Elder Care
Difficult Decision Making...
Are you also or maybe faced with some very difficult decisions on taking care of your elderly parents? Not sure what is right...maybe staying at home, maybe Assisted Living, Maybe in Home Care, Maybe a Nursing Home ?
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These are difficult decisions.. besides making it a family decision you need professional guidance to help you MAKE THE RIGHT CHOICE!
The Following article is reprinted by permission & Copyright by :
Stuart D. Zimring
Law Offices of Stuart D. Zimring
12650 Riverside Drive Suite 100
North Hollywood, CA 91607
818-755-4848
fax 818-755-4853
zimzim@ElderLawLA.com
www.ElderLawLA.com
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An elderly individual's home is often not only the center of the person's life, but also the nexus of opportunities and challenges-for both the senior and her advisors. This article explores housing issues of the elderly. |
Introduction1
Often, a person's home is the most valuable single asset he or she will ever own.2 Even though Americans are generally described as a mobile population (moving on average every seven to ten years), it is not uncommon for seniors today to be living in the same home they have lived in for decades. More importantly, many of them wish to remain in their own homes for as long as possible.
On the other hand, other elderly people prefer to sell their homes and relocate to "Leisure World® " type retirement communities to enjoy a leisurely retirement rather than continue to be responsible for a home and all it entails. The move may be motivated by concerns about security, health care, and a desire to be in an environment where planned social activities exist, not to mention a community of like-minded individuals.
In addition to being one's "castle," pragmatically speaking, the home is a source of great economic benefit. It is frequently debt-free, and the single biggest asset the elderly individual possesses. For this reason alone, most seniors wish to preserve the asset (or at least its economic value) for the benefit of themselves and their heirs.
Attorneys who advise seniors and their families are often called upon to advise their clients with respect to the home in a number of contexts:
* Its role as a potential source of tax-free dollars because of the exclusion from gain under current income tax laws;3
* Its role as a source of capital for the payment of unanticipated (or anticipated) expenses incident to incapacity or illness through reverse mortgages;4 and
* Its role as an exempt asset in Medicaid planning.5
A not uncommon scenario involves a client who consults her attorney and informs the attorney that she (the client) has decided to sell her home or give it to her children inter vivos, and move either to a retirement community or in with one of her children. The attorney is well-advised to aggressively explore with the senior why she has made this decision. Often, the decision is made in the heat of an emotional or physical trauma in which the senior believes (or is led to believe by others who may or may not be well-meaning), that disposing of the home is "the best thing to do." By focusing on what the home represents to the client and the impact-both economic and emotional-that selling the home will have on the client, the attorney may be able to guide the client to other, less draconian alternatives.
Unfortunately, as financial elder abuse is on the rise, the home has become one of the chief targets of abusers. Consequently, the attorney should always be sensitive to the possibility that a seemingly innocuous determination to sell or encumber the client's home (or add a third party as a co-owner) may be the tip of an elder abuse nightmare. Incorporating "checks and balances" in the planning process, and interviewing the senior privately to ascertain whether undue influence or other forms of elder abuse are occurring, are valuable services the attorney renders on behalf of her client.
Alternatively, there are those clients who have never owned a home but rather have spent their entire adult lives living in apartments. In these situations, especially where there is a possibility for the need for long-term care Medicaid benefits, the acquisition of a home by the senior may be a very wise planning option because it shelters assets.6
Preliminary issues
Several preliminary issues must be addressed in advising senior clients and their families about housing options. The health of the client, her age and life expectancy, lifestyle, assets, and location of other family members, friends and professional advisors are critical factors in determining the appropriate range of housing options. For example, someone who is ill should be near adequate medical services and probably does not qualify for lifetime care under a life care contract.7 An astute attorney, sensitive to more than the economics of the situation, will also discuss the impact of personality on housing options-an independent person may not be happy in a structured communal environment.
The best planning the attorney can do is to create (or retain) for the client as many options as possible, given almost infinite possible scenarios that face an aging population.8
Remaining at home
Remaining at home-even after a physically debilitating stroke or other incapacitating event-is not only possible, but can often be part of the recovery process. While not perfect or all-encompassing, Medicare can and will provide a significant amount of durable medical equipment to render a home usable by an incapacitated senior (if prescribed by a physician).9 Additionally, in some cases, the modifications (such as the installation of grab bars) can be paid for by publicly funded programs,10 and a cottage industry is developing that caters to exactly these kinds of modifications.
