Existing law, the Health Care Decisions Law, provides for the creation, form, and revocation of advance health care directives, and authorizes an adult having capacity to give an individual health care instruction. Under existing law, the advance health care directive of a patient in a skilled nursing facility is not effective unless a patient advocate or ombudsperson ombudsman signs the advance directive as a witness and declares that they are serving as a witness pursuant to this requirement. Existing law authorizes a witness who is a patient advocate or ombudsperson ombudsman to rely on the representations of the administrators or staff of the skilled nursing facility, or of family members, as convincing evidence of the identity of the patient, as specified.

This bill would delete a patient advocate from the above-described witness duties, thus requiring that an ombudsperson ombudsman witness the advance health care directive of a patient in a skilled nursing facility.

Existing law, the Health Care Decisions Law, provides for the creation, form, and revocation of advance health care directives, and authorizes an adult having capacity to give an individual health care instruction. Under existing law, the advance health care directive of a patient in a skilled nursing facility is not effective unless a patient advocate or ombudsperson signs the advance directive as a witness and declares that they are serving as a witness pursuant to this requirement. Existing law authorizes a witness who is a patient advocate or ombudsperson to rely on the representations of the administrators or staff of the skilled nursing facility, or of family members, as convincing evidence of the identity of the patient, as specified.

This bill would delete a patient advocate from the above-described witness duties, thus requiring that an ombudsperson witness the advance health care directive of a patient in a skilled nursing facility.

SENATE THIRD READING

STR Bill Id:SB 1189

Author:(Valladares)

As Amended Ver:June 4, 2026

Majority vote

SUMMARY

Removes the provision in existing law permitting a "patient advocate" in lieu of an "ombudsman" to witness the advance health care directive of a person in a skilled nursing facility, leaving an ombudsman designated by the California Department of Aging as the only permissible witness for this purpose.

Major Provisions

COMMENTS

California law allows individuals to provide instructions for their health care treatment through an advance health care directive in the event that they lose the capacity to do so in the future. (See generally Probate Code Section 4600 et seq.) An advance health care directive can provide instructions for serious life-altering decisions, including a decision to discontinue life-sustaining treatments. Accordingly, existing law sets out specific witnessing requirements before an advance health care directive can become effective. (See, e.g., Probate Code Section 4673.) For residents of skilled nursing facilities, the law adds an additional layer of protection by requiring additional witnesses, an ombudsman or patient advocate. (See Probate Code 4675.) However, the author and supporters argue that the term "patient advocate" in the existing statute is undefined, ambiguous, and has generated some confusion.

Advance Health Care Directives & the Long-Term Care Ombudsman Program. Among other things, existing law requires that a written advance health care directive be acknowledged before notary public or signed by at least two witnesses that satisfy specified requirements. (Probate Code Section 4673.) Those witnesses must be adults, and cannot be the patient's health care provider, an operator or employee of a community care facility or residential care facility for the elderly, nor the patient's agent, where the advance directive is a power of attorney for health care. (Probate Code Section 4674.)

Because residents of skilled nursing facilities are among the most vulnerable populations in the state, often elderly, with limited mobility, cognitive impairment, or reduced capacity to self-advocate, existing law imposes a special witnessing requirement for an advance health care directive involving these residents. (Probate Code Section 4675.) As mentioned above, Probate Code Section 4675 specifically requires a "patient advocate or ombudsman, as may designated by the Department of Aging" to sign the advance directive as a witness or in addition to notarization.

According to the sponsor, though the statute includes the term "patient advocate," it has been widely understood that only an ombudsman designated by the Department of Aging through its Long-Term Care Ombudsman program may serve as special witnesses in this role. The Office of the State Long-Term Care Ombudsman has stated that the Long-Term Care program has performed an average of 1,500 advance health care directives over the last five years, making this one of its core functions. Further, the State's Long-Term Care Ombudsman has specified that ombudsman are required to complete "an additional two hours of specialized training and field shadowing- above and beyond the program's rigorous 36-hour training- to be able to witness an [advance health care directive]." By contrast, the term patient advocate is not defined, and there are no equivalent training requirements for patient advocates under existing law.

This bill removes the term "patient advocate" from the statute altogether, making it clear that only an ombudsman designated by the Department of Aging may serve in this important role. Because this appears to be one of the core functions of the Long-Term Care Ombudsman program, limiting the statute to allowing only ombudsman to serve as special witnesses for this purpose should not alter current practice nor increase ombudsman workload. Furthermore, the required training and oversight by the department should ensure that skilled nursing facility residents continue to have qualified individuals witnessing these important and potentially life-altering documents.

According to the Author

SB 1189 amends Probate Code Section 4675 to remove the term "patient advocate" and replace [it] with "ombuds[man]," as designated by the Department of Aging. By removing the ambiguous "patient advocate" term, the bill ensures that only the [Long-Term Care] LTC Ombudsman, the sole entity designated for this purpose by the Department of Aging, can serve as the required special witness for AHCDs executed in skilled nursing facilities. This eliminates the risk of unauthorized individuals serving in that role and ensures the protective intent of the statute is fulfilled. SB 1189 is a technical cleanup bill that brings the statute into alignment with how it has been implemented in practice.

Arguments in Support

The bill's sponsor, California Advocates for Nursing Home Reform, the California Long Term Care Ombudsman Association, and the Office of the State Long-term Care Ombudsman generally contend that this bill eliminates legal ambiguity by removing the reference to "patient advocates" within existing law. Specifically, the sponsor states:

Although the statute lists both "patient advocate" and "ombudsman," the Long-Term Care Ombudsman is generally understood to be the required witness, as they are designated by the Department of Aging to advocate on behalf of nursing home residents. Recently, however, a misunderstanding occurred where an individual who believed themselves to be the patient's "advocate" witnessed the execution of an AHCD without the ombudsman present. The misunderstanding not only subjected the resident to an invalid AHCD, it exposed the risk of the statute's reference to a patient advocate position that does not exist. Others may similarly misinterpret the statute's special witnessing requirement, potentially bypassing ombudsman involvement and creating AHCDs that could later be deemed invalid.[…]

The bill's proposed change would not alter current practice or increase the ombudsman workload because they have long served as the witnesses for AHCDs executed in nursing homes. Ombudsman are assigned to each licensed nursing home in the state and conduct regular visits to address issues related to daily care, health, and safety of nursing home residents. Witnessing the execution of AHCDs is, therefore, part of their normal routine. In just the last five years, the ombudsman across the state witnessed an annual average of 1,514 AHCDs. Because no other entities currently serve in this role, the ability of nursing home residents to complete AHCDs would remain the same. SB 1189 simply updates the Probate Code to reflect current practice and stop further misunderstanding that any self-proclaimed patient advocates can witness nursing home residents' AHCDs.

