Assisted Living vs Nursing Home in California: Who Licenses Them and What Pays

The short answer

Assisted living and a nursing home are not the same thing. Assisted living is a residential setting with help for daily tasks. A nursing home serves people who usually need care around the clock, including skilled nursing.

In California, different state agencies license them. Medicare also treats them very differently when it comes to who pays.

We place people in assisted living homes only. If your parent's needs point to a nursing home, this guide shows you where to look instead.

What each setting is

Two terms matter here. Custodial care means help with daily living, such as bathing, dressing, meals and reminders to take medicine. Skilled nursing means care that needs a licensed nurse or therapist, such as wound care or rehab after a hospital stay.

• Assisted living is built around custodial care. People live in a home or apartment and get help with the tasks they cannot do alone.
• A nursing home serves people who usually need 24-hour care. It can give short-term skilled nursing or rehab, and it also gives long-term custodial care.

The line between them is not simply medical care versus personal care. Under California rules, an RCFE may accept some residents with certain health needs. Examples are injections given by a skilled professional and care for a healing wound, each under set conditions.

The same rules list some health needs an RCFE generally may not take on, such as a feeding tube. What a home can do depends on its license, its staff and your parent's needs.

In California, most assisted living homes are licensed as Residential Care Facilities for the Elderly, or RCFEs. Our guide to assisted living and board and care explains how RCFEs differ by size.

Who licenses each one in California

The California Department of Social Services licenses and monitors RCFEs through its Senior Care Licensing Program.

The California Department of Public Health regulates skilled nursing facilities through its Licensing and Certification Program. That office also certifies facilities for Medicare and Medi-Cal.

This matters when you check a home. A record from one agency tells you nothing about the other kind of setting. Look up each home with the agency that licenses it.

For an RCFE, use the CDSS facility search. For a nursing facility, use Cal Health Find from the Department of Public Health.

What Medicare does and does not pay

Medicare does not pay for long-term care. That includes the custodial care that makes up most of assisted living.

Medicare Part A can generally pay for a short stay in a skilled nursing facility when set conditions are met. First, your parent needs a qualifying hospital stay of at least 3 days in a row as an admitted inpatient.

The count starts on the day of admission and does not include the day your parent leaves the hospital. Time spent under observation or in the emergency room before admission does not count, even overnight.

Your parent usually has to enter the facility within about 30 days of leaving the hospital. A doctor or other health care provider must decide that they need daily skilled care, such as therapy or IV medicine.

That care must be for a condition that was also treated during the hospital stay, or a new condition that started while getting facility care for it. Your parent must get the care in a Medicare-certified skilled nursing facility.

Some Medicare Advantage plans and some doctor groups can waive the 3-day rule. Always ask the hospital or the plan.

Part A covers up to 100 days of skilled nursing care in each benefit period. In Original Medicare, the first 20 days have no daily charge once the deductible is paid. From day 21 to day 100 you pay a set amount each day, and after day 100 you pay all costs.

A benefit period starts the day your parent is admitted as an inpatient to a hospital or a skilled nursing facility. It ends when your parent has had no inpatient hospital care, and no skilled care in a skilled nursing facility, for 60 days in a row.

This is why the same parent can be covered one week and uncovered the next. Coverage follows the hospital stay and the type of care, and the facility must be Medicare-certified. We do not quote dollar amounts because Medicare changes them yearly.

For what assisted living costs and what can help pay for it, read how to pay for assisted living in California.

How to tell which one fits

No single question sorts every person into one setting. The fit depends on your parent's assessed needs and on what each licensed home is allowed to provide.

A doctor or a hospital discharge planner assesses care needs, not a placement service and not a website.

• Does a nurse need to give care every day, such as injections or wound care?
• Is the main need help with bathing, meals, medicine reminders and getting around?
• Is a hospital or rehab stay ending soon, and what does the discharge plan say?
• Could needs change in a few months, and what would the home do then?
• Is this home allowed to meet that need under its license?

If a hospital is discharging your parent, ask the discharge planner which setting the care team recommends. To find and compare nursing homes, use Medicare Care Compare or the state's Cal Health Find.

Where we can and cannot help

We help families find licensed RCFEs in Sacramento and Placer counties. We do not place people in nursing homes, and we cannot promise any placement or any coverage.

If your parent's needs fit what an RCFE may provide, we can help you compare assisted living homes. Tell us what your family needs and we will take it from there.

Nothing here is medical, legal or benefits advice for your own situation. To see how we are paid, read how senior placement services work.