2010 California Code
Health and Safety Code
Chapter 2.4. Quality Of Long-term Health Facilities

1417.  This chapter shall be known and may be cited as the Long-Term
Care, Health, Safety, and Security Act of 1973.



1417.1.  It is the intent of the Legislature in enacting this
chapter to establish (1) a citation system for the imposition of
prompt and effective civil sanctions against long-term health care
facilities in violation of the laws and regulations of this state,
and the federal laws and regulations as applicable to nursing
facilities as defined in subdivision (k) of Section 1250, relating to
patient care; (2) an inspection and reporting system to ensure that
long-term health care facilities are in compliance with state
statutes and regulations pertaining to patient care; and (3) a
provisional licensing mechanism to ensure that full-term licenses are
issued only to those long-term health care facilities that meet
state standards relating to patient care.



1417.15.  (a) (1) If one or more of the following remedies is
actually imposed for violation of state or federal requirements, the
long-term health care facility shall post a notice of the imposed
remedy or remedies, in the form specified in subdivision (c), on all
doors providing ingress to or egress from the facility, except as
specified in paragraph (2):
   (A) License suspension.
   (B) Termination of certification for Medicare or Medi-Cal.
   (C) Denial of payment by Medicare or Medi-Cal for all otherwise
eligible residents.
   (D) Denial of payment by Medicare or Medi-Cal for otherwise
eligible incoming residents.
   (E) Ban on admission of any type.
   (2) For purposes of this subdivision, a distinct part nursing
facility shall only be required to post the notice on all main doors
providing ingress to or egress from the distinct part, and not on all
of the doors providing ingress to or egress from the facility. An
intermediate care facility/developmentally disabled habilitative and
an intermediate care facility/developmentally disabled-nursing shall
post this notice on the inside of all doors providing ingress to or
egress from the facility.
   (b) A violation of the requirement of subdivision (a) shall be
issued and enforced in the manner of a class "B" violation.
   (c) The form of the notice established pursuant to subdivision (a)
shall be entitled "Notice of Violation Remedies." Each notice shall
list the remedy or remedies imposed, as set forth in subdivision (a),
and shall include the date the remedy was imposed. The notice shall
be typeset on white bond paper, 8 1/2 x 11 inches in size, in
boldface black type in a 16-point sans serif type font. A facility
may remove the notice on or after the date on which the sanction is
lifted.



1417.2.  (a) Notwithstanding Section 1428, moneys collected as a
result of state and federal civil penalties imposed under this
chapter or federal law shall be deposited into accounts that are
hereby established in the Special Deposit Fund created pursuant to
Section 16370 of the Government Code. These accounts are titled the
State Health Facilities Citation Penalties Account, into which moneys
derived from civil penalties for violations of state law shall be
deposited, and the Federal Health Facilities Citation Penalties
Account, into which moneys derived from civil penalties for
violations of federal law shall be deposited. Moneys from these
accounts shall be used, notwithstanding Section 16370 of the
Government Code, upon appropriation by the Legislature, in accordance
with state and federal law for the protection of health or property
of residents of long-term health care facilities, including, but not
limited to, the following:
   (1) Relocation expenses incurred by the department, in the event
of a facility closure.
   (2) Maintenance of facility operation pending correction of
deficiencies or closure, such as temporary management or
receivership, in the event that the revenues of the facility are
insufficient.
   (3) Reimbursing residents for personal funds lost. In the event
that the loss is a result of the actions of a long-term health care
facility or its employees, the revenues of the facility shall first
be used.
   (4) The costs associated with informational meetings required
under Section 1327.2.
   (b) Notwithstanding subdivision (a), the balance in the State
Health Facilities Citation Penalties Account shall not, at any time,
exceed ten million dollars ($10,000,000).
   (c) Moneys from the Federal Health Facilities Citation Penalties
Account, in the amount not to exceed one hundred thirty thousand
dollars ($130,000), may also be used, notwithstanding Section 16370
of the Government Code, upon appropriation by the Legislature, in
accordance with state and federal law for the improvement of quality
of care and quality of life for long-term health care facilities
residents pursuant to Section 1417.3.
   (d) The department shall post on its Internet Web site, and shall
update on a quarterly basis, all of the following regarding the funds
in the State Health Facilities Citation Penalties Account and the
Federal Health Facilities Citation Penalties Account:
   (1) The specific sources of funds deposited into the account.
   (2) The amount of funds in the account that have not been
allocated.
   (3) A detailed description of how funds in the account have been
allocated and expended, including, but not limited to, the names of
persons or entities that received the funds, the amount of salaries
paid to temporary managers, and a description of equipment purchased
with the funds. However, the description shall not include the names
of residents.



1417.3.  The department shall promote quality of care and quality of
life for residents, clients, and patients in long-term health care
facility services through specific activities that include, but are
not limited to, all of the following:
   (a) Research and evaluation of innovative facility resident care
models.
   (b) (1) Provision of statewide training on effective facility
practices.
   (2) Training also shall include topics related to the provision of
quality of care and quality of life for facility residents. The
topics for training shall be identified by the department through a
periodic survey. The curriculum for the training provided under this
paragraph shall be developed in consultation with representatives
from provider associations, consumer associations, and others, as
deemed appropriate by the state department.
   (c) The establishment of separate units to respond to facility
requests for technical assistance regarding licensing and
certification requirements, compliance with federal and state
standards, and related operational issues.
   (d) State employees providing technical assistance to facilities
pursuant to this section are only required to report violations they
discover during the provision of the assistance to the appropriate
district office if the violations constitute an immediate and serious
threat to the health and welfare of, or have resulted in actual harm
to, patients, residents, or clients of the facility.
   (e) The state department shall measure facility satisfaction and
the effectiveness of the technical assistance provided pursuant to
subdivision (c).
   (f) No person employed in the technical assistance or training
units under subdivisions (b) and (c) shall also participate in the
licensing, surveying, or direct regulation of facilities.
   (g) This section shall not diminish the department's ongoing
survey and enforcement process.


1417.4.  (a) There is hereby established in the state department the
Quality Awards Program for nursing homes.
   (b) The department shall establish criteria under the program,
after consultation with stakeholder groups, for recognizing all
skilled nursing facilities that provide exemplary care to residents.
   (c) (1) Monetary awards shall be made to Quality Awards Program
recipients that serve high proportions of Medi-Cal residents to the
extent funds are appropriated each year in the annual Budget Act.
   (2) Monetary awards presented under this section and paid for by
funds appropriated from the General Fund shall be used for staff
bonuses and distributed in accordance with criteria established by
the department.
   (3) Monetary awards presented under this section and paid for from
funds from the Federal Citation Penalty Account shall be used to
fund innovative facility grants to improve the quality of care and
quality of life for residents in skilled nursing facilities, or to
fund innovative efforts to increase employee recruitment, or
retention, or both, subject to federal approval.
   (d) The department shall establish criteria for selecting
facilities to receive the quality awards, in consultation with senior
advocacy organizations, employee labor organizations representing
facility employees, nursing home industry representatives, and other
interested parties as deemed appropriate by the department. The
criteria established pursuant to this subdivision shall not be
considered regulations within the meaning of Section 11342 of the
Government Code, and shall not be subject to adoption as regulations
pursuant to Chapter 3.5 (commencing with Section 11340) of Part 1 of
Division 3 of Title 2 of the Government Code.
   (e) The department shall publish an annual listing of the Quality
Awards Program recipients with the dollar amount awarded, if
applicable. The department shall also publish an annual listing of
the Quality Awards Program recipients that receive innovative
facility grants with the purpose of the grant and the grant amount.
   (f) All of the funds available for the programs described in this
section shall be disbursed to qualified facilities by January 1,
2002, and January 1 of each year thereafter.



1417.5.  (a) The department, in consultation with stakeholders,
shall develop recommendations to address the findings published in
the June 2010 report entitled, "Department of Public Health: It
Reported Inaccurate Financial Information and Can Likely Increase
Revenues for the State and Federal Health Facilities Citation
Penalties Accounts" (Report 2010-108). The recommendations shall
address, but not be limited to, all of the following:
   (1) Streamlining the citation appeal process, including the
citation review conference process.
   (2) Increasing citation penalty amounts, including late penalty
fees, and annually adjusting penalty amounts to reflect an inflation
indicator, such as the California Consumer Price Index.
   (3) Revising state law to enable the department to recommend that
the federal Centers for Medicare and Medicaid Services impose a
federal civil money penalty when the department's Licensing and
Certification Division determines that a facility is out of
compliance with both state and federal requirements.
   (4) Authorizing the department to collect citation penalty amounts
upon appeal of the citation and allowing the department to place
those funds into a special interest bearing account.
   (b) The department shall provide the recommendations to the fiscal
and policy committees of the Legislature no later than March 1,
2011.



1418.  As used in this chapter:
   (a) "Long-term health care facility" means any facility licensed
pursuant to Chapter 2 (commencing with Section 1250) that is any of
the following:
   (1) Skilled nursing facility.
   (2) Intermediate care facility.
   (3) Intermediate care facility/developmentally disabled.
   (4) Intermediate care facility/developmentally disabled
habilitative.
   (5) Intermediate care facility/developmentally disabled-nursing.
   (6) Congregate living health facility.
   (7) Nursing facility.
   (8) Intermediate care facility/developmentally disabled-continuous
nursing.
   (b) "Long-term health care facility" also includes a pediatric day
health and respite care facility licensed pursuant to Chapter 8.6
(commencing with Section 1760).
   (c) "Long-term health care facility" does not include a general
acute care hospital or an acute psychiatric hospital, except for that
distinct part of the hospital that provides skilled nursing
facility, intermediate care facility, or pediatric day health and
respite care facility services.
   (d) "Licensee" means the holder of a license issued under Chapter
2 (commencing with Section 1250) or Chapter 8.6 (commencing with
Section 1760) for a long-term health care facility.



1418.1.  (a) Any person receiving respite care services shall be
permitted to bring medications to the skilled nursing facility or
intermediate care facility if the contents have been examined and
positively identified upon the patient's admission to the facility by
the patient's personal physician and surgeon or a pharmacist
retained by the facility.
   (b) A skilled nursing facility or intermediate care facility
providing respite care services shall not be required to afford a
person receiving respite care services a bedhold when the person is
transferred to a general acute care hospital, as defined in Section
1250.
   (c) A skilled nursing facility or intermediate care facility
providing respite care services shall permit the personal physician
and surgeon of a person receiving respite care services to issue
advance orders for care and treatment for a period not to exceed 90
days from the date of admission of the person, based on the person's
medical history, diagnosis, and physical assessment conducted upon
admission. The skilled nursing facility or intermediate care facility
may readmit the person for respite care services on the basis of the
advance orders for care and treatment, unless the personal physician
and surgeon of the person indicates that there has been a
significant change in the person's medical condition. These advance
orders shall only be used by the skilled nursing or intermediate care
facility during periods in which the person is receiving respite
care services.
   (d) A skilled nursing facility or intermediate care facility
providing respite care services may implement an abbreviated resident
assessment and care planning procedure for persons admitted for
respite care services consistent with the facility's obligation to
protect the health and safety of residents and the general public.
The abbreviated resident assessment and care planning procedure shall
address the necessary care services required by the person admitted
for respite care during the length of the respite care stay. The
abbreviated resident assessment and care planning procedure documents
do not have to be updated with every readmission of the same person
to the facility for respite care services, unless the personal
physician and surgeon of the person indicates that there has been a
significant change in the person's medical condition.
   (e) As used in this section, "respite care services" means service
provided to frail elderly or functionally impaired persons in a
licensed skilled nursing facility or intermediate care facility, as
defined in Section 1250, on a temporary or periodic basis to relieve
persons who are providing their care at home.
   (f) As used in this section, "temporary or periodic" means a
period of time not to exceed 15 consecutive days or a total of 45
days in any one year.
   (g) No more than 10 percent of a skilled nursing or intermediate
care facility's total licensed bed capacity may be used during any
one calendar year for the provision of respite care services as
defined in this section. A facility may exceed this limit with the
prior written approval of the State Department of Health Services.