A challenge for the attorney is to anticipate this need during the estate planning process. For example, if the client indicates a desire to return home in the event of incapacity, documents such as revocable inter vivos trusts and powers of attorney (for both asset management and health care), should be customized to take this desire into account. Trustees should be given explicit authority to modify residential real property owned by the trust to accommodate the incapacitated beneficiary. This authority may need to deal specifically with the issue of whether or not such expenditures are "prudent," and perhaps the drafter should consider expressly exculpating the trustee from any liability for such expenditures.
Similarly, agents under powers of attorney can be granted authority to spend funds for home improvements on behalf of the principal, and (if there is a trust) the trustee can be authorized to reimburse the agent for such expenditures, or make the expenditures at the direction of the agent.
Senior specific housing
The number of senior specific housing options is growing rapidly throughout the country. Some of these are small "mom and pop" board and care facilities located in residential neighborhoods, providing assisted living for significantly impaired seniors. Others are large planned communities, catering to an active, healthy senior population with a wide range of activities and facilities, and providing continuing care throughout the aging process under one umbrella organization.
Unfortunately, the rather patchwork approach to regulation of these types of facilities in most states results in different agencies regulating different kinds of facilities with differing regulatory schemes. Further, there is no agreed-upon set of definitions, so that two "retirement homes" or "assisted living facilities" may not, in fact, be licensed by the same regulatory agency and may not provide the same level of care, even in the same state.11
Continuing Care Retirement Communities
Continuing Care Retirement Communities (CCRCs) have existed for over a century. Originally created by religious organizations to provide lifetime care for members of the religious community who did not have a family able to provide this care, the concept has grown and expanded. Today, while religious organizations continue to be a prime operator of CCRCs on a non-profit basis, for-profit entities also exist, providing similar services on a non-sectarian basis.12
The core concept of a CCRC is that it relieves the senior of the concern over who will take care of her in her declining years and how it will be paid for.13 This is usually accomplished through the mechanism of a "life care contract." Generically, these contracts are an agreement pursuant to which the senior pays an entrance fee (usually a substantial amount) and a monthly fee thereafter (usually fixed or tied to some objective index or measurement). In exchange for this, the community promises to provide a residence and, when needed, nursing home care.14
Because the financial commitment expected of the senior is quite substantial, careful attention should be paid to the terms of the contract and the financial condition of the CCRC and its owners and operators. Most CCRCs are not-for-profit organizations and are members of the American Association of Homes and Services for the Aging (AAHSA). The attorney and/or her client is well-served in determining whether or not the CCRC being considered is a member of AAHSA15 and whether it is accredited by the Continuing Care Accreditation Commission, which is sponsored by the AAHSA.16 Most states regulate CCRCs in one form or another.17
CCRCs today come in many varieties: high rise apartments, condominium developments, planned unit developments, cooperative apartments, etc. Thus, it is not uncommon for the senior to have an ownership interest in the development as part of the continuing care or life care contract. Often, this is part of the traditional "entrance" fee.
Because of the unique nature of a CCRC and the services it provides, the right of the resident to sell, lease, encumber, or otherwise convey her interest in the CCRC is frequently subject to restrictions and standards established by the developer/provider of the CCRC.
Counsel should review the continuing care contract to ascertain what services will be provided. At a minimum, they should include:
* Regular observation of the resident's health status to ensure that her dietary needs, social needs, and needs for special services are satisfied.
* Safe and healthful living accommodations, including housekeeping services and utilities.
* Maintenance of house rules for the protection of residents.
* A planned activities program, which includes social and recreational activities appropriate to the interests and capabilities of the resident.
* Three balanced, nutritious meals plus snacks made available daily, including special diets prescribed by a physician as a medical necessity.
* Personal care.
* Assistance with taking medications.
* Central storing, distribution, monitoring of supplies, and re-ordering of medications.
* Arrangements to meet health needs, including arranging transportation.
* An itemization of the services that are included in the monthly fee and the services that are available at an extra charge. The current fee schedule should be incorporated into the continuing care contract and should be modifiable only on written notice.
