California Elder Care Facilities SNFs, RCFEs, Memory Care & Assisted Living
Elder Abuse, Neglect, Wrongful Death & Regulatory Enforcement Demand Letters
Attorney Sergei Tokmakov – EADACPA Claims & Long-Term Care Regulatory Defense
California's elder care industry is heavily regulated—but enforcement is often reactive, arriving only after tragedy. Families face skilled nursing facilities (SNFs) that warehouse residents in understaffed units, residential care facilities for the elderly (RCFEs) that fail basic supervision duties, and memory care units that chemically restrain dementia patients rather than provide proper care. When neglect, abuse, or wrongful death occurs, the Elder Abuse and Dependent Adult Civil Protection Act (EADACPA) provides powerful civil remedies—including enhanced damages and attorney fees. I also represent facility owners in payment disputes, regulatory defense, and Medicare/Medicaid recovery. Whether you're a grieving family seeking justice or a facility owner facing unjust regulatory action—strategic demand letters backed by California elder care law can resolve disputes efficiently.
Overview: California Elder Care Facility Regulation & Enforcement
California operates over 7,000 elder care facilities—from large skilled nursing facilities (SNFs) with 100+ beds to small residential care homes with 6 residents. All are subject to strict licensing, staffing, and care standards under state and federal law. But violations are rampant: understaffing leading to pressure ulcers and falls, medication errors causing preventable deaths, financial exploitation by administrators, and outright neglect.
Types of California Elder Care Facilities
Facility Type
Regulator
Typical Services
Key Regulations
Skilled Nursing Facility (SNF)
CDPH (California Department of Public Health)
24-hour nursing care, post-acute rehabilitation, long-term care for medically complex residents
Title 22 CCR §§ 72000 et seq.; Federal Medicare/Medicaid conditions of participation (42 CFR Part 483)
Residential Care Facility for the Elderly (RCFE)
CDSS (California Department of Social Services)
Assistance with ADLs (bathing, dressing, medication management), meals, activities. No skilled nursing.
Health & Safety Code §§ 1569 et seq.; Title 22 CCR §§ 87000 et seq.
Assisted Living / Memory Care
CDSS (licensed as RCFEs with specialized dementia care designation)
Same as RCFE, plus specialized dementia care, secured perimeter, enhanced staffing ratios
RCFE regulations + specialized Alzheimer's/dementia care requirements
Adult Residential Facility (ARF)
CDSS
Smaller facilities (typically under 60), similar services to RCFE
Health & Safety Code §§ 1502 et seq.; Title 22 CCR §§ 80001 et seq.
Elder Abuse and Dependent Adult Civil Protection Act (EADACPA)
EADACPA (Welfare & Institutions Code §§ 15600 et seq.) creates enhanced civil liability for elder abuse and neglect. Unlike ordinary negligence claims subject to MICRA's $250K-$500K caps on non-economic damages, EADACPA claims allow unlimited pain and suffering damages plus attorney fees if recklessness or oppression is proven.
Key EADACPA Provisions:
Physical Abuse (W&I § 15610.63) – Infliction of physical pain or injury (hitting, restraining, force-feeding)
Neglect (W&I § 15610.57) – Failure to provide medical care, food, shelter, protection from health/safety hazards. Includes understaffing-driven neglect.
Enhanced Damages (W&I § 15657) – If abuse/neglect proven by clear and convincing evidence with recklessness, oppression, fraud, or malice: (1) unlimited pain and suffering damages (MICRA inapplicable), (2) attorney fees, (3) costs
Proving "Recklessness": Corporate defendants (facility owners) liable if officer, director, or managing agent authorized/ratified abuse, or corporate policy/practice created conditions enabling abuse (e.g., chronic understaffing despite known fall risks).
MICRA Post-AB 35 Changes
California's Medical Injury Compensation Reform Act (MICRA) historically capped non-economic damages (pain and suffering) at $250,000 in medical malpractice cases. AB 35 (effective 2023) increased caps:
Non-wrongful death cases: $350,000 (2023), increasing to $750,000 by 2033
Wrongful death cases: $500,000 (2023), increasing to $1,000,000 by 2033
CRITICAL: MICRA caps do NOT apply to EADACPA enhanced remedy claims (W&I § 15657). If you can prove recklessness/oppression, pain and suffering damages are unlimited. This creates massive liability exposure for facilities with systemic neglect (understaffing, failure to implement fall prevention, medication error patterns).
