Senate Bill No. 779

Introduced by Senator Hall

February 27, 2015

An act to amend Section 1276.65 of the Health and Safety Code, and to amend Section 14126.022 of the Welfare and Institutions Code, relating to health care facilities.

LEGISLATIVE COUNSEL’S DIGEST

SB 779, as introduced, Hall. Skilled nursing facilities: certified nurse assistant staffing.

(1) Existing law provides for the licensure and regulation by the State Department of Public Health of health facilities, including skilled nursing facilities. Existing law requires the department to develop regulations that become effective August 1, 2003, that establish staff-to-patient ratios for direct caregivers working in a skilled nursing facility. Existing law requires that these ratios include separate licensed nurse staff-to-patient ratios in addition to the ratios established for other direct caregivers. Existing law also requires every skilled nursing facility to post information about staffing levels in the manner specified by federal requirements. Existing law makes it a misdemeanor for any person to willfully or repeatedly violate these provisions.

This bill would require the department to develop regulations that become effective June 1, 2016, and include separate staff-to-patient ratios for certified nurse assistants that comply with specified requirements. The bill would require the posted information to include an accurate report of the number of staff working each shift and to be posted in specified locations, including an area used for employee breaks. The bill would require a skilled nursing facility to make staffing data available, upon oral or written request and at a reasonable cost, within 15 days of receiving a request. By expanding the scope of a crime, this bill would impose a state-mandated local program.

(2) Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions.

Existing law, the Medi-Cal Long-Term Care Reimbursement Act, operative until August 1, 2015, requires the department to make a supplemental payment to skilled nursing facilities based on specified criteria and according to performance measure benchmarks. Existing law requires the department to establish and publish quality and accountability measures, which are used to determine supplemental payments. Existing law requires, beginning in the 2011-12 fiscal year, the measures to include, among others, compliance with specified nursing hours per patient per day requirements.

This bill would also require, beginning in the 2016-17 fiscal year, the measures to include compliance with specified certified nursing assistant staff-to-patient ratio requirements. The bill would make this provision contingent on the Medi-Cal Long-Term Care Reimbursement Act being operative on January 1, 2016.

(3) The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

SECTION 1.  

Section 1276.65 of the Health and Safety Code
is amended to read:

1276.65.  

(a) For purposes of this section, the following
definitions shall apply:

(1) “Direct caregiver” means a registered nurse, as referred to
in Section 2732 of the Business and Professions Code, a licensed
vocational nurse, as referred to in Section 2864 of the Business
and Professions Code, a psychiatric technician, as referred to in
Section 4516 of the Business and Professions Code, and a certified
nurse assistant, as defined in Section 1337.

(2) “Skilled nursing facility” means a skilled nursing facility as
defined in subdivision (c) of Section 1250.

(b) A person employed to provide services such as food
preparation, housekeeping, laundry, or maintenance services shall
not provide nursing care to residents and shall not be counted in
determining ratios under this section.

(c) (1)  begin insert (A) end insert begin insert   end insert Notwithstanding any other begin delete provision of end delete law, the
State Department of begin delete Health Services end delete begin insert Public Health end insert shall develop
regulations that become effective begin delete August 1, 2003, end delete begin insert June 1, 2016, end insert
that establish staff-to-patient ratios for direct caregivers working
in a skilled nursing facility. These ratios shall include separate
licensed nurse staff-to-patient ratios begin insert and certified nurse assistant
staff-to-patient ratios, end insert in addition to the ratios established for other
direct caregivers.

begin insert

(B) (i) The certified nurse assistant staff-to-patient ratios
developed pursuant to subparagraph (A) shall be no less than the
following:

end insert begin insert

(I) During the day shift, one certified nurse assistant for every
five patients, or fraction thereof.

end insert begin insert

(II) During the evening shift, one certified nurse assistant for
every seven patients, or fraction thereof.

end insert begin insert

(III) During the night shift, one certified nurse assistant for
every 16 patients, or fraction thereof.

end insert begin insert

(ii) For the purposes of this subparagraph, the following terms
have the following meanings:

end insert begin insert

(1) “Day shift” means the 8-hour period during which the
facility’s patients require the greatest amount of care.

