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October 1, 2010

DENTAL BOARD of CALIFORNIA Officers


JOHN BETTINGER, DDS, President BRUCE WHITCHER, DDS, Vice President LUIS DOMINICIS, DDS, Secretary

Members
STEVEN AFRIAT, Public Member FRAN BURTON, Public Member STEPHEN CASAGRANDE, DDS REBECCA DOWNING, Public Member JUDITH FORSYTHE, RDA HUONG LE, DDS SUZANNE MCCORMICK, DDS STEVEN MORROW, DDS THOMAS OLINGER, DDS

Executive Officer
RICHARD DECUIR

Sunset Review Report Prepared By: The Dental Board of California 2005 Evergreen St., Ste. 1550 Sacramento, California 95815-3831 (916) 263-2300

TABLE OF CONTENTS
Page PART 1: BACKGROUND INFORMATION AND OVERVIEW OF THE CURRENT REGULATORY PROGRAM Background and Description of the Board and Profession .......................................... 1 Brief History ...................................................................................................... 1 Statutory Composition of the Board .................................................................. 2 Description of the Committees of the Board and their Functions ...................... 3 Major Changes Since Last Sunset Review ................................................................. 5 Internal Growth ................................................................................................. 5 Legislation ........................................................................................................ 7 Regulations....................................................................................................... 10 Major Studies.................................................................................................... 11 Licensing Data .................................................................................................. 12 Budget and Staff ............................................................... 14 Current Fee Schedule and Range .................................................................... 14 Revenue and Expenditure History .................................................................... 14 Expenditure by Program Component ............................................................... 16 Fund Condition ................................................................................................. 17 Licensure Requirements ............................................................................................. 18 Education, Experience and Examination Requirements ................................... 18 Continuing Education/Competency Requirements ........................................... 24 Comity/Reciprocity With Other States .............................................................. 24 Enforcement Activity.................................................................................................... 26 Enforcement Program Overview....................................................................... 27 Case Aging Data .............................................................................................. 31 Cite and Fine Authority ..................................................................................... 34 Diversion Program ............................................................................................ 35 Complainant Satisfaction Survey ...................................................................... 36 Enforcement Expenditures and Cost Recovery ........................................................... 37 Average Costs for Disciplinary Cases .............................................................. 37 Cost Recovery Efforts ....................................................................................... 38 Restitution Provided to Consumers ............................................................................. 39 Complaint Disclosure Policy ........................................................................................ 39 Consumer Outreach and Education ............................................................................ 40 PART 2: BOARDS RESPONSE TO ENFORCEMENT MONITOR ISSUES ............. 43 Prior Issues PART 3: ENFORCEMENT ASSESSMENT 2009 ....................................................... 49 Outside Assessment of Internal Enforcement Process

PART 1. DENTAL BOARD OF CALIFORNIA


BACKGROUND INFORMATION AND OVERVIEW OF THE CURRENT REGULATORY PROGRAM
As of October 1, 2010

BACKGROUND AND DESCRIPTION OF THE BOARD AND PROFESSION


The Dental Board of California (Board) is one of 38 regulatory boards, bureaus and commissions within the Department of Consumer Affairs (DCA). The Board was created by the Legislature and was empowered to regulate dental health professionals in California. The Board is responsible for regulating the practice of approximately 71,000 licensed dental health professionals, which includes dentists (DDS), registered dental assistants (RDA), and registered dental assistants in extended functions (RDAEF). In addition, the Board has the responsibility for setting the duties and functions of approximately 50,000 unlicensed dental assistants. Business and Professions Code Section 1601.2 sets forth the Boards purpose as follows; Protection of the public shall be the highest priority for the Dental Board of California in exercising its licensing, regulatory and disciplinary functions. Whenever the protection of the public is inconsistent with other interests sought to be promoted, the protection of the public shall be paramount. In concert with this statutory mandate, in July 2010, the Board formally adopted its strategic plan. The Boards mission is to protect and promote the health and safety of consumers of the State of California, while the Boards vision is to be a leader in public protection, promotion of oral health, and access to quality care.

Brief History
For more than a century the Board has overseen the practice of dentistry in California. In 1901, the Board promulgated its first regulations making it unlawful to practice dentistry without a license. In 1974, the California Legislature created a subcommittee to study the issue of dental auxiliary utilization. The subcommittee recommended that the Board also license dental auxiliaries. The Legislature also created a nine member advisory body to the Board referred to as the Committee on Dental Auxiliaries (COMDA). In 1976, the Board

adopted regulations governing the examinations and licensure of registered dental auxiliaries. In January 2001, appointment of the Board members as well as the Boards Executive Officer (EO) was repealed and the procedure for appointment of the Boards executive office was modified as a provision of SB 134 (Stats 2001 ch 532). The Joint Legislative Sunset Review Committee (JLSRC) reviewed the performance of the Board in 2000 and determined that the Board failed to effectively administer the Dental Practice Act and should be replaced with different members. This bill also repealed the independent authority of the Board to appoint an EO, and re-established that authority with the provision that the appointment of the EO would be approved by the Director of the DCA. The bill was double-joined with AB 447 (Stats 2001 ch 625) to specify that dentist board members include one faculty member of a dental college and one dentist practicing in a nonprofit community clinic. This bill extended the Boards sunset date to January 1, 2005. Between 2002 and 2009, the Board has appointed five permanent EOs and three acting EOs. In 2003, SB 362 (Stats 2003 ch 788) extended the Boards sunset date to January 1, 2006. In 2004, SB 1546 (Stats 2004 ch 667) extended the sunset date for the Board until January 1, 2007. Next, SB 248 (Stats 2005 ch 659) again extended the sunset date until January 1, 2009. Finally, in 2008 AB 1545 (Stats 2008 ch 35) again extended the sunset date to January 2012. Senate Bill 534 intended to create an independent hygiene committee. One of the provisions of this bill stated that if the Governor vetoed this legislation the Board would be sunset. The Governor vetoed the bill and the Board became a Bureau under the jurisdiction of the Director of the DCA. With the passage of AB 1545 (Stats 2008 ch 35), the Bureau was again reconstituted back to a board effective January 1, 2009. With the passage of SB 853 (Stats 2008 ch 31) the Committee on Dental Auxiliaries was abolished as of July 1, 2009. The regulatory authority for dental assisting was transferred to the Board and the Dental Hygiene Committee of California (DHCC) was created with authority over all Registered Dental Hygienists (RDHs) and Registered Dental Hygienists in Extended Functions (RDHEFs) and Registered Dental Hygienists in Alternative Practice (RDHAPs).

Statutory Composition of the Board


The composition of the Board is defined in B&P Code, Section 1603 as follows: Eight dentists appointed by the Governor Four public members: two appointed by the Governor, one by the Speaker of the Assembly and one by the Senate President ProTempore One licensed Registered Dental Hygienist appointed by the Governor One licensed Registered Dental Assistant appointed by the Governor

Members of the Board are appointed for a term of four years, and each member may continue to hold office until the appointment and qualification of his or her successor or until one year has elapsed since the expiration of the term, whichever occurs first. Each member may serve no more than two terms. Public membership is 29% of the Boards composition. CURRENT COMPOSITION OF THE BOARD
INCUMBENTS John Bettinger, DDS, President 2 Bruce Whitcher, DDS, Vice President Luis Dominicis, DDS, Secretary Steven Afriat, Public Member Fran Burton, Public Member Stephen Casagrande, DDS Rebecca Downing, Public Member Judy Forsythe, RDA 1 Huong Le, DDS Suzanne McCormick, DDS Steven Morrow, DDS Thomas Olinger, DDS Vacant - RDH Vacant - Public ENTITY APPOINTED BY Governor Governor Governor Speaker of the Assembly Senate Rules Committee Governor Governor Governor Governor Governor Governor Governor Governor Governor TERM EXPIRATION January 1, 2013 January 1, 2011 January 1, 2012 January 1, 2013 January 1, 2013 January 1, 2012 January 1, 2012 January 1, 2013 January 1, 2011 January 1, 2013 January 1, 2014 January 1, 2013

Legislation was enacted (AB 447 (Stats 2001 ch 625)) which specifies that dentist Board members include one dentist practicing in a nonprofit community clinic and one faculty member of a dental college.
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Dentist practicing in a nonprofit community clinic Faculty member of a dental college

Description of the Committees of the Board and Their Functions


The Board is organized by statute (B & P Code, Section 1601.1), into standing committees dealing with examinations, enforcement, and other subjects as the Board deems appropriate. Committee members are Board members who are appointed by, and serve at the will of, the Board President. There are a minimum of four Board meetings per year. Committees meet on the first day of the two-day meeting and give their reports to the full board on day two. Issues may be brought before the Committee by consumers, stakeholders, and/or Board members. When necessary, staff researches the issues and reports to the Committee. During the committee meeting, issues are discussed and public comment is accepted. When appropriate, the committee brings a recommendation before the full Board for adoption or direction on proceeding. At various times, the Board President will appoint a two member subcommittee (consisting of Board members) to work closely with staff on issues such as infection control, and Dental Assisting Duties, Educational Programs and Courses, and

Examinations. Currently the Board has active Committees dealing with dental assisting, enforcement, examinations, legislation; and licensing, certification, and permits. The Dental Assisting Committee looks at all issues relating to Dental Assistants (DAs), RDAs, and RDAEFs. The Enforcement Committee reviews complaint and compliance case aging statistics, citation and fine information, and investigation case aging statistics in order to identify trends that might require changes in policies, procedures, and/or regulations. This Committee also receives updates on the Diversion Program. The Examination Committee reviews clinical/practical and written examination statistics and receives reports on all examinations conducted by staff. Any issues relating to examinations can be brought before this Committee by consumers, stakeholders, or a Board member. The major discussion in the Committee for the past two years has been the portfolio pathway to licensure. This issue was vetted and eventually became Boardsponsored legislation (AB 1524 (Stats 2010 ch 446) signed by the Governor. When necessary, the Examination Appeals Committee meets in closed session to review those applications of candidates who are appealing examination results. The Legislative/Regulatory Committee monitors legislation, relating to the field of dentistry that might impact consumers and licensees, during each session and makes recommendations to the full Board whether or not to support, oppose, or watch the legislation. The Committee Chair attends Senate and Assembly Committee hearings and may meet with legislators if the Board so directs. The Committee also discusses prospective legislative proposals. Regulations are promulgated and amended by this Committee, with its recommendations going before the full Board. The Licensing, Certification, and Permits Committee reviews dental and dental assistant licensure and permit statistics, and looks for trends that would indicate efficiency and effectiveness or might identify areas in the licensing units that need modifications. When necessary, the Committee meets in closed session to review applications for reissuance of cancelled licenses. Two Committees were formed in 2010 in compliance with AB 2637 (Stats 2008 ch 499); the Registered Dental Assistant Examination (RDA-EX) Committee and the Registered Dental Assistant in Extended Functions Examination (RDAEF-EX) Committee. Both Committees met in 2010. The sole purpose of the RDA-EX Committee is to assign specific procedures for RDA practical examinations. The RDAEF-EX Committee met to assign specific procedures for RDAEF practical and clinical examinations and, to appoint examiners pursuant to B & P Code, Section 1753.4. Senate Bill 438 (Stats 2006 ch 909) created an avenue for specifically qualified oral and maxillofacial surgeons who obtain a permit from the Board to perform specified elective facial cosmetic surgical procedures. The bill required that the Board appoint a Credentialing Committee consisting of three (3) oral and maxillofacial surgeons, one (1) 4

physician and surgeon with a specialty in plastic and reconstructive surgery, and one (1) physician and surgeon with a specialty in otolaryngology, all of whom must maintain an active status on the staff of a licensed general acute care hospital in California. Credentialing Committee members are not Board members. Credentialing Committee members review the qualifications of an applicant for an Elective Facial Cosmetic Surgery permit in closed session at Committee meetings. The information discussed in closed session is confidential. Upon completion of the application review, the Committee shall make a recommendation to the Board on whether to issue or not issue a permit to the applicant. The permit may be unqualified, entitling the permit holder to perform any facial cosmetic surgical procedure authorized by the statute, or it may contain limitations if the Credentialing Committee is not satisfied that the applicant has the training or competence to perform certain classes of procedures, or if the applicant has not requested to be permitted for all procedures authorized in the statute. The Dental Assisting Forum (DAF) was created by SB 853 (Stats 2008 ch 31), effective July 1, 2009, which abolished the Committee on Dental Auxiliaries and created the Dental Hygiene Committee. The purpose of the DAF is to be a forum where dental assistants can be heard, and to discuss all matters relating to dental assistants in the State, including requirements for dental assistant licensure and renewal, duties and supervision, and appropriate standards of conduct and enforcement for dental assistants.

