Key Concepts: Personnel

37 key concepts from Title 22, Division 6, Chapter 8, Article 7: Personnel, for the RCFE Administrator exam. For the searchable, bookmarkable version, use the interactive Study Guide.

Every Facility Needs a Qualified, Certified Administrator
87405 p. 104
Every facility has to have a qualified, currently certified administrator, who can be the same person as the licensee. The administrator needs enough freedom from other duties, and has to be on-site enough hours, to properly manage and administer the facility. When they're not there, a qualified designated substitute has to cover for them. The Department can require more on-site hours if documented need shows it's necessary.

The administrator (of one or more facilities) has the responsibility and authority to carry out the licensee's policies. And failing to comply with certified-administrator requirements can be grounds for revoking the facility's license.
Show Title 22 source text
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.Part 3, Page 104
(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.Part 3, Page 104
(c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility.Part 3, Page 104
General Administrator Qualifications
87405 p. 104
Every administrator (including a licensee who also serves as administrator) has to have:
  • Knowledge of the care/supervision requirements appropriate to the residents.
  • Knowledge of, and the ability to follow, applicable laws/rules/regulations.
  • Ability to maintain (or supervise the maintenance of) financial and other records.
  • The ability to direct other people's work, where applicable.
  • Good character and a continuing reputation for personal integrity.
  • A high school diploma or equivalent (like a GED).
  • Be at least 21 years old.
Show Title 22 source text
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records. (4) When applicable, the ability to direct the work of others. (5) Good character and a continuing reputation of personal integrity. (6) Have a high school diploma or equivalent, such as a General Education Development (GED) certificate. (7) Be at least 21 years of age.Part 3, Page 104
Grandfather Clause for Pre-1982 Administrators
87405 p. 105
Administrators who were already employed/licensed before July 1, 1982 don't have to meet the newer college/continuing-education requirements, as long as they haven't had a break in RCFE administrator employment longer than 3 consecutive years.
Show Title 22 source text
(g) Administrators employed/licensed prior to July 1, 1982, shall not be required to comply with the college and continuing education requirements in Section 87405(e) or the college requirements in Section 87405(f) provided that they have no break in employment as a Residential Care Facility for the Elderly administrator exceeding three (3) consecutive years.Part 3, Page 105
The Administrator's Core Responsibilities
87405 p. 105
The administrator is responsible for:
  • Running the facility per these regulations and the facility's established policy, program, and budget.
  • Reporting to the licensee on facility operations (where applicable), and interpreting recognized care/supervision standards for them.
  • Developing an administrative plan with clear lines of responsibility, fair workloads, and adequate supervision.
  • Recruiting, hiring, and training qualified staff, and terminating staff who perform unsatisfactorily.
  • Making sure residents get services that appropriately address their physical/mental well-being and needs, including what's identified in their appraisals/reappraisals.
  • Making special provisions for residents with visual or hearing impairments.
  • Helping residents with unmet needs access available community programs, including arranging transportation.
  • Having the personal characteristics, energy, and competence to provide care/supervision and work effectively with social agencies where applicable.
Show Title 22 source text
(h) The administrator shall have the responsibility to: (1) Administer the facility in accordance with these regulations and established policy, program and budget. (2) Where applicable, report to the licensee on the operation of the facility, and provide the licensee with necessary interpretations of recognized standards of care and supervision. (3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision. (4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463. (6) Make special provisions for the safety and guidance of residents with visual or auditory deficiencies. (7) Make provision for the resident with unmet needs to attend available community programs, including but not limited to, arranging for transportation. (8) Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies.Part 3, Page 105
When the Licensee Is Also the Administrator
87405 p. 105
If the same individual is both the licensee and the administrator, they have to comply with all of the requirements for both roles, not just one or the other.
Show Title 22 source text
(i) In those cases where the individual is both the licensee and the administrator of a residential care facility for the elderly, the individual shall comply with all of the licensee and certified administrator requirements.Part 3, Page 105
Certification Required Before Employment: With a Nursing Home Administrator Exception
87406 p. 106
Everyone has to hold an RCFE administrator certificate before being employed as one. There's an exception for people who already have a valid Nursing Home Administrator license: they're exempt from the Initial Certification Training Program and written exam, as long as they complete 12 hours of classroom instruction covering laws/regulations, medication management, and resident admission/assessment procedures.
