Overview of Assisted Living/Residential Care Facilities for the Elderly (RCFEs)

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What is a Residential Care Facility for the Elderly?

Residential Care Facilities for the Elderly (RCFEs) — sometimes called “Assisted Living” (e.g., 16+ beds) or “Board and Care” (e.g., 4 to 6 beds) — are non–medical facilities that provide room, meals, housekeeping, supervision, storage and distribution of medication, and personal care assistance with basic activities like hygiene, dressing, eating, bathing and transferring.  RCFEs serve persons 60 years of age and older. 

This level of care and supervision is for people who are unable to live by themselves but who do not need 24 hour nursing care. RCFEs are considered non-medical facilities and are not required to have nurses, certified nursing assistants or doctors on staff.

How Does a Residential Care Facility for the Elderly Differ from an Assisted Living Facility?

From a licensing standpoint, there is no difference. In California, facilities describing themselves as assisted living and offering personal care and supervision are licensed as RCFEs.

RCFEs are dominated by smaller (i.e., 6 to 15 beds), locally owned facilities with shared rooms. Larger facilities usually offer private apartments and tend to be corporately owned. Many larger facilities have different fee options depending on the type of care needed.

Are Residential Care Facilities for the Elderly Regulated?

Yes. RCFEs must meet care and safety standards set by the State and are licensed and inspected by the Department of Social Services, Community Care Licensing (CCL).

Senior housing complexes, retirement villages or retirement hotels that provide only housing, housekeeping and meals are not required to be licensed as RCFEs.

Are Residential Care Facilities for the Elderly Required to Have Liability Insurance?

All RCFEs are required to maintain liability insurance in the amount of at least $1,000,000 per occurrence and $3,000,000 annually to cover injuries to residents or guests caused by the negligence of the facility owner or employees.  (HSC 1569.605)

Can A Residential Care Facility for the Elderly Care for Persons with Dementia?

Maybe. Some facilities offer special services to persons with dementia if they meet certain licensing requirements. (CCR 87705-87707)  Make sure that the facility has experience in providing dementia care and meets all of the state licensing standards to provide dementia care.

You may also come across RCFEs that label themselves as “memory care” facilities, but it is important to note that the term is not a legal term.  It is a marketing term to attract potential residents who may need additional assistance.  If you are looking into a facility that uses this term to describe their services, make sure to find out the additional services they provide, and make sure that the facility meets the state licensing standards to provide dementia care.

Will a Residential Care Facility for the Elderly Accept or Retain Someone Who Needs Medical Care?

Maybe.  It will depend on the type and severity of the medical condition(s) and whether the facility meets the state licensing standards for “restricted” health conditions. Some medical conditions are not allowed in a RCFE (e.g., tube feeding, or treatment of open bedsores). (CCR 87615)  The facility must inform residents in writing at or before the time of admission of any resident retention limitations set by the state or facility such as whether the facility can serve persons who need help in leaving the building in case of emergency (i.e., non-ambulatory) or with certain medical conditions (e.g., hospice waiver).  (HSC 1569.269(a)(15); CCR 87468.2(a)(13))

What if My Medical Needs Increase, Can I Stay?

Maybe. Since a RCFE is not licensed as a “medical” facility, persons requiring tube feeding, treatment of open bedsores or 24-hour nursing care are not permitted to reside in RCFEs. (CCR 87615.)  However, some RCFEs have permission to care for persons on hospice. (HSC 1569.73; CCR 87632, 87633) 

What Are the Qualifications for Staff?

Minimal Training: Administrators must take a 80–hour certification program, pass a simple state exam, and obtain 40 hours of continuing education every two years. Staff must receive at least 40 hours of training at the facility within the first year of employment (20 hours before working independently with residents, and 20 hours within the first four weeks of employment), and at least 20 hours annually thereafter. Dementia care training is required for all RCFE Staff (and not just for those RCFEs that advertise dementia care).  Additional training is required for Staff who assist residents with the self-administration of medication.  (HSC 1569.23, 1569.616, 1569.62, 1569.625, 1569.626, 1569.69; CCR 87405-87407, 87411)

Minimal Qualifications: Administrators must be 21 years of age and possess a high school diploma or equivalent for facilities of 15 beds or less — these comprise over 80% of all RCFEs. For facilities of 16 to 49 beds, the administrator needs 15 college credits; and for facilities of 50+ beds, 2 years of college or 3 years experience, or equivalent education and experience. (HSC 1569.613; CCR 87405)  Staff must only be 18 years of age and pass the criminal background check. (CCR 87411)  Note: Because RCFEs are non–medical facilities, there is no requirement for RNs, LVNs or CNAs or any medically–trained personnel. Check on the qualifications of the administrator and key staff.

