dangers for the residents or to be operated by administrators who need prodding in order to comply with regulations. In addition, the Department should be using commercially available computer software to generate a schedule of Licensing analysts' periodic visits to facilities in a pattern that is more random than the current visitation pattern. Random visitation would be more likely to give Licensing analysts an opportunity to observe routine facility operations and conditions. 10. Develop Fire Safety Regulations SpecifiC to Residential Care Facilities Over the course of the Commission's study, providers and residents alike complained about inappropriate and inconsistent enforcement of the State fire code and regulations pertaining to residential facilities. Problems stem from the existing definition of "nonambulatory," classification of residential facilities as "institutional," and decentralized, idiosyncratic enforcement of State regulations by California's 1,200 local fire districts. To bring fire code enforcement into better alignment with the nature and needs of residential facilities, the Commission offers the following recommendations: A. The Governor and the Legislature should enact legislation to amend Section 13129 of the Health and Safety Code to exclude individuals who use walkers and quad canes from the definition of "nonambu1atory." B. The Governor and the Legislature should enact legislation to create an intermediate fire code designation between "R" (residence) and "I" (institution) to apply specifically to residential facilities meeting facility standards established in Community Care Licensing regulations. C. The Department should advise all residential care licensees of informal resources available from the State Fire Marshal's Office to help licensees resolve disputes with local fire jurisdictions. D. The Governor and the Legislature should order a transfer of responsibility for tracking residential facility fire clearances from the Department of Social Services back to the State Fire Marshal. E. The Governor and the Legislature should enact legislation to authorize the State Fire Marshal to make rulings and handle appeals regarding local interpretation of fire safety code and regulations related to residential facilities for the elderly. -44- E X H I BIT S -45- EXHIBIT A WITNESSES WHO TESTIFIED AT COMMISSION PUBLIC HEARINGS February 26, 1988 - Santa Ana James Hahn Fran Christine Guest Los Angeles City Attorney Community Care Licensing Department of Social Services Roderick Leonard Deputy District Attorney Fred Miller, Deputy Director Los Angeles County Department of Social Services James Biesner, Deputy Coroner O. V. Smith, President Orange County Society of California Care Providers Dr. Deborah Newquist Charles W. Skoien, Jr. Gerontological Services of California Associations of Orange County Residential Care Homes Pam McGovern Linda Dean Orange County Long-Term Orange County Long-Term Ombudsman Ombudsman Barbara Scott, Provider David Valdez, Consultant Licensed Residential Care Department of Health Services Facility Medical Field Office, San Jose Barbara Chi1ow, Administrative Bob Ford, Administrator/Operator Manager Residential Care Homes for Children Mental Health Department Orange County Dennis McDaniel Smith's Residential Care Homes and Pete Alexander, Vice President Golden's Residential Retreat American Retirement Villas Alan Pearson, Operator of RFE and Lindajo Goldstein, Investigator Vice President of CARCH-Santa Cruz Audits & Investigations Department of Social Services Patricia Copass, Administrator Liberty Health Center-Irvine Bill Thomas, Operator of RFE and President of CARCH-Local Chapter Ellen Pratt, Owner/Operator Residential Care Home in Hayward Henry Ford, Staff Assemblyman Bill Bradley Elizabeth Hallihan, Operator Residential Care Home and Vice President of CARCH-Orange Co. -46- April 29, 1988 - San Francisco Pat McGinnis, Executive Director Marvin Navarro Bay Area Advocates for Nursing Family Members of Residents in Home Reform Convalescent Hospitals-San Francisco Michael Coonan, Long Term Care Sterling Boyer, State Ombudsman Ombudsman-Sacramento Patients' Department of Aging Rights Advocate Pat Nobis, Founder/President Derrell Kelch, Executive Director San Francisco Association of California Association of Homes Residential Care Homes for the Aging Cathy Taylor, Representative Charles Monedero, Chairman California Association of Health Residential Care Conference for Facilities the Elderly, CAHF Hannah Hamovitch, Director Betty Dahlquist, Executive Jewish Family Services-Los Angeles Director California Association of Social Kathy Badrak, President, LTC Rehabilitation Agencies Ombudsman Association-Santa Barbara Charles Skoien, Executive Kregg Miller, Administrator Director Las Palmas Estates-Turlock California Association of Residential Care Homes John Savoy, Operator Care Home-Santa Maria Elaine Harrison, Representative McCormick Foundation Parents' Kathleen Vogel, Administrator Guild Residential Care Home-Carmel Alan Pearson, Operator John Riggs, Coordinator Residential Care Home-Santa Cruz Case Management/After Care Service Community Mental Health Services- San Francisco Saul Bernstein Residential Care Owners Assoc. Benson Nadell, Coordinator Los Angeles Long Term Care Ombudsman Program San Francisco Bill Ott, Provider Gale Wright, Assistant to Director Robert Surler, Chairman Department of Social Services Residential Care Task Force Community Care Licensing San Francisco Terrie Kelly, Administrator Paul Rempen, Operator Residential Care Home-San Francisco Residential Care Home-Santa Clara County Dr. Eugene Gaenslen-San Francisco -47- EXHIBIT B LITTLE HOOVER COMMISSION COMMUNITY RESIDENTIAL CARE ADVISORY GROUP Ms. Kathy Badrak, Executive Director Mr. Leroy Gibson Long-Term Care Ombudsman Services REOCAL 423 W. Victoria 1225 8th Street, Suite 260 Santa Barbara, CA 93101 Sacramento, CA 95814 (805) 965-4446 (916) 443-1167 Ms. Jeanne Boyce, Consultant Ms. Emma Gunterman Assembly Committee on Aging and Senior Program Long Term Care CRLA Foundation 1100 J Street, Suite 505 926 J Street, Room 915 Sacramento, CA 95814 Sacramento, CA 95814 (916) 445-7272 (916) 447-1835 Mr. Sterling Boyer Ms. Hamovitch F~nnah State Long-Term Care Ombudsman Jewish Family Services Department of Aging 13222 F. Admiral Avenue 1600 K Street Marina Del Rey, CA 90292 Sacramento, CA 95814 (213) 822-2444 (916) 323-6679 Mr. Willie Hausey Ms. Donna Calame Willie Hausey & Associates California Law Center on 1127 11th Street, Suite 321 Long-Term Care Sacramento, CA 95814 110 Gough Street, Suite 203 (916) 443-6451 San Francisco, CA 94102 (415) 431-6321 Professor Robert J. Heilman School of Social Work Mr. Paul D. Carlton, Deputy Director California State University, Department o,f Developmental Services Sacramento 1600 9th Street 6000 J Street Sacramento, CA 95814 Sacramento, CA 95819 (916) 323-4828 (916) 278-6943 Mr. Michael Coonan Mr. Charlton Holland Executive Director Assistant Attorney General Sacramento County Office of Health, Education & Welfare Sec~ion Patients' Rights Civil Division P. O. Box 161840 350 McAllister Street, Room 6000 Sacramento, CA 95816 San Francisco, CA 94102 (916) 446-1541 (415) 557-2544 Ms. Naomi Dreskin Mr. Derrel1 Kelch Executive Director California Association of Eames CLTCOA for the Aging 1915 B. Street 7311 Greenhaven Drive, Suite 175 Eureka, CA 95501 Sacramento, CA 95831 (916) 392-5111 Ms. Sue Frauens Deputy City Attorney Ms. Brenda Klutz, Consultant Consumer Fraud Unit Senate Subcommittee on Aging 200 North Main Street, 1600 CHE 1100 J Street, Suite 312 Los Angeles, CA '90012 Sacramento, CA 95814 (213) 485-4515 (916) 323-8436 -48- Mr. Roderick W. Leonard Mr. David Riester, Executive Director Deputy District Attorney Central Valley Regional Center Consumer Protection Division 4747 N. First Street, Suite 195 540 Hall of Records Fresno, CA 93726 320 West Temple Street (209) 228-3024 Los Angeles, CA 90012 (213) 974-3981 Mr. Gresham Roskamp 35191 Camino Capistrano Ms. Patricia McGinnis Capistrano Beach, CA 92624 Executive Director (714) 240-8400 or (714) 472-4700 Bay Area Advocates for Nursing Home Reform Ms. Kathy Ruff 1610 Bush Street California Association of Health San Francisco, CA 94109 Facilities 1251 Beacon Blvd., Suite 210 Mr. Fred Miller, Deputy Director West Sacramento, CA 95891 Department of Social Services (916) 371-4700 Community Care Licensing 744 P Street, M.S. 17-17 Ms. Judith M. Sisneros Sacramento, CA 95814 P. O. Box 149 (916) 322-8538 Sunset Beach, CA 90742 Mr. Kregg Miller Mr. Charles W. Skoien, Jr. Las Palmas Estates Executive Director 1617 Colorado California Association of Turlock, CA 95380 Residential Care Homes (209) 632-8841 P. O. Box 160274 Sacramento, CA 95816 Mr. Steve Moran (916) 451-7265 Sun Dial Living Center, Inc. 3642 University Avenue Ms. Catherine A. Taylor Riverside, CA 92501 Associate Director of (714) 683-5350 Legislative Services California Association of Health Mr. Robert Newcomer, Ph.D. Facilities Institute for Health and Aging 1251 Beacon Blvd., Suite 210 University of California, West Sacramento, CA 95691 San Francisco -- N631Y (916) 371-4700 San Francisco, CA 94143 (415) 476-1408 Ms. Jean Kindy Walker Ombudsman Mr. Pat Nobis 1213 Country Club Drive Residential Care Owners Modesto, CA 95350 Association of San Francisco (209) 545-1759 760 35th Avenue San Francisco, CA 94121 Ms. Gale Wright, Chief (415) 387-3292 Central Operations Branch Community Care Licensing Dr. Michael O'Connor, Director Department of Social Services Department of Mental Health 744 P Street, M.S. 19-50 1600 9th Street Sacramento, CA 95814 Sacramento, CA 95814 (916) 324-4036 (916) 323-8176 -49- EXHIBIT C ST .... TE OF CAuRJRNIA OEP. .. ,UMENT OF SOO.A4. SE.R:VlCf5 HEALTH AIIIO WELFARE AGENCY CQMMUNIT'f ~E f..CHISiI'lCi FACILITY EVALUATION REPORT DISTRIBUTION: REFER TO: OngmlJI: Agency RESIDENTIAL FACILITIES - ELDERLY DUDhcIW': F8Cll'ty Tnel/care ReView This form is to provide a written report for site visits to residential facilities· Elderly, See other side for further explanattons, I fAouTY kAME fACILITY NUMBER CAPACfT'r' 'CENSUS A.OOFiE5S ,NUMBER. STREET, CITY, STATE. ZIP CODE} DATE I I TYPE OF VISIT o Prel" , c ens , n 9 DEvaluation o Follow up TIME VISIT BEGAN TIME COMPUTED NAME Of PERSON CONTACTED ·NOT NOT RE· MET MET VIEWED 1, 87206(allel . Facility ;5 clean, safe, sanitary and in (load recalf. 2, 87206(b) -Proner heatlno and cooling temoeratures mamtained. 3. 87602(a) -LivlnQ accommodations and phvsical olant meet reoUlrements. I 4. 87134 -Telephone service maintained on oremises. 5. 872061i) -Siqna! system meets specified criteria. 6. 87406(a) -Appropriate fire clearance maintained 7. 87602Ib~c -Sufficient toilets and bathlno facilities. 8. 87206(e), 87602(d)(e) • All persons are safe from hazards, 9 87604(al(bl • The auality and auanUty of food served os adeauate, 10. 87604(bl(261 • Adecuate supplv of staole and oeroshable foods on hand, 11. 87604(bl( 15)(23)(281 -Food ;5 orotected acaonst contaminalicn. 12. 87604(b~24l(25) -Soap and tOXIC substances are orooerlv stored. I 13. 87604(bX27)(29)(301(31) • Kilchen eQuipt. & utensils clean & well maintained. 14. 87604(bl -Food service staff sufficient In number adeauatelv tramed. 15. 87E04lb) -Modified diets oreoared for clients needino them. 16. 876041bl -Tray service and special eQUlDt. orovided when needed. I I 17. 8760~b) -Menus preDared. maintained and available for review 18. 87702lal(bl -Persons accepted for care limited to snecified criteria. I 19. 876051a) -Prior aooroval obtained for the use of sunnortive restraints. 20. 87600lfl -Minimum basic services are orovided to clients. I 21 876021a) -EaUiot. and suoolies for oersonal care/hvmene readllv available I 22. 87610lal -Assistance In obtaining routine medical/dental care provided. 23. 87610(a -ASSistance with self-admInistered medications as aD ro riate. 24. 87610(a . ASSistance with rosthetlc deVIces rovided as a oro riate. 25, 87610{c) -Medications centrallv stored and ocked when aoorooriate. 26. 87610/al -Record of centrallv stored medications is maintained. I 27 87610(a)(8) -First aid sUDolies maintained if no medIcal Unit on-site. I 28 87610fb) -Emeraencv numbers oosted In a viSIble location I 29. 87610fbl -Emeraencv Info. for phYSICIans/dentists/ambulance readilv available. r i 30 871441a) thru Id} -Clients oersonal fights are not Violated. i 31 87144la~1) -Clients treated With dignity. 32 87144laI(3) -No physical/mental abuse or Interference with dally functions I I 33. 87612fallb)(c} -Services orovlded promote indeoendent livina. I I 34 876121d) -Planned activities posted (capacltv 7 or more) I 35. 87612Ihl(i} -Sufficient soace.leQuioment/suoolies for activltv nroarams. I I 36. 87614 -Facility provides assistance and coooeration to client counCIls. I 37. 875201a) thru (dl -Personnel records are comolete and avaJiable for review I 38 877121a) -Clients medical assessment (inel. ambo status) on file. I 39 87716 -Documentation of pre-admission aooralsals and reaooraisals on file I I 40. 8771 8(a) thru (h) -Admission aqreements comolete and on ftle. I I 41- 87522(a)lb)(dHe) -Client records Current, comolete. available for revIew I 42. 87522(c) -Confidentiality of chent records is safeouarded. I 43. 87102.87114 -Facllitv has valid license. aocronflatelv nosted. I 4 4 87136{ a I(bl 87137 Pe rsons receive Imlted to rho se aut Qrlze dby I h e terms 0 I e Icense. 45. 87138(a) thru (a) -Clients cash/oersonal nronenv/valuables safecwarded. I 46, 87140lal thru (el -Facllitv is sufficientlv bonded. I 47. 87142 -Clients monev IS not commingled with those of another facility. I 48. 87510laWfl -There is sufficient competent oersonnel to orovrde services. I I 49 87S10(bl -Suoervlsinq personnel are at least 18 years of aqe. I I 50 87510fcHd) -Orrentatlon Itratninq/continurna education for all oersonnel I I 51- 875141a) -Niaht suoervlsion rn accordance with soeclfied crltena. I 52. 876121d) thru (al -There is aoorooriate staffinq for olanned actrVltles. I I 53 875161aWbllcl-Administrator or desianated auallfied substitute on oremises. I 5-1 87518 (a) thru (f) -Administrator IS qualified and fulfills resDonsrbilittes. I 55. 87404/aWb)(c) -Criminal record clearance for staff laooroorlate oersonnel/and other adults In facliit I 56. 87130(al{b) -FacilIty has written disaster Dian available for review I 57. 