What Assisted Living Provides in California, and What It Cannot Do

In California, assisted living communities and board and care homes are licensed as residential care facilities for the elderly (RCFEs). State law defines what they offer as care and supervision: ongoing assistance with activities of daily living without which a resident's physical health, mental health, safety or welfare would be endangered. The law says that assistance includes help with taking medications, money management and personal care.

The state's regulations then list basic services, which they define as the services a home is required to provide in order to obtain and keep a license. The Department of Social Services repeats the list in its consumer guide. At a minimum, basic services include:

• Safe and healthful living accommodations.
• Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity.
• Personal assistance and care as needed, with activities of daily living such as dressing, eating and bathing, and assistance with taking prescribed medications.
• Regular observation of the resident's physical and mental condition.
• Arrangements to meet health needs, including arranging transportation.
• A planned activities program with social and recreational activities suited to the resident's interests and capabilities.

The rule applies to a six-bed house and to a large community alike. The regulations also say a home need not accept any particular person. If it does accept someone, it is responsible for meeting the needs identified in that person's pre-admission appraisal, either directly or through outside resources. Our guide to the care assessment before admission explains that appraisal.

State law names the personal activities of daily living: dressing, feeding, toileting, bathing, grooming and mobility. It names a second group as well, the instrumental activities: housework, meals, laundry, taking medication, money management, transportation, correspondence and telephoning. How much help your mother or father gets with each one should follow the appraisal, not a standard package.

Medication is the area families ask about most. The regulations say the home shall assist residents with self-administered medications as needed. They also say facility staff, except those authorized by law, shall not administer injections, though designated staff may assist a person with self-administration.

The same regulation draws a firm line around consent. Assistance does not include forcing a resident to take medication, or hiding medication in food or drink without the resident's knowledge and consent. A resident keeps the right to refuse a medication. For storage, records and who may do what, see how medications are handled in an RCFE.

An RCFE is not a medical facility, but it is not allowed to ignore health either. Each home must have a plan for incidental medical and dental care. Under that plan the home arranges, or assists in arranging, medical and dental care suited to each resident's conditions and needs.

The home must also help with getting to appointments. The regulations say this includes transportation, which may be limited to the nearest available medical or dental facility that will meet the resident's need, and that the home either provides the ride or makes arrangements for it. Ask whether rides are included in the rate or billed separately.

Staff must be familiar with hearing aids, glasses and prosthetic devices and help residents use them. The home must keep a first aid kit on hand unless it has a medical unit on the grounds.

Outside professionals can come in. The regulations allow a home to accept people who receive needed medical care from a visiting nurse or outside the facility, and the state's consumer guide says a licensee may permit incidental medical services through a licensed home health agency when specified conditions are met. California Advocates for Nursing Home Reform (CANHR) adds that RCFEs are not required to have nurses, certified nursing assistants or doctors on staff.

The limits matter as much as the services, because they decide whether a home can admit your relative and whether it can keep them later.

Between routine care and those limits is a list of restricted health conditions that a home may care for only when it follows the rule written for each one. The list includes oxygen, catheter care, colostomy or ileostomy care, contractures, diabetes, incontinence, injections and healing wounds. A home may also ask the state for an exception in an individual case. The details are in health conditions an RCFE may accept.

Two more points. State law defines health-related services as services that must be provided directly by an appropriate skilled professional, such as a registered nurse, licensed vocational nurse, physical therapist or occupational therapist. And a resident whose main need for care results from dementia may be accepted only when the home meets the state's separate dementia care requirements, which is what a memory care home is set up to do.

Many homes do more than the minimum, and this is where they differ most. The California Department of Aging notes that RCFEs usually provide housekeeping and laundry, and that additional monthly fees may be charged for more extensive care based on the resident's assessed needs.

Some homes hold a hospice waiver from the Department of Social Services, which lets a resident who becomes terminally ill stay and receive hospice care there. CANHR says a home must tell residents in writing, at or before admission, about any limits on who it can keep.

The regulations require the admission agreement to specify which basic services each resident wants or needs and will receive. Before signing, ask the home to show you, line by line:

Hamssa Benrekia is a senior living placement specialist in Torrance who holds an RCFE Administrator Certificate. She helps families in the South Bay and Harbor area of Los Angeles County match a parent's care needs with licensed assisted living communities and board and care homes, and she goes on tours with them. She does not decide what a home may accept: the home, the doctor and the state's rules do. To talk through your situation, contact Hamssa. The full series is in the California Assisted Living Placement Guide.