SAMANTHA B., et al., Plaintiffs and Appellants, v. AURORA VISTA DEL MAR, LLC et al., Defendants and Appellants.
2d Civ. No. B302321
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA, SECOND APPELLATE DISTRICT, DIVISION SIX
Filed 4/5/22
on rehearing
CERTIFIED FOR PUBLICATION; (Super. Ct. No. 56-2015-00464635-CU-PO-VTA) (Ventura County)
The matter is reversed and remanded for a new trial on the issue of respondeat superior and ratification. In all other respects, the judgment is affirmed.
FACTS
Aurora Vista Del Mar, LLC (Aurora) is a licensed acute psychiatric hospital. Aurora is wholly owned by Signature Healthcare Services, LLC (Signature). Both entities are wholly owned by Doctor Soon Kim, who owns 11 similar hospitals nationwide.
Signature has a management agreement with Aurora. Among other tasks, Signature agreed to provide “[d]aily operational direction and management” and “[c]linical responsibility for all service programs.”
In July 2011, Aurora hired Juan Valencia as a mental health worker. The duties of a mental health worker include seeing that patients do not harm themselves or others, keeping patients in a safe environment, and helping patients with daily living activities. Mental health workers are not licensed.
When Valencia was hired, he was given a form in which he was asked whether he had been arrested for a crime requiring registration as a sex offender. He answered no.
In fact, Valencia had been arrested in 1989 for sexual penetration with a foreign object (
Aurora retained an investigative consumer reporting agency to conduct a background check on Valencia. Such agencies are prohibited from reporting an arrest or conviction that antedates the report by more than seven years. (
Had Aurora hired certified nursing assistants (CNA‘s), instead of unlicensed mental health workers, it would have had notice of any such prior conviction. CNA‘s are fingerprinted and licensed.
Training
To be a mental health worker, no license, experience, education, or training is required. As one former Aurora
The orientation included three to five minutes on countertransference, that is, the tendency of a caregiver to form an emotional bond with a patient. Thereafter, all Valencia needed to do was sign a form on patient and staff interactions and relationships once a year. Staff were not tested to see if they understood patient boundaries.
Plaintiffs’ expert testified, “If you read the depositions of multiple staff at the facility, nursing staff, nursing assistants or they call them ‘psyche techs’ at that facility, it was very clear that they had no idea what transference or countertransference even meant.”
Policy on Access to Patients
It is Aurora‘s policy to allow male mental health workers to be alone with female patients in their rooms for up to 20 minutes as long as the door to the room is open.
Jamie Tallman, an Aurora psychiatric nurse, testified that the charge nurse for the unit spends most of the time at the nursing station. The nurse cannot see into the patients’ rooms from the nursing station. One must go into the room to see what is happening there. Walking up and down the hallway is not enough. The charge nurse relies on the mental health workers for information on the patients.
Valencia Sexually Violates Plaintiffs
Plaintiffs were patients at Aurora in 2013 during the time Valencia worked there. Each was suffering from psychosis and did not have the mental capacity to consent to sex. Valencia
Valencia became known among hospital workers as “Rapey Juan.” A worker reported the nickname to the supervising nurse. The nurse‘s response was to roll her eyes and say something like “What are you going to do?”
Bravo Incident
In 2004, an Aurora male employee named Bravo sexually molested a 17-year-old female patient. Theresa Berkin, who was at that time Aurora‘s director of clinical services, recommended to Aurora‘s CEO that the hospital increase education to improve therapeutic boundaries. The CEO said that corporate, meaning Signature, would not pay for it. Berkin testified there were other incidents while she was at Aurora in which a staff member interreacted sexually with a patient.
Patient Vulnerability
Patients in an acute psychiatric hospital are vulnerable. Their mental disorders may impair their judgment. Some suffer from cognitive impairments similar to dementia. Some patients receive medications that render them temporarily unconscious. Plaintiffs’ expert testified that sexual assaults of mental patients are a known foreseeable risk.
Understaffing
Mark Martinez was a mental health worker at Aurora from 2011 to 2014. He testified that each patient was rated for “acuity” between one and four, with four being the most acute. The entire unit was rated for acuity based on an aggregation of scores of the individual patients. A formula would be applied to the unit‘s acuity rating to determine the appropriate staffing level. Martinez testified the unit was consistently understaffed.