Major Changes Since the Last Sunset Review


Since the Boards last sunset review there have been significant changes in internal growth, legislation, and regulations. The changes are discussed in the paragraphs that follow.

Internal Growth
The Board has undertaken a series of measures to realign the composition of its enforcement program to enhance consumer protection. The modifications facilitated additional positions that allow the Boards Enforcement Unit to run more effectively. A Supervising Investigator I position was added to the Boards Sacramento Office to supervise the sworn investigative staff and a non-sworn Inspector. This additional position has helped relieved the Supervising Investigator II of the direct supervision of field staff. The Board secured four (4) additional sworn investigator positions through a budget change proposal. The additional staff have been instrumental in reducing the backlog of our investigative case files. 5

A Staff Services Manager I (SSMI) was added to oversee the Complaint and Compliance Unit. This is an administrative supervisory class with responsibility for the supervision of the non-sworn enforcement staff. Additionally, the SSMI oversees the Outreach Program and is the Diversion Program Manager. The restructuring of the Complaint Unit, which includes the addition of one (1) complaint analyst, two (2) intermittent staff and administrative staff movement, has allowed the Board to respond to consumer complaints in a timelier manner and has therefore, reduced the processing time of our complaints by 36%. Legislation was enacted (AB 1428 (Stats 2001 ch 507)), which authorized the Board to license by credential without examination, dentists currently practicing in other states who meet specific requirements. This additional workload created a position for the implementation and ongoing licensure responsibilities. SB 1865 (Stats 2004 ch 670), allowed the Board to accept the clinical examination results of the WREB. This additional workload created a half-time position for the implementation and ongoing licensure responsibilities. With the passage of AB 1386 (Stats 2005 ch 539), a licensed dentist must obtain a certificate from the Board authorizing the holder to administer oral conscious sedation (OCS) to adult patients, defined in the law as dental patients 13 years of age and older. The additional workload created a position for the implementation and ongoing responsibilities of this program. Legislation prior to the Boards 2000 Sunset Review had established a similar certificate requirement for the administration of oral conscious sedation for minor patients. A minor patient is defined in the law as a dental patient under the age of 13. An OCS for Minors Certificate authorizes the holder to also administer OCS to adult dental patients. The additional workload created a position for the implementation and ongoing licensure responsibilities. A new permit was created for licensed dentists who completed an oral and maxillofacial surgeons residency to perform elective facial cosmetic surgery on patients by SB 438 (Stats 2006 ch 909). As part of the permit application process, candidates provide information showing education, training, and competence necessary to perform the surgical procedures, along with operative reports. This additional workload created a half-time position for the implementation and ongoing licensure responsibilities. SB 683 (Stats 2006 ch 805) allowed the Board to begin issuing licenses by residency to dentists who complete at least one additional year of clinical training after graduating from an approved dental school, without taking a clinical examination. The additional workload created a position for the implementation and ongoing licensure responsibilities. The Boards regulatory authority and responsibility was extended to all dental assisting functions by the passage of SB 853 (Stats 2008 ch 31). Eight positions responsible for

the examination, licensing and renewal of all dental assistants were transferred to the Board and an SSMI was added to oversee the program. The duties and licensure criteria for dental assisting were revised by the passage of AB 2637 (Stats 2008 ch 499). Effective July 1, 2009, all existing approved RDA programs had to implement additional training into the educational curriculum. Effective January 1, 2010, the duties, settings, supervision level, applicant qualifications and the required examinations for the RDA and the RDAEF were changed. The bill also created two new permits, the Orthodontic Assistant (OA) and the Dental Sedation Assistant (DSA). These permits require a combination of work experience and educational training through courses approved by the Board. In March 2008, the Boards headquarters and Northern Region Enforcement Office was relocated to a new building. In May 2009, the office underwent a major reconfiguration and expansion of the existing space to accommodate the addition of the dental assisting program and staff to the Board. In March 2010 the Boards Southern Region Enforcement Office was relocated from Tustin to Orange.

Legislation
There have been many changes impacting the Dental Board and the practice of dentistry since the last Sunset Review in 2002. Statutory changes resulted in three new pathways to dental licensure, the expansion and placing into statute of allowable duties for dental assistants and the merge of dental assisting licensure into the Board. Other significant changes include a permit to allow qualified oral and maxillofacial surgeons to perform elective facial cosmetic procedures, and new educational requirements for dentists who administer oral sedative agents to their patients. The Board was Sunset July 1, 2008 pursuant to the provisions of SB 797 (Stats 2008 ch 33), and the Board became a Bureau under the DCA for six months, when AB 1545 (Stats 2008 ch 35), reconstituted the Board. This was the second time that the Board had been sunset. In 2001, the Board was sunset and reconstituted as a provision of SB 134 (Stats 2001 ch 532. The bill also repealed the independent authority of the Board to appoint an executive officer, and re-established that authority with the provision that the appointment of the executive officer be approved by the Director of the Department of Consumer Affairs (DCA). The bill was double-joined with AB 447 (Stats 2001 ch 625), to specify that dentist Board members include one faculty member of a dental college and one dentist practicing in a nonprofit community clinic. Another important provision of this bill requires a dentist to provide a dental materials fact sheet to all patients regarding the safety of materials used for dental fillings and requires the patient to acknowledge receipt of the fact sheet. This provision was intended to increase awareness of materials used in dental fillings and their potential effects on patients. AB 1428 (Stats 2002 ch 507), allowed the Board to grant a California license based on an applicants dental license in another state, also known as Licensure by Credential, by allowing applicants currently licensed in another state for less than five years to obtain a 7

California dental license. SB 299 (Stats 2006 ch 4), expanded that authority to grant a license if the applicant contracts to work for at least two years either in a public health clinic in an underserved area or as faculty in a dental school. During the 2003-04 Legislative session, AB 539 (Stats 2004 ch 294), was passed to require the Board to license a third or fourth-year dental student to practice as a registered dental hygienist in dental practices serving patients insured by the Denti-Cal Program, the Healthy Families Program, or other government programs that charge fees based on income. The intent was to provide students with clinical experience, and underserved patients with access to dental care. The passage of SB 1865 (Stats 2004 ch 670), authorized state recognition of the WREB clinical exam for California licensure. A provision of the bill required a study to determine that the WREB clinical exam was comparable to the Boards clinical exam. That study was completed and the Board subsequently implemented this legislation through emergency regulations in 2006. Since that time, nearly all California dental license applicants have chosen to take the WREB exam because it is recognized in other states. In the 2005-06 Legislative session, AB 1386 (Stats 2005 ch 539), created educational and permit requirements for dentists who administer oral drugs and agents to adults for sedation purposes similar to existing requirements for dentists who administer such agents to minors. Also passed during this session, SB 438 (Stats 2006 ch 909), established permit requirements to allow qualified oral and maxillofacial surgeons to perform specified elective facial cosmetic surgical procedures. SB 683 (Stats 2006 ch 805), enabled dental students who complete a minimum one-year postgraduate general practice residency or advanced education in general dentistry subsequent to completion of their program in dentistry to qualify for a California dental license without clinical examination. Passed in the 2007-08 Legislative session, AB 269 (Stats 2007 ch 262), included new requirements for dentists and dental assistants to disclose on each renewal any specialty board certification and practice status (i.e., full-time, part-time, retired, etc.), and allows licensees to report on their license renewal application information regarding their cultural background and foreign language proficiency. This information is tabulated annually and posted on the Boards web site. The Board sponsored legislation in 2007, SB 252 (Stats 2007 ch 13), to require that registered sex offenders be prohibited from licensure and authorized the Board to revoke an existing license for such offenses. The Board was sunset in 2008 and became a Bureau under the DCA for six months, until passage of AB 1545 (Stats 2008 ch 35), reconstituted the Board effective January 1, 2009. This bill also made changes in the method of appointment of the Executive Officer, authorizing the Executive Officer of the previous board to serve as interim Executive Officer until the appointment of a permanent Executive Officer, and provided that members of the previous Board could serve temporarily as interim Board members until new members were appointed.

Legislation passed in 2008 placed dental assisting duties into statute, a recommendation of the previous Joint Legislative Sunset Review Committee. AB 2637(Stats 2008 ch. 499, expanded duties and settings for all categories of dental assistants and created two new specialty permit categories: Dental Sedation Assistant (DSA), and Orthodontic Assistant (OA). These two new permits allow expanded duties for assistants who wish to practice solely in these specialties. This bill also imposed new requirements for unlicensed dental assistants to complete an 8-hour course in infection control, a course in basic life support; and, a Board-approved course in the Dental Practice Act. These provisions are intended to ensure patient safety and infection control. The Dental Hygiene Committee of California was created by legislation passed in 2008. SB 853 (Stats 2008 ch 31), abolished the Committee on Dental Auxiliaries, created the Dental Hygiene Committee and merged the dental assisting functions into the Board effective July 1, 2009. SB 1441 (Stats 2008 ch 548), was passed to require the DCA to conduct an audit of the effectiveness, efficiency, and overall performance of the vendor contracted to manage boards diversion programs, to make recommendations based on the findings of the audit report to improve the programs, and to establish a DCA Substance Abuse Coordination Committee to formulate uniform and specific standards in various areas of the program including, but not limited to, clinical diagnostic evaluations, and temporary removal from practice. Implementation has resulted in the creation of uniform standards for all boards relative to diversion programs. This years SB 1172 (Stats 2010 ch 517) provides the Board the authority to implement the changes required as a result of SB 1441 (Stats 2008 ch 548). Two consumer protection bills were enacted in 2009. AB 667 (Stats 2009 ch 119), allows application of topical fluoride, including fluoride varnish, to students and anyone served in a public health setting or government program, under the general direction of a dentist. AB 1116 (Stats 2009 ch 509), requires that patients must receive a physical examination, including a complete medical history, prior to undergoing cosmetic surgery, including elective facial cosmetic surgery. This intent is to provide protection for patients undergoing those procedures, who may obtain the services from dental licensees who hold Elective Facial Cosmetic Surgery Permits. In the 2009-10 Legislative session, the Board sponsored AB 1524 (Stats 2010 ch 446), to replace the Boards clinical and written examinations with a comprehensive assessment process that would take place while a student is enrolled at a California dental program (Portfolio). The bill provides for an assessment of a students competency that includes a mandatory final assessment that must be passed to obtain a license to practice dentistry in California. AB 2699 (Stats 2010 ch 270) exempts a health care practitioner licensed in good standing in another state from Californias licensure and regulatory requirements while providing voluntary services on a shortterm basis to uninsured or underinsured persons. The bill specifies that there be no

charge to recipients for services and that the practitioner must obtain prior authorization from the applicable licensing board.

Regulations
Regulations promulgated by the Board include emergency changes to the California Code of Regulations (CCR), Sections 1021, 1028, 1034 and 1034.1 to implement SB 1865 (Stats 2004 ch 670), acceptance of the WREB clinical exam pathway to dental licensure. Amendments to CCR Section 1043, pertaining to administration of general anesthesia and conscious sedation modernized and conformed Californias requirements to reflect current national standards and to provide for patient safety. These amendments were adopted by the Board and approved by the Office of Administrative Law (OAL) in 2006. The Board also pursued emergency amendments to CCR Sections 1028.2 et seq. to implement SB 683 (Stats 2006 ch 805), which created the Licensure by Residency pathway to California dental licensure. These amendments were adopted by the Board and approved by OAL in 2007, allowing qualified applicants to more easily achieve licensure in California while protecting the consumer. Regulatory amendments were adopted by the Board and approved by OAL to amend CCR Section 1044, implementing AB 1386 (Stats 2005 ch 539), which established educational requirements for dentists to safely administer oral anesthetic agents to adult dental patients, comparable to existing regulations for administration of these agents to minor patients. Amendments to CCR Section 1079.2 were adopted by the Board at the request of the dental hygiene community to expand the definition of clinical practice allowing registered dental hygienists (RDHs) who practice in public clinic or educational settings to qualify for registered dental hygienist in alternative practice (RDHAP) licensure and increase the availability of dental care in underserved areas. These amendments were approved by OAL in 2008. CCR Sections 1016 and 1017, pertaining to continuing education requirements for licensees and continuing education providers, were extensively revised and adopted by the Board. Requirements now include courses in treatment of the special needs patient, cultural competencies, and dental terminology in foreign languages, to better serve the needs of Californias diverse population. These amendments were approved by OAL in 2010. Amendments to CCR Section 1007 have been adopted by the Board and are in progress to require that all licensees who have not been fingerprinted as a condition of issuance of a license, to submit fingerprints to the Board as a condition of renewal. The Board has also undertaken an extensive review and revision of its Disciplinary Guidelines, CCR Section 1018. These regulations were adopted by the Board and are at the Office of Administrative Law for review and approval.

