Article 7. Levels Of Care of California Health And Safety Code >> Division 2. >> Chapter 3.2. >> Article 7.
It is the intent of the Legislature to develop and
implement a plan to establish three levels of care under the
residential care facility for the elderly license, subject to future
Budget Act appropriations and statutory authorization to implement
levels of care.
(a) The guidelines for the development of these levels of care
(1) Level I--Base care and supervision. Residents at this level
are able to maintain a higher degree of independence and need only
minimum care and supervision, as defined, and minimal personal care
(2) Level II--Nonmedical personal care. Residents at this level
have functional limitations and psychosocial needs requiring not only
care and supervision but frequent assistance with personal
activities of daily living and active intervention to help them
maintain their potential for independent living.
(3) Level III--Health related assistance. Residents at this level
require the services of lower levels and rely on the facility for
extensive assistance with personal activities of daily living. This
level may include residents who also require the occasional services
of an appropriate skilled professional due to chronic health problems
and returning residents recovering from illness, injury, or
treatment that required placement in facilities providing higher
levels of care.
These levels are to be based on the services required by residents
at each level due to their functional limitations.
(b) The levels of care plan shall include:
(1) Guidelines for meeting requirements at each level of care by
utilizing appropriate community and professional services. Options
shall be provided to allow facilities to meet resident needs by
accessing community services or hiring appropriate staff.
(2) Assessment procedures for facility evaluation of residents'
level of care needs.
(3) Process for ensuring the individual facility's ability to
serve clients at each level of care they intend to provide.
(4) Recommendations for a supplemental rate structure based on the
services required at Levels II and III to be provided for residents
who need those levels of care and are recipients of SSI/SSP. These
rates shall be in addition to the basic SSI/SSP rate for providing
care supervision and shall reflect actual costs of operation for
residential care facilities for the elderly.
(5) Procedures for assessment and certification of SSI/SSP
recipients, by county social services departments to allow for
administration of the supplemental rate structure.
(6) Procedures for evaluating and monitoring the appropriateness
of the levels of care determined for SSI/SSP recipients.
(c) Implementation of the levels of care system shall consider the
applicability of the 1985 level of care report developed by the
California Health and Human Services Agency, so as to ensure
continuity in the residential care facility for the elderly program
as outlined under this chapter.
In consultation with the State Fire Marshal the department
shall develop and expedite implementation of regulations related to
nonambulatory persons that ensure resident safety but also provide
flexibility to allow residents to remain in the least restrictive
Following the implementation of levels of care, regulations
related to nonambulatory persons shall also provide the flexibility
necessary for those levels in residential care facilities for the
(a) Except as otherwise provided in subdivision (d), no
resident shall be admitted or retained in a residential care facility
for the elderly if any of the following apply:
(1) The resident requires 24-hour, skilled nursing or intermediate
(2) The resident is bedridden, other than for a temporary illness
or for recovery from surgery.
(b) (1) For the purposes of this section, "bedridden" means
requiring assistance in turning and repositioning in bed or being
unable to independently transfer to and from bed, except in a
facility with appropriate and sufficient care staff, mechanical
devices, if necessary, and safety precautions, as determined by the
director in regulations.
(2) The determination of the bedridden status of persons with
developmental disabilities shall be made by the Director of Social
Services or his or her designated representative, in consultation
with the Director of Developmental Services or his or her designated
representative, after consulting the resident's individual safety
plan. The determination of the bedridden status of all other persons
with disabilities who are not developmentally disabled shall be made
by the Director of Social Services, or his or her designated
(c) Notwithstanding paragraph (2) of subdivision (a), bedridden
persons may be admitted to, and remain in, residential care
facilities for the elderly that secure and maintain an appropriate
fire clearance. A fire clearance shall be issued to a facility in
which one or more bedridden persons reside if either of the following
conditions are met:
(1) The fire safety requirements are met. Residents who are unable
to independently transfer to and from bed, but who do not need
assistance to turn or reposition in bed, shall be considered
nonambulatory for purposes of this paragraph.
(2) Alternative methods of protection are approved.
(d) (1) For purposes of this section, "temporary illness" means
any illness which persists for 14 days or less.
(e) A bedridden resident may be retained in a residential care
facility for the elderly in excess of 14 days if all of the following
requirements are satisfied:
(1) The facility notifies the department in writing regarding the
temporary illness or recovery from surgery.
(2) The facility submits to the department, with the notification,
a physician and surgeon's written statement to the effect that the
resident's illness or recovery is of a temporary nature. The
statement shall contain an estimated date upon which the illness or
recovery will end or upon which the resident will no longer be
confined to a bed.
(3) The department determines that the health and safety of the
resident is adequately protected in that facility and that transfer
to a higher level of care is not necessary.
(4) This section does not expand the scope of care and supervision
of a residential care facility for the elderly.