87132· Vehicles transooninq clients maintained In safe ooeratlOQ condition. I 58. 87128Ia){b) -Persons received on non-dlscrrmlnatory baStS. I COMMENTS: .. -A LIcensing Report (LIe 809) will accompany yiolations are found in any of the areas noted on thIS report LICENSING EVALUATOR SIGNArUAE I UNDERSTAND MY LICENSING APPEAL RIGHTS. NAME OF SUPERVISOR FACILITY REPRESENTATIVE SIGNATURE {WE uc 860 A 18 85) rPt.Jbhc) -50- EXH I BIT D Table 33 Programs Available to Older Californians By Eligibility Type 1987-88 and 1988-89 (dollars in thousands) Estimated Number Prognms Available to Services Requirtme1lt tq of C/ienlt 19S7-88 1988-89 Low·Income Seniors Provided Qualify 1987-88 Stole FeaertJI Totol' Stole FeaertJ/ Totol' Income Support q) Supolemental Securi~come/State Cash grants Age 65 with limited re- 382,258 $915,300 $608,792 $1,524,172 $917,399 $657,244 $1,574,643 -Supplementary gr.tm (OSS) sources arid ( ) "countable" (average income that does not exceed the maximum grant mo~ntrh) Senior Citizens Renters' Assistance Pro- Annual grant based on prop- Renter age 62 or older and 196,675 21,414 21,414 18,roJ IB,roJ gram (m) erty tax equivalent low-income (less than $12,!XXl) or disabled (au ages) Senior Citizens Property Tax Assistance Direct reimbursements for Age 62 or older, or disabled; 54,625 4,836 4,836 4,flX: 4,!00 (m) portion of property taxes must own and occuKtj,ome; income less than $1 Senior Citizens Property Tax Deferral Postponement of property tax Age 62 or older; must own 3nd 8,658 6,100 6,100 6,!XXl 6,lXXl (m) payments ~v residence; income less than $24,!XXl Foster Grandparents Program (COA) STends for seniors who pro- /lge ro or older and income 112 370 370 370 370 VI e supportive selVlces to leSs than the poverty level (volun- children with special needs teers) Senior Companion Program (COA) S~~ds for ~ors ~ho foro- /lge ro and older and income 127 321 321 321 321 VI e supJl!>rtive semces 0 less than the poverty level (volun- adults WIth special needs teers) Hrolth Services MediUl (DHS) b Inpatient/outpatient acute Age 65 and older, and public 300,540 664,114 664,114 1,328,228 722,721 722,721 1,445,442 medical services, 10I).g-term assistance recipients or meet (average care, ancillary health services ag~, disability, and income re- ~r qmrements month) Multiruroose Senior Services Program Case management to linIc eli- le 65 or ol~Medi-Cal eli- 8,ml 10,322 10,322 10,515 10,515 {COA) ents to vanous health and l0- g! Ie and ce - ble for place- cia! senices ment in nursing homes S Bro u wn ~ Bag S ( o C c O ia A l ) S ervices Foodstuffs distributed to older A~e ro or older and SSI/SSP 42,200 780 71ll 780 71ll per;(lDS eligible In·Home Supportive Services (OSS) Domestic and nonmedical ser- SSI/SSP eligible 86,844 112,440 roJ,294 327,BH 174,416 200,674 300.100 vices provided at home (average - mo~nth) Employmerrt Senit'!" Qmmmnity Employment Services Subsidized part-time jobs /lge 55 or older and income- 1,048 4,995 4,995 4,995 {995 (rnA) less than 125 percent oi pov- erty level iY.sco-.r,>J Progroml Goicien Bear Passes (OPR) Reduced price on annual state Age 65 and older and below 3,lXXl 150 150 150 150 park pass SJiecified income level Discount Fzshing Licenses (OFG) Reduced price on fishing Ii- Age 65 and older and receiv- 15,3(71 252 252 2S1 2S1 cense ing SSI/SSP or F.th specified mcome ------------------ Subtotals, Programs Available to Low-Income Seniors .... ___ . _. ..... _. _. _______ .... _. _. _. _. ......... _. ...... _. -. ($1,736,479) ($1,478,195) ($3.229,754) ($1,856,339) ($1,585,634) ($3,4".,052) Pro!:rams Available to All Seniors HechhSeroices mventiYe Health Care for Aging (0 HS) RNs provide health appraisals, Older adults (age 55 and old- 1,647 $1,303 S2,~ $1,303 S2,~ counseling, referrals, e<1ucation er) in congregate settings who are well Suwr.troe SociIJI Seroice.r Nutritiro (COA) Meals provided at community Age ro or older \a nd spouses 263,9ll 11,970 $47,773 99,891 11,970 48,815 100,933 centers or delivered at home regardless oi age Supportive Services and Centers (COA) Include in-home, transporta- Age ro or older 834,817 2,004 25,864 54,ffil 2,004 23.B81 52,C6S tion and case management ser- VIces. EmvWvw:nt JohTr3inmz Partnership Act/Older Work- Employment and training ser- Age 55 and older Unknown 10,345 d 10,345 d 5,633 5,633 en (EDD) VIces Other SerrOas Senior Citizens' Shared Housing (HCO) Grants te no~fit entities to Age ro or older 4,500 500 500 500 500 assist seniors in finding a room- mate Vohmteer Service Credit Program Service credits for seniors who Age ro or older 65 65 (rnA) • provide supportive services to other seniors Health Insurance Counseling and Advlr Assistance in understandiI!g Medicare beneficiaries 123,618 1,248 2,248 cry Program (COA) coverage provided througli Medicare and private insur- ance -51- Discount P~m.r I Golde ( n D C S i. t . a I t C e D S A e ) n i , o r Discount Program d W is r c d o s W is lt r e u d e d g o f o o d r S p a u n rc d h a se s r e v i o c f e s Age 60 or older Unknown 72 72 72 72 from volunteer merchants Califo ( r O n F ia A ) Exposition and State Fair Reduced State Fair admission Seniors 22,&Xl !?J !?J 33 33 I C d a e l n if t o if r i n c i a a t i S o b n te W U rd n s i v ( e O rs M ity V ) ( C)U) I S R f t o e u r d i d o u e d c n e t o d f f e p V e r a ic w li e d a i i a t v y n e d o rs n e x id te e n n d ti e fi d c a- A Ag g e e 6 6 2 0 o o r r o o l l d d e e r r Unk 8 n 5 o ,1 w 0 n 0 3 4 3 9 3 9 b 3 4 3 9 3 ') h 3 4 5 9 5 9 b 3 4 5 9 5 ') b on cards Subtotals, Programs A\ 'lIiIable to All Seniors Programs Predominantly Serving Senion .................................................................... ($17,604) ($83,982) ($169,568) ($17,701) ($78,329) ($165.012) Income Support Low-I ( n O c E o O m ) e I Weatherization program Low-cost home weatherization o In f c p o o m v e e rt le y s s l e t v h e a l n 150 percent Unknown $5,(171 $5,1171 $3,563 $3,.563 Low- p In ro co g m ra e m ( H O o E m O e ) I E nergy Amance Heating amance grants o In f c p o o m ve e r l t e y s s l e t v h e a l n 150 percent Unknown 16,798 16,798 11,963 11,963 Eme(be E n2 ' ) ' C risis Intervention program h E o m u e se ~ e ol n dS ~ u a n s a si b s l t e a n t c o e p t a o y uti!- o In f c p o o m v e e r l t e y s s l e t v h e a l n 130 percent Unknown 2,069 2,069 2,069 2,069 ity bills - Health Seroices Alzhe T im r e e a r tr 's n en ~ t Centers ( ~ 0 o st ) ic and m Re e s n e t a r s ch e , ~ d r ia o ~ v os i ti d c e a d n d t o t r p e a a - t- ~Pt e o im m e s r' s o r D i is n e d a ic se at ions of Unknown $2,214 2,214 $2,249 2,249 tients and .e s Adult Day Health Care (CDA) J v H id ea e l d th i n a n n d o n s r o e c s i i a d l e s n e t r i v a i l c e c s e n p t r e o r - s Frail elderly and other adults 4,875 872 872 Supportive Sot:ia/ Seroices Alzhe ( i C m D e A r's ) Day Care-Resourre Centers S to u p p p a o ti r e t n iv ts e a s n er d v i c c a e r s e g p i r v o e v r i s d ed e S a y s m e p o t r o m re s l a o te f d A d lz i h so e r im de e r r s ' s dis- 639 !lXl !lXl !lXl !lXl Unkages (CDA) e C n a t s s e t m o a v n a a n g o e u m s s e o n c t i a to l s l e in rv k i c c e l s i- f A o d r u p lt l s a c w e h m o e n ar t e i n n o n t u r c s e i r n t g if iable 4,037 3,00> 3,900 3,00> 3.00> homes Respite Care program (CDA) R to e r f e e s rr p a i l t e o f c a c r li e e n p t r s o v a i n d d e r f s a milies e H n e t a a lt t h r i o sk f c o a f , e i g ns iv ti e tu r ti a o t n r a is li k z ; a e - li- 970 61 61 60 ro tion Senior Self-Reliance program (DOR) e A r s s s i t s o t a m nc o e b i i l n i ty o vercoming bani- V A lS ge u a 5 I 5 a c o u r it o y l der, with limited Unknov.'O 102 102 102 102 Counselor IT eacher program (DO R) Mobilitv orientation and other Dient of DOR UnknO\\'O 283 283 283 283 habilitition services Other Services Urban Mass T~rtation Act 16b(2) Capital assistance to private Elderly and/or handicapped Unknown 486 2,794 32&l 486 2.794 32&l program (Caltrans) • nonprofit agencies to purchase spe6aIized vehicles Adult Protective Services (DSS) Investigation and prevention Not applicable UnknO\\'D 16,302 22,225 16.568 22.641 of abuse i neglect oT elders hevention of Crimes Against the Elderly Information and technical as- Not applicable UnknOlI'D 44 44 N/AI ~/AI ~/AI (DO)) sistance Adultd;'8~)tion Courses for the Elderly Educational courses Eli fo'bcialli tv criteria established 216,(0) 32,(0) 32,(0) 33,573 33.573 by officials California Veterans' Home (DVA) Residential nursing and medi- Yeteran and qualifying resi- 1.300 22,445 12.059 34,514 24,855 10.071 :>l.9'26 cal semces oent Subtotals, Programs hedominantly Sening Seniors ............................................................. (S79.509) $38,791) ($124.2.'33) (~876) ($30.4&)) ISll9.4(9) Totals, All hograms ...... _. .................................................................................... $1,833,592 $1,(jX),968 $3,523,555 $1,956,916 $l,fB.l423 $3,741,473 • Local expenditures not shown separately, but they are included in the totals. b F"rores do not include amounts for recipients age 65 or older who receive aid to the blind or disabled. Federal funds totaling $10.3 million in both 19Bi-&l and 1988-89 are included in Medi-Cal figures. C d Includes $4.7 million in federal funds carried over from prior fiscal years . • Established January 1, 1988 by Ch 1199IBi. f Estimated revenue loss, assuming older persons receiving discounts otherwise would have purchased full priced services (except for the Golden State program). • Transferred January 1, 1988 from the Department of Consumer Affairs to CDA. Expenditures are for program administration. h Assumes estimated revenue loss remains the same as in 1986-87. I Expenditures for clients age 60 or older. J Except for $872,000 in start-up grants,. the amounts expended on this program ($11.2 million in 19Bi-&l and $12.3 million in 1988-89) are included in Medi-Cal fi.:ur= • Figu;es include amounts for handicapped as well as elderly. 1 Not available. . 'IDE UN; TEJ1.{ CAllE aH.rDUM Service Category License/Funding Source (s) Role in the Continut.Un Service Coordination (Case Mmagarent) An administrative service which acts Funded through Federal M2Clicaid A critical service for all long term as a link between the client and the waivers (Section 1115 of the Social care users. Helps to assure the providers of long tenn care. Often Security Act) in the Multipurpose awrcpriate, tirrely, and cost effec case managarent programs provide Senior Services Project (MSSP), and tive delivery of long term care ser client assessrent, service plan through state funds in the new vices and can assist in maintaining develcprent and follav-up nonit oring • "Linkages" program in the Dept. of older people in the least restrictive Aging. often a Central element of setting. M.lltiprrpose Senior Services other services such as adult day Program (MSSP): Furrled through health care. IDcal programs may rr1 Federal governrrent waivers to use receive Older Americans Act funds X I, I M:rli.caid funds, coordinated through or private funding. Vl 0:7 N case management, in non-traditional I am -I ways to reduce acute care rr1 institutional placerrent. Skilled Nurs~ Facilit~ (SNF) Continuous skilled nurSl11g care or License and Medi-cal certification Appropriate for people in need of other skilled rehabilitative care by the Depa.rtIrent of Health Services. continuous intense services, provided in a residential facility on Funded primarily by M2di-ca1. Sore especially those in need of nursing 24 hour a day basis. funding through »::rlicare and private care with rehabilitative therapy. payrrents. Minimal Coverage through' private health insurance. Intenrediate Care Facility (rCF) Health related services offered in an License and M:rli- cal certification Appropriate for those who are chronic institutional setting which are below by the Deparbrent of Health Services. ally ill and require intennittent those offered in a hospital or SNF, Funded primarily by M:rli-cal. Sane nursing care. but above that of residential care. funding through Medicare and priVate payrrents. Minimal coverage through private health insurance. Compliments of SENATOR HENRY J. MELLO Chairman, Senate Subcommittee on Aging Service cat~££i. Licenf3El/Funding SourceJs) Role in the Continuum Residential Care Facility A residential setting for people in Licensed by the Depart:Irent of Social Appropriate for people who do not need of personal assistance, such as Services (OSS). Funded primarily need intense rredical care but are . bathing, groaning, dressing, eating, through private payrrents of residents. nevertheless unable to maintain in etc. and protective supervision. 20-30% funded through SSI/SSP dependence and who require ongoing non-rredical out-of-hare care grants. assistance with activities of daily living. Co~ate Iblsing Hcosll'):] developrents with a cattrOn Grants provided through the Federal Intended as one option for providing living area and the provision of Goverrnrent (Housing an~ Urban sUH?Ort services to neet basic needs support services relating to the Development-HUD). for the primary purpose of assisting dietary, social, recreational am older people to function independently. housekeeping needs of tho! resident. Shared Housi.ng I \.n Assistance in matching seniors State funding through the Depart Helps to keep seniors in the \..