Show Title 22 source text
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.Part 3, Page 106
(1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas: (A) Four (4) hours of instruction in laws, regulations, policies, and procedural standards that impact the operations of residential care facilities for the elderly, including but not limited to the authority referenced in this Chapter. (B) Four (4) hours of instruction in medication management, including the use, misuse, and interaction of drugs commonly used by the elderly, including antipsychotics, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia. (C) Four (4) hours of instruction in resident admission, retention, and assessment procedures.Part 3, Page 106
Getting Certified: Training Program & Exam
87406 p. 106
To get certified (unless exempt), an applicant has to: successfully complete a Department-approved Initial Certification Training Program, and pass a Department-administered written exam within 60 days of finishing that training, with up to 3 attempts allowed.
Show Title 22 source text
(1) Unless exempted by Section 87406(a)(1), successfully complete a Department-approved Initial Certification Training Program as described in Section 87785(h).Part 3, Page 106
(2) Unless exempted by Section 87406(a)(1) or (a)(2), pass a written exam developed and administered by the Department within sixty (60) days of completion of an Initial Certification Training Program and within three (3) attempts.Part 3, Page 106
Submitting the Certification Application
87406 p. 107
Once someone passes the exam (or qualifies for exemption), they have 30 days (from being notified of passing, or from completing training if exempt) to submit a completed Application for Administrator Certification (LIC 9214). That application has to include:
  • Name, address, email, phone, and date of birth.
  • Whether they hold or have held any professional license/certification, whether they've worked at a state-licensed care facility, and whether they've had any related legal/administrative action taken against them.
  • Proof of completing the training program (or, for Nursing Home Administrators, the required 12 hours).
  • Proof of passing the exam or qualifying for an exemption.
  • A certification that the information is true and correct.
  • A Criminal Record Statement (LIC 508).
  • A Request for Live Scan Service (LIC 9163), or proof of an existing clearance/exemption.
  • A non-refundable $100 processing fee.
  • A copy of their current Nursing Home Administrator license, if applicable.
Show Title 22 source text
(3) Submit a completed Application for Administrator Certification form LIC 9214 to the Department's Administrator Certification section within thirty (30) days of being notified of having passed the exam, or if the applicant is exempt from taking the written exam, within 30 days of completing the Initial Certification Training Program. The application shall contain the following: (A) The applicant's name, address, e-mail address, phone number(s), and date of birth. (B) A statement of whether or not the applicant: (i) Held or currently holds a license, certification or other approval as a professional in a specified field and the certificate or license number(s). (ii) Held or currently holds a State-issued care facility license or was or is employed by a State-licensed care facility and the license number. (iii) Was the subject of any legal, administrative or other action involving licensure, certification or other approvals as specified in Sections 87406(b)(3)(B)(i) and (ii). (C) Proof that the applicant has successfully completed a Department-approved Initial Certification Training Program or, in the case of a Nursing Home Administrator, proof of completion of the required hours of classroom instruction as specified in Section 87406(a)(1). (D) Documentation of passing the written exam or qualifying for an exemption pursuant to Section 87406(a)(1) or (a)(2). (E) A statement certifying that the information submitted is true and correct. (F) A completed Criminal Record Statement form LIC 508. (G) A completed Request for Live Scan Service form LIC 9163, signed and dated by the live scan vendor, to document that the applicant has submitted fingerprints to the Department of Justice at a live scan location, or a statement that the applicant has a current criminal record clearance or an exemption on file with the Department. (H) A non-refundable one hundred dollar ($100) processing fee. (I) A copy of the front and back of his/her current nursing home wallet license, or equivalent, if the applicant is a current Nursing Home Administrator.Part 3, Page 107
No Certificate Until Criminal Clearance Confirmed
87406 p. 107
The Department won't issue a certificate until it gets confirmation from the Department of Justice that the applicant has a criminal record clearance or exemption, or is able to transfer an existing one.
Show Title 22 source text
(c) The Department shall not issue a certificate until it receives notification from the Department of Justice that the applicant has a criminal record clearance or an exemption pursuant to Health and Safety Code section 1569.17 or is able to transfer a current criminal record clearance or an exemption pursuant to Health and Safety Code section 1569.17(g)(1).Part 3, Page 107
Exam Integrity Rules
87406 p. 108
Cheating on the certification exam is prohibited, including communicating with anyone besides a proctor/exam official during the exam, having someone else take all or part of it, possessing unauthorized materials or devices (notes, textbooks, electronics) during the exam or on the exam premises, or failing to follow exam security rules.