Psychiatric nurse Tallman worked at Aurora from 2010 to 2014. She testified the hospital was frequently understaffed. She complained to the director and assistant director of nursing.
Judy Pittacora, a licensed psychiatric technician, worked at Aurora from 2003 to 2014. She testified the units were more often than not understaffed. She said her supervisors would cross out the acuity number she assigned to a patient and lower it to lower the number of staff needed. Understaffing had an impact on her ability to supervise mental health workers. The workers were often on their own with patients. She complained about understaffing to her supervisors but was told that is how the hospital CEO wanted it. She quit because of understaffing. She was afraid she was going to lose her license.
Failure to Report
Danielle W. was discharged from Aurora on November 29, 2013. The next day a student nurse saw Valencia and the plaintiff together at a party. They appeared to be romantically involved. Aurora suspended Valencia and, after a two-day investigation, terminated him on December 12, 2013.
Aurora‘s CEO testified that Valencia was terminated only for being with a former patient at a party. The CEO did not suspect there had been any wrongdoing while the patient was hospitalized, even though the patient had been discharged only the day before the party. She did not interview Valencia, the hospital staff, or the former patient to see if any wrongdoing occurred while the former patient was hospitalized. She did not know whether anyone did.
Procedure
Samantha B. was discharged from Aurora on March 6, 2013. She filed the instant action against Aurora and Valencia in February 2015, within two years of her discharge. In June 2015, she added Signature to her complaint. She alleged sexual assault; intentional infliction of emotional distress; and violation of
Verdict and Judgment
The jury found that Aurora and Signature were negligent in hiring, supervising, and retaining Valencia. The jury also found that Signature and Valencia committed acts constituting dependent adult abuse and that they acted with recklessness. The jury found that Signature acted with malice or oppression, but that Aurora did not.
The jury awarded Samantha B. $3.75 million; and Danielle W. $3 million, all in noneconomic damages. The jury allocated 30 percent fault to Signature, 35 percent fault to
DISCUSSION
Aurora and Signature‘s Appeal
I
MICRA‘s Limitation of Actions
Aurora and Signature contend Plaintiffs’ causes of action are time-barred and their damages limited under MICRA.
MICRA is a legislative scheme that is intended to reduce the cost of medical malpractice insurance by, among other matters, limiting the time for plaintiffs to bring their causes of action for professional negligence and limiting the amount of recovery for noneconomic damages. (Western Steamship Lines, Inc. v. San Pedro Peninsula Hospital (1994) 8 Cal.4th 100, 111.)
A “health care provider” is any person licensed to provide health care services including a health facility. (
Plaintiffs appear not to contest that if MICRA applies, their action is barred by the time limitations in
Elder Abuse Act
Unlike MICRA, which is designed to discourage medical malpractice suits, the Elder Abuse Act enables “interested persons to engage attorneys to take up the cause of abused elderly persons and dependent adults.” (
Section 15657, subdivision (a) provides, in part: “Where it is proven by clear and convincing evidence that a defendant is liable for . . . neglect as defined in Section 15610.57, or abandonment as defined in Section 15610.05, and that the defendant has been guilty of recklessness, oppression, fraud, or malice in the commission of this abuse, the following shall apply, in addition to all other remedies otherwise provided by law: [¶] (a) The court shall award to the plaintiff reasonable attorney‘s fees and costs. . . .”
The Legislature has made it clear that professional negligence and the Elder Abuse Act are separate and distinct. Section 15657.2 provides: “Notwithstanding this article, any cause of action for injury or damage against a health care provider, as defined in Section 340.5 of the Code of Civil Procedure, based on the health care provider‘s alleged
In Delaney v. Baker (1999) 20 Cal.4th 32, our Supreme Court discussed the relationship between section 15657, establishing a cause of action for elder abuse, and section 15657.2, exempting causes of action for professional negligence from causes of action under section 15657. There plaintiffs 88-year-old mother died in a nursing home due to neglect. Plaintiff sued the nursing home and its administrators alleging negligence and elder abuse. The jury found for plaintiff on both causes of action. In the elder abuse cause of action, the jury found the defendants were reckless. The jury awarded damages and the court awarded attorney fees under the Elder Abuse Act. (
In upholding the award under the Elder Abuse Act, the court rejected the defendant‘s argument that ” ‘based on . . . professional negligence,’ used in section 15657.2, applies to any actions directly related to the professional services provided by a health care provider.” (Delaney v. Baker, supra, 20 Cal.4th at p. 35.) Instead, the court distinguished between professional negligence and reckless neglect. The court stated:
“In order to obtain the remedies available in section 15657, a plaintiff must demonstrate by clear and convincing evidence that defendant is guilty of something more than negligence; he or she must show reckless, oppressive, fraudulent, or malicious conduct. The latter three categories involve ‘intentional,’ ‘willful,’ or ‘conscious’ wrongdoing of a ‘despicable’ or ‘injurious’ nature. [Citations.]