-l I with in:lividuals who wish to share rrent of Housing and Ccmmmi ty carmunity, reduces housing (Xlsts, existing hoosing units. Develq:mmt to local shared housing utilizes under-used housing stock, agencies. and increases security and carpanionship. Respi te care Soort term inpatient or hare care No separate license required. No A way to assist families win care delivered to an elderly person as specific funding for respite care or for their elderly relatives by a substitute for their regular special programs designed speci providing periodic relief from the caregiver. '!he program is designed fically to relieve caregivers. Could demands of caring for an older to provide relief to relatives and be provided by a variety of existing person. Although it may be friends who care for a disabled or licensed providers (day care, home provided as a component of other elderly person on a continuous basis. heal th, residential care, skilled services in the continuum, it differs nursing). Limited respite available in that the specific purpose is to through In-Hone Supportive Services. meet the needs of the family/ An MSSP waiv ered service. caregiver for relief. Service Category License/Funding Source (s) Role in the Continuum Hospice provided to tenninally ill people No separ?te license required. A critical CCIYpOnent in the continuum and their families offering care M::rlicare certification ~equired . designed to allow older people to and support to the family while also for ~icare payrrents. ~ Minimum die with dignity. Unlike many enhancing a,tenninally ill person's coverage through private health programs, hospice considers the quality of life by enabling him/her insurance. family the unit of care. to live as canfortably, alertly or irrlependently as possible. May be provided inpatient or at hare. Hare Health Care Medically oriented care for acute Licensed by the Depart.nent of Health ' A way to provide rredical care to or chronic illness provided in the Services. Funded through Medicare, people outside of an acute care, patient's hare. Includes services Medi-Cal and private payments. skilled nursing or interrrediate care like cleaning \o."Otlrrls, changing Minimum coverage through private facility, allowing them to remain at bandages, giving injections, in health insurance. hare. I serting catheters. Vl .j: I Chore/H::Jranaker Services Hoosehold services, such as shopping, No License required. SoIre funding An essential aspect of any hare care rooking, and cleaning. though In-fk::rre Supportive Services program. May be delivered in con for those eligible. Private junction with hare health care or as payrrents. waiv ered services in MSSP. a separate service to those with functional limitations who are otherwise healthy. Helps to maintain older people in their homes. N::m-fudical Personal Care Services Personal care includes such services No License required. Safe funding Seen as an essential aspect of any as bathing, dressing, and groaning through In-Hone Supportive Services hone care program usually delivered provided in the participant's hare. for those eligible. Private in conjunction with hare health care payrrents. waiv ered Services in MSSP. or chore/haremaker services. . Helps to maintain older people in their hares. Service Category License/Funding Source (s) Role in the Contimn.nn Preventive Health Care for the ~ Health awraisals, referrals, counsel- state :futrling through Departrrent The goal of the program is to assist ing, follcw-up and education provided of Health Services. 50% local match the well elderly in the cx::mrunity to to the well-ambulatory elderly 60 year~ required, cash or in-kind. Annual maintain or inprove their health so an:l older by public health nurses in report presented by Depart:nent of as to reduce the need for expensive local sites where seniors congregate. Aging. acute care and institutional placement. Home-Delivered Meals The delivery of inexpensive, l-bnit ored by Departrrent of l'lging. Helps to maintain older people in their nutritionally sound neals in the Funding through Older Americans Act, homes by providing a balanced meal each participant's hare. As well as USDA neal reirrbursarent, state and day. COntact with neals driver helps providing neals to pecple who are local funds, and participant to reduce social isolation. unable or unlikely to cook for contributions. themselves, the projram provides social contact to isolated people. I V1 V1 Congregate Nutrition Programs I Programs designed to provide inexpen Monitored by Depart:nent of l'lging Seen as a health prarotion service sive nutritionally sound neals to Funding through Older Americans Act which also encourages social inter elderly people in congregate settings. USDA neal reirobursarent, state and action among elderly people. local funds, and participant contributions. lIdult Day Care A wide variety of day care programs exist. '.IWo major rrodels are: Adult Day Health Care: An organized Licensed by Deparbrent of Health Mult Day Health Care programs day program of therapeutic, social Services. Start-up grants, ~ -Cal serve a very frail client population and health activities and services, certification and development through in need of intensive therapy and provided to elderly persons or other Dept. of Aging. Funding fran ~-cal rehabilitation. By providing these persons with physical or mental and private payrrents. services, the programs can delay impairments for the purpose of or prevent unnecessary placerrent restoring or maintaining optimal in skilled nursing facilities and capacity for self-care. help older people to remain at hare. "f\ Service Category License/Furrling Source (s) Role in the Continmun Adult Social Day care: programs Licensed by Depart:rrent of Social A needed service for many frail and which provide social interaction Services. No specific category of vulnerable elderly in order to remain and SUH?Ort services to elderly state reirrbursarent. Funding at hare. Programs provide a wide persons am functionally inpaired occasionally available through Older ranging variety of services that can adults who can benefit fran day care Americans Act,* private payments, irrprove and maintain functional status but do not require the full range of local contributions, foundations, etc. and reduce social isolation. services available in ADHC. An MSSP waiv ered service. Senior Centers and Recreation Services Program which increase social inter Older Americans Act funding, state Seen as a way to improve the quality actions for older people by providing and local. of life of its users through the pro forrra.l social activities and a central rrotion of social activity. rreeting place. In addition, senior centers act as clearinghouses for elderly people in need of information or services. I V1 (J\ I Transportation Services Programs designed to increase an Funding through Older Americans Act, Viewed as critical to insure adequate elderly person's mobility by improv Urban Mass Transit Act (UMI'A), access to camunity services. ing his or her financial am/or physi California Transportation Developrent cal access to transportation. These Act Funds and Local Match. i:bn programs range fran the provision of rredical transportation is an MSSP subsidies or public transit syste:ns waivered service. to the operation of special mini buses for the exclusive use of senior citizens. Telephone Reassurance A program designed to decrease social May receive Older Amer~cans Act Funds, Seen as a way to improve the quality isolation by providing ~uar tele local contributions, private founda of life of its users by increasing phone contact to elderly people tions. social interaction and making the living alone. users feel secure that help is avail able in t.iroos of energency. Service Cate<J?ry License/Funding: Source~s) Role in the Continuum Friendly Visiting/OompanionshiE A service designed to decrease the Sare funding through Older Arrericans Seen as a way to improve the qua Iit y social isolation of the elderly Act programs such as Senior of life of its users by increasing through regular in-h.cIre visits by Conpanions. local funds, private social interaction and making the professionals or volunteers. founda tions • users feel secure that help is avail- able in tines of errergency. Legal Services Free or partially subsidized assis- Funds provided by Older Americans Essential to assist older people to tance with legal rratters, such as Act, Legal Services Corporation make critical legal decisions and to wills, tenant rights, and benefit (Federal), State Bar Trust, and protect their rights. Can protect programs •. private contributions. An MSSP against abuse and unnecessary dis- waiv ered service. placerrent due to rent disputes. --~ .~ -------~-.. -~ (1/86) ##### ##### ##### ##### ##### I V1 -....J * I Older Arrericans Act funding for programs depends on local discretion and the actual availability of funds. References are to the p:>tential for Older Arrericans Act funds to be used for these programs. SOOICFS: "Expanding Long Tem Care Efforts: cptions and Issues in State Program Design" National Center for Health Services Research - Paula Steiner and Jack Needleman u.S. Depart:Irent of Health and Human Services - March 1981 ~ . "Bridging the Gaps: Non Traditional Services for the Elderly" California Association of Hares for the Aging - 1983 "Annual Report:. to the Legislature on the Preventive Health Care for the Pqing Program" Fiscal Year 1983-84 - Depart:rrent of Health Services "Multipurp:>se Senior Services Project - Final Rep:>rt" Health and welfare Agency - July 1984 PROJECTED POPULATlON GROWTH ~I Population Growth- va Senior PopulatJon Growth Cumulative Perc.ntage Increaaea 70% 60% 50% n rn c: ~ x 3 :r: c: I a; 40'4 OJ \ c o o n n c ~ _N:+lV}.\d'~ttP .~~ -I I . " , '0 , " ~ n ro':l" V"y i ~ J ~ ~ /,. Cl n , / / 5" !:! .... ~ ~aottr .n.. . , .... m ---- n &I t /_• •_ ~.,..",-- ---51>1-.,;.\0 -- --~ &It ,/ 10% :;...-~---- ..... 0"4 -r--' ,...-- I ' I I I I I a--,-I '19 '80 '81 '82 '83 '84 '85 '86 '87 '68 '89 "90 '91 $wee: [)ep¥1~ 0( FWlance Compliments of • 00 which lie G~ liril is based SENATOR HENRY J. MELLO Chairman ro __~ __ .J._,..... C',\h~-..rnn1 ~ +- .... ..-..r"I. ;"111 ~ nf"T -59- JXHIBITG rn © ~ ~ W ~ fnl/ OFFICE OF THE DISTRICT ATTORNEY dlilli COUNTY OF LOS ANGELES 'L , 5 1988 ~ ,,1! .. I BUREAU OF SPECIAL OPERATIONS CONSUMER PROTECTION DIVISION HALL OF RECORDS UTILE HOOVER COMMISSION 320 WEST TEMPLE STREET, ROOM 540 LOS ANGELES, CALIFORNIA 90012 IRA REINER, DISTRICT ATTORNEY (213) 974-3971 R. DA:-I MURPHY, DIRECTOR GILBERT GARCETII, CHIEF DEPlJTY DISTRICT ATTORNEY (213) 974-5905 SPEGAL OPERATIO~S CURT LIVESAY, ASSISTAST DISTRICT ATTORNEY July 12, 1988 Jeannine Engl ish Assistant Executive Director Commission on Cal ifornia State Government Organization and Economy 1303 "J" Street Sacramento, California 95814 Re: Residential Care Advisory Committee of the Little Hoover Commission Dea r J eanni ne: The attached report of June 8, 1988 to the Little Hoover Commission discusses recommendations regarding legislation in the area of community care facilities and residential care facilties for the elderly. The report cites Health and Safety Code Section 1543 which authorizes the "District Attorney" of every county "upon application of the State Department or its authorized representative" to prosecute any violation concerning community care facilities. Likewise, Health and Safety Code Section 1569.43 authorizes the "District Attorney" upon the same applciation, to prosecute matters concerning residential care facilities for the elderly. Our report recommends that both Sections 1543 and 1569.43 be amended to permit ~11 local prosecutor offices authority 1~E~~~~~~~~1Y to prosecute violations under those two sections. Recently, an incident was bought to my attention where a case was submitted by the State Department of Social ~ervices to the pr osecut i on off ice of a ci ty attorney. Th i s was D.2..!= Los Angeles City nor Los Angeles County. Apparently, that city prosecutor declined to prosecute the matter because of language in the quoted sections 1543 and 1569.43, copies of which are also attached, which states that the "District Attorney" prosecute th~se matters and which does not mention local -60- Ms. Engl ish Page Two July 12, 1988 prosecutors. The county district attorney's office also refused to prosecute the matter since it involved misdemeanors which are the jurisdiction of that city prosecutor's office. This specific example exemplifies the necessity that sections 1543 and 1569.43 be amended to provide independent authority of Ell ~~~~~~gtj~~_~~ti£~§, including but not limited to district attorney's offices, to inde~~QQ~nt1Y prosecute matters under the appropriate sections of Chapters 3 and 3.3 of the Heal th and Safety Code. If you have any questions, please feel free to call. Respectfully submitted, IRA REINBR---_- --- Di stri" ct, -/, Attorn--e-y-- - -', ,-'/ -.-:.- ->:~ By//) .;' C '-';/~/ ---~ / r---- ~ -- ________:---~-, RODERICK W. LEONARD ~-) Deputy District Attorney bj Attachment c: Sue Frauens, Esq. -61- OFFICE OF THE DISTRICT ATTORNEY COUNTY OF LOS ANGELES BUREAU OF SPECIAL OPERATIONS CONSUMER PROTECTION DIVISION HALL OF RECORDS 320 WEST TEMPLE STREET, ROOM 540 LOS A:\fGELES, CALlFOR:"iIA 90012 IRA REINER, D"TRleT \TTOR\E> (213) 974-3971 PHILIP H. "0.\:-':-'. DIRlt '''R GII.BERT GAReETTI, CHIEF DEPell DISTRICT AnOR~EI SPECI-\L OPER,\ fI()~S Cl'RT LIVESAY. -\S~I\T'\'T DISTR1Cl "nOR'EY LITTLE HOOVER COMMISSION COMMUNITY RESIDENTIAL CARE ADVISIORY COMMITTEE LICENSING AND ENFORCEMENT WORKING GROUP Set forth herein are present sanctions, generally excluding the California Administrative Code, and recommendations in regard to regulation of licensed and unlicensed residential care f acil i ti es. Regulation of community care facilities and residential care facilities for the elderly are found in the California Health and Safety Code. The Cal ifornia Communi ty Care Facil ities Act l found in Heal th and Safety Code Sections 1500 ~.L_~& address community care facilities. Sections 1569 §1_ _ ~ e& regulates residential care facilities for the elderly. ( 1) PERTINENT STATUTES -------------------- Section 15'03.5 sets forth the circumstances under which a community care facility must be licensed. 2 Specifically, a facility must be licensed if it provides "care or supervision, as defined in this Chapter or rules and regulations adopted pursuant to this Chapter".3 (Id.) While "care and supervision" is defined in the California Administrative Code, Title 22 Section 80001 subdivision (a)(lO), "care and supervision" is not defined in the Health and Safety Code Section 1502 which sets out the definitions for the California Community Care Facilities Act. Section 1508 requires licensure of community care facilities. I~--U-nless-othe-rw-fse-note(fall section references, are to the Cal ifornia Heal th and Safety Code. 2. All cited Sections are attached to this report. 