1418.2.  (a) Every facility licensed pursuant to subdivisions (c),
(d), (e), and (g) of Section 1250 and every skilled nursing facility
licensed separately under subdivision (a) of Section 1250 shall
establish and maintain a resident council. Each council shall include
the residents of the health facility, and may include family members
of residents, advocates, or ombudsman groups interested in residents
of health facilities, and personnel of the health facility. Family
members of residents shall be invited to meetings of resident
councils.
   The council shall meet at regularly scheduled intervals, maintain
written minutes, including names of council members present, and have
minutes available for review by the state department upon its
request. Facility policies on resident councils shall in no way limit
the right of residents to meet independently with outside persons or
facility personnel as determined solely by the residents of the
facility.
   Written minutes of regularly scheduled council meetings may
include recommendations from the council to the licensee of the
health facility which shall be provided to the licensee. The licensee
shall provide evidence of review and action on these recommendations
to the state department upon its request.
   (b) Any health facility which fails to establish a resident
council as prescribed in subdivision (a) shall be subject to the
provisions of Section 1280.
   (c) The state department shall, by regulation, specify those
circumstances under which a health facility may be exempted from the
provisions of subdivisions (a) and (b), including, but not limited
to, the following:
   (1) A resident population consisting of a majority of patients
with progressively disabling disorders defined in Section 1250.4.
   (2) Facilities with no more than six residents which provide
alternate means for residents to actively share in planning and
enhancing of life in the facility.
   (3) Other circumstances as determined by the state department.




1418.21.  (a) A skilled nursing facility that has been certified for
purposes of Medicare or Medicaid shall post the overall facility
rating information determined by the federal Centers for Medicare and
Medicaid Services (CMS) in accordance with the following
requirements:
   (1) The information shall be posted in at least the following
locations in the facility:
   (A) An area accessible and visible to members of the public.
   (B) An area used for employee breaks.
   (C) An area used by residents for communal functions, such as
dining, resident council meetings, or activities.
   (2) The information shall be posted on white or light-colored
paper that includes all of the following, in the following order:
   (A) The full name of the facility, in a clear and easily readable
font of at least 28 point.
   (B) The full address of the facility in a clear and easily
readable font of at least 20 point.
   (C) The most recent overall star rating given by CMS to that
facility, except that a facility shall have seven business days from
the date when it receives a different rating from CMS to include the
updated rating in the posting. The star rating shall be aligned in
the center of the page. The star rating shall be expressed as the
number that reflects the number of stars given to the facility by
CMS. The number shall be in a clear and easily readable font of at
least two inches print.
   (D) Directly below the star symbols shall be the following text in
a clear and easily readable font of at least 28 point:
   "The above number is out of 5 stars."
   (E) Directly below the text described in subparagraph (D) shall be
the following text in a clear and easily readable font of at least
14 point:
   "This facility is reviewed annually and has been licensed by the
State of California and certified by the federal Centers for Medicare
and Medicaid Services (CMS). CMS rates facilities that are certified
to accept Medicare or Medicaid. CMS gave the above rating to this
facility. A detailed explanation of this rating is maintained at this
facility and will be made available upon request. This information
can also be accessed online at the Nursing Home Compare Internet Web
site at https://www.medicare.gov/NHcompare. Like any information, the
Five-Star Quality Rating System has strengths and limits. The
criteria upon which the rating is determined may not represent all of
the aspects of care that may be important to you. You are encouraged
to discuss the rating with facility staff. The Five-Star Quality
Rating System was created to help consumers, their families, and
caregivers compare nursing homes more easily and help identify areas
about which you may want to ask questions. Nursing home ratings are
assigned based on ratings given to health inspections, staffing, and
quality measures. Some areas are assigned a greater weight than other
areas. These ratings are combined to calculate the overall rating
posted here."
   (F) Directly below the text described in subparagraph (E), the
following text shall appear in a clear and easily readable font of at
least 14 point:

   "State licensing information on skilled nursing facilities is
available on the State Department of Public Health's Internet Web
site at: www.cdph.ca.gov, under Programs, Licensing and
Certification, Health Facilities Consumer Information System."

   (3) For the purposes of this section, "a detailed explanation of
this rating" shall include, but shall not be limited to, a printout
of the information explaining the Five-Star Quality Rating System
that is available on the CMS Nursing Home Compare Internet Web site.
This information shall be maintained at the facility and shall be
made available upon request.
   (4) The requirements of this section shall be in addition to any
other posting or inspection report availability requirements.
   (b) Violation of this section shall constitute a class B
violation, as defined in subdivision (e) of Section 1424 and,
notwithstanding Section 1290, shall not constitute a crime. Fines
from a violation of this section shall be deposited into the State
Health Facilities Citation Penalties Account, created pursuant to
Section 1417.2.
   (c) This section shall be operative on January 1, 2011.




1418.3.  (a) Each licensed skilled nursing facility shall, when
requested by a member of a patient's family, allow the family to meet
privately with a family member who is a resident in the facility.
   (b) "Family member" for the purposes of this section means an
immediate family member or family member designated and documented on
the patient's record at the time of admission to the facility.



1418.4.  (a) No licensed skilled nursing facility or intermediate
care facility may prohibit the formation of a family council, and,
when requested by a member of the resident's family or the resident's
representative, the family council shall be allowed to meet in a
common meeting room of the facility at least once a month during
mutually agreed upon hours.
   (b) Facility policies on family councils shall in no way limit the
right of residents, family members, and family council members to
meet independently with outside persons, including members of
nonprofit or government organizations or with facility personnel
during nonworking hours.
   (c) "Family council" for the purpose of this section means a
meeting of family members, friends, or representatives of two or more
residents to confer in private without facility staff.
   (d) Family councils shall also be provided adequate space on a
prominent bulletin board or other posting area for the display of
meeting notices, minutes, newsletters, or other information
pertaining to the operation or interest of the family council.
   (e) Staff or visitors may attend family council meetings, at the
group's invitation.
   (f) The facility shall provide a designated staff person who shall
be responsible for providing assistance and responding to written
requests that result from family council meetings.
   (g) The facility shall consider the views and act upon the
grievances and recommendations of a family council concerning
proposed policy and operational decisions affecting resident care and
life in the facility.
   (h) The facility shall respond in writing to written requests or
concerns of the family council, within 10 working days.
   (i) When a family council exists, the facility shall include
notice of the family council meetings in at least a quarterly
mailing, and shall inform family members or representatives of new
residents who are identified on the admissions agreement, during the
admissions process, or in the resident's records, of the existence of
the family council. The notice shall include the time, place, and
date of meetings, and the person to contact regarding involvement in
the family council.
   (j) No facility shall willfully interfere with the formation,
maintenance, or promotion of a family council. For the purposes of
this subdivision, willful interference shall include, but not be
limited to, discrimination or retaliation in any way against an
individual as a result of his or her participation in a family
council, or the willful scheduling of facility events in conflict
with a previously scheduled family council meeting.
   (k) (1) Violation of the provisions of this section shall
constitute a violation of the residents' rights.
   (2) Violation of the provisions of this section shall constitute a
class "B" violation, as defined in Section 1424.



1418.5.  No regulation adopted with respect to skilled nursing
facilities or intermediate care facilities shall prohibit patients in
the facility from storing nonprescription or topical ophthalmic
medications at their bedside unless contraindicated by the patient's
attending physician or the facility.



1418.6.  No long-term health care facility shall accept or retain
any patient for whom it cannot provide adequate care.



1418.7.  (a) Long-term health care facilities, as defined in Section
1418, shall develop and implement policies and procedures designed
to reduce theft and loss.
   (b) The facility program shall include all of the following:
   (1) Establishment and posting of the facility's theft and loss
policies.
   (2) Orientation of employees to those policies.
   (3) Documentation of theft and loss of property with a value of
twenty-five dollars ($25) or more.
   (4) Inventory of patient's personal property upon admission.
   (5) Inventory of and surrender of patient's personal property upon
death or discharge.
   (6) Regular review of the effectiveness of the policies and
procedures.
   (7) Marking of patient's personal property, including dentures and
prosthetic and orthopedic devices.
   (8) Reports to local law enforcement of stolen property with a
value of one hundred dollars ($100) or more.
   (9) Methods for securing personal property.
   (10) Notification of residents and families of the facility's
policies.
   (c) The policies and procedures developed by the facilities
pursuant to this section shall be in accordance with Section 1289.4,
as added by Assembly Bill 2047 of the 1987-88 Regular Session of the
Legislature, if that bill is enacted and becomes effective.
   (d) If a facility has shown clear and convincing evidence of its
efforts to comply with the requirements of this section, no citation
shall be issued as a result of the occasional occurrence of theft and
loss in a facility.


1418.8.  (a) If the attending physician and surgeon of a resident in
a skilled nursing facility or intermediate care facility prescribes
or orders a medical intervention that requires that informed consent
be obtained prior to administration of the medical intervention, but
is unable to obtain informed consent because the physician and
surgeon determines that the resident lacks capacity to make decisions
concerning his or her health care and that there is no person with
legal authority to make those decisions on behalf of the resident,
the physician and surgeon shall inform the skilled nursing facility
or intermediate care facility.
   (b) For purposes of subdivision (a), a resident lacks capacity to
make a decision regarding his or her health care if the resident is
unable to understand the nature and consequences of the proposed
medical intervention, including its risks and benefits, or is unable
to express a preference regarding the intervention. To make the
determination regarding capacity, the physician shall interview the
patient, review the patient's medical records, and consult with
skilled nursing or intermediate care facility staff, as appropriate,
and family members and friends of the resident, if any have been
identified.
   (c) For purposes of subdivision (a), a person with legal authority
to make medical treatment decisions on behalf of a patient is a
person designated under a valid Durable Power of Attorney for Health
Care, a guardian, a conservator, or next of kin. To determine the
existence of a person with legal authority, the physician shall
interview the patient, review the medical records of the patient, and
consult with skilled nursing or intermediate care facility staff, as
appropriate, and with family members and friends of the resident, if
any have been identified.
   (d) The attending physician and the skilled nursing facility or
intermediate care facility may initiate a medical intervention that
requires informed consent pursuant to subdivision (e) in accordance
with acceptable standards of practice.
   (e) Where a resident of a skilled nursing facility or intermediate
care facility has been prescribed a medical intervention by a
physician and surgeon that requires informed consent and the
physician has determined that the resident lacks capacity to make
health care decisions and there is no person with legal authority to
make those decisions on behalf of the resident, the facility shall,
except as provided in subdivision (h), conduct an interdisciplinary
team review of the prescribed medical intervention prior to the
administration of the medical intervention. The interdisciplinary
team shall oversee the care of the resident utilizing a team approach
to assessment and care planning, and shall include the resident's
attending physician, a registered professional nurse with
responsibility for the resident, other appropriate staff in
disciplines as determined by the resident's needs, and, where
practicable, a patient representative, in accordance with applicable
federal and state requirements. The review shall include all of the
following:
   (1) A review of the physician's assessment of the resident's
condition.
   (2) The reason for the proposed use of the medical intervention.
   (3) A discussion of the desires of the patient, where known. To
determine the desires of the resident, the interdisciplinary team
shall interview the patient, review the patient's medical records,
and consult with family members or friends, if any have been
identified.
   (4) The type of medical intervention to be used in the resident's
care, including its probable frequency and duration.
   (5) The probable impact on the resident's condition, with and
without the use of the medical intervention.
   (6) Reasonable alternative medical interventions considered or
utilized and reasons for their discontinuance or inappropriateness.
   (f) A patient representative may include a family member or friend
of the resident who is unable to take full responsibility for the
health care decisions of the resident, but who has agreed to serve on
the interdisciplinary team, or other person authorized by state or
federal law.
   (g) The interdisciplinary team shall periodically evaluate the use
of the prescribed medical intervention at least quarterly or upon a
significant change in the resident's medical condition.
   (h) In case of an emergency, after obtaining a physician and
surgeon's order as necessary, a skilled nursing or intermediate care
facility may administer a medical intervention that requires informed
consent prior to the facility convening an interdisciplinary team
review. If the emergency results in the application of physical or
chemical restraints, the interdisciplinary team shall meet within one
week of the emergency for an evaluation of the medical intervention.
   (i) Physicians and surgeons and skilled nursing facilities and
intermediate care facilities shall not be required to obtain a court
order pursuant to Section 3201 of the Probate Code prior to
administering a medical intervention which requires informed consent
if the requirements of this section are met.
   (j) Nothing in this section shall in any way affect the right of a
resident of a skilled nursing facility or intermediate care facility
for whom medical intervention has been prescribed, ordered, or
administered pursuant to this section to seek appropriate judicial
relief to review the decision to provide the medical intervention.
   (k) No physician or other health care provider, whose action under
this section is in accordance with reasonable medical standards, is
subject to administrative sanction if the physician or health care
provider believes in good faith that the action is consistent with
this section and the desires of the resident, or if unknown, the best
interests of the resident.
   (l) The determinations required to be made pursuant to
subdivisions (a), (e), and (g), and the basis for those
determinations shall be documented in the patient's medical record
and shall be made available to the patient's representative for
review.


