Licensure Terms

Residential Care Facilities for the Elderly

General Approach

The Department of Social Services, Community Care Licensing Division, licenses residential care facilities (RCFs) for the elderly. There is no separate category of licensure for adult foster care. Between 2012 and 2015, the California legislature enacted several laws that will affect the operation of these facilities. Although the new laws supersede existing regulations, the state has not yet amended existing regulations or issued new regulations to reflect the statutory changes.

This profile includes summaries of selected regulatory and statutory provisions for RCFs for the elderly. The complete regulations are online at the links provided at the end.

Definitions

Residential care facility for the elderly means a housing arrangement chosen voluntarily by the resident, or the resident’s responsible person, where 75 percent of the residents are 60 years of age or older, and where varying levels of care and supervision are provided, as agreed to at the time of admission, or as determined necessary at subsequent assessments. Residents under age 60 must have needs compatible with the needs of other residents.

The licensing agency determines the maximum number of residents that a facility may admit based on the licensee’s skills, whether any of the licensee’s family members reside on-site, building features, and staff availability.

Facilities may admit residents who are diagnosed by a physician as having dementia if specified requirements are met, including an annual medical assessment, adequate supervision, enhanced physical plant safety requirements, and an appropriate activity program.

Resident Agreements

Admission agreements must be signed by the resident and his/her responsible party, if any, within 7 days of admission. Agreements must include information about basic and optional services; service rates, payment provisions, and refund policies; facility policies; and eviction and discharge criteria.

Disclosure Provisions

Prior to admission, the prospective resident and his/her responsible person, if any, must be interviewed by the licensee or the employee responsible for facility admissions, and sufficient information about the facility and its services must be provided to enable all persons involved in the placement to make an informed decision regarding admission.

Facilities that market themselves as special care facilities must describe the following in their plan of operation: program philosophy; pre-admission and ongoing assessment process; admission information (areas where special care is provided, services available, and procedures to review the plan of operation); activity programs; staff qualifications and staff training; building design features; resident change in condition policies; and procedures to review the program’s effectiveness.

Admission and Retention Policy

Facilities may not admit or retain anyone who requires any of the following services: (1) access to 24-hour skilled nursing or intermediate care; (2) care for Stage III and IV dermal ulcers; (3) care for gastrostomies, nasogastric tubes, or tracheostomies; and (4) treatment for staph or other serious infections. Individuals with the following conditions may also not be admitted or retained: (1) a need for assistance to perform all activities of daily living (ADLs); (2) a communicable disease; (3) unable to get out of bed; (4) mental disorders that result in ongoing behaviors that would upset other residents; and (5) dementia, unless certain requirements for specialized care are met.

Residents with specified health conditions that require incidental medical services may be admitted and retained if either the resident provides self-care or a licensed professional provides care. These services include, for example: (1) administration of oxygen; (2) catheter care; (3) colostomy/ileostomy care; (4) diabetes; (5) enemas, suppositories, and/or fecal impaction removal; (6) care for bowel and/or bladder incontinence; (7) injections; and (8) treatment of Stage I and II dermal ulcers.

Residents who will be bedridden for more than 14 days may be retained if the facility notifies the Department of Social Services that the condition is temporary and the building meets specified fire safety standards.

Facilities may admit or retain individuals: (1) who are capable of administering their own medications; (2) who receive medical care and treatment outside the facility or from a visiting nurse; (3) who because of forgetfulness or physical limitations need only be reminded or assisted to take medication usually prescribed for self-administration; (4) with cognitive impairment; and (5) with mild dementia or a mild temporary emotional disturbance resulting from personal loss or a change in living arrangement.

Services

Facilities provide two types of services in addition to room and board: (1) basic services, which include personal assistance and care; observation and supervision; planned activities; and arrangements for obtaining incidental medical and dental care; and (2) care and supervision, including assistance with dressing, grooming, bathing, and other personal hygiene; assistance with self-administered medications; and monitoring food intake or special diets.