” ‘Recklessness’ refers to a subjective state of culpability greater than simple negligence, which has been described as a ‘deliberate disregard’ of the ‘high degree of probability’ that an injury will occur (BAJI No. 12.77 [defining ‘recklessness’ in the context of intentional infliction of emotional distress action]); see also Rest.2d Torts, § 500.) Recklessness, unlike negligence, involves more than ‘inadvertence, incompetence, unskillfulness, or a failure to take precautions’ but rather rises to the level of a ‘conscious choice of a course of action . . . with knowledge of the serious danger to others involved in it.’ ” (Delaney v. Baker, supra, 20 Cal.4th at pp. 31-32, quoting Rest.2d Torts, § 500, com. (g), p. 590.)
The court concluded that because the jury found reckless neglect, and not merely professional negligence, plaintiff was not bound by the laws applicable to professional negligence but could avail herself of the enhanced remedies of section 15657 of the Elder Abuse Act. (Delaney v. Baker, supra, 20 Cal.4th at p. 35; see also Covenant Care, Inc. v. Superior Court (2004) 32 Cal.4th 771 [
Here, as in Delaney, the jury found both professional negligence and reckless neglect. Under Delaney, Plaintiffs are not bound by the laws specifically applicable to professional negligence. That includes MICRA and the one-year limitation of actions contained therein. Although Plaintiffs’ cause of action based on professional negligence may be barred by the statute of limitations, their cause of action for elder abuse is not.
Substantial Evidence of Elder Abuse
Aurora and Signature contend that as a matter of law Plaintiffs have failed to establish a right of recovery for elder abuse.
Aurora and Signature‘s contention amounts to nothing more than that the judgment is not supported by substantial evidence. They hope to prevail by presenting a view of the evidence in a light most favorable to themselves. But that is not how we view the evidence.
Because Plaintiffs must prove elder abuse by clear and convincing evidence, the standard is “whether the record, viewed as a whole, contains substantial evidence from which a reasonable trier of fact could have made the finding of high probability demanded by this standard of proof.” (Conservatorship of O.B. (2020) 9 Cal.5th 989, 1005.) We must affirm if any reasonable trier of fact could have made the required findings. (Ibid.) The standard necessarily requires that we give appropriate deference to a view of the evidence most favorable to the judgment and not view the evidence in a light most favorable to the losing party, as Aurora and Signature seem to suggest.
(a) Neglect
Aurora and Signature contend that as a matter of law there is no evidence of neglect. Section 15610.57, subdivision (b)(3) defines “neglect” as including “[f]ailure to protect from health and safety hazards.”
It is beyond dispute that Valencia was a hazard to the health and safety of female patients under Aurora and
Aurora and Signature cite Carter v. Prime Healthcare Paradise Valley LLC (2011) 198 Cal.App.4th 396, 406-407, for the proposition that neglect occurs only where the defendant “denied or withheld goods or services necessary to meet the elder or dependent adult‘s basic needs.” But to the extent Carter can be read as holding that neglect does not include the failure to protect from health and safety hazards, we decline to follow it as directly conflicting with section 15610.57, subdivision (b)(3).
The only question here is whether clear and convincing evidence shows Aurora and Signature were reckless in their failure to protect.
(b) Reckless
“Recklessness” means the deliberate disregard of the high degree of probability that an injury will occur. (Delaney v. Baker, supra, 20 Cal.4th at p. 31.) It rises to the level of a conscious choice of a course of action with knowledge of the serious danger to others. (Id., at pp. 31-32.)
