California Elder Care Legal Framework

California’s elder care regulatory system is among the nation’s most comprehensive—combining state licensing (CDPH for SNFs, CDSS for RCFEs), federal Medicare/Medicaid conditions of participation, and robust civil liability under EADACPA.

Elder Abuse and Dependent Adult Civil Protection Act (W&I §§ 15600 et seq.)

EADACPA creates special civil remedies for abuse and neglect of elders (age 65+) and dependent adults (18-64 with physical/mental limitations preventing self-care).

Physical Abuse (W&I § 15610.63)

Physical abuse includes: assault, battery, sexual assault, unreasonable physical constraint, prolonged or continual deprivation of food or water, use of physical/chemical restraints for discipline or convenience (not medical necessity).

Common examples in elder care facilities:

• Staff hitting or slapping residents
• Overuse of psychotropic medications to sedate residents (chemical restraint)
• Tying residents to wheelchairs without physician order or medical necessity
• Sexual assault by staff or other residents (failure to supervise)

Neglect (W&I § 15610.57)

Neglect is the failure to provide medical care, food, shelter, clothing, or other goods and services necessary to avoid physical harm or mental suffering. Includes failure to protect from health and safety hazards.

Common neglect in elder care facilities:

• Pressure ulcers (bedsores) from failure to reposition immobile residents
• Falls from failure to respond to call lights, inadequate staffing, or missing fall prevention protocols
• Dehydration and malnutrition from inadequate feeding assistance
• Medication errors (wrong dose, wrong patient, missed doses)
• Failure to obtain timely medical care for acute conditions (sepsis, fractures, heart attack)
• Understaffing – Chronic understaffing that prevents staff from providing necessary care (W&I § 15610.57(b))

Proving Neglect: Must show (1) facility had substantial caretaking/custodial relationship with elder, (2) facility failed to provide medical care, food, shelter, or protection from health hazards, (3) failure was result of facility’s recklessness, oppression, fraud, or malice (for enhanced remedies).

Financial Abuse (W&I § 15610.30)

Taking, secreting, appropriating, obtaining by undue influence, or retaining real or personal property of elder for wrongful use or with intent to defraud.

Common financial abuse in facilities:

• Administrator stealing from resident trust accounts
• Staff taking jewelry, cash, or valuables from residents’ rooms
• Undue influence over residents to change wills or add facility staff as beneficiaries
• Billing for services not provided (phantom services)

Enhanced Remedies (W&I § 15657)

If plaintiff proves by clear and convincing evidence that defendant is liable for physical abuse, neglect, or financial abuse and that defendant committed abuse with recklessness, oppression, fraud, or malice, plaintiff may recover:

• Unlimited pain and suffering damages (MICRA caps do not apply)
• Attorney fees and costs (typically 33-40% contingency fees fully recoverable from defendant)
• Punitive damages (if malice or oppression)

Corporate Liability for Enhanced Remedies: Facility owner/operator liable if officer, director, or managing agent (not just line staff) authorized, ratified, or was personally guilty of oppression, fraud, or malice (Civil Code § 3294(b)). Alternatively, corporate policy or practice that created conditions enabling abuse satisfies this standard.

Example: SNF chronically understaffed (2 CNAs for 60 residents on night shift, half the required ratio). Administrator receives monthly reports documenting increased fall rates and pressure ulcers. Administrator prioritizes profit margins over staffing. Resident falls, fractures hip, develops fatal sepsis. Corporate liability established via administrator’s knowing ratification of dangerous understaffing policy.

Skilled Nursing Facility Regulation (Title 22 CCR §§ 72000 et seq.)

