SISKIYOU HOSPITAL, INC., Plaintiff and Appellant, v. COUNTY OF SISKIYOU et al., Defendants and Respondents.
C097671, C098311 (Super. Ct. No. SCCV-CVPT-2019-1501)
IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA THIRD APPELLATE DISTRICT (Siskiyou)
Filed 2/25/25
CERTIFIED FOR PUBLICATION
Athene Law, Long X. Do and Felicia Y. Sze for Plaintiff and Appellant.
Jacquelyn J. Garman for California Hospital Association as Amicus Curiae on behalf of Plaintiff and Appellant.
Olson Remcho, Ariya Haghighat, Robin B. Johansen, and Margaret R. Prinzing for Defendants and Respondents County of Siskiyou and Sara Collard.
Jennifer Bacon Henning for California State Association of Counties as Amicus Curiae on behalf of Defendants and Respondents County of Siskiyou and Sara Collard.
Rob Bonta, Attorney General, Cheryl L. Feiner, Senior Assistant Attorney General, Gregory D. Brown, Supervising Deputy Attorney General, and Ricardo Enriquez, Deputy Attorney General for Defendants and Respondents California
This case involves a dispute between a hospital and a local government over how persons who present with symptoms of a psychiatric emergency medical condition are evaluated and treated in Siskiyou County. In 1967, the Legislature enacted the Lanterman-Petris-Short Act (
In this consolidated appeal, plaintiff Siskiyou Hospital, Inc., dba Fairchild Medical Center (Fairchild), challenges the order denying its motion for a preliminary injunction,
which sought an order prohibiting defendants County of Siskiyou and Sarah Collard, in her official capacity as director of the County‘s Health and Human Services Agency (collectively, the County), from taking any person to Fairchild‘s emergency department or “requesting and forcing” Fairchild‘s emergency department to “keep” the person pursuant to the LPS Act, when that person does not have a medical emergency condition having a ”physical, organic cause.” (Italics added.) In other words, Fairchild sought an order preventing the County from bringing any 5150 patient to its emergency department and requiring that person to be held there for up to 72 hours when they do not need physical emergency care but rather evaluation and treatment as a result of a mental health disorder. Fairchild also challenges the judgment of dismissal entered after the trial court sustained two separate demurrers to the operative complaint without leave to amend, which were filed by the County and defendants California Department of Health Care Services (DHCS) and Michelle Baass, in her official capacity as the director of the DHCS (collectively, the Department).
As will appear, at the center of the parties’ dispute is whether Fairchild is an appropriate facility to evaluate and treat 5150 patients in Siskiyou County. The parties
disagree as to whether Fairchild is a “designated facility” within the meaning of the LPS Act, such that Fairchild is the proper facility for the County to bring persons presenting with symptoms of a psychiatric emergency medical condition for a 5150 hold. Fairchild contends that because it is not licensed to provide acute-level psychiatric care, the County cannot lawfully bring persons to its emergency department who are suffering from a psychiatric emergency medical condition and insist that such patients be held there for up to 72 hours without receiving any SMHS for their condition.
For the reasons that follow, we affirm the judgment of dismissal entered after the trial court sustained the demurrers to the operative complaint without leave to amend, and dismiss as moot Fairchild‘s appeal from the order denying its motion for a preliminary injunction.
BACKGROUND
This lawsuit implicates federal and state laws (as well as their implementing regulations) concerning how California provides health care to low-income persons, including those persons who present with symptoms of a psychiatric emergency medical condition. Accordingly, to provide important context, we briefly summarize the underlying law before detailing the pertinent facts and procedure.
Medicaid
Medicaid is a joint federal and state program designed to aid states in providing health care to low-income persons. (Family Health Centers of San Diego v. State Dept. of Health Care Services (2023) 15 Cal.5th 1, 5 (Family Health); see National Federation of Independent Business v. Sebelius (2012) 567 U.S. 519, 541-542, 575 [describing the program].) In return for federal funding, participating states, including California, agree to reimburse health care providers for the costs of delivering care to enrolled program beneficiaries. (Family Health, at p. 5.) California participates in Medicaid through the program known as Medi-Cal. (Id.; see Allied Anesthesia Medical Group, Inc. v.
Inland Empire Health Plan (2022) 80 Cal.App.5th 794, 802-804 [describing Medicaid and Medi-Cal law].)
“To qualify for federal funds, participating states submit a ‘state plan’ to the federal government. [Citation.] ‘The State plan is a comprehensive written statement submitted by the [state] agency describing the nature and scope of its Medicaid program and giving assurance that it will be administered in conformity’ with federal law.” (Santa Rosa Memorial Hospital, Inc. v. Kent (2018) 25 Cal.App.5th 811, 815.) “California‘s Medi-Cal program implements the federal Medicaid Act. [Citations.] The [DHCS] is [the state agency] charged with administering Medi-Cal in accordance with the state plan, applicable Welfare and Institutions Code provisions, and Medi-Cal regulations.” (Id. at pp. 815-816.)
“Medi-Cal is intended to provide, to the extent practicable, medically necessary care to California residents ‘who lack sufficient annual income to meet the costs of health care, and whose other assets are so limited that their application toward the costs of such care would jeopardize the person or family‘s future minimum self-maintenance and security.’ [Citation.] Under Medi-Cal, beneficiaries may receive a broad range of services, including physician and hospital services, optometry, mental health care, and prescription medications.” (Marquez v. State Dept. of Health Care Services (2015) 240 Cal.App.4th 87, 94 (Marquez).)
