Senate Joint Business Professions — 2026-03-10

I had not.

Thank you, guys. So oversight is one of the more important functions of this legislature. It's actually one that we should probably engage in a little bit more. In my personal opinion, uh, we do hear hundreds of bills every year that create new programs and tell government to do something. Yet it is also very rare that we ask whether these agencies are actually functioning as they should. Um, many times, if you guys paid attention to our budget hearings. I have always talked about consolidation, duplicative services, a lot of bloat, and much more. So these oversight hearings are incredibly crucial, particularly for licensing boards, which can hold the ticket to someone's livelihood. It is important that we evaluate whether they are efficient and effective. I want to be clear at least my vision of this entire role is largely to make sure that we are protecting consumers, allowing more people to enter this particular workspace depending on which board we are talking about. And I look forward to learning about the boards we're talking about today and this year. Through this process, I'm especially interested in ensuring that we can provide opportunities for economic mobility to millions of licensees while ensuring access to quality care and service to the millions of California patients. So I look forward to this hearing and again, thank you.

Good morning, chairs and members. My name is Dolores Trujillo and I currently serve as the President of the

I am a registered nurse appointed by Governor Newsom to serve on the Board in a direct care provider role. I am joined today with Loretta Melvey,

Over the past four years, the Board has worked tirelessly to turn feedback from

We heard your concerns and we acted. The Board has modernized licensing and education systems, streamlined enforcement processes, and significantly improved consumer satisfaction. Processing timelines for every license type has

RN exam applications and a 42% decrease for RN endorsement applications, allowing nurses to enter the workforce faster. Despite an increase in both the volume and complexity of cases. We have maintained stable disciplinary timeframes while strengthening complaint prioritization and probation monitoring to protect the public. Despite an increase in both.

Annual enrollment in pre licensure nursing programs increased by over 30% since our last sunset review. As we continue to advance in growing California's nursing workforce. An overhaul of the faculty approval process led us to being the first board in the nation to capture statewide data on the number of nursing faculty by

Stakeholder engagement and education have been prioritized with the Board meeting consumers, licensees, educators

Lastly, consumer satisfaction with the board rose from 51% in 2022 to 70% in

over the last four years give us

advancing its mission while adapting to the

Loretta and I are happy to answer your questions. Loretta will be addressing the operational and

and available for any other policy issues related to our nine member board.

So the Nursing Board is one of the most crucial ones. We hear about nursing in pretty much all of our communities, especially now more than ever. You know, I kind of just wanted to understand what is the board's regulation limit for nurse practitioners to practice within one category of their certification? And aren't they still nurses at the end of the day? So with broad authority, depending on where they work? Thank you. I'll be happy to answer that. So nurse practitioners are initially licensed as an rna. That is accurate. So they could work as an rn. They are additionally licensed or certified in our state to work as an advanced practice rn, which is a nurse practitioner. They have in California, they have an option currently to become licensed without a national certification. The national certification is required for any billing. So that is a CMS requirement, not a Board of Registered Nursing requirement. So when they do provide services, they do have to have a national certification. We have a three tiered system in the state of California. When it comes to whether or not the nurse practitioner has to have specific supervision or whether they can have independent practice upon licensure, they work under what's called a standardized procedure that does require direct physician oversight. Direct physician oversight does not mean they have to be physically present at the premises, but they do develop these standardized procedures. They're in accordance with the healthcare facility. They're working within them as the practitioner and the physician. They work for that at a minimum of three years. Some choose to work in that role indefinitely. If after three years they complete the transition of practice, they apply to our board. We advance their certification to what's commonly referred to as a 103NP that allows them to work without standardized procedures. Again, in any specialty area that they want does not have to align with their national certification. It is only when they move to a 104 nurse practitioner that is an independent practicing nurse practitioner. That person must work with the way that the current law is written right now in alignment with their education, training and national certification. So the national certification is done at a population foci level. So it is still broad. You can specialize within that. So in my district, we have a lot of Nurses. We have obviously a nursing school as well. And just for reference, East Bay, in the Bay Area. And one of the things that we constantly hear is that there's a lot of people that will go abroad to get their nursing education and much more. What are we doing to kind of incentivize or create a bigger pathway for folks to get their degrees here, get their education here, and, and streamline it when they don't have to potentially jump through hoops as we have a shortage? Yeah. So when you say abroad, is that international, Is that preparation international and pay a cheaper price for a full year of education versus our effort? There's also, and I do have concern about this, we have a lot of people from the international community who move here that have the qualifications, that have worked in hospitals abroad, and we don't make it easier for them to get licensure here without going through everything or going into debt. So I just want to see, like we talk about this for years. The public is frustrated with it, the lack of available nurses in rural areas and much more. We're just making it harder. What are we doing to kind of fix this? So we've actually streamlined the licensing process exponentially. The example that you use is the Philippines. They updated their memo, and based on that memo, anybody that graduates from their BSN programs do qualify for licensure here in California, prior to them updating their memo, they did not meet our licensing standards for the minimum qualifications on their education. So once that memo was updated and they shared it out from the Philippines Ministry of Education, it aligned with our education requirements and preparations. And if you graduate from the Philippines, you should be able to obtain licensure fairly quickly. What about Latin America? Which areas in Latin America? Name a country. Let's go South America, Central America, and then Mexico. Typically, there's no issues with them as well. So what. What happens is they come in, they fill out the application, just like anybody does in the US or in California. Regardless of where you graduate from, based on that application, they give us their transcripts. If it's an intern, it does go through a company typically called True Merit, and that company translates the transcript for us. We do a review of the transcript. They meet our educational requirements. They either take the nclex, if they haven't taken the nclex, and the NCLEX is our national board exam that allows for anybody to be licensed in the United States to work as a nurse. And if they take that exam and pass it, they're licensed. There's not a different path in for anybody. Everybody is licensed under the same requirements. Whether it's California, US or international, the requirements stay the same. What's the timeline? That is actually just improved. And so we do our first review within about two weeks. And most of the applications we do find out that are deficient, they're missing at least a transcript once that transcript is received. And we just recently partnered with Parchment and Clearinghouse, which are the two major transcript companies in the nation. And then Trumerit is one of the international transcript that do that. And we partner with them as well based on receipt of that transcript. We process about two weeks after receipt of that transcript, but that's usually two weeks after we've reviewed it and said, oh, you failed to turn in an item. So if we get a complete application, it's processed within weeks.

And then are there any language barriers or for example, if they are not a primary English speaking country, are there any requirements that you guys place or some mid level proficiency in English or anything like that? We do, we do require a English proficiency exam. If the education, if the school that you received the education from does was not taught in English. And that is because our National Council State Boards of Nursing, the company that administers the nclex, it's only written in English. So we want to make sure that they're successful in passing the exam. But that's the extent. Okay. And final question, because I know I'm asking a lot. That's okay. Your online programs. I've had the pleasure of talking to a number of online nursing schools, some of them that have concerns with clinical placements or having this or have we talked about that? Because so many schools are going 100% online. And I just kind of want to understand how you guys see that. So we actually do not dictate whether they do online or ground. That is not something that's through the Board of Registered Nursing. We partner with the California Community College chancellor's office, the CSU's chancellor's office, as well as the Board of Bureau and Private Post Secondary Education, sorry, bppe. So they oversee the academic setting and they have their requirements. We only look at the nursing program within the nursing program of any academic institution. We look to make sure that that program will meet the licensing standards, be able to produce a safe practicing rn. So we don't state whether or not it has to be online or in person. The one qualification that we do require is that of the 864 hours that they have to complete in clinicals, that they complete, 500 of those in a direct patient care telehealth is also providing direct patient care. So a part of that can be counted towards that 500 hours. Okay. And let's say they were online, they did telehealth and you know, who knows what else. If they get a full time job eventually after they're licensed, is there just for the online students, is there one to two, three month period where they are having additional training just because of the fact that they haven't had the true in person contact? All of our new grads require some kind of additional training. They don't come out and hit the floor running. That is not something that is done. So each one of our healthcare organizations, which we, just to be clear, we don't have any jurisdiction over them, they provide what's called new grad programs. And those new grad programs vary from six weeks to a year depending on how they set them up and what specialty areas they're going into. And then with that they determine what kind of support is needed because the hiring entity is the one that verifies competence before they actually go in and can provide the direct care. Perfect. Well, I appreciate all of your work. I will say that I'm very much interested in making sure that we support the women and it's largely a women's profession at this point, are able to do it even if they have children, if they have, you know, competing priorities and there's flexibility there as well as that threshold be simplified as best as possible for those that are trying to transition, let's say in their 20s, 30s, 40s and are newer rivals to this country too. So that's my interest and hopefully you guys are paying attention to that. So thank you. Yeah, nursing is fantastic for that. I'm actually a direct result of that. I was a PIC student and I had a 16 year old. I was 16 when I had my daughter and I was able to go and be here today because of this profession.

