Filed 8/17/16

CERTIFIED FOR PUBLICATION

IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

SECOND APPELLATE DISTRICT

DIVISION FOUR

ST. JOHN OF GOD RETIREMENT & 

CARE CENTER,

Plaintiff and Appellant,

v.

DEPARTMENT OF HEALTH CARE 

SERVICES OFFICE,

Defendant and Respondent;

GLORIA GLOVER-WOODS,

Intervenor and Respondent.

 B265488

 (Los Angeles County

 Super. Ct. No. BS148766)

APPEAL from a judgment of the Superior Court of Los Angeles County, 

Luis A. Lavin, Judge. Reversed as moot.

Foley & Mansfield, Noelle M. Natoli-Duffy, M. Amadea Groseclose and 

Melanie A. Ayerh for Plaintiff and Appellant.

Kevin P. Kane & Associates, Inc., and Kevin P. Kane; BraunHagey & 

Borden and Matthew Borden for Intervenor and Respondent.
2

Gloria Glover Woods was a resident of St. John of God Retirement & Care 

Center (St. John), a skilled nursing facility in Los Angeles, who elected hospice 

care through a provider under contract to the facility. When Ms. Woods 

experienced a psychotic episode, the hospice provider directed that she be 

transferred from St. John to an acute care hospital for evaluation and treatment. 

When her treatment was concluded, St. John refused to readmit her to the first 

available bed under 42 Federal Code of Regulations, section 483.12 (section 

483.12), which governs the requirements for a skilled nursing facility’s involuntary 

transfer or discharge of a resident. After an administrative hearing, the Department 

of Health Care Services (DHCS) ordered St. John to readmit Ms. Woods. The 

superior court denied St. John’s petition for writ of administrative mandate seeking 

to vacate the order, and St. John appeals.

We conclude that in light of developments during the pendency of the 

appeal, the order requiring Ms. Woods’ readmission is now moot. However, 

because there is a separate civil lawsuit between the parties in which the issue is 

likely to arise again, we exercise our discretion to decide whether section 483.12

exempts a skilled nursing facility from the readmission requirement (§ 483.12, 

subd. (b)(3)) when the transfer to an acute care hospital from which the resident is 

returning was ordered by the resident’s hospice care provider rather than the 

facility itself. We conclude that section 483.12 contains no such exemption. Thus, 

to the extent St. John contends that its refusal to readmit Ms. Woods did not 

constitute an involuntary transfer because she was returning from an acute 

hospitalization ordered by her hospice care provider, and that therefore St. John 

was not bound by the involuntary transfer requirements of section 483.12,

subdivisions (a)(2) (identification of a justifying circumstance), (a)(3) 

(documentation of the justifying circumstance), and (a)(7) (preparation and 
3

orientation for a safe and orderly transfer, including giving notice of the effective 

date of the transfer or discharge and the new resident location (subds. (a)(6)(ii) and 

(iii)), St. John is mistaken. We also reject St. John’s contention that readmitting 

Ms. Woods and thereafter discharging her after complying with section 483.12’s 

requirements would have subjected St. John to liability under Health and Safety 

Code section 1432. 

We decline to resolve any other issues raised by the parties, as the resolution 

of those issues (to the extent they might arise again) is better suited to the separate 

civil litigation. Because the DHCS order directing readmission is moot, we reverse 

the trial court’s order denying the writ of administrative mandate solely for 

purpose of remanding the case with directions to dismiss the administrative 

mandate proceeding as moot.1

BACKGROUND

We summarize the proceedings prior to the filing of the notice of appeal. 

We leave to our Discussion section later developments regarding the issue of

mootness.

Admission to St. John

On September 19, 2013, Ms. Woods (then 72) was admitted to St. John. 

Based on records from her former hospice facility in Georgia, St. John admitted 

 

1

“‘“Where an appeal is disposed of upon the ground of mootness and without 

reaching the merits, in order to avoid ambiguity, the preferable procedure is to reverse the 

judgment with directions to the trial court to dismiss the action for having become moot 

prior to its final determination on appeal. [Citations.]” [Citations.]’ [Citation.]” (Giles 

v. Horn (2002) 100 Cal.App.4th 206, 229 (Giles).)
4

her with a diagnosis of amyloidosis, hypertension, anxiety, hypothyroidism, and 

psychosis. 

Ms. Woods’ daughter, Mikko Boutte-Evans, informed St. John that Ms. 

Woods was terminally ill and wanted to be with her mother, who also was a 

resident at St. John. According to Norma Bullen, Director of Nursing at St. John, 

she admitted Ms. Woods, despite the diagnosis of psychosis, because she saw no 

records suggesting that Ms. Woods manifested psychotic behavior, and because 

“when you are dying, you’re dying, and how much more can she be a potential 

danger to staff and to the other residents.” Ms. Bullen placed Ms. Woods in the 

same room with her mother. 

Hospice Care

On December 10, 2013, St. Liz Hospice, Inc. (St. Liz) evaluated Ms. Woods. 