“The Medi-Cal program does not directly provide services; instead, it reimburses participating health care plans and providers for covered services provided to Medi-Cal beneficiaries. [Citation.] Medi-Cal accomplishes this on a fee-for-service basis or a managed care basis.” (Marquez, supra, 240 Cal.App.4th at p. 94.)
Under the managed care system, the DHCS contracts with managed care plans to “provide health coverage to Medi-Cal beneficiaries, and the plans are paid a predetermined amount for each beneficiary per month, whether or not the beneficiary actually receives services. [Citations.] The beneficiary then obtains medical services
from a provider within the managed care plan‘s network.” (Marquez, supra, 240 Cal.App.4th at p. 94.) By contrast, under the fee-for-service system, “health care practitioners are reimbursed for each
Emergency Medical Care for Low-Income and Uninsured Persons
The Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) (
Under EMTALA and related California law, a hospital with an emergency department must, without regard to insurance or ability to pay, provide “an appropriate medical screening examination within the capability of the hospital‘s emergency department” to any individual who comes to the department and requests examination or treatment for a medical condition. If the hospital detects an “emergency medical condition,” it must provide such treatment as may be required to “stabilize” the condition
or transfer the individual to another medical facility. (Barris v. County of Los Angeles, supra, 20 Cal.4th at p. 109; see
EMTALA defines the term “emergency medical condition” to mean, in pertinent part, “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in-- [¶] (i) placing the health of the individual . . . in serious jeopardy, [¶] (ii) serious impairment to bodily functions, or [¶] (iii) serious dysfunction of any bodily organ or part.” (
Likewise, under California law, an emergency medical condition includes a psychiatric medical condition. (See
LPS Act
As previously indicated, the LPS Act governs the involuntary confinement of mentally disordered persons in California. ( Conservatorship of Eric B., supra, 12 Cal.5th at p. 1095.) One of the purposes of the Act is to provide “prompt evaluation and treatment of persons with mental health disorders or impaired by chronic alcoholism.” (
most acute form can pose a danger to the individuals themselves or others that requires immediate attention. To achieve this purpose, a number of [the] Act[‘s] provisions allow a person to be removed from the general population in order to be civilly committed based on a probable cause determination made by a mental health or law enforcement professional, and then to challenge the civil commitment within a reasonable time afterwards.” (Cooley v. Superior Court (2002) 29 Cal.4th 228, 253-254.)
Section 5150 of the LPS Act authorizes the involuntary confinement of persons suffering from a mental health disorder. In full, the statute provides: “When a person, as a result of a mental health disorder, is a danger to others, or to themselves, or gravely disabled, a peace officer, professional person in charge of a facility designated by the county for evaluation and treatment, member of the attending staff, as defined by regulation, of a facility designated by the county for evaluation and treatment, designated members of a mobile crisis team, or professional person designated by the county5 may, upon probable cause, take, or cause to be taken, the person into custody for a period of up to 72 hours for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment in a facility designated by the county for evaluation and treatment and approved by the State Department of Health Care Services. The 72-hour period begins at the time when the person is first detained. At a minimum, assessment, as defined in Section 5150.4, and evaluation, as defined in subdivision (a) of Section 5008, shall be conducted and provided on an ongoing basis. Crisis intervention, as defined in
subdivision (e) of Section 5008, may be provided concurrently with assessment, evaluation, or any other service.” (
At the
Factual Background8
Fairchild is a nonprofit public benefit corporation licensed by the California Department of Public Health to operate a 25-bed general acute care hospital in Yreka. It is one of two hospitals in rural Siskiyou County with the capability of providing the
medical clearance necessary for 5150 patients to be transferred to a psychiatric facility, with the other hospital located approximately 37 miles away. Fairchild is open 24 hours a day, seven days a week. Although Fairchild has an emergency department that provides emergency medical services to the public, it does not provide any acute-level psychiatric care or other mental health care services. Nor does the other hospital in Siskiyou County.
The County--through its law enforcement agencies, county jail staff, or Behavioral Health Division‘s Psychiatric Emergency Team (PET)--regularly brings persons (approximately 200-300 per year) to Fairchild‘s emergency department, the vast majority of whom are indigent Medi-Cal beneficiaries. These persons (i.e., 5150 patients or 5150 detainees) present with acute abnormal behavior and require evaluation and possible medical treatment. Some of the 5150 detainees are placed on a 5150 hold prior to arriving at Fairchild‘s emergency department, while others have a 5150 hold placed on them after they have been screened and medically cleared by Fairchild‘s emergency department.
As noted ante, under the federally funded Medicaid health care program, California receives funds to pay for the costs of medical services provided to low-income individuals and/or enrollees in its Medicaid program--Medi-Cal,
When a 5150 patient is brought to Fairchild‘s emergency department, they are triaged by the nursing staff and given a full medical examination by a physician,
including lab work. The treating physician relies on the lab work and a medical examination to determine whether there is any organic, physical (as opposed to mental health) basis for the acute abnormal behavior exhibited by the patient. When the treating physician determines that a 5150 patient‘s abnormal behavior is not rooted in an organic, physical cause, the physician can “medically clear” the patient for transfer to an appropriate facility. Inpatient psychiatric facilities, to which a significant portion of Fairchild‘s 5150 patients are eventually transferred, will not accept a 5150 patient until they have been medically cleared.