So I think there was a couple questions so I'm going to try to answer both of those. The first question that I understood was if they have their training in another country, can they come straight in and work, they are held to the same licensing standards as everybody in California. So if you meet the education requirements and you pass the nclex. And the NCLEX is a national recognized exam that all 50 states and four territories take, including two territories within Canada, they all have to take the NCLEX in order to.

It is a national exam. So they have to qualify to take that. That qualification is based on educational standards. We review the educational standards, we let the nclex, the people that deliver that test, know that they meet the standards and then they still have to take that test. That is a United States requirement to be a nurse. And so if we review your international program data and they meet the educational requirements that every nurse in the state of California is able to is required to meet, then we say that they can meet that. There are occasion where we will note that they did not have the type of education that we require in California. We will let them know that it's one course that they're missing. And if they, they can take that one course in any location that they choose to. Again, as long as it meets that requirements. We work very closely with them. We actually have a designated international licensing unit that works specifically with the international applicants.

That is for Everybody, whether it's US, California or international. 500 hours in direct patient care is required for anybody, regardless of where they're educated.

We do not have a separate exam here in California. No. So if you meet the national licensing exam, you're able to practice in California.

The first thing they have to do is they have to apply to some board of nursing in the United States. So we have 50 boards of nursing in four territories. And so they apply to one of those, one of those boards will review their academic preparation. And if that preparation meets, they let the national testing entity know that they can administer the exam. So it is two steps. They have to apply, education, evaluated and then they go and test.

Correct. Every, every advanced practice licensed RN in the state of California is an rn. First they pass and must take and pass that NCLEX exam. So they have to take that licensing exam to be an RN first. Then each one of our advanced practice RNs, there's four distinct roles, have a national certification examination that they can take and pass. Again, currently in California, we only require that for one advanced practice rn, and that is the certified registered nurse, an ethicist. There are three other advanced practice RN roles right now that are not required to have that national certification for licensure by our board. That doesn't mean they don't have to have that exam, that licensure exam. They have to have that national board exam in order to bill for insurance. And so CMS requires them to to have a national board certification in order to bill their patients for the services

Some of the hiring institutions do have that in their credentialing process. Again, that's outside of the Board of Registered Nursing. We have a minimum licensing standard. We have asked in our Sunset report to align with that requirement for all of our advanced practice RNs. What we want to ensure is that you don't license an individual who then can't practice in California because they're unable to bill or they're unable to get credentialed. And so if there is a length of time that passes from the completion of your nursing education, including your advanced practice education, and taking that exam, so the success rate for passing that exam exponentially drops. And so by us allowing for licensure without holding them to that standard, we can be setting them up so that they're licensed but not able to practice.

Not at this point. I'll explain that a little bit broader. Right now in California, we have about 45,000 nurse practitioners in our state that are licensed here. Only about 3,000 of those nurse practitioners have advanced from working under that standardized procedure, direct physician oversight, to what's called a 103NP. That 103 NP is still not fully independent at that point, they are limited to the group settings that they're able to practice in. And one of the requirements with that group setting to be able to practice in requires them to work with at least one physician and surgeon. So only 3,000 of our 45,000 nurse practitioners have even advanced to that level. In January of this year, we have had our first group of nurse practitioners of only those small group of 3,000 that have advanced to what's called the 104NP, which is that independent practicing NP. We probably have less than about 100 nurses practitioners in the entire state of California that have just recently received their ability to have a full independent practice that is in line with their education, training and national certification. Those initial people getting those granting, which again is only about 100, maybe even less, that have received, that could only start practicing in an independent manner as of last month. So we have not received any complaints, any concerns around this, because they haven't begun practicing in that independent manner yet.

So we have eight categories that are at the national population foci. Sorry. And so it's adult geri, pediatrics, neonatal women's health, and psychiatric mental health. And then there's various kind of, whether they're primary care or acute care delineations between that, but that again, is at the population foci. So if you have a family nurse practitioner, you can work in the emergency room, because that is a specialty of the family nurse practitioner. If you have a family nurse practitioner, you can also specialize in cardiac. And so we don't regulate any of the specialty areas. We only license and regulate and oversee at the population foci.

So nurse anesthesists are a little bit different, and so they're not the same as our nurse practitioners at all. So I'll explain what their practice is. The nurse anesthetist has a RN license, and then they also have an advanced practice certification. They're able to practice independently once the order for anesthesia is received. So the physician and surgeon must say, I need anesthesia services. They then bring in the nurse anesthetist to deliver that. And in the operating room, the pre operating room, getting them ready to go in during the procedure and immediately following the procedure, they are able to operate in an independent manner. Understanding that surgical suite, though, you are the nurse anesthetist at the head of the patient's bed. You have the physician in the room that is providing the operative services.

of, not necessarily supervision, there is a physician and surgeon there that is doing the surgery. They do not have to supervise the anesthesia, the nurse anesthesist that is providing the ability for them to have the pain relief and the sedation and stuff that's, that's needed to do the surgery. They're focused only on taking care of the patient that is having like they're, they're cutting and you know, doing everything that they do. As a surgeon, they would not be able to supervise the, the nurse anestheticist at that same time. That would require an additional person. And so that nurse anesthetist can select and administer all the medications, the oxygen, anything that is needed, any kind of emergency items that are needed to provide to that patient at that time, independent of the physician and surgeon that's in the room. There is also additionally a surgical tech there and an RN that is there as well.

Not typically, no. And nurse and ethicists have been practicing in this manner for greater than 40 years. And so we do not see an increase or anything that has occurred around having them as an independent practitioner in California.

Thank you.

Absolutely. We have a path in. It's called being board approved nursing program. And any out of state entity that would like to be able to provide education to our California residents are able to become board approved here in California. They have to go through the same review process as any California school. We re review them, we ensure that they meet the same standards. And as long as they meet the same standards, our board would consider all of their enrollments and all of the or their graduation metrics and attrition metrics and success measures the same as every other school here in California.

The Board of Registered Nursing does not require that. However, if you're an out of state entity, they would be able to have to apply through the Bureau of Private Post Secondary Education which is a separate governmental agency. They do at this point have to have an on ground location. However, consistent with our in in state nursing programs. That could be within a strip mall. It could really just be an office building that is a kind of centralized hub. And we have many, many nursing programs in the state of California that require that have a setup within a strip mall. Here in Sacramento county we actually have two schools in one strip mall located right next to each other sharing a similar space. And so that space requirement does not tend to be a detriment.

I think I can understand why you would see that on face value as being kind of a barrier, but I'd like to provide some additional education on that. So each one of our 50 states and four territories have different licensing requirements, different educational, different background fingerprint requirements, et cetera. So they have various licensing requirements. And federally each, each school, no matter what program you come from, whether it's nursing or it or anything, if it leads to a licensing exam or a licensing need in an individual state, you must prepare your curriculum to meet that. You won't know that unless you check in with each state to see what those licensing requirements are. So that's really what is occurring in our role with the Board of Registered Nursing. Our focus is 100% consumer protection. When you have a student entering day one into an academic setting, they're committing to two to three years of their life to go to school. And they want to say that if I start today, I'm going to graduate in three years and I'm going to be able to be licensed in three years. Because some schools are taking on upwards to $200,000 in tuition debt without A guaranteed outcome. You can get a degree from a program and still not be licensed because you weren't prepared correctly. So the initial thing that our board approval does is verify the quality of that program, verify that their graduation rates are great, their attrition rates are fine, that their pass rate for the NCLEX licensing exam is there, because without passing that exam, you can't work as an rn. So we at the California Board of Registered Nursing look at the metrics of the program. Then based on those metrics of the program, if they're not an at risk school, if their quality indicators are met, they're able to grow. The next thing that we look at is whether or not in that growth it would negatively affect a current approved nursing program. What we don't want to see because we have a lot of clinical impaction, I'm sure you guys have heard about that, which is why some of those students are going out of state, is if you have 100 students in one area that are already enrolled in a program, already paying their tuition, and already planning to graduate in a year or two, and you bring in another program that wants to do clinicals in that same space because direct patient clinical hours, hands on touching a patient is required, that they could lose those. And then the students that are currently enrolled won't be able to progress and graduate. So we require our schools to work collaboratively together to ensure that they have their clinical spaces, that they have faculty, that they have the resources in order to enroll day one and graduate at the end. Because what you don't want to have is generational debt. What you don't want to have is a person that graduates and has $200,000 in tuition and no ability to get a job or no ability to pay that back. And so that's really where our consumer protection comes in. And so it does look kind of pretty simple. Like, hey, just open up your borders, have everybody do clinicals. That is not the way that it actually works when your boots on the ground and you're trying to manage and organize all of that. But there is a pathway in. They just have to go through the approval process, make sure they meet our licensing requirements, allow us to oversee their metrics, and then make sure that they collaborate well with the current RN programs that are here in California.

