Regulatory Review of Adult Day Services: Final Report - Section 2. California

08/26/2005

Overview

In California, adult day care services are provided in two types of licensed facilities: adult day programs (ADP) and adult day health care (ADHC) centers. In addition, each local Area Agency on Aging designates at least one Alzheimer's day care resource center (ADCRC) in its planning and service area to provide specialized Alzheimer's care and community outreach and education.

Adult day program providers are licensed by the State Department of Social Services (DSS) Community Care Licensing Division as community care facilities. The term "adult day program" replaced two earlier program names in legislation (SB 1982, Statutes of 2002): adult day care facility (ADCF) and adult day support center (ADSC). These two programs were licensed by DSS under separate regulations in the California Code of Regulations (CCR) Title 22, based on California Health and Safety Code. Because the regulations have not yet been combined, whenever they differ, they are presented separately in this profile under the heading Adult Day Program. ADP services are not available under the Medicaid State Plan.

Adult day health care providers are licensed by the Department of Health Services (DHS) Licensing and Certification Division as health facilities. The California Department of Aging (CDA) administers the program and certifies each center for Medi-Cal (California's Medicaid State Plan) reimbursement. Licenses are not issued or renewed for an ADHC center that is not certified as a Medi-Cal provider of ADHC services. ADHC providers must meet, at a minimum, the licensing requirements specified in Health and Safety Code, Chapter 3.3; the certification requirements specified in Welfare and Institutions Code, Chapter 8.7; and additional requirements specified in the CCR, Title 22. If an ADHC center licensee also provides adult day care or ADSC services, the ADHC license shall be the only license required to provide these additional services.

ADP and ADHC services are also available to clients of the Multipurpose Senior Service Program (MSSP), a case management program targeted to frail elderly clients who are eligible for nursing facility placement. MSSP operates under a Home and Community-Based Services (HCBS) waiver and contracts with appropriately licensed and certified providers for services.

In August 2004, a 1-year moratorium on new ADHC centers enrolling in the Medi-Cal program was instituted and will most likely be extended until the state transitions the ADHC program from the Medicaid State Plan to an HCBS waiver program. During the time of the moratorium, ADHC applicants may be licensed to provide services to persons who pay privately or have insurance coverage for the services. ADHC centers may be certified for the Medi-Cal program only if they meet the exemptions to the moratorium as specified in SB 1103.

ADCRCs are specialized day care centers that target services to persons with Alzheimer's disease and other dementias. Until recently, the law permitted ADCRCs to function without a facility license, although the majority of ADCRCs are located in licensed ADP or ADHC centers. Legislation (AB 2127, Statutes of 2004) amended Welfare and Institutions Code 9542 as follows: an Alzheimer's day care resource center that was not licensed as an adult day program or adult day health care center prior to January 1, 2005, shall be required to be so licensed by January 1, 2008. A direct services program that qualifies to operate as an Alzheimer's day care resource center after January 1, 2005, shall be required to be licensed as an adult day program or adult day health care center. The ADCRC program is currently authorized by statutes, and specific requirements are specified in a program manual, not in regulation. Regulations that were being developed for the ADCRC program were suspended, effective November 1, 2003. All ADCRCs are funded by grants from CDA. Services are reimbursed by Medi-Cal for eligible participants if the program is housed in an ADHC center.

Licensure and Certification Requirements

Licensure and Certification Requirements
Licensure Only  ☒  ADP
Certification Only  ☐ 
Both Required  ☒  ADHC
Other  ☐ 

Definitions

Adult Day Program

Adult day program means any community-based facility or program that provides care to persons 18 years of age or older in need of personal care services, supervision, or assistance essential to sustaining the activities of daily living (ADL) or for the protection of the individual on less than a 24-hour basis.

Adult day care facility means any facility of any capacity that provides nonmedical care and supervision to adults on less than a 24-hour per day basis.

Adult day support center means a community-based group program designed to meet the needs of functionally impaired adults through an individual plan of care in a structured comprehensive program that provides a variety of social and related support services in a protective setting on less than a 24-hour basis.

Adult day support center services means those nonmedical services provided in an ADSC to adults with physical, emotional, or mental impairments and who require assistance and supervision.

