What is the Assisted Living Waiver?

The Assisted Living Waiver, or ALW, is a Medi-Cal home and community-based service that provides comprehensive care, including 24-hour care and supervision, for older adults and people with disabilities residing in licensed board and care facilities or publicly subsidized housing. The ALW is available in fifteen California counties, and is aimed at preventing or delaying institutional placement for individuals who require a high level of care.

Who Does ALW Serve?

ALW Participants

14,847 are enrolled, 18,365 are on the waitlist
82% speak English, 6% speak Spanish
78% are dual eligible for Medi-Cal and Medicare
74% are 65 years or older
52% are women

Eligibility for ALW is available to older adults and adults with disabilities in full-scope Medi-Cal with no share of cost. Eligible individuals must require institutional level of care, but would like to receive their care in a licensed residential care facility or publicly subsidized housing. ALW participants have to pay for their own room and board, and therefore must have sufficient income to cover their housing costs or a facility’s rate.

Participants residing in a facility and who receive Supplemental Security Income (SSI) pay a room and board rate that is set annually by the Department of Social Services. The majority of ALW participants—56%--have SSI and benefit from a set room and board rate. Individuals who do not receive SSI must pay a room and board rate set by the provider.

These individuals can only participate in the program if they have low enough income to have no share of cost, but high enough income to cover the market room and board rate. Because the rate for non-SSI recipients is not protected, these ALW participants are at risk of eviction if the provider increases their room and board rate.

What Services does ALW Provide?

ALW participants can receive a variety of services, delivered either by staff at their residence or by a home health care agency or other outside provider.

ALW waiver agencies work with participants to create an Individual Service Plan that can include the following services:

  • Care coordination
  • Nursing facility transition coordination
  • Residential rehabilitation
  • Homemaker, chore and laundry services
  • Personal care and 24-hour protective supervision services
  • Personalized behavioral plans with trained staff support
  • Meals
  • 24-hour awake staff
  • Licensed nursing staff
  • Transportation to medical appointments and services

Where is ALW Available?

ALW is available in 15 of California’s 58 counties:

  • Alameda
  • Contra Costa
  • Fresno
  • Kern
  • Los Angeles
  • Orange
  • Riverside
  • Sacramento
  • San Bernardino
  • San Diego
  • San Francisco
  • San Joaquín
  • San Mateo
  • Santa Clara
  • Sonoma

Most ALW recipients must move out of their home into a licensed Residential Care for the Elderly or Adult Residential Facility to receive ALW services. ALW is also available in publicly subsidized housing (PSH) when supported by an approved home health agency. Currently, only one agency is enrolled in ALW to provide PSH services, and is operating in only eight apartment buildings in Los Angeles County.

ALW participating residential care facilities must comply with federal law that requires facilities to be non-institutional in character, ensure residents have full access to their communities, and that they retain their independence and autonomy. Under law, ALW participants are entitled to a legally enforceable lease, privacy in their residence (including a lockable room, choice of roommates, control over their own schedule, and the right to have visitors at any time).

Alex’s Story

At 82 years old, Alex has lived on his own most of his adult life. He is used to cooking his own meals, taking the bus to his weekly grocery store trips, and walking around the neighborhood. But after he suffered a stroke, and fell several times in his apartment and on his outings, he became concerned about his safety. Luckily his senior housing is also an ALW public supporting housing complex. After enrolling in ALW he feels a lot safer and has been able to maintain his active lifestyle with the support of a dedicated staff of social workers and caregivers that help ensure he can continue going out into the community safely.

ALW’s Unique Role in Serving People with Alzheimer’s, Dementia, and Behavioral Health Needs

“All my life I've been living alone. I had my own apartment. But then I had a stroke, and I fell four times. Now I still live in my own apartment but I have help from the staff here—they check on me, they make sure that I’m safe, that I take my medication, that my blood pressure is under control and my knees are not swollen from my diabetes. During the night they call to ask me how I’m doing, and the caregiver will come up if I need help. It’s good to have a backup in case I really need someone, especially at night.”

The ALW is uniquely suited to support community living for older adults with Alzheimer’s or other dementias because it provides 24-hour care and supervision. The program also provides additional services for individuals who have a traumatic brain injury, behavioral health conditions, or a severe cognitive condition, like dementia. These services include habilitation and augmented plans of care that allow for increased provision of one-on-one care by trained staff.

ALW Capacity and Access Challenges

The ALW is limited geographically to 15 counties. It is also limited in the number of slots available to individuals in each county. As a result, in 2026, 18,000 individuals were on the program’s waitlist. Applicants who are transitioning from a nursing facility, receive a referral from Adult Protective Supervision or the Long-Term Ombudsman, or are transferring from another waiver, are prioritized for enrollment in the waiver.

Individuals who do not reside in an ALW county or who are on the waitlist can receive similar services through their managed care plans if offered by the plan. But advocates report difficulty accessing the service due to limited provider participation and low consumer awareness. In 2026, residents in 18 counties do not have access to the service. Only 3,000 received the community support benefit in the last reporting year.

Lawmakers can continue to support the desires of older Californians to remain at home and to live in dignity in their communities, invest in equity, and address the long-term sustainability of Medi-Cal by investing in provider participation, expanding capacity to eliminate long waitlists, and expanding the program to be available statewide so it can serve any older adult who needs it to remain in their home.