Service Planning 

A pre-admission appraisal of all applicants is required prior to move-in to evaluate functional capacity (measured by the ability to perform ADLs), mental condition, and social factors, in order to determine their suitability for admission. A physician- conducted medical evaluation is also required before admission and must include: diagnoses; current status; medications and treatments; and prescribed diets. The medical evaluation and resident appraisal must be updated when a significant change occurs in a resident’s condition and as needed to maintain an accurate record of the resident’s needs.

Third-Party Providers 

Residents may contract with home health or hospice agencies to provide treatment of conditions allowed in a licensed RCF for the elderly.

Residents may hire private paid personal assistants or caregivers only to provide services other than those the licensee is required to provide. Examples of private pay services include: companionship and additional baths beyond what the licensee is required to provide.

Medication Provisions

Only appropriately skilled medical professionals acting within their scope of practice, including employees and/or licensed home health agency personnel, may administer medications to residents.

Unlicensed staff may assist residents with the self-administration of medications, described as: (1) medications usually prescribed for self-administration that have been authorized by the resident’s physician; (2) medications during an illness determined by a physician to be temporary and minor; and (3) assistance required because of tremor, failing eyesight, and similar conditions. Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident’s knowledge and consent, or otherwise infringing upon a resident’s right to refuse a medication.

Staff who assist with self-administration must complete coursework and pass an examination. Sixteen hours of training is required for staff who work in facilities licensed for 16 or more residents, with 8 hours of hands-on shadowing and 8 hours of other training or instruction. Staff in facilities licensed for 15 or fewer residents must complete 6 hours of training, with 2 hours of hands-on shadowing and 4 hours of instruction. The training material and exam must be developed by, or in consultation with, a licensed nurse, pharmacist, or physician. Staff who assist with self-administration of medications must complete 4 hours of annual in-service training on medication-related issues.

Food Service and Dietary Provisions

Facilities that have responsibility for all food arrangements must provide at least three meals per day and snacks. If the meal service within a facility is elective, the facility must ensure the availability of an adequate daily food intake for all residents who purchase the meal service. Meals must include an appropriate variety of foods, planned in consideration of cultural and religious backgrounds and residents’ dietary preferences. Modified diets prescribed by physicians must be provided. The total daily diet must meet the recommended dietary allowances of the National Academy of Science’s Food and Nutrition Board.

Staffing Requirements

Type of Staff. All facilities must have a certified administrator, who may be the licensee, to manage the facility according to the rules. A designee must be assigned when the administrator is not available. Direct care staff provide personal care services and supervision. Appropriately skilled professionals (e.g., a licensed nurse) may be hired to provide medication administration and/or incidental medical services.

Staff Ratios. Sufficient staff must be employed to deliver services required by residents. Requirements for awake staff vary by facility size: for 16 or fewer residents, staff must be available in the facility; 16-100 residents, at least one awake staff; 101- 200 residents, one on call and one awake, with an additional awake staff for each additional 100 residents.

Training Requirements

Administrators must complete 40 hours of continuing education units every 2 years, which must include 8 hours training on Alzheimer’s disease and dementia. With prior approval, 20 of the 40 hours may be completed through online training. Licensed nursing home administrators are required to complete only 20 hours of continuing education.

All personnel must be given on-the-job training or have experience in: (1) housekeeping and sanitation procedures; (2) the skills and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents; (3) knowledge required to safely assist with prescribed medications; (4) how to recognize early signs of illness and the need for professional help;and (5) knowledge of community services and resources.

All staff who assist residents with ADLs must receive at least 10 hours of initial training within the first 4 weeks of employment and at least 4 additional hours annually. Training topics include: first-aid; the aging process; the importance and techniques of personal care services and universal precautions (at least 3 of the 10 hours); residents’ rights; medication policies and procedures (at least 2 of the 10 hours); psychosocial aspects of aging; and recognizing signs and symptoms of dementia.