Adult Day Health Care

Adult day health care means an organized day program of therapeutic, social, and health activities and services provided to elderly persons with functional impairments, either physical or mental, for the purpose of restoring or maintaining optimal capacity for self-care. Provided on a short-term basis, ADHC serves as a transition from a health facility or home health program to personal independence. Provided on a long-term basis, it serves as an alternative to institutionalization in a long-term health care facility when 24-hour skilled nursing care is not medically necessary or viewed as desirable by the recipient or their family.

Adult day health center or adult day health care center means a licensed and certified facility that provides ADHC, or a distinct portion of a licensed health facility in which such care is provided in a specialized unit under a special permit issued by the department.

Parameters for Who Can Be Served

Adult Day Program

Adult day care facility. Providers determine the parameters for who can be served insofar as they are required to determine whether they can meet prospective clients' service needs prior to admission. They may serve clients with "obvious symptoms of illness" only if these clients are "separated from other clients."

Adult day support center. Adults with physical, emotional, or mental impairments with nonmedical needs who require assistance and supervision may be served. Such persons include, but are not limited to, the following:

  • Persons who require assistance with ADL (e.g., bathing, dressing, grooming) and instrumental activities of daily living (IADL) (e.g., laundry, shopping, paying bills). These persons may live independently, at home with a care provider, in a community care facility, or in a health facility, but do not require a medical level of care during the day.
  • Persons who require assistance and supervision in overcoming the isolation associated with functional limitations or disabilities.
  • Persons who, without program intervention, are assessed to be at risk of physical deterioration or premature institutionalization due to their psychological condition.

Providers determine in part the parameters for who can be served insofar as they are required to determine whether they can meet prospective clients' service needs prior to admission and can discharge those whose needs they can no longer meet or who pose a danger to themselves or others. The regulations also state that participants cannot have specific restricted health conditions as specified in CCR, Title 22, Division 3, Subdivision 1, Chapter 5. (The list of these conditions is too extensive to include here.)

Adult Day Health Care

ADHC facilities may serve persons 55 years of age or older and other adults who are chronically ill or impaired and would benefit from ADHC. Providers may not admit individuals for whom, in their clinical judgment, they cannot appropriately care. They may serve persons with dementia and other special needs populations, such as persons with developmental disabilities or persons with mental disabilities. Providers may discharge participants if they are unable or unwilling to use the prescribed services and ADHC staff have made every effort to remove possible obstacles.

Medicaid provisions for enrollment in ADHC specify that providers may serve individuals: (1) with medical conditions that require treatment or rehabilitative services prescribed by a physician, (2) with mental or physical impairments that handicap ADL but which are not of such a serious nature as to require 24-hour institutional care, and (3) who are at risk for deterioration and probable institutionalization if ADHC services were not available.

Inspection and Monitoring

Inspection and Monitoring
Yes  ☒ 
No  ☐ 

Adult day program. Within 90 days after the date of issuance of a license or special permit, the department shall conduct an inspection of the facility for which the license or special permit was issued. Any duly authorized officer, employee, or agent of the State Department of Social Services may enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, any provision of the General Licensing Requirements, Health and Safety Code.

Every licensed community care facility shall be subject to unannounced visits by the department. The department shall visit these facilities as often as necessary to ensure the quality of care provided. The department will conduct random annual unannounced visits to no less than 10 percent of facilities. Under no circumstances shall the department visit a community care facility less often than once every 5 years.

Adult day health care. If an ADHC center or an applicant for a license has not been previously licensed, the department may only issue a provisional license to the center. A provisional license to operate an ADHC center shall expire 1 year from the date of issuance, or at an earlier time as determined by the department at the time of issuance. Within 30 days prior to the expiration of a provisional license, the department shall give the ADHC center a full and complete inspection, and, if the ADHC center meets all applicable requirements for licensure, a regular license shall be issued. Annual licenses are required; however, the director has discretion to approve applications for relicensure for a period of up to 24 months.