3. Chapter 3 of Division 2 of the California Health and Safety Code addresses the California Community Care Facilities Act. Chapter 3.3 of Division 2 of the California Health and Safety Code is directed to the California Residential Care Facil i ti es f or the El derly Act. -62- Section 1540 makes it a misdemeanor for any person to violate any of the provisions of Chapter 3 (California Community Care Facilities Act) or to willfully or repeatedly violate any rule or regulation promulgated under the Chapter. Penalty is a $1,000 fine, 180 days in the county jail, or both. Section 1540.1 provides that a facility violating Sections 1503.5 or 1508 (pertaining to operation of a community care facility without a license) is guilty of an infraction punishable by a fine of $200 for each day of violation. Section 1547 provides in part that "notwithstanding any other provision of this Chapter, anyone who violates Section 1503.5 or 1508 or both" may be assessed by the Department of Social Services a civil penalty of $200 per day of the violation. Section 1548 provides for civil penalties of $25 to $50 or more a day for each violation of Chapter 3. In no instance may the penalty assessment exceed $150 a day. A repeat violation of Chapter 3 within 12 months of the first violation is subject to a $150 per day fine. The Department of Social Services shall assess fines and develop regulations implementing this section. Section 1549 provides that civil, criminal and administrative remedies "available to the department pursuant to this article" (i.e. sections 1530-1549) are not exclusive. Section 1543 authorizes the district attorney of every county "upon application by the state department or its authorized representative", to prosecute any violation within his/her county of any provision of Chapter 3. Section 1502 sets forth definitions for the Community Care Facilities Act. That section does not include a definition of "care and supervision" or "care or supervision". It is suggested that the definition Section 1502 include a definition of "care and supervision" or "care or supervision" since Section 1503.5 requires licensure where "care or supervision", as defined by this Chapter, is provided or required. If "care and supervision" is the definition to be used, then Section 1503.5 will have to be amended from "care or supervision" to "care and supervision". Note that "care and supervision" is defined in Health and Safety Code Section 1569.2 (California Residential Care Facilities for the Elderly Act) as well as Title 22 of the California Administrative Code Section 87100 subdivision (a) (8). Violation of Sections 1508/1540, operation of an unlicensed community care facility, should be made a separate and distinct offense of those Sections in Chapter 3 which impose civil penalties (Sections 1540.1, 1547 and 1548). Sections 1508/1540 2 -63- should also clearly state that misdemeanors may be prosecuted irrespective of concurrent enforcement of the civil penalty sections of Chapter 3. Section 1540 should make clear that violation of that Section, including regulations promulgated thereunder, are independent and distinct crimes of those sections providing for civil penalties under Sections 1540.1, 1547, and 1548 irrespective of language of Section 1549. Additionally, punishment under Section 1540 should be increased from 180 days to one year in the county jail, in addition to the present $1,000 fine. Secti on 1543 provi des tha t an acti on may be brought by the district attorney "upon application of the department". That section should be amended to specify that all local prosecutor's offices have authority, independently, to prosecute for violations under Chapter 3. Present civil penalties which range from $25 to $150 (Section 1548) are inadequate. It is recommended that the penalty model utilized in the convalescent hospital context be utilized by increasing the amount of fines to be assessed and thereater collected, in respect to violations of the chapter or regulations promulgated thereunder. ( 1) • PERTINENT STATUTES Section 1569.10 provides that no residential care facility for the elderly shall be operated without a valid license. Section 1569.312 sets out the basic services which the licensee shall provide including "care and supervision" as defined in Sect i on 1569.2. Section 1569.40 makes it a misdemeanor to violate Chapter 3.3 (Residential Care Facilities for the Elderly) or to willfuly or repeatedly violate any rule or regulation adopted under that chapter. Penalty is a fine of $1,000 and/or 180 days imprisonment. Section 1569.405 makes it an infraction with a fine of $200.00 a day to operate a residential care facility for the elderly without an license. Section 1569.44 defines an unlicensed residential care facility for the elderly to be a facility which provides care and supervision or is held out as providing care and supervision as defined by Chapter 3.3 or the regulations promulgated thereunder. and supervision" is defined in section 1569.2 "C~He and also in section 87100 (a) (8) of Title 22 of California Administrative Code. 3 Section 1569.45 requires that a residential facility for the elderly be licensed "if it offers care and supervision, as defined, to its residents". Section 1569.485 provides that anyone who operates a residential facility for the elderly without a license (under Section 1569.10 or Section 1569.44) is subject to a civil penalty of $200 per day of violation. Section 1569.49 provides that daily fines from $25 to a maximun of $150 may be assessed f or vi ola ti ons under the Chapter 3.3. Section 1569.495 provides that criminal, civil and administrative remedies "available to the department" under this article (Sections 1569.10-1569.495) are not exclusive. Section 1569.43 authorizes the district attorney, "upon application of the state department or its authorized representative", to prosecute violations in Chapter 3.3. ( 2). B~~.911f1~~Q~~lQ~"§ Violation of Sections 1569.10/1569.40, operation of an unlicensed residential facility for the elderly, should be made a separate and distinct offense of those Sections in Chapter 3.3 which impose civil penalties (Sections 1569.485 and 1569.49). Section 1569.40 should clearly state that misdemeanors may be prosecuted irrespective of concurrent enforcement of the civil penal ty sections of Chapter 3.3. Section 1569.405 should make clear that violation of that Section, including regulations promulgated thereunder, are independent crimes of the sections providing for civil penalties under Sections 1569.49 and 1569.485. Additionally, punishment under Section 1569.40 should be increased from 180 days to one year in the county jail, in addition to the present $1,000 fine. Section 1569.43 provides that an action may be brought by the district attorney "upon application of the department". That section be amended to permit all local prosecutor's offices the authority, independently, to prosecute for violations under Chapter 3.3. Present civil penalties which range from $25 to $150 (Section 1569.49) are inadequate. It is recommended that the penalty model utilized in the convalescent hospital context be utilized by increasing the amount of fines to be assessed and 4 -65- thereafter collected, in respect to violations of the Chapter 3.3 and regulations promulgated thereunder. June 8, 1988 IRA REINER District Attorney By RODERICK W. LEONARD Deputy-i n-Char ge Nursing Horne & Dependent Care 5 -66- lSOOOI COMMUNm CARE FACII.Jl1ES· (p. t316) . (g) An eristing Eacility licensed as I Social Rehabilitation Center shaD by April 1. 1984, meet the requirementl for Adult Day Facilities. Between January ~ 1984 and Aprill, 1984 the facility shall comply with the requirementl fOr Adult Day Facl1ities except for changes &om the previous requirementl regard ing physiCal environment, staff training. staff rati~ and provision of care and supervisin to minon who are not emancipaL as ipeci£ied in Section 8(:001 (a) (1) and Civil Code Section 62. NOTE: Authority c:ited: Sect:icmJ 1S3O and lS3O.S, Health and Safety Coda. Refet etA»: ~ 1501. l.&l2. 1S3O aad ~1. Health aDd Safety Code.. .. ., HISTORY: 1. • Repecler ol Ctap\:llr 1 (Articles 1-7, Sectiona 8:)001-8098'7, DOt eozuecutfve) mil DeW Oa.,ter 1 <ArticleIl-7, Seet:iocs 80000-80088. Dot consecutive) filed 10.7-83; desis 3 u 4 te so d . e N £ O fe I c . t 3 i- 9 .. , . 2 l 4 -1 .! - 3 34 , 1 ( 1,1 ~ 0, 8 9, 3 8 a , nd N 7 o ; 7 . 9 t , i l N . o F s. o . r . . p . r ~ io r a h n i d s t 5 o ; r 7 y 8 , , l N ee o s R . e ~1 g . i . 4 r 4 te a n n 8 d 1 , 2 N 6; O 1 I 7 . . 3 N 9 o m . t i o l 78, NOI. 4.l, 5U and 4; aDd 75, No. 31. . . • The reorpnintioa ol Chapter 1 is printed u • repealer aad adoption for clarity. I. Amendmeat filed lJ..3O.83; designated e£feetive 1·1-34 pursuant to Govemmeat Code Sec:tioa 1l34U(d) (Register 83, No. ~). SOOOL Ddim1ions. (a> The following general definitions shall apply wherever the tenm are used throughout Division 6, Olapters 1 through 7 and Olapter 9, except where ~y noted otherwise. Additional de£iD.itions founa at the beginning of e&ch chapter in this division shall apply only to such ~c facility category. (1) .. Administrator" means the licensee, or the adUlt designated by the li censee to act in his/ber behalf in the overall management of the facility. (2) .. Adult" means a person who is 18 years of age or older. (3) • Adult ~~e Facility" means any facility of any capacity which provides nonm . ta."e and supervision to adultl on less than a 24-hour per ~~. (4) "Adult Residential Facility" means any facility of any Capacity which provides 24-hour a day nonmedical care and supervision to adults except elderly ~ Applicant" means any adult, firm, partnership, association. corporation, county, city, public agency or other governmental entity that has made applicr tion for an initial or renewal community care facility license. (6) "Authorized Representative" means any person or entity authorized by law to act on behalf of any client Such person or entity may include but not be limited to a minor's parent, a legal guardian, a conservator or a public ~tagency. . (7) "'Basic Rate" means the rate charged by a facility to prC?Vide basic servo ices. For SSl/SSP recipients, the basic rate means the estaollihed nonmedical out~-home care rate which includes any exempt income allowance but does not include that amount allocated for the recipient's personal and incidental needs. (8} "Basic Services" means those services required by applicable law and regulation to bt: provided by the licensee in order to obtain and maintain a community care facility license. (9) "Capacity" means the maximum number of persons authorized to be provided care and rupervision at anyone time in any licensed facility. (lO) "Care and Supervision" means anyone or more of the follOwing activi· ties provided by a person or facility to meet the needs of the clients: -67- TITLE 22 COMMUNITY CARE FACII...rI1ES 180001 (p.2317) (A) A5mbnce in dressing. grooming, bathing and other persooal hygiene.. (B) Assistance with taking medication, as specified in Section ~ (C) Central storing and/or distribution of medications, as specified in Sec- tion 8X175. (D) Arrangement of and a.ssist:ance with medical and dental cue. (E) Maintenance of bouse rules for the protection of clients. (F) Supervision of client schedules and activities. (G) Maintenance and/or supervision of client cash resources or property. (H) Monitoring food intake or special diets. (I) Providing oasic services as defined in Section ~1(a) (8). (11) "Cash Resources· means: (A) Monetary gifts. (B) Tax credits andloT refunds. (C) Earnings from employment or workshops. (D) Pel'3Onal and incidental need allowances from funding ~ inciuding but not limited to SSl/SSP. (E) Allowances paid to children. (F) Any other si.mi.lar ~ as determined by the licensing agency. (12) "'Oilld" means a penon who is under 18 years of age. (13) "Qilld Care Center" means any facility of any capacity other than a family day care home as defined in Section 88002 (i) in which less than 24-hour per day nonmedical supervision is provided for children in a group setting. (14) "Client" means a child or adult who is recei~ care and supervision in a community care facility. Oient includes "resident as used in the Com- munity Care Facilities Act. . . (15) "Community Care Facility" means any facility, place or building where nonmedical care and supervision, as defined in Section 8(XX)1 (a) (10) are pro- vided. . (16) "Completed Application" means: (A) The applicant has submitted and the licensing agency has received all reqUired materials including: an approved fire clearance, if appropriate, from the State FIre Marshal; a crlminal record clearance on the appocint and any other individuals specified in Section 80019. '. (B) The licensing agency has completed a site visit to the facility. (17) "Conservator" means a person appointed by the Superior Court pursu ant to the provisions of Section lroJ et seq. of the Probate Code or Section 5350 of the Welfare and Institutions Code, to care for the pel'3On, or estate, or person and estate, of another. - (18) '"Consultant" means a person professionally qualified by training or experience to provide expert information on a particular subject. (19) wDeficiency" meam any failure to comply with any provision of the Community Care Facilities Act (Health and Safety Code, Section 1500 eq seq.) andlor regulations adopted by the Department pursuant to the Act (2D) "Department" is defined in Health and Safety Code Section 1502(b). (21) "Developmental Disability" means a disability as de.11ned in Welfare and Institutions Code Section 4512(a). (22) ·'Dietitian" means a person who is a member of or registered by the American Dietetics Association. (23) ··Director" is defined in Health and Safety Code Section 1502(c). (24) wElderly Person" means any person who is 62 years of age or older. -68- CALIFORNIA COMMUNITY CARE FACILITIES ACT f 1511. VeruuUoaa As u.ed in um chapter: (a) "Community ~ facility" me1nE &By facihty. pt.a. or buildine whd • mam~ &.tid ~t.!<l Ul prond+- DOn:r,eoCx:a~ residt'!'tiaJ ~ da~ tru::m~n~ adult day can. or f~~r funih &(t-lX') ae~JCel; for ehlid.--er, addu. or child.--er. anc adl:!t.<. in~!~di.",. but DOt limr..ee to ~ ph;:-saD) ... .a.nc!ia.p?f"d. IT.er.~&!i: Impaired inc-t,:n~t.e::: ye~ru. and ~~ or nei:'~ ehu~::. ~ in,=Jud~ tht- rollc~'ing - OJ "R.esidE'n:il.' !a~lrr:'- mt'~ 1LIl~ !I.rnll: homE re',;;: C4.:"f fae:!.!!} o~ 1;... .., ilv faellin ;k~n:;,:nt"ci by ~f ~Ulr. for 24-h{>u~ ~on~.t--dic:a~ cr.n- of ~~:-..; iT, r.