end insert begin insert

(II) “Evening shift” means the 8-hour period when the facility’s
patients require more than minimal care.

end insert begin insert

(III) “Night shift” means the 8-hour period during which a
facility’s patients require the least amount of care.

end insert

(2) The department, in developing staff-to-patient ratios for
direct begin delete caregivers end delete begin insert caregivers, certified nurse assistants, end insert and licensed
nurses required by this section, shall convert the existing
requirement under Section 1276.5 of this code and Section 14110.7
of the Welfare and Institutions Code for 3.2 nursing hours per
patient day of care and shall ensure that no less care is given than
is required pursuant to Section 1276.5 of this code and Section
14110.7 of the Welfare and Institutions Code. Further, the
department shall develop the ratios in a manner that minimizes
additional state costs, maximizes resident access to care, and takes
into account the length of the shift worked. In developing the
regulations, the department shall develop a procedure for facilities
to apply for a waiver that addresses individual patient needs except
that in no instance shall the minimum staff-to-patient ratios be less
than the 3.2 nursing hours per patient day required under Section
1276.5 of this code and Section 14110.7 of the Welfare and
Institutions Code.

(d) The staffing ratios to be developed pursuant to this section
shall be minimum standards only. Skilled nursing facilities shall
employ and schedule additional staff as needed to ensure quality
resident care based on the needs of individual residents and to
ensure compliance with all relevant state and federal staffing
requirements.

(e) No later than January 1, 2006, and every five years thereafter,
the department shall consult with consumers, consumer advocates,
recognized collective bargaining agents, and providers to determine
the sufficiency of the staffing standards provided in this section
and may adopt regulations to increase the minimum staffing ratios
to adequate levels.

(f)  begin insert (1) end insert begin insert   end insert In a manner pursuant to federal requirements, effective
January 1, 2003, every skilled nursing facility shall post
information about staffing levels that includes the current number
of licensed and unlicensed nursing staff directly responsible for
resident care in the facility. This posting shall include staffing
requirements developed pursuant to this begin delete section. end delete begin insert section and an
accurate report of the number of staff working each shift. The
information shall be posted on paper that is at least 8.5 inches by
14 inches and shall be printed in a font of at least 16 point. end insert

begin insert

(2) The information described in paragraph (1) shall be posted,
at a minimum, in the following locations:

end insert begin insert

(A) An area readily accessible to members of the public.

end insert begin insert

(B) An area used for employee breaks.

end insert begin insert

(C) An area used by residents for communal functions,
including, but not limited to, dining, resident council meetings, or
activities.

end insert begin insert

(3) (A) Upon oral or written request, every skilled nursing
facility shall make direct caregiver staffing data available to the
public for review at a reasonable cost. A skilled nursing facility
shall provide the data to the requestor within 15 days after
receiving a request.

end insert begin insert

(B) For the purpose of this paragraph, “reasonable cost”
includes, but is not limited to, a ten-cent ($0.10) per page fee for
standard reproduction of documents that are 8.5 inches by 14
inches or smaller or a retrieval or processing fee not exceeding
sixty dollars ($60) if the requested data is provided on a digital
or other electronic medium and the requestor requests delivery of
the data in a digital or other electronic medium, including
electronic mail.

end insert

(g) (1) Notwithstanding any other begin delete provision of end delete law, the
department shall inspect for compliance with this section during
state and federal periodic inspections, including, but not limited
to, those inspections required under Section 1422. This inspection
requirement shall not limit the department’s authority in other
circumstances to cite for violations of this section or to inspect for
compliance with this section.

(2) A violation of the regulations developed pursuant to this
section may constitute a class “B,” “A,” or “AA” violation pursuant
to the standards set forth in Section 1424.

(h) The requirements of this section are in addition to any
requirement set forth in Section 1276.5 of this code and Section
14110.7 of the Welfare and Institutions Code.

(i) Initial implementation of the staffing ratio developed pursuant
to requirements set forth in this section shall be contingent on an
appropriation in the annual Budget Act or another statute.

