SB 43 and CARE Court: Community FAQ

This publication addresses common community questions about two new mental health laws in California: Senate Bill 43 (Grave Disability) and the CARE Act (CARE Court). The implementation of both laws is ongoing and varies by county. This publication was last updated on 2/6/24 and does not contain information about more recent developments.

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Disclaimer: This publication is legal information only and is not legal advice about your individual situation. It is current as of the date posted. We try to update our materials regularly. However, laws are regularly changing. If you want to make sure the law has not changed, contact DRC or another legal office.

This publication addresses common community questions about two new mental health laws in California: Senate Bill 43 (Grave Disability) and the CARE Act (CARE Court). The implementation of both laws is ongoing and varies by county. This publication was last updated on 2/6/24 and does not contain information about more recent developments.

If you need help with your specific situation, call DRC’s intake line at (800) 776-5746.

Senate Bill 43 (2023)

What is Senate Bill 43?

Senate Bill (SB) 43 was recently signed by the Governor and expands the definition of Grave Disability. Grave Disability is one of the criteria used to place people with disabilities on involuntary holds. An involuntary hold means you can be held against your will.

SB 43 changes the definition of Grave Disability in two ways:

Adds severe substance use disorder as a reason someone could be placed on an involuntary hold.
Adds inability to provide for one’s personal safety or necessary medical care as reasons that a person could be placed on an involuntary hold.

SB 43 went into effect on January 1, 2024, except in counties who choose to defer implementation by one or two years. It’s been reported all counties, except for San Francisco County and San Luis Obispo County, are delaying implementation of SB 43 by at least one year.1

What is Grave Disability?

The Old Definition:

Old Definition:	New Definition (SB 43):
A condition in which a person, as a result of a mental health disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter.	A condition in which a person, as a result of a mental health disorder, a severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder, is unable to provide for their basic personal needs for food, clothing, shelter, personal safety,or necessary medical care.2

Definitions of the terms in SB 43, according to the law:

Term	Definition
Severe Substance Use Disorder	A diagnosed substance-related disorder that meets the diagnostic criteria of ‘severe’ as defined in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM defines “severe” as meeting 6 or more of the 10 criteria for the disorder.
Personal Safety	The ability of one to survive safely in the community without involuntary detention or treatment
Necessary Medical Care	Care that a licensed health care practitioner, while operating within the scope of their practice, determines to be necessary to prevent serious deterioration of an existing physical medical condition which, if left untreated, is likely to result in serious bodily injury

So what that does this really mean?

A person may be considered gravely disabled, for example, if they are no longer eating enough to survive or they have become unable to maintain housing and the reason is due to a mental health disorder or a severe substance use disorder. This does not apply if the person does not have either a mental health disorder or a severe substance-use disorder. However, it is unclear how a first responder will determine a person’s underlying diagnosis.

A person can be placed on an involuntary hold, which could potentially lead to conservatorship, if their behavior meets the definition of Grave Disability.

What is a 5150?

A 5150 is a code section in state law that allows a person to be held involuntarily for 72 hours.3 A 5150 is not a criminal arrest. Grave Disability is one of the criteria which can be used to place you on a 5150. The other criteria are Danger to Self and Danger to Others.

A 5150 can be triggered by either a police officer or other peace officer or by a person approved by the county behavioral health department.

Under a 5150, law enforcement, ambulance, or other authorized persons can detain the person and transport them to a facility for the purpose of mental health assessment and evaluation.

5150s do not authorize involuntary medication or medical treatment.4

During this hold, the hospital will evaluate you to determine next steps. They do not need to keep you hospitalized for the full 72 hours if they believe you do not need to be there.5

What happens after the 72 hours of the 5150 hold?

After the 72 hours end, you can either be:

discharged from the 5150 hold and the hospital,
admitted as a voluntary patient for continued treatment, or
continue to be held involuntarily under a different type of hold.

For more information on the Lanterman Petris Short (LPS) Act, view our longer publication here: https://www.disabilityrightsca.org/publications/understanding-the-lanterman-petris-short-lps-act

Where will people be held under SB 43?

SB 43 will not change where individuals are held for mental health treatment. However, SB 43 expands the definition of grave disability to include severe substance use disorder. We do not know yet where someone would be held for severe substance use disorder. There are currently no facilities for involuntary substance use disorder treatment in California.

CARE Act (CARE Court)

What is CARE Court?

CARE Court is a California state law enacted by SB 1338 (2022). CARE Court is currently being phased-in throughout California by county. The counties that have already launched their CARE Court programs include: San Francisco, Orange, San Diego, Riverside, Stanislaus, Glenn, Tuolumne, and Los Angeles. All counties will eventually participate in CARE Court according to the law. There is no option to opt-out.