* The procedures and conditions under which residents may be voluntarily or involuntarily transferred from their designated living units.
* The amount of the entrance fee, any processing fee, and any monthly care fee.
* If the contract requires a monthly care fee or other periodic fee, the contract should provide statements advising the resident that occupancy and use of the residence is contingent on payment of the monthly fee. It should also state what the regular rate of payment is (per day, week, month); whether payment is to be made in advance or subsequent to the rendering of services; and what adjustments the provider can make for absences due to medical treatment.
* All contracts should specify the method of calculating changes in the monthly fees.
As a final protection, the attorney should determine what cancellation provisions are provided in the contract, either by law or through negotiation.
If the state imposes reporting and/or accounting requirements on providers, this information can be very valuable to the attorney investigating alleged improprieties or breaches by CCRC operators. Again, familiarity with the statutory scheme is invaluable in representing clients in this area.
Residential Care Facilities for the Elderly
Residential Care Facilities for the Elderly (RCFEs), whether they are referred to as "Assisted Living Facilities," "Board and Care Homes" or "Retirement Homes," are housing arrangements that provide room, board, supervision, protective supervision, or personal (non-medical) care for a person over age 60.
Clients (and their lawyers) are often confused about what RCFEs really are, and easily confuse them with nursing homes. One of the primary misconceptions regarding RCFEs is that Medicaid long-term care nursing home coverage (and long-term care insurance policies) will pay for the facility. That is not necessarily true. In many-if not most- jurisdictions, Medicaid long-term care coverage is available only for facilities licensed as nursing homes.18 Because, by definition, RCFEs furnish only non-medical care, they generally do not qualify for Medicaid benefits.19 Whether a private long-term care insurance policy covers the cost of an RCFE (or any part of it) is determined by the coverage provided; most policies do not.
What an RCFE does provide is a wide range of services and programs specifically geared for seniors who may need assistance in performing some activities of daily living (ADLs), but who do not require the level of care associated with a nursing home. Therefore, while an RCFE is generally not required to have either nurses or doctors on staff, and generally the staff cannot administer medication, staff members are permitted to help residents with the self-administration of medications. Theoretically, this reduced level of care is supposed to translate into more affordable housing for seniors. Compared to nursing homes, this is generally true. However, the cost of staying in an RCFE is not inexpensive and continues to rise at rates well above the rate of inflation.20
In counseling clients and their families regarding the selection of an RCFE, the attorney should educate the client and the family regarding the wide range of housing options that exist. Licensure and classification are usually based on levels of service and staffing, not on what the facility calls itself. Hence, a "retirement hotel" or "retirement home" may or may not be a licensed RCFE. If the facility provides a comparatively low level of service and supervision, it need not be licensed as an RCFE. Information regarding a particular facility's license status should be obtained prior to entering the facility.
Because there is no federal regulation in this area, the attorney should familiarize herself with the appropriate state regulatory framework (if any). The U.S. Senate held two hearings on assisted living in 1999 and 2001, and convened the national Assisted Living Workgroup after the second hearing. But no legislation at the federal level has resulted.21
Entry criteria. The basic difference between RCFEs and nursing homes is that the resident of an RCFE is expected to be significantly more independent than is a nursing home resident. Accordingly, an RCFE resident should be able to ambulate on her own, or at least transfer herself in and out of bed without assistance.
Similarly, RCFE residents are usually expected to be able to medicate themselves. However, depending on local statutes and regulations, under certain circumstances certain incidental medical services may be performed at the RCFE if the resident cannot perform them herself or if an "appropriately skilled professional" has been authorized to perform the services at the RCFE.
Because the RCFE will become the new home of the senior, many factors must be considered in selecting the facility. For example, careful consideration should be given to the location of the facility. Is it near family? Friends? The senior's medical providers? It is important for the senior and her family to scrutinize the physical plant carefully. To put it bluntly, one should look, listen and smell. Interview the staff and current residents and their families. What do they say about the food? The activities?22
If the facility is subject to inspection under state law, the inspecting agency should maintain records of its inspections. These records are probably public documents and should be reviewed by the prospective resident or her family.