Anyone caught willfully cheating fails that exam automatically, and can be denied certification under 87408 as a result.

Separately, it's unlawful for anyone to claim they're a certified administrator without actually being one; doing so willfully is a misdemeanor.
Show Title 22 source text
(d) No person shall cheat on, subvert, or attempt to subvert, the exam given by the Department, including, but not limited to, engaging in, soliciting, or procuring any of the following: (1) Any form of communication between one or more examinees and any other person, other than a proctor or exam official, while the exam is in progress. (2) The taking of all or a part of the exam by a person other than the applicant. (3) Possession or use at any time during the exam or while the examinee is on the exam premises of any device, material, or document that is not expressly authorized for use by examinees during the exam, including, but not limited to, notes, crib sheets, textbooks, and electronic devices. (4) Failure to follow any exam instruction or rule related to exam security.Part 3, Page 108
(e) Any applicant caught willfully cheating under this section shall be deemed to have failed that exam and may be denied certification pursuant to Section 87408 as a result of the conduct.Part 3, Page 108
(f) It shall be unlawful for any person not certified under this section to hold himself or herself out as a certified administrator. Any person willfully making any false representation as being a certified administrator is guilty of a misdemeanor.Part 3, Page 108
Certificate Renewal Cycle
87406 p. 108
Certificates get renewed every 2 years, as long as the holder meets all renewal requirements. Each certificate expires either on the anniversary of when it was first issued, or on the holder's birthday during the second calendar year after certification, and the holder has to irrevocably pick which of those two expiration patterns applies to their future recertifications.
Show Title 22 source text
(g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.Part 3, Page 108
(h) Certificates shall be valid for a period of two (2) years and expire on either the anniversary date of initial issuance or on the individual's birthday during the second calendar year following certification. (1) The certificate holder shall make an irrevocable election to have his or her recertification date for any subsequent recertification either on the date two (2) years from the date of issuance of the certificate or on the individual's birthday during the second calendar year following certification.Part 3, Page 108
Extending Certification Deadlines for Good Cause
87406 p. 108-109
The 60-day exam deadline and 30-day application deadline can be extended, for good cause, up to 60 days total. Any extension request has to be in writing to the Administrator Certification Section Manager, within 60 days of finishing training, explaining the facts that constitute good cause.

Good cause can include the death of an immediate family member, required military/civic service, or another unavoidable, verifiable event; failing the exam itself never counts as good cause.