Who Has Standing to Sue?
Family Members / Heirs: EADACPA authorizes private actions by elder's representative, including family members, conservators, and estate executors (W&I § 15657.3). Wrongful death claims under Code of Civil Procedure § 377.60.
Elder care facilities fear regulatory scrutiny and public exposure. A well-drafted demand letter citing CDPH investigation authority, CDSS licensing sanctions, and Long-Term Care Ombudsman involvement creates powerful settlement pressure. Most facilities carry liability insurance and prefer confidential settlements to jury trials with sympathetic elder abuse victims.
⚠ Extortion and Unauthorized Practice Warnings
Permitted: "Unless this matter is resolved within 30 days, I will file formal complaint with CDPH documenting the pattern of neglect (three falls in six weeks, each without incident report) and submit EADACPA wrongful death claim in superior court."
Prohibited: "Pay $500,000 in 48 hours or I will go to the media and destroy your facility's reputation." (Extortion under California Penal Code § 518.)
Licensed attorneys may draft demand letters and negotiate settlements. Non-attorneys providing legal advice or drafting demand letters engage in unauthorized practice of law (B&P § 6125).
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
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.
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.
Red Flags: When to Suspect Elder Abuse or Neglect
Unexplained injuries: bruises, fractures, burns (especially bilateral or in protected areas)
Pressure ulcers (bedsores) – particularly Stage 3 or 4 (preventable with proper care)
Rapid unexplained weight loss or dehydration
Poor hygiene (unchanged clothing, unwashed, body odor)
Over-sedation or unexplained changes in behavior (may indicate chemical restraint)
Fear or anxiety when specific staff members enter room
Facility refuses family access or isolates resident from family
Missing personal property (jewelry, cash, valuables)
Frequent falls (indicates inadequate supervision or failure to respond to call lights)
Medication errors documented in medical records
Staff unable to locate resident's care plan or incident reports missing
Facility chronically short-staffed (ask: what is current staffing ratio?)
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:
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
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.
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.
⚠ Distinguishing EADACPA Neglect from Ordinary Medical Malpractice
Medical Malpractice (MICRA applies, $500K cap): Physician or nurse makes professional judgment error (misdiagnosis, surgical error, medication dosing error) without recklessness.
EADACPA Neglect (MICRA does NOT apply, unlimited damages): Facility's systemic failure to provide care creates dangerous conditions (chronic understaffing, failure to implement fall prevention despite documented high risk, pattern of medication errors without corrective action). Key: must prove recklessness (knowing disregard of substantial risk) by corporate entity, not just line-staff negligence.
Strategic Pleading: Plead both medical malpractice (ordinary negligence) and EADACPA neglect (recklessness). If EADACPA claim succeeds, unlimited damages. If only malpractice, MICRA caps apply.
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.
SAMPLE FAMILY DEMAND LETTER – EADACPA WRONGFUL DEATH (FALL / HIP FRACTURE)
[Date]
[SNF Name]
[Administrator Name]
[Address]
[City, State ZIP]
SENT VIA CERTIFIED MAIL AND EMAIL
Re: Pre-Litigation Demand – Wrongful Death of [Resident Name]
EADACPA Neglect, Understaffing, Failure to Prevent Fall
Decedent: [Resident Name] (DOB: [Date], DOD: [Date])
Family Representative: [Your Name], [Relationship]
Dear [Administrator Name]:
I represent [Your Name] ("Claimant"), [son/daughter/executor] of [Resident Name] ("Decedent"), regarding Decedent's preventable death resulting from your facility's neglect and reckless understaffing.
FACTUAL BACKGROUND
Decedent, age [age], was admitted to [SNF Name] on [date] following [medical condition]. Decedent's care plan, prepared [date], documented:
• High fall risk (history of [number] falls in prior 6 months)
• Dementia with impaired judgment (unable to recognize mobility limitations)
• Requires 2-person assist for transfers and toileting
• Bed alarm and wheelchair alarm to alert staff to unsupervised movement
• Frequent toileting schedule (every 2 hours) to reduce bathroom-related falls
On [date of fall], night shift staffing was 2 CNAs for 60 residents (1:30 ratio, well below Title 22 required 1:10 ratio). At approximately [time], Decedent attempted to use bathroom unassisted. Bed alarm was either not functioning or not responded to. Decedent fell, fracturing right hip.
Staff did not discover Decedent on floor until [time] – over [number] hours after fall.