(j) In implementing this section, the department may contract
as necessary, on a bid or nonbid basis, for professional consulting
services from nationally recognized higher education and research
institutions, or other qualified individuals and entities not
associated with a skilled nursing facility, with demonstrated
expertise in long-term care. This subdivision establishes an
accelerated process for issuing contracts pursuant to this section
and contracts entered into pursuant to this section shall be exempt
from the requirements of Chapter 1 (commencing with Section
10100) and Chapter 2 (commencing with Section 10290) of Part
2 of Division 2 of the Public Contract Code.

(k) This section shall not apply to facilities defined in Section
1276.9.

SEC. 2.  

Section 14126.022 of the Welfare and Institutions
Code is amended to read:

14126.022.  

(a) (1) By August 1, 2011, the department shall
develop the Skilled Nursing Facility Quality and Accountability
Supplemental Payment System, subject to approval by the federal
Centers for Medicare and Medicaid Services, and the availability
of federal, state, or other funds.

(2) (A) The system shall be utilized to provide supplemental
payments to skilled nursing facilities that improve the quality and
accountability of care rendered to residents in skilled nursing
facilities, as defined in subdivision (c) of Section 1250 of the
Health and Safety Code, and to penalize those facilities that do
not meet measurable standards.

(B) A freestanding pediatric subacute care facility, as defined
in Section 51215.8 of Title 22 of the California Code of
Regulations, shall be exempt from the Skilled Nursing Facility
Quality and Accountability Supplemental Payment System.

(3) The system shall be phased in, beginning with the 2010-11
rate year.

(4) The department may utilize the system to do all of the
following:

(A) Assess overall facility quality of care and quality of care
improvement, and assign quality and accountability payments to
skilled nursing facilities pursuant to performance measures
described in subdivision (i).

(B) Assign quality and accountability payments or penalties
relating to quality of care, or direct care staffing levels, wages, and
benefits, or both.

(C) Limit the reimbursement of legal fees incurred by skilled
nursing facilities engaged in the defense of governmental legal
actions filed against the facilities.

(D) Publish each facility’s quality assessment and quality and
accountability payments in a manner and form determined by the
director, or his or her designee.

(E) Beginning with the 2011-12 fiscal year, establish a base
year to collect performance measures described in subdivision (i).

(F) Beginning with the 2011-12 fiscal year, in coordination
with the State Department of Public Health, publish the direct care
staffing level data and the performance measures required pursuant
to subdivision (i).

(b) (1) There is hereby created in the State Treasury, the Skilled
Nursing Facility Quality and Accountability Special Fund. The
fund shall contain moneys deposited pursuant to subdivisions (g)
and (j) to (l), inclusive. Notwithstanding Section 16305.7 of the
Government Code, the fund shall contain all interest and dividends
earned on moneys in the fund.

(2) Notwithstanding Section 13340 of the Government Code,
the fund shall be continuously appropriated without regard to fiscal
year to the department for making quality and accountability
payments, in accordance with subdivision (m), to facilities that
meet or exceed predefined measures as established by this section.

(3) Upon appropriation by the Legislature, moneys in the fund
may also be used for any of the following purposes:

(A) To cover the administrative costs incurred by the State
Department of Public Health for positions and contract funding
required to implement this section.

(B) To cover the administrative costs incurred by the State
Department of Health Care Services for positions and contract
funding required to implement this section.

(C) To provide funding assistance for the Long-Term Care
Ombudsman Program activities pursuant to Chapter 11
(commencing with Section 9700) of Division 8.5.

(c) No appropriation associated with this bill is intended to
implement the provisions of Section 1276.65 of the Health and
Safety Code.

(d) (1) There is hereby appropriated for the 2010-11 fiscal year,
one million nine hundred thousand dollars ($1,900,000) from the
Skilled Nursing Facility Quality and Accountability Special Fund
to the California Department of Aging for the Long-Term Care
Ombudsman Program activities pursuant to Chapter 11
(commencing with Section 9700) of Division 8.5. It is the intent
of the Legislature for the one million nine hundred thousand dollars
($1,900,000) from the fund to be in addition to the four million
one hundred sixty-eight thousand dollars ($4,168,000) proposed
in the Governor’s May Revision for the 2010-11 Budget. It is
further the intent of the Legislature to increase this level of
appropriation in subsequent years to provide support sufficient to
carry out the mandates and activities pursuant to Chapter 11
(commencing with Section 9700) of Division 8.5.