Arguments in Opposition

None on file

FISCAL COMMENTS

None

VOTES

SENATE FLOOR: 38-0-2

YES: Allen, Alvarado-Gil, Archuleta, Arreguín, Ashby, Becker, Blakespear, Cabaldon, Caballero, Cervantes, Choi, Cortese, Dahle, Durazo, Gonzalez, Grayson, Grove, Hurtado, Jones, Laird, Limón, McGuire, McNerney, Niello, Ochoa Bogh, Padilla, Pérez, Reyes, Richardson, Rubio, Smallwood-Cuevas, Stern, Strickland, Umberg, Valladares, Wahab, Weber Pierson, Wiener

ABS, ABST OR NV: Menjivar, Seyarto

ASM JUDICIARY: 12-0-0

YES: Kalra, Macedo, Bauer-Kahan, Bryan, Connolly, Dixon, Harabedian, Pacheco, Papan, Sanchez, Stefani, Zbur

ASSEMBLY FLOOR: 77-0-2

YES: Addis, Aguiar-Curry, Ahrens, Alanis, Alvarez, Arambula, Ávila Farías, Bains, Bauer- Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Castillo, Chen, Connolly, Davies, DeMaio, Dixon, Elhawary, Ellis, Flora, Fong, Gabriel, Garcia, Gipson, Jeff Gonzalez, Mark González, Hadwick, Haney, Harabedian, Hart, Hoover, Irwin, Jackson, Kalra, Krell, Lackey, Lee, Lowenthal, Macedo, McKinnor, Muratsuchi, Nguyen, Ortega, Pacheco, Papan, Patel, Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Celeste  Rodriguez, Michelle Rodriguez, Rogers, Blanca Rubio, Sanchez, Schultz, Sharp- Collins, Solache, Soria, Stefani, Ta, Tangipa, Valencia, Wallis, Ward, Wicks, Wilson, Zbur, Rivas

ABS, ABST OR NV: Johnson, Schiavo

UPDATED

VERSION: June 4, 2026

CONSULTANT: Kristian Wright / JUD. / (916) 319-2334 FN: 0003200

 UNFINISHED BUSINESS  

Bill No: SB 1189

Author: Valladares (R), et al.

Amended: 6/4/26

Vote: 21

SENATE JUDICIARY COMMITTEE: 12-0, 3/24/26

AYES: Umberg, Niello, Allen, Caballero, Durazo, Laird, Reyes, Stern, Valladares, Wahab, Weber Pierson, Wiener

NO VOTE RECORDED: Ashby

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SENATE FLOOR: 38-0, 4/16/26 (Consent)

AYES: Allen, Alvarado-Gil, Archuleta, Arreguín, Ashby, Becker, Blakespear, Cabaldon, Caballero, Cervantes, Choi, Cortese, Dahle, Durazo, Gonzalez, Grayson, Grove, Hurtado, Jones, Laird, Limón, McGuire, McNerney, Niello, Ochoa Bogh, Padilla, Pérez, Reyes, Richardson, Rubio, Smallwood-Cuevas, Stern, Strickland, Umberg, Valladares, Wahab, Weber Pierson, Wiener

NO VOTE RECORDED: Menjivar, Seyarto

ASSEMBLY FLOOR: 77-0, 6/15/26 (Consent) - See last page for vote

SUBJECT: Advance health care directive of a skilled nursing facility patient

SOURCE: California Advocates for Nursing Home Reform

DIGEST:

This bill eliminates the provision in the Health Care Decisions Law (HCDL) permitting a “patient advocate” to witness the advance health care directive of a person in a skilled nursing facility (SNF), thereby requiring every such advance directive to be witnessed by an ombudsman designated by the Department of Aging.

Assembly Amendments

of 6/4/26 change references to an “ombudsperson” designated by the Department of Aging to “ombudsman,” to align this bill’s terminology with that of the Office of the Long-Term Care Ombudsman, the office currently designated by the Department of Aging to witness advance health care directives in SNFs.

ANALYSIS:

Existing law:

1. Establishes the HCDL, which sets forth when and how a person may set forth their health care decisions in advance. (Probate (Prob.) Code, div. 4.7, §§ 4600 et seq.)
2. Defines the following relevant terms:
   1. “Advance health care directive” or “advance directive” means either an individual health care instruction or a power of attorney for health care. (Prob. Code, § 4605.)
   2. “Capacity” means a person’s ability to understand the nature and consequences of a decision and to make and communicate a decision, and includes in the case of a proposed health care, the ability to understand its significant benefits, risks, and alternatives. (Prob. Code, § 4609.)
   3. “Health care” means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a patient’s physical or mental health condition.” (Prob. Code, § 4615.)
   4. “Health care decision” means a decision by a patient or the patient’s agent, conservator, or surrogate, regarding the patient’s health care, including selection and discharge of health care providers and institutions; approval or disapproval of diagnostic tests, surgical procedures, and programs of medication, including mental health conditions; directions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation. “Health care decision” does not include placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. (Prob. Code, § 4617, 4652.)
   5. “Power of attorney for health care” means a written instrument designating an agent to make health care decisions for the principal. (Prob. Code, § 4629.)
   6. “Skilled nursing facility,” or SNF, means an SNF as defined in Health and Safety Code section 1250. (Prob. Code, § 4639.)
3. Establishes, within the HCDL, the Uniform Health Care Decisions Act, which sets forth the procedures for establishing an advance health care directive or a power of attorney for health care. (Prob. Code, div. 4.7, pt. 2, §§ 4670 et seq.)
4. Provides that any adult having capacity may give an individual health care instruction, which may be oral or written, and which may be limited to take effect only if a specified condition arises. (Prob. Code, § 4670.)
5. Provides that any adult having capacity may execute a power of attorney for health care, which may authorize the agent to make health care decisions and may also include individual health care instructions; the principal in a power of attorney for health care may grant authority to make decisions relating to the personal care of the principal, including, but not limited to, determining where the principal will live, providing meals, hiring household employees, providing transportation, handling mail, and arranging recreation and entertainment. (Prob. Code, § 4671.)
6. Provides that, as a general rule, a written advance health care directive is legally sufficient if all of the following requirements are satisfied:
   1. The advance directive contains the date of its execution.
   2. The advance directive is signed either by the patient or in the patient’s name by another adult in the patient’s presence and at the patient’s direction.
   3. The advance directive is either acknowledged before a notary public or signed by at least two witnesses who satisfy the requirements of 7) and 8). (Prob. Code, § 4673.)
7. Establishes criteria for who may serve as a witness for a written advance health care directive, including that they must be adults and may not be any of the following:
   1. The patient’s health care provider or an employee of the patient’s health care provider.
   2. The operator or an employee of a community care facility.
   3. The operator or an employee of a residential care facility for the elderly.
   4. The agent, where the advance directive is a power of attorney for health care. (Prob. Code, § 4674.)
8. Provides that, if an individual is a patient in an SNF when a written advance health care directive is executed, the advance directive is not effective unless a patient advocate or ombudsmen, as may be designated by the Department of Aging for this purpose, signs the advance directive as a witness, either as one of the two witnesses or in addition to notarization.
   1. The patient advocate or ombudsperson shall declare that they are serving as a witness as required.
   2. A witness who is a patient advocate or ombudsperson may rely on the representations of the administrators or staff of the SNF, or of family members, as convincing evidence of the identity of the patient if the patient advocate or ombudsperson believes that the representations provide a reasonable basis for determining the identity of the patient.
   3. The intent of these provisions is to recognize that some patients in SNFs are insulated from a voluntary decision making role, by virtue of the custodial nature of their care, so as to require that they are capable of willfully and voluntarily executing an advance directive. (Prob. Code, § 4675.)

This bill eliminates the provisions permitting a patient advocate to witness a written advance directive for a person in an SNF in lieu of an ombudman designated by the Department of Aging, so that the ombudsperson is required to witness every such written advance directive.

Comments

The HCDL establishes when and how a person may create an advance health care directive (or “advance directive”), which sets forth their wishes for what type of health care they wish to receive, establishes a power of attorney for health care, or both. Because an advance directive can involve serious, life-changing decisions—including the decision to refuse or discontinue life-preserving treatment—the HCDL requires an advance directive to be signed by the individual executing the document, dated, and either witnessed by two individuals or notarized; certain individuals, such as employees of a community care or residential facility in which the individual resides, may not serve as witnesses. For residents in an SNF, the HCDL imposes an additional requirement for executing a written advance directive: an SNF resident’s written advance directive must be witnessed by a patient advocate or an ombudsperson designated by the Department of Aging, in addition to either the two witness signatures or the notarization. “Patient advocate” is not defined in the HCDL.

This bill eliminates the provision of the HCDL permitting a “patient advocate” to witness an SNF resident’s advance directive in lieu of the Department of Aging’s designated ombudsman. According to the author and sponsor, this undefined term has led to confusion over whether the employee of a residential facility may serve as a “patient advocate,” which runs contrary to the protections for SNF residents. By eliminating the “patient advocate” witness option, this bill would require all advance directives executed by SNF residents to be witnessed by the ombudsman designated by the Department of Aging—the Office of the State Long-Term Care Ombudsman currently serves this role—thereby preserving the layer of oversight intended to ensure that the individual is executing their advance directive willingly and voluntarily.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

SUPPORT: (Verified 6/17/26)

California Advocates for Nursing Home Reform (source)
California Long-Term Care Ombudsman Association

Office of the State Long-Term Care Ombudsman

OPPOSITION: (Verified 6/17/26)

None received

ARGUMENTS IN SUPPORT: According to the California Advocates for Nursing Home Reform:

AHCDs completed in a nursing home require a special witness. This requirement ensures residents are not coerced by facility staff or other parties into an AHCD that does not reflect their health care wishes. Probate Code § 4675 names the potential special witnesses: “patient advocate or ombudsman, as may be designated by the Department of Aging...”

Although the statute lists both “patient advocate” and “ombudsman,” the Long Term Care Ombudsman is generally understood to be the required witness, as they are designated by the Department of Aging to advocate on behalf of nursing home residents. Recently, however, a misunderstanding occurred where an individual who believed themselves to be the patient’s “advocate” witnessed the execution of an AHCD without the ombudsman present. The misunderstanding not only subjected the resident to an invalid AHCD, it exposed the risk of the statute’s reference to a patient advocate position that does not exist. Others may similarly misinterpret the statute’s special witnessing requirement, potentially bypassing ombudsman involvement and creating AHCDs that could later be deemed invalid.

Removing outdated references to a “patient advocate” would prevent the further misunderstanding that people who claim to be patient advocates can witness nursing home residents’ AHCDs.