~ 0: ?t-~!'.a.~ ""!'\~. I~t*rnsio[,. or LnlS~ es.entl&! fClr sus:.&;nini' the ~;tie~ of ~!: bTin~ or fClr ~ j:Il'"J'~n of ~ iDdi\idlU.: (2) "Adult day ~ facility" tDeUll any facilit) .... h)d: p!'"O\Jde~ oor.::;e-di:1" :1.~ tc> ;>E.:'"i>Onf l~ \"~ of ~ or older in beeC of pE:~c.L s.er.5:es. s;:;~~ior,. o!' a.ssi.c~!Y.:f es...~n~: fo!' F.l.S~ing ~ ~ of daily l:ivmg or for the pro:.cctior. of ~ ind."'idua: or. ~ the: a U-OOtl1 basIS f!.' "Day ~~nt facility" mea:u aD'J facility ..l -..icl-, prt','id~ ZN!:"~ CL~. eo"'!'.t.e~i: ::u:... edJ::a~~ or v-~:Y.l:l.l.' n:pp..:,r"_ or 1o<X." .. ' ~}-... :']j~'jo: ~:-,;:::ef or. 1e!.S> tl.c: I 24-ho'~ to ~~:!'. . :DdEo~ :~ Y~"i o~ ",E "'h~ 1O".JC :>::'E~~ hf p~ ir. !CJIE·..e: ::....'"': c.: YO!;c L"'t ~~;r;i U. !c-2Jef trom f~ter::an Pr-o.-an: aa.."ld...rd5 for ti-,e&e !~ili:jes .J... .. n ~ (k;elo~ by ~ ck~ent. PI'-..,\aIlt to Se-c::ion 1530, in con.auJ~tivt with day tre~~En: and f05~r eut pro\iden (4) "Foster f&ll"ily &.iency" meam I.llY indhirluaJ or o:-ganiu;.~r, t'n~ed in thf recruitinl. oe~ini and ~, of, a.nd prondine profea.sior"': 'u?p0rt Ul. !os:.er j)L~r~, or in finding ho:-:0e5 or other pta.ca for pl.r..::ement of ehildren f~ t.e:r.po~ry or ~rr..&r,ent on • • •. Private f06tD b.rru..'y ~ncies ah&l1 ~ orpniz.eC a.nd ope~ te1:! on I nor. ?rofit ~ is. (5) ''F~ter fur..il:: home" ~&.nJ I.llj' :-eside!lti&J ~. pro\-idi."!g U-hour c;.."'f for .i.x or fewer fos:.er chli<ire: lIi'hid. iE oV'oed. le&se-d.. or ~cte-C Uld ~ tht resjdf~ce of ~ f.:l'St.er PL"eDt or ~nu. including their !amily, in lIi'hos.t :1."'f :.he f06t.er cl-.ildret ha,f ~r. p!r.ce-d Soch p~:r.ent may ~ by I public or prirat.P child p~;:::,~n: Ilit-rlcy or by I cow-: order, or b) vO:~~:&r1' p!J..cc<7.f:oDI by I pu-eot, pL"'ects, or l'~r..~. (61 "Smal: fl.;r.Dy ho:r.e·· :::>o>~s a..n)' resi.:ler.~ floC':li:y V·(j\-,di:-.g Z4-!J:,'~ C4.."t- for au or fE'\Oer fost.er dliJc..--e:. ... he l-..l "f rr..,r:A~ ~~rdo?ro or de\'flo}-:!,e:-:-..a.: or ~cy~,-:..~ d.:&;:'~~s a..:;C ... hv req~--e .~~ c:&.rt- and !I..:~:;".sioc U I T'efult of thfir dis .. bi2i':ies. (i) "Socia.: rehbJi:..a::>or: !~Jjty" means LIlY residHt;J;.~ !1>C:!i,:} ~ hid. ..r ...-',de!; &.:.cia.~ re~.6bili:..a::>On ae:-,':~ for 00 k'Ct;Er thAI: 18 rDOntiu ir. • vou;: &etti:,g t.c ad:.:b ~,7'''O?~..Ilg from rr.ena! ill:.ess ... h<, ~m?O:-L,,]Y 0E-i'C 1S!i5:4C:::t:. i'l..:-ieance. or COI..:L.>eling Proi:1"&rr. c:Jrr'rv~n:.s ,hall be subjee'. to pr?i"'l'rn sand.l...rds p~\lIL!lt to ~[; S458 l. (8) "Corr..::::mity ~:men! !~ility" meu-.s 1Jl}' res;:le!'.:a.~ !l>Cili:y ... tid ;'T'C',-ide.!. rr.ec~ he4.1th o-e.::r,e1:: i<r-,~ t.c. clllld.--er. i:r. I v-:>ut: ~~g Pror;ns..7. rom;'IQ~!,,:.s sl-..&r ~ sub~ to t-ror..m s~-:~IL.--ds det'eloye<! by the State De~ent of Men~ Healtb piJ$~IJ)~ to Se-c~n 5405 of ~ VI t-~ ...t ' I.!l c! I Wi tiw::>Onf Code. . 1\o:.\ing it ~ s.e<'tioc ah.Lr be eo~::-ued to prorubh or dis·::O'~6f pll..x~e!jt of pers-otl£ .... h<. han !Den:&] Qr physio: ~ili~ into cy C1t.e~lj of co=~'Y care f~ility tr.a.t mee~ the ~ of thf i.nd.~id1aJ p~ if the placement • cotl!lis~nt wit.b ~ OCensing ~.;.a~ns of the de-~. ..· t.=>ent. (9" "Adop::ior yreorr' muru; Ln, indivldtal oti-,er ~ l p;...~o:.. 0 .. ent::. eng--ot;e-C in the bu.s::-,~ of pro\idir.g .doptiol' ser.iees, ",he, doe!: 1LIl\' one or m0:-f of thf fo!k...mg- (A) .Wtu!lef are. e'USt,£)I:h, wd ClJntrol of I clilld ti-.rough relmql..:.!sh:--Jt'OI of thf' child te· thE' &£eOC} or in~vlun~.. .... t.e~a~t of ~"en~ rigi't.E to :.he ch;lc! (B' .~ thf blr''} p;.:cr::..s pT"'..rS;..:-:-tiw ~(''t'::Yf po..--e..,:..s or ch.:ld (C ~ P!1..":e! (:11:1':'- -e 1: f {Y. &do,:io t- {PI S;';t"':"·~""" ad:>:-::iH pt...::-=<7,eo:..s h"Ltc ~o?:ior. &.i~:'~~ 6h&!~ be o::fO'~~ anc! o~~",~ :-r. ;; :;(,~;:.~:.:;. ~is (b; "D;,~,,,n:" or "!':..:..r de~..r:-ri?:'''· ::.e.!I.:ll :.h € S:A~ ~;>..:-"-=r.: o! Sc.ci4: S<:~;ces (e) "Di.t '-:'t.Or·· !!:>U.~ the D-irector of 5-<-:-:L Se-,. ces. (. . l..I:-,ende-d by St.a:.s 1982. e. 1124. p. 4051. f 1. Sat.s 19-83. e 1(\~5. § 2 St.a:a ~%4, e. l~ .• 1. St.l~ l~. c 16:5 • 1.5: St.a:a :985, t. J IT.. P --, f 1: Sa:.h !~ e 14:~ p..--. t 2. Su.~ ~9~. e. ~, t 116, Su.U.l986, e. 112(,. f Z. I'-.."i'eocy eft Sep:. U, 19~ S·. ..: .s :98':, t. }!T22 i 2.5.', -69- f 1503.5. Vnlic~n~ community can facility; d~finition; o~!"atjon prohIbitPd; pr'OC1!dun apon lIIiaco,.ery (a) A facility shall be deemed to be an "unlice~ community care t.cility" and '"m.&iI!Wned and oper1.ted to provide nonmedical e:a.re" if it is unlicen&ed and not exempt from 5cen.s1On and &D'J' one of the f 0 !lowing conditions is s.atis fled: (1) The facility • pronding e:a.re or supenision, as dermed by thiE; ehapter or the rules and reguhtioDIS adopted pursuant to ~ chap~r. (2) ~ facili~' it; held out as or represe!1teC as pro\;d.ing ~ or lltipenisior.. as defuJed by till! cha Pt .er or the !'\.i.les I.Od :eg u.lli ti 0 rl5 a.d opted p l.il"S '.!aL: to th~ c±a Pt .er . (b) No unlicensed comrr,unity cr.n facility. a.; defined in lubdivision (al. arwl ope!'&te in tlili !t&~. (c) l'POD diJ.covery of ar. unlicensed communj~· (:1.. .' ""1: fadlity. th" department 6h.a1: refer reside~ts to the appropriate local or state ombuds:7lan. or placement, adult pro~tive lIen;ces, or child prot.e<=th· € senices agency if either of the, folJoo;o,"ing coDdi':ions exist: (1) There is lI.Il imme·dAte ti-.reat Ul the clients' health and safety. (2) The !&cility wiT! not eoo;><::-at.e with the licensing &gency to apply for a Iic€:lSe, mee~ licc:l5ing stand~, and obtai!". a valic license (Added by Stat.'!. 198.3. c. 7~. p.--. § 1. urgency. eff. Sept. 18, 198.3. Ame:lded by Su!.;.19~, c. 1016. § 1; Sta~.1ge7. c. 1022. § 3.) f 1508. Se-cessity of li~nlle; special permit.: community can fadUty; loc.a.I public ~ncy defined No person. firm. pa..""tnecr.;hip. as~ociation. or cor,x'!"atior. within the, state and no ~Ut.e or local public &gency shall opera~. es!.ablish. manage, conduct, or maintain a community cart' h.ciJ.ity in this state. without· •• a C\iJT"ent valid licellSf therefor as pro\;ded in this chapter. No person. finn. partnership. as;:.ociation. or co!?O:-atior: lrithin the ~tate and DO !.ltate or local public agenC}' shaE pro\ide s~ia1i::ed senices within a communir:' cr.n f&Cili~ in this sta:.e. v;ithout • • • a current nlid spe·cial pe~it the!""f€or as pro\ided in this cha?~r Except fo!" a j\'o\'enil" hall o~:at.€-d by a CO'.lnt}·. or a public 1"E-C!""eativr. prog-rarr• . this s-ectior: applies to cc,mr..~J::. . ca..~ fo.cilities di."t"Ctly ojX:-a~ by a st.;;te or loca: puhuc age!Jcy £ad. cor:-:~uni~' (:L.'"I.' facili:y open;.!k-<l by a sta~ or loca: public agency shall compJy with :..~e s:..andI.rd.s estabfu.hed by the c:iire<::.or for corr.muni:y ca..~ ~ac!:.;ties. }J usee ir this charter. "10C4.! public .ai'-::ncy" r:;e;.~:; ;. city c~unt}·. s~ia: ~~c:. schoo: <fu:rict, eomm~;-.ity co!;ege district. ch4r""..cre-C cIty. or char...:!"1o-d cIty &.no county. (A.m~ded by S!.a!'; !984. c. 14~€. § 2; Su~.19S5 c. 728. ~.--. § 2. urgE'!JC}". eff Sept lE. 198.5: SUtr..l986 c. 1016. § 2.1 -70- t 15-40. Violation of ChaPUT or reru1atloru: misdemeanor; punilhm~nt: o~ration of communi· ty eare facility without li~n~: .ummoru {!l Any pe~ ..b o vlolates ••• t.lU! chapter, or v. . ho W111.lully or rer>eat.edJy vlola~ LOy rule or r!g".J!ation promulgated under !.hi! eh.;>t.t'r. is gililty of a misdemeanor a.nC llpotl con.-iction thereof ,han be pl<cished by a fine not tc ex~ one thou.sanc dol!al"s (11.000) or by impr.sor.ment in the county jaIl for' period not to exct?ed ISO days, or by both such fine anC im"rii.onment. (b' Cl--tA'!"ation of , communi• • can (,cilin- withO;Jt a licer-oS" sb!: be sutject to , IIUm!TlN1S to appea: in court. tAn-.ended by Sta:s 1983. e. 1092.. § 146, urgency. eff. Sept. 2'i. 1983, operative Jan.. 1. 19&4.; SutJI.l985, e. 1-415. p.--. f 2.) t 15-10.1. Community care facilities; 'rial.tiona: ~naltier. notice r 1: a !indin bv th~ !ice:ls;n - a':.lt..~ori~Y tha~ a facilin- ~ ~ 0 !"atic:: v.it."out a Iice~ 1I;>!fJ.C€ officer a.s def.ned In Cha-:er 4.5 (com:7.e:Jcin \1oitb Section 830 of .. 3 of Part 2 of tile Per-..al Code may enforce tion 1503.5. or 'on 1508. or both sections by utilizing the procedures s.et ~ in Chapter 5 (commen~.ng with Se.:-tiOD 853.5) of Title 3 of Part 2 of the Pen.&l Code. A f&cility violating Se.:-tion 1503.5 or 1508. or both. is guilty cf &Il infraction puniahaMe by I fine of two hundred dollars (1200) for each day of violation_ epen a deterrnirultion that , ecmmunity care facility ill in vlolation of &ct:ion 1503.5 or 1508. or both. and after a citation has been iss ue-d , the peace officer shall immediately notify the !kensing authority in the depa.~nt. (Added by Stats.1985. e. 1415. p_-, § 3. Amended by Stats.l987. e_ 856. f L) § 1543. District attorney; institution and pros.ecution of a.ctions The district attorney of every county shall, upon application by the state department or its authorized representative, institute and conduct the prosecution of any action for .... iolation ~rithin his county of any pro\isions of this chapter. (Added by Stats.1973, c. 1203. p. 2590, § 4.) I l~t. V"~ 0( H 1513.1, er 1518; ariJ penalty; appeal <a> Notwithstanding any other provision of thU; chapter, any persoc w-hc nolates Section 1503_5 or 1508. or both, may be ~ by the depwtment an immediate civil per:.alty in the amount of two hundred dollan (S200) per day of the riolation. (b) The cm1 pena.lty ~Ulthori:uod ill sub divi&ion (I) shall be iJnpo6ed if an unlieeIued t.cility iia apented and ~ operator refu.Y.s W ISel!k ~ure or the operator _seek! Dct'ru;~ and the ~U!'I! app~ ia deIDed and the operator cootlnues to operate t.M unlicensed facility. (e) An ope~tor may &:ppeaJ the ~ment to the di.re<'tor. The de~.etlt r.ha.J1 &dopt regula tions setting forth the apyeaJ procedure. (Added by St&t&.!9&5, e. 1415, p.-. i 5. operative Jan. 1. 1986.) -71- I 1u s. Ciril penalties (a) 'In todditioc to StlSpeosion or ~oc::atior:. of. license ~ued un<kr this cMpt.er. the ~pu::m.eDt _y rvy I ciTil penalty in adOtion to the per..JJties of luspension or revootion. -~ The amount or the cmJ penalty Ihall not be ~ ~ tTen~e ~ ($"...51 or more ~ My doIlan ($50) per day for ead-. riolatioo of thia chapter except,.~ ~ tlatllTe or se~esa of dle violation or the frequency of the '-iolatioo W"&n'a.nU I higher penalty or an immedia~ c:ivi; penalty usessment, or both. » de:.ermined by the depit.1't1IlenL In no evenL .h&ll I chi: pe!la.l~' a.s...~::leot exceed o~ hundred fifty do!~ ($150) pe-r day. » (ci NOtvrith!-!a.!lding Sectl<in 1534. a.ny belli!)' tha~ cited fo~ repeating the u.~ m:':ion o! th~ c.h&.?t.e~ ,..-ithin 12 month! of the ft'-'st mlstior. is ~l.:b)e'ct to C1 in:medit.:c C:!'-U pe~. ..l :y o! O~ hund.-ed fi.~ do!: .. :'!' {1:501 a.nC fif-=,' dO:;lL~ (S.5(I. for er.cl·, cia" the ,iol. . tior cortiT1;Je~ unci: :.he de:;cienc:, ia co~..ed - - • (d) _Vl)" facility tlult ~ assessed I ci\-u penal!) purs;;. ..o t to subdiY1.sioo (ci whid. repeli';.E- :.he !>&::le \-iolation of this chapter v.;thin 12 monW of the \-iollltiOr. subject to 5ubdi,ision (ci is s~bject to an immediate O\-U penal!)' of one hundred flft) dolllL"'S ($:50) for each day the \;C>!r. .d or. co!l~i.le~ until the deficiency is rorrec<..ed. The department shall &dopt regulations imp)ernenting ~ section. V,dded by StAts.1985, c. 13'72, p.-. § 3.) § 1549. Remedies not el.c1usiH The ci\;l. cri.rr.inaL anc administratiVE remedies a\'a!lable to the dep411:ment purs~ant to ~ article are Dot eJtc)'\lS;ve, and may be sought and errlployed in any combination deemed ad. ... -:sable by the dep&rtmeot to enforce thi;. chApter. (Added by Stat.!; 1985. c. 1415. p.-, § 6) -72- TITLE 22 COMMUNm CARE FACIUTIES 487100 (p.2451) CHAPTER 8. RESIDENTIAL FACILITIEs FOR THE ELDERLY Article 1. Definitions 81100. Definitions. (a) For purposes of this chapter the follo\\ing definitions shall apply: (I) Administrator. Administrator" means the individual designated by W the licensee to act in behalf of the licensee in the overall management of the facility. The licensee, if an individual, and the administrator may be one and the same person. (2) Adult Adult" means a person who is eighteen (I8) years of age or W older. (3) Ambulatory Person. "Ambulatory Person" means a person who is capa ble 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. (4) Applicant "Applicant" means any individWll, firm, partnership, as sociation, corporation or county who has made application for a license. (5) Basic Rat~. "Basic Rate" means the SSI/SSP established rate, which does not include that amount allocated for the recipient's personal and inciden tal needs. (6) Basic Services. "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 follo\\iog: 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. (7) Capacity. "'Capacity" means that maximum number of persons author ized to be provided services at anyone time in any licensed facility. (8) Care and Supervision. "Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees ot responsibility for the safety and well-being of residents. "Care and Supervi sion" shall include, but not be limited to, anyone or more of the follo~"ing activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming. bathing and other personal hygiene; (B) Assistance with taking medication, as specified in Section 87610; (C) Central storing and distribution of medications, as specified in Section 87610; (D) Arrangement of and assistance with medical and dental care. This may include transportation, as specified in Section 87610; (E) Maintenance of house rules for the protection of residents; (F) Supervision of resident schedules and activities; (G) Maintenance and supervision of resident monies or property; (H) Monitoring food intake or special diets. (!1) Community Care Facility. "Community Care Facility" means any facil· ity, place or building providing nonmedical care and supervision, as defined in Section 87000 (a) (8). (10) Conservator. "Conservator" means a person appointed by the Superi or Court pursuant to the provisions of Sectibn 1800 et seq. of the Probate Code to care for the person, or person and estate, of another. -73- CALIFORNIA RESIDENTIAL CARE FACILITIES FOR THE ELDERLY ACT f 1"'~ Derwtiona AI ua.ed ill thia eh&pter: (al ~ ~ .wpe~iiioD" mearu ~ f&l:llit) ,,"".lm~ ~POl:lSit.il.