1. 1993-1997 California State Plan on Aging, California Department of Aging, 26.

2. "Long-Term Care: Current Issues and Future Directions," United States General Accounting Office, April 1995, 5.

3. "Long-Term Care: Diverse, Growing Population Includes Millions of Americans of All Ages," United States General Accounting Office, November 1994,7.

4. "Who'll Take Care of Mom and Dad? Improving Access to Long-Term Care Services," Senate Office of Research, March 1991, 9.

5. Ibid, 12.

6. Jane L. Ross, Associate Director of the United States General Accounting Office, "Long-Term Care: Demography, Dollars and Dissatisfaction Drive Reform," April 12, 1994, 2.

7. Lucien Wulsin Jr., "California at the Crossroads: Choices for Health Care Reform," 249.

8. Wulsin, op cit, 234.

9. Richard J. Price and Carol O'Shaughnessy, "Long-Term Care for the Elderly," Congressional Research Service, February 23, 1993.

10. Wulsin, op cit, 232.

11. Shelda Harden, "Long-Term Care for the Elderly," National Conference of State Legislatures LegisBrief, January 1996.

12. Ross, op cit.

13. 1993-1997 California State Plan on Aging, op cit, 27.

14. Ibid, Attachment 1.

15. "Medicaid Long-Term Care: Successful State Efforts to Expand Home Services While Limiting Costs," United States General Accounting Office, August 1994, 23-25.

16. Ibid.

17. Ibid.

18. Harry Nelson, "Knowing What the Problem Is...and Getting It Solved: State Reform in Long-Term Care," Milbank Memorial Fund, 1994, 6.

19. Elizabeth Kutza, "Long-Term Care in Oregon," Institute on Aging, Portland State University, 1994, 1.

20. Ibid, 7-8.

21. Ibid, 20.

22. Nelson, op cit, 7.

23. Handouts from Wisconsin entitled "Medicaid Home and Community-Based Services Waivers" and "Wisconsin's Medical Assistance Programs."

24. Nelson, op cit, 9.

25. Ibid, 10.

26. "The Role of Medicare and Medicaid in Long-Term Care: Opportunities, Challenges and New Directions," Health Care Financing Administration, September 1995, 50.

27. Ibid.

28. "Doing Without: The Sacrifices Families Make to Provide Home Care," Families USA Foundation, July 1994, 6.

29. Ibid, 8.

30. Ibid.

31. Ibid, 51.

32. "Federal Waivers for Medi-Cal, 9/11/96," chart provided by the Department of Health Services.

33. S. Kimberly Belshé, Director, Department of Health Services, in October 9, 1996 letter to the Little Hoover Commission, 2.

34. Senate Office of Research, op cit, 21.

35. "The Role of Medicare and Medicaid in Long-Term Care: Opportunities, Challenges and New Directions," The Health Care Financing Administration, September 1995,38.

36. Wulsin, op cit, 248.

37. "The Role of Medicare and Medicaid in Long-Term Care," op cit, 42.

38. Ibid, 39.

39. Ibid, 41.

40. Ibid, 4.

41. Ibid.

42. Ibid, 39.

43. Ibid, 5.

44. Ross, op cit, 3.

45. Dixon Arnett, Director of the California Department of Aging, in testimony prepared for the Little Hoover Commission hearing, September 25, 1996, 3.

46. "The Challenge is Clear, The Time Is Now: A Call for the Development and Restructuring of California's Long-Term Care System," California Association of Area Agencies on Aging, California Commission on Aging, California Foundation of Independent Living Centers, California Senior Legislature, Public Interest Center on Long-Term Care and Triple A Council of California, January 1995.

47. Ray Mastalish, Chairman, California Commission on Aging, in testimony to the Senate Subcommittee on Aging, July 11, 1996, 2-3.

48. Ibid, 3-4.

49. Ray Mastalish, Chairman, California Commission on Aging, in testimony to the Little Hoover Commission, September 25, 1996, 11.

50. "Long-Term Care Reform: States' Views on Key Elements of Well-Designed Programs for the Elderly," United States General Accounting Office, September 1994, 2.

51. 1993-97 California State Plan on Aging, op cit, 4-5.

52. Barbara Sklar, Executive Director of the Senior Services Program of Burlingame, in testimony to the Senate Subcommittee on Aging, February 27, 1986, 7.

53. Steven Garner, representing California Association of Homes for the Aging, in testimony to the Senate Subcommittee on Aging, February 27, 1986, 32.

54. John R. McCune, Acting Chairman, California Commission on Aging, in May 30, 1996 letter to the Governor.

55. Wulsin, op cit, 236.

56. Ibid, 238.

57. Sharon Tennstedt, Brooke Harrow and Sybil Crawford, "Informal Care vs. Formal Services: Changes in Patterns of Care Over Time," Haworth Press Inc., 1996.

58. Kutza, op cit, 1.

59. "Profile of State Administered Home and Community Based Services for the Functionally Impaired Elderly," the federal Administration on Aging and the National Network on Aging, 12.

60. Ian Ayres and John Braithwaite, "Tripartism: Regulatory Capture and Empowerment," Law and Social Inquiry, Vol. 16, No. 3, Summer 1991, 494.

