RCFE vs. Nursing Home: How California's Two Care Settings Differ

Two different kinds of care

After a hospital stay, or when a parent’s health slips, you may be weighing two settings: a residential care home or a nursing home. In California they are not two levels of the same thing. They are licensed by different state departments, under different laws, to provide different kinds of care.

A residential care facility for the elderly (RCFE) provides non-medical care and supervision. A skilled nursing facility (SNF), commonly called a nursing home, is a health facility that provides skilled nursing care around the clock. The California Department of Social Services (CDSS) draws the same line, contrasting “facilities licensed to provide health care, such as skilled nursing facilities, and those licensed to provide non-medical care such as Residential Care Facilities for the Elderly (RCFEs).”

A useful first question: does your parent need skilled nursing care available at all hours?

Who licenses each

RCFEs are licensed and inspected by the Community Care Licensing Division of CDSS. The division describes its role as overseeing “primarily non-medical, community-based facilities that care for seniors,” and its consumer guide points families to the California Department of Public Health (CDPH) for skilled nursing information.

Skilled nursing facilities are licensed by CDPH. Its Licensing and Certification Program regulates hospitals, home health agencies, hospices, skilled nursing facilities and other health facilities. It also acts as the state survey agency for the federal Centers for Medicare and Medicaid Services, certifying facilities to receive Medicare and Medi-Cal payments.

One setting can include both. In a continuing care retirement community, the residential care part is licensed by CDSS, and the skilled nursing units are licensed separately by CDPH to provide medical services. As of May 25, 2025, according to state licensing data, 132 California RCFEs are licensed as continuing care retirement communities.

What each one provides

State law defines an RCFE’s “care and supervision” as ongoing help with activities of daily living, without which a resident’s health, safety or welfare would be at risk. It specifically includes help with taking medications, managing money and personal care. Most of these homes are small. As of May 25, 2025, according to state licensing data, 6,265 of the 7,939 licensed RCFEs in California (79%) have six beds or fewer.

An RCFE can still bring in some medical help. Under the regulations, a licensed home health agency may provide incidental medical care to residents, under conditions that include a written agreement with the home.

A skilled nursing facility is built around medical care. Title 22 defines it as a facility providing continuous skilled nursing care to patients whose main need is skilled nursing on an extended basis. It provides 24-hour inpatient care and, at a minimum, physician, skilled nursing, dietary and pharmaceutical services and an activity program.

What is an RCFE? goes into more detail on how residential care homes work.

Health conditions an RCFE can’t care for

This is where the two settings separate most clearly. State law says an RCFE may not admit or keep a resident who needs 24-hour skilled nursing or intermediate care. It also bars residents who are bedridden for reasons other than a temporary illness or recovery from surgery, though the law makes exceptions, so being bedridden does not by itself always mean a move.

The regulations add active communicable tuberculosis and a list of prohibited health conditions. Under that list, a person who has or needs care for any of these may not be admitted or kept:

• stage 3 and 4 pressure injuries
• gastrostomy tubes
• naso-gastric tubes
• staph infection or another serious infection
• dependence on others for all activities of daily living
• tracheostomies

If a resident has a condition the home can’t care for within its license, needs inpatient care in a health facility, or has a prohibited condition, CDSS must order the home to relocate them. The resident has the right to ask for a review by an interdisciplinary team.

Hospice is the main exception. A home with a state hospice care waiver can keep a resident on hospice with some of these conditions, if the hospice care plan addresses them. Hospice care in a California residential care home explains how that works.

The two side by side

	RCFE (residential care home)	Skilled nursing facility (nursing home)
Licensed by	CDSS Community Care Licensing Division	CDPH Licensing and Certification Program
Kind of care	Non-medical care and supervision: help with daily activities, medications, money management, personal care	Continuous skilled nursing and 24-hour inpatient care, including physician, nursing, dietary and pharmaceutical services
Medical care on site	Incidental medical care through a licensed home health agency; hospice only with a state waiver	Part of the facility’s own services
Who can’t be admitted or kept	Anyone needing 24-hour skilled nursing or intermediate care, and people with prohibited health conditions (exceptions apply)	Built for people whose main need is skilled nursing
Medicare	Doesn’t pay for non-medical long-term care, including in an assisted living facility	Covers short-term skilled care after a qualifying hospital stay, up to 100 days per benefit period
Medi-Cal	See paying for assisted living in California	Covers skilled nursing facility services with prior authorization

What Medicare pays for

Medicare treats the two settings very differently.

It covers skilled nursing facility care only on a short-term basis and only under set conditions. Your parent must first have a medically necessary inpatient hospital stay of at least three days in a row, not counting the day they leave the hospital. Time spent in the emergency room or under observation before admission doesn’t count, even overnight. They must also have Part A with days left in the benefit period, enter the SNF within a short time of leaving the hospital (generally 30 days), have a doctor’s decision that they need daily skilled care, and receive it in a Medicare-certified SNF.

According to Medicare.gov, in 2026 your parent pays $0 a day for days 1 through 20 after the $1,736 Part A deductible, and $217 a day for days 21 through 100. From day 101, they pay all costs. Part A covers at most 100 SNF days in each benefit period. These amounts change every year.

Long-term care is a different matter. Medicare.gov puts it this way: “Since most long-term care is non-medical, Medicare and most health insurance, including Medicare Supplement Insurance (Medigap), don’t pay for long-term care services, including care in a nursing home or in the community.” It lists assisted living facilities among the places people receive that non-medical care. So Medicare does not pay for the care in a residential care home, and it doesn’t pay for non-medical long-term care in a nursing home either.

What Medi-Cal pays for

Medi-Cal, California’s Medicaid program, covers skilled nursing facility services needed to treat illness or injury, after prior authorization. Its rules describe the skilled nursing level of care as care for people who don’t need a full hospital but do need registered or vocational nurses continuously available.

If your parent is in a Medi-Cal managed care plan, ask the plan how it handles skilled nursing facility care before a move.

Medi-Cal and residential care homes are a separate subject, covered in paying for assisted living in California.

Questions to settle before you choose

• Does your parent need skilled nursing available around the clock, or help with daily activities and medications?
• Does your parent have any condition on the prohibited list above?
• If your parent is in the hospital now, were they admitted as an inpatient, and for how many days? Observation time doesn’t count toward Medicare’s three-day rule.
• If you’re considering a residential care home, could your parent’s needs be met with home health visits, or hospice under a waiver, later on?

You can find licensed residential care homes in our California directory.

If something in this guide looks out of date, please tell us.