Pursuant to her authority as Ms. Woods’ Durable Power of Attorney, Ms. BoutteEvans executed documents consenting to Ms. Woods receiving hospice care from 

St. Liz while residing at St. John, including an acknowledgement that “Inpatient 

Care will be provided by St. Liz Hospice, Inc. for pain control, symptom 

management, and management of psycho-social problems related to my terminal 

illness. I understand that this care will be provided at a facility contracted with St. 

Liz Hospice, Inc. [referring to St. John].” She also acknowledged that St. Liz 

would arrange any hospital outpatient treatment that might be required, and that 

“[h]ospitalization may be required for certain procedures or care, and these will be 

arranged through a contracted facility of the hospice.”
5

Hospitalization

Until March 2014, Ms. Woods was cooperative while residing at St. John, 

though at times she seemed confused. However, beginning in March 2014, she 

began displaying threatening and disruptive behavior, which included (according 

to Ms. Bullen) choking two nurses, trying to strike another, and throwing a snow 

globe at yet another (it broke against the wall). For the safety of other residents, 

Ms. Woods was transferred to a single room. 

In April 2014, an evaluator from the California Department of Health Care 

Services performed a mental health evaluation on Ms. Woods – a level II 

Preadmission Screening and Resident Review (PASRR). In the course of the 

evaluation, Ms. Woods reported that she had been raped at St. John. When St.

John asked Ms. Boutte-Evans about the report, she said that she had heard about it 

from Ms. Woods’ mother (Ms. Boutte-Evans’ grandmother), and that Ms. Woods 

was hallucinating. 

On April 10, 2014, based on Ms. Woods’ behavior and rape report, the St. 

Liz attending physician ordered Ms. Woods transferred to Brotman Medical Center 

(Hospital) for a psychiatric evaluation and management of her condition. 

Refusal of Readmission

On April 21, 2014, St. John received an inquiry from the Hospital about 

readmitting Ms. Woods. St. John refused readmission on the ground that it could 

not provide the specialized services recommended in Ms. Woods’ PASRR level II 

evaluation, which included a behavior modification program to reduce incidents of 

aggression and yelling, individual psychotherapy, and mental health rehabilitation 

activities. 
6

Ombudsman Appeal

On April 30, 2014, a representative of the Office of California State LongTerm Care Ombudsman (Ombudsman) filed an appeal and complaint on Ms. 

Woods’ behalf with the Department of Health Care Services Hearing and Appeals 

Unit. The complaint alleged that St. John’s refusal to readmit Ms. Woods 

constituted an improper discharge from the facility. The complaint also alleged 

that St. John failed to honor the seven-day bed hold required by California law. 

Administrative Hearing

On May 6, 2014, the ombudsman’s appeal went to an administrative hearing 

before a DHCS hearing officer with the Office of Administrative Hearings and 

Appeals Transfer/Discharge and Refusal to Readmit Unit. Present at the hearing 

on behalf of Ms. Woods were Ms. Woods herself, the ombudsman, and Ms. 

Boutte-Evans. Present on behalf of St. John were J.P. Cosico (St. John’s 

Administrator), Norma Bullen (Director of Nursing), Catherine Penlocky (RN 

Supervisor), and Dao Truong (the caseworker). Also present was Dr. Pontaya 

Fahardee (Ms. Woods’ treating psychiatrist at the Hospital). 

Neither side was represented by counsel, and the hearing was informal. 

Although the participants’ testimony was given under oath and subject to crossexamination, the hearing officer conducted much of the questioning and the 

testimony was elicited in conversational form.2The hearing officer also received 

documentary evidence.

 

2

The applicable rules of procedure for such a hearing are set forth in 34 Code of 

Federal Regulations section 222.156:

“Administrative hearings under this subpart are conducted as follows:

“(a) The administrative hearing is conducted by an ALJ appointed under 5 U.S.C. 

3105, who issues rules of procedure that are proper and not inconsistent with this subpart.
7

On May 13, 2014, the hearing officer issued her written Decision and Order. 

She reasoned that St. John failed to comply with its duty under section 483.12, 

subdivision (b), and Title 22, California Code of Regulations, section 72520, 

subdivision (b), (section 72520) to give written notice of Ms. Woods’ right to a 

seven-day bed hold under California law. Nonetheless, the evidence showed that 

St. John did, in fact, keep the bed open for that period. Also, the bed hold 

requirement does not apply if the facility is notified in writing that the patient’s

stay will exceed seven days. Because Ms. Woods’ stay ultimately exceeded seven

days, and because St. John held a bed open for seven days, the hearing officer

deemed the failure to give notice of the required seven-day bed-hold moot. 

However, the hearing officer concluded that St. John violated the nextavailable-bed requirement of federal law. Section 483.12, subdivision (b)(3), 

requires a skilled nursing facility to establish and follow a policy that permits a 

resident whose acute hospitalization exceeds the State bed-hold period to be 

readmitted to the first available bed if the resident requires the facility’s services

 

“(b) The parties may introduce all relevant evidence on the issues stated in the 

applicant’s request for hearing or on other issues determined by the ALJ during the 

proceeding. The application in question and all amendments and exhibits must be made 

part of the hearing record.