Without an approved extension, the Department won't process (and may consider withdrawn) an application that misses those deadlines, and anyone who misses them has to start the whole certification process over from scratch.
Show Title 22 source text
(i) Time deadlines specified in Sections 87406(b)(2) and (3) may be extended up to sixty (60) days in total for good cause as determined by the Department. Any request for an extension of time shall be made in writing to the Administrator Certification Section Manager within sixty (60) days of completing the Initial Certification Training Program and shall contain a statement of all facts the applicant believes constitute good cause to extend a time deadline.Part 3, Page 108
(1) Good cause may include death of an immediate family member, required fulfillment of military service or other civic duty, or another unavoidable and verifiable event as determined by the Department. Failure of the exam shall not constitute good cause for an extension.Part 3, Page 108
(2) Absent a good cause extension, the Department shall not process and may deem withdrawn an application that fails to meet the time deadlines specified in Sections 87406(b)(2) or (3).Part 3, Page 109
(3) Any applicant who fails to meet the time deadlines specified in Sections 87406(b)(2) and (3) must begin the certification process described in Section 87406(b) anew, and complete it within the time deadlines specified in Sections 87406(b)(2) and (3).Part 3, Page 109
Continuing Education Requirements
87407 p. 109
Every 2-year certification period, administrators need at least 40 classroom hours of continuing education, including at least 8 hours on Alzheimer's/dementia care (for those renewing on/after Jan 1, 2003).

Those hours have to be genuinely related to the Core of Knowledge, current/relevant to facility operations and care, and taken through Department-approved courses.

Courses generally require the certificate holder to be physically present in a classroom, though up to half of the 40 hours can be done through approved interactive online courses. No more than 10 hours (in-class and/or online combined) count toward the requirement if completed in a single day.
Show Title 22 source text
(a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period, including.Part 3, Page 109
(1) For administrators who renew their administrator certification on or after January 1, 2003, at least eight (8) hours in subjects related to serving residents with Alzheimer's Disease and other dementias, including, but not limited to, instruction related to direct care, physical environment, and admissions procedures and assessment.Part 3, Page 109
(b) Continuing education hours must be sufficiently related by subject matter and logic to the Core of Knowledge, current and relevant to facility operations and care, and completed through courses approved for residential care facility for the elderly administrators by the Department.Part 3, Page 109
(c) Courses approved for continuing education credit shall require the physical presence of the certificate holder in a classroom setting as defined in Section 87101(c)(7), except that up to one-half of the required forty (40) hours of continuing education necessary to renew the certificate may be satisfied through interactive online courses as specified in Section 87788(i)(1).Part 3, Page 109
(1) The Department will not count toward the continuing education requirements more than ten (10) hours of instruction, in-class and/or online, completed in a single day.Part 3, Page 109
What Doesn't Count Toward Continuing Education
87407 p. 110
A few things specifically don't count toward the 40-hour CE requirement: home study or correspondence courses (they're not interactive), completion of the Initial Certification Training Program itself (that's meant for brand-new administrators, not renewal), and taking the same specific course more than once in a renewal period.
Show Title 22 source text
(2) Home study or correspondence-type courses will not be counted toward completion of continuing education requirements as they are not interactive by design. (3) Completion of an Initial Certification Training Program or component(s) thereof will not be counted toward completion of continuing education requirements as the Program is intended for new administrators. (4) Any specific continuing education course may only be accepted once per renewal period toward completion of the continuing education requirements.Part 3, Page 110
Renewing Before Expiration
87407 p. 110
To renew before the certificate expires, the holder has to submit (postmarked on, or up to 90 days before, expiration) the LIC 9214 application, proof of the required CE hours (40, or 20 if they hold a Nursing Home Administrator license), a $100 processing fee, and (if applicable) a copy of their current Nursing Home Administrator license.
Show Title 22 source text
(d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department's Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date: (1) A completed Application for Administrator Certification form LIC 9214. (2) Evidence of completion of forty (40) continuing education hours as specified in Section 87407(a), or, if applicable, twenty (20) continuing education hours as specified in Section 87407(g). (3) Payment of a non-refundable one hundred dollar ($100) processing fee. (4) A copy of the front and back of his/her current nursing home wallet license, or equivalent, if the applicant is a current Nursing Home Administrator.Part 3, Page 110
Renewing After Expiration: Within 4 Years
87407 p. 110-111
If the certificate has already expired, the holder can still recertify within 4 years of the expiration date by submitting: the LIC 9214 application, proof of the CE hours they would've needed if they'd stayed certified the whole time (calculated as of the date the renewal application is received), and a $300 delinquency fee (3x the normal $100 fee).