Are There Staff Ratios?

There is not any specific staff to resident ratio for assisted living/residential care facilities. California law requires that facility personnel shall at all times be sufficient in numbers, qualifications, and competency to provide the services necessary to meet resident needs, and to ensure their health, safety, comfort, and supervision.   (HSC 1569.269(a)(6), 1569.618(c); CCR 87411, 87468.2(a)(4))   

There must be at least one administrator or designated substitute with qualifications adequate to be responsible for the management and administration of the facility be on premises 24 hours per day. (HSC 1569.618(b))  The facility must also have at least one staff member trained in CPR and first aid on duty and on the premises at all times. (HSC 1569.618(c))   

In regards to night supervision, for facilities with 15 or fewer residents, there must be one “qualified” person on call and on the premises; in facilities with 16–100 residents, there must be one person awake and on the premises, and another on call and capable of responding within 10 minutes. (CCR 87415)

What Does Residential Care for the Elderly or Assisted Living Cost?

The cost depends on a variety of factors such as the type of accommodations (e.g., apartment, private room, shared room), the range of services needed, and the geographic area. The median monthly cost in California is $5,000, with costs ranging from a low of around $1,079 a month for a resident on Supplemental Security Income (SSI) to over $10,000 a month. Specialized services like dementia or hospice care are more costly.

Is There a Limit on How Much Facilities Can Raise Private Pay Rates?

No. Since residential care is a private business, providers will charge what the market will bear. However, facilities must issue 60–day notices to increase rates, but can raise charges for level of care changes immediately and provide notice within 2 working days. (HSC 1569.655, 1569.657; see also CANHR’s factsheet on Admission Agreements)

Can Facilities Charge a Pre–Admission Fee?

Yes. Some providers charge nothing or a minimum amount to cover costs of conducting an assessment, obtaining medical records and setting up files. Others charge fees of thousands of dollars. Demand a written description of what the fees cover. Negotiate the amount if too high, or look for another facility. Facilities are prohibited from charging security deposits. (HSC 1569.651; see also CANHR’s factsheet on Admission Agreements)

Who Pays the Bill for Residential Care for the Elderly or Assisted Living?

Most people must pay privately for care. Long-term care insurance only covers a very small percentage of people. There is very limited public funding through Supplemental Security Income (SSI) for RCFE residents who qualify for this program (see CANHR’s fact sheet on SSI in a RCFE). Unfortunately, the SSI rate is so low that fewer and fewer facilities will accept persons on SSI.

Will Medicare or Medi–Cal Pay?

No. Because these are not medical facilities, neither Medicare nor Medi–Cal pays directly for residential care/assisted living. There is a special program in 15 counties (Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma) — the Assisted Living Waiver Program— in which Medi–Cal pays for eligible residents assessed to need nursing home level care to live in an RCFE or public housing.  (For more information, see CANHR’s fact sheet on the Assisted Living Waiver)

How Do I Find Out About the Track Record of a Facility?

Upon request, a facility must show you the most recent copy of its annual inspection report and a copy of any substantiated complaints within the past year. (HSC 1569.38.) Inspection reports and complaints for the most recent 60 months also are available online at the website of the state regulatory agency, the Department of Social Services, Community Care Licensing Division (CCL). The only way to view the complete facility record is to go to one of the district offices of CCL and request to see the public record of the facility.

How Do I Find Out More About Residential Care for the Elderly?

You can contact the local District Office of Community Care Licensing to receive a listing of facilities. Additional information and resources are posted online at the CCL website.  Some Ombudsman Programs also have listings, offer pre-placement services, and provide access to licensing reports. For additional information, see CANHR’s RCFE factsheets.

HSC refers to California Health and Safety Code; and CCR refers to the California Code of Regulations, Title 22, Division 6, Chapter 8: Residential Care Facilities for the Elderly.