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The Board has adopted amendments to CCR Section 1005, relative to infection control to realign Californias requirements with the Center for Disease Controls regulations. The Board has adopted amendments to place current dental assisting educational requirements into regulation, and will be pursuing regulations to implement the Portfolio pathway to dental licensure. The Board will also need to promulgate regulations to implement the provisions of AB 2699 (Stats 2010 ch 270) which requires the Board to authorize out of state licensees to volunteer to practice dentistry on uninsured or underinsured patients on a short term basis.

Major Studies Conducted By the Board


Provisions of SB 1865 (Stats 2004 ch 670) required a review of the WREB examination to assure compliance with the requirements of B & P Code, Section 139 and to certify that the examination process meets those standards. This required review was completed in 2005, in conjunction with the Boards occupational analysis, and it was determined that the WREB examination was comparable to Californias clinical dental exam. SB 683 (Stats 2006 ch 805) required the Board work with the Office of Examination Resources to ensure the alignment of competencies required are commensurate to the Boards examinations prior to implementation of Licensure by Residency. Statutes require, on or before January 1, 2009 and every four years thereafter, that the Board submit a report to the Joint Committee on Boards, Commissions and Consumer Protection on statistics relating to the Elective Facial Cosmetic Surgery Permit Program as outlined in B & P Code, Section 1638.1(k)(1) through (6). Studies alternative pathways for initial licensure was completed in 2009 to focus on alternatives to the Boards clinical examination for dental licensure and identify the best option. The study examined specific elements of an alternative pathway which would include oversight by the Board, an auditing system, and would meet all professional testing standards. The study determined that the Portfolio examination as described in AB 1524 (Stats 2010 ch 446) would best meet those criteria.

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Licensing Data
There are 35,500 licensed Dentists, 34,300 Registered Dental Assistants and 1,300 Registered Dental Assistants in Extended Functions of the Board for FY 2009/10. Information is provided to the public regarding a licensees educational background and any permits or certifications that the licensee holds through the Board upon request. The Board collects and tabulates data regarding licensees specialty practice, which is posted on its website annually. The following table provides licensing data for the past four years for Dentists and the past year for Registered Dental Assistants and Registered Dental Assistants in Extended Functions:
FY 2006/07 DENTIST FY 2007/08 DENTIST FY 2008/09 DENTIST FY 2009/10 DENTIST FY 2009/10 DENTAL ASSISTING

LICENSING DATA FOR DENTAL Total Licensed ** California Out-of-State Applications Received Applications Denied Licenses Issued Renewals Issued Statement of Issues Filed

Total: 33531 Total: 34394 Total: 35133 Total: 35529 Total: 35614 29535 30213 30763 31113 34286 3996 4181 4370 4416 1328 Total: 1353 Total: 1345 Total: 1265 Total: 1031 Total: 3310 Total: * Total: * Total: * Total: * Total: * Total: 1369 Total: 1183 Total: 1250 Total: 1020 Total: 2026 Total: 16345 Total: 17146 Total: 16786 Total: 17562 Total: 17697 29 Total: 2 Total: 21 Total: 0 Total: 39 Total: 3 Total: 25 Total: 3 Total: 15 Total: n/a n/a n/a

Total: Statement of Issues Withdrawn Total:

Licenses Denied Total: 4 Total: 4 Total: 6 Total: *Applications are only denied through a Statement of Issues. **Totals include both Dentists and Dental Auxiliaries for FY 2006/07 2008/09.

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OTHER LICENSURE CATEGORIES (If Applicable) Total Licensees (By Type) Additional Office Permit Conscious Sedation Permit Elective Facial Cosmetic Surgery Permit Fictitious Name Permit General Anesthesia/Medical General Anesthesia Permit Mobile Dental Clinic Permit Oral Conscious Sedation Permit Oral & Maxillofacial Surgery Permit Registered Provider Permit Special Permit Dental Sedation Assistant Permit Orthodontic Assistant Permit Licenses Issued (By Type) Additional Office Permit Conscious Sedation Permit Elective Facial Cosmetic Surgery Permit Fictitious Name Permit General Anesthesia/Medical General Anesthesia Permit Mobile Dental Clinic Permit Oral Conscious Sedation Permit Oral & Maxillofacial Surgery Permit Registered Provider Permit Special Permit Dental Sedation Assistant Permit Orthodontic Assistant Permit Renewals Issued (By Type) Additional Office Permit Conscious Sedation Permit Elective Facial Cosmetic Surgery Permit Fictitious Name Permit General Anesthesia/Medical General Anesthesia Permit Mobile Dental Clinic Permit Oral Conscious Sedation Permit Oral & Maxillofacial Surgery Permit Registered Provider Permit Special Permit Dental Sedation Assistant Permit Orthodontic Assistant Permit

FY 2006/07 DENTISTS Total 1798 347 0 3913 719/67 23 1080 65 1100 36 n/a n/a Total 334 46 1 651 55/0 0 162 5 100 7 n/a n/a Total 577 113 0 1474 362/0 0 385 34 378 33 * *

FY 2007/08 DENTISTS Total 1765 365 1 4187 744/81 26 1244 68 1108 36 n/a n/a Total 247 44 9 607 77/0 7 206 5 120 5

FY 2008/09 DENTISTS Total 1811 404 11 4330 761/68 26 1691 74 1157 35 n/a n/a Total 306 56 10 645 47/14 3 520 7 117 3

FY 2009/10 DENTISTS Total 1805 424 18 4480 778/59 21 1988 73 1198 35 n/a n/a Total 228 49 5 586 41/16 0 383 2 122 2

FY 2009/10 DENTAL ASSISTING Total

*0 *0 Total

Total 958 228 1 2448 386/0 12 506 29 510 32 * *

Total 703 193 5 1861 383/29 10 660 30 393 34 * *

Total 806 188 0 2098 376/25 11 834 33 549 32 * *

Total

* *

*(Notes) The Orthodontic Assistant (OA) and Dental Sedation Assistant (DSA) Permits became effective January 1, 2010. To date no licenses have been issued, but we now have 6 approved OA and 7 approved DSA courses. The first class completed in July 2010.

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BUDGET AND STAFF


Current Fee Schedule and Range The Board is authorized by the B & P Code Section 1724 and California Code of Regulations (CCR Section 1021 (g) & (h)) to charge and collect fees for an initial DDS license to practice dentistry in California, and for the renewal of that license. The Board is also authorized by B & P Code Section 1725 to charge and collect fees for the Dental Assisting Program, after they merged into the Board on July 1, 2009. The Boards primary source of revenue is the biennial renewal for DDS and Registered Dental Assistant (RDA) licenses. There is no initial license fee for the RDA license other than the application and exam fees. In October 2007, the renewal fee was increased from $55 to $70 by the COMDA, however, as noted in the Fund Condition Section of this report, there may be a need for an increase to the statutory limit of $80 in FY 2011/12. There have been no fee increases for the DDS license or renewal since 1998, however, with the implementation of the Consumer Protection Enforcement Initiative (CPEI), the Board may be looking at fee increases for the DDS license as soon as FY 2012/13.
DDS Fee Schedule Application Fee Exam Fee Administration Fee Original License Fee Renewal Fee RDA Fee Schedule Application Fee Exam Fee - Written/Practical Administration Fee Original License Fee Renewal Fee Current Fee $100 $450 n/a $365 $365 Current Fee $20 $43/$60 n/a n/a $70 Statutory Limit $500 $800 n/a $450 $450 Statutory Limit $50 $50/$60 n/a n/a $80

Revenue and Expenditure History The collection of fees supports the Boards ability to operate its Enforcement, Licensure, Examination, Renewal/Continuing Competency, Permit Programs and Dental Assisting Programs. The Board also receives revenue through its Cite & Fine Program. In August 2009, the Board began aggressively utilizing the Cite and Fine Program. Illustrated in the tables below are the Boards Revenue and Expenditure accounting for the four prior fiscal years, current year, and budget year; and Revenue and Expenditures accounting for FY 2009-10 for Dental Assisting Programs.

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ACTUAL REVENUES Dental Board Licensing Fees Cite/Fines/ Penalties Other Interest TOTALS FY 2006/07 $7,626,701 $96,922 $2,881,993 $248,325 $10,853,941 FY 2007/08 $7,588,258 $102,036 $346,430 $0 $8,036,724 FY 2008/09 $7,706,696 $96,552 $179,980 $0 $7,983,228 FY 2009/10 $7,753,624 $77,175 $89,570 $0 $7,920,369

PROJECTED FY 2010/11 $7,730,160 $86,864 $134,775 $0 $7,951,799 FY 2011/12 $7,730,160 $86,864 $3,134,775 $0 $10,951,799

Revenue Notes: 1 Includes other miscellaneous fees along with a GF loan payment of $2,500,000 in FY 2006-07, and a GF loan payment of $3,000,000 in FY 2011-12 leaving a balance owing of $1,400,000 on the original $10,000,000 loan 2 The decrease in the balance of this category is due to the decline in revenue for the Boards Investment Income on Surplus Monies as a result of the weak economy

REVENUES Dental Assisting Licensing Fees Cite/Fines/ Penalties Other Interest TOTALS

FY 2006/07

FY 2007/08

FY 2008/09

FY 2009/10 $1,481,905

FY 2010/11 $1,482,000 $73,000 $1,630,000 $0 $3,185,000

FY 2011/12 $1,482,000 $73,000 $1,630,000 $0 $3,185,000

n/a

n/a

n/a

$72,869 $1,629,642 $0 $3,184,416

EXPENDITURES Dental Board Personnel Services Operating Expenses (-) Reimbursements (-) Distributed Costs

FY 2006/07 $3,265,806 $4,316,678 $246,579 $440,365 $6,895,540

FY 2007/08 $3,506,528 $4,765,157 $330,528 $484,113 $7,457,044

FY 2008/09 $3,663,081 $4,867,786 $300,729 $510,413 $7,719,725

FY 2009/10 $3,221,714 $4,675,642 $338,352 $480,512 $7,078,492

FY 2010/11 $5,198,255 $6,210,745 $250,000 $478,850 $10,680,150

FY 2011/12 $5,520,508 $6,159,827 $278,335 $478,850 $10,923,150

TOTALS Expenditure Notes:

3 Includes additional expenditures for CPEI

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EXPENDITURES Dental Assisting Personal Services Operating Expenses (-) Reimbursements (-) Distributed Costs

FY 2006/07

FY 2007/08

FY 2008/09

FY 2009/10 $417,930 $832,922

FY 2010/11* $583,780 $1,133,220 ($600,00) $80,000 $992,000

FY 2011/12* $589,990 $1,145,100 $600,000 $80,000 $1,055,090

n/a

n/a

n/a $601,000 $80,080 $569,772

TOTALS NOTES:

*The Board has no historical data prior to July 1, 2009 when Dental Assisting was merged into the Dental Board, therefore projections are gross estimates

Expenditures by Program Component While many of the programs that the Board administers have been in existence for many years, (such as additional office permits, fictitious name permits, special permits, etc.), since last sunset review in 2002, the Board has been charged with implementing several new permit and certification programs. These include intravenous conscious sedation, oral conscious sedation for minors and adults, and elective facial cosmetic surgery permit programs. Enforcement related expenditures have generally represented in excess of 60% of the Boards total budgeted expenditure authority, with the major portion of these expenditures going to salary and wages followed by Attorney General, and Evidence and Witness costs. The Board anticipates a significant increase in Enforcement expenditures starting FY 2010-11, as it implements the new CPEI, Enforcement Reform Program. Increased productivity and a higher rate of case closures, in addition to reductions in processing timeframes, is expected to justify the costs. The Board will also be embarking on the implementation of the new Portfolio Examination as a result of AB 1524 (Stats 2010 ch 446) which will replace the current dental licensure examination.
EXPENDITURES BY PROGRAM COMPONENT Enforcement Licensing/Exams Dental Assisting* Administrative Diversion TOTALS NOTES: *The Board has no historical data prior to July 1, 2009 when Dental Assisting was merged into the Dental Board. Average % Spent by Program