1418.81.  (a) In order to assure the provision of quality patient
care and as part of the planning for that quality patient care,
commencing at the time of admission, a skilled nursing facility, as
defined in subdivision (c) of Section 1250, shall include in a
resident's care assessment the resident's projected length of stay
and the resident's discharge potential. The assessment shall include
whether the resident has expressed or indicated a preference to
return to the community and whether the resident has social support,
such as family, that may help to facilitate and sustain return to the
community. The assessment shall be recorded with the relevant
portions of the minimum data set, as described in Section 14110.15 of
the Welfare and Institutions Code. The plan of care shall reflect,
if applicable, the care ordered by the attending physician needed to
assist the resident in achieving the resident's preference of return
to the community.
   (b) The skilled nursing facility shall evaluate the resident's
discharge potential at least quarterly or upon a significant change
in the resident's medical condition.
   (c) The interdisciplinary team shall oversee the care of the
resident utilizing a team approach to assessment and care planning
and shall include the resident's attending physician, a registered
professional nurse with responsibility for the resident, other
appropriate staff in disciplines as determined by the resident's
needs, and, where practicable, a resident's representative, in
accordance with applicable federal and state requirements.
   (d) If return to the community is part of the care plan, the
facility shall provide to the resident or responsible party and
document in the care plan the information concerning services and
resources in the community. That information may include information
concerning:
   (1) In-home supportive services provided by a public authority or
other legally recognized entity, if any.
   (2) Services provided by the Area Agency on Aging, if any.
   (3) Resources available through an independent living center.
   (4) Other resources or services in the community available to
support return to the community.
   (e) If the resident is otherwise eligible, a skilled nursing
facility shall make, to the extent services are available in the
community, a reasonable attempt to assist a resident who has a
preference for return to the community and who has been determined to
be able to do so by the attending physician, to obtain assistance
within existing programs, including appropriate case management
services, in order to facilitate return to the community. The
targeted case management services provided by entities other than the
skilled nursing facility shall be intended to facilitate and sustain
return to the community.
   (f) Costs to skilled nursing facilities to comply with this
section shall be allowable for Medi-Cal reimbursement purposes
pursuant to Section 1324.25, but shall not be considered a new state
mandate under Section 14126.023 of the Welfare and Institutions Code.




1418.9.  (a) If the attending physician and surgeon of a resident in
a skilled nursing facility prescribes, orders, or increases an order
for an antipsychotic medication for the resident, the physician and
surgeon shall do both of the following:
   (1) Obtain the informed consent of the resident for purposes of
prescribing, ordering, or increasing an order for the medication.
   (2) Seek the consent of the resident to notify the resident's
interested family member, as designated in the medical record. If the
resident consents to the notice, the physician and surgeon shall
make reasonable attempts, either personally or through a designee, to
notify the interested family member, as designated in the medical
record, within 48 hours of the prescription, order, or increase of an
order.
   (b) Notification of an interested family member is not required
under paragraph (2) of subdivision (a) if any of the following
circumstances exist:
   (1) There is no interested family member designated in the medical
record.
   (2) The resident has been diagnosed as terminally ill by his or
her physician and surgeon and is receiving hospice services from a
licensed, certified hospice agency in the facility.
   (3) The resident has not consented to the notification.
   (c) As used in this section, the following definitions shall
apply:
   (1) "Resident" means a patient of a skilled nursing facility who
has the capacity to consent to make decisions concerning his or her
health care, including medications.
   (2) "Designee" means a person who has agreed with the physician
and surgeon to provide the notice required by this section.
   (3) "Antipsychotic medication" means a medication approved by the
United States Food and Drug Administration for the treatment of
psychosis.
   (4) "Increase of an order" means an increase of the dosage of the
medication above the dosage range stated in a prior consent from the
resident.
   (d) This section shall not be construed to require consent from an
interested family member for an attending physician and surgeon of a
resident to prescribe, order, or increase an order for antipsychotic
medication.


1418.91.  (a) A long-term health care facility shall report all
incidents of alleged abuse or suspected abuse of a resident of the
facility to the department immediately, or within 24 hours.
   (b) A failure to comply with the requirements of this section
shall be a class "B" violation.
   (c) For purposes of this section, "abuse" shall mean any of the
conduct described in subdivisions (a) and (b) of Section 15610.07 of
the Welfare and Institutions Code.
   (d) This section shall not change any reporting requirements under
Section 15630 of the Welfare and Institutions Code, or as otherwise
specified in the Elder Abuse and Dependent Adult Civil Protection
Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division
9 of the Welfare and Institutions Code.



1419.  (a) The department shall establish a centralized consumer
response unit within the Licensing and Certification Division of the
department to respond to consumer inquiries and complaints.
   (b) Upon receipt of consumer inquiries, the unit shall offer
assistance to consumers in resolving concerns about the quality of
care and the quality of life in long-term health care facilities.
   This assistance may include, but shall not be limited to, all of
the following:
   (1) Offering to provide to consumers education and information
about state licensing and federal certification standards, resident
rights, name and address of facilities, referral to other entities as
appropriate, and facility compliance history.
   (2) Offering to participate in telephone conference calls between
consumers and providers to resolve concerns within the scope of the
authority of the department. If the inquiry or concern is determined
to warrant an onsite investigation, the inquiry or concern shall be
considered a complaint and handled pursuant to the complaint
investigation process set forth in Section 1420.
   (3) Initiating onsite investigations in response to oral or
written complaints made pursuant to this section if the unit
determines that there is a reasonable basis to believe that the
allegations in the complaints describe one or more violations of
state law by a long-term care facility.
   (c) Nothing in subdivision (a) or (b) shall preclude the
department from taking any or all enforcement actions available under
state or federal law.
   (d) Any person may request an inspection of any long-term health
care facility in accordance with this chapter by giving to the
department oral or written notice of an alleged violation of
applicable requirements of state law. Any written notice may be
signed by the complainant setting forth with reasonable particularity
the matters complained of. Oral notice may be made by telephone or
personal visit. Any oral complaint shall be reduced to writing by the
department. The substance of the complaint shall be provided to the
licensee no earlier than at the commencement of the inspection.
   (e) Neither the substance of the complaint provided the licensee
nor any copy of the complaint or record published, released, or
otherwise made available to the licensee shall disclose the name of
any individual complainant or other person mentioned in the
complaint, except the name or names of any duly authorized officer,
employee, or agent of the state department conducting the
investigation or inspection pursuant to this chapter, unless the
complainant specifically requests the release of the name or names or
the matter results in a judicial proceeding.



1420.  (a) (1) Upon receipt of a written or oral complaint, the
state department shall assign an inspector to make a preliminary
review of the complaint and shall notify the complainant within two
working days of the receipt of the complaint of the name of the
inspector. Unless the state department determines that the complaint
is willfully intended to harass a licensee or is without any
reasonable basis, it shall make an onsite inspection or investigation
within 10 working days of the receipt of the complaint. In any case
in which the complaint involves a threat of imminent danger of death
or serious bodily harm, the state department shall make an onsite
inspection or investigation within 24 hours of the receipt of the
complaint. In any event, the complainant shall be promptly informed
of the state department's proposed course of action and of the
opportunity to accompany the inspector on the inspection or
investigation of the facility. Upon the request of either the
complainant or the state department, the complainant or his or her
representative, or both, may be allowed to accompany the inspector to
the site of the alleged violations during his or her tour of the
facility, unless the inspector determines that the privacy of any
patient would be violated thereby.
   (2) When conducting an onsite inspection or investigation pursuant
to this section, the state department shall collect and evaluate all
available evidence and may issue a citation based upon, but not
limited to, all of the following:
   (A) Observed conditions.
   (B) Statements of witnesses.
   (C) Facility records.
   (3) Within 10 working days of the completion of the complaint
investigation, the state department shall notify the complainant and
licensee in writing of the department's determination as a result of
the inspection or investigation.
   (b) Upon being notified of the state department's determination as
a result of the inspection or investigation, a complainant who is
dissatisfied with the state department's determination, regarding a
matter which would pose a threat to the health, safety, security,
welfare, or rights of a resident, shall be notified by the state
department of the right to an informal conference, as set forth in
this section. The complainant may, within five business days after
receipt of the notice, notify the director in writing of his or her
request for an informal conference. The informal conference shall be
held with the designee of the director for the county in which the
long-term health care facility which is the subject of the complaint
is located. The long-term health care facility may participate as a
party in this informal conference. The director's designee shall
notify the complainant and licensee of his or her determination
within 10 working days after the informal conference and shall
apprise the complainant and licensee in writing of the appeal rights
provided in subdivision (c).
   (c) If the complainant is dissatisfied with the determination of
the director's designee in the county in which the facility is
located, the complainant may, within 15 days after receipt of this
determination, notify in writing the Deputy Director of the Licensing
and Certification Division of the state department, who shall assign
the request to a representative of the Complainant Appeals Unit for
review of the facts that led to both determinations. As a part of the
Complainant Appeals Unit's independent investigation, and at the
request of the complainant, the representative shall interview the
complainant in the district office where the complaint was initially
referred. Based upon this review, the Deputy Director of the
Licensing and Certification Division of the state department shall
make his or her own determination and notify the complainant and the
facility within 30 days.
   (d) Any citation issued as a result of a conference or review
provided for in subdivision (b) or (c) shall be issued and served
upon the facility within three working days of the final
determination, unless the licensee agrees in writing to an extension
of this time. Service shall be effected either personally or by
registered or certified mail. A copy of the citation shall also be
sent to each complainant by registered or certified mail.
   (e) A miniexit conference shall be held with the administrator or
his or her representative upon leaving the facility at the completion
of the investigation to inform him or her of the status of the
investigation. The department shall also state the items of
noncompliance and compliance found as a result of a complaint and
those items found to be in compliance, provided the disclosure
maintains the anonymity of the complainant. In any matter in which
there is a reasonable probability that the identity of the
complainant will not remain anonymous, the state department shall
also notify the facility that it is unlawful to discriminate or seek
retaliation against a resident, employee, or complainant.
   (f) For purposes of this section, "complaint" means any oral or
written notice to the state department, other than a report from the
facility of an alleged violation of applicable requirements of state
or federal law or any alleged facts that might constitute such a
violation.


