Assisted Living Staffing Requirements in California

No. California Advocates for Nursing Home Reform puts it plainly: there is no specific staff-to-resident ratio for assisted living communities and board and care homes, licensed in California as residential care facilities for the elderly (RCFEs).

What the law sets is a standard. Title 22, section 87411, says facility personnel must at all times be sufficient in numbers, and competent, to provide the services residents need. It lets the licensing agency require a home to add staff when the needs of its residents, the services it offers or the layout of the building call for it. Health and Safety Code section 1569.618 adds that the home must employ, and the administrator must schedule, enough staff to provide the care written in each resident's record of care.

A few other rules shape who counts. Anyone who cares for residents or supervises staff must be at least 18. Volunteers may help but may not be counted in the staffing plan, and residents may not be used in place of required staff. Because RCFEs are non-medical, the same fact sheet notes there is no requirement to have registered nurses, licensed vocational nurses or certified nursing assistants.

So two homes of the same size can staff very differently and both be within the rules. That is why the questions at the end of this page matter.

Night is where the regulations get specific. Title 22, section 87415, covers supervision from 10 p.m. to 6 a.m. and ties it to the number of residents. Night staff must know the home's emergency procedures and be trained in first aid.

One more rule applies to small homes that care for people living with dementia. In a home with fewer than 16 residents, section 87705 requires at least one night staff person awake and on duty if any resident with dementia is found, through an appraisal or observation, to need awake night supervision. If your mother wakes and walks at night, ask a six-bed home directly whether its night caregiver is awake.

Separately, state law requires at least one staff member with CPR and first aid training to be on duty and on the premises at all times.

Every RCFE must have a certified administrator. The owner and the administrator can be the same person, which is common in small board and care homes.

Under Health and Safety Code section 1569.618, the administrator is to be present during normal working hours, and a facility manager is responsible when the administrator is temporarily away. At least one administrator, facility manager or designated substitute, who is at least 21, must be on the premises 24 hours a day. The substitute may be a direct care staff member, and must know the residents' care needs and the home's emergency procedures.

The qualifications, from Title 22 and the Health and Safety Code, are:

• All administrators: at least 21, with a high school diploma or equivalent.
• Certification: an approved training program of at least 80 hours, then a state exam of at least 100 questions.
• Renewal: 40 hours of continuing education every two years, according to California Advocates for Nursing Home Reform.
• Homes licensed for 16 to 49 residents: 15 college or continuing education units and at least one year of experience providing residential care, or an equivalent approved by the department.
• Homes licensed for 50 or more: the regulation lists two years of college, at least three years of experience providing residential care, or equivalent education and experience approved by the licensing agency.

Health and Safety Code section 1569.625 sets the hours for staff who help residents with personal activities of daily living, such as bathing and dressing.

Staff who help with medications need separate training on top of this, covered in our guide to medication management. Certified nursing assistants and licensed nurses are treated differently: they receive eight hours of training on the residents and the home's procedures before giving direct care.

Employees must also have a criminal record clearance or exemption before they start, and a physician's health screening, including a chest x-ray or skin test, around the time they are hired.

1. 1

   Before working alone with residents: 20 hours

   This includes six hours of dementia care and four hours on postural supports, restricted health conditions and hospice care.

2. 2

   In the first four weeks: 20 more hours

   This brings the initial training to 40 hours and includes another six hours of dementia care.

3. 3

   Every year after: 20 hours

   Eight of those hours are dementia care, and four cover postural supports, restricted health conditions and hospice care.

Because the rule is sufficiency and not a number, the home's own answers tell you the most. Bring these on a tour, along with our assisted living tour checklist.

Then compare the answers with the public record. Staffing and night supervision problems show up as citations, and how to check an RCFE license shows where to read them. For the agency behind those reports, see who regulates assisted living.

• How many caregivers are on each shift, on weekdays and on weekends, for how many residents?
• Is the night caregiver awake, and who is the backup on call?
• Who is in charge when the administrator is not here?
• Is there a nurse on staff, and during which hours?
• How long have the administrator and the main caregivers worked here?
• Homes licensed for 16 or more must keep a dated weekly staff schedule on display for employees. May I see this week's?

Hamssa Benrekia is a senior living placement specialist in Torrance who holds an RCFE Administrator Certificate, so she knows these rules from the operator's side. She helps families in the South Bay and Harbor area compare licensed homes, including small homes and memory care, and goes on tours with them, where staffing questions get asked in person. To talk about assisted living placement, contact Hamssa. The California Assisted Living Placement Guide covers the rest of the decision.