After a 5150 patient has been medically cleared (which includes stabilizing any emergency medical condition), Fairchild notifies the County and requests that the patient be immediately transferred to an appropriate facility to receive SMHS. In response, the County‘s PET sends a crisis worker or behavioral health specialist to Fairchild‘s emergency department to evaluate the patient and review lab results. This person, under the supervision of a licensed clinical supervisor, provides treatment to the 5150 patient as necessary during the evaluation process (including crisis intervention services), and then decides whether to impose a 5150 hold or to maintain a previously placed hold. If the crisis worker or behavioral health specialist decides to place or maintain a 5150 hold, they instruct the emergency department to maintain the 5150 patient until the PET can arrange for a transfer of the patient to another facility for mental health care services (e.g., an inpatient psychiatric facility).
During the waiting period, the PET requires Fairchild‘s emergency department to feed the 5150 patient, keep them medically stable, and provide security or monitoring to ensure they do not hurt themselves or others. While some medically cleared 5150 patients have been held in Fairchild‘s emergency department for several weeks while they await transfer to a psychiatric facility, most of the patients are discharged or transferred much sooner. From 2019 through the first quarter of 2022, the average length
of stay for a 5150 patient in Fairchild‘s emergency department was approximately 13 hours.
Commencement of the Instant Action
In December 2019, Fairchild filed suit against the County and others in Siskiyou County Superior Court, alleging a civil rights claim under
Removal to Federal Court
In March 2020, the matter was removed to federal court based on federal question jurisdiction. Thereafter, Fairchild filed a first amended verified complaint and petition for writ of mandate, and a motion for a preliminary injunction.
Dismissal of Federal Claims and Remand to State Court
In January 2022, after the DCHS filed a motion to dismiss and the County filed a motion for judgment on the pleadings, the federal district court dismissed Fairchild‘s federal claims for lack of standing, declined to exercise supplemental jurisdiction over the remaining state law claims, denied Fairchild‘s motion for preliminary injunction as moot, and remanded the matter back to the Siskiyou County Superior Court.
Motion for Preliminary Injunction
In July 2022, Fairchild filed a second motion for preliminary injunction in state court, which sought an order prohibiting the County from “bringing” any individual to
Fairchild‘s emergency department or “requesting and forcing” Fairchild‘s emergency department to “keep” or hold such individual pursuant to the LPS Act, when such individual does not have a medical emergency condition having a ”physical, organic cause.”10 In seeking such relief, Fairchild claimed: “Nothing by such a preliminary injunction would prevent anyone from accessing Fairchild‘s [emergency department] services within the hospital‘s staffing capabilities and within the scope of its state license.”
As for the merits, Fairchild argued that it was highly likely to succeed because the County was “blatantly flouting the carefully designed due process protections and public
policy goals underlying the LPS Act.” According to Fairchild, because it was “not a designated psychiatric care facility” approved to receive and treat 5150 patients (by providing the mental health services required under the LPS Act), the County could not “legally” bring 5150 patients to its emergency department or insist that such persons be kept there without providing them any of the mental health care services mandated by the LPS Act. Fairchild added that “most” of the 5150 patients brought to its emergency department are Medi-Cal beneficiaries, “to which the County owes broad obligations to ensure reasonably prompt access to [SMHS].” (Italics added.) In Fairchild‘s view, the County‘s practice of “secluding” 5150 patients in its emergency department without arranging for the provision of mental health care services was depriving these persons of their rights to medically necessary psychiatric care. Fairchild insisted that the County was violating the LPS Act by “forcing” Fairchild‘s emergency department to hold 5150 patients after they have been “medically cleared” without “providing any mandated mental health services.”
As for harm, Fairchild claimed it had and would continue to suffer great irreparable harm in the absence of injunctive relief. In support of its position, Fairchild explained that “receiving, screening, treating, and secluding” 5150 patients in its emergency department had resulted in “significant deterioration of the [emergency department‘s] ability to care for patients and the quality of care that [was] provided.” Fairchild further explained that the “unsettling and often violent behavior” of 5150 patients “severely impede[d]” emergency department operations and “threaten[ed] patient and staff safety,” and that the
Finally, Fairchild argued the public interest and balance of hardships tipped “sharply” in favor of injunctive relief. In making this argument, Fairchild explained: “[T]here is tremendous hardship on [Fairchild‘s emergency department] when it is forced
by the County to receive and seclude 5150 [patients]. Not only are [emergency department] physicians and staff negatively impacted, [other] patients who come to the [emergency department] also suffer consequences from encountering unsettling behaviors exhibited by the County‘s 5150 [patients]. A preliminary injunction in these circumstances serves the public interest in preserving access to health care to a remote region of the State.” Fairchild added that injunctive relief would also address the harms to 5150 patients, who do not receive any medically needed SMHS while being held in its emergency department. According to Fairchild, because it cannot provide any SMHS, keeping or holding 5150 patients in its emergency department was “tantamount to an absolute deprivation of needed medical care to these individuals.” Fairchild maintained that the County would suffer minimal, if any, hardship from the requested injunctive relief, since there was no public interest that would be preserved or protected by not issuing such relief. In support of its position, Fairchild noted that the 5150 patients held in its emergency department were already in the County‘s custody, some of whom were moved from the County‘s jail system where they received housing, shelter, food, and secured monitoring. Fairchild opined that the County was “better equipped” than Fairchild to “keep” 5150 patients pending their transfer to an inpatient psychiatric facility.