1421.  (a) Any duly authorized officer, employee, or agent of the
state department may enter and inspect any long-term health care
facility, including, but not limited to, interviewing residents and
reviewing records, at any time to enforce any provision of this
chapter.
   (b) Patients shall be treated with consideration, respect, and
full recognition of dignity during the course of the investigation or
inspection.
   (c) Inspections conducted pursuant to complaints filed with the
state department shall be conducted in such a manner as to ensure
maximum effectiveness while respecting the rights of patients in the
facility. No advance notice shall be given of any inspection
conducted pursuant to this chapter unless previously and specifically
authorized by the director or required by federal law.
   (d) Any public employee giving any advance notice in violation of
this section shall be deemed to be in violation of subdivision (t) of
Section 19572 of the Government Code and shall be suspended from all
duties without pay for a period determined by the director.
   (e) Except as otherwise specified by law, any duly authorized
officer, employee, or agent of the state department shall not limit
the scope of practice of registered nurses acting under Section 2725
of the Business and Professions Code. Further, these agents shall not
prohibit the performing of functions by registered nurses when those
nurses are performing under standardized procedures, where their
activity is consistent with the scope of nursing practice, as set
forth in Section 2725 of the Business and Professions Code.




1421.1.  (a) Within 24 hours of the occurrence of any of the events
specified in subdivision (b), the licensee of a skilled nursing
facility shall notify the department of the occurrence. This
notification may be in written form if it is provided by telephone
facsimile or overnight mail, or by telephone with a written
confirmation within five calendar days. The information provided
pursuant to this subdivision may not be released to the public by the
department unless its release is needed to justify an action taken
by the department or it otherwise becomes a matter of public record.
A violation of this section is a class "B" violation.
   (b) All of the following occurrences shall require notification
pursuant to this section:
   (1) The licensee of a facility receives notice that a judgment
lien has been levied against the facility or any of the assets of the
facility or the licensee.
   (2) A financial institution refuses to honor a check or other
instrument issued by the licensee to its employees for a regular
payroll.
   (3) The supplies, including food items and other perishables, on
hand in the facility fall below the minimum specified by any
applicable statute or regulation.
   (4) The financial resources of the licensee fall below the amount
needed to operate the facility for a period of at least 45 days based
on the current occupancy of the facility. The determination that
financial resources have fallen below the amount needed to operate
the facility shall be based upon the current number of occupied beds
in the facility multiplied by the current daily Medi-Cal
reimbursement rate multiplied by 45 days.
   (5) The licensee fails to make timely payment of any premiums
required to maintain required insurance policies or bonds in effect,
or any tax lien levied by any government agency.



1421.5.  (a) (1) Within 24 hours of the filing of a bankruptcy
petition under Title 11 of the United States Code or any other laws
of the United States, by any person or entity holding a controlling
interest in a long-term health care facility, the licensee of the
long-term health care facility shall provide written notification to
the department of the filing of the petition and the location of the
court in which the petition was filed. The written notification may
be provided to the department by telephone facsimile or overnight
mail.
   (2) Within 24 hours of the appointment of a trustee by the
bankruptcy court, the long-term health care facility shall provide
written notification to the department of the name, address, and
telephone number of the trustee. The written notification may be
provided to the department by telephone facsimile or overnight mail.
   (3) The department shall provide written notification to the
trustee of the requirements of operating a licensed long-term health
care facility within three days of being notified of the appointment
of the trustee. The contents of this written notice may be provided
to the trustee by telephone facsimile or overnight mail and shall
include, but not be limited to, all of the following:
   (A) The trustee is required to manage and operate the long-term
health care facility according to the requirements of state law, in
the same manner that the owner or possessor of the facility would be
required to manage and operate the facility, including, but not
limited to, complying with Article 8.5 (commencing with Section 1336)
of Chapter 2, Chapter 3.9 (commencing with Section 1599), and
Sections 72527, 73523, and 76525 of Title 22 of the California Code
of Regulations.
   (B) The transfer of patients pursuant to the liquidation of a
licensed long-term health care facility presents a compelling public
health and safety risk, and the trustee will not be exempted from
complying with applicable state law for any reason.
   (b) (1) As mandated by subdivision (b) of Section 959 of Title 28
of the United States Code, an individual appointed as a trustee in a
bankruptcy proceeding described in this section that involves any
person or entity holding a controlling interest in a long-term health
care facility shall comply with all state licensing and federal
certification requirements applicable to the long-term health care
facility, including, but not limited to, those governing patient
rights, transfer or discharge, and facility closure. The transfer of
patients pursuant to the liquidation of a licensed long-term health
care facility presents a compelling public health and safety risk,
and a trustee shall not be exempted from complying with applicable
state law for any reason.
   (2) If a trustee fails to comply with the state licensing
requirements applicable to a long-term health care facility, the
department shall report the trustee's actions to the bankruptcy court
and intervene as appropriate to ensure continued facility compliance
with those requirements.



1422.  (a) The Legislature finds and declares that it is the public
policy of this state to ensure that long-term health care facilities
provide the highest level of care possible. The Legislature further
finds that inspections are the most effective means of furthering
this policy. It is not the intent of the Legislature by the amendment
of subdivision (b) enacted by Chapter 1595 of the Statutes of 1982
to reduce in any way the resources available to the state department
for inspections, but rather to provide the state department with the
greatest flexibility to concentrate its resources where they can be
most effective. It is the intent of the Legislature to create a
survey process that includes state-based survey components and that
determines compliance with federal and California requirements for
certified long-term health care facilities. It is the further intent
of the Legislature to execute this inspection in the form of a single
survey process, to the extent that this is possible and permitted
under federal law. The inability of the state to conduct a single
survey in no way exempts the state from the requirement under this
section that state-based components be inspected in long-term health
care facilities as required by law.
   (b) (1) (A) Notwithstanding Section 1279 or any other provision of
law, without providing notice of these inspections, the department,
in addition to any inspections conducted pursuant to complaints filed
pursuant to Section 1419, shall conduct inspections annually, except
with regard to those facilities which have no class "AA," class "A,"
or class "B" violations in the past 12 months. The state department
shall also conduct inspections as may be necessary to ensure the
health, safety, and security of patients in long-term health care
facilities. Every facility shall be inspected at least once every two
years. The department shall vary the cycle in which inspections of
long-term health care facilities are conducted to reduce the
predictability of the inspections.
   (B) Inspections and investigations of long-term health care
facilities that are certified by the Medicare Program or the Medicaid
Program shall determine compliance with federal standards and
California statutes and regulations to the extent that California
statutes and regulations provide greater protection to residents, or
are more precise than federal standards, as determined by the
department. Notwithstanding any other provision of law, the
department may, without taking regulatory action pursuant to Chapter
3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title
2 of the Government Code, implement, interpret, or make specific this
paragraph by means of an All Facilities Letter (AFL) or similar
instruction. Prior to issuing an AFL or similar instruction, the
department shall consult with interested parties and shall inform the
appropriate committees of the Legislature. The department shall also
post the AFL or similar instruction on its Web site so that any
person may observe which California laws and regulations provide
greater protection to its residents or are more precise than federal
standards. Nothing in this subdivision is intended to change existing
statutory or regulatory requirements governing the care provided to
long-term health care facility residents.
   (C) In order to ensure maximum effectiveness of inspections
conducted pursuant to this article, the department shall identify all
state law standards for the staffing and operation of long-term
health care facilities. Costs of the additional survey and inspection
activities required by Chapter 895 of the Statutes of 2006 shall be
included as Licensing and Certification Program activities for the
purposes of calculating fees in accordance with Section 1266.
   (2) The state department shall submit to the federal Department of
Health and Human Services on or before July 1, 1985, for review and
approval, a request to implement a three-year pilot program designed
to lessen the predictability of the long-term health care facility
inspection process. Two components of the pilot program shall be (A)
the elimination of the present practice of entering into a one-year
certification agreement, and (B) the conduct of segmented inspections
of a sample of facilities with poor inspection records, as defined
by the state department. At the conclusion of the pilot project, an
analysis of both components shall be conducted by the state
department to determine effectiveness in reducing inspection
predictability and the respective cost benefits. Implementation of
this pilot project is contingent upon federal approval.
   (c) Except as otherwise provided in subdivision (b), the state
department shall conduct unannounced direct patient care inspections
at least annually to inspect physician and surgeon services, nursing
services, pharmacy services, dietary services, and activity programs
of all the long-term health care facilities. Facilities evidencing
repeated serious problems in complying with this chapter or a history
of poor performance, or both, shall be subject to periodic
unannounced direct patient care inspections during the inspection
year. The direct patient care inspections shall assist the state
department in the prioritization of its efforts to correct facility
deficiencies.
   (d) All long-term health care facilities shall report to the state
department any changes in the nursing home administrator or the
director of nursing services within 10 calendar days of the changes.
   (e) Within 90 days after the receipt of notice of a change in the
nursing home administrator or the director of nursing services, the
state department may conduct an abbreviated inspection of the
long-term health care facilities.
   (f) If a change in a nursing home administrator occurs and the
Board of Nursing Home Administrators notifies the state department
that the new administrator is on probation or has had his or her
license suspended within the previous three years, the state
department shall conduct an abbreviated survey of the long-term
health care facility employing that administrator within 90 days of
notification.



1422.1.  (a) Notwithstanding Section 1422, the State Department of
Health Services shall conduct, when feasible, annual licensing
inspections of licensed long-term health care facilities providing
special treatment programs for the mentally disordered, concurrently
with inspections conducted by the State Department of Mental Health
for the purposes of approving the special treatment program.
   (b) The State Department of Health Services survey teams
conducting inspections pursuant to this section shall include at
least one licensed mental health professional if the inspections are
not done concurrently pursuant to subdivision (a).
   (c) Survey team members shall receive training specific to the
mental health treatment needs of mentally disordered residents served
in these facilities.


1422.5.  (a) The department shall develop and establish a consumer
information service system to provide updated and accurate
information to the general public and consumers regarding long-term
care facilities in their communities. The consumer information
service system shall include, but need not be limited to, all of the
following elements:
   (1) An on-line inquiry system accessible through a statewide
toll-free telephone number and the Internet.
   (2) Long-term health care facility profiles, with data on services
provided, a history of all citations and complaints for the last two
full survey cycles, and ownership information. The profile for each
facility shall include, but not be limited to, all of the following:
   (A) The name, address, and telephone number of the facility.
   (B) The number of units or beds in the facility.
   (C) Whether the facility accepts Medicare or Medi-Cal patients.
   (D) Whether the facility has a special care unit or program for
people with Alzheimer's disease and other dementias, and whether the
facility participates in the voluntary disclosure program for special
care units.
   (E) Whether the facility is a for-profit or not-for-profit
provider.
   (3) Information regarding substantiated complaints shall include
the action taken and the date of action.
   (4) Information regarding the state citations assessed shall
include the status of the state citation, including the facility's
plan or correction, and information as to whether an appeal has been
filed.
   (5) Any appeal resolution pertaining to a citation or complaint
shall be updated on the file in a timely manner.
   (b) Where feasible, the department shall interface the consumer
information service system with its Automated Certification and
Licensure Information Management System.
   (c) It is the intent of the Legislature that the department, in
developing and establishing the system pursuant to subdivision (a),
maximize the use of available federal funds.
   (d) (1) Notwithstanding the consumer information service system
established pursuant to subdivision (a), by January 1, 2002, the
state department shall develop a method whereby information is
provided to the public and consumers on long-term health care
facilities. The information provided shall include, but not be
limited to, all of the following elements:
   (A) Substantiated complaints, including the action taken and the
date of the action.
   (B) State citations assessed, including the status of any citation
and whether an appeal has been filed.
   (C) State actions, including license suspensions, revocations, and
receiverships.
   (D) Federal enforcement sanctions imposed, including any denial of
payment, temporary management, termination, or civil money penalty
of five hundred dollars ($500) or more.
   (E) Any information or data beneficial to the public and
consumers.
   (2) This subdivision shall become inoperative on July 1, 2003.
   (e) In implementing this section, the department shall ensure the
confidentiality of personal and identifying information of residents
and employees and shall not disclose this information through the
consumer information service system developed pursuant to this
section.



