California SB 43: Grave Disability, Substance Use, LPS Holds

California SB 43, signed by Governor Gavin Newsom in October 2023, rewrites the state’s definition of “gravely disabled” so more people with severe mental illness or addiction can be placed under involuntary treatment or conservatorship. The law adds personal safety and necessary medical care to the list of basic needs a person must be able to meet, and it makes severe substance use disorder a standalone basis for a finding of grave disability. Every California county must enforce the changes as of January 1, 2026.¹²

What “Gravely Disabled” Now Means

Before SB 43, someone qualified as gravely disabled only if a mental health disorder or chronic alcoholism kept them from providing their own food, clothing, or shelter. A person could be visibly deteriorating on the street, and if they managed to eat and find a doorway to sleep in, the legal system had almost no way to intervene.

SB 43 amends Welfare and Institutions Code Section 5008(h) in two ways. It adds two new basic needs, personal safety and necessary medical care, and it broadens the qualifying conditions to include severe substance use disorder, either alone or with a mental health disorder.³ Under the amended statute, a person is gravely disabled if, because of one of those conditions, they cannot provide for food, clothing, shelter, personal safety, or necessary medical care.

Personal safety targets people whose impaired cognition puts them in recurring physical danger. Los Angeles County’s implementation guidance lists examples like walking into traffic, being unable to recognize ongoing victimization, or severely impaired judgment that creates life-threatening situations.⁴ The test is whether the person can survive safely in the community without being detained.

Necessary medical care covers physical health problems likely to cause serious injury or death if untreated. Untreated infections, diabetes requiring regular medication, and wounds a person cannot manage on their own can now support a grave disability finding, so long as a psychiatric or substance use condition is what prevents them from getting care.²

Severe Substance Use Disorder on Its Own

The biggest practical change is who counts. Before SB 43, involuntary holds and conservatorships based on substance use were limited almost entirely to chronic alcoholism. Someone addicted to fentanyl or methamphetamine, no matter how severe the addiction, generally could not be conserved unless they also carried a separate mental health diagnosis. SB 43 removes that requirement. A severe substance use disorder alone is now enough.²

Severity is determined using established diagnostic standards. Under the DSM-5-TR, a substance use disorder qualifies as severe when a person meets six or more of eleven criteria, including using far more of a substance than intended, failed attempts to stop, spending most of their time obtaining or recovering from the substance, continued use despite serious consequences, and increasing tolerance.⁵ Tolerance and withdrawal that occur during legitimate medical treatment, such as prescribed pain medication, do not count.

How Someone Gets Detained or Conserved

SB 43 does not create a new detention process. It expands who qualifies for the existing three-stage pathway under the Lanterman-Petris-Short Act.

The 72-Hour Hold

Under Section 5150, a peace officer, the professional in charge of a county-designated treatment facility, attending staff at such a facility, a mobile crisis team member, or a county-designated professional may place a person on a 72-hour hold if there is probable cause to believe the person is gravely disabled, a danger to themselves, or a danger to others.⁶ Family members cannot initiate a hold directly, but they can give a statement to someone who is authorized. Intentionally providing a false statement for this purpose carries civil liability.

The 14-Day Certification

If evaluation during the 72 hours shows the person is still gravely disabled or dangerous and has not accepted voluntary treatment, the facility may certify them for up to 14 additional days of intensive treatment under Section 5250.⁷ The person is entitled to a certification review hearing within four days.⁸ Section 5250 also carries an important limit: a person cannot be found gravely disabled if a family member, friend, or other responsible person confirms in writing that they are willing and able to help meet the person’s basic needs.

LPS Conservatorship

For people who remain gravely disabled after the shorter holds, the county may petition for an LPS conservatorship under Section 5350. A conservator can be given authority over the person’s care, their estate, or both.⁹ Conservatorships last one year and must be renewed through a new petition filed two to three months before expiration. If the county does not renew, the conservatorship ends automatically.¹⁰

Legal Protections That Still Apply

SB 43 broadened who can be detained. It did not weaken the safeguards attached to detention.