Aurora and Signature were well aware that their female patients were particularly vulnerable to sexual predation by male mental health workers. If they did not know before the Bravo incident, they certainly knew thereafter. Aurora and Signature are sophisticated parties. They are part of an organization that operates 11 psychiatric hospitals nationwide. It is reasonable to conclude that they know how to operate in a manner that protects their patients from sexual predation. Yet Aurora and Signature adopted policies that exposed their patients to a high degree of risk of sexual predation.
Valencia‘s training was minimal, consisting of a three- to five-minute talk and two days of following another worker around. Aurora employees did not know what countertransference is. Valencia was never tested to see if he knew what it was. After the Bravo incident, Aurora‘s director of clinical services recommended that the hospital increase education to improve therapeutic boundaries. Aurora‘s CEO told her that Signature would not pay for it.
Hospital policy allowed a male worker up to 20 minutes alone with a female patient in her room. The charge nurse cannot see inside the rooms from her station. One must enter into the room to see what is happening inside. Even walking down the hallway is not sufficient. The hospital is consistently understaffed. Supervisors change patients’ acuity ratings to justify understaffing. A reasonable conclusion is that understaffing prevents workers from noticing what other workers are doing. The situation is perfect for a sexual predator. That male workers were allowed 20 minutes alone with a vulnerable female psychiatric patient in a room secluded from view would by itself support a finding of recklessness.
This is not a case of a momentary failure in an otherwise sufficient system. Valencia was allowed to prey upon three different women. It is reasonable to conclude that had Valencia not been improvident enough to be seen at a private party with a
The flaws in Aurora and Signature‘s policies were so obvious that the jury could conclude that they intentionally turned a blind eye to the high probability of harm. Even when Aurora was informed that Valencia was known as “Rapey Juan,” the reaction was a shrug. There is more than ample evidence to support a finding of recklessness under the clear and convincing standard.
III
Instructions
Aurora and Signature challenge several jury instructions.
(a) Duty to Investigate
Regarding Valencia‘s prior arrest and conviction, the trial court instructed the jury:
”
Penal Code section 290 is the Sex Offender Registration Act, which includes a list of sex crimes for which registration as a sex offender is required.“Those crimes include
Penal Code section 289(a) sexual penetration with another person who is under 18 years of age.“An investigative consumer reporting agency may not make or furnish any investigative consumer report containing records of arrest or conviction of a crime that are more than seven years old. . . .
“An employer that does not use the services of an investigative consumer reporting agency is not limited by how far back they may go in collecting an applicant‘s criminal history.
“Every person in this state, including limited liability companies, has a fundamental and necessary right to access
public records. Public records include county courthouse criminal history records. “The Department of Justice maintains criminal history information. State summary criminal history information means the master record of information compiled by the Attorney General pertaining to criminal history of a person, such as dates of arrest.”
Aurora and Signature contend that they had no right, and therefore no duty, to search for criminal records more than seven years old.
Aurora and Signature rely on the Investigative Consumer Reporting Agencies Act. (
In fact,
Nor were Aurora and Signature confined to using investigative consumer reporting agencies. Every person has the right to inspect any public record. (
Aurora and Signature argue that
Aurora and Signature argue that the instructions run counter to former California Code of Regulations, title 2, section
First, the regulation is expressly subject to
Second, Valencia‘s conviction was not sealed, expunged, or statutorily eradicated. It was reduced to a misdemeanor pursuant to
The trial court‘s instructions were accurate.
(b) Staffing Ratios
Aurora and Signature contend the trial court erred in instructing with a staffing regulation.
The trial court instructed: “The licensed nurse-to-patient ratio in a psychiatric unit shall be 1 to 6 or fewer at all times. For purposes of psychiatric units only, licensed nurse[s] also include psychiatric technicians in addition to licensed vocational nurses and registered nurses.”
The instruction is taken verbatim from California Code of Regulations, title 22, section 70217, subdivision (a)(13). Aurora‘s own expert testified that title 22 regulations apply to Aurora.
But section 70217 of the California Code of Regulations applies by its terms to all hospitals. It makes no distinction between psychiatric units in free-standing psychiatric hospitals and psychiatric units in other types of hospitals. By the plain terms of the regulation, it applies to Aurora. No expert testimony is required to support it.
