BILL ANALYSIS Ó
SB 911
Page A
Date of Hearing: June 24, 2014
ASSEMBLY COMMITTEE ON AGING AND LONG-TERM CARE
Mariko Yamada, Chair
SB 911 (Block) - As Amended: June 19, 2014
SENATE VOTE : 25-11
SUBJECT : Residential care facilities for the elderly: Training
requirements
SUMMARY : Increases training requirements for licensees and
staff of Residential Care Facilities for the Elderly (RCFE).
Specifically, this bill :
1)Increases the initial certification training for
administrators from 40 hours to at least 100 hours including
60 hours of in-person classroom instruction and include
additional topics to the uniform core of knowledge, including,
but not limited to, the adverse effects of psychotropic drugs
for use in controlling the behavior of persons with dementia.
2) Increases the continuing education requirement for
administrators from 20 hours to at least 40 hours during each
two-year certification period.
3)Provides that no RCFE licensee, or officer or employee of the
licensee, may discriminate or retaliate against any person on
the basis, or for the reason that, the person dialed or called
911, and provides that any violation of this prohibition shall
result in a civil penalty, as specified.
4)Provides that a RCFE that accepts or retains a resident with a
prohibited health condition, as specified, shall assist
residents with accessing home health or hospice services to
ensure that the resident receives medical care as prescribed
by the resident's physician and contained in the resident's
service plan. Makes RCFEs violating this provision subject to
a civil penalty, as specified.
5)Provides that a RCFE that accepts or retains residents with
restricted health conditions, as specified, shall ensure that
residents receive medical care as prescribed by the resident's
physician and contained in the resident's service plan by
appropriately skilled professionals acting within their scope
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of practice. Makes RCFEs violating this provision subject to
a civil penalty, as specified.
6)Defines an "appropriately skilled professional" as an
individual who has training and is licensed to perform the
necessary medical procedures prescribed by a physician, which
includes but is not limited to a registered nurse, licensed
vocational nurse, physical therapist, occupational therapist,
or respiratory therapist who may be employed by a home health
agency (HHA), the resident, or a facility, and who are
currently licensed in this state.
7)Provides that an "appropriately skilled professional" may not
be required when the resident is providing self-care, as
defined by the Department of Social Services (DSS), and there
is no documentation in the resident's service plan that the
resident is capable of providing self-care.
8)Requires DSS to develop jointly with the California Department
of Aging requirements for a uniform core of knowledge for the
required initial certification and continuing education for
administrators, and their designated substitutes, and for
recertification of administrators of RCFEs, as specified.
Requires this training to be developed in consultation with
individuals or organizations with specific expertise in RCFEs
or assisted living services, or by an outside source with
expertise in residential care facilities for the elderly or
assisted living services.
9)Requires staff who assist residents with prescription
medication management in a RCFE with more than 16 persons to
complete 24 hours, instead of 16 hours, of initial training
related to medication management, as specified. For RCFEs
providing care to 15 or fewer persons, requires staff to
complete 10 hours, instead of six hours, of initial training.
10)Adds new training requirements for RCFE staff at facilities
serving residents with postural supports, restricted health
conditions or who receive hospice services to receive, in
addition to other training requirements, 4 hours of training
prior to providing direct care to residents on the care,
supervision, and special needs of those residents, and two
2-hour trainings thereafter of in-service training every 6
months on the subject of serving those residents.
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11)Delays implementation of the bill until January 1, 2016.
EXISTING LAW :
1)Establishes the California RCFE Act, which requires facilities
that provide personal care and supervision, protective
supervision or health related services for persons 60 years of
age or older who voluntarily choose to reside in that facility
to be licensed by the California Department of Social
Services' (DSS) Community Care Licensing Division (CCLD).
(H&S Code 1569 and 1569.1)
2)Requires RCFE licensee applicants to attend an orientation
given by the department which outlines the applicable rules
and regulations, and the scope and responsibility for
operation of a RCFE. (H&S Code 1569.235)
3)Requires a RCFE administrator to be at least 21 years of age,
have a valid RCFE administrator certificate, as specified, and
hold a high school diploma or pass a general educational
development (GED) test, as specified. (H&S Code 1569.613).