SNFs are licensed and regulated by California Department of Public Health (CDPH). Key requirements:

• Staffing Ratios (Title 22 CCR § 72329) – Minimum 3.2 nursing hours per patient day. Specific ratios for RNs, LVNs, CNAs.
• Care Plans (§ 72315) – Individualized care plan for each resident based on comprehensive assessment, updated quarterly or when condition changes
• Incident Reporting (§ 72527) – Report unusual occurrences (falls, medication errors, injuries, deaths) to CDPH within specified timeframes
• Resident Rights (§ 72527) – Informed consent, privacy, freedom from restraints, participation in care decisions
• Infection Control (§ 72525) – Policies and procedures to prevent/control infections

Federal Requirements: SNFs participating in Medicare/Medicaid must also meet federal conditions of participation (42 CFR Part 483), including quality of care standards, resident assessment protocols (MDS), and quality assurance programs.

Enforcement: CDPH conducts annual inspections and complaint investigations. Deficiencies are cited as “A” (no actual harm), “B” (actual harm, not immediate jeopardy), or “AA” (immediate jeopardy to resident health/safety). Penalties include civil fines ($100-$100,000 per violation), conditional licensure, license suspension/revocation.

Residential Care Facility for the Elderly (RCFE) Regulation (HSC §§ 1569 et seq.)

RCFEs (assisted living, board and care, memory care) are licensed by California Department of Social Services (CDSS). Key requirements:

• Resident Assessment & Service Plan (Title 22 CCR § 87468) – Assess residents’ care needs, develop individualized service plans
• Medication Management (§ 87465) – Staff must be certified to administer medications, maintain medication logs, ensure proper storage
• Supervision (§ 87411) – Staff on duty 24 hours; minimum 1:15 staff-to-resident ratio during waking hours, 1:30 at night (higher ratios for dementia care)
• Dementia Care Disclosure (HSC § 1569.626) – Facilities advertising Alzheimer’s/dementia care must meet enhanced standards and disclose staffing, training, and care practices
• Fire Safety & Building Standards (§ 87302) – Sprinklers, smoke detectors, evacuation plans, staff training

Enforcement: CDSS Community Care Licensing Division conducts inspections and investigates complaints. Enforcement actions include civil penalties ($150-$1,000 per violation), temporary suspension, license revocation, criminal referral for egregious violations.

Common Elder Care Facility Violations

Based on my practice representing families in EADACPA wrongful death cases and facility owners in regulatory defense, here are the most frequent violations:

Violation #1: Understaffing-Driven Neglect (Falls, Pressure Ulcers)

Fact Pattern: For-profit SNF operates with chronic understaffing to maximize profit margins. Night shift has 2 CNAs for 60 residents (required ratio: 1:10, actual ratio: 1:30). Resident with dementia, fall history, and documented high fall risk placed in room at end of long hallway. Call light placed out of reach. Resident attempts to use bathroom unassisted at 2 AM, falls, fractures hip. Staff does not discover resident on floor until 6 AM (4 hours later). Resident develops fatal pulmonary embolism from immobility.

Legal Violations:

• Neglect under EADACPA (W&I § 15610.57) – Failure to provide protection from health and safety hazards (fall prevention)
• Title 22 staffing violations – Operating below minimum staffing ratios
• Failure to implement care plan – Care plan documented fall risk and specified bed alarm, 2-person assist, frequent toileting. None implemented due to understaffing.
• Failure to respond to call light – Even if resident could reach call light, no staff available to respond

Proving Recklessness for Enhanced Remedies: Administrator’s budget documents show deliberate decision to cut staffing costs despite monthly reports documenting increased fall rates. Corporate policy prioritized profit over resident safety. Meets W&I § 15657 standard for unlimited damages and attorney fees.

Family Remedies: EADACPA wrongful death claim. Economic damages (funeral costs, medical expenses). Unlimited non-economic damages (decedent’s pain and suffering from fracture, family’s loss of companionship). Attorney fees. Punitive damages if malice proven. CDPH complaint for immediate jeopardy citation (AA-level deficiency).