~ for, Of' proridef or pro~~ to proridt- • • • if! ~ futlort. or.goU:£ usi!t..wce with •• • ..:t~ or daily lmni: ""_~l:t ..h lch ruidt'nt physY.:i.! heahh. ~nta: ~)t.r., wE-n' or welrUt would ~ we.~.g~red Auis~ tnd:.;~ u.sis~ witi ~i ~tio!l.E. !DO!)(" rn.&.."U.£ement.. or pe:-t..)na.' can. s.e... ... (h) "De~nt" IDeUli the Sau Deputment of ~: ices. k) "Di.~.or" meL~ the Di.-ector of Socia~ Scnice5. (dl "RuJ:l-. M!la~ 5e~" ~ II!~ ..-hid. shar ~ di.'"t":'tl~ pro\ide-C b~ IX .pp!"":~~~:.e ,k::":ic-: ?~,~es~!(.!".A~ iIx:~udir.g. I"'£o&is:..e:-ed n~. bc:e:::...ee ~·oca-x,::a.: t· .....~ ~rys;cL t."t"~~i,<.'_. or oc:t:i,;pa :>O~.&l ~1"i.t>is:. (e) '1nstr\l.mental a.cti\;ties of cwh lh-ing" met.ns &Jly of the fonewing: houuv;ork. mull. la undry. t.alcing of me-di-:a tion. moDeY manage ment, .pyropria t.e tnn.s poTU. tioD, eon-es. pon ~eJ:K:e. telephoning, And M!lated wo. (f) ''Uce~" means • ba.sic permit to o??rate • residential Cfo.n f.cility for the elderly. ~) "PenouJ actm~ of daily Ih-ing" me.ns &Jly of the foIk...-Ing- cireuing. feeding. to~tin&. bathing (7'?Oming. aM mobility ~ &S5oOCiated tAEu. (hl "PErsona.] care" means asS~t4r.ct ...-Tth pe~on.r.l act,j\;tie1; of dail)' lh-ing. to herr pro\ide for aM rnain~ir, phsical ~d pnchos.C>o:!tJ cur.Uort. til "~;deDti&! e:&rt' faci1ity fo~ the elderly" mearu: • group h0uSin~ ar;-;.r;~emeDt choser: "'OhlL~­ ily by M!Sldents O\'er 60_ but ~, mdl.idi.'1g ~r.>On!' under 6{1 .... tJ. corr.;:o.t:iblf Deeds ...h e an- prcl->Oed "'L.-:ing ~,els ~ in:.ensi':ies of cr...n: Uld s;J?f:~isioIl, p~:..e-<-ti\'f sl.;pe:.ision or ~:-EoO:l.L ~"e, bued U po ~ the ir l-ary;n g O'€-€is, &E de:..e ~..ine-d in 0 r-der to be a.dm.i:-..eC ~ tc. M! r..J.in in tht fat'ility. n.!! IUbd.~ior. sW be o~l"'IItive ooly uno: tht er.a.ct:nent of ~~1.t:ivr. irr.t'le~rt'Dti!Jg the tt.~ Je-;-e~ of C1l"'e ir. resideDti1l ~ facilitia for the eiderly punu.a.nt to Sectior. }56:'.70. !!: "Resideotia1 care facility for the eldP-rl)'" me~ a croup ho::..sin£, L."nL:lgement choser: vol~~­ Cy ,by :-eside!lu over 50, but a.l!.o including ~ns under 60 ,.ith eom~:lbJe need&. wbe an- pronde,C nrying }evel! aod iIit.e::.siti~ of CUt- Uld supenisior. prote<:t:H 5;J~~,isior. pers.o!l.&1 a.J"e, or bahl< rela:.eG &e.......-)ces, hUed ;rpm) their TWjin~ ~, &E dto:.cnni!lee iIl order t,c. ~ ~ and to rerr.&ic in the~. 'I"a.is Rlbd.'-<-i&ian ahal! ~ operatin upoo the e~t of ~lAtivo im~ting ~ tt.~ ~elJ of ~ iD resid.eDti&: OL."e fa.c:ilities for the elderly pu.."7-u..a.m tD Se-:-;jor: 1~.7e. ill ''SIlp~e~'' me&n.E ~ • ..-wahle to the M!S~ot ir tht eo!ILrounity "rue} helJ; tc ma.inta.iD their functionaJ abilin- aDd meet their ~ as ~o::6ed in ~ ~.dua.J resid~t ~ment. Supporti-.-e!le~ may iDch.ldto Uly of the following- ~. dent1l, And other he:ahl ~ 5ernces, tnlli'p or-... 000.; l"eO"ea::)on&! ~ Ie is urt ~; .ociL k:nces; • • • and CO\!!l.Se) ~ 5e:-rices. (Added by Stat.!. 1985. C 112':. t 3. Affie!lde-C by S:.ats:~ c. 8-« t l.l -74- • 1569.10. Resid~ntiaJ facility for ~ ~)der)y; ~ftK or ~t; ~ity ~,o pel"'Son. firm, pa.rtne:-ship, ~ociation. or corporatior; within the stet- and DO state or loc1l pa ... iIC ~e~ ,hall ~rate .• ~~blish. manag~: ~nduct, or m&irtaiL • res ide n tits 1 facility fo~ the ~Ill iD~~=Ciat .. ~ valid license or current nlid spt":ia' permr. therefor, &Ii '(Added by Stat.& 1985, e. 1127, f 3; Stat.&.l98.5, e. 728. § (, tlrien~y, eft. Sept.. 18, 198.5 Amended by StatE. 1987, e. 1069, t t.) t 1S.9.31~ Basic lUTict "'Qui~lIIenta Every facility req~ired to be licensed under t.hi£ chapter ,hal: prm-ide a~ Iea.s~ the !ollclOing basic ae~: (a i ('.an anc sU?<?!"isior. 11.!' oef:.."lt"i ir: Sectior, 156£i .2 (bl ••. .ssisu.n~ ...;th inl>~.;,rner,c.;;.l fs.C'tl\'1ties of dailv b-;ng in thE; cO!':'ll:.;r.a:iCt~ "'hid meet tile- !leeds ofresidenta. . !£) Helping residents gain ;occess to appropriate supportive SEn;ces, as defined, in the community. @ Being aware of the resident's leIl€ra.1 whereabouts, although the resident may travel indepen· dently in the community. ~ Monitoring tlle act:i>;ties of the residents wblJe u.ey are under the supervision of the facility to ensure their genera.! bea.h.h. safety, and well-being. ill Encouraging the residents to mai:,tain and develop their ma.rimum functional ability through partici~~tion in planned acti\;ties. (Added by Stats.1985, e. 1127, § 3. Amended by Stats.1986. c. 844. § •. ) § 1569.40. Mislemeaoor: punishment; lurnmon~ to appear in rourt {al Any person .....-ho nolates this chapter. or who willfully or re;>ea~y violates lLIly rule or regulation adopted tlDder this chapter. i!; guilty of a mi!.demeanor and upon ron>iction fr.ereof ToW be punished by a fine DOt tc e:xceed one thousand dollars (S1,OOO) or by irnp:-isonment in the COtlDty jail for a period not to -e:xceed 180 dAys. or by oot.h such fine and imprisvU!:lenL (h) Operation of a residential care facility for the elderly without a license &h.a.ll be lIubject to • lIummons to appear in court. (Added t>,. Stats.l985. e. 1127, § 3; Stats 1985. c. 1415, § 6.5.) ~ ! "Ci"'sr;.. or tlm 8C1 s.hall become ~"" aI tb: sam< time: • IB Scc-::>oa u ol Sua. 191 S. c. 141 ~. pro"ides 11~ or tlu> bill. w~ is la1c-- ""Scctioa b. S ol tlm acI IhalJ DO( become op=ari vt u.nlcss Addruoc ol § J 569 40 try SUa.! 91 S. c. 1127. § 3, 0,. ill SB l!~ o/'tbc 1985-36 JlquW Se:sS>OD [Sau 19!~. c 1127] 0--.11 t=l.. ' .... <ubordJ~ to tbc a6di:>oc ol i 1509.<<l, bec:::m:><:> e!fecti"" and opcno"" and in that -=asc ~ 6. ~ '" Sun :98~. c. 141S. § 6.5 § 1569.405. Violations: pt'naJties: notice Upon a finding by the licensing authority that a facility is in operatior. witbout a license, a peace OfflCeT. &5 defined in Chapter 4.5 (commencing with Se<-tion 830\ of Ti'Je 3 of Part 2 of the Penal Code. may enforce Section 1569.10 by utilizing t.be procffiures set forth iL ('ha.pter 5 (comI:Je~lcing ...;t1-, Se<-tion 853.5) of Title 3 of Part 2 of :.he- Pena! Code. A facuir:. \-jJ:.lating Section 1569.10 is guilt) of a.r. infraction punishabltc by a fine of ~.(o hu!'!d.-e-j do'l4."'!; !S~'J: for each day of nola~on. Vpon a det.ennir:ation that a residentia) care facihty for the elderly is in nolation of Section 1569.10. and af-wer a citati~:m has been issuf'd. W ?U'=" offIcer shaI: irr_":lediatE:i;' DOti..~ the 1iceru;~ authorTt}' in ~ department. (.. .. dded by Stats.l987. c. 856, f 2.) -75- § 1569.«. l:nlicense-d residential racility ror elderl.r; definition; operation 1rithout lieenae prohibi~: proa-dun "pon daco,.ery Cal A f~1ity .hal: be deemed to be an ."unlieer.se<! residenti&l facility for the elderly" and "ma.intained and operated to pro~-ide residential cue" if it is unlict'nsed and oot exempt from lice!l!'~. and anyone of ~ fonowi.ng conditions ~ sa~fied; (1 \ The f&eili:y iI prondi.~g er.rr anc 5t:pen-ision se~, u define<! by ~ chapter or ~ roles and reg-.JI&tl'J:lS adopt.f"d P:l.."'S1.:..I..Dt to tlus chapter .. (21 The facility is held out &5, or represented &.S, prov-iding ::r.rt' and 5uper';sion and aer.;ces, U defined by t.1U!< ch&pter or the n*s and regula~oIlE ~pted pun.U&Dt tc> tim ch&pter. (3) ThE' facilit}· .ccep~ or reams residE'n~ ..h o demoru:t:-aU: tilt' nE'eC for care and supe!"\isio~ and ser.;ces, &.S define<! by thi5 ch&pLer or the rul~ a.od :-egula'.::ioIlE adopted pu.~u&Dt to ~ chapter. Hi The facility rep~n~ itself as a lice~ residential facility for ~ elderly. (b) ~o unl>ct,~ !"'eSide:::ia: facility for;he eide!"ly. &.S defued in Jul:xbision (a). sh.a.E operate in thi; st.aU: (c) l'pon discovery of aT. unlicensed residential ~ facllity for the elder1y, the department shal! refer residents to the ap¥ropriate placement or adUit pro~tive S!€"\-lceS agency or the appropriate local or sUU: long·term ~ ombudsman, if either of the follorng conditions exist: (1) There i5,an immediate tllreat to the dientE' hea.lth a.nd safety. (2) The facilit)· will not eooperaU: with the licensi.qg ageocy to apply for a licenlle. me-et &enaing standards, and obtain a valid license. (Added by Stat6.1985, c. 112'7, f 3; Stats.:'985, c. 728, t 5, urgency, eff. Sept. 18,1985. A:meoded by Stats.1986, c. ~, ~ 7.) ~ 156~.'5. Mandatory liceruin, of radliti~ offenn, care and lIUpel""iiion to the elderly AfT' hall be ~nsed as a residential Cr.rt facility for the elderly if it ofre:: C4re and &Cl. It) f.. d ~ ~ .. tIi iu residentb. E"er, reSIdential Cr.rt facility for the elderly IT. tillS ~ta.te au p€ !"ns IOn. 8.S e.;,:)"". . - lIha.l~ be lice?:.S~ under ~ chapter. (Added by Stats 198.5. c. llZ;, ~ S.) t 1s.69~ Civil penalty; appeal . _ 15 ( 6 a 9 l .4 . ~ . 4 . · o , " o , - " - r - ' " b + o ' '- t " ' h U . ' . m ! ' ld a ' i y n " g b E a : n . a " s s o e t s h s e e r d p b ro y \ t is h i ~ o d t e o p f " . ~ :~m e c n h t ll .p a U n ! T u . , n a m n e y - d p i e a U ' r s : o C n' l n .. h r r. o . - . . - . r , i a o l n l . a t m es thS e e c & tio .m o o u 1 n 5 t 6 9 V .:. l , l . ? w .; U :r hundred dollars (S2001 per day of the nolaoon . . ) The civil penalty authori:.e<l in lubdi,-iI;ion (a' &haD be im~ if. an unliceru.ed !acili:y iI (b."t.ed anc the ope~tor ref-u.~~ I.e. M'ek licenFu.:"e or tht ope:-ator.s.e-eu hce::S~:"e and the bce::s;u-e ~ii:;&::iOr: is de::.iec L'1d the ope:-ator CO:1~nue~ tc> O?:€-ate the un;lce:-.se: !acili~·. ';>(C) An ope~tor may appea: th;: 8.Sses~men: t.o tht' dlrector Tnt de;:. ....~ eo~ st-.al~ a.JOy~ reii,;,a· bor~ ser-..u-:g forth the appea: proce-e",re. (..\ddec by Stats 198.5, c. 1415, t 6.':'.) -76- I lSOU9. Ch'U ptnalties (al In addition to lusptnllion or ~voeation of • license is~ueC under th~ chapter. the ~par.rnent 11IS~' ~"Y I civil penalty· in additior. to the yen;olti~ of 5J;!'pt.'nsior. or ~vocation (b) TIle Imount of the ovi1 penalty shall DOt he less tha.r. tV"oi!nty·fj\·e dollA..'"S (~, 01 more than fi.~ dolld.!'!' ($.5(1) pe~ day for elcr. \;olAtioI; of t.~is. d·..ap!J:r except 'A'here the nature or scn;)usr.ess of th~ \;ola~on or the frequency of the ";O:I~or: '\lr&rran~ a higher penalty· or an imrr.e<fu.te civil pen.alty. assessment. or hoC'• . ~ determined by the dep. .r t.:nenL In no even". sh&.l1 a civil penalty I.SSeS!.ment ex~ ont hU!'ldred fifty dollArs (S:;,o, per day (c) ~orv.ithst.2.!lding Section 1:.69.33, any residen:ia: cart- faci1i::- for the eJde:-ly t.~at is cite<l for ~peati!'li the same Yloiation of th.iE chApter v.ithin 12 months of the fl!"St \;olatior. ~ 5ubject to an irnrneC!B.tE- civil penalty of one hundn-d fifty dollAr!' ($150) and flfty doll.-.rs ($501 for each day the Tiolatior. continu~ unol the defICiency is CUl'n.'('u.-d. (dl Any resider;tial ~n' facility for the eid.,rly that is assessed a cinl pet:alty p~ull.nt to subdiv1Sior. (c) which repoeats the same v"iolatior. of th~ ch4pt.er within 12 monthE of the riolatior. Sl:t-it-c: :.0 sub<il\isioo fCI is su!:ljec: to a.n immeCia:.e civil ~~r..lty of one hundred fif,:) do~ ($:50) for €act; d4y the \;e,la:i0r. cor,tir.u~ until the deficiency is corn-cu.-d. Th-€ jt-p~.r.,en; ~hal: a.dop: ~~;":i(.!1S l::',ple!:',er.ting th~ sec-tior:. (.-\dj,.,j by Sta~.19~. c. 13'72. § 6.) § 1569.495. Sonuclush'~ reme-<iies Tht cj,·il. crimmal. ane administrati\'~ remedie:; available to the dep4rtrneDt p~uant to this a.,,'ticle IJ1' nN exclusive. and may be sou!'h: and tmployed ir, a.oy combi.nation d~med &d\"isable by the state depa...-unent to enforct: this. chapter. (Added by S".ats 1985, c. 1127. ~ 3.) § 15 6!U3. ProF-e'Cution of actioru for violation upon application of lM d~partrnent The d~t....jct a~"(>r:Jey of' e\'ery county shall. upon application by the st2.:.c department or its .ut~,or.lk\l represen~t::\'e, institute and conduct the pro~ution of any action for no!ation of this chap:.cr ';I,ithin his or he~ county. (Addee b\' ~~ats.198.). c. 1121, § 3.1 EXHIBIT H Homes , 755 H Mike's Mobile Service ..........•• 4578673 Sacramento Valley Home Improvements e Health Services Home Repair & Mr Flxlt 3541 Whitn.y Av ........ 4875720 5042 Vista Av ................. .4215317 Homes-Residential t'd} Maintenance (Coord) O M s r m F a l n x l F t a . u • z • la . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 4 5 5 1 4 7 1 3 3 7 1 4 0 SCOTT'S ALL AROUND MAINTENANCE Care (Cont'd) PAllEY MICHAEL H PAINTING - CARPENTRY-PlUMBING-ELECTRICAL ,me Hulth • ACTION HOME SERVICE & REPAIR - ,"WE DO IT A ll" Ann's Guest Home 2621 C.pltol Av .4433142 :ockton 81 ElkGrove ..... 685 9815 FREE E-STIMATES ......................... L1NOLEUM-CONCRETE-SHEETROCK Bounds S.nlor Caro Hom. . ; 'co 2020 Hurl.y Wy .. , .. 9227120 REASONABLE RATES PAINTING-SHEETROCK REPAIRS DRY ROT-PAINTING-MOST ANYTHING S. . Our Adv FOf' Nunl"9 Homes :ALTH CARE PLUMBING-ELECTRICAL 509 Michigan 81 WS ...........3 716862 j M ' I H lui Pllntl"l,Clrpentry,PIUmblng.RoOflng CAPITOL GUEST HOME 105 7';"'rIl asp , Inltorlal-Slte Cleaning . -CARPENTRY ,_ Free Estimates , 24 Hour Care • " :ttonwood Woodland .441 7828 SPRINKLER SYSTEMS-SOD LAWNS WINDOW & SIDING REPAIRS • '" . ' M.dlcal Transportation Furnlshtd ' SSISTED LIVING Installation & Repairs & INSTALLATION ........... , ... , ......... 4242554 )014 Capitol Av ....•...••• 4579085 ' ' . . I I 482 HOME 9216677 T TR ad I c A o N H G o L m E o S Im ER pr V ov IC em ES on C t O . ....... 332 8667 C 5 he 6 r 5 ry 0 L S o a d cr g a . m R e e n s t i o d e B n I t . i . a . l . C .. a . r . t ... , . . 422 3131 oonionship 1209 EI Taro Wy ......... , .. 4824663 R Hubbard Malnt.nanc. Country Club Manor , ~ Core in 5665 Power Inn Rd .............. 3860110 ANTENNAS D~n~~~a~!~ G,;~t ii';';'~" .. 481 9240 Action Hom. & Yard R.palr ......• 991 2682 ANDYS REPAIRS & RENOVATION -- DEADBOLTS _ LOCKS 3520 Dayton ................... 927 5202 :omfort of :~a~~~e;~:~~;;:~~~E·&·Ci.·E~~~~l~ GENERAL REPAIRS ~r~M~~~\tm~~AL-GENERAL E~~~e~~~~!~~ , Own Home RESIDENTIAL _ COMMERCIAL . DRY ROT SPECIALISTS SEWER & DRAIN CLEANING 24 Hour Sup.rvlslon 1M B R U E IL S D T I A N U G R - AN R T E P & A I S R I T - E D C E L L E IV AN E R U I P E S ' EXPERT CARPENTER WATER LINES Esk 5 a 7 t 2 o 1 n A S n u n tt . er ~ I A . , rC..nrmocrl .. : ._.., 4 828301 ,. senlcM that best fit .................. : .....< .3917601 DOORS -WINDOWS -ELECTRICAL 6221 Ev.rest'Wy .. : .. '. ...... 334 3130 d:it~n'S::~~I:~~,;iii"'''',',483 6031 no.ds, ranging from help PlUMBING -CONCRETE 7501 Sunrise BI CllnIsH.lghts ... 