As part of a client's "consumer education," the attorney should stress that during this interview process, the senior and/or her family should be aware that many facilities put on a wonderful facade, but there may be little to back it up. For example, the community bulletin board may show an extensive range of activities taking place on a daily basis. The prospective resident should inquire whether these activities are actually taking place and if so, the quality of the programs. If the RCFE offers field trips to museums and concerts, inquiry should be made whether special provisions exist for non-ambulatory residents. If the facility offers transportation services, are they handicap accessible?
The admission agreement. The admission agreement itself should set forth the basic and optional services the facility provides, together with the charges applicable to each. The agreement should specify the facility's policies regulating resident behavior and the bases on which a resident may be evicted. The method by which the agreement can be modified should also be set forth in writing.
Ordinarily, the method by which an RCFE prices its services is a matter of contract between the facility and the resident and is not governed by law. The RCFE can have one price for basic service, and can charge for additional services. The resident then selects which additional services (if any) she wants. Conversely, the facility could charge one price for all services and then deduct certain amounts if the resident elects not to use those services.
It is important for the attorney to keep in mind that unless there is specific law to the contrary, the relationship between the RCFE and the resident is essentially a landlord-tenant relationship.
Life in an RCFE
As part of the admission process, an RCFE will probably make a written assessment of the resident's needs, including the resident's medical condition, mental capacity, personal preferences, and her ability to carry out routine daily tasks. Based on this assessment, the RCFE is supposed to determine the appropriate care for the resident. As time goes on, the facility should monitor the resident's physical, mental and emotional status and, if significant changes are noted, report them to the resident's physician and family member or friend. Thus, the assessment performed at the beginning of the resident's occupancy should not be static. It should be updated with sufficient frequency to ensure that the assessment is accurate at all times. If this is not part of the state's regulatory scheme, the attorney should seek to have it incorporated as part of the contract.
Sometimes, facilities try to use a major change in the resident's assessment as grounds for eviction. If the attorney believes this is a ruse or excuse to accomplish an otherwise impermissible eviction, the attorney should review the resident's assessment over the years-especially the initial assessment-to see what changes have been documented. For example, if the resident was non-ambulatory upon entering the facility and it now seeks to evict her because she is non-ambulatory, there probably has not been a change in circumstance documented to permit the eviction.
From a social and cultural standpoint, RCFEs should provide services that "continue and promote, to the extent possible, independence and self-direction" for all of their residents. At a bare minimum, RCFEs should offer their residents at least three meals a day along with between-meal snacks. The special dietary needs of residents should be observed, including physician-mandated dietary guidelines and special food preparation, such as sodium-free, diabetic, etc.
The RCFE should see to it that each resident has access to medical and dental services, and must provide transportation if necessary. Within the facility, the staff should provide assistance in the use and safeguarding of aids such as hearing aids and prostheses, and should assist the residents in self-administering their medication.
Based on the resident's assessment, the RCFE should provide each resident with appropriate and necessary assistance in the activities of daily living (i.e., feeding, dressing, toileting, bathing, etc.).
Finally, each facility should provide activities that promote socialization among the residents and put the residents in contact with cultural events and opportunities outside the RCFE. Again, to the extent these items are not mandated by statute or regulation, the attorney should seek to have them included in the admission agreement or other contract between the resident and the facility.
Given the "institutional" look and ambiance of many RCFEs, it is easy to lose sight of the fact that this is the resident's home and each resident is entitled to the same rights and privileges, including privacy, security, unimpeded ingress and egress, that she would have in her own dwelling (obviously tempered by the reality that this is a communal living situation). Thus, the RCFE should not, by locking doors, prevent residents from going and coming as they please. Further, RCFEs should permit the residents to receive visitors during reasonable hours of the day and make sure that the residents and their guests are able to meet in private if they wish.
Problem resolution. It is inevitable that in any communal living situation, problems arise. The problems may be in the nature of landlord-tenant issues, such as leaky faucets or stopped-up drains, or problems more specific to RCFEs, such as quality of care, food or programming, or failure to provide promised services.
Anyone who has ever lived in an apartment knows the uneven bargaining power between landlord and tenant. The attorney needs to be sensitive to the additional pressure (and potential trauma) brought to bear by the fact that the "tenant" is an elderly individual, potentially frail and possibly of limited physical, emotional and psychological capacity. In such situations, it is particularly important for family members or friends to maintain close contact with the senior to monitor not only the RCFE resident, but also the quality of care being provided. Family members and friends must not be shy about insisting that the resident receive, at a minimum, the services promised at an acceptable level of quality.