Who is eligible for CARE Court?

CARE Court does not apply to all mental health disabilities. Specifically, a person must have schizophrenia spectrum or other psychotic disorders to qualify.6

Qualifying Diagnoses

Diagnoses That Do Not Qualify

Schizophrenia Spectrum Disorders:

Schizophrenia
Schizoaffective Disorder
Schizophreniform Disorder
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum

Other Psychotic Disorder including:

Brief Psychotic Disorder
Delusional Disorder
Schizotypal Personality Disorder
Substance Medication- Induced Psychotic Disorder
Catatonia Associated with Another Mental Disorder
Unspecified Catatonia

Psychotic Disorder Due to a General Medical Condition
Catatonia Associated with Another Medical Condition
Major Depression with Psychotic Features
Bipolar Disorder with Psychotic Features
Any other Substance-Related Disorder not listed above
Traumatic brain injury
Autism
Dementia
Neurologic conditions

You do not have to be homeless to qualify. A person must be 18 years or older to qualify.

Role	Description7	Considerations
Respondent	The individual going through the CARE process. Throughout this process, this individual will have access to behavioral health services, housing, and other community supports, as appropriate.
Volunteer Supporter	An adult chosen by the respondent to provide support throughout the CARE process and to promote the respondent’s preferences, choices, and autonomy.	Does not keep track of court dates
Petitioner	An individual who has filed a petition for the respondent to be considered for the CARE process. Example petitioners include a family member, a mental health professional, a first responder, a homeless outreach worker, or a roommate/housemate.	Must be present at initial hearing and if there is an adversarial relationship the presence of the Petitioner could be dramatic. After the initial court hearing, the County Behavioral Health Department will take over as the petitioner.
County Behavioral Health Agency	County behavioral health agencies and their teams have an important role in the court process. Agencies engage the respondent in mental health treatment and connect them with additional services. Individuals could include a contracted provider, prescriber, and/or care.	Reports to the court whether the respondent has the legal capacity to give informed consent regarding psychotropic medications if care agreement was not reached. Decision based on one evaluation with the last 30 days
Housing & Community Support Providers	The respondent may be connected with housing and community support providers through the CARE process. Examples of housing providers include permanent supportive housing, affordable housing, interim/transitional housing, and Behavioral Health Bridge Housing. Examples of community supports providers may offer social services funded through Supplemental Security Income/State Supplementary Payment (SSI/SSP), financial assistance for immigrants, CalWORKs, California Food Assistance Program, In-Home Supportive Services program, and CalFresh.	Currently most counties do not have the services in place.
Counsel for Behavioral Health	They are responsible for representing the county behavioral health department. This individual could be a county counsel or other designated attorney.
Legal Services for Public Defenders	They are responsible for representing the respondent’s interests and rights. They are court-appointed and provided regardless of the respondent’s ability to pay.
Judge	The judge serves as a neutral arbiter. Unless there is a dispute, they will conduct case in informal, non-adversarial atmosphere.

Who can file a petition under CARE Court?

A CARE Act petition starts the court-ordered response. The petition can be filed by:

Some family members including spouse, child, parent, sibling, or grandparent
Roommates
First responders who have had repeated interactions with respondent, including police, EMTs, paramedic, firefighter, or mobile crisis response worker
The director of the county behavioral health agency where respondent resides
The director of the county adult protective services where respondent resides
The director of a public or nonprofit organization providing the person behavioral health services
Hospital director of the hospital where the person is hospitalized
Behavioral health provider who has supervised treatment or provided the individual treatment
The public guardian or public conservator of the county in which the respondent is present or reasonably believed to be present
The director of a California Indian health services program or California tribal behavioral health department
The judge of a tribal court that is located in California8

What happens when someone initiates the CARE Court process?

These are the steps after someone files the petition:

County behavioral health agency investigates whether the person meets CARE criteria and submits the evaluation to the judge.
The judge decides whether the person likely meets the CARE criteria based on the report.
If the judge decides that the person likely meets the CARE criteria, then they set the initial appearance (14 days).
The initial appearance can include a hearing on merits, or the hearing can be separate.9 At the hearing on merits, the judge decides if the person qualifies under CARE criteria. After the hearing on merits, the court sets a case management hearing (14 days).
The topic of the case management hearing is whether there is a “CARE Agreement.”
1. If the person, their lawyer, and the court agree on the CARE agreement, then they set a follow up hearing for 60 days. The court can also make changes to the CARE agreement before approving it.
2. If the person, their lawyer, and the judge do not agree on the CARE agreement, then the court orders another clinical evaluation.
The county behavioral health agency conducts another evaluation to develop recommendations for the CARE Plan.
Within 21 days, there is a clinical evaluation hearing. This hearing is when the CARE Plan is proposed. At the clinical evaluation hearing, the county behavioral health agency presents a CARE Plan.10 The court then sets another hearing to review the CARE Plan within 14 days.
Care plan review hearing: At this next hearing, the judge can approve the CARE Plan. This starts the beginning of the year long CARE process.
1. As part of the CARE plan review hearing, the court decides whether the person has capacity to provide informed consent. If the court thinks the person cannot provide informed consent, then the CARE Plan can require medically necessary stabilization medication.11
2. For the CARE Plan, status review hearings occur every 60 days.