Violation #2: Pressure Ulcers (Bedsores) from Failure to Reposition

Fact Pattern: Resident admitted to SNF post-stroke, bedridden, unable to reposition self. Care plan requires repositioning every 2 hours to prevent pressure ulcers. Understaffing and lack of supervision result in repositioning occurring 1-2 times per 8-hour shift (not every 2 hours). Resident develops Stage 4 sacral pressure ulcer (bone exposed). Wound becomes infected, resident develops sepsis, dies.

Legal Violations:

• EADACPA neglect – Failure to provide medical care and protection from health hazards. Pressure ulcers are preventable injuries indicating neglect.
• 42 CFR § 483.25 (federal quality of care standard) – Facility must ensure resident does not develop pressure ulcers unless clinically unavoidable
• Title 22 care plan violations – Failure to implement care plan’s repositioning protocol

Medical Causation: Expert testimony that Stage 3-4 pressure ulcers do not develop with proper care. Presence of advanced ulcer is res ipsa loquitur evidence of neglect.

Family Remedies: EADACPA wrongful death. Unlimited pain and suffering damages (months of excruciating pain from infected wound). Attorney fees. CDPH complaint (pressure ulcer deficiencies are top citation category).

Violation #3: Medication Errors Causing Death

Fact Pattern: RCFE resident with diabetes requires insulin before meals. New staff member administers insulin to wrong resident (name mix-up). Wrong resident (non-diabetic) receives insulin, blood sugar drops dangerously low, resident becomes unconscious. Staff does not recognize hypoglycemia for 2 hours. Resident suffers brain damage from prolonged hypoglycemia, dies 3 days later.

Legal Violations:

• EADACPA neglect – Failure to provide necessary medical care (proper medication administration)
• Title 22 medication management violations (CCR § 87465) – Staff administering medications must be certified, must verify patient identity, must document administration
• Gross negligence / wrongful death – Administering insulin to wrong patient is extreme deviation from standard of care

Proving Recklessness: Facility’s medication error log shows pattern of errors over prior 6 months. Administrator aware but failed to implement corrective action (additional training, verification protocols). Corporate knowledge of ongoing problem + failure to correct = recklessness.

Family Remedies: EADACPA wrongful death with enhanced remedies. Medical malpractice claim (medication errors are professional negligence). CDSS complaint for immediate license suspension. Coroner referral for investigation.

Violation #4: Sexual Assault Due to Inadequate Supervision

Fact Pattern: Memory care unit houses residents with severe dementia. Male resident with history of sexual aggression (documented in records from prior facility, disclosed to current facility). Facility does not implement supervision plan. Male resident sexually assaults female resident with advanced dementia in shared activity room. No staff present. Assault discovered by family member during visit.

Legal Violations:

• EADACPA physical abuse (W&I § 15610.63) – Sexual assault
• EADACPA neglect – Failure to protect from health and safety hazards (failure to supervise resident with known propensity for aggression)
• Title 22 supervision violations – Inadequate staff presence in common areas
• Mandatory reporting failure (W&I § 15630) – Facility required to report abuse to Adult Protective Services and law enforcement immediately

Proving Oppression: Facility had actual knowledge of resident’s history of sexual aggression (prior facility sent transfer documentation). Facility failed to implement any protective measures (separate male/female activity areas, 1:1 supervision, discharge if cannot safely manage). Conscious disregard of known risk = oppression under EADACPA.

Victim’s Remedies: EADACPA claim for physical abuse and neglect. Unlimited damages. Attorney fees. Punitive damages. Criminal prosecution of assailant (if competent to stand trial) and potential criminal charges against administrator for willful failure to report (W&I § 15630(h) – misdemeanor).

Violation #5: Financial Abuse by Administrator (Theft from Resident Trust Accounts)

Fact Pattern: SNF administrator controls resident trust accounts (personal funds deposited for safekeeping per Title 22 § 72520). Administrator embezzles $150,000 from trust accounts over 2-year period to cover facility’s operating shortfalls. Residents’ families discover theft when requesting accounting.