Required and Optional Services

  Adult Day Program Adult Day Health Care*
Required Optional Required Optional
*ADHC centers are also required to provide medical services and psychiatric or psychological services.
ADL Assistance  ☒   ☐   ☒   ☐ 
Health Education and Counseling  ADSC only   ☐   ☒   ☐ 
Health Monitoring/Health-Related Services  ADSC only   ☐   ☒   ☐ 
Medication Administration  Medication assistance   ☐   ☒   ☐ 
Nursing Services  ☐   ☐   ☒   ☐ 
Physical Therapy, Occupational Therapy, or Speech Therapy  ☐   ☐   ☒   ☐ 
Skilled Nursing Services  ☐   ☐   ☒   ☐ 
Social Services  ADSC only   ☐   ☒   ☐ 
Transportation  ☐   ☐   ☒   ☐ 

Provisions Regarding Medications

Adult day program. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. In ADCFs and ADSCs, staff may be trained by the client's family or primary caregiver if the licensee obtains written documentation from the client's family or primary caregiver outlining the procedures and the names of facility staff whom they have trained in those procedures, and the licensee ensures that the client's family or primary caregiver reviews staff performance as necessary, but at least annually.

All staff training shall be documented in the facility personnel files. Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed. For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed and dated written order from a physician on a prescription blank maintained in the client's file and a label on the medication.

Adult day health care. Each participant's health record shall include a drug history that lists all medications currently being taken by the participant and any medications to which the participant is allergic. Medications stored in the center or administered by center personnel shall be labeled in conformance with state and federal laws and regulations. Medications shall be administered only by licensed medical or licensed nursing personnel. Self-administration of medications shall be permitted only under the following conditions: (1) the center shall have approved policies permitting self-administration of medications when approved by the multidisciplinary team; (2) training in self-administration of medications shall be provided to all participants based on the recommendation of the multidisciplinary team; and (3) the health record of each participant who is capable of self-medication shall name all drugs that are to be self-administered.

Provisions for Groups with Special Needs

Provisions for Groups with Special Needs
Dementia  ☒  ADHC
Mental Retardation/Developmental Disabilities  ☒  ADHC
Other  ☒  mental illness, traumatic brain injury (ADHC)

Staffing Requirements

Adult Day Program

Adult Day Care Facility

Type of staff. All ADCFs shall have an administrator. A licensee who is responsible for two or more ADCFs shall be permitted to serve as an administrator of one or more of the facilities. The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. When the administrator is absent from the facility, there shall be coverage by a substitute designated by the licensee who shall be capable of and responsible and accountable for management and administration of the facility in compliance with applicable law and regulation.

Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall at all times be employed in numbers necessary to meet such needs. The licensee shall provide for an overlap of staff at each shift change to ensure continuity of care. Care staff shall not be assigned to any of the support staff duties, such as housekeeping, cooking, or office work, unless the care and supervision needs of clients have been met.

Staffing ratios. There shall be an overall ratio of not less than one staff member providing care and supervision for each 15 clients present. Whenever a client who relies upon others to perform all ADL is present, the following minimum staffing requirements shall be met:

  • For Regional Center clients, staffing shall be maintained as specified by the Regional Center.
  • For all other clients, there shall be a staff-client ratio of no less than one direct care staff to four such clients.

Adult Day Support Center

Type of staff. All ADSCs shall have an administrator. If an administrator is responsible for two or more ADSCs, there shall be at each site an employee who is responsible for the day-to-day operation of the center and who meets the following qualifications: (1) a baccalaureate degree in psychology, social work, or a related human services field or (2) a minimum of 1 year of experience in a supervisory or management position in the human services delivery system. An administrator shall not be responsible for more than five centers. When the administrator or the employee specified above is absent from the center, there shall be coverage by a substitute designated by the licensee who is on site and who shall be capable of, and responsible and accountable for, the management and administration of the center in compliance with applicable laws and regulations.

Support staff and direct care staff are required. Direct care staff provide care and supervision to participants at least 70 percent of the hours of program operation per month.

There shall be at least two persons on duty, at least one of whom is a direct care staff member, at all times when there are two or more participants in the center. The licensee shall provide for an overlap of staff at each shift change to ensure continuity of care. The center shall have at least one full-time staff member who has a current certificate in first aid and cardiopulmonary resuscitation present in the facility during operating hours.