4)Requires RCFE licensee applicants to successfully complete a
certification program approved by DSS, consisting of a minimum
of 40 hours of classroom instruction, as specified, and
passage of a written test. (H&S Code 1569.23)
5)Requires DSS to authorize organizations, as specified, to
provide certificate and continuing education courses for RCFE
administrators. (H&S Code 1596.616(i))
6)Requires RCFE licensees, administrators, facility managers and
staff to undergo a criminal background check and clearance
prior to operation or employment. (H&S Code 1569.17)
7)Requires RCFE administrator certification to consist of 40
hours of classroom instruction, to be renewed every two years,
and makes issuance of the renewal conditional upon the
administrator to submit documentation of completion of 40
hours of continuing education, which shall include eight hours
of training on providing care to residents with dementia, as
specified. (H&S Code 1596.616(f))
8)Requires an RCFE administrator who holds a valid license as a
nursing home administrator, as specified, to comply with
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required administrator training requirements, but exempts him
or her from having to take the written administrator test.
(H&S Code 1596.616)
9)Permits a RCFE administrator to designate a "facility
manager;" defined as a person on the premises with the
authority and responsibility necessary to manage and control
the day-to-day operation of a RCFE and supervise residents.
(H&S Code 1596.618)
10)Requires RCFE staff to undergo ten hours of training within
the first four weeks of employment and four hours annually
thereafter, as specified. (H&S Code 1569.625)
11)Requires RCFE staff to undergo an additional six hours of
training on providing care to residents with dementia within
the first four weeks of employment and eight hours of
in-service training on dementia care annually thereafter.
(H&S Code 1569.626)
12)Requires DSS to provide appropriate training to CCLD
licensing personnel, which includes 40 hours of pre-service
training, as specified, and 36 hours of annual training, as
specified. (H&S Code 1569.652)
FISCAL EFFECT : According to the Senate Appropriations
Committee:
1)Significant one-time costs potentially in excess of $500,000
(General Fund) for DSS to revise regulations and consult with
specified groups to update the uniform core of knowledge for
RCFE administrators and training for direct care staff.
2)No new costs to the Department of Aging to continue existing
efforts of collaboration with the DSS in development of
training curriculum and a resident assessment tool.
3)Significant ongoing increase in training costs to employees
and/or facilities to meet the enhanced initial and continuing
education training requirements imposed.
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4)Potential minor non-reimbursable local enforcement costs for
violations of any of the provisions of this bill.
COMMENTS :
Background : California has the largest population of people age
65 and older of any state in the nation. California's 65+
population is projected to double from its 2010 census of about
4.3, to 8.4 million in 2030. By 2035, the 65+ population will
exceed 20 percent of the population. This year, California's
65+ population will reach 5 million people. Although research
shows that older, low-income women's life-spans are decreasing,
most other populations are experiencing longer life-spans. As
California's population ages, it is becoming more culturally and
ethnically diverse. Disability is highly associated with age,
and as the aged population expands, so will the presence of
disabilities within our communities.
RCFE is a model of care overseen by the Department of Social
Services. RCFEs provide care, supervision and assistance with
activities of daily living, such as bathing, dressing,
ambulating, grooming, and other personal activities. They may
also provide incidental medical services under special care
plans. Facilities provide services to persons 60 years of age
and over and persons under 60 with compatible needs. RCFEs are
also referred to as assisted living facilities or board and care
homes. Facilities can range in size from six or fewer, to over
100 beds. Residents in RCFEs require varying levels of personal
care and protective supervision. Since RCFEs are non-medical
facilities, they are not required to have nurses or other health
personnel on staff. Oversight of RCFEs consists of licensing
visits once every 5 years. For RCFEs under the scrutiny of the
CCL division, or on probation, annual unannounced visits from
CCL occur.