Before admitting a resident with a restricted health condition, the licensee must ensure that relevant direct care staff complete training provided by a licensed professional to meet the resident’s needs. Training includes hands-on instruction in both general procedures and resident-specific procedures; recognizing and responding to health problems; and knowing when to contact a physician or appropriately skilled professional.

Provisions for Apartments and Private Units

Private apartments are not required. Residents’ rooms may be single-occupancy or double-occupancy. There must be at least one toilet and a sink for each six residents and one bathtub/shower for each ten persons, including residents, family, and facility- dwelling staff (if any).

Requirements for residents served through the Medicaid Assisted Living Waiver program include private occupancy, with shared occupancy only by residents’ choice, and units must have a kitchen area equipped with a refrigerator and a cooking appliance.

Provisions for Serving Persons with Dementia

Dementia Care Staff.  Facilities must have an adequate number of direct care staff to support each resident’s physical, social, emotional, safety, and health care needs as identified in his/her current assessment. In facilities with fewer than 16 residents, at least one night staff person must be awake and on-duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation to require awake night supervision. Facilities with 16-100 residents must have at least one employee on-duty and awake, and another employee on call and capable of responding within 10 minutes. 

Dementia Staff Training. All staff who care for residents with dementia must receive training in dementia care, including 6 hours of orientation and 8 hours of annual in-service training on the following topics: common problems (wandering, aggression, and inappropriate sexual behavior); positive therapeutic interventions; communication skills; promoting resident dignity, independence, privacy, and choices; and end of life care.

Dementia Facility Requirements. Delayed-egress and locked doors/perimeters require special fire clearances, and are only allowed with prior Department approval.

The resident and/or his or her responsible person must consent to the use of delayed- egress devices or locked facility doors.

Background Checks

The licensing agency conducts a criminal background check of the organization’s officers, administrative staff, direct care staff, and employees having frequent contact with residents. A fingerprint clearance must be received by the licensing agency on all persons subject to criminal record review prior to issuing a license. All facility staff must be fingerprint cleared prior to their physical presence in the facility. Private paid personal assistants hired by residents must also have a criminal background clearance.

Inspection and Monitoring

Before a facility is licensed, the Department conducts an on-site survey of the proposed premises and a review of applicant qualifications. At least 20 percent of all facilities are inspected annually, and each facility must be inspected at least once every 5 years.

Public Financing

The state’s Medicaid 1915(c) Assisted Living Waiver program pays for services in RCFs for the elderly in several counties.

Room and Board Policy

The state provides an optional state supplement (OSS) to Supplemental Security Income (SSI) recipients who reside in a RCF for the elderly and limits room and board charges for Medicaid-eligible residents to the combined federal SSI and OSS payments minus a personal needs allowance (PNA) retained by the resident. In 2014, the average OSS payment was $361 and the PNA was $131.

An extra charge to the resident may be allowed for a private room if a double room is made available but the resident prefers a private room, provided the arrangement is documented in the admissions agreement and the charge is limited to 10 percent of the room and board portion of the SSI/OSS payment.

Family supplementation is not permitted.

Location of Licensing, Certification, or Other Requirements

California Code of Regulations, Title 22, Division 6, Chapter 8: Manual of Policies and Procedures, Community Care Licensing Division, Residential Care Facilities for the Elderly. http://www.dss.cahwnet.gov/ord/entres/getinfo/pdf/rcfeman1.pdf

California Code of Regulations, Title 22, Division 6, Chapter 4: Manual of Policies and Procedures, Community Care Licensing Division, Small Family Homes. http://www.dss.cahwnet.gov/ord/entres/getinfo/pdf/sfhman.PDF

Information Sources

Heather Harrison
Senior Vice President
Public Policy and Public Affairs
California Assisted Living Association