“(c) Technical rules of evidence, including the Federal Rules of Evidence, do not 

apply to hearings conducted under this subpart, but the ALJ may apply rules designed to 

assure production of the most credible evidence available, including allowing the crossexamination of witnesses.

“(d) Each party may examine all documents and other evidence offered or 

accepted for the record, and may have the opportunity to refute facts and arguments 

advanced on either side of the issues.

“(e) A transcript must be made of the oral evidence unless the parties agree 

otherwise.

“(f) Each party may be represented by counsel.

“(g) The ALJ is bound by all applicable statutes and regulations and may neither 

waive them nor rule them invalid.”
8

and is Medicare eligible. The hearing officer concluded that St. John’s refusal to 

readmit Ms. Woods to the first available bed when informed by the Hospital she 

was ready for transfer constituted an improper, involuntary transfer or discharge

under federal law.

The hearing officer reasoned: “In general, a facility should readmit a 

resident pending the resolution of the transfer/discharge process and initiate a more 

permanent move after it identifies a more appropriate facility. [¶] While this 

tribunal is mindful of the challenges that resident’s care may present, a SNF 

[skilled nursing facility] may not use hospitalization as a mechanism to circumvent 

the aforementioned involuntary transfer/discharge requirements. Hospitalization is 

for the purpose of evaluation and treatment of an acute condition. Resident is no 

longer in need of acute psychiatric or medical treatment and return to facility . . . is 

appropriate, as supported by the federal regulations. [¶] If facility believes that a 

transfer/discharge is necessary for resident’s welfare or that her behavior 

jeopardizes the safety of herself or others, then the regulations provide a remedy 

under 42, C.F.R. section 483.12, subdivision (a) et seq., which sets forth a number 

of requirements, including proper discharge planning. [¶] [F]acility failed to 

support that it complied with this requirement.”

On this reasoning, the hearing officer concluded that St. John improperly 

refused to readmit Ms. Woods, and ordered that St. John “MUST [sic] immediately 

offer to readmit [her] to the first available female bed in a semi-private room.” 

Administrative Mandate

St. John filed a petition for writ of administrative mandate in the superior 

court seeking to overturn the hearing officer’s ruling. The Department of Health 

Care Services, whose hearing officer conducted the administrative hearing, 
9

declined to participate in the matter. The superior court granted Ms. Woods’ 

motion to intervene in the writ proceeding, and also granted permission to file a 

separate civil complaint in intervention alleging various causes of action, including 

breach of contract and financial abuse of an elder. In the civil case (Los Angeles 

Superior Court case No. BC556147), among other allegations, Ms. Woods relies in 

part on St. John’s alleged failure to comply with the requirements for an 

involuntary transfer under section 483.12, subdivision (a), et seq., and incorporated 

an attached copy of the hearing officer’s decision. The superior court stayed action 

on the civil complaint in intervention pending determination of the petition for writ 

of administrative mandate.

3

 

In its briefing in support of its petition for writ of administrative mandate in 

the trial court, St. John argued that the hearing officer erred in concluding that it 

violated section 483.12. In relevant part, St. John noted that although Ms. Woods 

resided at St. John, the order to transfer her to the Hospital was made by St. Liz, 

thereby, according to St. John, absolving St. John of its duty to readmit. St. John 

also argued that even if it was responsible for the transfer, the hearing officer 

abused her discretion in ordering that Ms. Woods be re-admitted, because St. John 

could not meet her specialized psychiatric needs (see Cal. Code Regs., tit. 22, 

§ 72515, subd. (b) [“The licensee shall: [¶] . . . [¶] [a]ccept and retain only those 

patients for whom it can provide adequate care”].) Finally, St. John accused the 

hearing officer of being biased against it. 

Following hearing, the trial court issued a lengthy minute order denying St. 

John’s petition, and St. John appeals.

 

3 However, as we explain in our discussion of the mootness issue, based on the 

parties’ representations in their briefs, discovery in that case is ongoing.
10

DISCUSSION

I. Mootness

St. John contends that events subsequent to the filing of the appeal render 

the order requiring that Ms. Woods be offered the first available bed moot. The 

contention depends on facts outside the record on appeal, but which are conceded 

by Ms. Woods. 

In its opening brief, St. John states that “Ms. Woods’ counsel will likely 

stipulate to” the following facts: there is no evidence that Ms. Woods still lives in 

California, that she is currently receiving or in need of skilled nursing care, or that 

she intends to return to St. John. In response, in her respondent’s brief, apparently 

based on discovery that has occurred in the separate civil lawsuit, Ms. Woods 

concedes the following facts (we delete the argumentative language of the brief): 

“In this case . . . , after 40 . . . days in the hospital, respondent found another 

nursing home in California, where she lived . . . for 14 months. In steadily 

declining health, . . . respondent chose to move again in late August 2015, this time 

to her daughter’s home in New Jersey. . . . On October 2, 2015, . . . against 

medical advice . . . , respondent took an unaccompanied flight from Newark to Los 

Angeles, went directly to appellant’s nursing home to see her mother, and then 

went directly to Cedars Sinai with complaints of severe chest pains. Released from 

the hospital on October 6, 2015, respondent gave her deposition in the related case 