The number of RCFEs, and corresponding workload to oversee and
enforce laws and regulations therein, has grown rapidly during
the past decade. In 2004, there were about 6,500 licensed
facilities. By 2014, nearly 7,600 facilities housing over
175,000 people are in operation throughout the state. Recent
media has captured the ramifications of the rapid expansion, and
diversification of the RCFE industry, as it struggles to meet
the housing and care needs of a growing aged population, and the
growing presence of more disabilities. Although most RCFE's are
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administered and staffed by competent caregivers and people
committed to the wellbeing of their clients, frightening
accounts of poor care and administration has focused policy
makers on the RCFE model of care. In September 2013, the
California Health Care Foundation (CHCF) Center for Health
Reporting and San Diego Union Tribune reported that at least 27
San Diego County seniors died from neglect and injuries in
RCFEs, in some cases with no investigation by Community Care
Licensing (CCL). Also reported, The CCL Investigations Branch,
an internal police force, has not made an arrest in nine years
even though the investigation found that hundreds of RCFE
residents have suffered sexual assaults, physical abuse,
medication errors, life threatening bedsores and other abuses.
During the past year, Californians monitoring local, state and
national media have been confronted with no less than the
following range of media reports about RCFEs:
PBS Frontline/ProPublica: "Life and Death in Assisted Living"
and "Elderly, At Risk and Haphazardly Protected" July, 2013.
San Diego Union Tribune, California Health Care Foundation
Center for Health Reporting: "Deadly Neglect, Medical Errors,
Weaker Rules Signal Safety Problems in California Assisted
Living Homes" September, 2013.
San Jose Mercury: "Shuttering Castro Valley Senior Care
Facility Sparks Criminal Investigation" October, 2013.
The Sacramento Bee: "Care Home Owner to Stand Trial" March
2013.
No uniform common care model currently exists for RCFEs. The
types of assistive services can vary widely, which can include
differing levels of personal care and protective supervision,
based upon the needs of the resident.
If a resident needs medical care in his or her residence in
order to maintain an independent lifestyle, incidental medical
services are permitted to be provided by a licensed or otherwise
approved external provider, such as a home healthcare agency
(HHA), which is licensed by the California Department of Public
Health. Additionally, some RCFEs, upon approval of DSS and
after having met specified orientation and training
requirements, may provide assistive memory care services to
individuals with dementia or Alzheimer's disease.
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Existing regulations also lay out the circumstances under which
an individual may be allowed to reside in RCFEs. Specifically,
they include persons:<1>
1)Capable of administering their own medications;
2)Receiving medical care and treatment outside the facility or
who are receiving needed medical care from a visiting nurse;
3)Who because of forgetfulness or physical limitations need only
be reminded or to be assisted to take medication usually
prescribed for self-administration;
4)With problems including, but not limited to, forgetfulness,
wandering, confusion, irritability, and inability to manage
money;
5)With mild temporary emotional disturbance resulting from
personal loss or change in living arrangement;
6)Who are temporarily bedridden, as specified; and
7)Who are under 60 years of age whose needs are compatible with
other residents in care, if they require the same amount of
care and supervision as the other residents in the facility.
Regulations also provide specific prohibitions on individuals
who are allowed to reside in a RCFE, which includes whether the
resident has active communicable tuberculosis, requires 24-hour
skilled nursing or intermediate care, has an ongoing behavioral
or mental disorder, or has dementia, unless he or she is
otherwise permitted to be cared for in a RCFE by CCLD.<2>
Growing demand : Over the past thirty years, the demand for
RCFEs has grown substantially. Although RCFEs have been
generally available, they experienced explosive growth in the
1990s, more than doubling the number of beds between 1990 and
---------------------------
<1> Section 87455(b) of Title 22, California Code of
Regulations.
<2> Section 87455(c) of Title 22, California Code of
Regulations.
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2002,<3> and continued to grow 16 percent between 2001 and
2010.<4> Nationwide, states reported 1.2 million beds in
licensed RCFEs in 2010.<5> In 2010, the national Centers for
Disease Control reported that 40 percent of RCFE residents
needed help with three or more activities of daily living and
three-fourths of residents had at least two of the 10 most
common chronic conditions.<6>
According to DSS, as of June 2, 2014 there are 7,587 licensed
RCFEs in California with a capacity to serve 176,891 residents.