1422.6.  Each skilled nursing facility and intermediate care
facility shall post a copy of the notice required pursuant to Section
9718 of the Welfare and Institutions Code in a conspicuous location
in at least four areas of the facility, as follows:
   (a) One location that is accessible to members of the public.
   (b) One location that is used for employee breaks.
   (c) One location that is next to a telephone designated for
resident use.
   (d) One location that is used for communal functions for
residents, such as for dining or resident council meetings and
activities.



1422.7.  The state department shall provide the office, as defined
in subdivision (c) of Section 9701 of the Welfare and Institutions
Code, with copies of inspection reports for long-term health care
facilities upon request. The state department shall provide the
office with copies of all class "AA," "A," and "B" citations issued.




1423.  (a) If upon inspection or investigation the director
determines that any nursing facility is in violation of any state or
federal law or regulation relating to the operation or maintenance of
the facility, or determines that any other long-term health care
facility is in violation of any statutory provision or regulation
relating to the operation or maintenance of the facility, the
director shall promptly, but not later than 24 hours, excluding
Saturday, Sunday, and holidays, after the director determines or has
reasonable cause to determine that an alleged violation has occurred,
issue a notice to correct the violation and of intent to issue a
citation to the licensee. Before completing the investigation and
making the determination whether to issue a citation, the department
shall hold an exit conference with the licensee to identify the
potential for issuing a citation for any violation, discuss
investigative findings, and allow the licensee to provide the
department with additional information related to the violation. The
department shall consider this additional information, in conjunction
with information from the inspection or investigation, in
determining whether to issue a citation, or whether other action
would be appropriate. If the department determines that the violation
warrants the issuing of a citation and an exit conference has been
completed it shall either:
   (1) Recommend the imposition of a federal enforcement remedy or
remedies on a nursing facility in accordance with federal law; or
   (2) Issue a citation pursuant to state licensing laws, and if the
facility is a nursing facility, may recommend the imposition of a
federal enforcement remedy other than a federal civil monetary
penalty for a federal violation.
   No violation may result in the issuance of both a citation
pursuant to state laws and the recommendation that a federal civil
monetary penalty be imposed. If a state citation is issued it shall
be served upon the licensee within three days after completion of the
investigation, excluding Saturday, Sunday, and holidays, unless the
licensee agrees in writing to an extension of time. Service shall be
effected either personally or by registered or certified mail. A copy
of the citation shall also be sent to each complainant. Each
citation shall be in writing and shall describe with particularity
the nature of the violation, including a reference to the statutory
provision, standard, rule or regulation alleged to have been
violated, the particular place or area of the facility in which it
occurred, as well as the amount of any proposed assessment of a civil
penalty. The name of any patient jeopardized by the alleged
violation shall not be specified in the citation in order to protect
the privacy of the patient. However, at the time the licensee is
served with the citation, the licensee shall also be served with a
written list of each of the names of the patients alleged to have
been jeopardized by the violation, that shall not be subject to
disclosure as a public record. The citation shall fix the earliest
feasible time for the elimination of the condition constituting the
alleged violation, when appropriate.
   (b) Where no harm to patients, residents, or guests has occurred,
a single incident, event, or occurrence shall result in no more than
one citation for each statute or regulation violated.
   (c) No citation shall be issued for a violation that has been
reported by the licensee to the state department, or its designee, as
an "unusual occurrence," if all of the following conditions are met:
   (1) The violation has not caused harm to any patient, resident, or
guest, or significantly contributed thereto.
   (2) The licensee has promptly taken reasonable measures to correct
the violation and to prevent a recurrence.
   (3) The unusual occurrence report was the first source of
information reported to the state department, or its designee,
regarding the violation.



1423.5.  (a) The state department shall centrally review federal
deficiencies and supporting documentation that may require the
termination of certification for a nursing facility. The state
department shall develop a standardized methodology for conducting
the central review of these deficiencies. The standardized
methodology shall assess all of the following:
   (1) The extent to which the survey team followed established
survey protocols.
   (2) The thoroughness of the investigation or review.
   (3) The quality of documentation.
   (4) The consistency in interpreting federal requirements.
   (b) The state department shall develop a system for tracking
patterns and a quality assurance process for preventing, detecting,
and correcting inconsistent or poor quality survey practices.
   (c) (1) On or before December 1 of each year, the state department
shall provide to the Legislature a summary of federal and state
enforcement actions taken against nursing facilities during the
previous state fiscal year.
   (2) The report summarizing federal and state enforcement actions
required under this subdivision shall be combined with the report
required under Section 1438 into a single report. The time period for
each report shall cover the previous state fiscal year.




1424.  Citations issued pursuant to this chapter shall be classified
according to the nature of the violation and shall indicate the
classification on the face thereof.
   (a) In determining the amount of the civil penalty, all relevant
facts shall be considered, including, but not limited to, the
following:
   (1) The probability and severity of the risk that the violation
presents to the patient's or resident's mental and physical
condition.
   (2) The patient's or resident's medical condition.
   (3) The patient's or resident's mental condition and his or her
history of mental disability or disorder.
   (4) The good faith efforts exercised by the facility to prevent
the violation from occurring.
   (5) The licensee's history of compliance with regulations.
   (b) Relevant facts considered by the department in determining the
amount of the civil penalty shall be documented by the department on
an attachment to the citation and available in the public record.
This requirement shall not preclude the department or a facility from
introducing facts not listed on the citation to support or challenge
the amount of the civil penalty in any proceeding set forth in
Section 1428.
   (c) Class "AA" violations are violations that meet the criteria
for a class "A" violation and that the state department determines to
have been a direct proximate cause of death of a patient or resident
of a long-term health care facility. Except as provided in Section
1424.5, a class "AA" citation is subject to a civil penalty in the
amount of not less than five thousand dollars ($5,000) and not
exceeding twenty-five thousand dollars ($25,000) for each citation.
In any action to enforce a citation issued under this subdivision,
the state department shall prove all of the following:
   (1) The violation was a direct proximate cause of death of a
patient or resident.
   (2) The death resulted from an occurrence of a nature that the
regulation was designed to prevent.
   (3) The patient or resident suffering the death was among the
class of persons for whose protection the regulation was adopted.
   If the state department meets this burden of proof, the licensee
shall have the burden of proving that the licensee did what might
reasonably be expected of a long-term health care facility licensee,
acting under similar circumstances, to comply with the regulation. If
the licensee sustains this burden, then the citation shall be
dismissed.
   Except as provided in Section 1424.5, for each class "AA" citation
within a 12-month period that has become final, the state department
shall consider the suspension or revocation of the facility's
license in accordance with Section 1294. For a third or subsequent
class "AA" citation in a facility within that 12-month period that
has been sustained following a citation review conference, the state
department shall commence action to suspend or revoke the facility's
license in accordance with Section 1294.
   (d) Class "A" violations are violations which the state department
determines present either (1) imminent danger that death or serious
harm to the patients or residents of the long-term health care
facility would result therefrom, or (2) substantial probability that
death or serious physical harm to patients or residents of the
long-term health care facility would result therefrom. A physical
condition or one or more practices, means, methods, or operations in
use in a long-term health care facility may constitute a class "A"
violation. The condition or practice constituting a class "A"
violation shall be abated or eliminated immediately, unless a fixed
period of time, as determined by the state department, is required
for correction. Except as provided in Section 1424.5, a class "A"
citation is subject to a civil penalty in an amount not less than one
thousand dollars ($1,000) and not exceeding ten thousand dollars
($10,000) for each and every citation.
   If the state department establishes that a violation occurred, the
licensee shall have the burden of proving that the licensee did what
might reasonably be expected of a long-term health care facility
licensee, acting under similar circumstances, to comply with the
regulation. If the licensee sustains this burden, then the citation
shall be dismissed.
   (e) Class "B" violations are violations that the state department
determines have a direct or immediate relationship to the health,
safety, or security of long-term health care facility patients or
residents, other than class "AA" or "A" violations. Unless otherwise
determined by the state department to be a class "A" violation
pursuant to this chapter and rules and regulations adopted pursuant
thereto, any violation of a patient's rights as set forth in Sections
72527 and 73523 of Title 22 of the California Code of Regulations,
that is determined by the state department to cause or under
circumstances likely to cause significant humiliation, indignity,
anxiety, or other emotional trauma to a patient is a class "B"
violation. A class "B" citation is subject to a civil penalty in an
amount not less than one hundred dollars ($100) and not exceeding one
thousand dollars ($1,000) for each and every citation. A class "B"
citation shall specify the time within which the violation is
required to be corrected. If the state department establishes that a
violation occurred, the licensee shall have the burden of proving
that the licensee did what might reasonably be expected of a
long-term health care facility licensee, acting under similar
circumstances, to comply with the regulation. If the licensee
sustains this burden, then the citation shall be dismissed.
   In the event of any citation under this paragraph, if the state
department establishes that a violation occurred, the licensee shall
have the burden of proving that the licensee did what might
reasonably be expected of a long-term health care facility licensee,
acting under similar circumstances, to comply with the regulation. If
the licensee sustains this burden, then the citation shall be
dismissed.
   (f) (1) Any willful material falsification or willful material
omission in the health record of a patient of a long-term health care
facility is a violation.
   (2) "Willful material falsification," as used in this section,
means any entry in the patient health care record pertaining to the
administration of medication, or treatments ordered for the patient,
or pertaining to services for the prevention or treatment of
decubitus ulcers or contractures, or pertaining to tests and
measurements of vital signs, or notations of input and output of
fluids, that was made with the knowledge that the records falsely
reflect the condition of the resident or the care or services
provided.
   (3) "Willful material omission," as used in this section, means
the willful failure to record any untoward event that has affected
the health, safety, or security of the specific patient, and that was
omitted with the knowledge that the records falsely reflect the
condition of the resident or the care or services provided.
   (g) Except as provided in subdivision (a) of Section 1425.5, a
violation of subdivision (f) may result in a civil penalty not to
exceed ten thousand dollars ($10,000), as specified in paragraphs (1)
to (3), inclusive.
   (1) The willful material falsification or willful material
omission is subject to a civil penalty of not less than two thousand
five hundred dollars ($2,500) or more than ten thousand dollars
($10,000) in instances where the health care record is relied upon by
a health care professional to the detriment of a patient by
affecting the administration of medications or treatments, the
issuance of orders, or the development of plans of care. In all other
cases, violations of this subdivision are subject to a civil penalty
not exceeding two thousand five hundred dollars ($2,500).
   (2) Where the penalty assessed is one thousand dollars ($1,000) or
less, the violation shall be issued and enforced, except as provided
in this subdivision, in the same manner as a class "B" violation,
and shall include the right of appeal as specified in Section 1428.
Where the assessed penalty is in excess of one thousand dollars
($1,000), or for skilled nursing facilities or intermediate care
facilities as specified in paragraphs (1) and (2) of subdivision (a)
of Section 1418, in excess of two thousand dollars ($2,000), the
violation shall be issued and enforced, except as provided in this
subdivision, in the same manner as a class "A" violation, and shall
include the right of appeal as specified in Section 1428.
   Nothing in this section shall be construed as a change in previous
law enacted by Chapter 11 of the Statutes of 1985 relative to this
paragraph, but merely as a clarification of existing law.
   (3) Nothing in this subdivision shall preclude the state
department from issuing a class "A" or class "B" citation for any
violation that meets the requirements for that citation, regardless
of whether the violation also constitutes a violation of this
subdivision. However, no single act, omission, or occurrence may be
cited both as a class "A" or class "B" violation and as a violation
of this subdivision.
   (h) Where the licensee has failed to post the notices as required
by Section 9718 of the Welfare and Institutions Code in the manner
required under Section 1422.6, the state department shall assess the
licensee a civil penalty in the amount of one hundred dollars ($100)
for each day the failure to post the notices continues. Where the
total penalty assessed is less than two thousand dollars ($2,000),
the violation shall be issued and enforced in the same manner as a
class "B" violation, and shall include the right of appeal as
specified in Section 1428. Where the assessed penalty is equal to or
in excess of two thousand dollars ($2,000), the violation shall be
issued and enforced in the same manner as a class "A" violation and
shall include the right of appeal as specified in Section 1428. Any
fines collected pursuant to this subdivision shall be used to fund
the costs incurred by the California Department of Aging in producing
and posting the posters.
   (i) The director shall prescribe procedures for the issuance of a
notice of violation with respect to violations having only a minimal
relationship to patient safety or health.
   (j) The department shall provide a copy of all citations issued
under this section to the affected residents whose treatment was the
basis for the issuance of the citation, to the affected residents'
designated family member or representative of each of the residents,
and to the complainant if the citation was issued as a result of a
complaint.
   (k) Nothing in this section is intended to change existing
statutory or regulatory requirements governing the ability of a
licensee to contest a citation pursuant to Section 1428.
   ( l) The department shall ensure that district office activities
performed under Sections 1419 to 1424, inclusive, are consistent with
the requirements of these sections and all applicable laws and
regulations. To ensure the integrity of these activities, the
department shall establish a statewide process for the collection of
postsurvey evaluations from affected facilities.