Decedent was transported to [Hospital Name], underwent surgical hip repair [date]. Post-operatively, Decedent developed pulmonary embolism from immobility and died [date].
LEGAL VIOLATIONS AND LIABILITY1. EADACPA Neglect (W&I § 15610.57)
Your facility's failure to provide protection from health and safety hazards (fall prevention) constitutes neglect under the Elder Abuse and Dependent Adult Civil Protection Act.
Neglect is established by:
• Custodial relationship: SNF responsible for 24-hour care
• Failure to protect: No bed alarm, inadequate staffing preventing 2-person assists and frequent toileting, failure to respond to needs
• Causation: Fall and resulting death directly caused by failure to implement care plan
2. Recklessness for Enhanced Remedies (W&I § 15657)
Your facility's neglect was reckless, entitling Claimant to unlimited damages and attorney fees:
• Corporate knowledge of danger: [Administrator Name] received monthly incident reports documenting [number] falls in preceding 3 months, all attributed to understaffing
• Conscious disregard: Despite knowledge of fall epidemic, facility continued operating with unsafe staffing ratios to maximize profit margins
• Policy creating dangerous conditions: Budget documents (which we will obtain in discovery) will show deliberate decision to cut staffing costs below safe minimums
This knowing disregard of substantial risk to residents' safety meets clear and convincing evidence standard for recklessness.
3. Title 22 Violations
• Staffing ratios (Title 22 CCR § 72329) – Operating at 1:30 ratio vs. required 1:10
• Care plan implementation (§ 72315) – Failure to implement bed alarm, 2-person assist, frequent toileting protocol
• Incident reporting (§ 72527) – Delayed discovery of fall suggests inadequate rounding and supervision
4. Federal Medicare Conditions of Participation (42 CFR § 483.25)
Facility must ensure residents do not experience avoidable falls. Decedent's fall was entirely preventable with proper staffing and care plan implementation.
DAMAGESEconomic Damages:
• Medical expenses (hospital, surgery, post-op care): $[amount]
• Funeral and burial expenses: $[amount]
Subtotal Economic: $[amount]Non-Economic Damages (Unlimited under EADACPA W&I § 15657):
• Decedent's pain and suffering (fractured hip, surgical pain, awareness of impending death): $[amount]
• Family's loss of companionship, care, comfort, society: $[amount]
Subtotal Non-Economic: $[amount]Attorney Fees and Costs: Recoverable under W&I § 15657 (estimated $[amount] if litigation required)
Punitive Damages: Reserved pending discovery of corporate net worth and full extent of knowing disregard
TOTAL DEMAND: $[amount]PRE-LITIGATION SETTLEMENT OFFER
To resolve this matter without litigation, Claimant will accept $[settlement amount] (discounted from full damages) if paid within 30 days.
Payment must be via wire transfer or certified check payable to [Attorney Name] Trust Account, with written agreement releasing all claims and ensuring confidentiality.
REGULATORY AND LITIGATION CONSEQUENCES OF NON-SETTLEMENT
If this matter is not resolved within 30 days, Claimant will:
1. File EADACPA wrongful death action in [County] Superior Court seeking full damages, attorney fees, costs, and punitive damages
2. Submit formal complaint to CDPH documenting:
• Chronic understaffing and Title 22 § 72329 violations
• Pattern of falls (request investigation of all fall incidents in past 12 months)
• Failure to implement care plans
• Request immediate jeopardy (AA-level) citation and civil monetary penalties
3. Submit complaint to CMS (Centers for Medicare & Medicaid Services) regarding federal quality of care violations, potentially jeopardizing facility's Medicare/Medicaid certification
4. Notify Long-Term Care Ombudsman for systemic investigation
5. Public disclosure: Court filings are public record. Media frequently covers elder abuse wrongful death cases, particularly those involving for-profit SNFs prioritizing profit over safety.
Your liability insurance carrier should be immediately notified of this claim.
PRESERVATION OF EVIDENCE
You are hereby notified of litigation hold. Preserve all documents and records related to Decedent's care, including:
• Complete medical record and care plan
• All incident reports (falls, medication errors, other) for Decedent
• Staffing schedules and timesheets for [date range]
• Budget documents and financial records showing staffing decisions
• Administrator's incident review reports and corrective action plans
• All incident reports for facility (not just Decedent) for past 12 months
• Surveillance video if any
• Employee training records
Destruction or alteration of evidence will support spoliation sanctions and adverse inference instructions at trial.