(2) The department, in partnership with the California
Department of Aging, shall seek approval from the federal Centers
for Medicare and Medicaid Services to obtain federal Medicaid
reimbursement for activities conducted by the Long-Term Care
Ombudsman Program. The department shall report to the fiscal
committees of the Legislature during budget hearings on progress
being made and any unresolved issues during the 2011-12 budget
deliberations.

(e) There is hereby created in the Special Deposit Fund
established pursuant to Section 16370 of the Government Code,
the Skilled Nursing Facility Minimum Staffing Penalty Account.
The account shall contain all moneys deposited pursuant to
subdivision (f).

(f) (1) Beginning with the 2010-11 fiscal year, the State
Department of Public Health shall use the direct care staffing level
data it collects to determine whether a skilled nursing facility has
met the nursing hours per patient per day requirements pursuant
to Section 1276.5 of the Health and Safety Code.

(2) (A) Beginning with the 2010-11 fiscal year, the State
Department of Public Health shall assess a skilled nursing facility,
licensed pursuant to subdivision (c) of Section 1250 of the Health
and Safety Code, an administrative penalty if the State Department
of Public Health determines that the skilled nursing facility fails
to meet the nursing hours per patient per day requirements pursuant
to Section 1276.5 of the Health and Safety Code as follows:

(i) Fifteen thousand dollars ($15,000) if the facility fails to meet
the requirements for 5 percent or more of the audited days up to
49 percent.

(ii) Thirty thousand dollars ($30,000) if the facility fails to meet
the requirements for over 49 percent or more of the audited days.

(B) (i) If the skilled nursing facility does not dispute the
determination or assessment, the penalties shall be paid in full by
the licensee to the State Department of Public Health within 30
days of the facility’s receipt of the notice of penalty and deposited
into the Skilled Nursing Facility Minimum Staffing Penalty
Account.

(ii) The State Department of Public Health may, upon written
notification to the licensee, request that the department offset any
moneys owed to the licensee by the Medi-Cal program or any other
payment program administered by the department to recoup the
penalty provided for in this section.

(C) (i) If a facility disputes the determination or assessment
made pursuant to this paragraph, the facility shall, within 15 days
of the facility’s receipt of the determination and assessment,
simultaneously submit a request for appeal to both the department
and the State Department of Public Health. The request shall
include a detailed statement describing the reason for appeal and
include all supporting documents the facility will present at the
hearing.

(ii) Within 10 days of the State Department of Public Health’s
receipt of the facility’s request for appeal, the State Department
of Public Health shall submit, to both the facility and the
department, all supporting documents that will be presented at the
hearing.

(D) The department shall hear a timely appeal and issue a
decision as follows:

(i) The hearing shall commence within 60 days from the date
of receipt by the department of the facility’s timely request for
appeal.

(ii) The department shall issue a decision within 120 days from
the date of receipt by the department of the facility’s timely request
for appeal.

(iii) The decision of the department’s hearing officer, when
issued, shall be the final decision of the State Department of Public
Health.

(E) The appeals process set forth in this paragraph shall be
exempt from Chapter 4.5 (commencing with Section 11400) and
Chapter 5 (commencing with Section 11500), of Part 1 of Division
3 of Title 2 of the Government Code. The provisions of Section
100171 and 131071 of the Health and Safety Code shall not apply
to appeals under this paragraph.

(F) If a hearing decision issued pursuant to subparagraph (D)
is in favor of the State Department of Public Health, the skilled
nursing facility shall pay the penalties to the State Department of
Public Health within 30 days of the facility’s receipt of the
decision. The penalties collected shall be deposited into the Skilled
Nursing Facility Minimum Staffing Penalty Account.

(G) The assessment of a penalty under this subdivision does not
supplant the State Department of Public Health’s investigation
process or issuance of deficiencies or citations under Chapter 2.4
(commencing with Section 1417) of Division 2 of the Health and
Safety Code.

