Beta Hospice Care is a Care Coordination Agency listed by the California Department of Health Care Services (DHCS).Beta is listed by DHCS. Here’s how to check
  1. Find Beta on the DHCS list. Beta is listed as a participating Care Coordination Agency under the name Beta Hospice Care. How to verify Beta
  2. No charge for care coordination. Medi-Cal pays Beta. Residents pay room and board. Costs and room and board
  3. Your choice. You may choose any Care Coordination Agency listed by DHCS and any participating home. Rights and complaints
Español (inicio)
Assisted Living Waivercare coordination
(747) 293-5777Mon–Fri, 9 a.m.–6 p.m.
Menu
Request a callbackRefer a patient or client
5 lessonsAbout 35 minutesNo CE or licensure credit

Write a person-centered ALW service plan

Five short lessons for CCA care coordinators on the person-centered Individual Service Plan (ISP): who leads the plan, goals and preferences, assessed needs and services, risks and back-up plans, and how to modify a setting right, then sign, share, review and update the plan.

Begin the courseSee the sourcesPrint the job aids

Written for

  • CCA professionals
Course version
2026.10.4
Text checked against its sources

Before you begin

What you will be able to do

  • Set up an ISP meeting the participant leads, with the people the participant chooses, plain-language information and an informed choice of setting, services and providers.
  • Write strengths, goals and preferences that come from the participant, each goal with its supports and who provides them, whatever the person's age or diagnosis.
  • Turn every need the ALW Assessment Tool identifies into a planned service or support with a named provider, frequency and duration, and no unneeded services.
  • Record each risk with its contributing factors and a mitigation plan, add an individual back-up plan, and respect the person's right to take reasonable risks.
  • Document a setting-rights modification with all eight required elements and informed consent, then sign, share, review and update the plan on schedule.

Loading

In this course

  1. The participant leads the planAbout 7 minutes · Not yet
  2. Goals, strengths and preferences that belong to the personAbout 7 minutes · Not yet
  3. Assessed needs, services and who provides themAbout 7 minutes · Not yet
  4. Risks, back-up plans and who monitors the planAbout 7 minutes · Not yet
  5. Modify a setting right, then sign, share and update the planAbout 7 minutes · Not yet
  6. Course check · 10 questions0 of 5 lessons done

Sources

Sources behind this course

Each lesson lists the sources it uses. Open the original for the exact rule, form or instruction that applies to your work. The source library describes each one in more detail.

California DHCS

Assisted Living Waiver Individual Service Plan Desk Guide (August 2024)

How a care coordinator completes each section of the ALW ISP workbook: strengths, personal goals, preferences, assessed needs and services, risk management, the back-up plan, care coordination monitoring, rights modifications and the Patient's Rights Form.

Where to look: The section for the part of the ISP you are writing; Rights Modifications (pages 29 to 32) and the Patient's Rights Form (pages 33 to 38).

Open the DHCS ISP Desk Guide (PDF)
U.S. Centers for Medicare & Medicaid Services (eCFR)

42 CFR 441.301, contents of request for a waiver

The federal person-centered planning process, what the person-centered service plan must contain, how often it is reviewed, the qualities of home and community-based settings, and the rules for modifying the added conditions in provider-owned or controlled settings.

Where to look: Paragraphs (c)(1) to (c)(3), and (c)(4)(vi)(A) to (F).

Open section 441.301 on eCFR
California DHCS

Application for a 1915(c) HCBS Waiver, CA.0431.R04.00 (the Assisted Living Waiver, from March 1, 2024)

The approved ALW waiver, including how the ISP is developed, reviewed, monitored and kept, risk and back-up planning, informed choice of providers, and the safeguards on restraints.

Where to look: Appendix D-1 (service plan development) and D-2 (implementation and monitoring); the Care Coordination service definition in Appendix C; Appendix G-2.

Open the ALW waiver application (PDF)
Call the ALW teamFit check