Miss that 4-year window entirely, and the certificate can never be renewed, restored, reissued, or reinstated; the holder has to start the whole certification process over from scratch.
Show Title 22 source text
(e) To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department's Administrator Certification Section: (1) A completed Application for Administrator Certification form LIC 9214. (2) Evidence of completion of the required continuing education hours as specified in Section 87407(a), or 87407(g), if applicable. The total number of hours required for recertification shall be determined by computing the number of continuing education hours the certificate holder would have been required to complete if they had remained certified. The date of computation shall be the date application for renewal is received by the Department's Administrator Certification Section. (3) Payment of a non-refundable delinquency fee equal to three times the one hundred dollar ($100) renewal fee, or three hundred dollars ($300).Part 3, Page 110
(f) Certificates not renewed within four (4) years of their expiration date shall not be renewed, restored, reissued or reinstated.Part 3, Page 110
(1) Holders of certificates not renewed within four (4) years of their expiration date must begin anew the certification process specified in Section 87406(b).Part 3, Page 111
Other Recertification Rules
87407 p. 111
A few more recertification rules:
  • Nursing Home Administrator license holders only need 20 of the 40 CE hours (but must still cover the required Alzheimer's/laws/LGBT-competency topics).
  • Every certificate holder needs a current criminal record clearance or exemption to recertify.
  • Replacing a lost certificate costs $25.
  • Address changes have to be reported to the Administrator Certification Section within 30 days.
  • Whenever a certified administrator starts or stops administering a specific facility, they have to give written notice (within 30 days) to both the local licensing office for that facility and the Department's Administrator Certification Section.
Show Title 22 source text
(g) Certificate holders who possess a valid Nursing Home Administrator license shall be required to complete only twenty (20) of the required forty (40) hours of continuing education, but including the requirements of Section 87407(a)(1)-(3).Part 3, Page 111
(h) Certificate holders, as a condition of recertification, shall have a current criminal record clearance or exemption.Part 3, Page 111
(i) A non-refundable processing fee of twenty-five dollars ($25) shall be paid for the replacement of a lost certificate.Part 3, Page 111
(j) A certificate holder shall report any change of mailing address within thirty (30) days of the change to the Department's Administrator Certification Section.Part 3, Page 111
(k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated, and (2) The Department's Administrator Certification Section.Part 3, Page 111
Grounds for Denying or Revoking a Certificate (Part 1)
87408 p. 111-112
The Department can deny or revoke an administrator certificate for violating licensing regulations, or for specific grounds including:
  • Procuring (or attempting to procure) a certificate through fraud, misrepresentation, bribery, or other unlawful behavior.
  • Knowingly making a false statement or giving false information on the certification application.
  • Being subject to a Department exclusion order (issued after certification) that either wasn't appealed, or was appealed and upheld.
Show Title 22 source text
(a) The Department may deny or revoke any administrator certificate for violation of licensing regulations or on any of the following grounds:Part 3, Page 111
(1) The certificate holder or applicant procured or attempted to procure a certificate by fraud, misrepresentation, bribery, or other unlawful behavior.Part 3, Page 111
(2) The certificate holder or applicant knowingly made or gave a false statement or information in conjunction with the application for a certificate.Part 3, Page 111
(3) The Department has issued an exclusion order against the certificate holder pursuant to Health and Safety Code sections 1558, 1568.092, 1569.58 or 1596.8897 after the Department issued the certificate, and; (A) The certificate holder did not appeal the exclusion order, orPart 3, Page 111
(B) After the appeal, the Department issued a decision and order that upheld the exclusion order.Part 3, Page 112
Grounds for Denying or Revoking a Certificate (Part 2)
87408 p. 112
More grounds for denial or revocation:
  • Not having a current criminal record clearance or exemption.
  • Failing to comply with certificate renewal requirements, though the Department can reinstate a certificate revoked on this ground if the holder later satisfies all recertification conditions, including paying any renewal/delinquency fees owed.
  • Engaging in conduct that's harmful to the health, morals, welfare, or safety of a resident or the public.
Show Title 22 source text
(4) The certificate holder or applicant does not have a current criminal record clearance or exemption.Part 3, Page 112
(5) The certificate holder fails to comply with certificate renewal requirements. (A) The Department may reinstate a certificate that has been revoked for failure to comply with certificate renewal requirements provided all conditions for recertification have been satisfied, including payment of all appropriate renewal and delinquency fees.Part 3, Page 112
(6) The certificate holder engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.Part 3, Page 112
Staffing Levels & Minimum Supervisor Age
87411 p. 115
Facility personnel have to be sufficient in number and competence to meet resident needs at all times. Facilities licensed for 16+ residents need enough support staff for postural-support assistance (87608), plus additional staff for office work, cooking, housekeeping, laundry, and building/grounds maintenance. The licensing agency can require even more staff if documentation shows a particular facility's resident needs, service level, or physical layout demands it.