1424.1.  (a) On and after the effective date of this section, no
citation shall be issued or sustained under this chapter for a
violation of any regulation discovered and recorded by a facility if
all of the following conditions have been met:
   (1) The facility maintains an ongoing quality assurance and
patient care audit program, which includes maintenance of a quality
assurance log which is made available to the state department at the
commencement of each inspection and investigation. The facility shall
retain this log for the current year and the preceding three years.
   (2) The violation was not willful and resulted in no actual harm
to any patient or guest.
   (3) The violation was first discovered by the licensee and was
promptly and accurately recorded in the quality assurance log prior
to discovery by the state department.
   (4) Promptly upon discovery, the facility implemented remedial
action satisfactory to the state department to correct the violation
and prevent a recurrence. If the state department determines that
remedial action voluntarily undertaken by the facility is
unsatisfactory, the state department shall allow the facility
reasonable time to augment the remedial action before the condition
shall be deemed to be a violation.
   (b) Except as otherwise provided in this section, a quality
assurance log which meets the criteria of this section shall not be
discoverable or admissible in any action against the licensee. The
quality assurance log shall be discoverable pursuant to a motion to
produce under Chapter 14 (commencing with Section 2031.010) of Title
4 of Part 4 of the Code of Civil Procedure and admissible only for
purposes of impeachment. However, the court, in a motion pursuant to
Section 2025.420 of the Code of Civil Procedure, or at trial or other
proceeding, may limit access to those entries which would be
admissible for impeachment purposes.
   (c) The quality assurance log shall be made available upon request
to any of the following:
   (1) Full-time state employees of the Office of the State Long-Term
Care Ombudsman.
   (2) Ombudsman coordinators, as defined in Section 9701 of the
Welfare and Institutions Code.
   (3) Ombudsmen qualified by medical training as defined in Section
9701 of the Welfare and Institutions Code, with the approval of
either the State Long-Term Care Ombudsman or ombudsman coordinator.
   The licensee may make the quality assurance log available, in the
licensee's discretion, to any representative of the Office of the
State Long-Term Care Ombudsman, as defined in Section 9701 of the
Welfare and Institutions Code, without liability for the disclosure.
Each representative of the Office of the State Long-Term Care
Ombudsman who has been provided access to a facility's quality
assurance log pursuant to this section shall maintain all disclosures
in confidence.


1424.5.  (a) In lieu of the fines specified in subdivisions (c),
(d), and (e) of Section 1424, fines imposed on skilled nursing
facilities or intermediate care facilities, as specified in
paragraphs (1) and (2) of subdivision (a) of Section 1418, shall be
as follows:
   (1) A class "AA" citation is subject to a civil penalty in an
amount not less than twenty-five thousand dollars ($25,000) and not
exceeding one hundred thousand dollars ($100,000) for each and every
citation. For a second or subsequent class "AA" citation in a skilled
nursing facility or intermediate care facility within a 24-month
period that has been sustained following a citation review
conference, or where the licensee has chosen not to exercise its
right to a citation review conference, the state department shall
commence action to suspend or revoke the facility's license in
accordance with Section 1294.
   (2) A class "A" citation is subject to a civil penalty in an
amount not less than two thousand dollars ($2,000) and not exceeding
twenty thousand dollars ($20,000) for each and every citation.
   (3) Any "willful material falsification" or "willful material
omission," as those terms are defined in subdivision (f) of Section
1424, in the health record of a resident is subject to a civil
penalty in an amount not less than two thousand dollars ($2,000) and
not exceeding twenty thousand dollars ($20,000) for each and every
citation.
   (b) A licensee may, in lieu of contesting a class "AA" or class "A"
citation pursuant to Section 1428, transmit to the state department,
the minimum amount specified by law, or 65 percent of the amount
specified in the citation, whichever is greater, for each violation,
within 30 business days after the issuance of the citation.




1425.  Where a licensee has failed to correct a violation within the
time specified in the citation, the state department shall assess
the licensee a civil penalty in the amount of fifty dollars ($50) for
each day that such deficiency continues beyond the date specified
for correction. If the licensee disputes a determination by the state
department regarding alleged failure to correct a violation or
regarding the reasonableness of the proposed deadline for correction,
the licensee may request an informal conference and contest such
determination.


1426.  After consultation with industry, professional, and consumer
groups affected thereby, but not later than three months after the
effective date of this chapter, the director shall publish proposed
regulations setting forth the criteria and, where feasible, the
specific acts that constitute class "A" and "B" violations under this
chapter. Not later than six months after the effective date of this
chapter, the director shall adopt regulations setting forth criteria
and, where feasible, specific acts constituting class "A" and "B"
violations. The regulations shall be adopted as prescribed in Chapter
4.5 (commencing with Section 11371) of Part 1 of Division 3 of Title
2 of the Government Code, except that such regulations shall not be
adopted as emergency regulations pursuant to subdivision (b) of
Section 11421 of the Government Code and shall not mandate a quality
of care or new procedures which were not required on January 1, 1974,
without providing additional reimbursement if the change in quality
of care or the new procedures entail substantial new costs.
   For purposes of this section, "new costs" shall not include costs
which are the direct or indirect consequence of meeting the
requirements of the citation system established under this chapter.



1427.  (a) When the administration of medications, treatments, or
other care is not recorded, as required by law, in the health care
record for a patient of a long-term health care facility, it shall be
presumed that the required medication, treatment, or care has not
been provided.
   (b) The presumption established by this section may be rebutted by
a licensee only upon a showing of a preponderance of the evidence.
   (c) This presumption applies to any action against any long-term
health care facility which is filed by the state department pursuant
to this chapter or Chapter 2 (commencing with Section 1250). In any
other action against a long-term health care facility, the court may
apply the presumption when the interests of justice requires.