7263315 laundry driving to personal BENADOM PROPERTY MAINTENANCE - WE DO IT ALL -ESTIMATES GLADLY Valley Homelmprov.m.nt Services Eth.I's Daughters Home Cart ourS. diy. ' , _ DRYWALL - PLUMBING - DRYROT 195 Wlndl.y Dr ............. 925 9310' W6 a 1 1 1t,9, GHr n aa y y d m sto a n n e A&VR e C pa ltr l u r sH.lg . hts.4 86 8797 E 3 U 9 C 81 A l 8 V th P T A U v S .. . T . R . E .. E . . L .. O . D .. G . E . : ... 457 987B only for the ser,lces you n• •d . ELECTRICAL -FENCING ~ TUB ENCLOSER Rick's Shop ...................... 454 3232 Yrt~n~t~ R~ .... : ...... , :~. ....... 991 9300 1532 Rosalind ••••••••.••••• 929 4591 I for C~~1.iv~:d ,:~~re ~:o.~~~~ RESIDENTIAL & COMMERCIAL ' 6~el unlv.~~rt~~v· '; 4834357 FAIR OAKS MAJlOR DRYWALL PATCHING SPECIALISTS '. HOW TO FIGURE Wh •• ler's Acoustical c~iil~i"~::: :4213770 7710 Sunset.Av FalrOaks ..••••8 7 2040 :sidiary of Kelly Services, Inc. MOST JOBS DONE IN ONE DAY Y K HANDYMAN SERVICE PIN_ s.. Adltertis«nent Th,. P_ 'FOR SERVICE CALL" SERVING GREATER SACRAMENTO HOW MANY KILOMETRES REMODELING. F~o;~~ C2O::I~~.":,~.~~~~~~I. ...... 422 4825 listed Living .: ",', ~~~I~~/ld~~'~~nchO Cordou '.:--YOU ARE TRAVELING.. CONCRETE, DECKS FORD'S RESIDENTIAL CARE ,Iar<oni Av .......... _. . 484 nOl ......... , " ............. 6381505 CARPENTRY _ .,' PLUMBING 24 Hour Nursl"9 Care 3 8 .YNURSES California Hom. S.rvlc •.......... 364 7620 _ 20 mph = 32 km/h PAIN F T O I R N F G R EE EST : -I . M ' A B T R E I C C K AL W L ORK GO 2 L 1 D 7 E 1 N 2 0 Y th E A A v R S . . R . E . S . T .. H .. O . M .. E . S 4 5 9 88 "Under CERTIFIED APARTMENT & olics 4859017 . ~ ., u ,, r ,c ' a " n R R e i g ve is r t r O ie r s ..... 4855826 RE P S lU ID M E B N IN TI G A L E R L E EC P T A R IR IC A S L E RV G I E C N E E RAL .. 25 mph = 40 k",!/h 362-5518 . "2 518 HARMON'y MAiioR···· 8899090 . ' P N E , R -L S V O N N s N -L EL lv e P - O ln O s- L A id.s ........... - ....... ,., .. - .. 4249226 30 mph = 48 km/h 96 A 08 ft e K r I H .f o e u r r s B I C . . . II . . . . , . .. ~ , ; . • .. . . . ; , ' . . . . " 36 " 2 5 0 666 H 8 .r 7 J 0 .m 8 a G G . u _ .st R H d o . m . e . ......... . mom-Therapists-Bathing Srvc. Ev.nlngs call . , , ..... , , ... 427 7088 l~i{& ~~RKCSE~~~ii i:ciiicE" .. 3839827 MEDICARE/MEDI-CAL Chan.y's G.n. Hom. R.palr & Yard 35 mph = 56 km/h s• • Ad This Section ,,' Oaks 61 ........... 486 8484 ;:~v~C~rangerl' Wy Crmcl ....... 944 1768 40 mph = 64 km/h LAW A~~ES 'GuiiST 'RAN'CH' 421 7000 AN JUAN HOSPITAL CHUCK'S HANDYMAN SERVICE = Country Llvl"9 At Its Best -, .......... , ..•.. 5375248 Carp.ntry-EI.ctrlcal-Plumbing-Etc 45 mph 72 km/h 7104 S.nta Ju.nita Av , l M CY E CARE-MAPS Circ . l . . . J . H .. o . m . . . R . e . p . a . i . r . . . . . . . . . .. . . . . . . . . . . . 3 . 6 48 2 4 3 7 9 1 9 0 7 9 50 mph = 80 km/h A 9 M 4 E 7 R 5 IC Fo A r N t W R o IV rth E R W y G . U . E . S .. T . . H . O . M 3 E 6 1 7777 LE O M r O .n N g .v H al i . l . l . lO .. D . G .. E . ........ 988 0157 . . ' , . ~A 2 C 7 Pt 5 S. 5 P•I 1. C a.r o •m t . t a a .c g . y . . W .. y . . . . . . 4 . 2 9 3 71 4 1 0 1 0 1 1 3 D D; . ~ r ' ry :5 B H ~ o ~ m ~' . ; , I : m ~~ p ~ r ~ o r v . e s m . . e . n . t . & .. . H . a . n . d . y . m . 4 an 2 19847 55 mph = 88 km/h A 4 M 5 E 33 R I P C a A s N ad . R n I a V E A R v . G .. U . E . S .. T . . R . A . N 4 C 8 H 7 9094 76 P 0 I b H L st e J m s o ( n . C . H o A i n li d tl A l-t v 'e- r- . t . iNs . « . n . t . e P . n . t . T . h ) 3 i5 8 P 37 _ 1 00 , 4101 Pow., Inn Rd .... 454 0444 10488 Ambassador Dr RnchoC ... 638 5053 ,~ ex ag. ~~ningServ~e D~IO~Houuh~dServ~es ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ _' ",s.s &. Nrs R'glstrles 5631 Auburn BI .................3 44 46461 -"ican River Dr ........ 972 7882 DIXON DON HOME REPAIR 9442138 ~E COMMUNITY 4021 California Av Crmcl .... . RESIDENTIAL CARE lL Duyarit. Ent 1854 Crossmlll Wy ... 9290640 "Av Ros.vlli •...•. 781 1070 Gary Barn.s Service ~ R.palr :oly .............. 7811099 P 0 B~x 19009 ...., . ............. 457 9256 We offer an atmosphere of independent living in a _ George sHame Repalf ............. 1>38 4686 I HE Glenn's Handymans Servlc. :- quiet neighborhood setting 2 FACILITIES TO SERVE YOU 24-HOUR CARE 2905 Hunt Dr RnchOC ........... 363 3709 Gold.n Rul. Contractors, • JME HEALTH AIDES 4322 Drang.Grov.Av ... ,'. ...... 4858555 _ companionship Goldi. Ray ...: ................... 3317770 • DAILY MAID SERVICE • MEAL PLUS SNACKS -. 24 HOUR ATIENDANCE . 001 care -shopping H~~~a;~~:'~'I~~·~~n:.~ ....•...... 386 0112 • SUPERVISION OF • ARRANGEMENTS FOR • SUPERVISED ~reparation -bathing Hubby FOf' Hire MEDICATION & DIETS TRANSPORTATION ACTIVITIES ry -housekeeping ~~k~~o~~k G~~~~. ~~~r.I~.~~ .-..-...-...- 68-51-8715 r'i.ld, , ....... , .... 9253658 KING'S HOME REPAIR ·LEMON HILL LAND PARK JILDERS HEAL TH CARE - LODGE SENIOR LODGE :ES COMPLETE MOBILE SHOP • LVN's ' Hom. H.alth Ald.s 383-7100 421-7000 . t's' Aides· Home Companions WELL STOCKED • Oa.s 81 , •.•.• , .••. 484 1555 WITH SUPPLIES 1EAl THCARE SERVICES 7606 LEMON HILL AVE. SAC. 966 43RD AVE. SAC. .y Wy ............ 929 2229 UNDER SAME OWNERSHIP HURSE ASSOCIATION ~V~YOUnME&MII ON~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ .rseS & N1ISt Registries ELECTRICAL-PLUMBING -\Con,. Rd .......... 927 3481 Repair & PAINT-SHEETROCK REPAIRS FAIR OAKS Sere". Community Hom.. provide the a<:c8pted LINOLEUM-FENCE REPAIRS psychiatric and psychological casework services provided enance '. GENERAL MANOR In well run homes In general. In addition. strong emph.si. Is placed upon nutrition and the Spiritual valuel of the community. this Is based on the premise that I strong. JING & MAINTENANCE PROMPT EMERGENCY healthy. and w'I"-nourilhed body and a philOSOPhy of life , U ,, I , N o T n E D N r A E N lk C G E ro v C • O . .. 383 6916 SERVICE WITH A RETIREMENT HOME w pa h t i h c w h aY v I a lu to e s a c l c o e v p e t an a c n e d In i n a n n e d r a p d e j a u c s e tm e a n re t to t h t e t le su C r O e m s - t ONE OF THE COUNTIES .. munlty, al well as In Interpersonal rolatlonships, -";ng All Sacramento Area MOST BEAUTIFUL AREAS artme W n E lt ' L - L H F o I m X e I s T -Office R C E E FE LL R U E L N A C R E S T E A L V E A P I H L O AB N L E E • • • 2 A H 4 O C M T H I R E V . L I I T S K U I E E P S E L . R IV O V I N N IS G B I O U N S LINE 454-0668 Air -Heat Appliances • SPQ~CRIOOUUNSD P S A RK·lIKE entTy -Electrical -Plumbing 971-9311 WE GO OUT OF OUR WAY TO 'oin Link or Woad Fences PREPARE OUTSTANOING FOOD .. • .747 LoomiS. , , ...... 962 0637 SPrEC:I-A:L- D:I ETS AVAILABLE Sacramento CALL ~ )epair Senite .•••••.•• 4472506 ......................... 9719311 !967 - 20!lOl ~ tile Telephone Directory 4587 -25TH AVE. .' andy. , , , It soves you 7710 SUNSET AVE. FAIR OAKS . SACRAMENTO lime and eHort, - -78- .' . Fl' 756:' Homes', ; " -----1 Homes-Residential SALVATION ARMY THE .. Horse Breeders' Horse Training Hose Couplings Care (Cont'd). " ;~ ;.. (Cont'd) Fittings . CAMElLIA ======1 Amulet Arabian C.nter . lindale Manor RUBAIYAT ARABIANS 12141 Keating Rd Wilton ....... 6876172 Adult Males 18 To 61' , HOUSE REGISTERED SPANISH AND A~~~g~no~:~~~eT~:"OUghbredS Inc AERO QUIP HOSE AND FITT 5200 Stockton BI .••... ~ ........ 7361167 SPANISH CROSS ARABIANS RanchoMurleta ......... : ... .' .... 354 2074 OYer 100 hoses & ' ... . Manna Home F or Adults' ,<, .. M 2 A 9 R 59 K S L a E n E J o M se A N W O y R . .......... , .. 739 8035 Residential Care Home Sil P 6 k 2 O R 5 B o 0 a o d B x a A 1 r r t 4 a o 9 b n 0 i a R n Z d s ip L o 9 o 5 m 6 i 5 s 0 . ...... 652 6551 CR B AC O K A ER R D JA I C N K G R . • A S NC t a H I I s • P a stures p 3 1 r 0 / o 1 0 s 6 ' s s u " r o e t f h s F ru t i o t l 1 l 1 n 2 0 " o 0 s 1 0 0 0 ; A ~. MEN & WOMEN WElCOME Blacks-Sales & Service TRAINING: . .. psi. Temperatures ''''. OPERA TED BY REGISTERED NURSE .For Senior Citizens 7405 26th RL ................ 9911949 Western, English & ' ~:5Q.~.OK~f Wt." 1.',' " AMBULATORY & NON· AMBUlATORY .. " f· . SILVER HILLS MORGAN HORSE Race Track Preparation lings, adapters, couplings. HA H IR O M & E B C E O A O U K T E Y D S M E E R A V L IC S E S All Meals and S R 6 p 2 A ir 9 N it 4 C O P H f le C . a a . s l . a if . n o . t r n . G . i r a o . v . S e . t a . R n . d d . a . r . d . b . re . d . 9 F 8 a . r 8 m 058B LE E S n S g O lI • N S h S : -West . ern '. '.-. , " ' J7HER . E TO Bu . Y• T. . 24 HOUR SUPERVISION Housekeeping Services PleasantGrove ................ :.9910070 10004Jackso Rd " 3634309 DISTRIBlfTORS Home-Lik. Atmosphere SUNRISE ARABIAN CENTER n .......... - B & T HYDRAULICS . b025 Riza Av .....' ,., .'.;: .... 3911933 Personal Care and Transportation 1713 G RL .••..•••••••.... 9914013 Greenbrier Farms 3822 ElkhomBI .9297532 2324 Del Monte WS ••••• WHISTLING WINDS ARABIANS LACEY'S ARABIAN CENTER BIGGERS INDUSTRIAL Meadowgate Guest Hom. Recreation Program, Outings 450 W Elverta Rd Elvta .• -••• 991 2444 5374 Tassajara Rd ,.C· GERLINGER 7309 Meadowgate Dr ... : .. : .'. . ;'::392 4022 WINDS ALOFT FARMS Pleasanton ............ 415 829 0443 555 Sequoia Pacific BI .. . Morse Avenue Care Home ..' .... , Chapel Services Registered ~.~ . Lion Cr.st Arabians DELTA RUBBER CO INC M I 1 N O 8 T U 3 E 3 N R T M A M o I r E N s D e M I A A v A T N . E . O . C R .. A . R ~ ' E .' ~ . f . :: ; ' \ : , . ' . , :' . ' . , : . ; F ' , . ', , ' , ; '. 4 8702 , 6 ' 1 60 ." 4 '~ 6 . • . L ; ... e .. - m r. o , n .. . H -- ili Av .......... 3836865 A H Fo o u rs r e - r S s h _ a a A rr t 4 S b 5 tu 5 d 3 : 1 i an ""~O ' , " "' * r• • "" M Q 1 u 2 S rp 5 3 h 6 1 y 6 F E l F d o i g r C i n u R t R d t d in . W g . . i H l . to o . n r . s . e . . s . . . . . . . . . . . . . .. . . . . . 3 6 6 8 3 7 3 7 4 7 4 0 0 0 2 N P b o a 4 r C t 8 y h . a N r . o g . e r . t h . T . o T . e C . e a p . l e l . i e . n g . . S . tk . 8 .;: 0 biOI Fair Oaks BI Crmcl ..... :4887211 Parada Del Sol ••••• "~M.. OYer look Farms 5632 20th RL .... 9913448 HOFFMEYER-tOOK Natomas Guest Home ." ,';: SENIOR OAKS RESIDENT CARE 142682 S & H Horse Hotel " CORPORA TlON ,.:,. 421 San Juan Rd .................. 925 7180 7586 Sto kton BI 423 1091 Sponsor Of Th. Ar.bian Horse Youth 1905 Elkhorn BI RL ............. 991 2537 752 Northport Dr WS .'i .. IIORTHGATE RESIDENTIAL SERENE HOME FINDING 'AciiNCY Ownership & Training Program Shandonl Ranch KAYSER CO ., 1 "" CARE HOME "'. "'. ".. 4567 25th Av·. .... : ......... 454 0668 (A Qualified Non·Profit Organization) S~~~~ ~~:~t!t~~'e~ivta ......... 9915232 30 Main Av ....... ~ .. .. ELDERLY· AMBlA.ATORY PleaSB See AdvertiSBment Previous Page "FOR JSFOR.IIATIOI' CALL" Sunrise8 Ar abian Cent.r. BIGGERS INDUSTRIAL NON AMBUlATORY. 'I Silyerer ..t Manor Guest Home 4897004 Winds Aloft Farms 1713 RL .. H· .. · .............. 991 4013 GERLINGER ' ·WkGJ:~slH~:~~~RE 'S~~~~s;:G~'de~si~i~'c~~~~i;~~;~t 10400 Combie Rd Auburn ..... 268 1515 S:;;~ AUu~~~ Blo~~~~ ...........•• 482 6247 555 S«lUoia Pacific 81 .~ • 24 HOUR SUPERVISION Hospital 2215 Oakmont Wy Ws .3711890 Windsong Farms Whistling Winds Arabians. CAPITAL RUBBER COf : 925·5109 ,," TW C I A N R P E I N H E O S M R E E SIDENTIAL 5902 Twin Cities Rd ElkGrove .... 6856219 450 W Elverta Rd Elvta ......•.. 991 2444 735 Pelican Wy ...... '. ... '. .. 925 5109 BOARD & WE CARE Horse Dealers Horse Transporting S H h o e s e e t · P B a e c l k t i i n n g g .. . OL C IV H E R G IS L T E IA N N H S O C M I E E - N R T E I S S I T D S E NCE FOR NOT C BO AR RE E D S & H O N M O E B ODY Esler Arabians CHEYENNE HORSE A T E u l d e b h c i e n t s r g i i Y c & e T s D · o S o u e l c s a t i n l - a g n F l i s ll - i G n a g • s s k , e : ts AMBULATORY MEN & WOMEN CABLE TV & SPA 10327 Kost Rd Galt c ••..••• 209 745 3300 TRANSPORTATION Protective Clothing-Soots-Glo PARK LIKE ATMOSPHERE , . EXERCISE WITH FRAN Please See AdvertIsement Th,s Page 7835 EI Verano Elvta ......•. 991 3296 Mattir19-Material Handling 3037 Becerra Wy ............ 489 8255 CAL1JOR OTHER SERVICES Gibson Ranch Equestrian Center FL YING H EXPRESS ...• 209 836 4505 ' 4519050 See Our Ad Under Stables Nation.Wide Horse Transportation Inc • -_. "'J7HERE TO BUY TI Pettigrew's Family Care 2015 23d . . . . . ... .. . . . . . . . 8554 Gibson Ranch Park Rd POBox 5368 ' Capital Rubber Co 3012 California Av Crmcl ....... 944 2200 Walnut House Elvta ......................... 9919500 ColoradoSpringsCo 3036351BBB 2112 Alhambra 61 •••• : ••• Plea,ant Ridge Home 2030 23d .. .4551734 See Ad Retirement Communities REATA QUARTER HORSE RANCH -- ......... . RANCHO MANOR 3401 Wainut Av Crmcl ......... 483 6612 WINNING QUALITY, Horseshoers - GOODYEARINSTA-COUPLE ST A TE LICENSED WILLIAMS CARE HOME COLOR, and CLASS AT A FAIR PRICE HYDRAULlCS 14489 N Jack Tone Rd DISTRIBUTORS RESIDENTIAL MEN & WOMEN AGES 18 TO 61 Lodi ., .............. 209 334 6800 A & J Farrier Service . CAPITAL RUBBER CO CARE FOR SENIORS Shandoni Ranch 230 Illinois Travis ......•.. 707 437 2381 2112 Alhambra 81 •••••••• T V & HOME COOKED MEALS See Ad Under Stables . 'Aldous Chuck HOME LIKE ATMOSPHERE LAUNDRY SERVICE 8846 Sorento Rd Elvta ......... 9915232 B 1 O 0 B 5 ' 8 S 0 H L O ow R e S ll E R S d H O E E lv I t N a G .. ........ 9915448 Ho 7 f 5 f 2 m N ey o ~ rt - l' C lp o o o rt k D C r or W p S or a .• ti • o • n •' . • • ME H D O N I M E C E P E A L D A T U C S C I S O O T S S N O I U V N K P I & T A E E I C E R D I'E S V K M R I S S E S E A O D L N S A L Wi 4 lli 3 a 7 m 0 s C C u a s R r ti e s E H C A o v R m E . e . A N . T . o I O : 2 . N . . R .. O . O .. M 4 56 9443 CR H E IT q o TE u rs R ip e C m O F R e a R n A rm L t S s IN C & - . ' C "Y O O RR U E R C B T O H IV B O E H G R O S A T S H L O E S L E ' I H S A S O , F E B P A I E N A R S D G R T S I E & F R R B I O E R N IU D M " IIM ~ P & : ~ P ' m C - E a : O R ~ n ' U t I ~ A P n C L h t L o I s N E a e G n A . d S S . T _ M . A V A N ' I E H M O A S S P E ARRANGE FOR TRANSPOR TATI ON W 5 i 0 ll 0 ia 3 m A 's rg L o i l W lie y R .. e . s . id .. e . n . ti . a . l . C .. a . re . . H .. o 7 m 3 e 6 9222 D 4 A 2 L 0 E 1 C W L e I s P t P C E a R p it R ol E A P v A IR w s & . ... 3725714 DEPENDABLE---RELIABLE r li t n u g s s a . b S l w e i c Y o e u l p - , . Male & Female-Ages 18-64, b5 & Over SHARPENING ' SERVING ALL AREAS joints, adapters. Local produc' 24 HOUR CARE 7468 Red Wdlow .............. 392 5376 3112 Fulton Av ...... , ...... 9720549 ............ , .... :. : ..... 