It is. And just to be blunt, it's almost consistently a problem in every location. So we are very much aware of that have a nine member board. So this is our board president here. And all enrollment decisions, whether it's approval of our new program, growth of a current program, moving to a new location, is all reviewed by our nine member board. And they look to make sure that kind of everything is equitable. One of the things when you say, what does a school have to do or a person that's not a school yet that wants to start a nursing program have to do? We have a very step by step outlined in regulation, a form that they can pull from our website. It's up there, there, it's there they can go that they start off by submitting a letter. It's actually written to me right now, the executive officer. But they submit a letter and at submission of that letter, we assign a person on staff called a nursing education consultant. And so that nursing education consultant works side by side with them through the entire approval process. And then once they're approved, they continue to review them on an, on a schedule to ensure that all the metrics continue to remain high and that the students and the community they serve continues to be happy with that. And so they do have somebody that is assisting them through that entire process when it goes to clinical placements. In our background paper, we have talked about a statewide nursing consortium that has regional focus. We don't have that currently, but that is something that would benefit us.

Yes, it would.

Thank you.

Thank you so much for being here today. It's been very informative and I'm extremely grateful to our nurses. They provide incredible services in our communities. So I was just. And I'm really grateful for this background paper too. It was very, very comprehensive. So understanding is that this is the only board that still requires that the executive direct officer be an actively licensed registered nurse. And my understanding is that other boards don't have that. So I'm curious, is it necessary for the BRN executive officer to also be a licensed nurse? It might be a little biased because I am, that is, and you are. And so. And I'm grateful for that I'm just curious. I just thought, been an RN for 25 years or longer, and our board president is an RN right now, so we might be slightly biased. We are the only board in the state of California that requires RN licensure, however, equal to most the boards in the nation. It is a requirement to have an RN in the executive officer role. It's not that you have an RN and you can be an eo, right? So in order to be an executive officer, you still have to possess that minimum skill set of administrative. Having that experience, having that work ethic, you still have to have that. It's the additional layer that we also want to have the licensee because there is some nuance in things that come up frequently that unless you're an rn, you may not have a full understanding of that. That was really kind of ran home with me. I started in this executive officer role in an acting position on February 20, 2020, just two weeks before the world shut down. And I truly believe that because I had an extensive nursing background, that that truly allowed me to jump in and really lead the board through the largest amount of nurses in the entire nation, through that ext. Kind of disaster that came right in front of us. So being able to take in my knowledge of working as an RN at the bedside, as well as working in nursing programs, I was a prior nursing program director and faculty. And so I was able to understand all of those distinct roles and how they all must play together in order for us to come out and be successful in this. And so having that experience, extensive background education and nursing knowledge, I think really, truly did allow for us to move through this a lot faster and better than if we did not have that. Thank you. Thank you.

So there's a couple ways to become licensed. So if you're already licensed as an RN in another state and you're here on military orders, or your partner or spouse is here with you, and they are an RN licensed in another country, in another state, sorry, they just go on a listing here. There's no licensing requirement in California. They can just come right in, be part of that listing and work as long as they're here doing their duty. If they're in a federal agency, again no license required in California, they can work in that federal hospital area without having a California license. If they have military preparation and they haven't sat for that national licensing exam that again is required throughout the United States in order to take patients, they have to meet that qualification. That qualification is based on experiential credit to meet the educational standards. So the educational standards are still the ones that have to be met. Our staff are not specialized in that. So what they do is any military personnel that has their military transcripts or their experiential credit will bring it to a board approved program in the state of California, have that program evaluated for licensing requirements or degree granting requirements. And if there is anything that is lacking in their preparation specifically, they probably aren't birthing babies out on the field. And that's something that is part of our general licensing requirement. They may need to take some additional obstetrics or women's health kind of stuff and then once they receive that, that school grants them their licensing completion. Education requirements for licensing completion. Sorry. And then we treat them the same as everybody else at that point. Point.

Yes.

So each one of our nursing programs in the state of California are assigned a nursing education consultant. That is a board staff, that is a person who is an RN with at least a master's degree in nursing that has extensive education, regulatory knowledge and they help them get approved and help them become a institution of higher education for all of our nurses to be able to successfully graduate them into the nursing pipeline. So every single school has an assigned nursing education consultant. So they probably have a ratio about a 1 to 21 to 30 at our peak. But they are able to email them directly, call them directly. They actually email and call me directly. And then I get on teams meeting with them extensively. I go to various different areas and present to their staff, to their students, et cetera. So we all, we work very, very closely with all of our approved nursing programs.

Yeah, and we actually do that as well. So our community colleges, all of their nursing programs are with us as well, and we work with them extensively. And then I have done two speaking engagements just last year at local high schools to encourage them to come in.

Thank you.

Thank you so much. Chair Berman, thanks for your presentation. Today I represent District 52, which is Northeast LA, South Glendale, East LA. I have six hospitals in my district, including the only children's hospital in Los Angeles. And collectively they employ about 5,500 nurses. Also come from a family of nurses. And I'm also Filipino, Senator Archuleta, so very familiar with the nursing field. But I guess for me I wanted to ask big picture. I know that. Thank you, Juan, for your work and your leadership leading us through the COVID crisis. What are you seeing now as it relates to kind of the nursing profession? Is there a shortage that we should be working to address? Is one question. And then the second question is also when I meet with constituents, students specifically, I know that the pre nursing programs and nursing programs are some of the most competitive to get into and what are we doing to address that? So I'm going to actually pass this over to my board president just to address the work source stuff. She's a currently working RN right now, does NICU at nights, and so she's right there with it. Thank you, Lori. Thank you for that question. We have approximately 500,000 nurses licensed in this state.

even though they have an active RN license. While some of this loss can be attributed to retirements, There are many RNs who report that they left the workforce for preventable reasons, including job related stress

or employers, lack of work life balance. Work as a nurse can be emotionally challenging. Lack of a positive culture to work

So the shortage in our state, while part of it is a Pipeline issue, getting nurses in. We have schools that are graduating new grads, and these new grads are now

their student loans, and a lot of them are not able to do that. A lot of them are having to go out of state to get this experience as an rn, because many hospitals have done away with their new grad training programs, and they're hiring nurses with experience. Right. Because it's cheaper. And so they're hiring nurses with, let's

So I feel like a lot of this problem is employment of our new grads.

I think it would not solve the whole shortage through that pipeline, but it

and then our rural areas have a shortage. So I think also by hiring these new grads into some of those rural

Yeah. So just to add some additional information on that. So we have a pretty robust pipeline in California. We graduate out of, I think, the nation. We are one of the top three producers of nurses academically. And so with that, we have a stable pipeline. We're continuing to grow that pipeline. We're continuing to revalue. We've approved new schools. We approve new campuses. Enrollment growth. That's in our background paper as well. So thousands of new nursing students every year added to the pipeline. Really, that focus is, once they've graduated and completed and met licensing standards, how do you keep them here in California so that you don't have them taking travel positions out of state or leaving the profession completely? And some of that comes through what we have authority over where we look and approve all of our California schools based on that. We review curriculum, we review faculty requirements. We do all of that to make sure that we're assisting that program to meet all those minimum standards and be able to support them when they're fresh and new and out there so that they don't run away. The largest exodus of RNs is within the first two years from licensure, they decide not to leave the job but leave the person profession because they don't feel supported. And there's a little bit of a shock once they go from academic preparation to in person working. Thank you for sharing that. And you know, I would love to work with you on that to see how I can better support from my family's own lived experience in the profession. But something I know I'm deeply concerned about and how do we make sure we retain the nurses that but we're working really hard to train and license in California and how do we keep them in this profession. But thank you both for your work and I'll follow up with you after. Thank you.

Thank you. Thank you so much, Chair and thanks to both of you for presenting. I too am the daughter of the nurse of a nurse and have heard many of these stories around the dinner table, particularly why people stay and why people go. And my questions were similar to Assemblymember Colossae but maybe a little bit more around data. So we hear the stories around there being pockets of surplus and pockets of shortage. My area certainly we have what we call a healthcare desert on the central coast and have done a lot of work to build up the allied professionals, physicians, nurses and others in the healthcare field. But for some healthcare professions, there's data that shows that they actually do stay where they've gone to school. And I'm just wondering about the data for nursing school, if that data exists or if it's more anecdotal. I did hear you say we have a stable pipeline, we have a lot of growth in terms of the number of schools, but that there are people leaving the state at the same time that we're bringing in nurses from other states as well as internationally to serve in California. But what does the data say around people staying where they went to school and then what else can we do? Which is similar to what you just answered. I realize that's okay. Thank you for asking the question. I work closely with HCAI and so they are responsible governmental agency for really tracking a lot of our healthcare data, both growth and recession. And where is that at? I can give you a copy of this map. This is actually our map that is used to predict no shortage, low shortage, medium high or severe shortage. And they take into consideration nursing migration. So where they went to school and where they work and where they live and those might be different locations. So we watch all of that. I work very closely with them and we monitor that. And so based on that we do have a lot of really great reliable data that where they go to school is where they end up typically working. What we need to do better at is really recruiting into those rural areas or the areas that do not have a high nursing population population at this point. And so one of the kind of catch 22s that happen with that is they don't have the clinical spaces in those areas because they don't have a fully licensed hospital. They might have an emergency access hospital. They might have emergency access hospital like some in like Bishop and Mammoth and stuff like that, where it their census or their patient population increases during the winter when there's a lot of people there, but there's nobody there in the summer. And so taking all of that stuff into consideration in order to get appropriate clinical preparation. Because the one thing is even in those rural areas, if you want to have students there, they need to be prepared because they're going to be working in a very unsupported fashion because again, they don't have the providers in that area. And you might be the only nurse on two or three different floors in that hospital. And that's a very difficult thing to step into as a new grad. And so in those areas you really want to make sure that that training stays robust and that you continue to produce qualified licensees in that area. You don't want to decrease any of the educational standards. So we work closely. I meet with schools that are out of state. There is a school in Nevada and a school in Arizona right now that are currently going through our approval process because they want to become a school, a board approved program in California so that they can have some of their students that might be there in Reno to go across to Susanville or Lone Pine or anything in those areas to be able to provide clinicals as well as provide any kind of nursing services in there. So we have that pathway. We look at that all the time. That is something we're very much aware of and we continue to encourage schools because you might have to have a ground location in California based on bppe, but you don't have to be located in that area. So that's the thing is you can have a campus in la, but you can provide online coursework and direct patient care in Big Pine, in Lone Pine. In any of those areas you don't have to be physically present. And so by allowing that flexibility to capture that online student is really a benefit to meet those needs.