(f) Notwithstanding the length of stay of a bedridden resident,
every facility admitting or retaining a bedridden resident, as
defined in this section, shall, within 48 hours of the resident's
admission or retention in the facility, notify the local fire
authority with jurisdiction in the bedridden resident's location of
the estimated length of time the resident will retain his or her
bedridden status in the facility.
(g) Nothing in this section shall be used for purposes of Section
1569.70 to determine the appropriateness of residents being admitted
or retained in a residential care facility for the elderly on the
basis of health-related conditions and the need for these services
until the three levels of care set forth in Section 1569.70 are fully
implemented. This section shall not prohibit the Community Care
Licensing Division of the State Department of Social Services from
continuing to implement the regulations of Article 8 (commencing with
Section 87700) of Chapter 8 of Division 6 of Title 22 of the
California Code of Regulations, as promulgated and approved on
February 13, 1990.
(h) (1) The department and the Office of the State Fire Marshal,
in consultation with the State Department of Developmental Services,
shall each promulgate regulations that meet all of the following
(A) Are consistent with subdivisions (a) to (f), inclusive.
(B) Are applicable to facilities regulated under this chapter,
consistent with the regulatory requirements of the California
Building Standards Code for fire and life safety for the respective
occupancy classifications into which the State Department of Social
Services' community care licensing classifications fall.
(C) Permit residents to remain in home-like settings.
(2) At a minimum, these regulations shall do both of the following
with regard to a residential care facility that provides care for
six or fewer residents, at least one of whom is bedridden:
(A) Clarify the fire and life safety requirements for a fire
clearance for the facility.
(B) (i) Identify procedures for requesting the approval of
alternative means of providing equivalent levels of fire and life
(ii) Either the facility, the resident or resident's
representative, or local fire official may request from the Office of
the State Fire Marshal a written opinion concerning the
interpretation of the regulations promulgated by the State Fire
Marshal pursuant to this section for a particular factual dispute.
The State Fire Marshal shall issue the written opinion within 45 days
following the request.
(i) For facilities that care for six or fewer clients, a local
fire official may not impose fire safety requirements stricter than
the fire safety regulations promulgated for the particular type of
facility by the Office of the State Fire Marshal or the local fire
safety requirements imposed on any other single family dwelling,
whichever is more strict.
(j) This section and any regulations promulgated thereunder shall
be interpreted in a manner that provides flexibility to allow
bedridden persons to avoid institutionalization and be admitted to,
and safely remain in, community-based residential care facilities.
(a) A residential care facility for the elderly may
permit incidental medical services to be provided through a home
health agency, licensed pursuant to Chapter 8 (commencing with
Section 1725), when all of the following conditions are met:
(1) The facility, in the judgment of the department, has the
ability to provide the supporting care and supervision appropriate to
meet the needs of the resident receiving care from a home health
(2) The home health agency has been advised of the regulations
pertaining to residential care facilities for the elderly and the
requirements related to incidental medical services being provided in
(3) There is evidence of an agreed-upon protocol between the home
health agency and the residential care facility for the elderly. The
protocol shall address areas of responsibility of the home health
agency and the facility and the need for communication and the
sharing of resident information related to the home health care plan.
Resident information may be shared between the home health agency
and the residential care facility for the elderly relative to the
resident's medical condition and the care and treatment provided to
the resident by the home health agency including, but not limited to,
medical information, as defined by the Confidentiality of Medical
Information Act, Part 2.6 (commencing with Section 56) of Division 1
of the Civil Code.
(4) There is ongoing communication between the home health agency
and the residential care facility for the elderly about the services
provided to the resident by the home health agency and the frequency
and duration of care to be provided.
(b) Nothing in this section is intended to expand the scope of
care and supervision for a residential care facility for the elderly,
as prescribed by this chapter.
(c) Nothing in this section shall require any care or supervision
to be provided by the residential care facility for the elderly
beyond that which is permitted in this chapter.
(d) The department shall not be responsible for the evaluation of
medical services provided to the resident of the residential care
facility for the elderly by the home health agency.
(e) Any regulations, policies, or procedures related to sharing
resident information and development of protocols, established by the
department pursuant to this section, shall be developed in
consultation with the State Department of Health Services and persons
representing home health agencies and residential care facilities
for the elderly.
(a) Notwithstanding Section 1569.72 or any other provision
of law, a residential care facility for the elderly may obtain a
waiver from the department for the purpose of allowing a resident who
has been diagnosed as terminally ill by his or her physician and
surgeon to remain in the facility, or allowing a person who has been
diagnosed as terminally ill by his or her physician and surgeon to
become a resident of the facility if that person is already receiving
hospice services and would continue to receive hospice services
without disruption if he or she became a resident, when all the
following conditions are met:
(1) The facility agrees to retain the terminally ill resident, or
accept as a resident the terminally ill person, and to seek a waiver
on behalf of the individual, provided the individual has requested
the waiver and is capable of deciding to obtain hospice services.