Before resorting to administrative or judicial procedures, attorneys should advise their clients to first approach the supervisory personnel of an RCFE as soon as a problem arises. As in any other bureaucracy, it may be necessary to move up the chain of command until a satisfactory answer or resolution is obtained to the problem.
Whoever is dealing with the administrative staff should pay close attention to what is said by the staff and keep accurate records of these conversations. While it may seem that the staff is antagonistic, frequently the problems arise out of miscommunication and can be resolved simply by clearing the air.
If the direct approach does not work, the resident's next recourse should be to the Ombudsman Program. Pursuant to federal law,23 each state is required to implement an Ombudsman Program. The office of State Long-Term Care Ombudsman operates through local offices, staffed by professionals and trained volunteers. all "long-term care facilities" (defined as nursing or skilled nursing facilities and RCFEs) are required to post in a prominent place a notice containing the name, address, and phone number of the office of the nearest Ombudsman.
Anyone who has a concern or problem with a long-term care facility can call the Ombudsman Program and report the problem. These reports can be anonymous if the caller wishes. Upon receipt of a complaint, the representative visits the facility to investigate the allegations. By law, the representatives have access to the facilities and, with the consent of the resident, access to the resident's medical or personal records in order to conduct a thorough investigation.
Where the complaint or problem is sufficiently serious, a formal complaint can be lodged directly with the appropriate regulatory agency. However, regulation of the assisted living industry as a whole is spotty at best and does not exist at the federal level.
Of course, the judicial system remains the forum of last resort if all else fails. Because of the hybrid nature of the relationship between the RCFE and its residents, the theories that can support litigation are myriad-tort, contract, unfair business practices, landlord-tenant, fraud, etc.24
Property tax relief and renter's credit programs for seniors
To make it easier for seniors (and the disabled) to remain in their own homes, some states have established programs that provide financial assistance to homeowners, renters, and/or mobile homeowners in the form of property tax relief or deferral and/or income tax credits.
In exchange for the postponement of the tax payments, a lien is placed on the property. The lien becomes payable upon the earlier of the sale of the property or the death of the resident. If the resident leaves a surviving spouse living in the home, the lien does not become due until the death of the surviving spouse.
Reverse mortgages
Reverse mortgages or "home equity conversion mortgages" are defined as non-recourse loans secured by real property that meet all of the following criteria:
* The loan provides cash advances to a borrower based on the equity or the value in the borrower's owner-occupied principal residence.
* The loan requires no payment of principal or interest until the entire loan becomes due and payable.25
The events which cause the loan to mature usually include: (1) sale or transfer of the residence by the borrowers; (2) all borrowers cease occupying the home as their principal residence; (3) the occurrence of an event specified in the loan documents which jeopardizes the lender's security; or (4) a fixed maturity date if agreed upon by the lender and borrower.
Counsel should be aware that reverse mortgages are currently a source of much litigation throughout the country, mostly involving unconscionable loan terms and the selling of unnecessary and/or inappropriate annuities funded by reverse mortgages.26
Conclusion
The "greying of the population" has brought with it an exponentially growing number of opportunities and challenges. Our homes, often the centers of our lives in many ways, are also the nexus of opportunities and challenges, not only for seniors but for their advisors as well.