(c) Refused Remedial Instruction
Aurora and Signature contend the trial court erred in refusing the following proposed instructions: “When considering the question of negligence, you must not consider whether or not Aurora Vista Del Mar or Signature Health made any reports of the events involving Juan Valencia to the Joint Commission (JCAHO), California Department of Public Health (CDPH) or any other law enforcement or licensing agency.”
But the obvious purpose of regulations requiring such reports is to protect patient safety. Aurora‘s failure to make a timely report is simply evidence of a lack of concern for patient safety. It is relevant to show neglect, that is, the failure to protect patients from health and safety hazards. The trial court did not err in refusing the proposed instruction.
IV
Excessive Damages
Aurora and Signature contend the damages are excessive. Aurora and Signature argue that all the compensatory damages awarded to Plaintiffs are noneconomic damages. Aurora and Signature rely on section 15657, subdivision (b) for
Section 15657, subdivision (b) provides: “The limitations imposed by
V
Fault Allocation
Aurora and Signature contend that they are entitled to a new trial because there is no substantial evidence to support the fault allocation.
We review an apportionment of fault for substantial evidence. (Scott v. County of Los Angeles (1994) 27 Cal.App.4th 125, 147.) Aurora and Signature argue that there is no basis in the evidence for allocating only 35 percent fault to Valencia, the person who played the most direct and active role in the injury. Aurora and Signature cite Scott for the proposition that an apportionment of fault is not supportable when it overlooks or minimizes the fault of the party who plays the most direct and culpable role in the injury. (Citing id., at p. 148.)
But that is not what Scott says. In Scott, the county‘s department of children‘s services placed a child in the home of her grandmother. The grandmother intentionally scalded the child, causing severe injuries. A jury awarded substantial damages to the child, finding the grandmother 1 percent at fault and the county 99 percent at fault.
Although Scott concluded that placing only 1 percent of the fault on the grandmother was unsupported, the court had no problem with placing the great majority of the fault on the county
Here Aurora and Signature are sophisticated parties who should know how to operate a psychiatric hospital to assure the safety of their patients. Instead, they operated the hospital recklessly and maliciously to make what happened almost inevitable. First, it was Bravo; then it was Valencia. If the perpetrator had not been Valencia, it would have been someone else. The jury correctly attributed 70 percent of the fault to Aurora and Signature.
VI
Punitive Damages
Signature contends the punitive damages award must be struck because there is no clear and convincing evidence of malice or oppression.
Exemplary damages may be awarded where the plaintiff proves by clear and convincing evidence that the defendant has been guilty of oppression, fraud, or malice. (
Signature relies on
Here there is clear and convincing evidence that Signature was personally guilty of oppression and malice. Under Signature‘s management agreement with Aurora, Signature agreed to provide “[d]aily operational direction and management” and “[c]linical responsibility for all service programs.” The jury could reasonably conclude that it was Signature that set the policies that made sexual predation of patients almost inevitable, and that in setting those policies, it acted willfully and with a conscious disregard for the safety of others.
Indeed, a single incident illustrates both Signature‘s control and its willful and conscious disregard for the safety of others. After the Bravo incident, Aurora‘s then director of clinical services recommended increased education of employees on
Moreover, Doctor Kim owns both Signature and Aurora. The jury could reasonably conclude that the owner was well aware of the policies that resulted in harm to Plaintiffs.
VII
Motion for Nonsuit
The trial court granted Aurora‘s motion for nonsuit on Plaintiffs’ causes of action alleging vicarious liability under the doctrine of respondeat superior and ratification.5
A trial court properly grants a motion for nonsuit only if the evidence presented by the plaintiff would not support a verdict in the plaintiffs favor. (Carson v. Facilities Development Co. (1984) 36 Cal.3d 830, 838.) The trial court may not weigh the evidence, but must accept as true the evidence most favorable to the plaintiff and disregard conflicting evidence. (Ibid.)
(a) Respondeat Superior
Under the rule of respondeat superior, an employer is vicariously liable for the torts of its employees committed within the scope of employment. (John R. v. Oakland Unified School Dist. (1989) 48 Cal.3d 438
Courts have generally held that an employer is not liable under the doctrine of respondeat superior for sexual assaults committed by an employee. (3 Witkin Summary of Cal. Law (11th ed. 2017) Agency and Employment, § 201, p. 263; but see Mary M. v. City of Los Angeles (1991) 54 Cal.3d 202, 217 [city liable for assault by a police officer in view of the considerable power and authority a police officer possesses].) But a sexual tort will be considered to be within the scope of employment if “its motivating emotions were fairly attributable to work-related events or conditions.” (Lisa M. v. Henry Mayo Newhall Memorial Hospital, supra, 12 Cal.4th at p. 301.)
