KAWEAH DELTA HEALTH CARE DISTRICT
MEMO
To:

District Board Members

From:

Marc Mertz, VP of Strategic Planning & Development
Deborah Volosin, Director of Community Engagement

Subject:

District Boundaries Study

Date:

May 29, 2019

In preparation for the special Kaweah Delta Health Care District Board meeting scheduled for
June 3rd to discuss district boundaries, we have attached a report for your review. We engaged
with QK, Inc. to help us conduct a study of California health care district regulations and
processes as well as any potential opportunities to merge with neighboring districts. The
attached report presents their findings. Representatives from QK, Inc. will attend the meeting on
the 3rd to answer any questions you may have. Kaweah Delta management will facilitate a
board discussion regarding district boundary opportunities and corresponding next steps.

 BOUNDARIES STUDY

 

IKAWEAH DELTA HEALTH CARE DISTRICT

 

 

MAY 2019

 



BOUNDARIES STUDY

KAWEAH DELTA HEALTH CARE DISTRICT
Prepared for:
Marc Mertz, Vice President of Strategic Planning
Deborah Volosin, Director of Community Engagement
216 South Johnson Street
Visalia, CA 93291
Phone: (559) 624-2511
(559) 624-2529

Consultant:

901 East Main Street
Visalia, CA 93292
Contact: Steve Brandt, AICP
Phone: (559) 733-0440

May 2019

© Copyright by Quad Knopf, Inc.
Unauthorized use prohibited.
Project #190032/02

 TABLE OF CONTENTS
Introduction............................................................................................................................................................. 1
The Study and Its Objectives ............................................................................................................................ 1

Executive Summary .............................................................................................................................................. 4
SECTION 1 - Kaweah Delta Emergency and Urgent Care Facilities ..................................................... 6
1.1 - Facilities within the District Boundary ............................................................................................... 6
1.2 - Facilities Outside the District Boundary ............................................................................................ 6
1.2.1 - Dinuba ........................................................................................................................................... 6
1.2.2 - Exeter ............................................................................................................................................. 8
1.2.3 - Lindsay .......................................................................................................................................... 8
1.2.4 - Woodlake/Three Rivers Area .............................................................................................. 9

SECTION 2 - Data Summary ............................................................................................................................ 11
2.1 - Population ................................................................................................................................................... 11
2.2 - Registered Voters and Participation Rates .................................................................................... 12
2.3 - Assessed Valuation of Properties ...................................................................................................... 16
2.4 - Community Facilities Financing ......................................................................................................... 18

SECTION 3 - Consolidation/Annexation Law and Procedures ........................................................... 21
3.1 - Consistency with LAFCo Policy ........................................................................................................... 21
3.2 - Consolidation ............................................................................................................................................. 22
3.2.1 - Initiation by Kaweah Delta HCD and Another Supportive District ..................... 22
3.2.2 - LAFCo Review and Protest Provisions ........................................................................... 23
3.2.3 - Effects of Consolidation ....................................................................................................... 25
3.3 - Annexation of Other Areas not within a District.......................................................................... 27
3.3.1 - Annexation Application Initiation and LAFCo Review Process ........................... 27

SECTION 4 - Analysis and Area-Related Recommendations ............................................................... 30
4.1 - Potential Consolidation/Annexation Conditions ......................................................................... 30
4.2 - Existing Services ....................................................................................................................................... 30
4.3 - District/Community Approaches....................................................................................................... 30

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page i

 LIST OF TABLES
Table 1 Kaweah Delta’s Visalia Emergency/Urgent Care Facilities Market Share, 2017 ......... 6
Table 2 Study Areas Population Estimates .............................................................................................. 12
Table 3 Registered Voters and Voter Participation Rates within Study Areas .......................... 14
Table 4 Assessed Valuation within Study Areas .................................................................................... 16
Table 5 Cost Impacts, Residential Properties – Bond Issues for Hospital Facilities (Kaweah
Delta only) ............................................................................................................................................................ 18
Table 6 Median Single-family Home Assessed Values ......................................................................... 18
Table 7 Median Single-family Assessed Values and Related Bond Issue Costs ......................... 20