RCFE licensee and administrator requirements : California
statute differentiates between administrators and facility
licensees, who often are the business owners and may be property
owners and administrators charged with overseeing the quality of
the day-to-day operations and are generally required to be
present at the facility during normal working hours. However,
initial training and certification requirements for licensees
and administrators are similar.
At minimum, in order to be eligible to apply for a RCFE license,
a person must be at least 21 years of age, pass a criminal
background check and have a high school diploma or pass a GED
test. A prospective licensee must then provide evidence that he
or she is of "reputable and responsible character," which
includes providing an employment history and character
references. A prospective licensee must also document that he
or she has sufficient financial resources to maintain the
standard of care required by law and must disclose any prior
role as an administrator or licensee of another community care
facility, including whether any disciplinary action was taken
against him or her.
Regarding training, a licensee and an administrator are both
---------------------------
<3> Flores and Newcomer, "Monitoring Quality of Care in
Residential Care for the Elderly: The Information Challenge".
Journal of Aging and Social Policy, 21:225-242, 2009.
<4> SCAN Foundation. "Long Term Care Fundamentals: Residential
Care Facilities for the Elderly." March 2011.
http://thescanfoundation.org/sites/thescanfoundation.org/files/LT
C_Fundamental_7_0.pdf
<5> "Assisted Living and Residential Care in the States in
2010," Mollica, Robert, AARP Public Policy Institute
<6> "Residents Living in Residential Care Facilities: United
States, 2010, Caffrey, Christine, et al., US Centers for
Disease Control, April 2012
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required to undergo 40 hours of classroom instruction in order
to be certified. This training covers relevant laws and
regulations and core competencies as follows:
1)Laws, regulations, and policies and procedural standards that
impact the operations of residential care facilities for the
elderly;
2)Business operations;
3)Management and supervision of staff;
4)Psychosocial needs of the elderly;
5)Community and support services;
6)Physical needs for elderly persons;
7)Use, misuse, and interaction of medication commonly used by
the elderly;
8)Resident admission, retention, and assessment procedures;
9)Training focused specifically on serving clients with
dementia; and
10)Cultural competency and sensitivity in issues relating to the
underserved aging lesbian, gay, bisexual, and transgender
community.
Once completed, licensees and administrators must pass a written
exam administered by CCLD, and once they are certified,
licensees and administrators must renew their certification
every two years. However, for administrators, in order to have
their certification renewed, they must have participated in at
least 40 hours of continuing education. The continuing
education hours are required to include at least eight hours of
education on providing dementia care, and no more than half of
the hours of continuing education can be completed through
online courses.
RCFE staff requirements : Licensees employ a wide range of staff
to provide day-to-day support and care for residents of RCFEs.
Although many employ individuals with specific expertise and
certifications, such as Licensed Vocational Nurses and Certified
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Nursing Assistants, at minimum staff "who assist residents with
personal activities of daily living" are required to be at least
18 years of age and undergo 10 hours of training within four
weeks of being employed by the RCFE and four hours of training
each year thereafter. The training is somewhat similar to that
required of licensees and administrators, but is limited to
covering the physical limitations and needs of the elderly, the
importance and techniques for personal care services, residents'
rights, policies and procedures regarding medications and the
psychosocial needs of the elderly.
There are also additional training requirements for staff who
work in RCFEs that "provide" dementia care or who assist
residents with managing their medication. Staff who work in a
RCFE that advertises or promotes special care, special
programming, or a special environment for persons with dementia
are required to undergo an additional six hours of training on
providing care to persons with dementia. Staff also must
annually complete eight hours of continuing training on dementia
care. Training for staff who assist residents in the management
and self-administration of medication depends on the size of the
facility in which they work. For facilities with 16 or more
residents, staff must undergo 16 hours of training, and for
facilities with 15 or fewer residents, staff must complete six
hours of training on medication management. Both training
requirements must be completed within the first two weeks of
employment and conclude with an examination. Four hours of
annual continuing medication management training is required, as
well.