In response, the County argued Fairchild had failed to demonstrate that this is an “extreme case” justifying the imposition of a pretrial mandatory injunction. Among other things, the County claimed that Fairchild‘s attempt to “bar certain patients from its emergency department” would violate federal law (e.g., EMTALA), and that Fairchild had failed to cite any authority in support of its “novel theory” that the County could not bring 5150 patients to Fairchild‘s emergency department because Fairchild was not a “designated facility” within the meaning of the LPS Act. The County further argued that, contrary to Fairchild‘s contention, it does in fact provide mental health treatment to 5150 patients while they are being held at Fairchild, and that the balance of harms required the
denial of injunctive relief, as the requested injunction could deprive 5150 patients of potentially life-saving medical care and would add to the delays Fairchild claimed were already too long. As for the duty to provide mental health care services, the County maintained that “Medicaid law” did not require it to immediately provide 5150 patients such services. Rather, those services must be provided with “reasonable promptness.”
In August 2022, Fairchild filed a second amended verified complaint and petition for writ of mandate against the County and the Department. This pleading (the operative complaint) alleged six causes of action, five of which sought a traditional writ of mandate compelling compliance with the LPS Act and other laws (e.g., Medicaid laws).
As for the LPS Act, Fairchild sought an order compelling the County to fully comply with the Act, which included, but was not limited to: (1) “Transporting and keeping 5150 patients in the County‘s custody only to county-designated and DHCS-approved mental health facilities consistent with the LPS Act; and transporting and secluding such patients to Fairchild only for purposes of addressing emergency medical conditions within Fairchild‘s capabilities and scope of its licensure“; (2) “For the entire duration that 5150 patients are at Fairchild‘s facilities, provide, arrange, and/or pay for security (including 24-hour security when necessary) and all other related services to house, feed, and protect the 5150 patients from harming themselves; to ensure the 5150 patients do not disrupt Fairchild‘s operation of its hospital or needlessly drain the hospital‘s staff and resources; and to protect Fairchild staff and patients . . . .“; (3) “Promptly transferring 5150 patients after Fairchild has medically cleared them of all physical emergency medical conditions and determined that a transfer is safe and appropriate“; (4) To the extent it is not possible to transfer 5150 patients from Fairchild after they are medically cleared of all physical emergency medical conditions, provide for, arrange, and/or pay for all mental health services and evaluations required under the
LPS Act“; and (5) “Reimbursing Fairchild for services and costs rendered to 5150 patients.”
Demurrers
In October 2022, the County demurred to the operative complaint,11 arguing that it was subject to dismissal because Fairchild sought relief prohibited by law (writ of mandate) and/or because Fairchild had failed to state an actionable claim for relief. Among other things, the County asserted that Fairchild could not identify any legal authority supporting its writ claims, including any authority supporting its theory that the County had a legal duty to provide mental health treatment in a different manner than it does (e.g., more prompt or faster care). For example, the County argued the operative complaint did not include allegations establishing a clear legal mandate requiring it to provide mental health treatment to 5150 patients while they were being held in Fairchild‘s emergency department pursuant to the LPS
The Department also demurred to the operative complaint,12 arguing that the three writ claims alleged against it (i.e., the first, second, and third claims) were subject to dismissal. Among other things, the Department argued that the first and third claims failed as a matter of law because the Medicaid laws do not provide for a private right of action, and the second claim failed as a matter of law because Fairchild lacked standing to bring it.13 Additionally, the Department asserted that all three claims failed to state an
actionable claim for relief because Fairchild did not identify any ministerial duty (i.e., clear legal mandate) that was violated by the Department or the County.
Fairchild opposed the demurrers, insisting that the operative complaint sufficiently stated cognizable claims for relief.
Trial Court‘s Ruling on Motion for Preliminary Injunction
In November 2022, after the submission of supplemental briefing and a hearing, the trial court denied Fairchild‘s motion for a preliminary injunction. In so ruling, the court found that Fairchild had failed to demonstrate that it was likely or very likely to prevail on the merits of its claims, and that the “burden” to the County in granting the motion would be “much greater” than the “burden” on Fairchild in denying the motion. The court explained that it was “very concerned” that the “population of people . . . subject to a 5150, 72 hour hold” would be “endangered by the granting of the [requested] injunction,” and that if an injunction were issued, the other hospital in Siskiyou County would seek the same relief based on the same criteria, which would “put an even greater strain” on persons subject to a 5150 hold in Siskiyou County.
Trial Court‘s Ruling on the Demurrers and Judgment of Dismissal
In February 2023, after a hearing, the trial court sustained both demurrers without leave to amend. In doing so, the court found that Fairchild‘s claims were subject to dismissal for a variety of reasons. As for the writ claims, the court concluded that several of the claims improperly sought an order
their respective demurrers without leave to amend, we need not and do not discuss the alternative relief sought by the motions to strike.
In March 2023, a judgment of dismissal was entered against Fairchild and in favor of the County and the Department.
Appeals and Consolidation Order
In December 2022, Fairchild timely appealed from the order denying its motion for a preliminary injunction. In April 2023, Fairchild timely appealed from the judgment of dismissal entered after the trial court sustained the demurrers without leave to amend. In May 2023, we granted the County‘s motion to consolidate the appeals for all appellate procedures, including argument and disposition. The case was fully briefed in September 2024 and the case was assigned to the current panel at the end of that month. We permitted the filing of two amicus briefs in October 2024 and considered those briefs as well as the responses thereto filed by the parties.
DISCUSSION
As we next explain, we conclude the trial court properly sustained the demurrers to the operative complaint without leave to amend. As a consequence, we will affirm the judgment of dismissal entered against Fairchild, and dismiss as moot Fairchild‘s appeal from the denial of its motion for a preliminary injunction, as there is no remaining viable cause of action to support injunctive relief.