ASSEMBLY FLOOR: 77-0, 6/15/26

AYES: Addis, Aguiar-Curry, Ahrens, Alanis, Alvarez, Arambula, Ávila Farías, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Castillo, Chen, Connolly, Davies, DeMaio, Dixon, Elhawary, Ellis, Flora, Fong, Gabriel, Garcia, Gipson, Jeff Gonzalez, Mark González, Hadwick, Haney, Harabedian, Hart, Hoover, Irwin, Jackson, Kalra, Krell, Lackey, Lee, Lowenthal, Macedo, McKinnor, Muratsuchi, Nguyen, Ortega, Pacheco, Papan, Patel, Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Celeste Rodriguez, Michelle Rodriguez, Rogers, Blanca Rubio, Sanchez, Schultz, Sharp-Collins, Solache, Soria, Stefani, Ta, Tangipa, Valencia, Wallis, Ward, Wicks, Wilson, Zbur, Rivas

NO VOTE RECORDED: Johnson, Schiavo

Prepared by: Allison Whitt Meredith / JUD. / (916) 651-4113

6/17/26 16:28:21

**** END ****

Date of Hearing: June 9, 2026

ASSEMBLY COMMITTEE ON JUDICIARY

Ash Kalra, Chair

SBPCA Bill Id:SB 1189

Author:(Valladares) – As Amended Ver:June 4, 2026

SENATE VOTE: 38-0

SUBJECT: ADVANCE HEALTH CARE DIRECTIVE OF A SKILLED NURSING FACILITY PATIENT

SYNOPSIS

Advance health care directives allow individuals to provide instructions for their medical care in the event that they are unable to do so in the future. These directives allow patients to provide instructions for life-altering decisions, including decisions to discontinue life-sustaining treatment. Accordingly, existing law sets out specific requirements for a directive to be effective, including witness requirements. Because residents of skilled nursing facilities are among the most vulnerable populations in the state, often elderly, with limited mobility, cognitive impairment, or reduced capacity to self-advocate, existing law imposes an additional special witnessing requirement for an advance health care directive involving these residents. Specifically, current law requires a patient advocate or an ombudsman designated by the California Department of Aging to sign the advance health care directive for it to be effective. However, according to the author and sponsors, the only individuals that have been fulfilling this role are ombudsman who have been certified through the State’s Long-Term Care Ombudsman program. By contrast, the term “patient advocate” is undefined, and has no designated entity behind it. This, according to supporters, has led to confusion as to whom may serve as a special witness for advance health care directive in these facilities.

This bill would simply remove the term patient advocate from the existing statute, leaving an ombudsman designated by the California Department of Aging as the only permissible witness for advance health care directives in skilled nursing facilities. The bill is sponsored by the California Advocates for Nursing Home Reform. It also enjoys the support of the California Long Term Care Ombudsman Association and the Office of the State Long-term Care Ombudsman. Collectively, they contend that this bill will remove the legal ambiguity surrounding those who may act as a witness for this purpose and update the law to align with current practices. This bill has no registered opposition.

SUMMARY: Removes the provision in existing law permitting a “patient advocate” in lieu of an “ombudsman” to witness the advance health care directive of a person in a skilled nursing facility, leaving an ombudsman designated by the California Department of Aging as the only permissible witness for this purpose.

EXISTING LAW:

1. Defines “advance health care directive” or “advance directive” as either an individual health care instruction or a power of attorney for health care. (Probate Code Section 4605.)
2. Defines “individual health care instruction” or “individual instruction” as a patient’s written or oral direction concerning a health care decision for the patient. (Probate Code Section 4623.)
3. Defines “skilled nursing facility” as a health facility that provides skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. (Health and Safety Code Section 1250 (c).)
4. Provides that an adult having capacity may give an individual health care instruction, which may be oral or written, and may be limited to take effect only if a specified condition arises. (Probate Code Section 4670.)
5. Provides that a written advance health care directive is legally sufficient if all of the following requirements are satisfied:
   1. The advance directive contains the date of its execution;
   2. The advance directive is signed either by the patient or in the patient’s name by another adult in the patient’s presence and at the patient’s direction;
   3. The advance directive is either acknowledged before a notary public or signed by at least two witnesses who satisfy specified requirements under existing law. (Probate Code Section 4673 (a).)
6. Provides that, if a written advance health care directive is signed by witnesses, the following requirements must be satisfied:
   1. The witnesses must be adults.
   2. Each witness signing the advance directive must witness either the signing of the advance directive by the patient or the patient’s acknowledgment of the signature or the advance directive.
   3. Specifies that none of the following persons may act as witnesses:
      1. The patient’s health care provider or an employee of the patient’s health care provider.
      2. The operator or an employee of a community care facility.
      3. The operator or an employee of a residential care facility for the elderly.
      4. The agent, where the advance directive is power of an attorney for health care. (Probate Code Section 4674 (a) –(c).)
7. Provides that if an individual is a patient in a skilled nursing facility when a written advance health care directive is executed, the advance directive is not effective unless a patient advocate or ombudsman, as may be designated by the Department of Aging for this purpose, signs the advance directive as a witness, either as one of two witnesses or in addition to notarization. Specifies that the patient advocate or ombudsman must declare that they are serving as a witness. (Probate Code Section 4675 (a).)
8. Provides that a witness who is a patient advocate or ombudsman rely on the representations of the administrators or staff of the skilled nursing facility, or of family members, as convincing evidence of the identity of the patient if the patient advocate or ombudsman believes that the representations provide a reasonable basis for determining the identity of the patient. (Probate Code Section 4675 (b).)
9. Establishes the Office of the State Long-Term Care Ombudsman within the California Department of Aging. (Welfare and Institutions Code Section 9710.)
10. Establishes the federal Older Americans Act, which authorized the establishment of the Long-Term Care Ombudsman Program nationally. (42 U.S.C. Section 3001 et seq.)

FISCAL EFFECT: As currently in print this bill is keyed non-fiscal.

COMMENTS: California law allows individuals to provide instructions for their health care treatment through an advance health care directive in the event that they lose the capacity to do so in the future. (See generally Probate Code Section 4600 et seq.) An advance health care directive can provide instructions for serious life-altering decisions, including a decision to discontinue life-sustaining treatments. Accordingly, existing law sets out specific witnessing requirements before an advance health care directive can become effective. (See, e.g., Probate Code Section 4673.) For residents of skilled nursing facilities, the law adds an additional layer of protection by requiring additional witnesses, an ombudsman or patient advocate. (See Probate Code 4675.) However, the author and supporters argue that the term “patient advocate” in the existing statute is undefined, ambiguous, and has generated some confusion.