(g) The State Department of Public Health shall transfer, on a
monthly basis, all penalty payments collected pursuant to
subdivision (f) into the Skilled Nursing Facility Quality and
Accountability Special Fund.

(h) Nothing in this section shall impact the effectiveness or
utilization of Section 1278.5 or 1432 of the Health and Safety Code
relating to whistleblower protections, or Section 1420 of the Health
and Safety Code relating to complaints.

(i) (1) Beginning in the 2010-11 fiscal year, the department,
in consultation with representatives from the long-term care
industry, organized labor, and consumers, shall establish and
publish quality and accountability measures, benchmarks, and data
submission deadlines by November 30, 2010.

(2) The methodology developed pursuant to this section shall
include, but not be limited to, the following requirements and
performance measures:

(A) Beginning in the 2011-12 fiscal year:

(i) Immunization rates.

(ii) Facility acquired pressure ulcer incidence.

(iii) The use of physical restraints.

(iv) Compliance with the nursing hours per patient per day
requirements pursuant to Section 1276.5 of the Health and Safety
Code.

(v) Resident and family satisfaction.

(vi) Direct care staff retention, if sufficient data is available.

begin insert

(B) Beginning in the 2016-17 fiscal year, compliance with the
certified nursing assistant staff-to-patient ratio requirements
pursuant to Section 1276.65 of the Health and Safety Code.

end insert begin delete

(B)

end delete

begin insert ( end insert begin insert C) end insert  If this act is extended beyond the dates on which it becomes
inoperative and is repealed, in accordance with Section 14126.033,
the department, in consultation with representatives from the
long-term care industry, organized labor, and consumers, beginning
in the 2013-14 rate year, shall incorporate additional measures
into the system, including, but not limited to, quality and
accountability measures required by federal health care reform
that are identified by the federal Centers for Medicare and Medicaid
Services.

begin delete

(C)

end delete

begin insert ( end insert begin insert D) end insert  The department, in consultation with representatives from
the long-term care industry, organized labor, and consumers, may
incorporate additional performance measures, including, but not
limited to, the following:

(i) Compliance with state policy associated with the United
States Supreme Court decision in Olmstead v. L.C. ex rel. Zimring
(1999) 527 U.S. 581.

(ii) Direct care staff retention, if not addressed in the 2012-13
rate year.

(iii) The use of chemical restraints.

(j)  (1)  Beginning with the 2010-11 rate year, and pursuant to
subparagraph (B) of paragraph (5) of subdivision (a) of Section
14126.023, the department shall set aside savings achieved from
setting the professional liability insurance cost category, including
any insurance deductible costs paid by the facility, at the 75th
percentile. From this amount, the department shall transfer the
General Fund portion into the Skilled Nursing Facility Quality and
Accountability Special Fund. A skilled nursing facility shall
provide supplemental data on insurance deductible costs to
facilitate this adjustment, in the format and by the deadlines
determined by the department. If this data is not provided, a
facility’s insurance deductible costs will remain in the
administrative costs category.

(2) Notwithstanding paragraph (1), for the 2012-13 rate year
only, savings from capping the professional liability insurance cost
category pursuant to paragraph (1) shall remain in the General
Fund and shall not be transferred to the Skilled Nursing Facility
Quality and Accountability Special Fund.

(k) Beginning with the 2013-14 rate year, if there is a rate
increase in the weighted average Medi-Cal reimbursement rate,
the department shall set aside the first 1 percent of the weighted
average Medi-Cal reimbursement rate increase for the Skilled
Nursing Facility Quality and Accountability Special Fund.

(l) If this act is extended beyond the dates on which it becomes
inoperative and is repealed, in accordance with Section 14126.033,
beginning with the 2014-15 rate year, in addition to the amount
set aside pursuant to subdivision (k), if there is a rate increase in
the weighted average Medi-Cal reimbursement rate, the department
shall set aside at least one-third of the weighted average Medi-Cal
reimbursement rate increase, up to a maximum of 1 percent, from
which the department shall transfer the General Fund portion of
this amount into the Skilled Nursing Facility Quality and
Accountability Special Fund.