I
Demurrers
Fairchild argues the trial court erred in sustaining the demurrers to the operative complaint without leave to amend.
A. Applicable Standards of Review
1. Traditional Writ of Mandate
”
A ministerial duty is an act that a public agency or officer is required to perform in a prescribed manner in obedience to the mandate of legal authority without regard to any personal judgment concerning the propriety of the act. (Picklesimer, supra, 48 Cal.4th at p. 340; Kavanaugh v. West Sonoma County Union High School Dist. (2003) 29 Cal.4th 911, 916.) ” ‘In order to construe a statute as imposing a mandatory duty, the mandatory nature of the duty must be phrased in explicit and forceful language.’ ” (Collins v. Thurmond (2019) 41 Cal.App.5th 879, 914; see Citizens for Amending Proposition L v. City of Pomona (2018) 28 Cal.App.5th 1159, 1186 [a duty is ministerial when the action is ” ‘unqualifiedly required’ “]; Carrancho v. California Air Resources Board (2003) 111 Cal.App.4th 1255, 1267 [” ‘[w]here a statute or ordinance clearly defines the specific duties or course of conduct that a governing body must take, that course of conduct becomes mandatory and eliminates any element of discretion’ “].) ” ‘It is not enough that some statute contains mandatory language. In order to recover plaintiffs have to show that there is some specific statutory mandate that was violated by the [public entity] . . . .’ [Citation.] Thus, ‘the enactment at issue [must] be obligatory, rather than merely discretionary or permissive, in its directions to the public entity; it must require, rather than merely authorize or permit, that a particular action be taken or not taken.’ [Citation.] In addition, the enactment allegedly creating the mandatory duty must impose a duty on the specific public entity sought to be held liable.” (In re Groundwater Cases (2007) 154 Cal.App.4th 659, 689; see Alejo v. Torlakson (2013) 212 Cal.App.4th 768, 780 [” ‘Even if mandatory language appears in the statute creating a duty, the duty is discretionary if the [entity] must exercise significant discretion to perform the duty.’ “].)
When a writ petition seeks an order requiring a public entity or its officers to act, the crucial issue is often whether the act that the petitioner seeks to compel is a mandatory and ministerial duty, or, on the contrary, is a
In reviewing a trial court‘s judgment on a petition for a traditional writ of mandate, we independently review the petition to determine whether the appellant has stated a viable cause of action for mandamus relief. (Center for Biological Diversity v. Department of Conservation (2018) 26 Cal.App.5th 161, 171.)
2. Demurrer
A demurrer tests the legal sufficiency of the factual allegations in a complaint and/or petition for writ of mandate. (SJJC Aviation Services, LLC v. City of San Jose (2017) 12 Cal.App.5th 1043, 1051-1052.) On appeal from a judgment of dismissal based on an order sustaining a demurrer, we apply a de novo standard of review; we exercise our independent judgment about whether the pleading sufficiently states a viable cause of action under any legal theory. (Loeffler v. Target Corp. (2014) 58 Cal.4th 1081, 1100; Committee for Green Foothills v. Santa Clara County Bd. of Supervisors (2010) 48 Cal.4th 32, 42; Dilbert v. Newsom (2024) 101 Cal.App.5th 317, 322.) We also review questions of statutory interpretation de novo. (John v. Superior Court (2016) 63 Cal.4th 91, 95.)
In determining whether a demurrer was properly sustained, we accept as true “all facts properly pleaded by the plaintiffs, as well as those that are judicially noticeable.” (Howard Jarvis Taxpayers Assn. v. City of La Habra, supra, 25 Cal.4th at p. 814.) However, we do not assume the truth of contentions, deductions, or conclusions of fact or law. (Yvanova v. New Century Mortgage Corp. (2016) 62 Cal.4th 919, 924Evans v. Berkeley (2006) 38 Cal.4th 1, 6.) ” ’ “We affirm [the judgment] if any ground offered in support of the demurrer was well taken. . . . We are not bound by the trial court‘s stated reasons, if any, supporting its ruling; we review the ruling, not its rationale.” ’ ” (Ramirez v. Tulare County Dist. Attorney‘s Office (2017) 9 Cal.App.5th 911, 924.)
When a trial court
B. Appellate Rules of Procedure
“[A] fundamental principle of appellate procedure [is] that a trial court judgment is ordinarily presumed to be correct and the burden is on an appellant to demonstrate, on the basis of the record presented to the appellate court, that the trial court committed an error that justifies reversal of the judgment. [Citations.] ‘This is not only a general principle of appellate practice but an ingredient of the constitutional doctrine of reversible error.’ ” (Jameson v. Desta (2018) 5 Cal.5th 594, 608-609)
Each argument made in an appellate brief must be “under a separate heading or subheading summarizing the point,” and each point must be supported “by argument and, if possible, by citation of authority.” (
C. Analysis
As we shall explain, Fairchild makes several undeveloped arguments that we deem forfeited. We also reject Fairchild‘s claims of error on the merits.