Anyone who supervises employees, or supervises/cares for residents, has to be at least 18 years old.
Show Title 22 source text
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.Part 3, Page 115
(b) All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age.Part 3, Page 115
How Direct-Care Staff Training Has to Be Delivered
87411 p. 116
Staff who assist residents with personal activities of daily living need appropriate first aid training from a qualified source (like the American Red Cross). That training, and the broader initial/annual training required under Health and Safety Code 1569.625/1569.69, can be delivered on the job, in a classroom, or through a combination of both.
Show Title 22 source text
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.Part 3, Page 116
(2) This training shall be administered on the job, in a classroom setting, or any combination of the two.Part 3, Page 116
Direct-Care Staff Training Hours
Instructor guidance (not in Title 22 text)
This isn't in the Title 22 regulation text; it came from your instructor rather than the statute (the regulation itself just requires "initial and annual training," and the specific hour counts cited in the Numbers & Deadlines "New Staff Training Requirements" card are 10 hours initial / 4 hours annual). Worth knowing for the exam anyway:
  • Within 4 weeks of employment, staff must receive 40 hours of training.
  • Before working alone with a resident, staff need 20 hours of training.
  • After that, 20 hours of training is needed every year.
Who's Qualified to Deliver Staff Training
87411 p. 116
Whoever conducts staff training has to be knowledgeable in the relevant subject area, and meet at least one of these qualifications:
  • A four-year college degree, graduate degree, or professional degree, plus 2 years of experience relevant to elder care, or
  • A California health care provider license, or
  • At least 2 years of experience (within the last 8 years) as a California RCFE administrator, with a record of keeping facilities in substantial compliance.
Show Title 22 source text
(4) All training shall be conducted by a person who is knowledgeable in a subject that is relevant to the subject area in which training is to be provided, and who satisfies at least one of the following criteria related to education and experience:Part 3, Page 116
(A) Both a four-year college degree, graduate degree or professional degree, and two (2) years of experience in an area relevant to caring for the needs of the elderly, orPart 3, Page 116
(B) License to work as a health care provider in California, orPart 3, Page 116
(C) At least two years of experience in California as an administrator of an RCFE, within the last eight years, and with a record of administering facilities in substantial compliance, as defined in Section 87101(s)(9).Part 3, Page 116
Training Materials & Documentation
87411 p. 117
Training can be delivered using books, video, interactive CD-ROMs, or similar materials, but only if a qualified trainer (meeting the trainer criteria) approves that material first.