Note that by the start of the year-long CARE process, an individual has received two clinical evaluations and appeared in court at least four times.12

What is the difference between a CARE Agreement and a CARE Plan?

A CARE Agreement is entered into by the individual, the county behavioral health department, the individual’s advocate, and the individual’s lawyer. It has to be approved by the court. Although the state calls this CARE Agreement voluntary, the judge has authority to make changes to it before it is approved. The CARE Agreement pathway has follow-up every 60 days once the agreement begins. The follow-up involves more appearances in court.

A CARE Plan is court-ordered. The individual and their attorney do not have to agree to it in the same way as the CARE Agreement.

Both are assumed to be 1 year long and involve a combination of different services.

What can be in the CARE Plan?

The CARE Plan is a year-long court-ordered treatment plan. This treatment plan can include court-ordered stabilization medications. Depending on the county and availability of services, other services like counseling and housing may be available. The court can order status hearings to keep track of whether a person is complying with the CARE Plan.

What are court-ordered stabilization medications?

Court-ordered stabilization medications can include anti-psychotic drugs. They are not the same as involuntary medication because it cannot be forcibly administered. But, even though they cannot be forcibly administered, failure to take the medication according to the plan can result in further actions from the court, like referral to conservatorship. Although is legally different from “involuntary medication,” this is still coercive.

The medications can include:13

Amitriptyline-perphenazine (Duo-Vil, Etrafon, Triavil, Triptafen)
Aripiprazole (Abilify)
Asenapine (Saphris)
Brexpiprazole (Rexulti)
Cariprazine (Vraylar)
Chlorpromazine (Thorazine)
Clozapine (Clozaril)
Fluphenazine
Haloperidol (Haldol)
Iloperidone (Fanapt)
Loxapine
Lumateperonee (Caplyta)
Lurasidone (Latuda)
Molindone
Olanzapine (Zyprexa)
Paliperidone (Invega Sustenna)
Perphenazine
Prochlorperazine
Quetiapine (Seroquel)
Risperidone (Risperdal)
Thioridazine
Thiothixene
Trifluoperazine (Stelazine)
Ziprasidone (Geodon)

What happens if I don’t show up to my CARE Court hearing?

The judge has discretion on how to respond to someone not participating or complying with treatment. Different counties plan to handle it different ways.14 There is no specific consequence in statute for not showing up to their initial court proceedings. A person could be subject to conservatorship for failing to comply with the CARE Court process at any step. A judge could also decide to dismiss the proceedings.

I want to get some of the help from my CARE Plan, like housing, but I don’t want to take the medication. What will happen?

Not complying with any part of the CARE Plan means that the court can take additional actions like referral to conservatorship.

If LPS proceedings, like a 5150 or conservatorship, occur with 6 months, details of non-compliance in a CARE Plan will be considered as evidence. However, they are not supposed to include information about not taking medication.15

Is CARE Court a housing program?

No.

There are no housing funds attached to CARE Court implementation.

CARE Court participants are prioritized for existing bridge housing programs. However, entering the CARE Court process does not give an individual access to services that are not available through other pathways.16

Who will represent me in my CARE court hearing?

Individuals subject to CARE Court proceedings are entitled to representation by counsel at all stages.17 Some counties have contracted with legal aid organizations to represent individuals in their CARE Court hearings. The public defender may provide representation in other counties. This will vary county by county.

Do I have to comply with the CARE Court treatment plan?

If you do not comply, the court can presume that a less restrictive alternative for your treatment does not exist and refer you to conservatorship.18

However, counties have some discretion on how to approach it. Noncompliance does not automatically mean you will enter a conservatorship.

How can CARE Court and SB 43 lead to conservatorship?

If you are subject to CARE Court proceedings and fail to comply with the treatment plan, there is a presumption that no other less restrictive treatment is appropriate, which triggers a referral to conservatorship.

SB 43 makes it easier to conserve someone by broadening the definition of Grave Disability. Grave disability is a criteria that allows someone to be placed on involuntary holds and conservatorship.

How can I challenge a mental health conservatorship?

View our publication on this topic: https://www.disabilityrightsca.org/publications/handbook-for-challenging-mental-health-conservatorships