I await your response within 30 days.
Sincerely,
[Attorney Name]
Attorney for [Claimant Name]
[Contact Information]
SAMPLE FACILITY OWNER DEMAND LETTER – UNPAID PRIVATE PAY BALANCE
[Date]
[Resident Name] (or Estate of [Resident Name])
c/o [Responsible Party Name]
[Address]
[City, State ZIP]
Re: Demand for Payment of Outstanding Balance
Resident: [Resident Name]
Account No.: [Account Number]
Outstanding Balance: $[amount]
Dear [Responsible Party Name]:
I represent [SNF/RCFE Name] ("Facility") regarding the unpaid balance on the account of [Resident Name] ("Resident"), your [mother/father/relationship].
ACCOUNT SUMMARY
Resident was admitted to Facility on [date] pursuant to Admission Agreement signed by you as Responsible Party on [date]. The Agreement obligated you to pay monthly private pay rate of $[amount] for [skilled nursing care / assisted living services].
Resident resided at Facility from [admission date] through [discharge date or date of death]. During this [number]-month period, monthly charges totaled $[amount].
Payments received to date: $[amount]
Outstanding balance: $[amount]
Despite multiple invoices and phone calls, this balance remains unpaid.
LEGAL OBLIGATION TO PAY1. Admission Agreement
The Admission Agreement you signed constitutes a binding contract obligating you as Responsible Party to pay for Resident's care. California law permits facilities to require responsible party guarantees for private pay residents.
2. Unjust Enrichment
Resident received [number] months of 24-hour care, meals, medication management, and [other services]. Facility is entitled to compensation for value of services provided.
3. No Medicaid Pending Claim
[If applicable: We are aware Resident applied for Medi-Cal retroactive coverage. Facility is Medicaid-certified and will accept Medi-Cal payment for any months Resident is retroactively approved. However, Responsible Party remains liable for any months NOT covered by Medi-Cal.]
DEMAND FOR PAYMENT
Facility demands payment of $[amount] within 15 days of this letter.
Payment may be made via:
• Check payable to [Facility Name], mailed to [address]
• Wire transfer to [bank details]
• Credit card by calling [phone number]
If full payment is not feasible, Facility is willing to discuss payment plan: $[amount] down payment plus $[amount]/month for [number] months.
CONSEQUENCES OF NON-PAYMENT
If payment is not received within 15 days and no payment plan is arranged, Facility will:
1. File civil action in [County] Superior Court for breach of contract, seeking:
• Full balance owed ($[amount])
• Pre-judgment interest at 10% per annum (Civil Code § 3289)
• Attorney fees and costs (if Admission Agreement includes attorney fee provision)
• Post-judgment interest
2. Report unpaid debt to credit bureaus, negatively impacting your credit score
3. Pursue collection through judgment enforcement: wage garnishment, bank levy, real property lien
OFFSETTING CLAIMS
If you contend Facility provided substandard care or breached any obligations, you must assert those claims as offsets or counterclaims. Facility strongly disputes any allegations of deficient care. [Resident Name] received appropriate care throughout [his/her] stay, as documented in medical records.
[If applicable: We are aware of your attorney's inquiry regarding alleged [fall / pressure ulcer / other]. Facility's investigation found no negligence or regulatory violations. Any personal injury claims you may assert are separate from your contractual obligation to pay for services received.]
NO WAIVER OF DEFENSES
This demand letter does not waive any of Facility's rights or defenses, including statute of limitations, dispute resolution procedures in Admission Agreement, or limitations on damages.
SETTLEMENT OFFER
To resolve this matter efficiently, Facility will accept $[reduced amount] as payment in full if received within 10 days. This represents [percentage]% discount from full balance.
If settlement offer is accepted, send payment with reference "Settlement – [Account Number]" and Facility will provide written satisfaction of debt.
Please contact me immediately to arrange payment or payment plan.
Sincerely,
[Attorney Name]
Attorney for [Facility Name]
[Contact Information]
SAMPLE CDPH COMPLAINT – SNF IMMEDIATE JEOPARDY (UNDERSTAFFING, FALLS)
[Date]
California Department of Public Health
Licensing and Certification Program
[District Office Address]
[City, State ZIP]
Re: Complaint Against [SNF Name] – Immediate Jeopardy to Resident Health and Safety
Facility Name: [SNF Name]
Facility License No.: [License Number]
Facility Address: [Address]
Complainant: [Your Name], [Relationship to Resident]
Dear CDPH Licensing and Certification:
I submit this complaint regarding immediate jeopardy to resident health and safety at [SNF Name] due to chronic understaffing, resulting in preventable falls, pressure ulcers, and at least one resident death.
