Closures of Adult Residential Care and Residential Care for the Elderly Facilities and the Unknown Impact on Homelessness in California: Problem will Likely be Exacerbated by COVID-19

–More than 6,000 of these care facilities have closed throughout California
since 2015 and the maximum number of individuals that
could be cared for was more than 100,000–

(see tables below for a breakdown by county)

— According to recent reports, these care facilities have experienced
COVID-19 outbreaks resulting in hundreds of residents
sickened and dozens dead from the disease–

Prior to the COVID-19 outbreak, operators of Adult Residential Care Facilities and Residential Care Facilities for the Elderly (Assisted Living Facility) licensed by the state were closing their facilities at an alarming rate. Because reimbursement rates for all the services required under licensing have fallen far behind inflation, operators are selling their properties for other residential or commercial development uses or converting their facilities to serve other populations for which they can receive higher reimbursement rates.

The closures of more than 6,000 Adult Residential Care Facilities and Residential Care Facilities for the Elderly (Assisted Living Facility) and the loss of a maximum number of individuals that could be cared for of more than 100,000, may have contributed to the significant increases of persons counted as homeless according to annual homeless counts. Other data to confirm increases is not yet available.

COVID-19 Pandemic is Compounding the Problem

The current pandemic caused by the 2019 Novel Corona Virus is compounding the problem. Assisted living facilities, or Residential Care Facilities for the Elderly, and the total count of COVID-19 positive cases which is in the hundreds, is being compiled by the California Department of Social Services. However, not all counties with positive cases are included. One media report noted that Los Angeles, Riverside and Santa Clara counties have suffered the brunt of COVID-19 outbreaks in these long-term care facilities for the elderly, with hundreds of residents sickened and at least two-dozen dead from the disease.

Recent Residential Care Facilities for the Elderly Closures

The Community Care Licensing Division of the California Department of Social Services (DSS) listed 3,980 closures of Residential Care Facilities for the Elderly between 2015 and March 2020 on their web site. Also, listed was the maximum number of individuals that could be cared for by each facility, which collectively was 72,207 individuals.

Residential Care Facilities for the Elderly have been defined by DSS as a

Residential care facility for the elderly (RCFE) means a housing arrangement chosen voluntarily by persons 60 years of age or over, or their authorized representative, where varying levels and intensities of care and supervision, protective supervision, or personal care are provided, based upon their varying needs, as determined in order to be admitted and to remain in the facility. RCFEs are also referred to as assisted living facilities and board and care facilities. Persons under 60 years of age with compatible needs may be allowed to be admitted or retained in an RCFE, if certain conditions are met.

The following table notes the current number of Residential Care Facilities for the Elderly listed by DSS on their web site, the number and percent of facilities closed since 2015, and facility capacity, which is defined by DSS as “The maximum number of individuals that may be cared for by the facility” by county.

Table 1. Number of Residential Care Facilities for the Elderly, Number and Percent of Facilities Closed since 2015, and Facility Capacity, which is the Maximum Number of Individuals that May be Cared for by a Facility by County.

County#

of Facilities

# and %

of Facilities Closed

Capacity of

Closed Facilities

#%
  

Alameda

44417539%3,086

Alpine

000%0

Amador

9333%14

Butte

501632%279

Calaveras

3267%52

Colusa

22100%30

Contra Costa

60820634%3,308

Del Norte

000%0

El Dorado

531325%91

Fresno

2988328%1,113

Glen

9111%6

Humboldt

22627%216

Imperial

12325%24

Inyo

100%0

Kern

1955930%614

Kings

10330%16

Lake

9556%130

Lassen

100%0

Los Angeles

2,32084637%16,174

Madera

12433%70

Marin

732129%376

Mariposa

2150%4

Mendocino

25832%93

Merced

421433%171

Modoc

000%0

Monterey

843137%1,058

Napa

551731%137

Nevada

13431%178

Orange

1,46940828%9,421

Placer

2857928%1,151

Plumas

100%0

Riverside

82630837%5,550

Sacramento

94632835%4,909

San Benito

400%0

San Bernardino

41313332%1,859

San Diego

97334535%5,930

San Francisco

983839%962

San Joaquin

1555535%2,001

San Luis Obispo

1675432%709

San Mateo

39213434%1,959

Santa Barbara

1835932%768

Santa Clara

40113534%2,384

Santa Cruz

411229%351

Sierra

000%0

Shasta

863440%307

Siskiyou

6350%260

Solano

2147736%1,387

Sonoma

2608131%1,314

Stanislaus

1414431%1,004

Sutter

18844%246

Tehama

16850%160

Trinity

000%0

Tulare

681826%424

Tuolumne

6233%96

Ventura

3208527%1,625

Yolo

31723%136

Yuba

6233%54

Total:

11,8783,98034%72,207

Recent Adult Residential Facility Closures

The Community Care Licensing Division of the California Department of Social Services (DSS) also listed 2,181 closures of Adult Residential Facility between 2015 and March 2020 on their web site. Correspondingly, the maximum number of individuals that could be cared for by each facility, which collectively was a total of 29,809 individuals.

An Adult Residential Facility is defined by DSS as a

A residential home for adults ages 18 through 59 with mental health care needs or who have physical or developmental disabilities and require or prefer assistance with care and supervision.

The following table notes the current number of Adult Residential Facilities listed by DSS on their web site, the number and percent of facilities closed since 2015, and facility capacity, which is defined by DSS as “The maximum number of individuals that may be cared for by the facility” by county.

Table 2. Number of Adult Residential Facilities, Number and Percent of Facilities Closed since 2015, and Facility Capacity, which is the Maximum Number of Individuals that May be Cared for by a Facility by County.

County#

of Facilities

# and %

of Facilities Closed

Capacity of

Closed Facilities

#%
Alameda3719526%1,647
Alpine000%0
Amador000%0
Butte753547%538
Calaveras000%0
Colusa4125%20
Contra Costa3197624%981
Del Norte8450%53
El Dorado25624%139
Fresno2264721%896
Glen000%0
Humboldt27933%109
Imperial18317%22
Inyo000%0
Kern1893116%615
Kings201050%82
Lake13431%24
Lassen8225%51
Los Angeles2,32755824%8,013
Madera18422%38
Marin74912%203
Mariposa3267%9
Mendocino16213%14
Merced26623%59
Modoc2150%4
Mono000%0
Monterey531121%242
Napa22523%63
Nevada1318%6
Orange59913623%1,712
Placer802329%318
Plumas4250%18
Riverside53712523%1,463
Sacramento50113828%1,488
San Benito10330%23
San Bernardino51511422%1,066
San Diego78317322%3,000
San Francisco1113632%560
San Joaquin3108929%1,317
San Luis Obispo781924%297
San Mateo1732917%319
Santa Barbara982121%165
Santa Clara4049123%1,411
Santa Cruz44920%125
Shasta1314232%326
Sierra000%0
Siskiyou5240%12
Solano1895127%441
Sonoma1474027%488
Stanislaus1072725%365
Sutter24417%51
Tehama531325%136
Trinity3133%30
Tulare1793721%479
Tuolumne10330%32
Ventura1382619%293
Yolo21314%36
Yuba2428%10
Total:9,135218123.929,809

Implications for Next Steps

Recent state legislation has included language to help stabilize board and care facilities/homes. The two main type of board and care homes licensed by the state are Adult Residential Care Facilities, which serves adults between 18 and 59 years old and Residential Care Facilities for the Elderly, which serves adults age 60 or older.

A one-time expenditure of $500 million is proposed to “shore up financially struggling board and care homes” in order “to preserve potentially hundreds of homes that are on the brink of closure because the state reimbursement rate is too low to cover their rising costs.” Providing a one-time expenditure of $500 million would help stabilize the facilities/homes and buy time for the state to authorize a new funding structure that would raise the state’s monthly reimbursement rate to cover the full array of services required under the board and care licensing arrangement. Licensed board and care operators are not free to raise their prices, which are set by the state.

Parallel Negative Impacts of Closures on Adult Residential Care and Residential Care for the Elderly Facilities and Homelessness

Parallel negative impacts of closures on both Adult Residential Care and Residential Care for the Elderly Facilities and homelessness involve A) limited number of existing beds; B) difficulty in siting new beds; C) taxing already overwhelmed public systems of care; and D) draining unprecedented state funding for new homeless housing and services.