(BC556147) on October 8, 2015, and then returned directly to her mother’s 

bedside at appellant’s nursing home. Respondent was still there when her mother 

passed away on October 10, 2015. Respondent now resides in her daughter’s 

home in New Jersey.” Ms. Woods concedes that her mother’s death resulted in the 

“end to [her] desire for re-admittance to” St. John. 
11

On these conceded facts, the specific order issued by the hearing officer –

that St. John “immediately offer to readmit [Ms. Woods] to the first available 

female bed in a semi-private room” – is moot. “‘It is well settled that an appellate 

court will decide only actual controversies and that a live appeal may be rendered 

moot by events occurring after the notice of appeal was filed. We will not render 

opinions on moot questions or abstract propositions, or declare principles of law 

which cannot affect the matter at issue on appeal.’ [Citations.] [¶] The general 

rule regarding mootness, however, is tempered by the court’s discretionary 

authority to decide moot issues.” (Building a Better Redondo, Inc. v. City of 

Redondo Beach (2012) 203 Cal.App.4th 852, 866-867.)

Here, the record demonstrates that Ms. Woods’ motivating reason for 

wishing to reside at St. John was to be near her mother, who also resided there. As 

Ms. Woods now concedes, her mother has passed away, and Ms. Woods no longer 

wishes to return. Ms. Woods no longer lives in California, but rather in New 

Jersey at her daughter’s home. Given these facts, the order to offer re-admittance

can provide no effective relief, because Ms. Woods will not accept re-admittance. 

However, even “if an appeal is technically moot, [when] ‘there may be a 

recurrence of the same controversy between the parties and the parties have fully 

litigated the issues,’ a reviewing court may in its discretion reach the merits of the 

appeal. [Citation.]” (See City of Hollister v. Monterey Ins. Co. (2008) 165 

Cal.App.4th 455, 480.) Here, Ms. Woods contends that there is a likelihood that 

the same controversy regarding St. John’s refusal to readmit her will arise again, 

because she still has a separate civil complaint for damages against St. John. As 

we have noted, in the civil case, Ms. Woods relies in part on St. John’s alleged 

failure to comply with the requirements for an involuntary transfer under section 

483.12, subdivision (a), et seq., and incorporated in her complaint an attached copy 
12

of the hearing officer’s decision. In arguing that it did not violate section 483.12, 

St. John has raised an issue of law, requiring an interpretation of section 483.12. 

St. John contends that under the plain meaning of section 483.12, it was not bound 

by the first-available-bed requirement, because Ms. Woods was under the care of 

her hospice provider (St. Liz) while residing at St. John, and because a St. Liz 

physician directed her transfer to the Hospital. We exercise our discretion to 

review this issue, because it is likely to be a key legal issue in the pending civil 

case, and because the parties have briefed it both in the trial court and on appeal. 

We decline to consider any other issues on appeal, which can be better handled 

through discovery and litigation in the civil case. 

II. First Available Bed Requirement – Right of Return

A. Relevant Provisions

In construing the meaning of section 483.12 (a Medicare administrative 

regulation), we use the same rules applicable to the interpretation of statutes. 

“Hence, this court should attempt to ascertain the intent of the regulating agency. 

[Citation.] Further, in construing a regulation, we may consider other regulations 

which may shed light on the meaning of the regulation at issue. [Citation.] 

Indeed, similar regulations should be construed in light of one another, and similar 

phrases in each would be given like meanings. [Citation.]” (Goleta Valley 

Community Hospital v. Department of Health Services (1983) 149 Cal.App.3d 

1124, 1129.)

In order to place the issue we shall decide in proper context, we must begin 

by summarizing the relevant provisions: section 483.12, which governs a skilled 

nursing facility’s involuntary transfer or discharge of a resident; section 72520, 

which governs California’s bed-hold policy; and Health and Safety Code section 
13

1599.1, subdivisions (h)(1) and (h)(2), which specify the appeal rights of a longterm care resident who is denied readmission in violation of section 483.12. 

1. Transfer and Discharge

Subdivision (a)(1) of section 483.12 defines the terms “[t]ransfer and 

discharge.” It provides: “Transfer and discharge includes movement of a resident 

to a bed outside of the certified facility whether that bed is in the same physical 

plant or not. Transfer and discharge does not refer to movement of a resident to a 

bed within the same certified facility.” 

2. Resident’s Right to Remain in the Facility

Section 483.12, subdivision (a)(2) governs the requirements for an 

involuntary transfer or discharge, meaning one in which the facility transfers or 

discharges a resident under circumstances that overcome the resident’s right to 

remain in the facility. It provides, as here relevant: “The facility must permit each 

resident to remain in the facility, and not transfer or discharge the resident from the 

facility unless – [¶] (i) The transfer or discharge is necessary for the resident’s

welfare and the resident’s needs cannot be met in the facility; [¶] [or] [¶] . . . 