All personnel, including the licensee, administrator and staff,
are required to undergo and receive a criminal background
clearance, and must demonstrate they are of good health, which
means they must be physically and mentally capable of performing
assigned tasks. In order to ensure that all personnel are of
good health, they are required to undergo a health screening not
more than six months prior or seven days after employment or
licensure.<7>
Adequacy and relevance of existing training and certification
requirements : Nearly 25 years have passed since existing RCFE
licensing and certification requirements have been changed. The
last noted change was in AB 1615 (Hannigan), Chapter 848,
---------------------------
<7> Section 87411(f) of Title 22, California Code of
Regulations.
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Statutes of 1991, which required prospective licensees to
undergo an orientation training prior to commencing the licensee
certification process. Additionally, there are no requirements
that licensees or administrators have a college degree or
professional license, and staff are only required to be 18 years
of age regardless of whether they have a high school diploma.
The staff training requirements pale in comparison to those of
many service related positions that do not provide direct care
to the infirm, elderly or disabled. In its 2013 special report,
"Residential Care in California: Unsafe, Unregulated, and
Unaccountable," California Advocates for Nursing Home Reform
wrote that even a manicurist "must have 400 hours of training
and pass a state exam."
The existing training requirements and methods by which RCFE
personnel access and meet their ongoing training needs are also
antiquated. Currently, RCFE licensees and administrators are
required to undergo 40 hours of training and complete a written
exam. However, as noted by DSS, "currently, no proctoring
protocol exists, resulting in no statewide uniformity on how the
exams are administered. This lack of consistency and guidance
results in errors and can ultimately result in candidates
getting certified who may not meet the minimum
qualifications."<8>
Staff Comments: This measure is part of a package of
legislative measures that seek to establish the RCFE Reform Act
of 2014. Previously, SB 911 was in conflict with AB 1570
(Chesbro), which, like this bill, proposes to increase training
requirements for licensees and staff, and dementia care. The
Assembly Human Services Committee approved this measure with
amendments agreed to by the respective authors of this bill and
AB 1570 to avoid any conflict and to address increased training
requirement for RCFE administrators.
AB 1570 will continue to address licensee, staff and dementia
care training, but will be amended in Senate Human Services
Committee to resolve the policy differences in the training
requirements between the two bills.
With the adoption of these amendments, the two bills will become
companion measures that provide for a holistic and comprehensive
---------------------------
<8> 2014-15 Budget Change Proposal #CCLD-2; Department of Social
Services; Social Services and Licensing. 2014-15 Budget. Page
12.
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reform of RCFE training requirements.
Author's Statement : According to the author:
Residential Care Facilities for the Elderly (RCFE) law
is more than 20 years old and has not been updated to
reflect changes in medical and industry practices in
caring for the elderly. RCFEs now serve more residents
with serious health problems and higher levels of
dementia. Five years ago these residents would have
been treated in nursing homes. And although residents'
health care needs are greater, the lack of
qualifications and training required of administrators
and direct care staff is inadequate to meet the
residents' needs for care and supervision, placing RCFE
residents at risk.
SB 911 seeks to uplift RCFE care and services to our
most vulnerable population by increasing administrator
and specified training for direct care staff, by adding
higher staffing requirements to care for residents with
higher acuity, and finally protecting residents and
staff from any retaliation when they call 911 if they
notice someone needs emergency assistance.
Previous Hearing : SB 911 was previously heard and amended in
the Assembly Human Services Committee where it passed on a vote
of 6-1 (Grove).
Current Related Legislation:
SB 894 (Corbett) Would increase the responsibilities of the
California Department of Social Services (DSS) when issuing a
temporary suspension order (TSO) or when revoking the license of
a RCFE. It also establishes a private right of action for RCFE
residents when a facility is alleged to have violated the law.
SB 895 (Corbett) Would require CDSS to conduct annual
unannounced comprehensive inspections for all facilities,
requires CDSS to verify compliance following deficiencies within
10 days, and requires results of inspections to be available on
the CDSS website.
SB 1153 (Leno) Would permit CDSS to order a suspension of new
admissions for an RCFE when the facility has violated applicable
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laws and regulations that present a direct risk to the health
and safety or residents, is not providing adequate care and
supervision, has been cited for subsequent violations of the
same law within 12 months, or has failed to pay existing fines.
