3 lessonsAbout 18 minutesNo CE or licensure credit

The care plan meeting: how to take part

A short guide for families and representatives in three lessons: what the ALW care plan (the Individualized Service Plan, or ISP) is and who writes it, how your loved one leads the plan meeting and who they invite, what to bring and ask, how often the plan is reviewed, and what to do if the plan does not fit.

Written for

  • Families and representatives
Course version
2026.10.3
Text checked against its sources

Before you begin

What you will be able to do

  • Explain to a relative what the ALW care plan is, who writes it, and that it starts from your loved one's own goals and preferences.
  • Help your loved one get ready for the plan meeting: who leads, who they invite, a time, place and language that suit them, and what to bring.
  • Check a draft plan for goals in your loved one's words, a named helper for each need, a back-up plan, and any limit on a right.
  • Know when the plan is reviewed, how to ask for a review, and which route fits a disagreement, a complaint or a Notice of Action.

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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 program page

The program description, the eligibility criteria, the counties, the current waiver and its amendments, grievances and enrollment information.

Where to look: The Eligibility, Current Waiver, Approved Amendments, Emergency Amendments and Current Enrollment sections.

Open the DHCS ALW page
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)
California Department of Aging

Long-Term Care Ombudsman

What the Ombudsman program does for residents of long-term care facilities, the statewide hotline and how to find a local office.

Where to look: How To Find Services In My Area; What Services Are Available; An Ombudsman.

Open the Ombudsman page
Call the ALW teamFit check