Staffing ratios. There shall be an overall ratio of not less than one direct care staff member providing care and supervision for each group of eight participants, or fraction thereof, present. For each group of 25 participants, or fraction thereof, there shall be at least one direct care staff person who has a baccalaureate degree in a health, social, or human service field, or 1 year documented full-time experience providing direct services to frail or physically, cognitively, or emotionally impaired adults. Whenever a participant who relies upon others to perform all ADL is present, the following minimum staffing requirements shall be met:

  • For Regional Center participants, staffing shall be maintained as specified by the Regional Center.
  • For all other participants, there shall be a staff-participant ratio of no less than one direct care staff to four such participants. Volunteers may be included in the staff-to-participant ratio if the volunteer meets the requirements for direct care staff.

Adult Day Health Care

Type of staff. Each center shall have an administrator. The administrator shall have the responsibility and authority to carry out the policies of the licensee. Each center shall make provision for continuity of operation and assumption of the administrator's responsibilities during the administrator's absence. The administrator shall not be responsible for more than three centers without prior written approval by the Department. In this circumstance, there shall be one or more assistant administrators for every three additional centers.

Each center shall have a full-time program director. The program director shall be on the premises and available to participants, employees, and relatives. When the program director is temporarily absent, another adult on the staff shall be designated to serve as the acting program director. Centers with a capacity of 50 and over shall provide both an administrator and a full-time program director.

The program director of centers whose average daily attendance is 20 or fewer may also serve as the registered nursesocial workeroccupational therapistphysical therapistspeech therapist, or dietitian, provided that the program director meets the professional qualifications for that position and the program director and the administrator are not the same person. Program aides shall be employed in a sufficient number to meet the needs of the participants and the staffing requirements of the Department.

The program director, a registered nurse with a public health background, a medical social worker, a program aide, and the activity coordinator shall be on duty during the hours the center offers basic services. Other staff shall be employed in sufficient numbers to provide services as prescribed in the individual plans or care in accordance with minimal requirements determined by each center's average daily attendance based on the previous quarter experience. Medical services shall be provided to each participant by a personal or a staff physician.

Occupational, physical, and speech therapy services staff shall work the hours necessary to meet the needs of each participant as specified in the individual plan of care and in accordance with the staffing requirements of the Department.

For the provision of psychiatric or psychological services, the center shall have consultant staff available a minimum of 3 hours per month and consisting of a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse. Consultant staff shall spend a sufficient number of hours in the center to meet the needs of each participant and the staffing requirements of the Department.

Support employees shall include maintenance, food service, and clerical employees sufficient in number to perform the necessary duties. Volunteers may be used in centers but shall not be used to replace required employees. Each volunteer shall receive orientation, training, and supervision.

Staffing ratios. There must be one program aide for every 16 participants during the hours of operation. An additional half-time social work assistant and an additional half-time licensed vocational nurse shall be provided for each increment of ten in average daily attendance exceeding 40.

Training Requirements

Adult Day Program

Adult day care facility. All personnel shall be given on-the-job training or shall have related experience that provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance: (1) principles of nutrition, food preparation and storage, and menu planning; (2) housekeeping and sanitation principles; (3) provision of client care and supervision, including communication; (4) assistance with prescribed medications that are self-administered; (5) recognition of early signs of illness and the need for professional assistance; (6) availability of community services and resources; and (7) Universal Precautions as defined in Title 22, Section 8001(u)(1). Training in Universal Precautions may be provided in the facility, or staff may attend training provided by a local health facility, county health department, or other local training resources.

Adult day support center. The licensee shall develop, maintain, and implement a written plan for the orientation, continuing education, on-the-job training and development, supervision, and evaluation of all direct care staff. (1) The plan shall require direct care staff to receive and document a minimum of 20 hours of continuing education during the first 18 months of employment or within 18 months after the effective date of these regulations and during each 3-year period thereafter. (2) The administrator shall receive and document a minimum of 30 hours of continuing education every 24 months of employment. (3) Continuing education shall include completion of courses related to the principles and practices of care of the functionally impaired adult including, but not limited to, workshops, seminars, and academic classes. The center shall train program staff and participants in emergency procedures.