1. Medicaid Laws
Fairchild‘s first cause of action, asserted against both the County and the Department, sought a writ of mandate compelling compliance with various state and federal Medicaid laws and regulations. In support of this claim, Fairchild alleged that the County failed to comply with certain rules governing how 5150 patients enrolled in Medi-Cal must be treated for mental health conditions, and that the Department failed to ensure the County complied with these rules. According to the operative complaint, the County violated the
Fairchild argues reversal is required because the operative complaint sufficiently alleged the County failed to arrange for or provide 5150 patients any of the medically necessary SMHS the Medicaid laws mandate be provided in a reasonably prompt manner, including while 5150 patients were being held in Fairchild‘s emergency department pursuant to the
Forfeiture aside, we see no basis for reversal. In its appellate briefing, Fairchild has not pinpointed any clear ministerial duty that was violated or could be remedied by the issuance of a writ of mandate. As previously indicated, a ministerial duty is an act that a public agency or officer is required to perform in a prescribed manner in obedience to the mandate of legal authority without regard to any personal judgment concerning the propriety of the act. (Picklesimer, supra, 48 Cal.4th at pp. 339-340; Kavanaugh v. West Sonoma County Union High School Dist., supra, 29 Cal.4th at p. 916.) Having independently reviewed the Medicaid laws cited in the operative complaint, we discern no basis for mandamus relief. Fairchild‘s first cause of action is largely predicated on the County‘s failure to: (1) timely provide or arrange SMHS (e.g., psychiatric care) for 5150 patients brought to Fairchild‘s emergency department; and (2) timely arrange for the transfer of 5150 patients to an appropriate “psychiatric care provider” after Fairchild‘s emergency department medically clears them of all physical emergency medical conditions and determines that a transfer is safe and appropriate.
As the trial court correctly observed, none of the statutes or regulations identified in the operative complaint include a mandatory and ministerial duty requiring the County or the Department to affirmatively act in a certain way upon learning of the facts alleged in the operative complaint. For example, Fairchild cites
In short, the operative complaint does not state a viable claim for a traditional writ of mandate. Even accepting as true the allegations in the operative complaint, they do not demonstrate that the County or the Department failed to act in the face of a nondiscretionary duty imposed by law. It is well-settled that a traditional writ of mandate will only lie where there is a ministerial duty capable of direct enforcement. (Professional Scientists, supra, 195 Cal.App.4th at p. 1236.) Accordingly, the trial court properly sustained the demurrers to the first cause of action.
2. Disability Discrimination Laws
Fairchild‘s second cause of action, asserted against both the County and the Department, sought a writ of mandate compelling compliance with certain state and federal disability discrimination laws. In support of this claim, Fairchild alleged that all Medi-Cal and indigent patients (including 5150 patients) in Siskiyou County are discriminated against on the basis of mental disability because the County and the DHCS fail to ensure that they have “equal access” to all covered health care services (e.g., SMHS), and that the Department failed to ensure that the County implemented its mental health plan in accordance with the nondiscrimination laws. According to the operative complaint, Medi-Cal and indigent patients seeking medical care at Fairchild “face long waits to access emergency care for their mental health conditions that patients with physical health conditions do not face” as a result of the “manner in which the County and DHCS have implemented the provision of SMHS.” The operative complaint further alleged that the DHCS has “established payment rates for acute psychiatric hospital services in a manner completely different than reimbursement for physical health services rendered by hospitals,” which had resulted in “rates for psychiatric hospital services per diem [that] are less than half the rates available for physical health hospital services per diem.”
The operative complaint also alleged: “The 5150 patients are otherwise qualified individuals with a disability (a mental health condition) but, solely by reason of the disability, were excluded from the full participation in, and denied the benefits of, the Medi-Cal program and the County‘s indigent programs. If the 5150 patients’ emergency condition arose out of physical conditions, rather than mental health conditions, they would have had immediate access to treatment. Furthermore, on the basis of mental disability, the County has: a) denied the 5150 patients and other eligible individuals the opportunity to participate in or benefit from Medi-Cal-covered health care services: b) failed to afford these patients with mental disabilities an opportunity to receive emergency services that is equal to patients without mental disabilities; c) failed to provide these patients with mental disabilities with coverage for mental health conditions that is as effective as the coverage for physical health conditions; d) limited the Medi-Cal benefits available to persons with mental health conditions; and e) imposed additional restrictions on mental health benefits not imposed on physical health benefits. Such disparate treatment by the County amounts to discrimination on the basis of disability in violation of
Fairchild argues reversal is required because the operative complaint sufficiently stated violations of “anti-disability discrimination laws,” since it includes allegations establishing that “the County gives unfavorable treatment to Medi-Cal beneficiaries who require SMHS as compared to beneficiaries who need physical health care services,” and that the Department failed to guard against such violations and “established a Medi-Cal reimbursement system that contributed to the disparate treatment.” In making this argument, Fairchild claims the trial court erred in determining that this claim failed as a matter of law because Fairchild lacked standing to assert it.
Preliminarily, we note that Fairchild does not cite any authority or provide reasoned legal analysis explaining how and why the trial court committed reversible error. Fairchild‘s conclusory assertion of legal error, without citation and application of pertinent authority, results in forfeiture of its claim. (United Grand, supra, 36 Cal.App.5th at p. 153.) In any event, we conclude that Fairchild‘s second cause of action was properly dismissed. As the Department and the County argued in the trial court, the operative complaint does not state an actionable claim for mandamus relief. Fairchild failed to identify any clear legal mandate requiring the County or the Department to affirmatively act in any particular way upon learning of the facts alleged in the operative complaint. On appeal, Fairchild has not directed us to any specific statutory language imposing a mandatory and ministerial duty in explicit and forceful language. And nothing in the operative complaint establishes the existence of such a duty--that is, an obligation on the part of the County or the Department to perform a specific, nondiscretionary act in a certain way. As we have noted, a traditional writ of mandate will only lie where there is a ministerial duty capable of direct enforcement. (Professional Scientists, supra, 195 Cal.App.4th at p. 1236.) Because the operative complaint does not identify such a duty, the second cause of action was subject to dismissal. The trial court, therefore, did not commit reversible error in sustaining the demurrers to this claim. (See Fremont Indemnity Co. v. Fremont General Corp. (2007) 148 Cal.App.4th 97, 111 (Fremont) [an appellate court must affirm an order sustaining a demurrer “if any of the grounds stated in the demurrer is well taken“].)