FY 2006/07 $4,832,720 $1,683,113 N/A $825,032 $242,284 $7,583,149

FY 2007/08 $5,310,717 $1,735,168 N/A $850,548 $249,777 $8,146,210

FY 2008/09 $5,373,274 $1,788,834 N/A $876,854 $257,502 $8,296,464

FY 2009/10

$5,351,113 68% $1,819,825 13% $1,292,540 10.60% $903,973 5% $265,466 3.40% $9,632,917

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Fund Condition It is the Boards objective to maintain a three-month reserve of funds for economic uncertainties and to operate with a prudent reserve. This reserve is essential in order to maintain Board operations and allow for continued operation within authorized allotments. In addition, a prudent reserve is necessary in the event of unforeseen litigation. As stated previously, better than 60% of the Boards budget has been allocated to Enforcement related functions. Since the Board cannot spend more than the budgeted allotment for any given fiscal year, staff must anticipate, or prudently project, these expenditures to cover any unforeseen or unpredictable enforcement actions. Each year, unspent monies revert back to the State Dentistry Fund, and effective July 1, 2009, the Dental Assisting Fund. In past years, the Board was able to maintain the necessary reserve levels. However, a weakening economy, and difficulties enacting a State budget each year, resulted in a loan from the State Dentistry Fund to the States General Fund, in the amount of $10,000,000. Of this amount, $4,400,000 is still outstanding. This large transfer resulted in a significant drop in the MIR for the Dentistry Fund, which has continued to decline each year. As noted in the table below, the Boards expenditures will soon exceed its revenue leading it into a negative MIR balance for the Dentistry Fund. This trend would suggest the need for a fee increase in FY12/13 with the anticipated $3 million and $1.4 million GF reimbursement as indicated below. For the Dental Assisting Fund, the Fund Condition shows the Board in a deficit spending situation in FY 2010-13. Therefore, the Board will need to increase, via Board Resolution, the renewal fee for RDA, from $70 to the statutory maximum of $80 in FY 2011/12. The tables below detail the analysis of the Boards funding condition for the State Dentistry Fund and the Dental Assisting Fund.

ANALYSIS OF FUND FY 2010CONDITION State FY 2007/08 FY 2008/09 FY 2009/10 2011 Dentistry Fund (Projected) Total Reserves, July 1 $7,053,000 $7,394,000 $7,320,000 $7,865,000 Total Rev. & Transfers $8,037,000 $7,985,000 $7,920,000 $7,758,000 Total Resources $15,345,000 $15,548,000 $15,424,000 $15,623,000 Total Expenditures $7,948,000 $8,230,000 $7,559,000 $11,159,000 Unreimbursed Loans to $4,400,000 $4,400,000 $4,400,000 $4,400,000 General Fund Accrued Interest $0 $0 $0 $0 Loans to General Fund $7,394,000 $7,318,000 $7,865,000 $4,464,000 Reserve, June 30 MONTHS IN RESERVE 10.8 11.6 8.5 4.7 NOTES: *Includes a $3,000,000 loan payment from GF

FY 2011-12 (Projected)

FY 2012-13 (Projected)

$807,000 $146.00 $10,721,000* $7,721,000 $11,528,000 $7,867,000 $11,386,000 $11,641,000 $1,400,000 $0 $142,000 0.1 $1,400,000 $0 $3,774,000 -3.8

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ANALYSIS OF FUND FY 2010CONDITION State FY 2007/08 FY 2008/09 FY 2009/10 2011 Dentistry Fund (Projected) Total Reserves, July 1 $7,053,000 $7,394,000 $7,320,000 $7,865,000 Total Rev. & Transfers $8,037,000 $7,985,000 $7,920,000 $7,758,000 Total Resources $15,345,000 $15,548,000 $15,424,000 $15,623,000 Total Expenditures $7,948,000 $8,230,000 $7,559,000 $11,159,000 Unreimbursed Loans to $4,400,000 $4,400,000 $4,400,000 $4,400,000 General Fund Accrued Interest Loans $0 $0 $0 $0 to General Fund $7,394,000 $7,318,000 $7,865,000 $4,464,000 Reserve, June 30 MONTHS IN RESERVE 10.8 11.6 8.5 4.7 NOTES: **Includes $1,400,000 payment for balance in full of GF loan

FY 2011-12 (Projected)

FY 2012-13 (Projected)

$807,000 $146.00 $10,721,000 $9,121,000** $11,528,000 $9,267,000 $11,386,000 $11,641,000 $1,400,000 $0 $142,000 0.1 $0 $0 $2,374,000 -2.4

ANALYSIS OF FUND CONDITION Dental Assistant Fund Total Reserves, July 1 Total Rev. & Transfers Total Resources Total Expenditures Unreimbursed Loans to General Fund Accrued Interest Loans to General Fund Reserve, June 30 MONTHS IN RESERVE

FY 2007/08

FY 2008/09

FY 2009/10

n/a

n/a

FY 2010FY 2011-12 FY 2012-13 2011 (Projected) (Projected) (Projected) $0 $1,925,000 $1,354,000 $760,000 $3,183,000 $1,146,000 $1,141,000 $1,134,000 $3,183,000 $3,071,000 $2,495,000 $1,894,000 $1,258,000 $1,715,000 $1,735,000 $1,787,000 $0 $0 $0 $0 $0 $0 $0 $0 $ $0 0 $0 $0 $1,925,000 $1,354,000 $760,000 $107,000 13.5 9.4 5.1 0.7

LICENSURE REQUIREMENTS
Education, Experience and Examination Requirements Requirements for the various categories of dental professionals have been modified over the last several years through legislation and regulation to allow applicants to qualify for licensure in a variety of ways in order to increase access to dental care in California. Following is a description of the requirements for each: There are four possible pathways to licensure as a Dentist (DDS): 1. California Clinical Examination. Applicants must have graduated from an approved dental program or have passed the Boards restorative technique exam and take a six part examination, passing at least 4 of the six subjects and attaining an overall score of at least 75% and pass the California Law and Ethics examination. 2. WREB Clinical Examination. Applicants must have graduated from an approved dental program or have passed the Boards restorative technique exam and must pass a regional examination and pass the California Law and Ethics examination.

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3. Residency. Applicants must have completed at least one year of postgraduate education in an approved Advanced Education in General Dentistry or General Practice Residency and pass the California Law and Ethics examination. 4. Credential. Applicants must have been licensed in another state for at least 5 years and practiced at least 5,000 hours in the preceding 5 of 7 years, or agree to at least a two year contract with an approved dental program in California as an instructor, or practice in a public health clinic in an underserved area as designated by Office of Statewide Health Planning and Development (OSHPD). Licensure as a Registered Dental Assistant (RDA) has 3 possible pathways: 1. Graduation from an approved dental assisting program. 2. Completion of 15 months of on the job training, certified by a licensed US dentist. 3. Work experience combined with education from a non-approved program totaling 15 months. All applicants must pass a written competency examination, a Law and Ethics examination and a Practical examination for Registered Dental Assistant Licensure consisting of three of four statutorily prescribed procedures prior to issuance of the license. Licensure as a Registered Dental Assistant in Extended Functions (RDAEF) requires: Graduation from an approved extended functions program, Passage of a written competency examination, and Passage of a clinical/practical examination. Applicants licensed prior to January 1, 2010 may qualify to expand their duties by completing additional education and passing a practical examination. The Board also issues several different types of permits. An Oral and Maxillofacial Surgery Permit may be issued to an applicant who has: Completed a residency program in oral and maxillofacial surgery, Holds a California medical license, and Either holds or has held a license to practice dentistry in another state. An Elective Facial Cosmetic Surgery Permit may only be issued to a licensee who: Has completed an oral and maxillofacial surgery residency, Submits proof of the training and competence necessary to perform such procedures, and Provides documentation through operative reports and possession of surgical privileges at a licensed acute care hospital. A Conscious Sedation Permit may be issued to a licensed dentist in good standing who intends to administer agents that induce a minimally depressed level of consciousness and submits: Proof of completion of an approved course, Documentation that required drugs and equipment are on the premises, and 19

Evidence of satisfactory completion of at least 20 cases of administration of conscious sedation. A General Anesthesia Permit may be issued to a licensed dentist or an oral and maxillofacial surgeon who: Submits evidence of completion of at least one year of advanced training in anesthesiology, or Submits evidence of completion of an oral and maxillofacial surgery residency, or Submits evidence of equivalent training or experience approved by the Board. A Medical General Anesthesia Permit may be issued to a physician and surgeon licensed by the Medical Board of California who: Submits evidence of completion of at least one year of advanced training in anesthesiology, or Submits evidence of equivalent training or experience approved by the Board. A Mobile Dental Clinic Permit may be issued to a clinical facility used by a dental school for instruction in dentistry, in which dental services are provided to the public as part of the dental education program. Approved dental schools must register mobile dental clinics with the Board and provide information pertaining to faculty supervision, scope of treatment, postoperative care, and a description of the facilities and equipment available. An Oral Conscious Sedation Permit may be issued to a dentist who intends to administer sedation to minor and/or adult patients via oral drugs or agents who: Submits proof of completion of a post-doctoral program in periodontics, or Submits proof of completion of a general practice residency, or Submits proof of completion of an advanced education in general dentistry postdoctoral program, or Submits proof of completion of an educational program approved by the Board. A Special Permit may be granted to an applicant who has a pending contract with a California dental college as a full time professor and submits proof of graduation from an approved dental school and evidence of certification or qualification in a dental specialty. An applicant for an Orthodontic Assistant (OA) Permit or a Dental Sedation Assistant (DSA) Permit must submit: Evidence of completion of at least 12 months of work experience as a dental assistant, Proof of completion of a Board-approved course in the Dental Practice Act and a Board-approved course in infection control, Evidence of successful completion of a course in basic life support, Proof of completion of a Board-approved course, and Pass a written competency examination administered by the Board. 20

All applicants must submit to fingerprinting by the Department of Justice and the Federal Bureau of Investigations. A license will not be issued until fingerprinting results have been received and reviewed by the Board. The Board is authorized by law to receive subsequent arrest and subsequent disposition reports from the Department of Justice. Applicants must submit acceptable proof of qualifications depending on the pathway chosen for licensure. Other than License by Credential, applicants must submit written verification of graduation from an approved program including certification from the dental school (with the school seal). All applicants who are licensed in any other State or Country must submit written Certification of licensure from the issuing licensing agency. Each applicant must answer questions on the application that pertains to prior criminal history, disciplinary actions or other unlawful acts, and the applicant then signs the application under penalty of perjury. If an applicant answers yes, further investigation is done prior to any license being issued. License by Credential applicants are also checked in the National Practitioner Data Bank (NPDB). Information collected by the NPDB and reported directly to Board would include disciplinary actions taken by another State, a peer review body at the association level, a health care facility, or health care plan. Also included would be malpractice settlements, arbitrations or judgments. These reports are reviewed by Enforcement Unit for action. Two of the new pathways to dental licensure, Licensure by Credential and Licensure by Residency, do not require a clinical examination. California has not given a clinical dental examination during the past fiscal year. The number of applicants who apply for Californias clinical exam have dramatically dropped since the recognition of the WREB clinical exam. The last clinical exam held consisted of a total of 18 applicants. In 2005, an occupational analysis was completed validating the need for an examination for consumer protection, as well as a comparison of the California exam and the WREB exam. The comparison, required by B & P Code Section 1632.5, showed that the WREB exam was comparable to Californias. As required with the implementation of Licensure by Residency, the Board worked with the Office of Examination Resources to develop the core competencies required for licensure. This pathway was implemented January 1, 2008. The next dentist occupational analysis is due in approximately 2012. The last full occupational analysis for the Registered Dental Assistant (RDA) was performed in 2005. AB 2637(Stats 2008 ch 499), modified the allowable duties for the RDA and created two additional permit types. A modified occupational analysis was performed in 2009 to update the RDA for compliance with B & P Code Section 139. The information was also used to create written examinations for the new permit types and to create a new RDA in Extended Functions written examination. The next occupational analysis is due in 2012. Candidates taking the California clinical examination decreased markedly since the last Sunset Review. The last exams given show an increased rate of failure, likely due to 21

the fact that the results were skewed by the small number of participants and tended to be re-examinations by candidates who had previously passed the Restorative Technique examination.
CALIFORNIA CLINICAL EXAMINATION YEARS FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 NATION-WIDE n/a n/a n/a n/a n/a n/a n/a n/a CALIFORNIA ONLY 379 176 41 0 75% 77% 61% n/a TOTAL CANDIDATES PASSAGE RATE TOTAL CANDIDATES PASSAGE RATE

* NOTES: Since the Dental Boards acceptance of the Western Regional Examining Boards (WREB) clinical exam for licensure in 2006, applicants for the Dental Boards clinical exam have declined. We attribute this to the fact that WREB clinical examination results are recognized by 33 states.