Legal Violations:

• EADACPA financial abuse (W&I § 15610.30) – Taking, appropriating, or obtaining elder’s property for wrongful use
• Title 22 trust fund violations (§ 72520) – Misappropriation of resident trust funds
• Theft / embezzlement (Penal Code §§ 484, 503) – Criminal prosecution

Remedies: EADACPA civil action for financial abuse. Unlimited damages if recklessness/fraud proven. Attorney fees. Punitive damages. Treble damages under Penal Code § 496 if administrator converted property (3x actual damages). Criminal prosecution. CDPH enforcement action (license suspension/revocation). Facility owner may also have civil claims against administrator for breach of fiduciary duty.

Violation #6: Wrongful Discharge / Eviction (Medicaid Discrimination)

Fact Pattern: Resident exhausts private pay funds, transitions to Medicaid (Medi-Cal) payment. SNF issues 30-day eviction notice claiming “behavior issues” (pretext). True reason: Medicaid reimbursement is lower than private pay rate, facility wants to replace with higher-paying private pay resident.

Legal Violations:

• Federal Medicaid discrimination prohibition (42 CFR § 483.12(d)) – SNF accepting Medicaid cannot discharge resident solely because payment source changed to Medicaid
• State Medicaid regulations – Same prohibition under California law
• Contract violation – Resident admission agreement typically guarantees continued occupancy as long as medically appropriate

Resident Remedies: Injunctive relief (TRO/preliminary injunction preventing discharge). Breach of contract claim. Federal Medicaid complaint to CMS (Centers for Medicare & Medicaid Services). CDPH complaint. Long-Term Care Ombudsman involvement.

Sample Demand Letters – Elder Care Facility Disputes

Below are sample demand letters for common elder care scenarios. These are templates for educational purposes and must be customized to your specific facts, jurisdiction, and legal claims. I draft demand letters for clients as part of comprehensive representation.

Regulatory Leverage in Elder Care Facility Disputes

Elder care facilities face multiple regulatory agencies with enforcement authority. Strategic use of regulatory complaints creates powerful settlement pressure in EADACPA and payment dispute cases.

California Department of Public Health (CDPH) – SNF Licensing & Certification

Jurisdiction: CDPH Licensing and Certification Program licenses and regulates all skilled nursing facilities in California under Title 22 and federal Medicare/Medicaid conditions of participation.

Enforcement Actions:

• Citations and Deficiency Reports – “A” (no actual harm), “B” (actual harm), “AA” (immediate jeopardy)
• Civil Monetary Penalties – $100 to $100,000 per violation per day (immediate jeopardy violations: $3,050-$20,000 per day)
• Temporary Management – CDPH installs temporary manager to operate facility
• License Suspension or Revocation – For egregious or repeat violations
• Conditional License – Facility on probation, subject to enhanced monitoring
• Medicare/Medicaid Decertification – Federal termination of participation (financial death sentence for most SNFs)

How to File Complaint: Online at cdph.ca.gov or call District Office. Complaints can be anonymous. CDPH required to investigate within specified timeframes (immediate jeopardy: 2 working days).

Strategic Value: CDPH investigation findings (deficiency reports) are public record and admissible in civil litigation. AA-level immediate jeopardy citation creates extreme settlement pressure (facility fears license revocation and Medicare decertification). Use in demand letter: “I have submitted immediate jeopardy complaint to CDPH documenting chronic understaffing. CDPH investigation is pending.”

California Department of Social Services (CDSS) – RCFE Licensing

Jurisdiction: CDSS Community Care Licensing Division licenses and regulates RCFEs (assisted living, board and care, memory care) under Health & Safety Code §§ 1569 et seq. and Title 22 CCR §§ 87000 et seq.