The licensee has to document staff training in personnel records. For on-the-job training, that documentation is a trainer's statement/notation of what was covered, plus a note showing which trainer-qualification criterion the trainer met.
Show Title 22 source text
(5) Training may include use of books, video instruction tapes, interactive CD-ROMs and similar materials, upon the approval of that material by a trainer who satisfies the criteria of Section 87411(c)(3).Part 3, Page 117
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.Part 3, Page 117
What On-the-Job Training Has to Cover
87411 p. 117
All personnel need on-the-job training or equivalent related experience for their assigned job, demonstrated through safe, effective job performance. Depending on the role, that covers:
  • Good nutrition, food prep/storage, and menu planning.
  • Housekeeping and sanitation.
  • Resident care/supervision skills, including communicating with residents.
  • Safely assisting with self-administered prescribed medications.
  • Recognizing early signs of illness that need professional help.
  • Knowledge of community services and resources.
Show Title 22 source text
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. (2) Housekeeping and sanitation principles. (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. (4) Knowledge required to safely assist with prescribed medications which are self-administered. (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. (6) Knowledge of community services and resources.Part 3, Page 117
Staff Health & Fitness for Duty
87411 p. 117
All personnel (including the licensee and administrator) have to be in good health and physically/mentally capable of their assigned tasks. A physician's health screening (chest x-ray or intradermal TB test) has to happen no more than 6 months before, or 7 days after, starting employment/licensure. The examining physician signs a report on whether the person is fit for their duties and whether they pose any health-related hazard to themselves, staff, or residents. Volunteers just need a signed self-affirmation of good health.

Anyone showing physical illness or emotional instability that significantly threatens residents' well-being has to be relieved of duty.
Show Title 22 source text
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.Part 3, Page 117
Criminal Record Clearance Before Starting Work
87411 p. 118
Before starting employment or first being present at the facility, every employee/volunteer subject to a criminal record review has to: get a California clearance or exemption as required, or request a transfer of an existing clearance, or request (and get approved for) a transfer of an existing exemption, unless the Department allows presence while that transfer is pending.
Show Title 22 source text
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.Part 3, Page 118
Specialized Services, Resident Roles & Volunteers
87411 p. 118
Specialized services have to be performed by personnel qualified through training or experience, meeting recognized professional standards.

Residents can't be used as substitutes for required staff, though they can voluntarily take part in household duties or other tasks that fit their own needs and abilities, as part of their activity program.