(2) The terminally ill resident, or the terminally ill person to
be accepted as a resident, has obtained the services of a hospice
certified in accordance with federal medicare conditions of
participation and licensed pursuant to Chapter 8 (commencing with
Section 1725) or Chapter 8.5 (commencing with Section 1745).
(3) The facility, in the judgment of the department, has the
ability to provide care and supervision appropriate to meet the needs
of the terminally ill resident or the terminally ill person to be
accepted as a resident, and is in substantial compliance with
regulations governing the operation of residential care facilities
for the elderly.
(4) The hospice has agreed to design and provide for care,
services, and necessary medical intervention related to the terminal
illness as necessary to supplement the care and supervision provided
by the facility.
(5) An agreement has been executed between the facility and the
hospice regarding the care plan for the terminally ill resident or
terminally ill person to be accepted as a resident. The care plan
shall designate the primary caregiver, identify other caregivers, and
outline the tasks the facility is responsible for performing and the
approximate frequency with which they shall be performed. The care
plan shall specifically limit the facility's role for care and
supervision to those tasks allowed under this chapter.
(6) The facility has obtained the agreement of those residents who
share the same room with the terminally ill resident, or any
resident who will share a room with the terminally ill person to be
accepted as a resident, to allow the hospice caregivers into their
(b) At any time that the licensed hospice, the facility, or the
terminally ill resident determines that the resident's condition has
changed so that continued residence in the facility will pose a
threat to the health and safety to the terminally ill resident or any
other resident, the facility may initiate procedures for a transfer.
(c) A facility that has obtained a hospice waiver from the
department pursuant to this section need not call emergency response
services at the time of a life-threatening emergency if the hospice
agency is notified instead and all of the following conditions are
(1) The resident is receiving hospice services from a licensed
(2) The resident has completed an advance directive, as defined in
Section 4605 of the Probate Code, requesting to forego resuscitative
(3) The facility has documented that facility staff have received
training from the hospice agency on the expected course of the
resident's illness and the symptoms of impending death.
(d) Nothing in this section is intended to expand the scope of
care and supervision for a residential care facility for the elderly
as defined in this act, nor shall a facility be required to alter or
extend its license in order to retain a terminally ill resident or
allow a terminally ill person to become a resident of the facility as
authorized by this section.
(e) Nothing in this section shall require any care or supervision
to be provided by the residential care facility for the elderly
beyond that which is permitted in this chapter.
(f) Nothing in this section is intended to expand the scope of
life care contracts or the contractual obligation of continuing care
retirement communities as defined in Section 1771.
(g) The department shall not be responsible for the evaluation of
medical services provided to the resident by the hospice and shall
have no liability for the independent acts of the hospice.
(h) Nothing in this section shall be construed to relieve a
licensed residential care facility for the elderly of its
responsibility to notify the appropriate fire authority of the
presence of a bedridden resident in the facility as required under
subdivision (f) of Section 1569.72, and to obtain and maintain a fire
clearance as required under Section 1569.149.
(a) Licensed residential care facilities for the elderly
that employ health care providers may establish policies to honor a
request to forego resuscitative measures as defined in Section 4780
of the Probate Code.
(b) Any policy established pursuant to subdivision (a) shall meet
all of the following conditions:
(1) The policy shall be in writing and specify procedures to be
followed in implementing the policy.
(2) The policy and procedures shall, at all times, be available in
the facility for review by the department.
(3) The licensee shall ensure that all staff are aware of the
policy as well as the procedures to be followed in implementing the
(4) A copy of the policy shall be given to each resident who makes
a request to forego resuscitative measures and to the resident's
(5) A copy of the resident's request to forego resuscitative
measures shall be maintained in the facility and shall be immediately
available for review by facility staff, the licensed health care
provider, and the department.
(6) Facility staff are prohibited, on behalf of any resident, from
signing any directive document as a witness or from being the
legally recognized surrogate decisionmaker.
(7) The facility shall provide the resident's physician with a
copy of the resident's request to forego resuscitative measures form.
(c) Any action by a facility that has established policies
pursuant to subdivision (a), to honor a resident's request to forego
resuscitative measures as provided for in subdivision (a) may only be
taken in either of the following ways:
(1) By a licensed health care provider who is employed by the
facility and on the premises at the time of the life threatening
(2) By notifying, under those conditions specified in subdivision
(c) of Section 1569.73, the hospice agency that is caring for a
resident receiving hospice services.
(d) Licensed residential care facilities for the elderly that have
not established policies pursuant to subdivision (a), may keep an
executed request to forego resuscitative measures form in the
resident's file and present it to an emergency medical technician or
paramedic when authorized to do so in writing by the resident or his
or her legally recognized surrogate decisionmaker. The request may be
honored by an emergency medical technician or by any health care
provider as defined in Section 4621 of the Probate Code, who, in the
course of professional or volunteer duties, responds to emergencies.