Good morning. Thank you. I was looking at some of the amazing data. You all are one of the boards that collect a lot of workforce data and I know my colleague just asked about some of the indicators from that data. One of the things I'm curious about is sort of the mobility within the nursing profession, particularly the LVN to RN steps. I'm also the daughter of a nurse. My mother was an LVN who became an rn and at the time there were so many programs that were available and accessible and really fast tracked programs. So I'm curious about the 30 unit optional program. If you could give us a little bit of an update on, you know, are LVNs acquiring a license through that pathway? Is it appropriate in terms of the the amount of training that folks are getting but also the efficiency in which they're able to transition into a higher pay, higher skilled classification? And then my last question is, you know, I represent South Central Los Angeles and unfortunately we are also in a health care desert, particularly where it comes to maternal health. We are critically short of diverse workforce that really has the cultural competency to support our communities. We have a large, the largest, highest density of black women in my district in the state. We also have, you know, we're a gateway community. So we have a lot of newly arrived families, both from Central America but also from East Africa, a lot of French speakers and so forth. So I'm curious about the upward mobility for nurses, particularly from the LVN to rn. And I'm also curious about what is our data showing us in terms of the diversity of the workforce overall and particularly those underrepresented populations that exist, particularly black nurses and nurses that are able, are multilingual and able to serve vast communities. There's a lot to unpack there. Thank you. So I'm going to try to remember it. I might have to ask you to repeat if I didn't get everything there. So when you're looking at the diverse pipeline that is typically seen with our community colleges, our community colleges serve the community that's around them and they have specific enrollment requirements that are met and we work with them on growing them and doing that. Recently, our private colleges and universities are also saying, hey, we'll take anybody in. We're going to help them, we're going to help them be successful. That's really our focus at the Board of Registered Nursing is not where you go to school, but that the school that you do go to gives you what they say they're going to do that's that consumer protection. And so we really want to grow the schools in the areas that need that. We also want to ensure that they have the support. When you come from a impacted area where they don't have the same access to everybody, getting to clinicals and from clinicals is very difficult. Right. So not everybody has transportation. So when you have a school that's growing beyond their means and they've got a clinical location that's 50 miles away, how do you get your student to that clinical location? That becomes problematic as well. And so really working through the various support systems, looking at what is occurring and how we can better support them, we have had on occasion where people say, well, the student, this, this and this. And our board routinely flips it back and say, well, no, you enrolled that student. So if you're saying that this student is consistently not prepared or not successful, what are you doing to support them? So that's really another avenue that we have for just getting anybody in that is interested in this. One of the other things when you're looking at getting a diverse nursing population is all of the entries into practice. How does this happen? We are the only state in the nation that does not require a nursing degree in order to become licensed in California. Every other state requires at minimum an associate degree that is not obtainable by all. And so as long as we have licensing requirements that are met, we are able to offer apprenticeships, we are able to offer any kind of these pathways in. Over on this side of the room, there was a talk of military. That is the same kind of situation that we do with our LVNs. And so we have many LVNs that want to go back to be RNs. We have our generic path, which means it's exactly the same as anybody that enters off the street. They just walk in. You have zero education. We're going to start you at the beginning and carry you all the way through. If you're an lvn, if you're emt, if you're a paramedic, if you have a medic background as part of the military services, they do an evaluation and see where you land within the program. And they are required through our regulatory process that they give credit to where that person is. So they do. They can get partial credit even for part of a program or part of a course. They have to get that done. So they look at experiential credit, they look at transfer credit, they look at CLEP credit. Then additionally is that 30 unit option now each one of our board approved nursing programs are required to give the credit for anything that's there. They are also required to offer the 30 unit option as part of every nursing program. So we have about 163 nursing programs in the state of California with well over 30,000 nursing students. In every single one of them. They have to have this option in addition to that option being offered. They do have to give them some counseling around that. Because the 30 unit option does not lead to a degree, it is a certificate. The 30 unit option only allows them to sit for that licensing exam. It makes them eligible to sit for that nclex. What that means is because we are the only state that doesn't require a degree for licensure, they typically are not able to get licensed in another state if they complete that program here. However, we know the vastness of California. So if that student is staying in California and wants to be a nurse in California and they're an lvn, that is a viable pathway for them. It is that the school cannot require more than 30 units of semester units. So that is where we hold them to is they must be educated in as few as 30 units. They cannot go over that. There are specific requirements where they have to take some specific coursework so that everybody is prepared. When I was a nursing program director, I had three students take that pathway. Only one of them successfully completed the pathway and gained licensure. However, she was amazing. She was an LVN and now she's a critical care transport nurse flying around in helicopters doing amazing things. So there is that option there. It is not taken routinely, but it does open that pathway up to apprenticeships and really recruiting in and making that non traditional student something that the nursing pipeline can support. Did I answer all of your questions? I'm so sorry. No. You did a great, you did a fair job of getting to most of the issues. So in terms of the. And maybe I'm appreciating understanding the pathway and how folks get there. I guess I'm also curious how many percentage wise, I don't know if we have this data of LVNs do take either the 30 unit path or they go through a non traditional. How many are transitioning and moving up in the profession? That's one. And then and I think you sort of answered the question about the diversity of the workforce. And I'm hoping to get more of a sense of what does our nursing field look like demographically and particularly when we look at underserved communities. So yeah, a little more global on the demographics and then a little more specific in terms of the upward mobility of LVNs into the RN status we have on our website and if you want me to I can pull it up. We have all the demographic data for every of our all of our pre licensure nursing programs. Those are all kept on our website. And it does show that we actually do a pretty amazing job with the diversity. We're not there yet. There is more that needs to be done. We need more males in nursing. We actually need more African American in nursing. 100% across the board. When nursing was kind of brought forward, they wanted bachelors of nursing to be an entry level requirement. When you require a bachelor's of nursing as an entry level requirement, you're not going to get the diverse population. I shared earlier that I was a teen parent. I had my daughter when I was 16. I did not get a bachelor's degree starting I came in and got an associate degree. I did it in accelerated program while I had my job so I could support my daughter. I then went back and got my bachelor's and then while I had my bachelor's continuing to work, I then went back and got my master's and now I was able to be here. I wouldn't have been able to do that if I didn't have a pathway into nursing that was non traditional. I was not the traditional student and could not be that traditional student. So having the no degree requirement in California is key. That is key to having a diverse nursing population. I also work at the national level, so I work with national council, state boards of nursing. We work with the United nations, with the World Health Organization. And the birth rate in the world is not enough to sustain the amount of nurses that we will need in the future. So that becomes an issue. So what you have to do is not rely on kids coming From K through 12 to go into nursing. You want that, but you don't want to rely on that is how do you attract other professionals into healthcare. Healthcare is the second largest profession in our nation. Second to it computerized kind of specialties. So knowing that healthcare is the second largest employment opportunities in the nation and being mostly female, how do you support that? So supporting them so they don't leave, getting the pathways in that are not a strict requirement and making it accessible through apprenticeships, being able to work while you go to school is key. I couldn't have done it if I wasn't working. We would have been homeless. And in la actually they have at ELAC East LA College they have a parking lot that they allow their nursing students to park and live right next to the school because many of them are homeless that go to that school. But LA City College tends to have an amazing success and pass rate because they have the support services in place. So those there's so many different avenues that need to be addressed to be able to support the non traditional student, to get a more diverse background, diverse workforce, apologize for that. But currently nursing tends to do a really good job at that. I could pull it up and read off of it to you or I can send it to you afterwards. Yeah, please do send it to the office after. And I would like to get drill down a little bit more on the pathways. We have an amazing network of K through 12, some magnet schools that do a lot of health and science, stem and we have a tremendous number of community colleges. I have west la, which is a biology and health campus that is also significantly black in terms of student population. So I think it's the question of how do you build the right partnerships and pathways that folks know that the field is for them and that they have an entry point that's accessible in their community. So I'm happy to work with you on that and look forward to seeing that data so that we can follow up on this conversation. Thank you.