DENTAL LAW AND ETHICS EXAMINATION FY 2006/07 CANDIDATES PASS % 699 96 FY 2007/08 1165 96 FY 2008/09 1121 98 FY 2009/10 932 98%

The dental assisting program was not part of the Dental Board prior to July 1, 2009. A variety of written examinations are administered to dental assisting candidates via computer based testing. The RDA written examination was updated on January 1, 2010. Between July 1, 2009 and December 31, 2009, 3,154 candidates tested with a 52% pass rate. Since January 1, 2010, through the end of the fiscal year, candidates taking the updated examination totaled 1,184 with a 54% pass rate. Effective, January 1, 2010, the RDA applicants are required to also pass a law and ethics examination. Prior to January 1, 2010, the RDAEF consisted of a clinical examination only. As of January 1, 2010, a practical portion was added as well as a written exam. Existing RDAEFs licensed prior to January 1, 2010, have the option to take additional training and pass a practical exam to allow them to perform enhanced duties. Any RDA who wants to become an RDAEF as of January 1, 2010, must complete both the clinical and practical portions of the exam.
RDA PRACTICAL EXAMINATION FY 2006/07 CANDIDATES PASS % n/a n/a FY 2007/08 n/a n/a FY 2008/09 n/a n/a FY 2009/10 3674 73%

* NOTES: The dental assisting program was not part of the Dental Board prior to July 1, 2009

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RDA WRITTEN EXAMINATION FY 2006/07 CANDIDATES n/a FY 2007/08 n/a FY 2008/09 n/a FY 2009/10 4349

n/a n/a n/a 53% PASS % * NOTES: The dental assisting program was not part of the Dental Board prior to July 1, 2009. A new exam version was implemented on January 1, 2010. We have tested 1,184 candidates with a 54% pass rate.

RDA LAW AND ETHICS EXAMINATION FY 2006/07 CANDIDATES PASS % n/a n/a FY 2007/08 n/a n/a FY 2008/09 n/a n/a FY 2009/10 159 74%

* NOTES: Prior to January 1, 2010 the RDA applicants were not required to take a Law and Ethics Examination. The dental assisting program was not part of the Dental Board prior to July 1, 2009.

RDAEF CLINICAL/PRACTICAL EXAMINATION FY 2006/07 CANDIDATES PASS % n/a n/a FY 2007/08 n/a n/a FY 2008/09 n/a n/a FY 2009/10 112 72%

* NOTES: Prior to January 1, 2010, the RDAEF consisted of a clinical examination. As of January 1, 2010, a practical portion was added. Existing RDAEFs licensed prior to January 1, 2010 have the option to take additional training and pass a practical exam to allow them to perform enhanced duties. Any RDA who wants to become an RDAEF as of January 1, 2010 must complete both the clinical and practical portions. The dental assisting program was not part of the Dental Board prior to July 1, 2009.

RDAEF WRITTEN EXAMINATION FY 2006/07 CANDIDATES PASS % n/a n/a FY 2007/08 n/a n/a FY 2008/09 n/a n/a FY 2009/10 6 67%

* NOTES: There was no written examination prior to January 1, 2010. The exam is not required for all candidates. Existing RDAEFs licensed prior to January 1, 2010 are not required to take this examination. Any RDA who wants to become an RDAEF as of January 1, 2010 must take the examination. The dental assisting program was not part of the Dental Board prior to July 1, 2009.

The timeframe for processing examination applications remains consistent with those reported in the previous Sunset Review report, averaging 45 to 150 days. Filing periods are established for each scheduled examination, and some pathways to dental licensure do not require examination. Other factors include delays in receiving fingerprinting results and NPDB data, required before a license can be issued. The

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dental candidate must complete an application and apply for a license number. Once all requirements for licensure are met the license is issued.
AVERAGE DAYS TO FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 RECEIVE LICENSE (ALL TYPES) Application to 14-120 days prior to 14-120 days prior to 14-120 days prior to 14-120 days prior to Examination exam exam exam exam Examination to 15-30 days 15-30 days 15-30 days 15-30 days Issuance Total Average Days 45-150 days 45-150 days 45-150 days 45-150 days

Continuing Education/Competency Requirements Since the Boards last Sunset Review, regulations regarding continuing education requirements for licensees have been reviewed and revised to allow licensees to claim full credit for courses in cultural competencies such as bilingual dental terminology, cross cultural communication, public health dentistry and management of pediatric, sedated or special-needs patients. This prepares dentists to better serve the dental needs of Californias diverse population. As a result of those regulatory amendments, licensees may now also obtain credit toward license renewal for courses in administration of general anesthesia or conscious sedation, dependency issues and medical emergencies so that dental personnel are educated to recognize the signs of dependency and safely administer anesthesia or sedation. To verify licensees continuing education requirements, the Board resumed continuing education audits of licensees in 2009. An average of 98% of licensees audited were found to be in compliance with the Boards regulatory requirements. Effective January 1, 2010, all unlicensed dental assistants in California must complete an approved 8-hour infection control course, an approved 2-hour course in the California Dental Practice Act and a course in basic life support. All licensed dental assistants in California must also complete, as a condition of renewal, a 2-hour infection control course, an approved 2-hour course in the California Dental Practice Act and a course in basic life support. Comity/Reciprocity With Other States In 2002, the Board approved the dental program at Universidad de La Salle in Mexico. Students who graduate from this Board-approved program qualify to take either the California clinical examination or the WREB. Since 2006, applicants who pass the WREB may apply for a dental license in California without further clinical examination. Licensure by Credentialing, implemented in 2006, allows an applicant who holds a dental license in another state to qualify for a California dental license. 24

Licensure by Residency, implemented in 2007, allows an applicant who has graduated from an approved dental program and completed at least one year of a general residency program to be issued a California dental license without further clinical examination. AB 2699 (Stats 2010 ch 270) exempts a health care practitioner licensed in good standing in another state from Californias licensure and regulatory requirements while providing voluntary services on a short-term basis to uninsured or underinsured persons. This allows out of state licensees to practice on a short-term, volunteer basis.

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ENFORCEMENT ACTIVITY
ENFORCEMENT DATA Inquiries Complaints Received (Source) Public Licensee/Professional Groups Governmental Agencies Other Complaints Filed (By Type) Criminal Charges Fraud Personal Conduct Competence/Negligence Sexual Misconduct Unprofessional Conduct Discipline by Another State Unlicensed Activity Unsafe/Unsanitary Conditions Non-Jurisdictional Other Substance Abuse Drug Related Complaints Closed Investigations Commenced Compliance Actions ISOs & TROs Issued Citations and Fines Public Letter of Reprimand Cease & Desist/Warning Referred for Diversion Total: Total: Total: Total: FY 2006/07 Total: Total: * 1858 454 633 137 3563 Total: 129 73 0 2109 24 416 13 174 131 237 202 19 36 3183 Total: 711 Total: 111 Total: 2 25 0 77 5 FY 2007/08 Total: * 2175 286 1154 94 3399 Total: 365 30 0 2129 12 258 9 116 64 266 119 11 20 2814 Total: 880 Total: 99 Total: 3 16 3 66 10 FY 2008/09 Total: * 2528 87 833 79 3527 Total: 288 194 0 1626 13 349 11 135 81 327 453 11 39 3203 Total: 519 Total: 33 Total: 1 11 1 9 11 FY 2009/10 Total: * 3172 2370 67 639 96 3172 174 167 0 1649 18 334 62 97 70 366 201 10 24 3917 785 70 1 48 8 1 12

3082 Total:

3709 Total:

3527 Total:

Compel Examination 2 1 0 0 *Inquiries originate from Board website hits, calls received at the DCA call center, and calls directly made to the Board. Telephone calls make up the majority of inquiries. Data can only be captured for the previous 40 days. The complaint unit will begin collecting call data on a monthly basis.

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ENFORCEMENT DATA Referred for Criminal Action Referred to AGs Office Accusations Filed Accusations Withdrawn Accusations Dismissed Stipulated Settlements Disciplinary Actions Revocation Voluntary Surrender Suspension Only Probation with Suspension Probation Probationary License Issued Probation Violations Suspension or Probation Revocation or Surrender

FY 2006/07 Total: Total:

FY 2007/08 30 Total:

FY 2008/09 15 Total: 86 Total: 76 8 2 51 Total:

FY 2009/10 20 Total: 11 119 106 8 5 68 118 38 10 0 2 62 6 10 3 7

120 Total: 106 8 6

110 Total: 100 6 4 38 Total: 77 Total: 23 6 1 3 35 9 13 Total: 3 10

Total: Total:

44 Total: 90 Total: 40 8 0 7 33 2

107 Total: 32 9 1 0 51 14 9 Total: 4 5

Total:

8 Total: 5 3

ENFORCEMENT PROGRAM OVERVIEW


Complaint Activity The Board receives between 3,000 and 3,800 complaints per year and processes and closes about 3,900 complaint cases a year. The Board categorizes the sources of the complaints it receives into four (4) distinct groups. These four groups consist of complaints received from the public, other governmental agencies, and licensee/professional groups. The fourth group is defined as other. Public complaints remain the highest category. Most complainants voluntarily decide whether to file complaints with the Board. However, there are mandatory reporting requirements that compel complaints to be filed with the Board in some instances. B&P Code 801 requires providers of professional liability insurance to report dental malpractice settlements, arbitration awards, and judgments to the Board whenever the awarded amount exceeds $10,000. The report must be sent to the Board within 30 days of the disposition of the civil case. These mandatory complaints are classified under other in the chart below. B&P Code Section 805(b) requires peer review bodies, such as health care service plans, dental societies, and committees that review quality of care, to report to the Board whenever one of the following situations occurs: 1. A licentiates application for staff privileges or membership is denied or rejected for a medical disciplinary cause or reason, 2. A licentiates membership, staff privileges, or employment is terminated or revoked for a medical disciplinary cause or reason, or 27

3. Restrictions are imposed, or voluntarily accepted, on staff privileges, membership of employment for a cumulative total of 30 days or more for any 12-month period, for a medical disciplinary reason.
FY 2006/07 2009/10 Source of Complaint Public Governmental Agencies Licensee/Professional Groups Other Total Complaints 8931 3259 894 406 Percentage of Complaints 67% 24% 6% 3%

B&P Code Section 1680(z) requires licensed dentists to report any patient death within 30 days of discovery if it may be related to dental treatment. Finally, Penal Code Section 11105.2 establishes a protocol whereby the DOJ reports to the Board whenever Board licensees are arrested and convicted of crimes. In such instances, the DOJ notifies the Board of the identity of the convicted licensee in addition to specific information concerning the conviction. The Board is not experiencing any problems regarding the receipt of reports from entities required to report identified incidents to the Board. The Board collects and analyzes data on the types of complaints reported by complainants. The Board categorizes the types of complaints it receives into 13 distinct groups. The majority of complaints filed with the Board, against its licensees, are included within the four following categories:
FY 2006/07 2009/10 Type of Complaint Competence/Negligence Unprofessional Conduct Non-Jurisdictional Other Total Complaints 7513 1357 1196 975 Percentage of Complaints 55% 10% 9% 7%

There are fluctuations in the enforcement data since the Boards previous Sunset Review. Of note were the following: 1. In 2008/2009, there was an increase in the number of cases classified as other. A closer review indicated the variation was related to the number of malpractice cases reported pursuant to B&P Code section 801. 2. The number of Cease and Desist letters has decreased significantly in the last two years. These letters were issued primarily to practitioners for advertising violations. The Board has changed its approach and now issues a letter requesting the subject demonstrate compliance with the regulation.