Adult Day Health Care

A planned in-service education program, including orientation, skill training, and continuing education, shall be provided for employees. All staff members shall receive in-service training in first aid and cardiopulmonary resuscitation within the first 6 months of employment. An ADHC that provides care for adults with Alzheimer's disease and other dementias must provide staff training regarding the use and operation of the egress control devices (precluding the use of exits) used by the center, the protection of participants' personal rights, wandering behavior and acceptable methods of redirection, and emergency evacuation procedures for persons with dementia.

Relevant Medicaid Contracting Requirements for Adult Day Services Providers

To obtain certification as a provider of ADHC under the state's Medicaid program (Medi-Cal), a provider must meet all the requirements of licensure as an ADHC center pursuant to Chapter 3.3 (commencing with Section 1570) of Division 2 of the Health and Safety Code, and Chapter 10, Division 5, Title 22 of CCR. Medi-Cal has additional requirements for providers of ADHC services guided by the Adult Day Health Medi-Cal Law pursuant to Chapter 8.7 of the Welfare and Institutions Code, and Chapter 5, Division 3, Subdivision 1, Title 22 of CCR. CDA may implement a 1-year moratorium on the certification and enrollment into the Medi-Cal program of new ADHC centers.

Purpose. The Medi-Cal benefit is intended to establish and continue a community-based system of quality day health services that will: (1) ensure that elderly persons not be institutionalized prematurely and inappropriately; (2) provide appropriate health and social services designed to maintain elderly persons in their own homes; (3) establish adult day health centers in locations easily accessible to the economically disadvantaged elderly person; and (4) encourage the establishment of rural alternative ADHC centers, which are designed to make ADHC accessible to impaired Californians living in rural areas.

Discharge. An adult day health center shall not terminate the provision of adult day health services to any participant unless approved by the state department.

Optional services. (1) Podiatric services, (2) optometric screening and advice for low-vision cases, (3) dental screening for the purpose of appraising the participant of the necessity of regular or emergency dental care, and (4) such other services within the concept and objectives of ADHC as may be approved by the department.

Inspection. Initial Medi-Cal certification for ADHC providers shall expire 12 months from the date of issuance. The director shall specify any date he or she determines is reasonably necessary, but not more than 24 months from the date of issuance, when renewal of the certification shall expire. The certification may be extended for periods of not more than 60 days if the Department determines it to be necessary. Every ADHC center shall be periodically inspected and evaluated for quality of care by a representative or representatives designated by the director, unless otherwise specified in the interagency agreement entered into pursuant to Section 1572 of the Health and Safety Code. Inspections shall be conducted prior to the expiration of certification, but at least every 2 years, and as often as necessary to ensure the quality of care being provided. As resources permit, an inspection may be conducted prior to, as well as within, the first 90 days of operation.

Staffing. A provider shall employ appropriately licensed personnel for furnishing required services. A provider serving a substantial number of participants of a particular racial or ethnic group, or participants whose primary language is not English, shall employ staff who can meet the cultural and linguistic needs of the participant population.

Training. An in-service training plan for each center staff member shall commence within the first 6 months of employment. The training plan shall address, at a minimum, the specific medical, social, and other needs of each participant population the center proposes to serve.

Location of Licensing, Certification, or Other Requirements

  1. http://www.dss.cahwnet.gov/getinfo/pdf/adcfman.PDF.
  2. http://www.dss.cahwnet.gov/getinfo/pdf/adscman.PDF.
  3. http://www.dss.cahwnet.gov/getinfo/pdf/genman1.PDF.
  4. http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=hsc&codebody=&hits=20.
  5. http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=wic&codebody=&hits=20.
  6. http://files.medi-cal.ca.gov/pubsdoco/Pubsframe.asp?hURL=/pubsdoco/io_search.asp.
  7. http://ccr.oal.ca.gov/cgi-bin/om_isapi.dll?clientID=138589&infobase=ccr&softpage= Browse_Frame_Pg42.