I was prepared to sit next to Laurie, so. Good morning, Chairs while in Berman. My name is Sarani Harequan and I'm a family nurse practitioner in the beautiful state of California. And I'm here on behalf of canp, the California association association for Nurse Practitioners. CAMP is here in support of the continuation of the BRN Sunset. The BRN plays an important role in overseeing our profession and fulfilling its consumer protection mandate. CAMP has provided extensive comments to the committee about the policy changes you are considering from the perspective of nurse practitioners. We would ask that the committee focus on clarifying Assembly Bill 890, the landmark legislation passed by this legislature in 2020 with Dr. Jim Wood that allowed specified nurse practitioners to work without physician supervision. It was a very complex piece of law and we have continued to work with the Board of Nursing on its full implementation. Yet we are still not there. We asked the committee to amend the sunset bill to address these outstanding issues as well as all of the other nurse practitioner issues highlighted in our letters. Thank you for your work on behalf of nursing profession and CNP looks forward to working with you as a partner and a resource through this process. Thank you.

Good morning. I'm Roxanne Gould representing the association of Clinical Nurse Specialists. They are highly educated master's, doctoral or postgraduate certificate level education. I'm here for two different reasons. One is to try to request full scope of practice. Currently, they wouldn't be authorized to prescribe vitamins. They wouldn't be authorized if someone chokes. They wouldn't be authorized to assess the swallowing capability of a patient. If a doctor says a patient needs crutches but forgets to order the crutches, they aren't authorized to order crutches despite this just amazing education that they have. And so we're hoping to advance their ability and allow them to practice to the full scope of their education.

government has limited the number of certificates, certifications that they authorize. And there are only three. And I have them listed. You would know them obviously, but there are only three. And what that will do is completely eviscerate the number of clinical nurse specialists that can practice in the state if they aren't in those three particular categories. And so we're hoping to find another avenue, working with the board to figure

what kind of training, some other way to allow those clinical nurse specialists to continue to offer the vital services that they do.

So thank you for the time.

Good Morning. My name is Divya Shiv and I'm with the California alliance of Child and Family Services which represents over 200 community based organizations that serve children, youth and families throughout the state. All of our CBOs struggle with the behavioral health workforce shortage and the 103 and 104 nurse practitioners is when critical path for our members to address this shortage. However, many of these nurse practitioners have difficulty in attaining the 103 and 104 licensures that enables them to practice with greater autonomy and this is despite the fact that these nurse practitioners are taking on senior leadership roles within these organizations. Specifically, many nurse practitioners struggle to accrue the 4600 clinical hours required of the 103 licensure as many of them use some of their work hours to engage in administrative duties and organizations also report difficulties around limited administrative support to track hours in compliance, lack of structured guidance on completing the transition to practice requirements and limited organizational education around AB890. Organizations also struggle with the ability to hire full time psychiatric mental health nurse practitioners because these organizations do not have psychiatrists that can do not have enough psychiatrists to provide the supervision required. We thank you so much for the sunset review and we look forward to working with you to address these challenges and that our members nurse practitioners experience in attaining the 103 and 104 licensures. Thank you.

Good Morning Chair and members. Jen Chase on the behalf of the University of California, UC contributes to the nursing workforce through our four schools of nursing and by providing thousands of clinical placements for nursing students from CSU community colleges and private school programs at our UC Academic Medical Center. So the csu, the uc along with the csu, AICCU and California association of Nurses submitted a joint letter. So I was just going to briefly mention one of our concerns were Overall, we're very deeply invested in ensuring that the BRN oversight supports high quality nursing education, workforce development and patient safety. But one thing we would like to consider as the Board moves forward for the review is that the Board review and align its standards, data requests and documentation requirements with those already accepted by nationally recognized accrediting body. Currently, the BRN requires extensive documentation that is duplicative and in addition to the extensive information our programs already report through the accreditation process, these additional requirements are extremely time intensive and resource intensive. So we encourage the BRN to review its current accreditation standards and provide clear justification for acquiring any additional data elements. Thank you and we look forward to community engagement on on the sunset process.

Good morning Chairs Wahab and Berman and members of the Committees. I'm Evangeline Fangaling Gagalang and I serve as the Associate Dean of the Colleges of Nursing and Health Sciences at Azusa Pacific University and I'm also the President of the California association of Colleges of nursing representing over 60 colleges and universities across the State of California. Thank you again for the opportunity to offer brief remarks and thank you to the VRN for their continued work. We join our colleagues from the UC and CSU in making four key considerations as written in our letter. I'd like to focus on the continued need for clarification and consistency among nurse education consultants as it pertains to the role in faculty hiring processes as outlined in existing statute. As President of the California association of Colleges of Nursing and serving in an Associate Dean's position, I hear many of my nurse educator colleagues continue to voice concern about their BRN nurse education consultant requiring them to fill out forms to provide faculty eligibility to teach BRN regulated courses. So those are courses like pediatrics, med surgs, psych, mental health, obstetrics and geriatrics. Many of us know that this rule is now obsolete, at least for nursing programs that have national accreditation such as ours. Our understanding of existing laws that if a program is nationally accredited, forms such as the EDP PO2 are no longer needed. But we find that because the BRN's website is not fully functional, program directors or designees still must fill out these forms. These forms take a lot of time to complete. It is unnecessary and time consuming and it is taking us away from what we need to do, which is teach our students and administer our programs. We ask the BRN to follow the current statute as it is written and stopped requiring program directors to submit the EDP PO2. Thank you again for the opportunity to provide this input as part of this process. Thank you.

Good morning. My name is Kristin Roman and I have the honor of serving as the President of the California association of Nurse Anesthesiology. Today. I'm speaking on behalf of more than 2,800 certified registered nurse Anesthetists and Nurse Anesthesia residents across California. Ken is pleased to express our strong support for the California board of registered nursing's 2026 Sunset Review Report as it's currently written. We appreciate the Board's thoughtful work, transparency, and meaningful stakeholder engagement throughout this process. I want to thank the Chairs, Senator Wahab and Assembly Member Berman, and the members of the Senate Business, Professions and Economic Development Committee and the Assembly Business and Professions Committee for your continued engagement and diligence in conducting the BRN Sunset Review. This process is vital in supporting the regulatory appropriate framework that keeps pace with modern nursing practice and supports a workforce that can meet the needs of patients across our state. We would like to specifically highlight Canna's strong support for issue 13 regarding APRN to RN delegation. This provision clarifies existing practice and provides explicit statutory authority recognizing how care is delivered today in hospitals and facilities everywhere. As noted in the Sunset Review Report, the ability for APRNs to direct registered nurses is critical from both an operational and an access to care standpoint, and CANNA strongly agrees. Across hospitals, ambulatory surgery centers, rural facilities and community based settings, APRNs serve as clinical leaders, coordinating care, overseeing nursing teams and ensuring appropriate delegation consistent with their education and licensure. Clarifying this authority promotes regulatory certainty, strengthens team based care, and helps preserve timely patient access to services. At a time when California continues to face workforce shortages and increasing demand for care, clear and modern statutory language is essential in maintaining efficiency while upholding patient safety. We respectfully urge your support for the statutory language recommended in the BRN Sunset Review Report as drafted and we look forward to continued collaboration to strengthen California's nursing workforce and to protect the patient's research. Thank you for your time and consideration.

Hello, I am Melanie Rowe. I'm a CRNA Certified Registered Nurse Anesthetist and I serve as a Practice Director for the California association of Nurse Anesthesiology. Along with the support that we have for the APRN to RN regulation, we also support any move that California makes towards a consensus model framework for APRNs to best support professional consistency leading to increased access to care. Canada also appreciates number 24 on your report. Nationally, we have been advocating for the nurse anesthesia profession to be included in the definition of professional degrees. Due to the rigor and intensity of CRNA doctoral programs, they can carry heavy tuition costs. Exclusion from the higher student loan cap will have a devastating impact on the future CRNAs here in California. The ability to afford nurse anesthesia programs and exacerbate access gaps to essential health care for the patients with the greatest needs. Thank you.

a half hour period.

Hello. Good morning, Chairs, Assemblymember Berman and committee members. My name is Diana Hakula and I'm a certified registered nurse anesthesiologist and I'm practicing in Northern California. I'm a professor where I teach doctoral students in nurse anesthesia. I am also a clinician at a Kaiser facility as well as a sole provider in a rural association. So I would like to underscore the critical Importance of issue 10.7 and the clarification it provides regarding APRN to RN delegation in rural critical access hospitals where the nurse anesthesiologist may be the sole anesthesia provider on site. The ability to direct RNs efficiently and clearly delegate responsibilities to RNs is essential to safety, efficiency and keeping surgical services available within that rural community. Without the clarity of care, care would be delayed or services may not be offered at all. Regulatory ambiguity does not protect patients. It can delay care and discourage providers from practicing in rural areas. We heard a lot of you speak about the rural areas within California. For these reasons, I respectfully urge your support of the BRN Sunset Report as written. Thank you for your time and consideration.

