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There are seven Activities of Daily Living that are required for personal care. Inability to perform any of these will require some level of Custodial Care.


ADLs (Activities of Daily Living)
Ambulating (Ability to walk, get around the house, stability with cane or walker, use of wheelchair or motorized chair)
Bathing (Ability to bathe or shower and shampoo hair without assistance)
Continence (Ability to control bladder and bowel function)
Dressing (Ability to dress without assistance)
Eating (Ability to get food from the dish into mouth. Sometimes the definition includes ability to eat with a feeding tube.
Toileting (Ability to use the toilet and adequately clean oneself)
Transferring (Ability to move from a bed to a wheelchair to a toilet, etc. without assistance)


There are eight Instrumental Activities of Daily Living. Inability by someone in the household to perform any of these will require help to continue living at home.


IADLs (Instrumental Activities of Daily Living)

For definitions go to

Food Preparation


Cognitive Impairment (Requiring supervision, wander risk, needing help with ADLs and IADLs.) Care needs are generally Custodial Care. Specialized care for those impaired with dementia is known as “Memory Care.”

Custodial Care: Custodial Care is help with ADLs and sometimes IADLs. This care is required by anyone unable to perform any or all of these tasks on their own and can be provided in the home or in all care facilities.


Skilled Care: Skilled Care is the care usually performed by medical providers such as doctors, registered nurses, and physical therapists, often in a Skilled Nursing Facility or in the home through a Home Health Agency. Skilled Care is usually temporary, but some conditions such as requiring a feeding tube or insulin injections will necessitate ongoing skilled care. Usually this care is provided in a Skilled Nursing Facility, but some Assisted Living Facilities and RCFEs (See Below) employ Registered Nurses and other Skilled professionals equipped to provide the required Skilled Level of care.


Hospice Care: Hospice Care is end-of-life care. Medicare pays for Hospice Services if a physician declares the patient has a life expectancy of six months or less, regardless if the patient lives longer. Hospice Agency nurses provide care in whatever setting the patient is living, i.e., in the home or in a facility.

Home care is often the first choice, especially when the care needs are minimal or a sudden illness occurs. The spouse, children, friends, and neighbors combine their efforts to help in situations where some recovery is possible. As the care needs increase, the support system decreases if no long-term care coordination is utilized. The primary caregiver becomes the full-time caregiver with occasional help.


The family caregiver (spouse, son, daughter, etc.) faces many stress-related challenges that are common to caregivers. It is imperative that they plug in to community support programs and that family members understand the caregiver’s need for respite (rest from caregiving), without which, the caregiver usually suffers depression, declined health, and often does not outlive the one receiving care.

If the caregiver is experiencing declining health or burnout, it is time to find facility care. The caregiver will be able to visit and have time off to de-stress and reenter living.


A successful long-term home care plan should be organized and doable for all participants. Most communities have senior care support programs that offer care coordination services at no cost.


Many who choose home care are able to continue living at home until their passing. One of the main concerns with this type of care is the cost. For the highest care level, costs can exceed $9000 per month for a full-time, 24 hours per day caregiver. A lower care level combined with more family and friend support will reduce the need and expense of outside help and care.


Community resources are available to supplement a home care plan. They range from Home Health Care agencies, Home Care agencies, Home Modification services, Adult Day Care programs, Medical Supply programs, Housekeeping services, Shopping and Transportation services, in addition to care training and support organizations. Planning for long-term home care is complex, requiring the coordination of health and care professionals, legal documents, and financial planning. The success of a home plan hinges on these three elements working in harmony.



Board and Cares or RCFEs (Residential Care Facilities for the Elderly) are usually converted from single family homes in residential neighborhoods. They typically average six beds in private and semi-private rooms. They appeal to those who can private pay for this care because the care ratio averages six (residents) to one (caregiver).


Care levels vary among facilities. Some are run by registered nurses or other skilled care providers, while others provide custodial care only. Some require mobility, while others are able to continue care for the remainder of life. There are facilities that specialize in “memory care” for dementia patients.


Some facilities have furnished rooms, while others allow residents to bring some of their own furnishings. Some allow small dogs or cats or have a shared “facility pet.” Some offer activities such as gardening, day trips, etc. It is also possible to encounter a language or cultural barrier at some facilities. And unfortunately, there are some that should not still be licensed.


Especially with RCFEs, finding the right care home should not be attempted without professional help which is provided at no charge to the potential resident. Good Placement Agencies will visit the care facilities in their area to better understand what each has to offer. They will assess the care needs and personality of the patient to make a suitable placement within the patient’s budget, which The Light for Seniors can help determine.


Planning for long-term home care is complex, requiring the coordination of health and care professionals, legal documents, and financial planning. The success of a home plan hinges on these three elements working in harmony.



Assisted Living Facilities typically consist of apartments with private bathrooms and kitchenettes with microwave cooking only. Often the residents are allowed to bring in their own furniture and décor to add a familiar, homey touch. Gourmet Chefs serve three meals daily in the main dining room.