Citations

  1. Adult Day Care Facilities--Community Care Licensing Division--Manual of Policies and Procedures (CCR, Title 22, Division 6, Chapter 3). Department of Social Services. [Updated 9/30/02]
  2. Adult Day Support Center--Community Care Licensing Division--Manual of Policies and Procedures (Title 22, Division 6, Chapter 3.5). Department of Social Services. [Updated 3/08/00]
  3. General Licensing Requirements. (CCR, Title 22, Division 6, Chapter 1, Article 1) Department of Social Services. [Updated 12/17/04]
  4. California Adult Day Health Care Act--California Health and Safety Code (Chapter 3.3, Section 1570-1596.5). [Effective 1978]
  5. Adult Day Health Care Program, California Welfare and Institutions Code (Chapter 8.7, Section 14520-14588). [Effective 1978]
  6. Adult Day Health Care Centers, Medi-Cal Inpatient/Outpatient Provider Manual, Department of Health Services. [Effective August 2000]
  7. Adult Day Health Care, California Medical Assistance Program, Health Care Services (CCR, Title 22, Division 3, Subdivision 1, Chapter 5) and Adult Day Health Centers, Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, (CCR, Title 22, Division 5, Chapter 10). [Effective date unknown]

Additional Information

A licensed and certified ADHC center may establish one or more satellites. A satellite may be in the county of the parent or a rural service area. The parent center's license and certification shall cover ADHC services at one or more satellites.

A rural alternative ADHC center shall operate its programs a minimum of 3 days weekly unless the program can justify, to the satisfaction of the department, fewer days of operation due to space, staff, financial, or participant reasons.

In December 2003, the Centers for Medicare & Medicaid Services (CMS) notified DHS that the ADHC program should not have been approved as an optional Medi-Cal benefit and directed the state to transition the program into an HCBS waiver. DHS and CDA are currently working on the waiver application, and the administration has introduced legislation that authorizes the state to obtain a waiver to continue ADHC services.

View full report

Preview
Download

"adultday2.pdf" (pdf, 1.66Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayAK.pdf" (pdf, 539.27Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayAL.pdf" (pdf, 539.15Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayAR.pdf" (pdf, 544.99Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayAZ.pdf" (pdf, 535.67Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayCA.pdf" (pdf, 592.9Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayCO.pdf" (pdf, 530.85Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayCT.pdf" (pdf, 534.59Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayDC.pdf" (pdf, 534.72Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayDE.pdf" (pdf, 536.39Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayFL.pdf" (pdf, 545.04Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayGA.pdf" (pdf, 555.98Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayHI.pdf" (pdf, 542.33Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayIA.pdf" (pdf, 535.91Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayID.pdf" (pdf, 534.37Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayIL.pdf" (pdf, 532.86Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayIN.pdf" (pdf, 546.05Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayKS.pdf" (pdf, 542.19Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayKY.pdf" (pdf, 543.73Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayLA.pdf" (pdf, 532.91Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMA.pdf" (pdf, 540.54Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMD.pdf" (pdf, 552.4Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayME.pdf" (pdf, 545.52Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMI.pdf" (pdf, 549.91Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMN.pdf" (pdf, 544.57Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMO.pdf" (pdf, 540.46Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMS.pdf" (pdf, 539.31Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayMT.pdf" (pdf, 546.04Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNC.pdf" (pdf, 564.56Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayND.pdf" (pdf, 552.2Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNE.pdf" (pdf, 566.6Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNH.pdf" (pdf, 562.71Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNJ.pdf" (pdf, 569.8Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNM.pdf" (pdf, 565.53Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNV.pdf" (pdf, 557.28Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayNY.pdf" (pdf, 572.07Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayOH.pdf" (pdf, 552.63Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayOK.pdf" (pdf, 551.42Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayOR.pdf" (pdf, 543.33Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayPA.pdf" (pdf, 552.98Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayRI.pdf" (pdf, 551.81Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdaySC.pdf" (pdf, 550Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdaySD.pdf" (pdf, 544.06Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayTN.pdf" (pdf, 549.93Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayTX.pdf" (pdf, 561.86Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayUT.pdf" (pdf, 542.45Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayVA.pdf" (pdf, 579.91Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayVT.pdf" (pdf, 560.2Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayWA.pdf" (pdf, 552.11Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayWI.pdf" (pdf, 552.97Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayWV.pdf" (pdf, 552.39Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®

View full report

Preview
Download

"adultdayWY.pdf" (pdf, 548.31Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®