(m) (1)  (A)  Beginning with the 2013-14 rate year, the
department shall pay a supplemental payment, by April 30, 2014,
to skilled nursing facilities based on all of the criteria in subdivision
(i), as published by the department, and according to performance
measure benchmarks determined by the department in consultation
with stakeholders.

(B) (i) The department may convene a diverse stakeholder
group, including, but not limited to, representatives from consumer
groups and organizations, labor, nursing home providers, advocacy
organizations involved with the aging community, staff from the
Legislature, and other interested parties, to discuss and analyze
alternative mechanisms to implement the quality and accountability
payments provided to nursing homes for reimbursement.

(ii) The department shall articulate in a report to the fiscal and
appropriate policy committees of the Legislature the
implementation of an alternative mechanism as described in clause
(i) at least 90 days prior to any policy or budgetary changes, and
seek subsequent legislation in order to enact the proposed changes.

(2) Skilled nursing facilities that do not submit required
performance data by the department’s specified data submission
deadlines pursuant to subdivision (i) shall not be eligible to receive
supplemental payments.

(3) Notwithstanding paragraph (1), if a facility appeals the
performance measure of compliance with the nursing hours per
patient per day requirements, pursuant to Section 1276.5 of the
Health and Safety Code, to the State Department of Public Health,
and it is unresolved by the department’s published due date, the
department shall not use that performance measure when
determining the facility’s supplemental payment.

(4) Notwithstanding paragraph (1), if the department is unable
to pay the supplemental payments by April 30, 2014, then on May
1, 2014, the department shall use the funds available in the Skilled
Nursing Facility Quality and Accountability Special Fund as a
result of savings identified in subdivisions (k) and (l), less the
administrative costs required to implement subparagraphs (A) and
(B) of paragraph (3) of subdivision (b), in addition to any Medicaid
funds that are available as of December 31, 2013, to increase
provider rates retroactively to August 1, 2013.

(n) The department shall seek necessary approvals from the
federal Centers for Medicare and Medicaid Services to implement
this section. The department shall implement this section only in
a manner that is consistent with federal Medicaid law and
regulations, and only to the extent that approval is obtained from
the federal Centers for Medicare and Medicaid Services and federal
financial participation is available.

(o) In implementing this section, the department and the State
Department of Public Health may contract as necessary, with
California’s Medicare Quality Improvement Organization, or other
entities deemed qualified by the department or the State
Department of Public Health, not associated with a skilled nursing
facility, to assist with development, collection, analysis, and
reporting of the performance data pursuant to subdivision (i), and
with demonstrated expertise in long-term care quality, data
collection or analysis, and accountability performance measurement
models pursuant to subdivision (i). This subdivision establishes
an accelerated process for issuing any contract pursuant to this
section. Any contract entered into pursuant to this subdivision shall
be exempt from the requirements of the Public Contract Code,
through December 31, 2013.

(p) Notwithstanding Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code,
the following shall apply:

(1) The director shall implement this section, in whole or in
part, by means of provider bulletins, or other similar instructions
without taking regulatory action.

(2) The State Public Health Officer may implement this section
by means of all facility letters, or other similar instructions without
taking regulatory action.

(q) Notwithstanding paragraph (1) of subdivision (m), if a final
judicial determination is made by any state or federal court that is
not appealed, in any action by any party, or a final determination
is made by the administrator of the federal Centers for Medicare
and Medicaid Services, that any payments pursuant to subdivisions
(a) and (m), are invalid, unlawful, or contrary to any provision of
federal law or regulations, or of state law, these subdivisions shall
become inoperative, and for the 2011-12 rate year, the rate increase
provided under subparagraph (A) of paragraph (4) of subdivision
(c) of Section 14126.033 shall be reduced by the amounts described
in subdivision (j). For the 2013-14 rate year, and for each
subsequent rate year, any rate increase shall be reduced by the
amounts described in subdivisions (j) to (l), inclusive.

SEC. 3.  

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.

SEC. 4.  

Section 2 of this act shall only become operative if the
Medi-Cal Long-Term Care Reimbursement Act (Article 3.8
(commencing with Section 14126) of Chapter 7 of Part 3 of
Division 9 of the Welfare and Institutions Code) is operative on
January 1, 2016.