1428.  (a) If the licensee desires to contest a citation or the
proposed assessment of a civil penalty therefor, the licensee shall
use the processes described in subdivisions (b) and (c) for classes
"AA," "A," or "B" citations. As a result of a citation review
conference, a citation or the proposed assessment of a civil penalty
may be affirmed, modified, or dismissed by the director or the
director's designee. If the director's designee affirms, modifies, or
dismisses the citation or proposed assessment of a civil penalty, he
or she shall state with particularity in writing his or her reasons
for that action, and shall immediately transmit a copy thereof to
each party to the original complaint. If the licensee desires to
contest a decision made after the citation review conference, the
licensee shall inform the director in writing within 15 business days
after he or she receives the decision by the director's designee.
   (b) If a licensee notifies the director that he or she intends to
contest a class "AA" or a class "A" citation, the licensee may first,
within 15 business days after service of the citation, notify the
director in writing of his or her request for a citation review
conference. The licensee shall inform the director in writing, within
15 business days of the service of the citation or the receipt of
the decision of the director's designee after the citation review
conference, of the licensee's intent to adjudicate the validity of
the citation in the superior court in the county in which the
long-term health care facility is located. In order to perfect a
judicial appeal of a contested citation, a licensee shall file a
civil action in the superior court in the county in which the
long-term health care facility is located. The action shall be filed
no later than 90 calendar days after a licensee notifies the director
that he or she intends to contest the citation, or no later than 90
days after the receipt of the decision by the director's designee
after the citation review conference, and served not later than 90
days after filing. Notwithstanding any other provision of law, a
licensee prosecuting a judicial appeal shall file and serve a case
management statement pursuant to Rule 212 of the California Rules of
Court within six months after the department files its answer in the
appeal. Notwithstanding subdivision (d), the court shall dismiss the
appeal upon motion of the department if the case management statement
is not filed by the licensee within the period specified. The court
may affirm, modify, or dismiss the citation, the level of the
citation, or the amount of the proposed assessment of the civil
penalty.
   (c) If a licensee desires to contest a class "B" citation, the
licensee may request, within 15 business days after service of the
citation, a citation review conference, by writing the director or
the director's designee of the licensee's intent to appeal the
citation through the citation review conference. If the licensee
wishes to appeal the citation which has been upheld in a citation
review conference, the licensee shall, within 15 working days from
the date the citation review conference decision was rendered, notify
the director or the director's designee that he or she wishes to
appeal the decision through the procedures set forth in Section
100171 or elects to submit the matter to binding arbitration in
accordance with subdivision (d). The administrative law judge may
affirm, modify, or dismiss the citation or the proposed assessment of
a civil penalty. The licensee may choose to have his or her appeal
heard by the administrative law judge or submit the matter to binding
arbitration without having first appealed the decision to a citation
review conference by notifying the director in writing within 15
business days of the service of the citation.
   (d) If a licensee is dissatisfied with the decision of the
administrative law judge, the licensee may, in lieu of seeking
judicial review of the decision as provided in Section 1094.5 of the
Code of Civil Procedure, elect to submit the matter to binding
arbitration by filing, within 60 days of its receipt of the decision,
a request for arbitration with the American Arbitration Association.
The parties shall agree upon an arbitrator designated from the
American Arbitration Association in accordance with the association's
established rules and procedures. The arbitration hearing shall be
set within 45 days of the election to arbitrate, but in no event less
than 28 days from the date of selection of an arbitrator. The
arbitration hearing may be continued up to 15 additional days if
necessary at the arbitrator's discretion. Except as otherwise
specifically provided in this subdivision, the arbitration hearing
shall be conducted in accordance with the American Arbitration
Association's established rules and procedures. The arbitrator shall
determine whether the licensee violated the regulation or regulations
cited by the department, and whether the citation meets the criteria
established in Sections 1423 and 1424. If the arbitrator determines
that the licensee has violated the regulation or regulations cited by
the department, and that the class of the citation should be upheld,
the proposed assessment of a civil penalty shall be affirmed,
subject to the limitations established in Section 1424. The licensee
and the department shall each bear its respective portion of the cost
of arbitration. A resident, or his or her designated representative,
or both, entitled to participate in the citation review conference
pursuant to subdivision (f), may make an oral or written statement
regarding the citation, at any arbitration hearing to which the
matter has been submitted after the citation review conference.
   (e) If an appeal is prosecuted under this section, including an
appeal taken in accordance with Section 100171, the department shall
have the burden of establishing by a preponderance of the evidence
that (1) the alleged violation did occur, (2) the alleged violation
met the criteria for the class of citation alleged, and (3) the
assessed penalty was appropriate. The department shall also have the
burden of establishing by a preponderance of the evidence that the
assessment of a civil penalty should be upheld. If a licensee fails
to notify the director in writing that he or she intends to contest
the citation, or the proposed assessment of a civil penalty therefor,
or the decision made by the director's designee, after a citation
review conference, within the time specified in this section, the
decision by the director's designee after a citation review
conference shall be deemed a final order of the department and shall
not be subject to further administrative review, except that the
licensee may seek judicial relief from the time limits specified in
this section. If a licensee appeals a contested citation or the
assessment of a civil penalty, no civil penalty shall be due and
payable unless and until the appeal is terminated in favor of the
department.
   (f) The director or the director's designee shall establish an
independent unit of trained citation review conference hearing
officers within the department to conduct citation review
conferences. Citation review conference hearing officers shall be
directly responsible to the deputy director for licensing and
certification, and shall not be concurrently employed as supervisors,
district administrators, or regional administrators with the
licensing and certification division. Specific training shall be
provided to members of this unit on conducting an informal
conference, with emphasis on the regulatory and legal aspects of
long-term health care.
   Where the department issues a citation as a result of a complaint
or regular inspection visit, and a resident or residents are
specifically identified in a citation by name as being specifically
affected by the violation, then the following persons may attend the
citation review conference:
   (1) The complainant and his or her designated representative.
   (2) A personal health care provider, designated by the resident.
   (3) A personal attorney.
   (4) Any person representing the Office of the State Long-Term Care
Ombudsman, as referred to in subdivision (d) of Section 9701 of the
Welfare and Institutions Code.
   Where the department determines that residents in the facility
were threatened by the cited violation but does not name specific
residents, any person representing the Office of the State Long-Term
Care Ombudsman, as referred to in subdivision (d) of Section 9701 of
the Welfare and Institutions Code, and a representative of the
residents or family council at the facility may participate to
represent all residents. In this case, these representatives shall be
the sole participants for the residents in the conference. The
residents or family council shall designate which representative will
participate.
   The complainant, affected resident, and their designated
representatives shall be notified by the department of the conference
and their right to participate. The director's designee shall notify
the complainant or his or her designated representative and the
affected resident or his or her designated representative, of his or
her determination based on the citation review conference.
   (g) In assessing the civil penalty for a violation, all relevant
facts shall be considered, including, but not limited to, all of the
following:
   (1) The probability and severity of the risk which the violation
presents to the patient's or resident's mental and physical
condition.
   (2) The patient's or resident's medical condition.
   (3) The patient's or resident's mental condition and his or her
history of mental disability.
   (4) The good faith efforts exercised by the facility to prevent
the violation from occurring.
   (5) The licensee's history of compliance with regulations.
   (h) Except as otherwise provided in this subdivision, an
assessment of civil penalties for a class "A" or class "B" violation
shall be trebled and collected for a second and subsequent violation
for which a citation of the same class was issued within any 12-month
period. Trebling shall occur only if the first citation issued
within the 12-month period was issued in the same class, a civil
penalty was assessed, and a plan of correction was submitted for the
previous same-class violation occurring within the period, without
regard to whether the action to enforce the previous citation has
become final. However, the increment to the civil penalty required by
this subdivision shall not be due and payable unless and until the
previous action has terminated in favor of the department.
   If the class "B" citation is issued for a patient's rights
violation, as defined in subdivision (e) of Section 1424, it shall
not be trebled unless the department determines the violation has a
direct or immediate relationship to the health, safety, security, or
welfare of long-term health care facility residents.
   (i) The director shall prescribe procedures for the issuance of a
notice of violation with respect to violations having only a minimal
relationship to safety or health.
   (j) Actions brought under this chapter shall be set for trial at
the earliest possible date and shall take precedence on the court
calendar over all other cases except matters to which equal or
superior precedence is specifically granted by law. Times for
responsive pleading and for hearing the proceeding shall be set by
the judge of the court with the object of securing a decision as to
subject matters at the earliest possible time.
   (k) If the citation is dismissed, the department shall take action
immediately to ensure that the public records reflect in a prominent
manner that the citation was dismissed.
   (l) Penalties paid on violations under this chapter shall be
applied against the department's accounts to offset any costs
incurred by the state pursuant to this chapter. Any costs or
penalties assessed pursuant to this chapter shall be paid within 30
days of the date the decision becomes final. If a facility does not
comply with this requirement, the state department shall withhold any
payment under the Medi-Cal program until the debt is satisfied. No
payment shall be withheld if the department determines that it would
cause undue hardship to the facility or to patients or residents of
the facility.
   (m) The amendments made to subdivisions (a) and (c) of this
section by Chapter 84 of the Statutes of 1988, to extend the number
of days allowed for the provision of notification to the director, do
not affect the right, that is also contained in those amendments, to
request judicial relief from these time limits.



1428.1.  Except as provided in subdivision (b) of Section 1424.5, a
licensee may, in lieu of contesting a citation pursuant to Section
1428, transmit to the state department the minimum amount specified
by law, or 65 percent of the amount specified in the citation,
whichever is greater, for each violation within 15 business days
after the issuance of the citation.



1428.2.  In the case of a class "A" or class "AA" citation issued to
a long-term health care facility which is appealed, the citation
shall expire and have no further legal effect, if the Attorney
General has not filed an action in the court of competent
jurisdiction, within one year from the date the facility notifies the
State Department of Health Services of its intent to contest the
citation in court. Notwithstanding the time limit prescribed in
subdivision (a) of Section 1428, at the facility's request, the
department shall conduct a citation review conference within 35 days
from the date of the request for a citation review conference. Unless
a conference is requested by the facility, this section shall not
require the department to conduct the conference within the 35-day
period. The hearing officer shall issue the decision within 30 days
of the citation review conference.



1429.  (a) Each class "AA" and class "A" citation specified in
subdivisions (c) and (d) of Section 1424 that is issued, or a copy or
copies thereof, shall be prominently posted for 120 days. The
citation or copy shall be posted in a place or places in plain view
of the patients or residents in the long-term health care facility,
persons visiting those patients or residents, and persons who inquire
about placement in the facility.
   (1) The citation shall be posted in at least the following
locations in the facility:
   (A) An area accessible and visible to members of the public.
   (B) An area used for employee breaks.
   (C) An area used by residents for communal functions, such as
dining, resident council meetings, or activities.
   (2) The citation, along with a cover sheet, shall be posted on a
white or light-colored sheet of paper, at least 8 1/2 by 11 inches in
size, that includes all of the following information:
   (A) The full name of the facility, in a clear and easily readable
font in at least 28-point type.
   (B) The full address of the facility, in a clear and easily
readable font in at least 20-point type.
   (C) Whether the citation is class "AA" or class "A."
   (3) The facility may post the plan of correction.
   (4) The facility may post a statement disputing the citation or a
statement showing the appeal status, or both.
   (5) The facility may remove and discontinue the posting required
by this section if the citation is withdrawn or dismissed by the
department, or is dismissed as a result of a citation review
conference.
   (b) Each class "B" citation specified in subdivision (e) of
Section 1424 that is issued pursuant to this section and that has
become final, or a copy or copies thereof, shall be retained by the
licensee at the facility cited until the violation is corrected to
the satisfaction of the department. Each citation shall be made
promptly available by the licensee for inspection or examination by
any member of the public who so requests. In addition, every licensee
shall post in a place or places in plain view of the patient or
resident in the long-term health care facility, persons visiting
those patients or residents, and persons who inquire about placement
in the facility, a prominent notice informing those persons that
copies of all final uncorrected citations issued by the department to
the facility will be made promptly available by the licensee for
inspection by any person who so requests.
   (c) A violation of this section shall constitute a class "B"
violation, and shall be subject to a civil penalty in the amount of
one thousand dollars ($1,000), as provided in subdivision (e) of
Section 1424. Notwithstanding Section 1290, a violation of this
section shall not constitute a crime. Fines imposed pursuant to this
section shall be deposited into the State Health Facilities Citation
Penalties Account, created pursuant to Section 1417.2.



1429.1.  (a) If a long-term health care facility licensed as a
skilled nursing facility or an intermediate care facility, as defined
in paragraphs (1) and (2) of subdivision (a) of Section 1418, has
one or more of the following remedies actually imposed for violation
of state or federal requirements, the facility shall provide written
notification of the action to each resident, the resident's
responsible party and legal representative, and all applicants for
admission to the facility:
   (1) Termination of the facility's provider agreement to
participate in the Medicare program, medicaid program, or both
programs.
   (2) Denial of Medicare or medicaid payment for new admissions to
the facility.
   (3) Denial by the Health Care Financing Administration of Medicare
or medicaid payment for all individuals in the facility.
   (4) A ban on admissions, of any type.
   (b) A violation of the requirements of this section shall be a
class "B" violation.



1430.  (a) Except where the state department has taken action and
the violations have been corrected to its satisfaction, a licensee
who commits a class "A" or "B" violation may be enjoined from
permitting the violation to continue or may be sued for civil damages
within a court of competent jurisdiction. An action for injunction
or civil damages, or both, may be prosecuted by the Attorney General
in the name of the people of the State of California upon his or her
own complaint or upon the complaint of a board, officer, person,
corporation, or association, or by a person acting for the interests
of itself, its members, or the general public. The amount of civil
damages that may be recovered in an action brought pursuant to this
section may not exceed the maximum amount of civil penalties that
could be assessed on account of the violation or violations.
   (b) A current or former resident or patient of a skilled nursing
facility, as defined in subdivision (c) of Section 1250, or
intermediate care facility, as defined in subdivision (d) of Section
1250, may bring a civil action against the licensee of a facility who
violates any rights of the resident or patient as set forth in the
Patients Bill of Rights in Section 72527 of Title 22 of the
California Code of Regulations, or any other right provided for by
federal or state law or regulation. The suit shall be brought in a
court of competent jurisdiction. The licensee shall be liable for the
acts of the licensee's employees. The licensee shall be liable for
up to five hundred dollars ($500), and for costs and attorney fees,
and may be enjoined from permitting the violation to continue. An
agreement by a resident or patient of a skilled nursing facility or
intermediate care facility to waive his or her rights to sue pursuant
to this subdivision shall be void as contrary to public policy.
   (c) The remedies specified in this section shall be in addition to
any other remedy provided by law.



1431.  It is a misdemeanor for any person to do any of the
following:
   (a) Willfully prevent, interfere with, or attempt to impede in any
way the work of any duly authorized representative of the state
department in the lawful enforcement of any provision of this
chapter.
   (b) Willfully prevent or attempt to prevent any such
representative from examining any relevant books or records in the
conduct of his official duties under this chapter.
   (c) Willfully prevent or interfere with any such representative in
the preserving of evidence of any violation of any of the provisions
of this chapter or of the rules and regulations promulgated under
this chapter.



