Sacramento Behavioral Healthcare Hospital in Sacramento on May 30, 2026. New staffing requirements are set to go into effect in psychiatric hospitals throughout California sparking concerns from unions and workers about layoffs.
Andri Tambunan/For the S.F. Chronicle
Gov. Gavin Newsom’s administration on Monday enacted historic staffing requirements for psychiatric hospitals in California aimed at keeping tens of thousands of people a year safe while they are being treated for emotional crises.
The California Department of Public Health (CDPH) emergency regulations specify that the hospitals must assign 1 nurse for every 6 patients in adult psychiatric units, and 1 nurse for every 5 adolescent patients. Hospitals found in violation of this standard can be fined $15,000 to $30,000 per day.
Major healthcare worker unions and frontline caregivers applauded the reforms as an essential step to improving treatment in locked facilities where patients are often held against their will, with California’s largest nurses union celebrating the changes as “a win.”
Article continues below this ad
“CDPH is finally doing the right thing and fixing its emergency regulations for safe nurse-to-patient ratios in our acute psychiatric hospitals,” according to a statement submitted by hundreds of nurses during the public comment period preceding the June 1 enactment.
But labor organizations also raised significant concerns that hospital operators are already planning to undercut the reforms by firing droves of unlicensed staff, who have historically provided the bulk of direct patient care in psychiatric facilities, in order to meet the new requirements while still minimizing costs.
San Francisco Chronicle Logo
Make us a Preferred Source to get more of our news when you search.
Add Preferred Source
“Licensed nurses will be added on paper, unlicensed direct-care staff will be removed, and most patients will experience little or no improvement in care,” Sal Rosselli, president emeritus of the National Union of Healthcare Workers, wrote to the state health department last month, after union members at Sacramento Behavioral Healthcare Hospital received notice that the hospital would cut dozens of full time, unlicensed mental health worker positions.
“The result is a shell game,” Rosselli said.
Article continues below this ad
Sal Rosselli, then-president of the National Union of Healthcare Workers, speaks at a rally for more hospital staffing outside of a Kaiser Permanente facility in San Francisco on Jan. 12, 2015. (AP Photo/Jeff Chiu)
Jeff Chiu/AP
The new staffing standards are in response to the Chronicle’s “Failed to Death” investigative series that uncovered widespread abuse and neglect of patients in psychiatric hospitals operated by for-profit companies, often due to inadequate staffing.
A 1999 state law mandated that California leaders set minimum nurse-to-patient ratios in psychiatric hospitals decades ago, but the Chronicle found that never happened.
In the absence of these requirements, reporters uncovered hundreds of reported patient assaults in for-profit psychiatric hospitals, and at least 18 deaths between 2019 and 2024 that state health inspectors had connected to deficient care.
CDPH originally unveiled a draft of the regulations in December with implementation planned on Jan. 31 for the state’s 35 freestanding psychiatric hospitals, the majority of which are run by for-profit chains. However, after hearing from hospital administrators and workers, the agency decided to move the start date to June 1 to give facilities more time to ramp up staffing.
Article continues below this ad
The emergency regulations will be in effect for about a year as the state develops permanent staffing requirements through the regular rulemaking process, which includes public hearings.
“These updates clarify expectations on nursing services, establish required documentation and staffing policies, and set minimum staffing standards intended to support patient safety and quality of care,” said CDPH spokesperson Mark Smith.
Under the emergency regulations, registered nurses, who are among the highest paid and most well trained nurses, must make up at least 50% of the caretakers counted toward the ratios. Licensed vocational nurses and licensed psychiatric technicians are allowed to make up the rest. If patients need more intensive supervision, hospitals must employ additional staff, including unlicensed mental health workers.
The rules mirror decades-old requirements for psychiatric units in general hospitals, which the Chronicle investigation found had been cited for far fewer serious safety violations than for-profit psychiatric hospitals.
Elsy Jimenez (left) and her husband Lionel Jimenez (right) with a photo of their son, Raymond, at what would have been his graduation ceremony at Oxnard High School in June 2024. Raymond died inside a psychiatric hospital in Ventura after staff members failed to monitor him.
Gabrielle Lurie/S.F. Chronicle
Kirsten Barlow, vice president of policy at the California Hospital Association, told the Chronicle in an interview that the state’s psychiatric hospitals have hired hundreds of frontline workers in recent months, many of them new graduates from nursing school.