Thus, in Lisa M. v. Henry Mayo Newhall Memorial Hospital, supra, 12 Cal.4th 291, the court held that a hospital is not liable for a sexual assault committed by a technician under the pretense of conducting an ultrasound examination. The motivating emotions were not fairly attributable to work-related conditions. (Id. at p. 301.)
But this case is not like Lisa M. In that case the employee‘s interaction with the victim was brief and the employee‘s duties were technical. The circumstances of
In contrast, here there is sufficient evidence for a jury to conclude Valencia was acting within the scope of his employment. The duties of a mental health worker include helping patients with daily living activities. The workers are personally involved with the patients over an extended period of time. The patients are vulnerable; they may suffer from impaired judgment or other cognitive impairments. Sexual exploitation of the patients by employees is a foreseeable hazard arising from the circumstances of the job. That hazard was exponentially increased by Aurora‘s policies, including allowing male workers 20 minutes alone with patients and providing inadequate training on worker-patient boundaries.
In concluding that the ultrasound technician in Lisa M. was not acting within the scope of his employment, the court stated, “We deal here not with a physician or therapist who becomes sexually involved with a patient as a result of mishandling the feelings predictably created by the therapeutic relationship.” (Lisa M. v. Henry Mayo Newhall Memorial Hospital, supra, 12 Cal.4th at p. 303.) Quite the contrary. That is what is happening here. Ample evidence supports a finding that Valencia was acting within the scope of his employment. The trial court erred in granting a judgment of nonsuit on the question.
The remedy requires that we reverse and remand for a new trial on the cause of action for which the trial court granted nonsuit. (See McNall v. Summers (1994) 25 Cal.App.4th 1300, 1315.) Plaintiffs request, however, that we simply amend the judgment to include a finding of respondeat superior. Plaintiffs
(b) Ratification
As an alternative to respondeat superior, an employee may be liable for an employee‘s act where the employer subsequently ratifies the originally unauthorized tort. (C.R. v. Tenent Healthcare Corp. (2009) 169 Cal.App.4th 1094, 1110.) The failure to investigate or respond to charges that an employee has committed an intentional tort or the failure to discharge the employee may be evidence of ratification. (Ibid.) Generally, ratification is a question of fact. (Ibid.)
Here an Aurora employee informed a supervisor that Valencia‘s reputation among other employees was so bad he had earned the nickname “Rapey Juan.” Aurora failed to undertake any investigation. Instead, Aurora continued to allow Valencia up to 20 minutes alone with vulnerable female patients in rooms that could not be observed from outside of the room. It is true that Aurora terminated Valencia soon after it learned that he was at a party with a recently discharged patient. But a jury could reasonably determine that Aurora should have acted to investigate sooner, when it first learned of Valencia‘s reputation as “Rapey Juan.” An employer is not relieved of liability for ratification simply because it eventually terminates the employee.
There is substantial evidence from which a jury could have determined that Aurora ratified Valencia‘s acts.
Punitive Damages and Civil Code Section 1431.2
For the first time in a petition for rehearing, Plaintiffs contend the award of punitive damages allows them to escape the limitation on joint and several liability in
DISPOSITION
The matter is reversed and remanded for a new trial on the issue of respondeat superior and ratification. In all other respects, the judgment is affirmed. Costs on appeal are awarded to Plaintiffs.
CERTIFIED FOR PUBLICATION.
GILBERT, P. J.
We concur:
YEGAN, J.
PERREN, J.
Superior Court County of Ventura
Law Office of David Feldman and David Feldman for Plaintiffs and Appellants.
Horvitz & Levy, Andrea M. Gauthier, Bradley S. Pauley; Kendall Brill & Kelly, Nicholas F. Daum; Beach Law Group, Thomas E. Beach, Mindee J. Stekkinger and Molly M. Loy for Defendants and Appellants.
Cole Pedroza, Curtis A. Cole and Cassidy C. Davenport for California Medical Association, California Dental Association, and California Hospital Association as Amici Curiae on behalf of Defendants and Appellants.