Good morning. My name is Allison Bouck and I am a certified registered nurse anesthesiologist, independently practicing in Fresno, California Community Regional Medical Center. I strongly support the California Board of registered nursing's 2026 Sunset Review Report as drafted, and I respectfully urge this committee to adopt this recommendation without amendments. I want to quickly provide an example to highlight this importance which was relevant just yesterday as I served in the operating room as an independent anesthesia provider. After safely getting my patient through surgery, I transported them to the recovery unit. I gave a detailed handoff to the PACU nurse while remaining responsible for anesthesia related orders and oversight with each patient. I direct the recovery nurse to continue specific monitoring parameters, titrate oxygen within defined limits, administer medications as ordered, or notify me if certain clinical thresholds are met. As the patient remains stable, I began preparing for the next surgical case while remaining immediately available and accountable for anesthesia care. That coordination is essential to operating room efficiency, reducing patient wait times, and ensuring that anesthesia professionals can safely care for multiple patients across the perioperative continuum. As the sunset review report notes, the ability for APRNs to direct RNs is critical from both an operational an access to care standpoint. I strongly agree. For these reasons, I respectfully urge your support of the BRN Sunset report as written. Thank you for your time and consideration.

time and have a great day.

Mr. Chair and members, Monica Miller, on behalf of the American association of Nurse Practitioners. And briefly, we want to thank the BRN for their work and their leadership with regard to putting this report forward. We look forward to working with both the BRN as well as Senate and Assembly Business and Professions Committee and your staff, particularly where we align on national standards and best practices. And thanks for your time today.

Good morning, Chair and members. Karen Stout here on behalf of the California Nurse Midwives association, or CNMA. CNMs are advanced practice RNs. I'll be able to just briefly comment on issue 11. CNMA is in support of streamlining nurse midwife license and furnishing renewals into a single application instead of two. Furnishing is a core competency of nurse midwives and a skill set normally expected as a part of that role. Integrating prescriptive authority into the core licensure process is practical, efficient and overdue. I won't belabor the point of issue 13. We'll just say we're in support of the statutory changes to authorize Nurse B advice to delegate to rns as appropriate to the scope of licensure, particularly on issue 24. I just wanted to note that CNMA is very concerned about the federal loan limits that are being imposed by HR1, which are still under final consideration. These will significantly reduce access to federal loans, decrease accessibility of graduate education for advanced practice nurses, including CNMs, by either forcing students to take out more expensive private loans or forgo graduate nursing education altogether. We anticipate increased decreased enrollment from individuals from diverse socioeconomic backgrounds and accelerated shortages, impeding our efforts to build a diverse, well prepared health care workforce for all Californians. We request that the brn, the Legislature and HCA continue to monitor the ongoing threats to the growth of our health care workforce. And we appreciate your time. Thank you.

Good afternoon. I think almost Liz Bambouchet on behalf of California association of Nurse Anesthesiology. Great to see so many of you in person again and just wanted to submit my support to keep the language as drafted without amendment for the BRN sunset. And thank you to our BRN leaders who are making this happen.

Thank you. Sandra Borde, last but not least, certified registered nurse anesthetist. I give anesthesia in Southern California, Kaiser. And I'm one of the program faculty at one of the nurse anesthesia programs in California here. First of all, I just want to really thank Executive Officer Lori Melby and the BRN for creation of the CRNA Advisory Committee. It's been very instrumental and having nurse anesthetist experts who can advise the practice committee on concerns that are brought from the public. So thank you for that. We really appreciate that. And ensuring safe, high quality, accessible anesthesia services throughout California. And similar to my colleagues that were up here, I'd like to again support as written the language in regards to the APRN delegation to rns. Thank you.

We're double dipping.

I'm here now for the American Nurses association of California.

Me too. In terms of the comments, in terms of nursing students, studies show 30 to 40% are leaving within two to three years after getting into the field. But nursing faculty is a huge issue. So many are retiring and we don't have a pipeline behind them.

Thank you.

Thank you. Good morning, Chairs Berman, and Wahab and the distinguished members of the committee. My name is Dr. Karen Brandon and I'm honored to serve as the president of the Physical Therapy Board of California. Thank you for the opportunity to appear today as part of our 2026 Sunset Review oversight Hearing to discuss the Board's work in protecting the people of California. The Physical Therapy Practice act was established in 1953 and today our board is comprised of seven diverse members. Four governor appointed professional members, one governor appointed public member, one senate appointed public member, and one assembly appointed public member. And we currently have two vacancies. Our mission is clear to advance and protect the interests of the people of California through the effective administration of the Physical Therapy Practice Act. Public protection remains our highest priority and guides every licensing, regulatory enforcement and outreach decision we make. The Board currently oversees more than 41,000 active licensees, including physical therapists and physical therapist assistants, representing about 15% growth rate since 2021 when we were last here. We are well above the national average, reflecting continued expansion of the profession statewide. California is home to 19 California. I'm sorry, 19 Capti accredited physical therapy programs and 27 Capti accredited physical therapist assistant programs, all of which have a 90% or higher pass rate for the National Board exam. We are doing our part in supporting a strong and growing workforce pipeline. In addition, the board recognizes 125 continuing competency approval agencies helping to ensure that licensees maintain ongoing professional competence throughout their careers. Over the last year, we have continued to strengthen our core responsibilities, improving licensee efficiency, maintaining rigorous enforcement standards, advancing through thoughtful regulatory updates, and engaging proactively with the stakeholders. We recognize the challenges Californians and licensees face in accessing timely, competent care, and we remain committed to fostering a regulatory environment that balances strong consumer protection with practical workforce realities. We also value the collaboration of licensees, patients, educators, professional associations and public members whose input actually strengthens our deliberations and informs sensible regulation. The Board takes seriously its responsibility to be transparent, accountable and responsive to legislative oversight. We are confident in the progress we have made and remain committed to continuous improvement in the service to the public. With that, I will turn over to our Vice President, Dr. Dale Armstrong on WebEx to share further detail regarding the Board's implementation efforts and stakeholder engagement.

Thank you for that question. As a practicing physical therapist, I do believe that the relationship and creating a safe and professional relationship with the patient goes a long way. Not only do you have to garner trust for the process, some things are uncomfortable, and some things are things that you're doing with a patient that are unfamiliar to the patient. But they have to believe you, not only in your credentials and your expertise, but that you actually care about them. Right. So that relationship also transitions into how effective your practice and your recommendations are going to be with them. Because many of those things have to go on to be lifelong practices that they do to maintain their level of function, to continue to improve physically. So it's both of those things are important. The ability to convey your expertise, but also the awareness that you care about the outcome and you care about them as people.

Yes. So definitely this is very close to home. My father sustained a stroke three years ago, very profound one, affecting multiple functions in my practice and in my education as a physical therapist, noticing maybe even early signs of compromise of blood to the brain. We learn those early like cues. Number two, going into the acute care and making sure that those providers are part of the medical team that helps the patient with early mobility and make sure they have good circulation and also follows the practices that are necessary to keep people safe in the icu. Moving forward to the rehab facilities, many of those therapists, physical therapists and physical therapist assistants are trained in neurological rehabilitation. So it's not just getting somebody up and walking, it's how to engage and facilitate certain parts of the body that are important as the baseline to them being able to recover, whether it's working on trunk motion or working on their breathing or working side by side with occupational or a speech therapist to do collaborative care and definitely making sure that the family is involved. Right. And then of course, there's home health services and outpatient rehab that continues to progress the patient to the fullest extent of their function. So not only have I had the opportunity of working in multiple settings and implementing those for neurological patients, but I've also been on the other side as a family member and seen the benefits. And I'm very thankful for those physical therapists that worked with my family.

Thank you.

Thank you so much. Good morning. My question has to do with AI. I noticed that in my, in some of the reporting and materials that the use of AI is becoming more prevalent in your practice area. I would love to hear a little bit more about that. I always get concerned when we have AI being integrated into our healthcare field. We hear so often from nurses, for example, of technology being wrong and too often overriding the human knowledge and expertise. So I'm just curious, how are you integrating this technology in. Are there particular consumer protections that the board feels is essential for us to consider and particularly around making sure that there's proper enforcement too, when these tools are utilized and, and problems arise.

I also want to say the practice of healthcare in general is seeing a boost in three different areas I would say for AI. The first one obviously generative AI, which is your typical hey, I have something wrong with my shoulder, what are the exercises I should do? And that certainly, as Mr. Kaiser says, the buyer beware. And we definitely want to make sure that consumers are aware. But also practitioners and licensees are not allowing these new innovations to replace the judgment that we as the state of California have put in that license for them to give to an individual. The second one would be predictive AI. So predictive AI is okay, if this person has this problem and this problem, they likely need this thing. And certainly those are still in the works. Regarding research, we utilize a lot of it in statistics when we're doing predictive models for disease, but I don't think we're utilizing it currently with actual care. The final one would be assessment models. So the ability for us to put markers on a patient's body and be able to evaluate their gait and see if they could change something about their running speed or how their utilizing certain muscles. And that really doesn't have a direct correlation yet with practice, but it's definitely another area that physical therapy is active in that the AI wave.