(iii) The safety of individuals in the facility is endangered.”4

 

4

Section 483.12, subdivision (a)(2) provides in full:

“Transfer and discharge requirements. The facility must permit each resident to 

remain in the facility, and not transfer or discharge the resident from the facility unless –

“(i) The transfer or discharge is necessary for the resident’s welfare and the 

resident’s needs cannot be met in the facility;

“(ii) The transfer or discharge is appropriate because the resident’s health has 

improved sufficiently so the resident no longer needs the services provided by the 

facility;

“(iii) The safety of individuals in the facility is endangered;

“(iv) The health of individuals in the facility would otherwise be endangered;
14

3. Documentation for Transfer or Discharge

Section 483.12, subdivision (a)(3) specifies the documentary procedure 

necessary for a facility to implement such a transfer or discharge of a resident:

“When the facility transfers or discharges a resident under any of the 

circumstances specified in paragraphs (a)(2)(i) through (v) of this section, the 

resident’s clinical record must be documented. The documentation must be made 

by – [¶] (i) The resident’s physician when transfer or discharge is necessary 

under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and [¶] (ii) A 

physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this 

section.” 

4. Transfer and Discharge Planning

Section 483.12, subdivision (a)(7) requires, in substance, that the facility 

provide a plan for transfer or discharge: “Orientation for transfer or discharge. A 

facility must provide sufficient preparation and orientation to residents to ensure 

safe and orderly transfer or discharge from the facility.” Further, as mentioned 

below in conjunction with the notice requirements, the facility must notify the 

resident of “[t]he effective date of transfer or discharge” (subd. (a)(6)(ii)) and 

“[t]he location to which the resident is transferred or discharged” (subd. (a)(6)(iii)).

 

“(v) The resident has failed, after reasonable and appropriate notice, to pay for (or 

to have paid under Medicare or Medicaid) a stay at the facility. For a resident who 

becomes eligible for Medicaid after admission to a facility, the facility may charge a 

resident only allowable charges under Medicaid; or

“(vi) The facility ceases to operate.”
15

5. Notice of State Bed-hold Policy and Readmission

Section 483.12 has several notice provisions applicable to transfers and 

discharges. We mention only some as potentially relevant to our issue.

Under subdivision (a)(4): “Before a facility transfers or discharges a 

resident, the facility must – [¶] (i) Notify the resident and, if known, a family 

member or legal representative of the resident of the transfer or discharge and the 

reasons for the move in writing and in a language and manner they understand. [¶] 

(ii) Record the reasons in the resident’s clinical record; and [¶] (iii) Include in 

the notice the items described in paragraph (a)(6) of this section.” The items in 

subdivision (a)(6) include “[t]he effective date of transfer or discharge” (subd. 

(a)(6)(ii)) and “[t]he location to which the resident is transferred or discharged” 

(subd. (a)(6)(iii)).

5

Generally, this notice must be given at least 30 days before the transfer or 

discharge. (§ 483.12, subd. (a)(5).) However, under certain circumstances listed 

in subdivision (a)(5)(ii), such as when “the safety of individuals in the facility 

 

5

Subdivision (a)(6) provides in full:

“(6) Contents of the notice. The written notice specified in paragraph (a)(4) of 

this section must include the following:

“(i) The reason for transfer or discharge;

“(ii) The effective date of transfer or discharge;

“(iii) The location to which the resident is transferred or discharged;

“(iv) A statement that the resident has the right to appeal the action to the State;

“(v) The name, address and telephone number of the State long term care 

ombudsman;

“(vi) For nursing facility residents with developmental disabilities, the mailing 

address and telephone number of the agency responsible for the protection and advocacy 

of developmentally disabled individuals established under Part C of the Developmental 

Disabilities Assistance and Bill of Rights Act; and

“(vii) For nursing facility residents who are mentally ill, the mailing address and 

telephone number of the agency responsible for the protection and advocacy of mentally 

ill individuals established under the Protection and Advocacy for Mentally Ill Individuals 

Act.”
16

would be endangered” (§ 483.12, subd. (a)(5)(ii)(A)) the notice may be given “as 

soon as practicable before transfer or discharge.” (§ 483.12, subd. (a)(5)(ii).)

Subdivision (b)(1) provides an additional pre-transfer notice requirement, 

applicable when “a nursing facility transfers a resident to a hospital or allows a 

resident to go on therapeutic leave.” That notice “must provide written 

information to the resident and a family member or legal representative that 

specifies – [¶] (i) The duration of the bed-hold policy under the State plan, if any, 

during which the resident is permitted to return and resume residence in the 

nursing facility; and [¶] (ii) The nursing facility’s policies regarding bed-hold 

periods, which must be consistent with paragraph (b)(3) of this section, permitting 

a resident to return.” (§ 483.12, subd. (b)(1).)

Finally for our purposes, when a facility transfers a resident, subdivision 

(b)(2) of section 483.12 provides the notice requirement that must occur at the time

of transfer. It provides: “At the time of transfer of a resident for hospitalization or 

therapeutic leave, a nursing facility must provide to the resident and a family 

member or legal representative written notice which specifies the duration of the 

bed-hold policy described in paragraph (b)(1) of this section.” The reference to 

“paragraph (b)(1) of this section” refers to subdivision (b)(1)(i), “[t]he duration of 

the bed-hold policy under the State plan, if any, during which the resident is 

permitted to return and resume residence in the nursing facility.” 