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Since 2000, the number of licensed dentists (35,500) has increased 31%. Similarly, the number of registered dental assistants in California (34,300) has increased 49% in the same time period. As a result of the increase in the licensee populations, the number of complaints referred to investigation has increased from 14% in 2000 to 25% in 2009.
NUMBER AND PERCENTAGE OF COMPLAINTS DISMISSED, REFERRED FOR INVESTIGATION, TO ACCUSATION AND FOR DISCIPLINARY ACTION Complaints Received Complaints Closed Referred for Investigation Accusation Filed Disciplinary Action FY 2006/07 3082 3183 711 114 198 103% 23% 3% 6% FY 2007/08 3709 2814 880 69 205 76% 24% 1% 6% FY 2008/09 3527 3203 519 85 298 76% 15% 3% 8% FY 2009/10 3172 3917 785 98 293 123% 25% 3% 9%

Complaint Activity

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With the exception of patient death and sexual misconduct, the type of the complaint that is filed against the licensee has no bearing on whether the resulting disciplinary case is stipulated for settlement. In fact, pre-hearing settlement stipulations, mediated by an Administrative Law Judge (ALJ), are possible in nearly all disciplinary cases. This is because the cost of prosecuting a case during an administrative hearing and the uncertain outcome of prosecuted cases causes pre-hearing settlements to be a sensible option for the Board and its accused licentiates. In its goal to achieve reasonable prehearing settlement terms in disciplinary cases, the Board seeks to achieve the outcome that would have been achieved in the event that the case had been considered by an ALJ who rendered a proposed decision. The percentage of complaints which ultimately result in the filing of accusations and disciplinary action averages 3%, which has remained stable over time.

Investigations Fiscal Years 2006/07 through 2009/10

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Case Aging Data


Cases are tracked through three phases: Complaint Processing in the Complaint and Compliance Unit; Investigation; and Pre- and Post-Accusation at the Office of the Attorney General (OAG). Each is discussed below. Time Frames for Processing Complaints in the Complaint and Compliance Unit The Boards Complaint and Compliance Unit processes all complaints received. The complainant is notified within ten (10) days that the Board has received the complaint. The complaint is processed through the internal intake process and is assigned to a Consumer Services Analyst (CSA). Cases are prioritized during complaint intake, with the highest priority assigned to cases where it is believed there is imminent consumer harm. Incompetence/negligence and unprofessional conduct are the most frequent types of complaints against licensees. Egregious cases (i.e. patient death, sexual misconduct, gross negligence, substance abuse and unlicensed activity) are immediately referred for formal investigation and cases that involve convictions are referred for record collection by a CSA. Violations that are confirmed are referred for formal investigation. An accusation can result in discipline including but not limited to remedial education, probation, public reprimand, suspension, or revocation. The CSA reviews the complaint for jurisdiction, complexity, and availability of basic factual materials. A complaint may be closed because the Board lacks jurisdiction in the issues alleged, such as instances of fee or civil disputes, or Ethical/Office issues. At this point, the following actions may be taken: Complaint may be closed because the Board lacks jurisdiction, The complaint is assigned to a CSA to obtain additional information in order to continue the investigation. The case is referred to a Dental Consultant for review. After the Dental Consultant reviews the case, it is returned to the CSA to close, send to a specialty consultant, i.e., prosthodontist, orthodontist, endodontist, periodontist, etc. for further review, or forwarded to Enforcement for further investigation. Cases are not typically opened, investigated, and prosecuted in the same fiscal year. The average number of days to process a case ranged from a high of 280 days in FY 2007/08 to a low of 180 days in FY 2009/10. The recent hiring of additional dental consultants has contributed to improved complaint processing. Time Frames for Processing Cases in Investigations Once the Complaint and Compliance Unit has referred a complaint for investigation, the cases are sorted by county and assigned to a field office (Orange County for Southern California, Sacramento for Northern California). 31

The Supervising Investigator for that field office evaluates the case and assigns it to an investigator based upon a number of criteria including: Case complexity, Investigator experience, Companion cases on the same licensee, and Caseload In turn, the investigator evaluates the case in order to prioritize it within their existing caseload. Considerations include actual or potential consumer harm, criminal and administrative statute of limitations, and travel requirements. Investigators will routinely work multiple cases in a given area in order to limit the amount of investigative time spent on travel. Over the past four years the average length of time required to complete investigations has risen from 247 to 351 days. Factors contributing to this include: Investigator vacancies (up to 30% per year), The length of time to train new staff (may include a four month peace officer academy) before they are considered competent to carry a full caseload, The increase in the number of complaints referred for investigation, and Mandatory furloughs reducing productivity by 3 days per month
AVERAGE DAYS TO PROCESS COMPLAINTS, INVESTIGATE AND PROSECUTE CASES FY 2006/07 Complaint Processing Investigations Pre-Accusation* Post-Accusation** TOTAL AVERAGE DAYS*** 238 247 208 341 668 FY 2007/08 280 211 283 363 773 FY 2008/09 278 302 182 361 836 FY 2009/10 180 351 187 335 857

*From completed investigation to formal charges being filed. **From formal charges filed to conclusion of disciplinary case. ***From date complaint received to date of final disposition of disciplinary case.

If the results of an investigation indicate the licensee violated the Dental Practice Act, the case is referred by the investigator to OAG for preparation and review of the administrative accusation. Time Frames for Processing Cases through Prosecution (Pre- and PostAccusation) The pre-accusation phase runs from a completed investigation to formal charges being filed. The time frame for the pre-accusation phase of disciplinary cases has decreased from an average of 370 days in 2000, to an average of 201 days (while the number of cases referred for discipline has continued to increase).

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The post-accusation phase runs from formal charges filed to conclusion of a disciplinary case. The time frame for this phase with the OAG has shown an increase* from an average of 317 days in 2000 to an average of 350 days. [See Chart] [*In the event that a writ is filed on a final decision, the case is reopened and continues to age until a final resolution.] The OAG is aware of these time frames and recognizes that their staffing constraints have contributed to case aging. The CPEI has allocated two limited term non-sworn staff to assist the Enforcement Program with tracking accusation processing times. It is anticipated this additional support will assist in reducing the time required to file and track administrative filings. Older investigations (3 years or older) may be single instances of unprofessional conduct or negligence cases wherein the licensee has no previous complaint or disciplinary history, or pending criminal charges. Investigators focusing their efforts on gross negligence, consumer harm, and patient death cases have caused these other cases to begin aging. Sexual misconduct, allegations involving pharmaceuticals or substance abuse, and unlicensed dentistry are also priorities for investigative staff. The CPEI has allocated 6.5 non-sworn Special Investigator positions to investigate these quality of care cases and address the case aging concerns faced by the Board's enforcement program. These positions are anticipated to become available effective October 1, 2010, and Board staff are already actively preparing to hire and train this anticipated resource. Overall, the Board has shown a significant improvement in the time it takes to complete a case from beginning to end. In comparison to figures reported from the 2000 Sunset Review, there has been a decrease in the number of days to process a case from complaint through prosecution from an average of 1069 days to 783 days. [See chart on next page.]

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AVERAGE INVESTIGATIONS CLOSED WITHIN: FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 % CASES CLOSED 90 Days 232 164 208 87 24.98 180 Days 1 Year 2 Years 3 Years Over 3 Years Total Cases Closed AG CASES CLOSED WITHIN: 1 Year 2 Years 3 Years 4 Years Over 4 Years Total Cases Closed Disciplinary Cases Pending 84 148 159 76 31 730 63 104 134 48 22 535 108 131 179 162 54 842 69 108 175 160 60 659 11.71 17.75 23.39 16.12 6.04

AVERAGE FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 % CASES CLOSED 27 40 53 2 35.88 31 16 5 8 87 357 27 9 6 6 88 222 27 18 7 4 109 305 15 21 18 0 56 184 29.41 18.82 10.59 5.29

Cite and Fine Authority


B&P Code section 125.9 authorizes the Board to issue citations and fines for certain types of violations. The Board has decided to implement a more proactive use of cite and fine to compel licentiates to respond to the Boards requests for records in enforcement cases. B&P Code section 1611.5 authorizes the Board to inspect the books, records, and premises of any dentist in response to a complaint that a licensee has violated any law or regulation that constitutes grounds for disciplinary action by the Board. The Boards inspection functions are typically performed by its inspectors. It is important to note that the Board is not permitted to perform random or periodic inspections of dental offices and can only act upon a complaint. Regulation 1005 sets forth the minimum standards for infection control. The majority of the citations issued by the Inspectors are for violations of B&P Code section 1680 (t) and (ad) for unsafe and unsanitary conditions. 34

Pursuant to the authorizing statute, the Boards licensees failure to allow an inspection or any part thereof shall be grounds for suspension or revocation of their license. Furthermore, in the event that a citation is issued, the cited licensee is required to pay a fine and provide evidence that the cited violation has been corrected. Failure to pay the administrative fine will result in non renewal of the cited licensees dental license at the end of the renewal cycle. Beginning in January 2010, the Board began issuing administrative citations in accordance with B&P Code section 1684.1(a)(1) to dentists who failed to produce requested patient records within the mandated 15 day time period. Focused enforcement of this regulation has resulted in a significant increase in the number of citations issued and fines assessed. Administrative citations may also be issued to licensees who fail to conform to fictitious name permit requirements. As a result of this activity, the Board is experiencing an increase in the number of requests for informal conferences from licensees wanting to dispute the violation. Reasons for requesting an informal conference include disagreement with the violation charged, concern for the fine amount, and the citation being posted on Board's website for the duration of licensure.
CITATIONS AND FINES Total Citations Total Citations With Fines Amount Assessed Reduced, Withdrawn, Dismissed Amount Collected FY 2006/07 25 21 $24,497 3 $9,140 FY 2007/08 16 16 $14,300 3 $5,000 FY 2008/09 11 10 $11,500 2 $3,500 FY 2009/10 48 42 $75,100 6 $6,700

Diversion Program
The Board contracts with MAXIMUS, Inc. to provide confidential intervention, assessment, referral, and monitoring services. Licensees enter the program through a probation referral, investigative referral, or self referral. To ensure the safety and protection of the public, steps are taken to ensure that the Diversion Programs drug testing results are consistently shared with the enforcement programs probation monitors in those instances where a participant is also on probation with the Board. A formal referral to the Enforcement Program is provided whenever a participant is terminated for non-compliance and is determined to be a possible public risk and/or a danger to his/her patients. Monthly meetings are held with the Diversion Program Managers, Contract Administrator, and the Boards Program Manager to identify needed protocols for the Diversion Program. MAXIMUS, Inc. was awarded a new three (3) year contract effective January 1, 2010 and a new Diversion Program Handbook was completed in May, 2010. 35

SB 1441 (Stats 2008 ch 548), required DCA to conduct an independent audit of the effectiveness, efficiency and overall performance of the vendor managing the Diversion Program, make recommendations based on the findings of the audit to improve the programs, and establish a Substance Abuse Coordination Committee to formulate uniform and specific standards in various program areas. DCA also adopted uniform guidelines on sixteen specific standards that would apply to all substance abusing health care licensees, regardless of whether a board has a Diversion Program. Some of these changes must be statutorily adopted to be fully implemented, while others required regulatory changes by the affected Boards and Bureaus. SB 1172 (Stats 2010 ch 517), provides the statutory authority to allow boards to order a licensee to cease practice if the licensee tests positive for any prohibited substance under the terms of the licensee's probation or Diversion Program; allows the Board to adopt regulations authorizing the order of a licensee on probation or in a Diversion Program to cease practice for major violations, and when the Board orders, a licensee to undergo a clinical diagnostic evaluation. The Board will be reviewing the remaining uniform standard criteria for possible incorporation into regulations at the November 2010 meeting, or at the first meeting for the 2011 calendar year.
DIVERSION PROGRAM STATISTICS Total Program Costs Total Participants Successful Completions Unsuccessful Completions FY 2006/07 $141,060 58 9 2 FY 2007/08 $113,026 52 5 7 FY 2008/09 $137,452 61 4 4 FY 2009/10 $133,471 59 4 1

Results of Complainant Satisfaction Survey


An integral component of previous Sunset Review Reports has been the implementation and results of Consumer Satisfaction Surveys. The importance of a survey document was also emphasized by the Enforcement Monitor in his 2003 and 2004 reports. The DCA, in conjunction with their ongoing performance measures, has developed an online survey tool using the SurveyMonkey website. Effective August 1, 2010, the Board has joined in this effort. Consumers are provided with a web address at the bottom of complaint and case closure letters and encouraged to visit the site and provide feedback on their satisfaction with the Boards complaint process. The questions used in the survey and the identifying five-rankings for evaluating the consumers responses are consistent with the Joint Legislative Sunset Review Committees recommendations. 36

The nine questions from the current survey are as follows: 1. Which Board or Bureau? 2. How did you contact our Board/Bureau? a. Web site b. Regular Mail c. E-Mail d. Phone e. In-person 3. How satisfied were you with the time it took to respond to your initial correspondence? 4. How satisfied were you with our response to your initial correspondence? 5. How satisfied were you with the time it took for us to resolve your complaint? 6. How satisfied were you with the explanation you were provided regarding the outcome of your complaint? 7. Overall, how satisfied were you with the way in which we handled your complaint? 8. Would you contact us again for a similar situation? 9. Would you recommend us to a friend or family member experiencing a similar situation? On a monthly basis, the Department will compile the consumer response data and provide the Board with reports for analysis.