I also wanted to add, if it came to the rulemaking if this actually became part of the practice Act. We have really been engaged with multiple states in how they evaluate competency. I think that's really important. And also, you know what their relationship is with the other stakeholders in that state regarding the use of penetrative procedures.

I wanted to mention too, I think a big part of that change, if it happens in California, really will be reflected in our ability for consumers to access us and to know what to expect when they have physical therapy and what they shouldn't expect. And. And we utilize a lot of online available messaging and also the mandated requirement for all physical therapy practice in designated areas to have our access 1-800-number for complaints or questions or concerns. So I think it's also keeping the consumer aware so that we can maintain that connection and openness to any questions or concerns. Hello? Can you hear me now?

Hello. Would it be all right with you for me to present my introduction?

Thank you so much. Thank you. Dr. Brandon. My name is Dale Armstrong and I am a professional member of the Physical Therapy Board and I currently serve as Vice President. Physical therapists in our communities continue to provide services to our diverse populations to improve their quality of life and to maximize functional ability. The Physical Therapy Board continues to prioritize strategic planning for operations, alignment with its mission to protect the public. During the current sunset period, the Board completed nearly all objectives in its 20182022 strategic plan. Highlights include objective tracking, cross program participation, facilitation of public engagement, strengthening internal processes and adoption of the 20242029 strategic strategic plan. The Board's implementation efforts include staffing enhancements, creating positions to support licensing operations, consumer protection, and a dedicated military liaison to assist applicants and inquiries. Stakeholder engagement includes participation in the Federation of State Boards of Physical Therapy, expansion of digital platforms to keep the public engaged and and in 2023, the board launched a redesigned website focused on improving user experience. In addition, the Board participates in community and educational events along with presentations to PT and PTA degree programs to California schools and universities. Jason Keizer has continued to serve as Executive officer, providing consistent and mission focused leadership. In October 2023, the board enhanced operational alignment resulting in a dedicated executive unit by centralizing functions, responsiveness, stakeholder engagement and governance support are enhanced. And I very much appreciate you allowing me to speak out of order.

Good morning, chairs and members of the board, I mean, of the committee. My name is Karen Atlas and I am a licensed physical therapist and owner of Atlas Rehabilitation for Canines in Santa Barbara where I work together with veterinarians helping animals recover from orthopedic injuries, neurologic disease and surgery. I also serve as the president of the Animal Physical Therapy Coalition, representing veterinarians, physical therapists, veterinary technicians and animal welfare advocates. I am here today because a regulatory gap that has persisted for more than 20 years limits access to care and workforce utilization. I appreciate that. The Sunset review backgrounder identified this issue under issues number seven. Across the country, animal physical therapy is recognized as the practice of physical therapy when performed by licensed PTs with additional education on animals and under veterinary referral consistent with the national standards established by the Federation of State Boards of Physical Therapy. However, our regulatory framework remains out of step with national standards. Licensed pts providing rehabilitation to animals are currently classified as unlicensed veterinary assistants requiring direct veterinary supervision. The PT Board has suggested this issue belongs under the vmb, but that approach has already been tried and failed. Two legislative efforts, AB3013 and AB814 with Assemblymember Lowenthal, attempted to include PTs within the Veterinary Practice Act. Both were opposed by the VMB, leaving the regulatory gap unresolved. In 2022, the VMB removed a veterinarian's ability to determine supervision levels and mandated direct supervision, placing previously lawful collaborative practices out of compliance and raising concerns about anti competitive regulatory effects and reduced access to care. States such as Colorado recognize that pts providing rehabilitation under veterinary medical clearance are practicing PT and remain accountable to their licensing board. No complaints of harm of animal harm have been reported across the country demonstrating its safety.

I respectfully asked the Legislature to establish clear statutory Authority so licensed PTs with advanced animal training can collaborate with veterinarians. If sunset review is not the appropriate vehicle, I ask for your support in separate legislation. Clear rules protect consumers and expand access

Good morning Chair and members, and thank you for the opportunity to speak today. My name is Dr. Jenny Moore. I am speaking on behalf of the Animal Physical Therapy Association's Animal Physical Therapy Special Interest Group for which I'm the Vice President. I also own and operate a custom animal wheelchair company called Doggone Wheels. I'd like to provide a personal perspective related to, I believe issue 7 I've been a licensed PT for 23 years, certified to work with animals for 16 where I focus my practice in the San Francisco Bay Area. I worked in specialty veterinary hospitals in the Bay Area as part of a cohesive team. In 2018 I decided to move to Stateline, Nevada where I was able to open my own practice as I could not do so in California due to current regulatory restrictions. The Nevada model worked beautifully to allow PTs and veterinarians to collaborate and expand access to PT services. I was able to help a wide range of animals including post op patients, canine athletes, neurological and orthopedic patients, and search and rescue dogs. However, I continue to face limitations as vets in South Lake Tahoe cannot directly refer to me as a non veterinary professional without additional expense and time to the client. Upon returning to San Francisco in 2020, I've been unable to fully practice animal PT unless I'm employed directly by a veterinarian. This restriction persists despite my license or training and decades of experience. The wait times about three months. In the Bay Area we are lucky to have many options, but everyone is backlogged with the surplus of clients. The long delay may lead clients to find self service options that provide a generic treatment plan that may not be safe for the patient in question, whether that be from AI, online forums or word of mouth. Chair Berman I actually have the pleasure of collaborating with veterinary colleagues to serve a lot of constituents in your own district, especially along the coast. Clients are desperate for in home services and skilled rehab in general. I have submitted letters to your office alongside some of my clients and those vets to your district to support my statement. Today I look forward to a day when animal PTs are able to serve our clients and patients freely under proper regulation, ideally under the Board of Physical Therapy. We hope to be able to collaborate with the veterinary field to do what we all set out to do, make the lives of the animals we love the best it possibly can be for as long as possible. Thank you.

Thank you. Mr. Chair and members, I'm Christina DeCaro, lobbyist for the California Veterinary Medical Association. I just wanted to indicate CVMA's strong opposition to the concept of opening up the Physical Therapy Practice act or the Chiropractic act, which you'll hear next, to allow physical therapists or chiropractors to work on animals without proper veterinary supervision. Your comprehensive background document notes how current law actually does allow a physical therapist or a chiropractor to work on animals in a safe and controlled environment as long as they are under veterinarian oversight. And that structure has been working very well for many, many years. We see no reason to change it now. So thank you very much.

It.

Nothing to add, just here to answer questions. Thank you.

Hi. Morning. Quick question about the enforcement. Some of the enforcement issues that were raised, I believe it was under issue area 9. Can you talk a little bit about how you look at practitioners who may have had some experience with sexual misconduct? What is your sort of review process? What are the steps that you currently have in terms of issuing a license or not issuing a license? And how are you ensuring that there is consumer protection in regards to those individuals who may have the challenge of getting access to a license outside of sexual misconduct just in for non violent offenses? I'm just curious what your review process looks like and what are the barriers to licensing and then how do you ensure consumer protections when there are more serious offenses involved?

And I would also just add more broadly when we receive. So in general, we find that Business and professions code section 480 and the changes that were made back in 2018 actually work quite well for our board. The majority of our license applicants have no criminal history. And those that do really don't meet that substantial relationship criteria that we apply when we're reviewing their background information. But with that in mind, you know, when you look at our statistics, we tend to deny, you know, one if any license applications every year. But we are seeing a serious gap there when it comes to the professional discipline, if it involves sexual misconduct, because really the focus is on rehabilitation, not necessarily when that conduct occurred. We do have a few examples of individuals that we've denied licensure to because they haven't made a showing of rehabilitation. And we're concerned that down the road, eventually that time will tie the board's hands. If we don't take action, we'll have to grant them a license rather than ensuring that they make that showing and can protect consumers. I appreciate that. I think I'm an advocate for second chance. I'm an advocate for folks who've made, gone through rehabilitation, done their time to be able to access us the career that they want and that they want to pursue and invest in and be able to be a contributor to our society. And at the same time, we have to make sure that folks that are involved in violent crime, particularly sex crimes or sexual misconduct, that we do hold them to a higher standard, particularly when they are in such an intimate field of practice. So I appreciate the thoughtfulness and how you're threading this needle that you are keeping the opportunity open for folks who are returning citizens into our communities, who want to do this craft, but also protecting the consumers at the same time. So I appreciate that answer.

And I would just add at this point we don't have any data that suggests an increase unfortunately in chiropractic licensure. What we've kind of observed is looking at our past decade as far as licensure population, I call it a slow trickle, but we are seeing a net decrease in our overall licensee population. It's not drastic, but that year over year decrease does as you start looking at 5, 10 year periods it is rather significant.