SB 1382 (Block) Would increase the annual licensure fees by 30
percent and make related findings and declarations.
AB 1571 (Eggman) Would increase disclosure requirements for
RCFE licensee applicants and require applicant information to be
cross-referenced with the State Department of Public Health.
Would require, by 2015, CDSS to create an online inquiry system
posting detailed information about RCFE facilities including
complaints, deficiencies and enforcement actions resulting in
fines. In subsequent years, would require CDSS to post
additional information, as specified.
AB 1572 (Eggman) Would require RCFEs, at the request of two or
more residents, to assist the residents in establishing and
maintaining a single resident council, as specified, and would
require the facility to interact with the council in specified
ways.
AB 1523 (Atkins and Weber) Would require RCFEs to maintain
liability insurance covering injury to residents and guests in
the amount of $1 million per occurrence and $3 million annually.
AB 1436 (Waldron) Would require the results of all reports of
inspections, evaluations or consultations and lists of
deficiencies to be posted on the department's Internet Web site.
AB 1454 (Calderon) Would require all licensed community care
facilities, RCFEs, and child day care centers to be subject to
an annual unannounced visit by CDSS.
AB 1570 (Chesbro) Would increase the certification training
requirements for RCFE administrators, training requirements for
RCFE staff that care for residents, and training requirements
for staff providing dementia care.
AB 1554 (Skinner) Would make various changes to existing RCFE
complaint procedures including requiring the department to make
an onsite inspection within 24 hours of a complaint alleging
abuse, neglect or a threat of imminent danger. Additionally
would require the department to complete its investigation
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within 90 days of receiving a complaint. Would permit a
complainant to file an appeal of departmental findings.
AB 1899 (Brown) Would make a person whose license is revoked or
forfeited for abandonment of the facility ineligible for
reinstatement of the license for a period of 10 years following
the revocation or forfeiture. Additionally would require CDSS
to establish and maintain a telephone hotline and an Internet
Web site dedicated to receiving complaints.
AB 2171 (Wieckowski) Would establish specified RCFE resident's
rights and require facilities to inform residents of these
rights as specified.
AB 2044 (Rodriguez) Would require every licensed residential
care facility to be subject to an annual unannounced visit by
the department, as specified. Additionally, would require
complaints to be inspected within three days if the complaint
involves alleged abuse or serious neglect, or within 10 days for
all other complaints and would require investigations to be
completed within 30 days. Would provide a complainant with the
right to request an informal conference and subsequent appeal,
as specified. Also would require certain staff to be present in
the facility for specified times.
REGISTERED SUPPORT / OPPOSITION :
Support
Hazel's Army (Co-Sponsor)
Stand Up for Rosie (Co-Sponsor)
AARP
Alliance on Aging of Monterey County
Assisted living Consumer Alliance (ALCA)
California Advocates for Nursing Home Reform (CANHR)
California Association of Public Authorities (CAPA)
California Continuing Care Residents Association (CALCRA)
California Long-Term Care Ombudsman Association (CLTCOA)
California Senior Legislature (CSL)
Catholic Charities Diocese of Stockton
Consumer Attorneys of California
Consumer Federation of California (CFC)
Contra Costa Advisor Council on Aging (CCACOA)
County of San Diego
Elder Abuse Task Force of Santa Clara County
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Elder law & Advocacy (ELA)
Johnson Moore Trial Lawyers
Long Term Care Ombudsman Services of San Luis Obispo County
Long Term Care Services of Ventura County, Inc.
National Association of Social Workers, California Chapter
(NAWS-CA)
National Consumer Voice for Quality Long-Term Care (Consumer
Voice)
Office of the State Long-Term Care Ombudsman
Ombudsman Services of Contra Costa
Stanislaus County Commission on Aging
Valentine Law Group
Two individuals.
Opposition
California Association for Health Services at Home (CAHSAH)
(Unless Amended)
LeadingAge California (Unless Amended)
Analysis Prepared by : Eric Astacaan / AGING & L.T.C. / (916)
319-3990