The California Department of Public Health issued All Facilities Letter 26-04 on January 27, 2026, providing general acute care hospitals guidance on the implementation of Senate Bill 596, a new law that increases enforcement exposure for nurse-to-patient ratio violations under Health and Safety Code section 1280.3. Most notably, the AFL confirms that violations occurring on separate calendar days will be cited as separate violations, even if they arise from a single staffing shortfall spanning multiple days (a “day” is a 24-hour period, running from midnight to midnight).
According to Section 1280.3, CDPH is required to assess escalating administrative penalties for violations by GACHs of nurse-to-patient staffing ratios: $15,000 for a first violation and $30,000 for a second violation. SB 596 made two significant changes to the statute, both of which took effect January 1, 2026.
The first change, emphasized in the AFL, requires CDPH to treat violations occurring on separate days as separate violations. For example, if a single nursing shift violates staffing ratio requirements across two calendar days, CDPH must issue two separate violations, significantly increasing potential penalties for extended or overnight staffing deficiencies. However, Section 1280.3 continues to provide a limited penalty exemption for GACHs if the facility can demonstrate all of the following: (1) any fluctuation in the required staffing was unpredictable and uncontrollable; (2) prompt efforts were made to maintain required staffing levels; and (3) the facility satisfied the “exhaustion requirement” by immediately using and exhausting its on-call list.
SB 596’s second change clarifies both what qualifies as an on-call list and what actions do not satisfy the exhaustion requirement. Under the amended statute, an on-call list must consist of nurses who are either scheduled to be on call for the specific shift and unit at issue or assigned to a regularly scheduled float pool shift covering one or more specific units. Importantly, the statute specifies that contacting nurses who are not scheduled to be on call or assigned to the applicable float pool does not satisfy the exhaustion requirement.