Enforcement Actions:

• Citations and Civil Penalties – $150 to $1,000 per violation
• Temporary Suspension – Immediate suspension of admissions or all operations for imminent danger
• Conditional License – Probationary status with compliance requirements
• License Revocation – Permanent closure
• Criminal Referral – For egregious neglect or abuse (Health & Safety Code § 1569.60 – misdemeanor/felony)

How to File Complaint: Online at ccld.dss.ca.gov or call Community Care Licensing Division. CDSS required to investigate complaints alleging immediate danger within 10 days.

Strategic Value: CDSS less politically constrained than CDPH (CDPH reluctant to close SNFs due to bed shortage). CDSS more willing to revoke RCFE licenses for serious violations.

Long-Term Care Ombudsman Program

Jurisdiction: California Department of Aging operates statewide Ombudsman program to investigate and resolve complaints by or on behalf of long-term care residents (SNFs and RCFEs).

Ombudsman Powers:

• Investigate complaints (access to facility and residents)
• Advocate for residents in disputes with facilities
• Refer violations to CDPH, CDSS, Adult Protective Services, law enforcement
• Testify in administrative and judicial proceedings
• No enforcement authority (cannot issue citations), but serves as powerful advocate and referral source

How to File Complaint: Contact local Ombudsman (directory at aging.ca.gov) or call statewide hotline at 800-231-4024.

Strategic Value: Ombudsman involvement signals seriousness to facility. Ombudsman reports are admissible evidence. Useful for resolving non-litigation disputes (wrongful discharge, missing personal property, access restrictions).

Adult Protective Services (APS) – Criminal Investigations

Jurisdiction: County APS agencies investigate elder abuse and neglect under Welfare & Institutions Code §§ 15600 et seq. APS has authority to remove endangered elders and refer for criminal prosecution.

Mandatory Reporting: Health care practitioners, facility staff, and others with elder contact must report suspected abuse to APS and/or law enforcement within 24 hours (W&I § 15630). Failure to report is misdemeanor.

How to Report: Contact county APS (directory at cdss.ca.gov/adult-protective-services) or call statewide hotline at 833-401-0832.

Strategic Value: APS investigations can result in criminal charges against facility staff and administrators (willful endangerment, W&I § 15656 – imprisonment up to 1 year and $6,000 fine). Criminal prosecution strengthens civil settlement position.

Medicare/Medicaid (CMS) – Federal Enforcement

Jurisdiction: Centers for Medicare & Medicaid Services (CMS) certifies SNFs for participation in Medicare/Medicaid. CMS enforces federal conditions of participation (42 CFR Part 483).

Enforcement Actions:

• Civil Monetary Penalties – Federal fines (up to $21,000 per day for immediate jeopardy)
• Termination of Medicare/Medicaid Participation – Financial death sentence (most SNFs derive 70%+ revenue from Medicare/Medicaid)
• Denial of Payment for New Admissions – Interim sanction while facility corrects deficiencies

How to File Complaint: File with state CDPH (which conducts Medicare/Medicaid inspections on behalf of CMS) or directly with CMS at medicare.gov/nursinghomecompare.

Strategic Value: Threat of Medicare decertification is existential for SNFs. Credible CMS complaint creates maximum settlement pressure.

Private Civil Actions – EADACPA, Wrongful Death, Medical Malpractice

EADACPA (W&I §§ 15600 et seq.):

• Physical abuse, neglect, financial abuse claims
• Enhanced remedies if recklessness/oppression proven: unlimited pain and suffering damages (MICRA inapplicable), attorney fees, punitive damages
• Clear and convincing evidence standard (higher than ordinary negligence’s preponderance standard)
• Corporate liability if officer/director/managing agent authorized, ratified, or was personally guilty of abuse, or corporate policy created conditions enabling abuse

Wrongful Death (Code of Civil Procedure § 377.60):