COMPLAINANT INFORMATION
Name: [Your Name]
Relationship to Resident: [Daughter/Son/etc.] of [Resident Name] (deceased)
Contact: [Phone], [Email]
FACTUAL BASIS FOR IMMEDIATE JEOPARDY DETERMINATION1. Chronic Understaffing Below Title 22 Minimums
During [Resident Name]'s residency ([date range]), facility consistently operated with dangerously low staffing:
• Night shift: 2 CNAs for 60 residents (1:30 ratio)
• Required under Title 22 CCR § 72329: minimum 1:10 ratio
• Verified by: (a) statements from CNAs [Name 1], [Name 2]; (b) sign-in logs; (c) facility's own staffing records (attached if obtained)
This chronic understaffing persists currently (verified by family members of current residents).
2. Pattern of Preventable Falls
Due to understaffing, facility cannot:
• Respond to call lights in timely manner (residents report 20-30 minute waits)
• Implement 2-person transfer assists per care plans
• Provide frequent toileting (major cause of falls)
• Maintain bed/wheelchair alarms (alarmed equipment found unplugged or broken)
Known fall incidents in past 6 months (partial list based on family reports):
• [Date]: [Resident Name] – fell attempting to use bathroom, fractured hip
• [Date]: [Resident Name] – fell during transfer, head laceration
• [Date]: [Resident Name] – fell in hallway, no staff present
• [Date]: [Resident Name (decedent)] – fell, fractured hip, died from complications
Request: CDPH obtain and review ALL incident reports for past 12 months to identify full scope of fall epidemic.3. Pressure Ulcer Epidemic
Multiple residents have developed Stage 3-4 pressure ulcers, indicating failure to reposition per care plans:
• [Resident Name]: Stage 4 sacral ulcer (family photo attached)
• [Resident Name]: Stage 3 heel ulcers bilateral
• [Resident Name (decedent)]: Stage 4 ulcer, infected, fatal sepsis
Pressure ulcers are preventable with proper care. Pattern of advanced ulcers indicates systemic neglect.
4. Administrator Aware But Failed to Correct
[Administrator Name] receives monthly incident reports documenting falls and ulcers. Despite this knowledge, facility continues prioritizing profit over resident safety (budget cutting, rejecting requests for additional CNAs).
TITLE 22 AND FEDERAL VIOLATIONS
• § 72329 – Staffing: Operating below minimum ratios
• § 72315 – Care Plans: Failure to implement fall prevention, repositioning, toileting protocols
• § 72527 – Incident Reporting: Suspect underreporting (families report falls not documented)
• 42 CFR § 483.25 – Quality of Care: Failure to prevent avoidable falls and pressure ulcers
IMMEDIATE JEOPARDY STANDARD MET
Per CMS State Operations Manual, immediate jeopardy exists when facility's noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to residents.
This standard is clearly met:
• At least one death directly caused by understaffing-driven fall ([Resident Name], [date])
• Multiple serious injuries (hip fractures, Stage 4 ulcers)
• Ongoing risk to all current residents (understaffing persists)
REQUESTED ENFORCEMENT ACTIONS
1. Immediate unannounced investigation (within 48 hours)
2. Cite as AA-level immediate jeopardy deficiency
3. Impose civil monetary penalties (maximum $100,000 per day while immediate jeopardy exists)
4. Mandatory corrective action plan with timeline:
• Immediately achieve Title 22 staffing ratios (verified by daily staffing reports to CDPH)
• Comprehensive fall risk assessment for all residents
• Implement bed alarms, frequent toileting, 2-person assists per care plans
• Pressure ulcer audit and treatment plans for all residents with ulcers
5. Temporary management if facility cannot achieve immediate compliance
6. Mandatory training for all staff on fall prevention and pressure ulcer prevention
7. License suspension or revocation if immediate jeopardy not abated within [timeframe]
SUPPORTING DOCUMENTATION
Attached:
• Death certificate for [Resident Name]
• Hospital records documenting hip fracture from fall
• Photos of pressure ulcers (if available)
• Statements from family members of current residents
• [Any other evidence obtained]
CONFIDENTIALITY REQUEST
Please maintain confidentiality of complainant identity to extent permitted by law to prevent retaliation against current residents' family members.