According to the author:

SB 1189 amends Probate Code Section 4675 to remove the term “patient advocate” and replace [it] with “ombuds[man],” as designated by the Department of Aging. By removing the ambiguous “patient advocate” term, the bill ensures that only the LTC Ombudsman, the sole entity designated for this purpose by the Department of Aging, can serve as the required special witness for AHCDs executed in skilled nursing facilities. This eliminates the risk of unauthorized individuals serving in that role and ensures the protective intent of the statute is fulfilled. SB 1189 is a technical cleanup bill that brings the statute into alignment with how it has been implemented in practice.

Advance Health Care Directives & the Long-Term Care Ombudsman Program. Among other things, existing law requires that a written advance health care directive be acknowledged before notary public or signed by at least two witnesses that satisfy specified requirements. (Probate Code Section 4673.) Those witnesses must be adults, and cannot be the patient’s health care provider, an operator or employee of a community care facility or residential care facility for the elderly, nor the patient’s agent, where the advance directive is a power of attorney for health care. (Probate Code Section 4674.)

Because residents of skilled nursing facilities are among the most vulnerable populations in the state, often elderly, with limited mobility, cognitive impairment, or reduced capacity to self-advocate, existing law imposes a special witnessing requirement for an advance health care directive involving these residents. (Probate Code Section 4675.) As mentioned above, Probate Code Section 4675 specifically requires a “patient advocate or ombudsman, as may designated by the Department of Aging” to sign the advance directive as a witness or in addition to notarization.

According to the sponsor, though the statute includes the term “patient advocate,” it has been widely understood that only an ombudsman designated by the Department of Aging through its Long-Term Care Ombudsman program may serve as special witnesses in this role. The Office of the State Long-Term Care Ombudsman has stated that the Long-Term Care program has performed an average of 1,500 advance health care directives over the last five years, making this one of its core functions. Further, the State’s Long-Term Care Ombudsman has specified that ombudsman are required to complete “an additional two hours of specialized training and field shadowing- above and beyond the program's rigorous 36-hour training- to be able to witness an [advance health care directive].” By contrast, the term patient advocate is not defined, and there are no equivalent training requirements for patient advocates under existing law.

This bill removes the term “patient advocate” from the statute altogether, making it clear that only an ombudsman designated by the Department of Aging may serve in this important role. Because this appears to be one of the core functions of the Long-Term Care Ombudsman program, limiting the statute to allowing only ombudsman to serve as special witnesses for this purpose should not alter current practice nor increase ombudsman workload. Furthermore, the required training and oversight by the department should ensure that skilled nursing facility residents continue to have qualified individuals witnessing these important and potentially life-altering documents.

ARGUMENTS IN SUPPORT: The bill’s sponsor, California Advocates for Nursing Home Reform, the California Long Term Care Ombudsman Association, and the Office of the State Long-term Care Ombudsman generally contend that this bill eliminates legal ambiguity by removing the reference to “patient advocates” within existing law.

Specifically, the sponsor states:

Although the statute lists both “patient advocate” and “ombudsman,” the Long-Term Care

Ombudsman is generally understood to be the required witness, as they are designated by the

Department of Aging to advocate on behalf of nursing home residents. Recently, however, a

misunderstanding occurred where an individual who believed themselves to be the patient’s

“advocate” witnessed the execution of an AHCD without the ombudsman present. The

misunderstanding not only subjected the resident to an invalid AHCD, it exposed the risk of the statute’s reference to a patient advocate position that does not exist. Others may similarly

misinterpret the statute’s special witnessing requirement, potentially bypassing ombudsman

involvement and creating AHCDs that could later be deemed invalid.

[…]

The bill’s proposed change would not alter current practice or increase the ombudsman workload because they have long served as the witnesses for AHCDs executed in nursing homes. Ombudsman are assigned to each licensed nursing home in the state and conduct regular visits to address issues related to daily care, health, and safety of nursing home residents. Witnessing the execution of AHCDs is, therefore, part of their normal routine. In just the last five years, the ombudsman across the state witnessed an annual average of 1,514 AHCDs. Because no other entities currently serve in this role, the ability of nursing home residents to complete AHCDs would remain the same.

SB 1189 simply updates the Probate Code to reflect current practice and stop further

misunderstanding that any self-proclaimed patient advocates can witness nursing home residents’ AHCDs.

REGISTERED SUPPORT / OPPOSITION:

Support

California Advocates for Nursing Home Reform
California Long Term Care Ombudsman Association (CLTCOA)
Office of the State Long-term Care Ombudsman

Opposition

None on file

Analysis Prepared by: Kristian Wright / JUD. / (916) 319-2334

 CONSENT  

Bill No: SB 1189

Author: Valladares (R), et al.

Introduced: 2/19/26

Vote: 21

SENATE JUDICIARY COMMITTEE: 12-0, 3/24/26

AYES: Umberg, Niello, Allen, Caballero, Durazo, Laird, Reyes, Stern, Valladares, Wahab, Weber Pierson, Wiener

NO VOTE RECORDED: Ashby

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SUBJECT: Advance health care directive of a skilled nursing facility patient

SOURCE: California Advocates for Nursing Home Reform

DIGEST:

This bill eliminates the provision in the Health Care Decisions Law (HCDL) permitting a “patient advocate” to witness the advance health care directive of a person in a skilled nursing facility (SNF), thereby requiring every such advance directive to be witnessed by an ombudsperson designated by the Department of Aging.