1432.  (a) No licensee shall discriminate or retaliate in any manner
against any complainant, or any patient or employee in its long-term
health care facility, on the basis or for the reason that the
complainant, patient, employee, or any other person has presented a
grievance or complaint, or has initiated or cooperated in any
investigation or proceeding of any governmental entity relating to
care, services, or conditions at that facility. A licensee who
violates this section is subject to a civil penalty of no more than
ten thousand dollars ($10,000), to be assessed by the director and
collected in the manner provided in Section 1430.
   (b) Any attempt to expel a patient from a long-term health care
facility, or any type of discriminatory treatment of a patient by
whom, or upon whose behalf, a grievance or complaint has been
submitted, directly or indirectly, to any governmental entity or
received by a long-term health care facility administrator or any
proceeding instituted under or related to this chapter within 180
days of the filing of the complaint or the institution of the action,
shall raise a rebuttable presumption that the action was taken by
the licensee in retaliation for the filing of the complaint.
   (c) Any attempt to terminate the employment, or other
discriminatory treatment, of any employee who has presented a
grievance or complaint or has initiated, participated, or cooperated
in any investigation or proceeding of any governmental entity as
specified in subdivision (a), and where the facility or licensee had
knowledge of the employee's initiation, participation, or
cooperation, shall raise a rebuttable presumption that the action was
taken by the licensee in retaliation if it occurs within 120 days of
the filing of the grievance or complaint, or the institution of the
action.
   (d) Presumptions provided for in subdivisions (b) and (c) shall be
presumptions affecting the burden of producing evidence as provided
in Section 603 of the Evidence Code.
   (e) Where the civil penalty assessed is one thousand dollars
($1,000) or less, the violation shall be issued and enforced in the
same manner as a class "B" violation, except in no case shall the
penalty be trebled. Where the civil penalty assessed is in excess of
one thousand dollars ($1,000), the violation shall be issued and
enforced in the same manner as a class "A" violation, except in no
case shall the penalty be trebled.
   (f) Any person who willfully violates this section is guilty of an
infraction punishable by a fine of not more than ten thousand
dollars ($10,000).
   (g) A licensee who violates this section is subject to a civil
penalty or a criminal fine, but not both.
   (h) Each long-term health care facility shall prominently post in
a facility location accessible to staff, patients, and visitors
written notice of the right to request an inspection pursuant to
Section 1419, the procedure for doing so, including the right to
remain anonymous, and the prohibition against retaliation.
   (i) For purposes of this section, "complainant" means any person
who has filed a complaint, as defined in Section 1420.



1432.1.  No licensee shall be cited for any violation caused by any
person licensed pursuant to the Medical Practice Act (Chapter 5
(commencing with Section 2000) of Division 2 of the Business and
Professions Code) if the person is independent of, and not connected
with, the licensee and the licensee shows that he or she has
exercised reasonable care and diligence in notifying these persons of
their duty to the patients in the licensee's long-term health care
facility.


1433.  The remedies provided by this chapter are cumulative, and
shall not be construed as restricting any remedy, provisional or
otherwise, provided by law for the benefit of any party, and no
judgment under this chapter shall preclude any party from obtaining
additional relief based upon the same facts.



1434.  Commencing in 1974, the state department shall, on or before
February 1 of each year, notify all public agencies which refer
patients to long-term health care facilities of all of the long-term
health care facilities in the area found upon inspection within the
previous 12-month period to be without class "A" or "B" violations.
Public agencies shall give priority to such long-term health care
facilities in referring publicly assisted patients. No public agency
shall refer patients to long-term health care facilities with any
uncorrected class "A" violations or five or more uncorrected class "B"
violations, except those long-term health care facilities which the
director may exempt because of a lack of facilities of the same type
in the area sufficient to satisfy the demand for services provided by
such type of facilities.



1436.  On or before July 1, 1974, the state department shall provide
for additional and ongoing training for inspectors charged with
implementation of this chapter in investigative techniques and
standards relating to the quality of care provided by long-term
health care facilities. The investigative-technique element of such
training shall be adopted after consultation with the Department of
Justice and such investigative training may, but need not, be
provided through a contract with the Department of Justice.



1437.  If a health facility, or an applicant for a license has not
been previously licensed pursuant to Chapter 2 (commencing with
Section 1250), the state department may only provisionally license
the facility as provided in this section. A provisional license to
operate a health facility shall terminate six months from the date of
issuance. Within 30 days of the termination of a provisional
license, the state department shall give the facility a full and
complete inspection, and, if the facility meets all applicable
requirements for licensure, a regular license shall be issued. If the
health facility does not meet the requirements for licensure but has
made substantial progress towards meeting the requirements, as
determined by the state department, the initial provisional license
shall be renewed for six months. If the state department determines
that there has not been substantial progress towards meeting
licensure requirements at the time of the first full inspection
provided by this section, or, if the state department determines upon
its inspection made within 30 days of the termination of a renewed
provisional license that there is lack of full compliance with the
requirements, no further license shall be issued.
   If an applicant for a provisional license to operate a health
facility has been denied provisional licensing by the state
department, he or she may contest the denial by filing a request for
a hearing pursuant to Section 100171.
   The department shall not apply less stringent criteria when
granting a provisional license pursuant to this section than it
applies when granting a permanent license.
   General acute care hospitals and acute psychiatric hospitals are
exempt from this section.


1437.5.  (a) If a facility is certified to participate in the
federal Medicare program as a skilled nursing facility under Title
XVIII of the Social Security Act, in the medicaid program as a
nursing facility under Title XIX of the Social Security Act, or in
both and any of the following occurs, the state department may
rescind its regular license to operate and issue a provisional
license under Section 1437:
   (1) The facility's provider agreement is terminated, by the
federal government or the department.
   (2) A temporary manager is appointed, under federal law, to
operate it.
   (3) Payment becomes due on a federal civil money penalty of seven
thousand dollars ($7,000) per day, or greater, imposed on it.
   (4) A federal civil monetary penalty of any amount is imposed and
has continued for a period of 30 days or more.
   (5) A federal civil monetary penalty of any amount is imposed and
has accrued in an amount equal to, or greater than, thirty-five
thousand dollars ($35,000).
   (b) The state department may not take action pursuant to
subdivision (a) until a final administrative decision is issued if
the facility has requested a hearing pursuant to federal law, until a
facility has waived its right to a hearing under federal law, or
until the time for requesting a hearing under federal law has expired
and a hearing request was not received by federal authorities.
   (c) If a receiver or temporary manager is appointed to operate a
skilled nursing facility or an intermediate care facility, specified
in paragraphs (1) and (2) of subdivision (a) of Section 1418,
pursuant to state law, or as otherwise specified in regulations
adopted by the department, the state department may rescind its
regular license to operate and issue a provisional license under this
section.
   (d) (1) A provisional license issued pursuant to this section
shall terminate six months from the date of issuance unless extended
by the department.
   (2) At least 30 days prior to the termination of a provisional
license, the department shall give the facility a full and complete
inspection. If, at the time of the inspection, it is determined that
the facility meets all applicable requirements for licensure, a
regular license shall be restored. If, at the time of the inspection,
it is determined that the facility does not meet the requirements
for licensure, but the facility has made substantial progress towards
meeting the requirements, as determined by the department, the
provisional license shall be renewed for six months. If, at the time
of the first inspection, the department determines that there has not
been substantial progress towards meeting the requirements for
licensure, or, if at any subsequent inspection the department
determines that there has not been substantial progress towards
meeting requirements identified at the most recent previous
inspection, a regular license shall not be issued.
   (e) The facility may request a hearing in writing within 10 days
of the receipt of notice from the department denying a regular
license under this section. The provisional license shall remain in
effect during the pendency of the hearing. The hearing shall be held
in accordance with Section 100171. The hearing officer shall uphold
the denial of a regular license if the department proves, by a
preponderance of the evidence, that the licensee did not meet the
requirements for licensure.


1438.  The state department shall review the effectiveness of the
enforcement system in maintaining the quality of care provided by
long-term health care facilities and shall submit a report thereon to
the Legislature on enforcement activities, on or before December 1,
2001, and annually thereafter, together with any recommendations of
the state department for additional legislation which it deems
necessary to improve the effectiveness of the enforcement system or
to enhance the quality of care provided by long-term health care
facilities. This report shall be combined with the report required
under Section 1423.5 into a single report. The time period for each
report shall cover the previous state fiscal year.




1439.  Any writing received, owned, used, or retained by the state
department in connection with the provisions of this chapter is a
public record within the meaning of subdivision (d) of Section 6252
of the Government Code, and, as such, is open to public inspection
pursuant to the provision of Sections 6253, 6256, 6257, and 6258 of
the Government Code. However, the names of any persons contained in
such records, except the names of duly authorized officers,
employees, or agents of the state department conducting an
investigation or inspection in response to a complaint filed pursuant
to this chapter, shall not be open to public inspection and copies
of such records provided for public inspection shall have such names
deleted.



1439.2.  Every long-term health care facility shall provide an
activity program to the residents of the facility to meet the needs
and interests of the residents and to encourage self-care and
resumption of normal activities, in accordance with a patient
activity plan developed by the facility including, but not limited
to, self-help skills, such as personal hygiene, care of personal
effects and living environment, nutrition, management of bedside
medications of nonprescription drugs, management of petty funds for
personal use, and cooperative relations with peers and staff to help
keep them closer to the reality of their environment. The patient
activity plan of each individual shall be reviewed and approved in
writing at least quarterly by the attending physician as not being in
conflict with the patient's treatment plan.



1439.5.  (a) The state department shall undertake the immediate
development, implementation, and maintenance of an automated
information system. The automated information system shall be
developed to ensure both of the following:
   (1) The most effective operation of this chapter and Chapter 2
(commencing with Section 1250), including, but not limited to, all of
the following:
   (A) Gathering data necessary to maximize enforcement and
monitoring capabilities.
   (B) Increasing accessibility of facility information.
   (C) Identifying any trends of substandard care.
   (D) Providing management information.
   (2) The provision of information to the general public pursuant to
subdivision (b).
   The state department shall take all necessary action to obtain
maximum federal funding assistance to develop, implement, and
maintain an automated information system.
   (b) The state department shall develop a consumer information
system, pursuant to Section 1422.5, to provide information to the
general public and long-term health care services consumers regarding
long-term health care facilities in this state. The state department
shall utilize, to the extent possible, the information provided by
its automated information system. Prior to implementation, the
consumer information system shall be presented to the Health Care
Advisory Committee for its review and comments.



1439.7.  Notwithstanding Section 14124.7 of the Welfare and
Institutions Code, a long-term health care facility participating as
a provider under the Medi-Cal program may transfer or seek to evict a
resident, within 90 days of admission, if all of the following
conditions are met:
   (a) The facility requests specific information regarding the
assets and liabilities of a prospective private-pay resident prior to
acceptance of the resident into the facility.
   (b) The facility relies on the information provided pursuant to
subdivision (a) in deciding to admit the resident.
   (c) The facility promptly and diligently investigates the
representation regarding the resident's assets and liabilities, and
discovers that the resident's financial assets and liabilities are
materially different than represented.
   (d) The 90-day limit on transfer or eviction shall not apply if,
in fact, the resident fraudulently misrepresented his or her assets
and liabilities so that if the material facts were known at the time
by the facility the resident would not have been admitted, and the
facility could not have discovered the misrepresentation with the
exercise of reasonable diligence.
   (e) In no event, shall the facility take action to transfer or
evict a resident under subdivision (d) unless the action is initiated
within 18 months of the date of admission.
   (f) A facility shall promptly notify the state department and the
Office of the Long-Term Care Ombudsman as defined in subdivision (c)
of Section 9701 of the Welfare and Institutions Code, prior to taking
action to transfer or evict a resident under this section.



1439.8.  Every long-term health care facility shall reveal to
applicants for admission, or their designated representatives, orally
and in writing, and prior to admission, whether the facility
participates in the Medi-Cal program, and the circumstances under
which the law permits a Medi-Cal recipient to be transferred
involuntarily.