ENFORCEMENT EXPENDITURES AND COST RECOVERY


Average Costs for Disciplinary Cases The costs to investigate an allegation include the salary and number of sworn and nonsworn enforcement staff during a fiscal year, combined with the payments to dental Experts for their initial case reviews and case evaluations. An analysis of the cost of investigation has shown gradual increases from $2,696,146 in FY2006/07 to $3,352,643 in FY2009/10. Over the last four (4) years, there has been an increase in the cost of prosecution and hearings. Civil litigation and the number of cases which go forward for administrative hearing rather than stipulated settlements can affect the costs. The average cost per disciplinary case is a combination of the investigative costs and prosecutorial costs. The expenditure will fluctuate based upon the number of administrative cases during the fiscal year.

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Since the addition of the RDA program in July 1, 2009, the authorized Attorney General allotment for the RDAs has been $70,363 however the Board actually spent $213,125. The 302% increase over the allotment has caused the Board to redirect funds from other areas to address Statement of Issues filed on licensing applicants. The board will be seeking a Budget Change Proposal (BCP) to augment this line item.

AVERAGE COST PER CASE INVESTIGATED Cost of Investigation & Experts Number of Cases Closed Average Cost Per Case AVERAGE COST PER CASE REFERRED TO AG Cost of Prosecution & Hearings Number of Cases Referred Average Cost Per Case AVERAGE COST PER DISCIPLINARY CASE

FY 2006/07 $2,696,146 730 $3,693 FY 2006/07 $1,846,424 205 $9,007 $12,700

FY 2007/08 $2,964,313 535 $5,540 FY 2007/08 $1,906,315 74 $25,761 $31,301

FY 2008/09 $3,099,324 842 $3,680 FY 2008/09 $1,923,564 195 $9,864 $13,544

FY 2009/10 $3,352,643 659 $5,087 FY 2009/10 $1,974,650 154 $12,822 $17,909

Cost Recovery Efforts


Pursuant to Business and Professions Code Section 125.3, the Board is authorized to request that its licensees, who are disciplined through the administrative process, reimburse the Board for its costs of investigating and prosecuting the cases. The Boards request is made to the Administrative Law Judge (ALJ) who presides over the hearing. The ALJ may award full or partial cost recovery to the Board or may reject the Boards request for cost recovery. In cases where cost recovery has been ordered, licensees may be granted a payment schedule, allowing them to reimburse the Boards costs over multiple years.
COST RECOVERY DATA Total Enforcement Expenditures # Potential Cases for Recovery* # Cases Recovery Ordered Amount of Cost Recovery Ordered Amount Collected FY 2006/07 $4,832,720 86 46 $125,216 $90,376 FY 2007/08 $5,310,717 100 46 $116,796 $160,970 FY 2008/09 $5,373,274 75 56 $229,195 $148,905 FY 2009/10 $5,351,113 132 97 $469,040 $211,654

*The Potential Cases for Recovery are those cases in which disciplinary action has been taken based on a violation, or violations, of the Dental Practice Act.

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RESTITUTION PROVIDED TO CONSUMERS


Although the Board has participated in past mediation efforts to assist consumers with efforts to obtain restitution, this practice no longer continues. Upon review by the Boards legal counsel, it was determined that the Board does not have the authority to mediate a complaint or order restitution to the consumer. However, the Board does, when possible, try to negotiate restitution to consumers, but does not track this information. Staff will be recommending the Board seek statutory authority in this area.
RESTITUTION DATA Amount Ordered Amount Collected FY 2006/07 n/a n/a FY 2007/08 n/a n/a FY 2008/09 n/a n/a FY 2009/10 n/a n/a

COMPLAINT DISCLOSURE POLICY


Government Code Section 6254 (f) protects consumer complaints and other documents within a complaint file from being considered within the public domain. The Board acts within the existing code and does not disclose information on open complaints or investigations. However, the Board does provide interested consumers with full disclosure on a licensee disciplinary record. The information made available to the public includes accusations, statements of issues, proposed decisions, stipulations, and decisions. Upon request, citizens may receive copy of any of the above documents.

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TYPE OF INFORMATION PROVIDED Complaint Filed Citation Fine Letter of Reprimand Pending Investigation Investigation Completed Arbitration Decision Referred to AG: Pre-Accusation Referred to AG: Post-Accusation Settlement Decision Disciplinary Action Taken Civil Judgment Malpractice Decision Criminal Violation*: Felony Misdemeanor

YES X X X

NO X

X X n/a X X X X X X X X

*Criminal Violations would only be provided if the underlying conviction was the basis of the accusation.

CONSUMER OUTREACH, EDUCATION AND USE OF THE INTERNET


In recent years, the Board has increased its public affairs and outreach in an effort to provide and maintain effective and timely outreach to all stakeholders and the States underserved diverse population. This goal was added to the Boards 2010-2012 Strategic Plan. The Board is working to achieve their goal through the creation and implementation of its Communications and Outreach Plan (Plan). The Plan identifies the Boards stakeholders and outlines the goals of the communication efforts to reach and inform each group. These high-level strategies and goals are intended to provide guidance in planning and measuring results of current and future communication efforts. In concert with these objectives, the Board created an Outreach Committee comprised of internal staff to provide input and resources from across various divisions and programs. The Outreach Committee provides oversight to ensure that planning and executing communications and outreach efforts will be integrated with the goals of the Plan. The Board maintains a comprehensive website, which is updated daily. In 2009, the Board acted to make the full text of final enforcement decisions, including the 40

accusation, available to the public. A consumer may look up a licensee by name and/or license number, and is provided with all information relevant to the final decision. Individuals without internet access may telephone the Boards to check on the status of a licensee. The website also offers consumers an online complaint form for filing of a complaint, a Frequently Asked Questions section, a pamphlet on Problems with Your Dentist, and general information about the Boards complaint process. Board licensees may visit the website to review continuing education requirements, disciplinary guidelines, and to access various forms including an online address change form. Licenses can be renewed, or a duplicate license can also be requested online. One of the biggest additions to the website is E-News service. Visitors to the Boards website are encouraged to sign up for an E-News subscription. By joining the Board's mailing list, interested parties will receive notification of Board activities, including meeting agendas, advisory notices, and special bulletins. The Boards newsletter is also utilized as a tool to inform licensees of regulation changes, enforcement actions, and other current events at the DBC. The recently adopted Strategic Plan outlines, as an objective, a plan to produce at least one newsletter per year. The Board hopes to publish, more frequently, an online newsletter beginning in 2011. RDA and RDAEF applicants can take the required Law and Ethics and written examinations to qualify for Registered Dental Assistant and Registered Dental Assistant in Extended Functions licensing via a computer-based examination administered at 13 locations in California. The Board may explore the feasibility of offering online testing for written examinations in the future, however it would not be feasible to administer the required practical or clinical examinations online. The Board may explore the feasibility of offering online testing for the required Law and Ethics examination to qualify for Registered Dental Assistant and Registered Dental Assistant in Extended Functions licensing currently offered as a computerbased examination at 13 locations in the state. The Board has plans to begin live webcasting of its meetings. This process will allow greater access to the public. Additionally, in order to streamline administrative functions, the Board has begun modifying its website to allow for the posting of meeting material. Consumers, stakeholders, and interested parties will be able to download the information at no charge. The estimated completion date is December 2010. For those interested parties without internet access, a hard copy will remain available.

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42

PART 2. DENTAL BOARD OF CALIFORNIA


BOARDS RESPONSE TO ENFORCEMENT MONITOR ISSUES

Background SB 26 (Stats 2001 ch 615), mandated that the Director of the DCA appoint an Enforcement Monitor to assist in evaluating and improving the performance of the Enforcement Program of the Board. A series of Enforcement Monitor reports were provided to the Board beginning in August of 2002 and ending in February 2004. An improvement plan was drafted, and efforts began to implement many of the recommendations while others were deferred due to budgetary constraints. The following actions have been taken as a result of these Enforcement Monitor reports.

ISSUE #1. Statistical Data & Computer Tracking System Enhancements


One of the critical issues that emerged from the Enforcement Monitors review was the lack of reliable statistical data generated from the Consumer Affairs System (CAS), a computerized case tracking system, which is maintained by the DCA and utilized by the various boards and bureaus. In recognition of some of the constraints of the current system, the DCA has recently entered into the Request for Proposal process to identify a vendor and develop an updated applicant and licensing database to better meet the needs of all DCA users. This project, titled BreEZe had already begun forming user groups to identify key processes in the data entry and reporting requirements to ensure the new product provides the Boards with the means to measure business processes and productivity. Although implementation of BreEZe is several years out, the DCA has stopped providing formalized training for the CAS system as it redirects staff towards this new project. New Board staff are provided with limited on-the-job training by peers, resulting in less staff with comprehensive knowledge of the data collection and reporting features which are necessary for comprehensive data collection. Monitoring the quality of the data we are collecting has become an increasing concern. Currently the Enforcement

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Chief is partnering with Medical Board staff to learn some of the reporting features in the existing system. An additional issue identified was the need for tracking investigative case activity. In 2003, the Board utilized a version of the Investigation Activity Reporting (IAR) program already being used successfully by the Medical Board of California. This Access database provided a method for managers to track casework on all cases, provided information for cost recovery purposes and allowed them to better monitor staff performance and productivity. The Dental Boards enforcement program has partnered with the Medical Board to utilize their newest version of the IAR to maintain the ability to track casework. Transition to the new IAR is anticipated to be completed by the end of 2010.

ISSUE #2. Expert Reviewers


Expert reviewers (consultants) serve a pivotal role in the enforcement process. Whether experienced in general dentistry or specialty fields, these practicing dentists review cases of suspected gross negligence and/or incompetence. Several challenges were identified which had limited the Boards ability to attract and retain a sufficient pool of experts to continue to serve in this capacity. One significant challenge had been the low rate of compensation for services. The rate has been increased from $75.00 to $100.00 per hour. The potential need to testify at hearing, causing a practicing dentist to have to shut down their practice, has also discouraged qualified candidates. Ongoing recruitment efforts include advertising in professional association newsletters and bulletin sites. Advertising has resulted in a greater pool of expert resources. Expert reviewers have been provided with formal training sessions and informal training with a lead consultant as they are hired. A Guidebook for Experts was also completed and used in conjunction with five (5) training sessions to provide experts with report and testimony training and ensure consistent case analysis. The Board plans to offer updated training next year.