ANALYSIS:

Existing law:

1. Establishes the HCDL, which sets forth when and how a person may set forth their health care decisions in advance. (Probate (Prob.) Code, div. 4.7, §§ 4600 et seq.)
2. Defines the following relevant terms:
   1. “Advance health care directive” or “advance directive” means either an individual health care instruction or a power of attorney for health care. (Prob. Code, § 4605.)
   2. “Capacity” means a person’s ability to understand the nature and consequences of a decision and to make and communicate a decision, and includes in the case of a proposed health care, the ability to understand its significant benefits, risks, and alternatives. (Prob. Code, § 4609.)
   3. “Health care” means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a patient’s physical or mental health condition.” (Prob. Code, § 4615.)
   4. “Health care decision” means a decision by a patient or the patient’s agent, conservator, or surrogate, regarding the patient’s health care, including selection and discharge of health care providers and institutions; approval or disapproval of diagnostic tests, surgical procedures, and programs of medication, including mental health conditions; directions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation. “Health care decision” does not include placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. (Prob. Code, § 4617, 4652.)
   5. “Power of attorney for health care” means a written instrument designating an agent to make health care decisions for the principal. (Prob. Code, § 4629.)
   6. “Skilled nursing facility,” or SNF, means an SNF as defined in Health and Safety Code section 1250. (Prob. Code, § 4639.)
3. Establishes, within the HCDL, the Uniform Health Care Decisions Act, which sets forth the procedures for establishing an advance health care directive or a power of attorney for health care. (Prob. Code, div. 4.7, pt. 2, §§ 4670 et seq.)
4. Provides that any adult having capacity may give an individual health care instruction, which may be oral or written, and which may be limited to take effect only if a specified condition arises. (Prob. Code, § 4670.)
5. Provides that any adult having capacity may execute a power of attorney for health care, which may authorize the agent to make health care decisions and may also include individual health care instructions; the principal in a power of attorney for health care may grant authority to make decisions relating to the personal care of the principal, including, but not limited to, determining where the principal will live, providing meals, hiring household employees, providing transportation, handling mail, and arranging recreation and entertainment. (Prob. Code, § 4671.)
6. Provides that, as a general rule, a written advance health care directive is legally sufficient if all of the following requirements are satisfied:
   1. The advance directive contains the date of its execution.
   2. The advance directive is signed either by the patient or in the patient’s name by another adult in the patient’s presence and at the patient’s direction.
   3. The advance directive is either acknowledged before a notary public or signed by at least two witnesses who satisfy the requirements of 7) and 8). (Prob. Code, § 4673.)
7. Establishes criteria for who may serve as a witness for a written advance health care directive, including that they must be adults and may not be any of the following:
   1. The patient’s health care provider or an employee of the patient’s health care provider.
   2. The operator or an employee of a community care facility.
   3. The operator or an employee of a residential care facility for the elderly.
   4. The agent, where the advance directive is a power of attorney for health care. (Prob. Code, § 4674.)
8. Provides that, if an individual is a patient in an SNF when a written advance health care directive is executed, the advance directive is not effective unless a patient advocate or ombudsmen, as may be designated by the Department of Aging for this purpose, signs the advance directive as a witness, either as one of the two witnesses or in addition to notarization.
   1. The patient advocate or ombudsperson shall declare that they are serving as a witness as required.
   2. A witness who is a patient advocate or ombudsperson may rely on the representations of the administrators or staff of the SNF, or of family members, as convincing evidence of the identity of the patient if the patient advocate or ombudsperson believes that the representations provide a reasonable basis for determining the identity of the patient.
   3. The intent of these provisions is to recognize that some patients in SNFs are insulated from a voluntary decisionmaking role, by virtue of the custodial nature of their care, so as to require that they are capable of willfully and voluntarily executing an advance directive. (Prob. Code, § 4675.)

This bill eliminates the provisions permitting a patient advocate to witness a written advance directive for a person in an SNF in lieu of an ombudsperson designated by the Department of Aging, so that the ombudsperson is required to witness every such written advance directive.

Comments

The HCDL establishes when and how a person may create an advance health care directive (or “advance directive”), which sets forth their wishes for what type of health care they wish to receive, establishes a power of attorney for health care, or both. Because an advance directive can involve serious, life-changing decisions—including the decision to refuse or discontinue life-preserving treatment—the HCDL requires an advance directive to be signed by the individual executing the document, dated, and either witnessed by two individuals or notarized; certain individuals, such as employees of a community care or residential facility in which the individual resides, may not serve as witnesses. For residents in an SNF, the HCDL imposes an additional requirement for executing a written advance directive: an SNF resident’s written advance directive must be witnessed by a patient advocate or an ombudsperson designated by the Department of Aging, in addition to either the two witness signatures or the notarization. “Patient advocate” is not defined in the HCDL.

This bill eliminates the provision of the HCDL permitting a “patient advocate” to witness an SNF resident’s advance directive in lieu of the designated ombudsperson. According to the author and sponsor, this undefined term has led to confusion over whether the employee of a residential facility may serve as a “patient advocate,” which runs contrary to the protections for SNF residents. By eliminating the “patient advocate” witness option, this bill would require all advance directives executed by SNF residents to be witnessed by the ombudsperson designated by the Department of Aging, preserving the layer of oversight intended to ensure that the individual is executing their advance directive willingly and voluntarily.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

SUPPORT: (Verified 4/13/26)

California Advocates for Nursing Home Reform (source)
California Long-Term Care Ombudsman Association

OPPOSITION: (Verified 4/13/26)

None received

ARGUMENTS IN SUPPORT: According to the California Advocates for Nursing Home Reform:

AHCDs completed in a nursing home require a special witness. This requirement ensures residents are not coerced by facility staff or other parties into an AHCD that does not reflect their health care wishes. Probate Code § 4675 names the potential special witnesses: “patient advocate or ombudsman, as may be designated by the Department of Aging...”

Although the statute lists both “patient advocate” and “ombudsman,” the Long Term Care Ombudsman is generally understood to be the required witness, as they are designated by the Department of Aging to advocate on behalf of nursing home residents. Recently, however, a misunderstanding occurred where an individual who believed themselves to be the patient’s “advocate” witnessed the execution of an AHCD without the ombudsman present. The misunderstanding not only subjected the resident to an invalid AHCD, it exposed the risk of the statute’s reference to a patient advocate position that does not exist. Others may similarly misinterpret the statute’s special witnessing requirement, potentially bypassing ombudsman involvement and creating AHCDs that could later be deemed invalid.

Removing outdated references to a “patient advocate” would prevent the further misunderstanding that people who claim to be patient advocates can witness nursing home residents’ AHCDs.