3. Mental Health Parity Laws
Fairchild‘s third cause of action, asserted against both the County and the Department, sought a writ of mandate compelling compliance with the
We find no basis for reversal. A review of the operative complaint reveals that Fairchild‘s MHPAEA claim is predicated on the County‘s “delay and denial of meaningful access to SMHS [for 5150] patients” (italics added), which is “unequal to the manner and limitations on the provision of physical medical services under Medi-Cal.” According to the operative complaint, mandamus relief was proper because the County and the Department failed to “ensure parity between the mental health care services and physical health care services that are provided through the Medi-Cal program,” which resulted in Fairchild not receiving “reimbursement for providing SMHS within its capabilities.” The operative complaint further alleged that, due to such inaction, Fairchild was forced to “divert staff and resources while waiting for the patients to be transferred or discharged” and to “incur costs related to keeping these patients in [its] emergency department.”
We need not decide whether the trial court erred in determining that this claim failed as a matter of law because there is no private right of action to enforce the mental health parity provisions of the
4. Section 17000
Fairchild‘s fourth cause of action, which is only asserted against the County, sought a writ of mandate compelling compliance with section 17000. In support of this claim, Fairchild alleged that the County violated the statute by failing to provide “meaningful access” to medically necessary SMHS and “post-stabilization services” to indigent patients “who present to Fairchild with emergency medical conditions.” Fairchild further alleged that the County violated the statute by failing to reimburse it for costs incurred for services rendered to indigent patients who present to Fairchild with emergency mental health conditions.
Courts have construed
Fairchild argues reversal is required because it sufficiently stated a violation of
As an initial matter, we deem Fairchild‘s undeveloped claim of error forfeited. Fairchild again fails to cite authority or provide reasoned legal analysis explaining how and why the trial court committed reversible error in determining that Fairchild had failed to state a viable cause of action. (United Grand, supra, 36 Cal.App.5th at p. 153.) But even were we to consider the merits of Fairchild‘s claim, we would reject it. The trial court properly determined that the operative complaint failed to state an actionable claim for mandamus relief. Fairchild did not identify any clear legal mandate requiring the County to affirmatively provide indigent 5150 patients with medically necessary psychiatric and mental health care services (i.e., SMHS) while these patients are being held at Fairchild pursuant to the
5. LPS Act
Fairchild‘s fifth cause of action, which is only asserted against the County, sought a writ of mandate compelling compliance with the
Fairchild argues reversal is required because it sufficiently alleged the County violated the
Under the version of the
As for DHCS approval, we do not read the
Our construction of the statute comports with a longstanding rule of statutory construction known as the ” ’ “last antecedent rule,” ’ ” -- provides that “qualifying words, phrases and clauses are to be applied to the words or phrases immediately preceding and are not to be construed as extending to or including others more remote.” ” ” (Renee J. v. Superior Court (2001) 26 Cal.4th 735, 743; White v. County of Sacramento (1982) 31 Cal.3d 676, 680.) Additional support for our interpretations is provided by the punctuation of the statute. “Evidence that a qualifying phrase is supposed to apply to all antecedents instead of only to the immediately preceding one may be found in the fact that it is separated from the antecedents by a comma.” (White, at p. 680.) Here, the phrase “in a facility designated by the county for evaluation and treatment and approved by the [DHCS]” (
We reject Fairchild‘s remaining contention that reversal is required because the operative complaint alleged that “the County provides no mental health services by qualified health care professionals that its 5150 detainees need.”
6. Breach of Contract
Fairchild‘s sixth cause of action, which is only asserted against the County, alleges breach of an implied-in-fact contract. In support of this claim, Fairchild alleged that it provides the County written notice whenever a 5150 patient (including indigent and Medi-Cal beneficiaries) is stabilized and capable of being safely transferred to another facility. Fairchild‘s written notice also informs the County that the 5150 patient needs SMHS immediately or promptly, that the patient requires continued poststabilization services to maintain his or her stabilized condition, and that the patient will continue to receive poststabilization services at Fairchild. As part of its written notice, Fairchild requests that the County transfer the 5150 patient to an appropriate facility to receive SMHS. As an alternative, Fairchild offers to continue to render the required poststabilization services for the 5150 patient but at Fairchild‘s standard “full billed charges.” According to the operative complaint, because the County took “no steps to transport any of the 5150 patients to another appropriate facility” and instead “knowingly authorized, permitted, and instructed Fairchild to continue to render post-stabilization services for the 5150 patients at Fairchild‘s standard full billed charges,” an implied-in-fact contract was created.