ISSUE #3. Staffing


The enforcement program has encountered several staffing challenges, particularly within the peace officer classification. SB 826 (Stats 1997 ch 704) limited the number of peace officers the Board could hire from 17 to 7. In 1999, AB 900 (Stats 1999 ch 840) increased that number to 10. In 2007, a Budget Change Proposal further increased the number of sworn staff to 15. The ability to recruit and hire well qualified investigators was impacted by State Restriction of Appointment (SROA) rules which limited the candidate pool. Although the SROA candidates met State Personnel Board rules, their academy training did not qualify them for full peace officer duties as an investigator. Resulting high caseloads distributed between the remaining Board staff also served to discourage applicants from applying for vacant positions. Staffing vacancies combined with the increase in 44

complaints referred for investigation contributed to case aging. In addition, the Enforcement Chief position was not permanently filled for over 12 months. More recently, the Board hired a new supervisor for the Orange County office, and an aggressive recruitment effort has resulted in several candidates having been selected to fill three of four staff vacancies. In addition, a new Enforcement Chief was hired in July 2010. Beginning FY2010/11, the number of vacancies in the Enforcement Program has been reduced by 50%. In addition, the CPEI has designated a number of new positions to augment the existing enforcement program staff. Three sworn positions will assist with investigation of the highest priority criminal and consumer harm cases. 8.5 non sworn positions have been designated to assist in processing disciplinary cases, and support the enforcement program.
Fiscal Year 2006/07 Classification Supervising Investigator II Supervising Investigator I Staff Services Manager Senior Investigator 1 1 1 7 2 5 1 0 0 0 0 0 0 0 2007/08 1 1 0 9 4 3 1 0 0 0 3 2 0 0 2008/09 1 1 1 8 6 2 1 1 0 0 0 0 0 0 2009/10 1 2 1 8 5 3 1 1 1 0 3 2 0 0 Positions Vacant Positions Vacant Positions Vacant Positions Vacant

Enforcement Program Staff

Sworn

Mgmt

Investigator Inspector I/II Dental Consultant Associate Gvmt Program Analyst Staff Services Analyst Office Technician/Office Asst Total Sworn Staff Total Non-Sworn Staff Total Enforcement PYs

Support

1 4 3 11 15 26

0 0 0 0 0 0

3 5 4 15 16 31

0 0 0 5 0 5

3 6 7 16 20 36

0 0 1 1 1 2

8 6 6 16 25 41

0 1 0 7 1 8

ISSUE #4. Consumer Survey


A consumer survey was recommended by the enforcement monitor as a tool to measure consumer satisfaction with the enforcement program performance. As of August 1, 2010, the Enforcement Chief directed the implementation of a new survey procedure. In conjunction with the Departments performance improvements, an online survey has been developed with SurveyMonkey. Consumers are provided with a web address at the bottom of their closure letters and encouraged to visit the site and 45

provide feedback on their satisfaction with the Boards complaint process. Once a sufficient number of survey responses have been received (four), the Department will begin generating monthly reports of the results saving the Board staff time and effort to collect, report and store the data. Analysis of the survey results will be used to evaluate program and personnel effectiveness. This data will also be included in the Departments future performance measures.

ISSUE #5. Improved Tracking of Disciplinary Cases and Associated Costs


In 2004, the Enforcement Monitor raised the question of how the Board was tracking legal actions. In response, the OAG began providing the Board with quarterly Aging Case Status reports. The reports provide accountability of all cases referred to the office, as well as the dates of each phase of the case (assignment, pleading, hearing, settlement, etc.). A second report provides quarterly and year-to-date budget totals. In 2009, the Enforcement analyst implemented a detailed tracking spreadsheet to manage the Boards internal steps and timeframes for compliance with disciplinary requirements. The information allows managers to monitor case aging, statute concerns, and the status of their ongoing budget allocation. As a result, the Board has determined that the processing time has decreased from a high of 1,284 days in 2000, to 857 days at the end of FY2009/10.

ISSUE #6. Investigations


The Enforcement Program is allocated 16 peace officer positions to perform criminal and complex quality of care investigations. However, due in part to vacancies within enforcement management, up to five positions have been vacant for 6 or more months at a time beginning in July 2006. Contributing to these lengthy vacancies are required background processes which can take six to nine months, training academies (four months), and the establishment of a new hiring list. More recently, mandatory furloughs have reduced the number of hours staff can legally work by three days per month. As a consequence, case age has increased as less staff hours were available to perform the necessary work. During previous reviews a number of efforts (case reviews, approved overtime) were initiated to focus on closing the oldest cases and reducing the overall number of cases pending investigation. Case reviews have been ongoing with field investigative staff and continue to focus on case progress and closing older cases. Overtime has not been an option in the current fiscal environment. Despite these challenges, the additional positions from the CPEI offer the potential for the enforcement program to show marked improvements in its case statistics.

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ISSUE #7. Disciplinary Guidelines


Beginning in 2007, the Board began the extensive process of revising the Disciplinary Guidelines. The Board consulted with staff, legal counsel, and various stakeholders while drafting the proposed language. The revised Disciplinary Guidelines incorporate changes made to Dental Practice Act, remove outdated and unnecessary terms, ensure consistency between the Disciplinary Guidelines and the Dental Practice Act, and incorporate new changes necessary to ensure the Boards ability to provide consumer protection. The Board adopted the proposed text at the August 2008 Board meeting and directed staff to move forward with the rulemaking process. The proposed changes included model language, rationales, and specific factors to be used by an Administrative Law Judge when determining whether a license should be suspended, revoked, or placed on probation. The initial rulemaking package was filed with the Office of Administrative Law (OAL) in December 2008 and a regulatory hearing was held March 25, 2009. The final rulemaking package was filed with OAL in February 2010. In March 2010, staff was notified by OAL Staff Counsel that the final rulemaking package was disapproved for deficiencies in the rulemaking process, and the Board was granted 120 days to re-submit a corrected rulemaking package. The deficiencies were corrected and the final rulemaking was resubmitted to OAL in July 2010. While reviewing the re-submitted rulemaking, OAL Staff Counsel found inconsistencies between modified text and meeting minutes recording the Boards response to comments. The Board was granted an additional 120 days to correct the inconsistencies and notice the modified text for public comment. The final rulemaking package was noticed and was adopted by the Board in September 2010. The final rulemaking package is required to be resubmitted to OAL by November 19, 2010. The Board anticipates the regulatory package will be approved by OAL. Once codified, the Disciplinary Guidelines will assist the Boards Enforcement staff and the Attorney Generals Office in pursuing enforcement actions against dental licensees who are in violation of the law to better protect consumers. They will also assist the Administrative Law Judge in determining the penalty to be imposed by providing clear recommendations and rationale so that dental licensees are prevented from practicing and consumers are protected from dental licensees who commit serious violations of the law.

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48

PART 3. DENTAL BOARD OF CALIFORNIA


Enforcement Assessment 2009

In the Fall of 2009, the Board requested an outside assessment of their internal enforcement processes, to measure their progress and determine if there were any new barriers to efficiency and productivity. The areas reviewed included: Complaint Intake & Assignment Non-Sworn Enforcement Processes Sworn Investigative Services Enforcement Tools and Investigative Resources Administrative Discipline Processes Enforcement Program Data for Management Oversight Personnel Resources Peace Officer Training Requirements Policies and Procedures Customer Satisfaction Surveys A summary of each area is included below. Complaint Intake & Assignment In general, close management of the complaint process has shown marked improvements in the time frames for responding to an incoming complaint, complaint input, records requests, and consultant referrals. Staff workload and output is closely monitored through weekly staff meetings. Issuance of administrative citations after the licensee fails to provide requested records has also contributed to a reduction in complaint process time. Dental Consultants are utilized during the complaint intake process to evaluate the patient records along with any statements provided by the dentist to determine if the treatment met the standard of care. Additional consultants have been hired to reduce the backlog of pending complaints, and in-house training sessions have been provided to ensure consistency of the work product. Based on the Enforcement Monitors initial report, modifications to the closure letters were performed.

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Non-Sworn Enforcement Processes The probation monitoring program was evaluated. Non sworn inspection staff are responsible for the majority of the caseload and perform functions comparable to other allied health boards. Although this shift in workload allows sworn staff to focus on investigative work, it may take away from the inspectors primary function (to inspect dental offices for compliance with infection control guidelines). To limit safety concerns, probationers requiring toxicology testing are assigned to sworn investigative staff. The inspection program was also reviewed. An inspection worksheet was developed to ensure consistency of information gathered between offices. In April 2010, the result of the 15% program cut of fleet vehicles has impacted the Board inspectors ability to perform inspections and quarterly probation monitoring functions in the field. Inspectors must now attempt to carpool with sworn staff and schedule their visits to coincide with investigative travel, or rent vehicles as needed. It has been recommended that when the new case activity tracking system (the IAR) is in place, that inspectors also enter their time spent performing probation and inspection tasks to provide management with an additional tool to measure work performed in both program areas, and for cost recovery purposes. Sworn Investigative Services A number of processes were evaluated for compliance with the Enforcement Monitor recommendations and best practices. Initial case prioritization, case assignment and staff caseload procedures were reviewed and are within the recommendations. The high volume of unassigned cases was noted, as well as the extensive travel requirements of two offices statewide. The new positions allocated through CPEI will be primarily responsible for addressing the unassigned caseload. The investigative report format has been modified to meet current information security standards. Enforcement Tools and Investigative Resources Areas reviewed included access to law enforcement databases, toxicology services, evidence handling, case reviews, and case referrals for prosecution. The lack of direct access to the DOJ's California Law Enforcement Telecommunications System (CLETS), was noted during this assessment. However, the recently hired Enforcement Chief is actively pursuing setting up a contract with DOJ to establish access. Limitations to the existing toxicology services prompted the Board to seek a new vendor. In concert with DCA, a new contract is being established and will provide online 50

registration, witnessed collection services, expanded testing panels, and greater mailing and drop-off options for field collection. Criminal cases referrals lacked an effective tracking mechanism to measure whether investigators are performing due diligence, and whether filings are resulting in dismissals or successful prosecutions. Recommendations were made for policy and procedure improvements. Administrative case referrals are managed internally by a single analyst (Enforcement Coordinator). In response to the enforcement monitors reports, the Board receives quarterly reports from the AGO on case status and aging. The need for additional support was evident from the 2009 assessment. The CPEI has designated two additional two-year limited term analysts to help support this vital role. Enforcement Program Data for Management Oversight Several complaint and investigative status reports are provided to management staff and Board members at quarterly Board meetings. Additional reports showing case aging, Investigator activity and closure rates were proposed as additional tools for management to effectively evaluate the enforcement program in the future. Implementation of a new IAR program will provide additional reports to supplement this data and allow for future cost recovery efforts in the Inspection and Probation Monitoring programs as well. In addition, due to the current lack of training offered in the use of the CAS, the Board is working with the Medical Board to obtain copies of their procedure manuals to ensure that data collection, entry and reporting processes are being performed consistently and accurately. Personnel Resources Low staffing levels attributed to vacancies had been noted in earlier sunset reviews, and were revisited in the 2009 assessment. Investigator vacancies have contributed to case aging and low closure rates. The Board has taken several steps to address the resultant backlog by hiring retired annuitants to work quality of care cases on an interim basis. The appointment of a new Supervising Investigator for the Orange County office has resulted in a focused recruitment effort to fill existing vacancies. Once the hiring process is initiated, staff are required to complete either a limited or full background clearance to perform their enforcement functions. Previously, this background requirement was performed by outside law enforcement services. Several sworn staff have completed the Peace Officer Standards and Training (POST) certification course as background investigators. Staff will be able to perform this task internally at a significant cost and time savings.

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Failure to provide staff with regular performance appraisals was noted in earlier reports. The new Enforcement Chief is working with supervisory staff to ensure that probation monitoring and performance appraisals are being completed in a timely manner. Peace Officer Training Requirements During the assessment, concerns were raised that sworn staff were not meeting recommended training standards. A review of existing training profiles confirmed that at least 5 staff were out of compliance with legislatively mandated training requirements. Since the assessment, one investigator has been sent for instructor training and will begin providing regular training to staff. Based upon the time and cost of initial and refresher training, one instructor was considered adequate to provide minimum training for the Boards sworn staff. In addition, the enforcement staff has partnered with Medical Board to share training resources. Our instructor will assist Medical Board at their training sessions, and Medical Board has agreed to provide us with an additional instructor for our Boardspecific training dates. Shared resources will allow more individualized attention during sessions without the associated ongoing costs of maintaining instructor training levels for two or more people. Policies and Procedures Existing operational manuals were reviewed and noted to have one or more areas which were out of date or obsolete. Updates were recommended.

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