6. California Bed-Hold Policy

California’s bed-hold policy is contained in section 72520, which provides, 

as here relevant: “If a patient of a skilled nursing facility is transferred to a general 

acute care hospital as defined in Section 1250(a) of the Health and Safety Code, 

the skilled nursing facility shall afford the patient a bed hold of seven (7) days, 
17

which may be exercised by the patient or the patient’s representative.” (§ 72520, 

subd. (a).)6

7. Return after Transfer

When the state bed-hold period has expired, section 483.12, subdivision 

(b)(3) provides a transferred resident with a right to return to the facility, to the 

next available bed. It states: “Permitting resident to return to facility. A nursing 

facility must establish and follow a written policy under which a resident, whose 

hospitalization or therapeutic leave exceeds the bed-hold period under the State 

plan, is readmitted to the facility immediately upon the first availability of a bed in 

a semi-private room if the resident – [¶] (i) Requires the services provided by the 

facility; and [¶] (ii) Is eligible for Medicaid nursing facility services.” 

8. Refusal to Re-admit

After a transfer for treatment in an acute care hospital, if a facility refuses to 

re-admit a resident under section 483.12, subdivision (b)(3), the refusal is 

tantamount to an involuntary transfer. Health and Safety Code section 1599.1, 

subdivision (h) provides in relevant part: “(h)(1) If a resident of a long-term 

 

6

Like section 483.12, section 72520 also has a notice provision, which requires that 

“upon transfer of the patient of a skilled nursing facility to a general acute care hospital, 

the skilled nursing facility shall inform the patient, or the patient’s representative, in 

writing of the right to exercise this bed hold provision.” (§ 72520, subd. (b).) A skilled 

nursing home that “fails to meet these requirements shall offer to the patient the next 

available bed appropriate for the patient’s needs,” and “[t]his requirement shall be in 

addition to any other remedies provided by law.” (§ 72520, subd. (c).) However, “[i]f 

the patient’s attending physician notifies the skilled nursing facility in writing that the 

patient’s stay in the general acute care hospital is expected to exceed seven (7) days, the 

skilled nursing facility shall not be required to maintain the bed hold.” (§ 72520, subd. 

(a)(3).)
18

health care facility has been hospitalized in an acute care hospital and asserts his or 

her rights to readmission pursuant to bed hold provisions, or readmission rights of 

either state or federal law, and the facility refuses to readmit him or her, the 

resident may appeal the facility’s refusal. [¶] (2) The refusal of the facility as 

described in this subdivision shall be treated as if it were an involuntary transfer 

under federal law, and the rights and procedures that apply to appeals of transfers 

and discharges of nursing facility residents shall apply to the resident’s appeal 

under this subdivision.”

9. Summary

As relevant to the issue we are deciding, the plain meaning of these

provisions makes clear that when a skilled nursing facility involuntarily transfers 

or discharges a resident because of circumstances described in section 483.12, 

subdivision (a)(2)(i) (for the resident’s welfare and whose needs the facility cannot 

meet) or subdivision (a)(2)(iii) (for the safety of persons at the facility), the 

following requirements apply. First, the facility must identify the appropriate 

reason for transfer or discharge as specified in section 483.12, subdivision (a)(2). 

Second, it must comply with the documentation requirements of section 483.12, 

subdivision (a)(3). Third, as applicable to the case, it must comply with the notice 

provisions of section 483.12, subdivisions (a)(4), (a)(5), (a)(6), (b)(1), and (b)(2). 

Fourth, it must provide the resident with “sufficient preparation and orientation . . . 

to ensure a safe and orderly transfer or discharge from the facility” as required by 

section 483.12, subdivisions (a)(7), including giving notice of the effective date of 

the transfer or discharge and the location to which the resident will be transferred 

or discharged (subds. (a)(6)(ii) and (iii)). Fifth, it must follow a written policy 

consistent with section 483.12, subdivision (b)(3), under which a resident who was 
19

transferred for “hospitalization or therapeutic leave” is readmitted to the first 

available bed if the State bed-hold period (in California, a 7-day bed-hold period 

(§ 72520)) has expired, and if the resident requires the services provided by the 

facility and is Medicaid eligible. Finally, a refusal to readmit is “treated as if it 

were an involuntary transfer under federal law” (§ 1599.1, subd. (h)(2)), meaning 

that absent compliance with the applicable involuntary transfer requirements under 

section 483.12, the refusal to readmit is improper. 

B. St. John’s Contention

St. John contends that it was not bound by section 483.12 (in particular, the 

requirements of notice before or at the time of that transfer, the bed-hold period,

readmission after the State bed-hold period expire, and transfer planning). The 

reason: Ms. Woods’ hospice care provider, St. Liz, ordered her transfer to the 

Hospital, rather than St. John.

As best we understand it, St. John’s logic is as follows. The language of 

section 483.12 provides that the justification for an involuntary transfer under 

subdivision (a)(2) and the documentation required under subdivision (a)(3) apply

only if the facility “transfers” the resident.7Thus, St. John asserts, the other 

section 483.12 requirements also apply only if the facility “transfers” the resident. 