61. Alan J. Richardson and Bruce McConomy, "Three Styles of Rule," CA Magazine, May 1992, 40-44.

62. Christopher Demuth, president, American Enterprise Institute for Public Policy Research, in testimony to the Senate Committee on the Judiciary, March 17, 1995.

63. Ayres and Braithwaite, op cit, 437.

64. Toni Makkai and John Braithwaite, "Reintegrative Shaming and Compliance with Regulatory Standards," Criminology, Vol. 32, No. 3, 1994, 379.

65. Dr. Robert L. Kane, "Improving the Quality of Long-Term Care," JAMA, Vol. 273, No. 17, May 3, 1995, 1380.

66. "Long-Term Care: Status of Quality Assurance and Measurement in Home and Community-Based Services," United States General Accounting Office, March 1994, 4.

67. Various studies including: Elliot Markus and Martin Bloom, "The Impact of Relocation upon Mortality Rates of Institutionalized Aged Persons," Journal of Gerontology, Vol. 26 No. 4, 537-541, and Elisa Bonardi, Irwin Pencer and Marie-France Tourigny-Rivard, "Observed Changes in the Functioning of Nursing Home Residents after Relocation," International Journal of Aging and Human Development, Vol. 28(4), 295-304, 1989.

68. Marie-Louise Ansak, then-Executive Director of On Lok, in testimony to the Senate Subcommittee on Aging, February 27, 1986, 4-6.

69. "Levels of Care Initiative," California Association for Adult Day Services, June 1995, 1.

70. Sheldon Blumenthal, Executive Director of Grancell Village of the Jewish Homes for the Aged, in testimony to the Senate Subcommittee on Aging, February 27, 1986, 29-30.

71. Garner, op cit, 34.

72. Ansak, op cit, 7.

73. "Levels of Care Initiative," op cit, 2.

74. Lynn Friss Feinberg and Kathleen Kelly, "A Well-Deserved Break: Respite Programs Offered by California's Statewide System of Caregiver Resource Centers," The Gerontologist, Vol. 35, No. 5, 702.

75. "Overworked, Underestimated: The Employed Caregiver Doing Double Duty," Family Caregiver Alliance.

76. "California's Caregiver Resource Centers: Information Fact Sheet," Caregiver Resource Centers, April 1996, 2-3.

77. Lynn Friss Feinberg, Manager for Family Caregiver Alliance, in a letter to the Little Hoover Commission, May 10, 1996.

78. "Unsafe in Their Own Homes: State Programs Fail To Protect Elderly From Indignity, Abuse and Neglect," Little Hoover Commission, November 1991, 3.

79. Eloise Anderson, Director, Department of Social Services, in written testimony to the Little Hoover Commission for its September 25, 1996 hearing, 5.

80. Ibid, 7.

81. Carole Barnes, Sandie Sutherland and Jeff Johnson, "Tulare County IHSS Demonstration Project: An Evaluation of Managed Care," August 1995.

82. A. Alan Post, "Analysis of the Tulare County Managed Care Demonstration Project," February 1996.

83. Anderson, op cit, 7.

84. Carol Widemon, Deputy Director, Department of Social Services, in letter to the Little Hoover Commission, March 28, 1996.

85. Anderson, op cit, 9.

86. "Unsafe in Their Own Homes," op cit, 19.

87. "Doing Without: The Sacrifices Families Make to Provide Home Care," op cit, 4.

88. "Faces of Care: An Analysis of Paid Caregivers and Their Impact on Quality Long-Term Care," Older Women's League, 1996 Mother's Day Report, 7.

89. The lawsuit and the State's early position are described in the Little Hoover Commission's 1991 report, "Skilled Nursing Homes: Care Without Dignity."

90. "Department of Health Services' Licensing and Certification Program Performance Audit," State Auditor, January 1994.

91. "Department of Health Services: The Orange County District Office Needs to Further Improve Its Oversight of Health Care Facilities," State Auditor, July 1995.

92. "Comprehensive Evaluative Report: Titles XVIII & XIX Survey and Certification Operations, California Department of Health Services," Health Care Financing Administration, 1995, Part II.

93. CAHF Long-Term Care News, California Association of Health Facilities, Vol. XV, No. 30, October 25, 1996.

94. Information provided by the Department of Social Services during testimony to the Little Hoover Commission on September 25, 1996 and in meetings with the Commission's advisory committee.

95. From a survey of 102 facilities that have 16 or more beds conducted by the California Partnership, an offshoot of the Community Residential Care Association of California.

96. Robert Newcomer, Wendy Breuer and Xiulan Zhang, "Residents and the Appropriateness of Placement in Residential Care Facilities for the Elderly: A 1993 Survey of California RCFE Operators and Residents," Institute for Health and Aging, University of California, San Francisco, July 1994, 18.

97. Peter Hansel, "Beyond Bricks and Mortar: Issues Facing Senior Housing in California," Senate Office of Research, March 1993, 22.

98. "Blueprint to Explore a Private/Public Partnership for Community Residential CareFacilities," Community Residential Care Association of California.

99. Hansel, op cit, 7.

100. Diana Spore, Vincent Mor, Jeffrey Hiris and others, "Psychotropic Use Among Older Residents of Board and Care Facilities," Journal of the American Geriatrics Society, December 1995, 1403-1409.