Article continues below this ad
As of late May, Barlow estimated that the facilities were 80% of the way to meeting the staffing requirements, but frequent turnover and time-intensive training had made full compliance challenging. The association has asked CDPH to allow hospitals to apply for an extension if they are unable to meet all the proposed requirements by June 1. On Monday, the agency said no extensions have been granted.
“To the extent any of these hospitals are unable to hit that June 1 deadline, they either are really forced with the choice of closing beds or face a very stiff penalty,” Barlow said.
The hospital association has also warned that without additional state financial support, the new staffing requirements would pose a heavy financial burden on hospitals, potentially resulting in hundreds of unlicensed workers being laid off. The entry-level caretakers are among the lowest paid patient care staff in for-profit psychiatric hospitals and typically make between $25-30-an-hour.
“It’s not as though hospitals wouldn’t want to retain mental health workers to do those tasks. They simply can’t afford the cost,” Barlow said. “In order to hit the ratio, they need to focus on nurses.”
Dan Shearn at his office in Santa Rosa on Oct. 16, 2025. Shearn was the director of nursing at a Santa Rosa psychiatric hospital from 2022 to 2024 before resigning during a stretch of patient assaults tied to persistent understaffing.
Gabrielle Lurie/S.F. Chronicle
The two publicly traded psychiatric hospital chains operating in California have raised financial concerns in investor meetings — while also reporting massive earnings.
Article continues below this ad
A Universal Health Services executive said in a February earnings call that the new staffing regulations would cost the company’s seven psychiatric hospitals in California an estimated $30 million per-year, mostly due to increased labor costs. Those same facilities reported a combined $120 million in profits in 2024, the most recent year with audited state financial data.
Acadia, another publicly traded behavioral healthcare giant, said in a February earnings call that the regulations would result in an estimated $4 million hit to the company’s earnings, before factoring in other costs like interest, taxes and depreciation. The two California Acadia psychiatric hospitals that operated in 2024 reported nearly $30 million in profits that year.
Universal and Acadia did not respond to requests for comment. California’s largest psychiatric hospital operator, the privately-held company Signature Healthcare Services, also did not respond to a request for comment.
In a May 21 letter to state officials, a law firm representing Universal and Signature asked CDPH to withdraw or revise the proposed regulations, saying they were “arbitrary and capricious” and not backed by research. “The evidence cited by CDPH … does not support the specific ratios established,” an attorney at the law firm wrote.
Sacramento Behavioral, operated by Signature, cut back on unlicensed mental health workers in late May to prepare for the new regulations, according to a spokesperson for the National Union of Healthcare Workers, which represents nurses and other patient care employees in the facility.
In its letter to CDPH, the union warned that the reductions stood to make a dangerous work environment even more hazardous. In an April survey of 18 mental health workers and nurses, the union said that 16 reported recently being involved in serious workplace incidents that included patient and employee injuries and assaults. “The substantial majority believed those incidents could have been avoided, or made less likely, with adequate staffing,” Rosselli wrote.
Signature did not respond to questions about conditions at Sacramento Behavioral.
Bree Zorrilla, a nurse at Sacramento Behavioral Healthcare Hospital, in Sacramento on May 30, 2026. Zorrilla praised California’s new nurse-to-patient minimum ratios, but said that unlicensed mental health workers are also vital to quality of care and patient safety.
Andri Tambunan/For the S.F. Chronicle
Bree Zorrilla, a licensed vocational nurse and union member who was recently hired by Sacramento Behavioral, told the Chronicle in an interview that nurses used to primarily focus on patient assessments and administering medication. But she said the staffing changes have forced nurses to do tasks previously handled by unlicensed mental health workers, such as checking on patients every 5-to-15 minutes, or staying within arms reach of patients when they pose an elevated risk to themselves or others.
“The mental health technicians are the eyes and ears on the floor,” Zorrilla said, referring to the unlicensed workers whose jobs have been cut back. “Getting rid of them is not only awful for their livelihoods, but also awful for the patients.”
Editor’s note: The Chronicle will continue to cover the state’s implementation of minimum, nurse-to-patient ratios in psychiatric hospitals, including the development of permanent regulations over the next year. If you have information you would like to share about the impacts of the new staffing standards on workers or patients, please contact reporter Joaquin Palomino at jpalomino@sfchronicle.com or reporter Cynthia Dizikes at cdizikes@sfchronicle.com.