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[Sidebar] |
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Practice Notes |
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One of the primary misconceptions regarding Residential Care Facilities for the Elderly is that Medicaid long-term care nursing home coverage (and long-term care insurance policies) will pay for the facility. That is not necessarily true. |
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[Footnote] |
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1 Portions of this article are reprinted with permission from Tax, Estate and Financial Planning for the Elderly: Forms & Practice by John J. Began, Michael Gilfix, Rebecca C. Morgan, and David M. English (Matthew Bender), and California Guide to Tax, Estate and Financial Planning for the Elderly by Stuart D. Zimring and Donna Bashaw (Matthew Bender) (hereafter "California Guide"), copyright © 2001-2003 by Matthew Bender & Co., Inc. all rights reserved. |
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2 In the context of this discussion, the word "home" is used to describe any form of residential property in which the individual owns a marketable interest, including a standalone single-family residence, a condominium, cooperative apartment, mobile-home (even if the owned prefabricated dwelling is located on leased land), or houseboat. |
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3 see IRC section 121. For a general discussion of the home sale exclusion, see Gruer, "The Reduced Home Sale Exclusion," NAELA News, pp. 22-23 (May/June 2003). |
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4 see Regan, Morgan, and English, Tax, Estate & Financial Planning for the Elderly (Matthew Bender, 2001) (hereafter "Planning for the Elderly"), § 12.05(5]. |
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5 see Planning for the Elderly, supra note 4, at § 10.14. |
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6 Id. at § § 2.11, 10.14. |
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7 see California Guide, supra note 1, at § 14.3[2][d][ii]. |
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8 An excellent discussion of housing options as an integral component of a senior's over all health care can be found in Frolick, Appropriate Housing for the Elderly in the United States, Aging: Caring for Our Elders, Chapter 7, (Weisstub, Thomasma, Gauthier, and Tomossy, eds., Kluwer Academic Publishing, 2001). |
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9 Planning for the Elderly, supra note 4, at § 9.09111. |
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10 see, e.g., CaI. WeIf. & lnst. Code § 14132(m). The Administration on Aging website (www.aoa.dhhs.gov/aoa), in the link "Elder Action," has further information on home modifications and possible government assistance and subsidies. |
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11 The growth of the senior housing industry has been documented in numerous articles. see, e.g., Laden, "Senior Housing Driven by Need," Colorado Springs Gazette, p. IB6 (11/5/01). |
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12 Frolick, Residence Options for Older or Disabled Clients, § 8.01 (Warren, Gorham & Lamont 1997). see also Carlson, Long Term Care Advocacy, Chapter 6 (Matthew Bender 2001). |
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13 Planning for the Elderly, supra note 4, at § 15.06. |
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14 Id. at § 15.06. |
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15 This information can be determined from AAHSA's website at www.AAHSA.org. |
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16 Information on accreditation standards and a list of accredited institutions can be found at the Continuing Care Accreditation Commission (CCAC) website www.ccaconline.org. |
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17 see, e.g.,CaI. Health & Safety Code § 1770. |
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18 see California Guide, supra note 1, at § 6.03(3]. |
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19 See, e.g., CaI. Health & Safety Code § 1569.2(k). |
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20 Green, "The Cost of Assisted Living," WaI Street Journal (10/12/03). Estimates are that the cost of care in an RCFE increased 10.2% over the last 18 months. |
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21 For a discussion of the current state of regulation in the assisted living industry, see Edel man, "Enforcement in the Assisted Living Industry: Dispelling the Industry's Myths," NAELA Quarterly, p. 9 (Spring 2003), and "Assisted Living Final Report Is Not the Final Word on the Matter," NSCLC Washington Weekly, Vol. XXIX, No. 18 (5/2/03). |
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22 An invaluable resource in this regard is the pamphlet "How to Get Care From a Board and Care Home," available from Bet Tzedek Legal Services, 145 South Fairfax Ave., Suite 200, Los Angeles, CA 90036. For more information, please visit their website at www.la4seniors.com/bet_tzedek.htm. |
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23 42 U.S.C. § 3058g. |
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24 For more information on RCFEs, see Carlson, "In Search of Humane Long Term Care: Is Assisted Living an Oasis or a Mirage?," 11th Annual NAELA Symposium (1999). |
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25 see Planning for the Elderly, supra note 4, at § 12.05. |
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26 see, e.g., Black v. Financial Freedom, 92 CaI. App.4th 917, 112 CaI. Rptr.2d 445 (2001) (fraud, unfair business practices, elder abuse), and Flores v. TransAmerica Homefirst, Inc., 93 CaI. App.4th 846, 113 CaI. Rptr.2d 376 (2001) (unconscionability, unfair business practices). |
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[Author Affiliation] |
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STUART D. ZIMRING, ATTORNEY |
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[Author Affiliation] |
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STUART D. ZIMRING practices law in Los Angeles. he is a Fellow of the American College of Trust and Estate Counsel and President of the National Academy of Elder Law Attorneys. he is also a specialist in estate planning, probate, and trust law, certified by the State Bar of California Board of Legal Specialization. Copyright © 2004, Stuart D. Zimring. |