386 2175 acilities for factory type, per G:A.N CHRISTIAN ENVIROI'!MENT P~;to~-gr~a~'g:n~':~ Rd Brent's Farrier Seryice ......... , .. 991 0756 coupling assemblies. 1 Blk fast Of Bradshaw 0 . Th S 1290 A d BI 9250750 CastroValley ............... 4155388044 Chernich Dale A D STRIBllTO .847 Folsom BI ........•.... 363 9468 s:~;~me~;r;,a~eekeePin9r~~pp";;es'" SILVAS VILLAGE SADDLERY Normal & Co~rectlve-Certifi.d I RS RE-ED WEST CENTER FOR 2400 21st...................... 45 337 1D2ON' T LET AN AMATEUR PO Q R 4 T 2 E 0 R P V er I s L h L in E g H A O v R O S r E a S ng H e O va E le I N .. G . 9 & 8 8 0529 A T ss .c o h ci a D t > ! v d 8 P 2 r 3 o 0 c e A ss lp C in o . n A tr v o l . s . , CHILDREN INC Honeycomb Materials~. WORK ON YOUR GOOD TRAINING SCHOOL INC California Equipm.nt Psychiatric Treatment For ' 11120 Bradley Rnch Rd 2345 Evergreen Av WS. ,_ C~i~r;~,Ai;n~,;c~ S~~r~~~ ~~~J;~enter SADDLES OR BRIDLES ElkGrove .................. 6894460 HO 0 .. ......... 481 8010 Dr RnchoC .. 63562&2 ENGLISH & WESTERN TACK OrCall ......................... 6B9 4900 PARKER SE & H SE R 7 o 0 m 8 e 5 's E R l o d o e m r C & re e B k o a R r d d . ............ 383 B064 Horse· Breeders' WESTERN & ENGLISH APPAREL R W e e " l , c s h o n D a D y u e a n F e a R rr i . e 0 r 9 3 S 0 e r 2 v d ic e R . L . . , . . . . . . . . 7 9 2 9 2 1 5 4 2 0 2 0 2 3 FITTINGS- DJSTRJ BUTO.~S ROYAL GARDEN SENIOR CARE (Across From Town & Country Village) HOME BARRISTER FARMS 2628 Marconi Av ........... :489 5747 Horseshoers BA Y PNEUMA TIC INC .gu b2 A.nd Over-Men & Women _ Barrister Dr MeadowVista ~ ..• 8780901 440 Convention W'I Ambulato'Y & Non-Ambulatory Box W Ranch .. .. f---------------, Equipment & Supplies RedwoodCit'l ............. ~ 5915 L.mon Hill Av ......... 383 6100 7908 Elmont Av Elvta .......... 991 4647 AllABOUT--- WESTERN FLUID LINE PROD SACRAMENTO GUEST HOME Cameo Farms Arabians INC 4015 Sea Dart BI WS. 2 M 4 e d H i o ca u l r C T a ra re n - s I p n o t r e t r a c t o io m n S Fu y rn s is t h e ed m . C & hr 8 i 4 st 2 i a S n h a a w Sa ~ d n d le L b i r n e c d o s ln .......... 645 873.3 ARABIANS Bob's Horseshoelng .........•••... 380 2175 W 4 E 0 S 1 T 5 E R S N ea M po E r T t R 61 O WSac. ;: Sai 2 n 7 t 1 R 5 it G a C .. u . es . t . H . o . m .. e . 2 . ....... 4471502 C 4 od 7 y 8 0 C r G ee a k rd e A n r a H b w ia y n s . .............. 9254462 * Classes H 1 o 6 rs 1 e 2 sh o A e u - b B ur a n r n B I T h . e . ............... 925 6534 PARKER PARKRIMP FIELD I . 101 ArteSia Av Elvta ........... 9913355 D V R a A c G av O il N l . F . I . R .. E . . M .. O . R .. G . A .. N . S .. .. 7074471626 * Boarding H 4 o 2 rs 3 e 7 s h S o o ei u n th g S M u a p r p k l e i t e s C t ........... 9228688 SYSTEM- DJSTRI ", B .~ l · l ,' T 1 . O . R . S . .; HOW TO FIGURE 8100 Turner Dr Loomis ...•.. 791 4366 * Breeding Horticultural BAY PNEUMA TIC INC HOW MANY KILOMETRES G E 1 s K l 0 e 3 r A 2 A 7 R r a A K b B o ia s I n A t s R N d C G E a N lt T . E . R .. .... 209 745 3300 * * A S p a p le r s a / i l s e a a l s s e s . Consultants 4 R 4 ed 0 w C o o o n d v C e i n ty ti o . n . . ~ W .. ' ' I ; . ; . ...... .:1 YOU ARE TRA VEUNG: H 5 om 01 e O W f in C t h e a rh m a p v i e o n n s A S v i n . c . e . 1 . 9 . 7 . 1 . . 925 451B * Investments PARKER QUICK COUPLINGS t 20 mph = 32 km/h Hidden Villa Morgans ............. 484 6191 Hoover Horticultural Services DISTRJ BllTORS Hunter Stallion Station ... using champion POBox 13962 ................ .' .. 372 8119 BAY PNEUMATIC INC 25 mph = 40 km/h 10163 Badg.r Creek Ln Wilton .. 6876870 -4"0 convention Wy J Bar C Appaloosas bloodlines. Visitors, RedwoodCity .............. : 30 mph = 48 km/h LA 86 C 3 E 6 Y C 'S a lv A n R e A Rd B I . A .. N . . C .. E . N . T .. E . R .. ... 682 7310 inquiries welcome. T Fo o u o r t h S : teps to Save a Knocked Out : (Contin~d Next Pag 35 mph = 56 km/h 5374 Tassajara Rd 1. Rinse tOOth in cool water. 00 not 40 mph = 64 km/h M P a le re a s s ' a N nt e o s n t .... . . ..•.... 415 829 0443 Janine Esler· scrub tooth. Diol 0 w~ong nurn 12514 Plum Ln Wilton .......... 6B7 6331 All About Arabians, 2. If possibl •. replace tooth in socket Ask the party who on, 45 mph = 72 km/h O 9 li 7 v 8 e 5 G r D o i v ll e a r F d a r R m d Wilton ......... 6877773 Galt, CA 95632 3. I a f n t d h i h s o c ld a n i n t o in t b p e la c d e o . n e. put the , the city you reached. '~. "5 5 5 0 ' m m p p h h = = " 8 S 0 8 k k m m / / h h '7" Pr 1 is q c q iJ 5 Ia E B d e l R l ~ F u a r R m d ElkGrove .... :.6B5 4212 (?mn 74.!'i-::\::\nn .... : .... 4. S w to e e o e t t h a c l u o d n t e h d n , e t i r o s r t t h d i e m r o t m p o n e it g d u i i n a e t . a e o l g r y l a . w s r s a o p f i t m i i n lk a . O~rof b o e r c h ri a g r h g t e o d w fo c r y t ~ he -79- EXHIBIT I PROPOSED STATUTORY LANGUAGE TO DEFINE. UNIFORM CORE OF KNOWLEDGE The uniform core of knowledge 20 clock hour training requirement for administ:::at:ors shall focus on the following areas: 1. LAWS. REGULATIONS. POLICIES AND PROCEDURAL STANDARDS THAT IMPAC':' T..J-:;' OPERATIONS OF RESIDENTIAL CARE FACILITIES FOR Tr~ ELDERLY (RCFE). Such information shall include but not be limited to: a. RCFE laws. regulations, policy and procedures b. Local ordinances c. Fire Marshall standards d. Role and Authority of Long Term Care Ombudsman Program e. Social Security Administration's standards that i:npact SS:/SSP recipients f. Guardian/Conse~latorship 2. BUSINESS OPERATION a. Developing and operating a facility budget b. Review and approve contracts for se~lices and personnel c. Keeping appropriate business and financial records d. Payroll information e. Professional Development 3. MANAGEMENT/SUPERVISION OF STAFF Such information shall include but not be limited to: a. Hiring/firing of staff b. Staff training and development c. Scheduling of employees to ensure sufficient coverage d. Addressing staff complaints e. Responding to staff suggested changes for i:nproved facility operation £. Labor laws -80- Provosed Statutory Language Unifo~ Core of Knowledge -i'age 2 4. PSYCHOSOCIAL NEEDS OF ELDERLY RESIDENTS Such information shall include but not be limited to: a. Protective supervision of residents with dementia b. Utilization of community resources c. Activities to maximize resident independence d. Maximiz in g resident's communication with family. fr:"ends and significant others. e. Recreational activities f. Resident's need for community involvement g. Advocacy for the elderly popUlation h. Resident's Personal Rights (87144) 5. PHYSICAL NEEDS FOR ELDERLY RESIDENTS Such information shall include but not be limited to: a. Recognition of health-related needs of the elderly in RFE's b. Nutrition c. Personal care services d. Promoting exercise and physical therapy programs e. Transportation (arranging and providing) f. Maintaining records of resident's monies and personal property g. Specialized equipment h. Assessment/reassessment of the elderly persons i. Medication (use and abuse) 6. COMMUNITY SERVICES Such information shall include but not be limited to: a. Adult Day Health Care b. Home Health Agency c. Linkages Program d. Transportation e. Adult Protective Services f. Foster Grandparent Program g. Adult Educational Program h. Multipurpose Senior Services Program (MSSP) ~. Senior Centers j. AAA's -81- EXHIBIT J SOURCES CONSULTED Alter, Catherine Foster. "The Changing Structure of Elderly Service Delivery Systems," !~! __ ~!E~~!~!~~!~!. February 1988. American Association of Retired Persons. "A Profile of Older Americans," Program Resources Department, Washington D.C., 1984. Beyer, Jane et al. A Model Act Regulating Board and Care Homes: Q~!~!!!~!~_i£!_~!~!~~~--A--Report--prepared--Ior--the--U~-S~ Deparment of Health and Human Services by the American Bar Association's Commission of Legal Problems of the Elderly and Commission on the Mentally Disabled, 1983. Brody, Barbara and Harold Simon. "The Aging of California," ~~!~!~_~!~!!_~!~£~!. May 1987. CARCH (California Association of Residential Care Homes). "329 Community Care Licenses Revoked in 1987." ~~~~!!--!!~~~, Sacramento. July. 1988. CARCH (California Association of Residential Care Homes). "State Continues Stepped-Up Activity in Community Care," CARCR News, Sacramento, August, 1988. California Assembly Committee on Aging and Long Term Care. __ __ __ __ __ !~!!!!~ !!~~~!~~ !E~~~~E!~! ~~ ~~~~ !~E~_~~E!_!~~~E~~~~· Sacramento, January 23-24. 1986. ! California Assembly Office of Research. California 2000: A Sacramento, June 1986~--------------- ~!£E!!_!~_!!~~~!!!£~' California Association of Health Facilities. "Elder Abuse and __ Dependent Adult Abuse Reporting," ~~!!K_~~~~ !~E~_~~~!_!!!~~' December 18, 1987. California Department of Aging. ."Report to the Legislature on Long Term Care." Sacramento, December 1985. "Report to the Legislature on Home and Community- -----based Long Term Care," Sacramento, 1986. Long Term Care Ombudsman Program Crisisline Report. -----Sacramento~-A~g~st-T987~----------------------------------- _ _ _____ ~~~~_!~~~_~~!!_Q~~~~~~~~_~!£~!~~_~~~~~!_~!E£!!_l~~~= - - -87. Sacramento. January 1988. -82- California Department of Finance. California Statistical Abstract 1987. Sacramento, 1987. California Department of Social Services. ~~~~E! __ !~ __ !~~ __ ~~~!~!~!~E~_~~ ~~£!~~~~!~!!~~_~i_~_~~~~!_~i_~~!~_~Y~i~~_!~E Residential Care Facilities for the Elderly. Pursuant to SB I8S-(Chapter-II27:-198S):-Sacramento:-December 1986. "Evaluation of the Adult Protective Services and Elder/Dependent Adult Emergency Shelter Pilot Projects" (DRAFT). Sacramento: Department of Social Services. (Undated). California Health and Welfare Agency. A Study of California's Publicly Funded Long-Term Care Programs~--Sacramento:---­ California-Health-and-Welfare-Agency:-I988. California Health and Welfare Agency, Department of Social Services. "Dependent Adult and Elder Abuse." Sacramento, 1985. California Office of the Legislative Analyst. "California's Long Term Care System," !~2=~~_~~~~~!":'_~~E~E.~£'!!~~~ __ ~~~_!~~~~~' Sacramento, 1987. . "The Impact of Demographic Changes on California," -----and-TIState Programs for Older Californians," !~~~=~~_~~~~~!..:. ~~E~E~~!!~~~_~~~_~~~~~~' Sacramento, 1988. Sacramento, California Senate Subcommittee on Aging. ~!!!!~ __ ~~~~~E Commission Report on Community Care Facilties-- I~£!I~~!I~~~=I~~=!E~=~!~~~!i~--San-Jose~-October-I984~------ Fact Sheet, SB 438 (Mello), Chapter 1166 (1987), -----September 29, 1987. California Senate Subcommittee on Aging and Senate Office of Research. ~~~~~E~~!~E~~!E._~~_!~~_~!~~E!I":' __ ~~£'~~~~~~~!!~~~ for Its Interface with Programs and Services for Older Californians~---by---Marquart--Policy--Analysis--Associates~ Sacramento:- Senate Subcommittee on Aging and Senate Office of Research, September 1988. Capitol Associates Project Staff. -83- __ __ ~~~!~~!_!£_~~~E~~~£!~_~~~~!l ~~~_~~~~~~~~~~!!~~~ !~_!~~E~~~_!~~ ~~E~i~~_~l~!~~. Sacramento, November 1985. Center for the Study of Social Policy, The. .f£'~E.!~E..!.~~_E.!!.~_!:£.~~ __ __ ___ !E_ __ ___ __ !~E~ .f~E~ .f£E!!E~~~~ lE~£~~ ~~E.E.1~~~E! ~!!~!~~l· Washington, D.C., March 1988. Commission on California State Government Organization and Economy (Little Hoover Commission). .f£.~~~~.!.E.I_~~~.!.de~!.!.~! .f~E~ __. !.E __ .f~1!!£E~!~~ __. f£~~~~!!Z __~ ~E~ __~ ~ __~ _~£'E~_!~E~_~~!~ Service. Sacramento, December 1983. Cheren, Connie (Chief of Bureau of Long Te rm Car e , S tat e f 0 Illinois, Department of Public Aid). "A 'Carrot' Approach to Better Nursing Care," Memo, 1987. Collins, Glenn. "Benefits: New Era Dawns," Sacramento Bee. July 24, 1988. Consortium for ~E lder Abuse Prevention. "Helping Clients Help Themselves: Working through Resistance," E:.!~~E. __ ~~~~~ Awareness. San Francisco Institute on Aging, Mount Zion Hospital-and Medical Center, December 1987. County Welfare Directors Association. Protecting the Silent Population: Remedying Elder and Dep;nd;nt--Ad~lt--Abus~~ Sacra;ento~-March-T988~------------------------------------ Henderson, Carter. "Old Glory: America Comes of Age," The Futurist. March/April 1988. Joint Economic Committee Congress of the U. S. The Impact of Demographic Changes on Social Programs. WashIngton~-D~C~: U~-S~-Government-Printing-Office~-T982~ Kapiloff, Paul. "Financial Security: Long Term Health Care Insurance," Long Term Health Care Education. Published quarterly by--Long--T;rm--H;alth--Car~--Education, Inc. El Cerrito, California, No.2, 1987. Leon, Joel and Dawn Braisted. "Single-point Entry: An Organizational Form in the Delivery of Services to the Aged," !1!~_.:!£~EE~1_£! __ ~E.E..!!~~_~~!!~~!£E~! __ ~E.!~~E.~~. Volume 21, No.4, 1985. Magnus, Margaret. "Elder Care: Corporate Awareness, But Little -84- McCarthy, Lieutenant Governor Leo. "Adult Day Health Care and Community-based Long Term Care Systems: Can We Get There from Here?," Summary of Report presented to the California Senior Legislature, Sacramento, October 6, 1986. McLeod, Ramon. "The Elderly Who Live Alone are One Step from Disaster," San Francisco Chronicle. June 28, 1988. McMahon, Linda S., Director, California Department of Social Services. Letter to Little Hoover Commission, July 25, 1988. Melemed, Brina B. Community-based Long Term Care: Descriptive Summaries of Statewide--Programs~n-f1Iinois-and-Colorado~ Deceiber-I984:--------------------------------------------- Perry, Donald M., Vice President of Operations, Health Care Group, Letter to Deanna Marquart, San Diego, July 25, 1988. Rich, Bennett M. and Martha Baum. !~~_~K!~~~_~_Q~!~~_!~ Public ~~!!~~. University of Pittsburgh Press: Pittsburgh, 1984. Thompson and Associates. ~~E£~~~~ __ ~~~ __! ~~~!!~~~ __~ !_~~~~~ni!Z Care: An Orchestra without a Conductor. Phase I Report, Senate-Conc~rrent-ResoI~tion--No:--22:--Sacramento, November 1980 .. University of California SystemWide Headquarters, Office of the Vice President, Health Affairs. !~~ ___ ~~!~~E~!!Z __ ~ California Academic Geriatric Resource· Program Progress ~~£~£!~=I~~!=I~~I:--Berkeley:-T987:------------------------- U. S. Department of Commerce. Statistical Abstract of the United States. Washington, D.c.,-T987~---------------------------- U. S. Department of Health and Human Services, National Institute £~_~~!~~ __ ~~~E~~~~E~~!~=~~~~~E~£~~~_~~~~~.---NIH-Publication No. 84-2492, Washington, D.C., June 1984.