Prepared by: Allison Whitt Meredith / JUD. / (916) 651-4113

4/14/26 16:16:07

**** END ****

SENATE JUDICIARY COMMITTEE

Senator Thomas Umberg, Chair

2025-2026 Regular Session

Bill No: SB 1189 (Author:Valladares)

Version: February 19, 2026

Hearing Date: March 24, 2026

Fiscal: No

Urgency: No

Consultant: AWM

SUBJECT

Advance health care directive of a skilled nursing facility patient

DIGEST

This bill eliminates the provision permitting a “patient advocate” to witness the advance health care directive of a person in a skilled nursing facility (SNF), thereby requiring every such advance directive to be witnessed by an ombudsperson designated by the Department of Aging.

EXECUTIVE SUMMARY

The Health Care Decisions Law (HCDL) establishes when and how a person may create an advance health care directive (or “advance directive”), which sets forth their wishes for what type of health care they wish to receive, establishes a power of attorney for health care, or both. Because an advance directive can involve serious, life-changing decisions—including the decision to refuse or discontinue life-preserving treatment—the HCDL requires an advance directive to be signed by the individual executing the document, dated, and either witnessed by two individuals or notarized; certain individuals, such as employees of a community care or residential facility in which the individual resides, may not serve as witnesses. For residents in an SNF, the HCDL imposes an additional requirement for executing a written advance directive: an SNF resident’s written advance directive must be witnessed by a patient advocate or an ombudsperson designated by the Department of Aging, in addition to either the two witness signatures or the notarization. “Patient advocate” is not defined in the HCDL.

This bill eliminates the provision of the HCDL permitting a “patient advocate” to witness an SNF resident’s advance directive in lieu of the designated ombudsperson. According to the author and sponsor, this undefined term has led to confusion over whether the employee of a residential facility may serve as a “patient advocate,” which runs contrary to the protections for SNF residents. By eliminating the “patient advocate” witness option, this bill would require all advance directives executed by SNF residents to be witnessed by the ombudsperson designated by the Department of Aging, preserving the layer of oversight intended to ensure that the individual is executing their advance directive willingly and voluntarily.

This bill is sponsored by California Advocates for Nursing Home Reform (CANHR) and is supported by the California Long-Term Care Ombudsman Association. The Committee has not received timely opposition to this bill.

PROPOSED CHANGES TO THE LAW

Existing law:

1. Establishes the HCDL, which sets forth when and how a person may set forth their health care decisions in advance. (Prob. Code, div. 4.7, §§ 4600 et seq.)
2. Defines the following relevant terms:
   1. “Advance health care directive” or “advance directive” means either an individual health care instruction or a power of attorney for health care. (Prob. Code, § 4605.)
   2. “Capacity” means a person’s ability to understand the nature and consequences of a decision and to make and communicate a decision, and includes in the case of a proposed health care, the ability to understand its significant benefits, risks, and alternatives. (Prob. Code, § 4609.)
   3. “Health care” means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a patient’s physical or mental health condition.” (Prob. Code, § 4615.)
   4. “Health care decision” means a decision by a patient or the patient’s agent, conservator, or surrogate, regarding the patient’s health care, including selection and discharge of health care providers and institutions; approval or disapproval of diagnostic tests, surgical procedures, and programs of medication, including mental health conditions; directions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation. “Health care decision” does not include placement in a mental health treatment facility, convulsive treatment, psychosurgery, sterilization, or abortion. (Prob. Code, § 4617, 4652.)
   5. “Power of attorney for health care” means a written instrument designating an agent to make health care decisions for the principal. (Prob. Code, § 4629.)
   6. “Skilled nursing facility,” or SNF, means an SNF as defined in Health and Safety Code section 1250. (Prob. Code, § 4639.)
3. Establishes, within the HCDL, the Uniform Health Care Decisions Act, which sets forth the procedures for establishing an advance health care directive or a power of attorney for health care. (Prob. Code, div. 4.7, pt. 2, §§ 4670 et seq.)
4. Provides that any adult having capacity may give an individual health care instruction, which may be oral or written, and which may be limited to take effect only if a specified condition arises. (Prob. Code, § 4670.)
5. Provides that any adult having capacity may execute a power of attorney for health care, which may authorize the agent to make health care decisions and may also include individual health care instructions; the principal in a power of attorney for health care may grant authority to make decisions relating to the personal care of the principal, including, but not limited to, determining where the principal will live, providing meals, hiring household employees, providing transportation, handling mail, and arranging recreation and entertainment. (Prob. Code, § 4671.)
6. Provides that, as a general rule, a written advance health care directive is legally sufficient if all of the following requirements are satisfied:
   1. The advance directive contains the date of its execution.
   2. The advance directive is signed either by the patient or in the patient’s name by another adult in the patient’s presence and at the patient’s direction.
   3. The advance directive is either acknowledged before a notary public or signed by at least two witnesses who satisfy the requirements of 7) and 8). (Prob. Code, § 4673.)
7. Establishes criteria for who may serve as a witness for a written advance health care directive, including that they must be adults and may not be any of the following:
   1. The patient’s health care provider or an employee of the patient’s health care provider.
   2. The operator or an employee of a community care facility.
   3. The operator or an employee of a residential care facility for the elderly.
   4. The agent, where the advance directive is a power of attorney for health care. (Prob. Code, § 4674.)
8. Provides that, if an individual is a patient in an SNF when a written advance health care directive is executed, the advance directive is not effective unless a patient advocate or ombudsmen, as may be designated by the Department of Aging for this purpose, signs the advance directive as a witness, either as one of the two witnesses or in addition to notarization.
   1. The patient advocate or ombudsperson shall declare that they are serving as a witness as required.
   2. A witness who is a patient advocate or ombudsperson may rely on the representations of the administrators or staff of the SNF, or of family members, as convincing evidence of the identity of the patient if the patient advocate or ombudsperson believes that the representations provide a reasonable basis for determining the identity of the patient.
   3. The intent of these provisions is to recognize that some patients in SNFs are insulated from a voluntary decisionmaking role, by virtue of the custodial nature of their care, so as to require that they are capable of willfully and voluntarily executing an advance directive. (Prob. Code, § 4675.)