 

7

See subdivision (a)(2) [“[t]he facility must permit each resident to remain in the 

facility, and not transfer or discharge the resident from the facility unless” one or more of 

the listed circumstances are met]; subdivision (a)(3) [documentation of the reason for 

transfer or discharge must be made “[w]hen the facility transfers or discharges a resident” 

under circumstances described in subdivision (a)(2)].
20

Although Ms. Woods resided at St. John, she had elected St. Liz as her hospice 

provider under 42 Code of Federal Regulations section 418.24, subdivision (a).8 

Further, as required by 42 Code of Federal Regulations section 418.112, 

subdivision (b), St. Liz had “assume[d] responsibility for professional management 

of the resident’s hospice services provided, in accordance with the hospice plan of 

care and the hospice conditions of participation.” As such, it was Ms. Woods 

attending physician, acting for St. Liz (as opposed to St. John), who determined 

that Ms. Woods should be transferred from St. John to the Hospital for a 

psychiatric evaluation and treatment. Therefore, St. John argues, it did not 

“transfer” Ms. Woods. Rather, St. Liz did. Further, according to St. John, it was

not obligated to comply with section 483.12, including the duty to readmit her. 

We disagree. There is no doubt that Ms. Woods’ relocation from St. John to 

the Hospital was a transfer under section 483.12, subdivision (a)(1) – it was a 

“movement of a resident to a bed outside of the certified facility.” St. John asserts 

that St. Liz was responsible for the transfer, but St. John does not state, or even 

imply, that St. Liz was responsible for complying with the requirements of section 

483.12. The reason is obvious. St. Liz was not the skilled nursing facility where 

Ms. Woods resided, and thus St. Liz was not covered by section 483.12. Under St. 

John’s logic, section 483.12 simply did not apply. 

But that result violates the plain meaning of section 483.12 as a whole and 

common sense. Section 483.12 expressly refers to the obligations the facility bears 

 

8

42 Code of Federal Regulations section 418.24, subdivision (a)(1) provides: “An 

individual who meets the eligibility requirement of § 418.20 may file an election 

statement with a particular hospice. If the individual is physically or mentally 

incapacitated, his or her representative (as defined in § 418.3) may file the election 

statement.” An individual is qualified to file a hospice election if the person is entitled to 

Medicare Part A and is certified as being terminally ill. (42 C.F.R. § 418.20, subds. (a) & 

(b).)
21

to a “resident,” and does not contain any suggestion that if the resident is under the 

care of a hospice provider, the involuntary transfer provisions do not apply. 

Indeed, that result makes no sense. Surely, given that a terminally ill resident at a

skilled nursing facility is authorized to elect hospice care, and that the skilled 

nursing facility is authorized to contract with hospice care providers to provide 

such care at the facility, federal regulations would not deprive such a resident of 

the protections of section 483.12 simply based on whose employee – the hospice’s 

or the facility’s – determines the need for a transfer. And if that were the intent, 

we presume that the regulations would so state. Thus, we decline to read into 

section 483.12 any exemption that applies solely because a resident’s hospice care 

provider determines the need for an acute care hospitalization rather than the long 

term care facility. 

St. John summarily asserts, without explanation, that if it had prepared a 

discharge plan in connection with its refusal to readmit Ms. Woods, it would have 

violated both its contract with St. Liz and 42 Code of Federal Regulations section 

418.112, subdivision (c)(3), which provides that a skilled nursing facility such as 

St. John “must have a written agreement that specifies the provision of hospice 

services in the facility” including “[a] provision stating that the hospice assumes 

responsibility for determining the appropriate course of hospice care, including the 

determination to change the level of services provided.” 

But St. John fails to explain the purported conflict. Section 483.12 required 

St. John to identify a justifying circumstance for refusing to re-admit Ms. Woods

under subdivision (a)(2), to document it under subdivision (a)(3), and to provide 

preparation and orientation for a safe and orderly transfer under subdivision (a)(7), 

including determining the effective date of transfer or discharge and the location to 

which Ms. Woods would be sent (subds. (a)(6)(i) and (ii)). Certainly St. John, as 
22

the facility in which Ms. Woods resided, could comply with these duties in 

consultation with St. Liz, without purporting to dictate the appropriate course of 

hospice care or level of service provided. Indeed, several provisions of 42 Code of 

Federal Regulations section 418.112 contemplate such cooperation. (See 42 Code 

of Fed. Regs., § 418.112, subd. (c)(1) [skilled nursing facility’s written agreement 

with hospice service must explain “[t]he manner in which the SNF/NF [skilled 

nursing facility or nursing facility] and the hospice are to communicate with each 

other and document such communications to ensure that the needs of patients are 

addressed and met 24 hours a day”]; id., subd. (c)(2) [agreement must require the 

skilled nursing facility to “immediately notif[y] the hospice if – [¶] (i) A 

significant change in a patient’s physical, mental, social, or emotional status 

occurs; [¶] (ii) Clinical complications appear that suggest a need to alter the plan 

of care; [or] [¶] (iii) A need to transfer a patient from the SNF/NF . . . , and the 

hospice makes arrangements for, and remains responsible for, any necessary 

continuous care or inpatient care necessary related to the terminal illness and 

related conditions”]; id. subd. (c)(4) [agreement must require the skilled nursing 

facility “to continue to furnish 24 hour room and board care, meeting the personal 

care and nursing needs that would have been provided by the primary caregiver at 

home at the same level of care provided before hospice care was elected”].) Thus, 

we see no conflict between, on the one hand, St. John’s duty to perform discharge 

planning under section 483.12, and, on the other hand, either the requirements of 

42 Code of Federal Regulations section 418.112, subdivision (c)(4), or St. John’s 

contract with St. Liz.