• Statutory beneficiaries: surviving spouse, domestic partner, children, grandchildren (if children deceased), parents (if no spouse or children)
• Damages: economic (funeral, medical), non-economic (loss of companionship, comfort, care, society)
• Can be combined with EADACPA for enhanced remedies

Medical Malpractice (MICRA applies unless EADACPA enhanced remedy):

• Professional negligence by physicians, nurses, SNF facility
• Non-economic damages capped at $500,000 (post-AB 35, for cases filed after 2023) unless EADACPA enhanced remedy
• Expert testimony required (standard of care, causation)
• Notice of intent to sue (Code of Civil Procedure § 364) – 90 days before filing

Attorney Services – Elder Care Facility Disputes

I represent families in EADACPA wrongful death and abuse cases, and facility owners in payment disputes and regulatory defense. My practice focuses on strategic demand letters, regulatory enforcement, and civil litigation in California elder care law.

Family Representation – EADACPA & Wrongful Death

I help families seek justice and compensation when nursing homes, assisted living facilities, and memory care units harm or kill loved ones through neglect or abuse:

• Case Evaluation – Review medical records, incident reports, autopsy reports to determine if EADACPA enhanced remedy case (recklessness/oppression) or ordinary medical malpractice
• Expert Consultation – Retain geriatric medicine experts, nursing experts, economists to establish standard of care violations, causation, and damages
• Demand Letters – Draft pre-litigation demands documenting neglect, corporate recklessness, and full damages calculation to achieve early settlement
• Regulatory Complaints – File CDPH or CDSS complaints to create settlement pressure and develop admissible evidence (deficiency reports)
• EADACPA Litigation – File and prosecute wrongful death and elder abuse actions through trial, seeking unlimited damages, attorney fees, and punitive damages
• Wrongful Death – Represent statutory beneficiaries in wrongful death claims for economic and non-economic losses

Facility Owner Representation – Payment Disputes & Regulatory Defense

I represent SNF and RCFE owners in collection matters, contract disputes, and defense of regulatory actions:

• Payment Disputes – Collect unpaid private pay balances, enforce admission agreements and responsible party guarantees
• Medicare/Medicaid Recovery – Navigate Medicare/Medicaid appeals for denied claims and retroactive payment adjustments
• Regulatory Defense – Defend against CDPH/CDSS citations, prepare informal dispute resolution (IDR) and appeal of deficiencies
• License Defense – Defend facilities in license suspension or revocation proceedings
• Contract Disputes – Landlord-tenant disputes, vendor contracts, employment agreements
• Compliance Counseling – Advise on Title 22 compliance, staffing requirements, care plan protocols, incident reporting

Why Clients Choose My Practice

California Elder Care Law Expertise: I focus on California elder abuse law, EADACPA enhanced remedies, Title 22 regulations, CDPH/CDSS enforcement procedures, and post-AB 35 MICRA changes. I understand the technical requirements for proving recklessness and corporate liability.

Medical Record Fluency: I read medical charts, incident reports, care plans, and MDS assessments. I know what to look for (staffing ratios, repositioning documentation, fall risk assessments, medication administration records).

Regulatory Leverage: I know how to use CDPH/CDSS complaints strategically to create settlement pressure and develop trial evidence without crossing ethical boundaries.

Realistic Case Assessment: Not every nursing home death is EADACPA case. I provide candid evaluation of whether your case meets enhanced remedy standard (recklessness) or is ordinary medical malpractice (MICRA caps apply). I don’t overpromise or encourage frivolous claims.

Trial Experience: While most elder abuse cases settle, I am fully prepared to try cases to verdict. Defense counsel knows I will not accept lowball settlement offers.

Dual Perspective: Representing both families and facility owners gives me unique insight into both sides’ priorities, enabling more effective negotiation.

Contact Information

Attorney Sergei Tokmakov
California Elder Care Law & EADACPA Litigation
Email: owner@terms.law

Schedule consultation using Calendly widget above or contact me directly to discuss your elder care facility dispute.