Fairchild argues the trial court erroneously concluded that an implied-in-fact contract “cannot lie” against the County because “a county is
However, aside from citing a handful of cases for general legal principles--namely, that a public agency may be bound by an implied contract or found liable on the basis of an implied-in-fact contract--Fairchild offers no reasoned legal analysis establishing the existence of a viable cause of action for breach of an implied-in-fact contract. Indeed, Fairchild fails to explain how and why the parties’ conduct created a valid implied-in-fact contract, such that it was error for the trial court to dismiss this claim. In the absence of cogent argument applying the asserted legal principles to the relevant facts, we may and do disregard the claim of error. (United Grand, supra, 36 Cal.App.5th at p. 153; see Department of Alcoholic Beverage Control v. Alcoholic Beverage Control Appeals Bd. (2002) 100 Cal.App.4th 1066, 1078 [“Mere suggestions of error without supporting argument or authority other than general abstract principles do not properly present grounds for appellate review“].) But even were we to consider the merits of Fairchild‘s claim, we would reject it.
A contract may be written, oral or inferred from the parties’ conduct as an “implied-in-fact” contract. (Westside Estate Agency, Inc. v. Randall (2016) 6 Cal.App.5th 317, 328; see
“As with any contract claim, a key element [of an implied-in-fact contract] is the mutual assent of the parties to the contract. . . . ‘[T]he vital elements of a cause of action based on contract are mutual assent (usually accomplished through the medium of an offer and acceptance) and consideration. As to the basic elements, there is no difference between an express and implied contract.’ ” ( Berlanga v. University of San Francisco (2024) 100 Cal.App.5th 75, 82 [an implied-in-fact contract require a meeting of minds or an agreement].) Thus, an implied-in-fact contract (like a written contract) is founded upon an ascertained agreement or, in other words, is consensual in nature. (Ibid.) “Mutual assent is determined under an objective standard applied to the outward manifestations or expressions of the parties, i.e., the reasonable meaning of their words and acts, and not their unexpressed intentions or understandings.” ( Aton Center, Inc. v. United Healthcare Insurance Co., supra, 93 Cal.App.5th at p. 1231.)
We recognize that a ” ‘county may be bound by an implied contract under California law if there is no legislative prohibition against such arrangements, such as a statute or ordinance.’ ” (San Mateo Union High School Dist. v. County of San Mateo (2013) 213 Cal.App.4th 418, 439.) However, we need not decide whether the trial court erred in determining that Fairchild‘s breach of contract claim failed as a matter of law because such a claim “cannot lie” against the County as a matter of law, as the operative complaint fails to state facts sufficient to state an actionable cause of action. As pointed out by the County in its demurrer, Fairchild did not allege that the County agreed or promised to pay for “post-stabilization services” at Fairchild‘s “standard full billed charges.” And the operative complaint concedes that the County has never paid for those services in response to Fairchild‘s demands. In short, because there are no allegations of conduct manifesting mutual consent to enter into an implied contract (i.e., a meeting of the minds between the parties as to the essential terms), Fairchild‘s breach of contract claim was subject to dismissal. Accordingly, the trial court properly sustained the County‘s demurrer to Fairchild‘s sixth cause of action. (See Fremont, supra, 148 Cal.App.4th at p. 111 [an appellate court must affirm an order sustaining a demurrer “if any of the grounds stated in the demurrer is well taken“].)
7. Declaratory Relief
Given our determination that the operative complaint fails to state a viable cause of action, we find no error in the trial court‘s ruling that Fairchild failed to state a claim for declaratory relief. A trial court may, as here, dismiss a declaratory relief claim at the demurrer stage where it is ” ‘wholly derivative’ ” of other failed claims. (Smyth v. Berman (2019) 31 Cal.App.5th 183, 191-192.)
8. Leave to Amend
” ‘If we see a reasonable possibility that the plaintiff could cure the defect by amendment, then we conclude that the trial court abused its discretion in denying leave to amend. If we determine otherwise, then we
No abuse of discretion appears. In the trial court, Fairchild did not suggest any specific amendments to cure the defects of the operative complaint. In its opening brief on appeal, Fairchild simply asserts that it could “provide amendments” to cure “some of the defects that the superior court identified.” This conclusory assertion is insufficient to satisfy Fairchild‘s burden to show “in what manner” it could amend the operative complaint and how the proposed amendment(s) would change the “legal effect” of the pleading. (Graham v. Bank of America, N.A., supra, 226 Cal.App.4th at pp. 618-619 [the assertion of an abstract right to amend does not satisfy burden to show how complaint can be amended to cure defects].)
Equally unavailing are the arguments for reversal Fairchild makes for the first time in its reply brief. In support of its position, Fairchild only offers, in general terms, the type of allegations it could add to the operative complaint to cure the defects. And Fairchild fails to offer cogent legal analysis clearly explaining how its proposed amendments would change the legal effect of the operative complaint. For example, Fairchild asserts: “[T]o the extent any claim [was] dismissed because it challenge[d] the County‘s or [the Department‘s] exercise of discretion under the Medi-Cal laws,
II
Preliminary Injunction
As we next explain, we conclude Fairchild‘s appeal from the denial of its motion for a preliminary injunction is subject to dismissal.
DISPOSITION
The judgment of dismissal entered against Fairchild after the trial court sustained the demurrers to the operative complaint without leave to amend is affirmed, and Fairchild‘s appeal from the denial of its motion for a preliminary injunction is dismissed as moot. The County and the Department shall recover their costs on appeal. (
/s/
Duarte, Acting P. J.
We concur:
/s/
Krause, J.
/s/
Wiseman, J.*
* Retired Associate Justice of the Court of Appeal, Fifth Appellate District, assigned by the Chief Justice pursuant to article VI, section 6 of the California Constitution.
Notes
We are unpersuaded by Fairchild‘s contention that the current or amended version of