This bill eliminates the provisions permitting a patient advocate to witness a written advance directive for a person in an SNF in lieu of an ombudsperson designated by the Department of Aging, so that the ombudsperson is required to witness every such written advance directive.

COMMENTS

1. Author’s comment

According to the author:

SB 1189 amends Probate Code Section 4675 to remove the term “patient advocate” as a permissible witness for advance health care directives (AHCDs) executed by skilled nursing facility residents, leaving the Long-Term Care (LTC) Ombudsperson as the sole designated special witness for such signings.

Residents of skilled nursing facilities are in a uniquely vulnerable position when executing AHCDs. Because of the custodial nature of their care, special protections are required to ensure that their health care wishes are expressed freely and voluntarily. California law has long required an independent witness for these signings, and the LTC Ombudsperson, designated by the Department of Aging, has served as that witness in practice.

However, the current statutory language in Probate Code Section 4675 lists both a “patient advocate or ombudsperson” as permissible witnesses. The Department of Aging has not designated any entity as a “patient advocate” separate from the LTC Ombudsperson program, leaving the term ambiguous. This ambiguity recently led at least one nursing home social services designee to serve as an AHCD witness under the mistaken belief that they qualified as a “patient advocate.” This undermines the protective intent of the law. SB 1189 corrects this by deleting references to “patient advocate” from Probate Code Section 4675 and replacing them with “ombudsperson,” consistent with the actual practice and the intent of the statute. The bill also updates gendered pronoun language. This is a technical cleanup bill that brings the statute in line with how it has been implemented and ensures nursing home residents’ AHCDs are witnessed by the appropriate, independent party.

2. Background on advance health care directives

California law “recognizes that an adult has the fundamental right to control the decisions relating to [their] own health care, including the decision to have life-sustaining treatment withheld or withdrawn.”^[1] To that end, the HCDL permits adults who are legally permitted to make their own decisions—known as “having capacity”—to set forth their instructions for health care treatment in the event that they are unable to articulate those wishes in the future.^[2] An advance directive can include an advance health care directive, which sets forth specific requirements for what sorts of treatment the person consents to or does not consent to; a power of attorney for health care, which grants a designated person the right to make health care decisions for the person in the event that the person is incapacitated; or both.^[3]

Because an advance directive can involve serious, life-changing decisions—including the decision to refuse or discontinue life-preserving treatment—the HCDL requires an advance directive to be signed by the individual executing the document, dated, and either witnessed by two individuals or notarized.^[4] The HCDL also prohibits specified persons from serving as a witness, due to potential conflicts of interest, including the person’s health care provider or the operator of a community care facility or residential facility for the elderly.^[5]

For residents in an SNF, the HCDL imposes an additional requirement for executing a written advance directive. An SNF resident’s written advance directive must be witnessed by a patient advocate or an ombudsperson designated by the Department of Aging, in addition to either the two witness signatures or the notarization.^[6] This added requirement is intended to provide another layer of protection for SNF residents, who, by nature of the custodial care of the SNF, may be less likely to have the ability to willfully and voluntarily execute an advanced directive.^[7] “Patient advocate,” however, is not defined in the HCDL.

3. This bill eliminates the provisions allowing a “patient advocate,” in lieu of the ombudsperson, to witness a written advanced directive for a person in an SNF

The failure to define “patient advocate” in the HDCL has, according to the author and sponsor, given rise to confusion over who may witness an advance directive for a person in an SNF. The sponsor reports an incident where a nursing home’s social services designee witnessed an advance directive as a “patient advocate,” which is contrary to the spirit, if not the letter, of the law. The purpose of the additional witness signature requirement is to provide an added layer of protection for persons whose ability to execute an advance directive may be in question; this added protection is lost when the additional signatory is an employee of the SNF.

To close this gap in the law, this bill deletes the option to have a “patient advocate” serve as an additional witness for an advance directive executed by a person in an SNF, so that all such advance directives must be signed by the ombudsperson designated by the Department of Aging. This deletion ensures that a person outside of the SNF will be involved in the execution and determine whether the person has the capacity to execute the document. This Committee has not received any opposition to this bill or concerns that it will overly burden SNFs.

4. Arguments in support

According to CANHR:

AHCDs completed in a nursing home require a special witness. This requirement ensures residents are not coerced by facility staff or other parties into an AHCD that does not reflect their health care wishes. Probate Code § 4675 names the potential special witnesses: “patient advocate or ombudsman, as may be designated by the Department of Aging...”

Although the statute lists both “patient advocate” and “ombudsman,” the Long Term Care Ombudsman is generally understood to be the required witness, as they are designated by the Department of Aging to advocate on behalf of nursing home residents. Recently, however, a misunderstanding occurred where an individual who believed themselves to be the patient’s “advocate” witnessed the execution of an AHCD without the ombudsman present. The misunderstanding not only subjected the resident to an invalid AHCD, it exposed the risk of the statute’s reference to a patient advocate position that does not exist. Others may similarly misinterpret the statute’s special witnessing requirement, potentially bypassing ombudsman involvement and creating AHCDs that could later be deemed invalid.

Removing outdated references to a “patient advocate” would prevent the further misunderstanding that people who claim to be patient advocates can witness nursing home residents’ AHCDs.

SUPPORT

CANHR (sponsor)
California Long-Term Care Ombudsman Association

OPPOSITION

None received

RELATED LEGISLATION

Pending legislation: None known.

Prior legislation:

AB 2288 (Choi, Ch. 21, 2022) clarified that advance health care directives can include instructions for mental health treatment.

AB 1234 (Arambula, 2021) would have, among other things, allowed a witness to a written advance directive to witness the subject’s signature via audiovisual means, and reduced the digital signature requirements to require merely an electronic signature. AB 1234 died in the Assembly Health Committee.

**************

1. Prob. Code, § 4650(a). ↑

2. See generally Prob. Code, div. 4.7, §§ 4600 et seq. ↑

3. Ibid. ↑

4. Id., § 4673. ↑

5. Id., § 4674. ↑

6. See Prob. Code, § 4675. ↑

7. See id., § 4675(a).) ↑