Sure. And we kind of just touched on it right there at the beginning. The problem that we observed is when we looked at our last two fee studies that were done with external consultants, they failed to recognize our core issue, which is we have a decreasing licensee population, while as everyone is aware, the cost of doing everything in California and actually in the country and the world continues to go up every year. So we've got those two trajectories that's driving that need. Also, when looking at the prior fee increase that we did in 2022, we failed to account for the resulting impacts on continuing education course applications that we had received when we adjusted the fees to reflect our cost of providing the service at that time. Now, looking four years later and being before you again asking to have the fee discussion, what we're seeing is that when it comes to the primary driver of our revenue, the DC license renewal fee, we do have statutory authority to adjust that through regulations. But when we look at our overall funding model and we look at the costs that we've associated with, say a continuing education course application fee and the various licensure fees, we need another reset. We need to look at. We're not necessarily looking to increase every single fee. We know that we've realized some efficiencies in our continuing education course application process. So we're actually recommending that we reduce that fee. So we need to take a deeper dive at all of the fees and really make an adjustment. And this time around, what we're going to be doing is submitting a report that's internally authored by the board staff along with the DCA budget office so we can get ourselves back on the right track. But also when we look further into the future, we can account for things like our decreasing licensee population and get us back to like the other boards that are really adjusting fees through regulation. Not making this requirement request before you every four years.

Yes, certainly. And then also when we. When we talk about costs of entering the profession, one other area that the board's acutely aware of and as Dr. Adams touched on, is the cost of chiropractic education. We're very interested in encouraging students to enter into the chiropractic profession, particularly getting into community colleges. But the cost and the price tag along with that and the potential student loan debt coming out of the program remains one of the barriers that. That keeps the board from really engaging in that. So we're really wanting to explore solutions in that area. We are seeing with chiropractic programs. They are beginning to expand. University of Pittsburgh is now the first public university that has a chiropractic program. And our local life Chiropractic College west is actually moving, and they're going to be integrating into the Cal State East Bay campus. So exploring those kind of models and see if there's a future for chiropractic education in public schools.

Good morning, chairs and members, and thank you for the opportunity to speak. My name is Dr. Marissa Palmer. I am a licensed chiropractor in Rancho Cucamonga and an IVCA and AVCA certified animal chiropractor. Speaking on behalf of the California Chiropractic Association, I am here today to address issue number 12 and ask the committee to consider providing clarity in the chiropractic section of the code regarding the practice of animal chiropractic. Currently, the chiropractic statute is silent on this issue. As a result, the only language addressing animal chiropractic appears in the Veterinary Code. A challenge with this structure is that the Veterinary Medical Board does not regulate chiropractors. When another board investigates a chiropractor, enforcement often must proceed through civil or criminal processes involving the courts and the California Attorney General. This process is longer and more complicated, creating uncertainty for practitioners, regulators, and the public. However, when a chiropractic board is investigated by the chiropractic board, the board has direct jurisdiction over its licensee. The board can conduct an administrative investigation using chiropractic experts, making the process faster, more efficient, and more cost effective. Ensuring chiropractors remain regulated by their own licensing board provides clearer oversight and more efficient system for public protection. Establishing clear language in the code improves public safety by allowing the BCE to cite or discipline unlicensed or untrained individuals who advertise themselves as animal chiropractors or providing animal chiropractic services. The BCE already oversees chiropractic education, standards of practice and professional conduct. As noted in the background paper, many states have used this model for more than two decades in which chiropractic boards regulate certified, trained and insured animal chiropractors. We have documentation showing that this model works and is safe. And we have seen that these states that have this model have seen significant growth in their animal chiropractic population. Placing this language in the chiro code keeps chiropractors regulated by the board that already licenses, trains and discipline them. It's a simple statutory fix that strengthens oversight and improves public protection. Thank you for your time and consideration.

Hello.

Sorry, I'm a little nervous.

Well, that's what everybody says, but you never know. My name is Dr. Pamela Riggs. I am a licensed chiropractor and a certified animal chiropractor by the American Veterinary Chiropractic Association. Currently, chiropractic law is silent regarding animal chiropractic. Chiropractors are a separate and distinct profession. That is something that is frequently overlooked when we're considering the fact of what our patient is. The veterinary board is not trained in chiropractic, be it animal or human, unless, of course, they go through a school that is specific for animal chiropractic. Just wanted to make that very, very specific point. Because chiropractors are not regulated by the veterinary board because we are regulated by our chiropractic board. The current structures do not. They create a gap. Here we are simply asking the legislature to clarify that when a licensed chiropractor performs chiropractic care on an animal, that chiropractor remains regulated by the chiropractic board. This does not change what chiropractors do. As I said previously, we are a separate and distinct profession that addresses the body through a chiropractic adjustment. As chiropractors, we are proficient at telling when our patients are a chiropractic case or need to be referred out. It simply ensures that chiropractors are overseen by our own licensing board. Many chiropractors already work collaboratively with veterinarians. Our request is not to eliminate veterinary involvement, but to ensure chiropractors remain regulated by their own licensing board. The Chiropractic board already regulates chiropractors in any capacity. For example, athletes, pediatrics, pregnancy, geriatric neurology. Chiropractors have been working on animals since its inception in the early 1900s. We ask that you please address this regulatory gap so that there is more regulatory clarity and proper oversight for animal chiropractors. Thank you so much for your time.

Good morning. My name is Rachel Knoff. I'm a licensed chiropractor here in California in Sonoma County. I'm also certified by the ivca, the International Veterinary Chiropractic Association. I did additional training in addition to my chiropractic school to work on animals, and I just wanted to express my agreement with the points raised by Dr. Palmer and Dr. Riggs. Thank you for your time. Time.

There we go. Is that better?

Good morning, Chair, Senators and Assembly members, my name is Tanya Fairleigh, and I am the President of the Board of Barbering and Cosmetology. Presenting with me today is our Executive Officer, Christy Underwood. I was appointed by Governor Newsom in April 2021, and then reappointed November 2024 as a licensed cosmetologist, salon owned, and educator. It has been an honor for me to be a part of this board. I understand that you all have received a background paper on our board, so I will not take up the committee's time with a history of the board. I will touch very briefly on a few points that may be of value to this hearing. As you know, the board's mandate is to protect consumers. I would like to just take a minute to talk about consumer harm in the barbering and cosmetology industry. Many people believe that the industry is just cutting or coloring hair, and that these skills can be learned by watching YouTube videos. And that may be somewhat true. But what they do not learn is infection control. And just because someone can provide a good haircut or good balayage color does not mean that they are following health and safety protocols. The Board continues to see a rise in harm by Californians, by individuals who have not received proper training, who are not using clean tools, or worse, crossing into the medical field. Our board sees harm every day in the form of ringworm, scalp burns, facial burns and more, all stemming from individuals who are not following health and safety rules. We also have seen significant changes to skin care services. More and more individuals are receiving services at Salon that should be performed by medical professionals. This includes microneedling, medical grade chemical pills and more. Our board's presence is more important than ever to enforce the laws that we were made to protect consumers. I also want to touch quickly on our board's efforts in diversity, equity and inclusion. With over 600,000 licensees, we want to ensure that all of our licensees are receiving valuable information in their native language. The Board has historically provided examinations in English, Vietnamese, Spanish, and now also provide examinations in Simplified Chinese and Korean. In addition to those languages, the Board provides health and safety regulation in Farsi, Russian and Ukrainian. The Board also has dedicated social media pages specifically to Spanish and Vietnamese speaking communities. One area we are excited to work with your committee on is strengthening the apprenticeship programs for barbering and cosmetology. This program is very near and dear to my heart as I have personally trained many apprentices over the years. However, we do need legislative changes so that we can ensure apprentices are receiving their training while also being paid an hourly rage. Lastly, I would like to just highlight our work on reducing barriers to entry. We work with the California Department of Corrections and Rehabilitation on educating and examining individuals within state facilities. We also played an integral role in establishing the first ever approved cosmetology and barbering school within the Napa State Hospital. And we have barbering schools inside of state correctional facilities. We are thankful for this opportunity to address any of your concerns. And I would also like to extend our gratitude to the staff of both committees for the communication that they provided to our executive officer and our board. With that, we are happy to answer any of your questions.

We've looked at various areas for their Spanish pass rates for many, many years. One of our biggest concerns is the quality of education. So I think in hoping to work with staff of both committees, I think if we really focus. We've looked at everything. We've looked at the curriculum, we've looked at the exam. We've looked at translations. I think we need to look at quality of education. So partnering with your staff, I think we could come up with some ideas of how to address the. That.

So the board has always had a goal of sole oversight of schools that they had many, many years ago. We currently work with the bureau of private post secondary and we do have some overlap with enforcement. So we asked big for sole oversight. But we understand what we're looking at is more authority for schools, not necessarily to contradict what the bureau of private post secondary does. They have student tissue and recovery fund. They have the office, you know, where they handle close schools. They are experts at that. We. But we definitely want to get more into our schools. We're out there doing inspections on health and safety. We could look more into that equality of education so that we could try to get these pass rates up.