A. Limited Number of Existing Beds

1. Open Adult Residential Care and Residential Care for the Elderly Facilities are being used to re-house displaced residents from closed facilities, which further limits housing options for homeless persons in need of specialized care;

2. Conversely, displaced Adult Residential Care and Residential Care for the Elderly Facilities residents from closed facilities can wind up competing with homeless persons in need of specialized care for the limited supply of temporary and permanent supportive housing.

B. Difficulty in Siting New Beds

1. Not only are board and care facility beds limited and lost, siting new beds in some communities may prove insurmountable due to NIMBYism and compounded by increasing land and construction costs;

2. Shelters, transitional housing, and permanent supportive housing for homeless persons have a long history of intense NIMBY opposition that would be compounded by siting new board and care facilities in some of the same communities. Increasing land and construction costs would also hinder siting.

C. Taxing Already Overwhelmed Public Systems of Care

1. Most communities already experience a number of homeless persons who repeatedly and excessively use public systems of care as their primary source of services and health care. Repeated use includes correctional, mental health, and substance use systems among others.

2. Displaced board and care residents from closed facilities who become homeless would likely increase the number of frequent users of health care and mental health public systems of care among others.

D. Draining Unprecedented Funding for New Homeless Housing and Services

1. Insufficient State of California funding to fully reimburse board and care facilities will likely overburden and limit the impact of the recent and unprecedented amount of funding allocated by the state for new homeless housing and services, which have been targeted for the increasing number of persons already living on the streets, which in turn includes those languishing while aging and/or with life-threatening illnesses;

2. Adult Residential Care and Residential Care for the Elderly Facilities residents with mental health care needs and/or disabilities who are displaced from closed facilities and who in turn become homeless, require a level of care and supervision that would likely drain the unprecedented funding coming from the state. The aforesaid funds are aimed at increasing permanent supportive housing and supportive services to obtain and maintain the housing targeted for the mentally ill who are already languishing while living on the streets.

The unprecedented amount of funding from the state includes funding sources for increasing permanent supportive housing for persons who are chronically homeless or at risk of chronic homelessness and in need of mental health services, e.g., the No Place Like Home Program. Another source for increasing permanent supportive housing is Housing for a Healthy California, which is for persons who are recipients of or eligible for health care provided through the California Department of Health Care Services, Medi-Cal program.

Unprecedented funding also includes the Homeless Emergency Aid Program, California Emergency Solutions and Housing Program, Homeless Housing, Assistance and Prevention Program, and the California Access to Housing Act. Assembly Bill 3300 is a recently submitted bill that would provide $2 billion annually for local flexible funding for housing and services.

Summary

The current Adult Residential Care and Residential Care for the Elderly facilities system is a non-sustainable business model for many of the facilities and absent corrective action, this housing resource will continue to erode and contribute to an already growing homeless population. The current pandemic caused by COVID-19 can only but exacerbate the problem of a non-sustainable business model. Stabilizing board and care facilities with a one-time expenditure of hundreds of millions of dollars will likely limit more closures in the immediate future and provide time for the state to authorize a new funding structure that would raise the state’s monthly reimbursement rate.

The parallel negative impacts on Adult Residential Care and Residential Care for the Elderly facilities and homelessness noted above would likely drain the unprecedented funding from the state for the current homeless population. Shoring up the current Adult Residential Care and Residential Care for the Elderly facilities system now, instead of later, would lessen the draining and expected benefits of the unprecedented funding for people experiencing homelessness.

2 Comments

  1. Maria I Marquez on April 21, 2020 at 11:59 am

    This is great and much needed data and analysis. However, while it highlights the impact of the loss of facilities on rising levels of homelessness; it omits that the loss and of residential care facilities and beds also places a growing burden of persons with mental illness having to remain in higher levels of care (e.g. locked SNF/IMDs) because there is no appropriate lower level care and supervision facility for them to move in to. This has placed increasing stress on the limited long-term system of care beds but also creates a backlog of individuals in acute care facilities awaiting long term care place. All of which not only is inappropriate to the individual’s service needs but also comes at great public funding expense for high cost inpatient care.

    • Joe Colletti, PhD on April 21, 2020 at 1:05 pm

      Important point about persons with mental illness. Will have to see what can be said about this in light of any available data.

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