St. John also contends that if it readmitted Ms. Woods, and then complied 

with the requirements of section 483.12 to transfer or discharge her, including 

preparation of a discharge plan, it would have violated Health and Safety Code 
23

section 1432 (section 1432). That statute prohibits a long term care facility from 

discriminating or retaliating against any “complainant or . . . patient . . . on the 

basis or for the reason that the complainant, patient, . . . or any other person has 

presented a grievance or complaint, or has initiated or cooperated in any 

investigation or proceeding of any governmental entity relating to care, services, or 

conditions at that facility. A licensee who violates this section is subject to a civil 

penalty of no more than ten thousand dollars ($10,000), to be assessed by the 

director and collected in the manner provided in Section 1430.” (§ 1432, subd. 

(a).) 

St. John’s contention that it would violate section 1432, subdivision (a) by 

readmitting Ms. Woods and planning her discharge is based on the presumption 

created by section 1432, subdivision (b), which provides: “Any attempt to expel a 

patient from a long-term health care facility, or any type of discriminatory 

treatment of a patient by whom, or upon whose behalf, a grievance or complaint 

has been submitted, directly or indirectly, to any governmental entity or received 

by a long-term health care facility administrator or any proceeding instituted under 

or related to this chapter within 180 days of the filing of the complaint or the 

institution of the action, shall raise a rebuttable presumption that the action was 

taken by the licensee in retaliation for the filing of the complaint.” (Italics added.) 

Although St. John does not fully develop the argument, it appears that St. 

John is contending that if it had readmitted Ms. Woods, complied with the 

discharge requirements of section 483.12, and then discharged Ms. Woods, all 

within 180 days of the ombudsman’s complaint, it would be presumed to be in 

violation of section 1432, subdivision (a). However, the presumption of section 

1432, subdivision (b) is one “affecting the burden of producing evidence as 

provided in Section 603 of the Evidence Code.” (§ 1432, subd. (d).) The effect of 
24

such a presumption is that “when the party against whom such a presumption 

operates produces some quantum of evidence casting doubt on the truth of the 

presumed fact, the other party is no longer aided by the presumption. The 

presumption disappears, leaving it to the party in whose favor it initially worked to 

prove the fact in question.” (Rancho Santa Fe Pharmacy, Inc. v. Seyfert (1990) 

219 Cal.App.3d 875, 882.)

Thus, St. John’s concern about being found in violation of section 1432 is 

unfounded. Obviously, if St. John complied with the requirements of a discharge 

under section 483.12, and thereafter discharged Ms. Woods, that evidence would

show that St. John was not discriminating or retaliating against her, but rather 

complying with the nondiscriminatory and non-retaliatory discharge requirements 

of section 483.12. Thus, the presumption affecting the burden of proof under 

section 1432, subdivision (b) would disappear. In short, it is inconceivable that 

that St. John would have been in violation of section 1432 had it readmitted Ms. 

Woods and validly complied with section 483.12 in later discharging her. 

Thus, for all of the foregoing reasons, we conclude that section 483.12 does 

not exempt a skilled nursing facility from the readmission requirement (483.12, 

subd. (b)(3)) solely because the transfer to an acute care hospital from which the 

resident is returning was ordered by the resident’s hospice care provider rather than 

the facility itself. To the extent St. John contends that its refusal to readmit Ms. 

Woods did not constitute an involuntary transfer because she was returning from 

an acute hospitalization ordered by St. Liz, St. John is mistaken. Further, that St. 

Liz ordered the acute hospitalization also did not exempt St. John from complying 

with the involuntary transfer provisions of section 483.12, subdivision (a)(2) 

(requiring identification of a justifying circumstance), subdivision (a)(3) (requiring 

documentation of the justifying circumstance) and subdivision (a)(7) (requiring 
25

preparation and orientation for a safe and orderly transfer), including giving notice 

of the effective date of the transfer or discharge and the new resident location 

(subds. (a)(6)(ii) and (iii)), before terminating Ms. Woods’ residency. Finally, 

there was no risk that readmitting Ms. Woods and later discharging her in 

compliance with section 483.12 would have placed St. John in violation of section 

1432.

DISPOSITION

The order denying the petition for writ of administrative mandate is 

reversed solely on the ground that the DHCS order for Ms. Woods’ readmission to 

St. John is moot. (See Giles, supra, 100 Cal.App.4th at p. 229.) We remand the 

matter to the superior court, with directions to dismiss the petition for writ of 

administrative mandate as moot. Each side shall bear its own costs on appeal.

CERTIFIED FOR PUBLICATION

WILLHITE, J.

We concur:

EPSTEIN, P. J. COLLINS, J.