Volunteers can help out, but can't be counted as part of the facility's staffing plan, and always have to be supervised.
Show Title 22 source text
(h) All services requiring specialized skills shall be performed by personnel qualified by training or experience in accordance with recognized professional standards.Part 3, Page 118
(i) Residents shall not be used as substitutes for required staff but may, as a voluntary part of their program of activities, participate in household duties and other tasks suited to the resident's needs and abilities.Part 3, Page 118
(j) Volunteers may be utilized but may not be included in the facility staffing plan. Volunteers shall be supervised.Part 3, Page 118
Basic Personnel Record Contents
87412 p. 118
The licensee has to maintain a personnel record for themselves, the administrator, and every employee, including at minimum: full name, Social Security number, date of employment, and written verification the employee is at least 18 (like a birth certificate or driver's license copy).
Show Title 22 source text
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (1) Employee's full name. (2) Social Security number. (3) Date of employment. (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license.Part 3, Page 118
More Personnel Record Contents
87412 p. 119
The personnel record also has to include: educational background (for administrators, specifically verifying they meet the 87405(d)-(g) education requirements), past work experience (types of employment, former employers), and a copy of the required health screening (87411).
Show Title 22 source text
(6) Educational background. (A) For administrators this shall include verification that he/she meets the educational requirements in Sections 87405(d) through (g).Part 3, Page 119
(7) Past experience, including types of employment and former employers.Part 3, Page 119
(11) A health screening as specified in Section 87411, Personnel Requirements - General.Part 3, Page 119
Personnel Records for Volunteers
87412 p. 119
Volunteers get their own personnel records too, containing at minimum: a health statement and health screening documentation, both per 87411(f).
Show Title 22 source text
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 87411(f). (2) Health screening documents as specified in Section 87411(f).Part 3, Page 119
Documenting the Required Staff Training
87412 p. 120
The licensee has to keep personnel-record verification of required staff training and orientation, including documentation that staff who assist with personal activities of daily living completed at least 10 hours of initial training within their first 4 weeks, and at least 4 more hours annually after that. (Same hours as the Numbers & Deadlines "New Staff Training Requirements" card.)
Show Title 22 source text
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.Part 3, Page 120
(1) The following staff training and orientation shall be documented:Part 3, Page 120
(A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2).Part 3, Page 120
Documenting Administrator Certification & Staffing Hours
87412 p. 121
The personnel records also have to show that the administrator meets the certification (or recertification) requirements under 87406/87407, and have to document actual hours worked, to demonstrate the facility maintains adequate staff coverage.
Show Title 22 source text
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.Part 3, Page 121
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.Part 3, Page 121
Licensing Agency Access to Personnel Records
87412 p. 121
Personnel records have to be available to the licensing agency for inspection, audit, and copying during normal business hours, and can be removed if needed for copying, subject to a few protections:
  • Current emergency/health-related info for current staff generally can't be removed if it's otherwise available elsewhere.
  • Before removing anything, the agency has to prepare, sign, and date a list of what's being taken and leave a copy with the administrator/designee.
  • Removed records have to come back undamaged, in good order, within 3 business days.
Show Title 22 source text
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: (1) Licensing representatives shall not remove any current emergency or health-related information for current personnel unless the same information is otherwise readily available in another document or format. (2) Prior to removing any records, a licensing representative shall prepare a list of the records to be removed, sign and date the list upon removal of the records, and leave a copy of the list with the administrator or designee. (3) Licensing representatives shall return the records undamaged and in good order within three business days following the date the records were removed.Part 3, Page 121
Where Records Are Kept & How Long
87412 p. 121
Personnel records generally have to be kept at the facility, though the licensee can store them at a central administrative location instead, as long as they're readily available to the licensing agency at the facility when needed. Either way, records have to be kept for at least 3 years after an employee's termination.
Show Title 22 source text
(g) All personnel records shall be maintained at the facility. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f). (h) All personnel records shall be retained for at least three (3) years following termination of employment.Part 3, Page 121
Posted Weekly Staff Schedule
87413 p. 122
Facilities licensed for 16 or more residents have to display a dated weekly employee schedule where staff can conveniently see it, showing each employee's name, job title, hours, and days off.
Show Title 22 source text
(b) If the facility is licensed for sixteen (16) persons or more, there shall be a dated weekly employee time schedule displayed conveniently for employee reference. The schedule shall contain employee's name, job title, hours of work, and days off.Part 3, Page 122
Night Supervision Staffing Requirements
87415 p. 122
Anyone providing night supervision (10:00 p.m. to 6:00 a.m.) has to be familiar with the facility's emergency procedures and trained in first aid (87465), and has to be available to help residents in an emergency according to this staffing scale:
Facility SizeRequirement
Under 16 residents1 qualified person on call
16-100 residents1 employee awake and on duty, plus 1 more on call (able to respond within 10 minutes)
101-200 residents1 on call on premises, plus 1 awake and on duty, plus 1 more on call (within 10 minutes)
Each additional 100 residents+1 more awake staff person on duty
Show Title 22 source text
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:Part 3, Page 122
(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.Part 3, Page 122
(2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.Part 3, Page 122
(3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes.Part 3, Page 122
(4) Every additional 100 residents, or fraction thereof, shall require an additional one (1) staff person on duty, on the premises and awake.Part 3, Page 122

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