Social activities such as sing-alongs, musical guest appearances, shopping and/or casino trips, exercise classes, religious services, etc., are available regularly. Salon services are located on the premises.


Basic housekeeping and laundry services are included for the residents. Additional care needs are assessed and added to the basic cost of the facility rent.


Assisted Living Facilities are often the care choice when at least one spouse requires care and the couple wants to stay together, but home care is not an option.


The level of care provided in Assisted Living Facilities varies greatly. Some facilities have memory care, limited skilled services, and accept incontinent residents. The best way to find a suitable facility is to work closely with a Placement Agency, a free service for the potential resident.


Although Assisted Living is a private-pay facility, some programs may be available to help cover the expense. Veterans Aid & Attendance will contribute directly to the rent of the facility. Medi-Cal will not directly pay for facility rent, but it does cover medical costs thereby increasing resources available for rent.


Planning for long-term home care is complex, requiring the coordination of health and care professionals, legal documents, and financial planning. The success of a home plan hinges on these three elements working in harmony.



Skilled Nursing Facilities (SNFs) are the most commonly known care homes, also known as Convalescent Hospitals or simply “Nursing Homes.” If rehab is required after a hospital stay, the patient will most likely be discharged to a SNF. Medicare and private insurance will pay for some or all SNF care during “rehab,” up to 100 days, although more typically care will be discontinued after about two weeks. A notification will be provided by the facility that skilled care will be discontinued. This is not an eviction notice. (Contact us for advocacy help.)


Although the name “Skilled Nursing Facility” reflects a skilled level of care, custodial and memory care are also provided. Once Medicare stops paying for skilled care, the cost for custodial and/or memory care is private pay or covered by Medi-Cal (California’s Medicaid). An application for Medi-Cal must be made on the patient’s behalf for Medi-Cal coverage. (Contact us to insure approval.)


Facilities vary greatly. Some look like hospitals, while others look like hotels. Some have in-room dining, and some serve meals in a dining room. Some have activity directors on staff to provide variety and entertainment for the patients. The administrators’ are unique to each facility and determine the attitudes of the staff and quality of care.


When looking for a Skilled Nursing Facility, you are on your own. Placement Agencies do not help with SNF placement. You can print out a list of SNFs in your county at Choose the “Find a Nursing Home” option.


There are some basic tips to finding the right facility:

1.The most important test is the smell test. Every facility has an incontinenceIf you smell urine, you are smelling dirty patients and dirty rooms. This is the prime indicator that cleanliness is not a priority to the administration. This is not acceptable.


2.Next in importance is location. It is important that the facility is convenient for one or more family members to visitThe patients need hugs, touch, and affection (which should be provided by the family). And, by providing a presence, your loved-one is more likely to receive better care than one who never receives visitors.


3.You also must meet the needs of theIf cognitively impaired, a wander alert system or lock-down facility may be necessary if your loved-one is active and may wander off. Or, the patient may be a smoker and need a covered outdoor smoking area. Remember, this may be a long-term home and the patient’s happiness and comfort depends on your good choice.


4.Try to get an indication if the staff is pleasant and helpful. If you see family members visiting patients in the facility, ask them what they think of the facility. Also notice if the staff is smiling while talking to the patients.


5.If the patient has Kaiser, the Care Coordination department at a local Kaiser hospital can provide a list of SNFs who participate with visiting Kaiser physicians and KaiserIf you choose a facility that does not participate with Kaiser, it is advisable to drop Kaiser upon Medi-Cal approval.


When you find the desired facility, you want to move immediately if a bed is available. The facility loses money if the bed is empty one day, so any delay may cause you to lose the bed. You want to talk to the patient’s doctor to have the appropriate paperwork ready to fax when the facility is available.


If the facility is not providing the appropriate care, it is important that you realize that the facility is probably understaffed. Demanding, arguing, and threatening are rarely helpful for the continued harmonious and loving care of your loved-one. But politely asking for help from the patient’s CNA to correct the problem may go a long way. You may need to go a step further and ask for help from the RN or LVN. But if the problem is not fixable, the patient has an advocate: In the facility, look for the “Ombudsman” poster. A phone number will be provided.


Planning for long-term home care is complex, requiring the coordination of health and care professionals, legal documents, and financial planning. The success of a home plan hinges on these three elements working in harmony.


Skilled Nursing Facility placement presents an additional set of issues. After multiple months, Medi-Cal may deny the application. The facility may attempt to collect from the family member who was responsible for the Medi-Cal application. In addition, our clients value our advocacy services. Facility staff will tell you “their policy” and “their rules.” They often conflict with California law. Our clients are able to exercise decisions based on complete information.


Sometimes care can be provided in Assisted Living, an RCFE, or home. Care needs can decrease and change the course of the plan. Knowing options unique to your situation and continued case management with us can insure the best care choices and preservation of assets.



Carol Costa-Smith
Tel: (858) 751-0752 
Toll Free: (888) 413-3113 
Fax: (888) 308-9223 8250 
The Light for Seniors, Inc. 
dba Light Source Insurance Solutions
Vickers Street, Suite G, 
San Diego, CA 92111