The court must appoint counsel for a proposed conservatee within five days of the conservatorship petition being filed. In certification review hearings, the detained person has the right to an attorney or a county patients’ rights advocate.¹¹⁸
A proposed conservatee can demand a court or jury trial on whether they are gravely disabled. The demand must be made within five days of the conservatorship hearing, and trial must begin within ten days of the demand.⁹
The court must find grave disability beyond a reasonable doubt, the same standard used in criminal cases.¹⁰
Conservatorships expire after one year and require a new petition to continue.
The willing-caretaker exception in Section 5250 blocks a grave disability finding when someone confirms in writing that they will help meet the person’s basic needs.

The beyond-a-reasonable-doubt standard is worth pausing on. It is the highest burden of proof in American law. Expanding the definition of grave disability did not lower what the government must show to take someone’s liberty.

SB 43 did add one new evidentiary rule that critics have flagged: a hearsay exception allowing health practitioner statements in medical records to be discussed by an expert witness during conservatorship hearings.

When Counties Must Enforce It

SB 43 took effect as state law on January 1, 2024, but the statute let counties delay enforcement by adopting a resolution of their governing body. The outer deadline for that deferral was January 1, 2026.³ Los Angeles and San Francisco implemented earlier. Other counties used the extra time to expand treatment capacity, train staff, and update evaluation protocols. As of January 1, 2026, all California counties must enforce the expanded standard.¹

Referrals for conservatorship evaluations come from hospitals, designated treatment facilities, and community clinics, not from individuals or family members directly. Medi-Cal covers medically necessary services for eligible beneficiaries, and counties pick up costs that fall outside Medi-Cal or other insurance.¹² Families of conservatees do not bear the treatment costs.

SB 43 Is Not CARE Court

California launched a separate involuntary treatment program around the same time, the CARE Act (SB 1338). The two are distinct. CARE Court is limited to adults diagnosed with schizophrenia spectrum disorders, other psychotic disorders, or bipolar I disorder with psychotic features, and the person must be deteriorating in the community.¹³ SB 43 applies to anyone who meets the broader grave disability standard, including people whose only qualifying condition is severe addiction.

The two programs can interact. If someone in CARE Court fails to follow their treatment plan, that non-compliance creates a legal presumption that no less restrictive option exists, which can lead to a conservatorship referral. When LPS proceedings start within six months of CARE Court participation, evidence of CARE plan non-compliance may be introduced, though refusal to take medication specifically cannot be used.

Criticisms of the Law

Civil liberties and disability rights organizations have objected to SB 43 on several grounds.

Treatment capacity is the first. Expanding who qualifies means little without enough psychiatric beds, residential centers, and trained clinicians. Early implementation data from counties that adopted the law in 2024 showed significant shortages of locked subacute beds and long-term residential placements. A person found to meet the conservatorship standard can end up detained without receiving meaningful treatment.

Disproportionate impact is the second. Given the racial demographics of California’s unhoused population and documented disparities in how mental health conditions are diagnosed across racial groups, critics argue Black and Latino Californians will be subjected to involuntary state control at higher rates.

Some researchers also question whether involuntary treatment produces better outcomes than intensive voluntary services. Studies on court-ordered substance use treatment have shown mixed results, and there is evidence that coerced treatment can increase overdose and relapse risk compared to voluntary alternatives.

Supporters counter that the old standard left people dying on the street while the legal system stood by, and that expanding the definition was necessary to reach the most vulnerable residents. The tension between individual autonomy and state intervention in a crisis has run through California law for decades, and SB 43 has sharpened it.

1
San Mateo County Health. Senate Bill 43 Launches, CARE Court Expands in San Mateo County
2
Office of Governor Gavin Newsom. Modernizing Conservatorship Law: SB 43
3
California Legislative Information. California Welfare and Institutions Code WIC 5008
4
Los Angeles County Department of Mental Health. Senate Bill 43 (SB 43) FAQ
5
National Center for Biotechnology Information. DSM-5-TR Criteria for Diagnosing and Classifying Substance Use Disorders
6
California Legislative Information. California Welfare and Institutions Code WIC 5150
7
California Legislative Information. California Welfare and Institutions Code WIC 5250
8
California Legislative Information. California Welfare and Institutions Code WIC 5256
9
California Legislative Information. California Welfare and Institutions Code WIC 5350
10
Superior Court of California, County of Santa Clara. LPS (Mental Health) Conservatorship
11
Justia Law. California Code WIC 5350-5371
12
Department of Health Care Services. SB 43 FAQs
13
California Courts Newsroom. Eligibility