California provides long-term care resources to seniors through its Assisted Living Waiver, available in only certain counties. The program works to help seniors who are either already in a nursing home or would otherwise require a nursing home level of care to residents in their own home or a community setting while still receiving Medicaid benefits for long-term care.  

Medicaid Waiver Program for Assisted Living and In-Home Care

California Assisted Living Medicaid Waiver (HCBS Assisted Living Waiver)

The Assisted Living Waiver (ALW) is an alternative to long-term placement in a nursing facility. It is presently available in the following counties: Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, San Mateo, Santa Clara, and Sonoma. The ALW is currently enrolling beneficiaries residing in skilled nursing facilities and in the community into licensed Residential Care Facilities (RCF) and Public Subsidized Housing (PSH).

The goal of the ALW is to: 1) facilitate a safe and timely transition of Medi-Cal-eligible seniors and persons with disabilities from a nursing facility to a community home-like setting in a Residential Care Facility (RCF), an Adult Residential Care Facility (ARF), or public subsidized housing, utilizing ALW services; and 2) offer eligible seniors and persons with disabilities, who reside in the community, but are at risk of being institutionalized, the option of utilizing ALW services to develop a program that will safely meet his/her care needs while continuing to reside in an RCF, ARF, or public subsidized housing.


Services included in the ALW are: 24-hour awake staff to provide oversight and meet the scheduled and unscheduled needs of residents (24-hour awake staff is not required in RCFs with 6 beds or less); Provision and oversight personnel and supportive services (assistance with activities of daily living and instrumental activities of daily living); Health-related services including skilled nursing (e.g., medication management services, treatments, wound care, etc.); Social services; Recreational activities; Meals; Housekeeping and laundry; and Provide or arrange transportation.

Additional services may include Assistance in developing and updating ALWP participants’ Individualized Service Plans (ISP), which details, in part, the frequency and timing of assistance. Participants play active roles in the development process and must sign their ISP; Provide personal care and assistance with Activities of Daily Living and Instrumental Activities of Daily Living; Washing, drying and folding laundry; scheduled and unscheduled needs of the residents; Perform all necessary housekeeping tasks; Maintaining the facility; Providing three meals per day plus snacks (food must meet minimum daily nutritional requirements and meet the resident’s special dietary needs as prescribed by their PCP); Providing intermittent skilled nursing services as required by residents; In accordance with State law, providing assistance with self-administration of medications, or administering medications by an RN or LVN; Providing or coordinating transportation; Providing daily recreational activities; Providing social services; Providing a response system that enables waiver beneficiaries to summon assistance from personal care providers.


  1. Health: An applicant must require a Nursing Home Level of Care.
  2. Financial: An applicant must either be an SSI recipient or meet certain income limits as determined by the waiver, which in the case of the ALW is 100% of the Federal Poverty Line. In 2022, the state set the monthly income limit at $1,564 for a single applicant and $2,106 for a married couple (with both applying for benefits).  The income limits are expected to increase for 2023 to 138% of the Federal Poverty Level.  For 2022, the community spouse resource allowance (CSRA) is $137,400; and the community spouse may keep an additional $3,435 per month in income, known as the Maximum Monthly Maintenance Needs Allowance (MMMNA), in order to live off of while their spouse is participating in the ALW program.

Practical Considerations

The fact that the income limit in California is 100% of the Federal Poverty Level, even with the “medically needy spend-down provision, makes qualifying for the program more difficult. Again, please note that this level is expected to increase to 138% of the poverty level in 2023.  Also, the limited number of slots and limited scope of this waiver (geographically and services provided) make it hard to qualify for eligibility.


California is not a great state for seniors wishing to reside in their home or community setting instead of a nursing facility because of the eligibility requirements and certain restrictions on the availability of the program.

Access all state Medicaid Waiver pages.