I am available for interview and to provide additional information.
Respectfully submitted,
[Your Name]
[Address]
[Phone]
[Email]
✓ Demand Letter Best Practices for Elder Care Cases
Medical Records: Obtain complete medical record before sending demand (use HIPAA authorization signed by resident or executor). Records document care plan violations, incident reports, staffing notes.
Expert Review: Have geriatric medicine expert or nursing expert review records before demand to confirm standard of care violations. Expert declaration strengthens settlement position.
Damages Calculation: For wrongful death, economic damages are relatively modest (funeral, medical bills). Real value is non-economic damages (decedent's pain and suffering, family's loss). Research recent EADACPA verdicts for comparable injuries to establish valuation range.
Corporate Knowledge: Discovery should target administrator's knowledge of systemic problems (monthly incident reports, budget meetings, staffing complaints). Corporate knowledge + failure to correct = recklessness for enhanced remedies.
Regulatory Parallel Track: File CDPH or CDSS complaint simultaneously with demand letter. Agency investigation findings (citations, deficiency reports) are admissible in civil case and strengthen settlement leverage.
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).
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.
⚠ Ethical Use of Regulatory Leverage
Permitted:
"I have filed complaint with CDPH documenting immediate jeopardy. If we cannot resolve this matter within 30 days, I will request expedited investigation and appear at any license revocation hearing."
"I intend to report this matter to APS and local law enforcement for criminal investigation of willful endangerment under W&I § 15656."
"Your facility's Medicare certification is at risk due to these federal quality of care violations."
Prohibited (Extortion):
"Pay $500,000 in 3 days or I will call the media and destroy your facility's reputation, causing you to lose your license and go bankrupt."
"I have connections at CDPH and can make this complaint go away for the right settlement."
"Agree not to contest my CDPH complaint as part of settlement." (Conditioning settlement on waiver of regulatory defense may violate public policy.)
Key Distinction: Stating intent to pursue legitimate regulatory complaints is protected speech and appropriate settlement leverage. Demanding payment in exchange for withdrawing or not filing complaints may constitute extortion or violate public policy requiring reporting of elder abuse.
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
Compliance Counseling – Advise on Title 22 compliance, staffing requirements, care plan protocols, incident reporting
Submit Your Elder Care Case for Review
I offer confidential case evaluations for California elder care disputes. Whether you're a family member seeking justice for a loved one harmed by nursing home neglect, or a facility owner facing unjust regulatory action or payment disputes—I can help you understand your rights and develop a strategic plan.
Schedule a consultation below to discuss your case. I'll analyze the specific facts, review medical records or facility documents, evaluate applicable law (EADACPA, Title 22, MICRA), and provide clear guidance on your options.
Fee Structure: Family-side EADACPA and wrongful death cases are handled on contingency fee basis (typically 33-40% of recovery, no upfront fees, no recovery = no fee). Facility owner representation (payment disputes, regulatory defense) is hourly or flat fee. Specific fee arrangements discussed during consultation.
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.
✓ Recent Results (Illustrative Examples – Not Guarantees)
EADACPA Wrongful Death Settlement – Fall/Hip Fracture: $875,000 settlement for family of 82-year-old SNF resident who died from pulmonary embolism after fall caused by chronic understaffing. CDPH investigation resulted in AA-level immediate jeopardy citation, strengthening settlement position.
Pressure Ulcer Neglect Settlement: $650,000 settlement for family of resident who developed Stage 4 sacral ulcer leading to fatal sepsis. Medical records documented failure to reposition per care plan over 6-week period. Corporate emails showed administrator rejected requests for additional staffing despite known ulcer epidemic.
Facility Payment Dispute – Collection: Recovered $240,000 unpaid private pay balance for SNF client against estate of deceased resident. Defended against estate's counterclaim for alleged neglect (no merit, resident's death from end-stage cancer unrelated to facility care).
CDPH Citation Defense: Successfully defended RCFE client in immediate jeopardy citation appeal. CDPH alleged elopement risk due to unlocked door. Proved door was alarmed and resident had right to leave facility (not memory care). Citation reduced to "A" level (no actual harm), avoiding civil monetary penalty.
Past results do not guarantee future outcomes. Each case depends on specific facts, proof of recklessness, and jury evaluation of damages.
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.