LIST OF FIGURES
Figure 1 Study Areas ............................................................................................................................................ 3
Figure 2 Dinuba Rural Health Care Clinic .................................................................................................... 7
Figure 3 Exeter Rural Health Clinic................................................................................................................ 8
Figure 4 Lindsay Rural Health Care Clinic................................................................................................... 9
Figure 5 Woodlake Rural Health Care Clinic ........................................................................................... 10
Figure 6 Population Distribution within Study Areas ......................................................................... 13
Figure 7 2018 Primary Election Voter Distribution within Study Areas ..................................... 15
Figure 8 Property Assessed Value Distribution within Study Areas ............................................. 17
Figure 9 Consolidation Process Flow Chart ............................................................................................. 26
Figure 10 Inhabited Annexation Process Flow Chart .......................................................................... 29

APPENDICES
A

ER and Rural Health Care Usage Data

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page ii

 Introduction

INTRODUCTION
The Study and Its Objectives
At the time of the last, unsuccessful, Kaweah Delta District bond issue campaign to authorize
financing of needed Hospital facilities, there were two major concerns expressed by District
voters:
1. The cost of the proposed facilities; and
2. The fact that approximately 48% of the Hospital’s patients reside outside the Kaweah
Delta District and ‘were not sharing in the costs of building and operating the
Hospital.’ Approximately 24% of the patients reside in these study areas being
evaluated for consolidation or annexation in this report.
With respect to these concerns, Kaweah Delta is preparing for the badly needed “extra bed”
expansion of its facilities by reducing costs of and step-scheduling construction, and by
seeking all available non-bond issue financing. In addition, there is an effort to educate
stakeholders about the District’s finances, including the understanding that all the annual
District property tax revenues (for both facilities construction and Hospital operations) are
a very small fraction of the District’s total annual costs. In 2017, the total portion of the 1%
property tax collected for Hospital operations and maintenance was $1,334,210, which
provides less than one day of the operating costs of the Hospital.1 The overwhelming
majority of the costs are patient or public/private insurance financed.
It is also true that the rural health care clinics operated by Kaweah Delta in out-of-District
communities pay their own way from usage fees and revenues.
Nevertheless, Kaweah Delta District voters perceived an inequity, feeling that other nearby
Kaweah District Hospital-served areas should be part of the District. This could be achieved
in different ways for each outlying area. There are seven other hospital districts at least
partially within Tulare County besides Kaweah Delta. Three of them, Alta Hospital District,
Exeter District Ambulance, and Lindsay Local Hospital District do not operate a hospital.
There are only two District Hospitals – Kaweah Delta and Sierra View. The former Tulare
District Hospital is being operated by Adventist Health Care. The North Kern/South Tulare
Health Care District and Kingsburg Tri-County Healthcare District are mostly in other
counties.
In the Alta Hospital District area, and in the Exeter District Ambulance and Lindsay Hospital
District areas, amalgamation could be achieved by action of the District Boards, merging the
Districts through a process called district consolidation. In other areas – Woodlake, for
example, where Kaweah Delta also operates a rural health clinic – other forms of boundaries
change such as annexation are legally feasible.

1

CA State Controller’s Office, 2017

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 1

 Introduction
This study has been prepared to assist Kaweah Delta Health Care District and other
interested parties in evaluating the benefit, costs, and feasibility or desirability of
considering expansion of the District’s boundaries. To that end, the study provides data and
analysis for informed decision-making by both Kaweah Delta’s Board and its citizens and
other District Boards and their citizens. The areas included in the study are shown on the
attached Figure 1.

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 2

 Introduction

Figure 1
Study Areas

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 3

 Executive Summary

EXECUTIVE SUMMARY
This study documents and evaluates the costs and benefits provided by Kaweah Delta’s core
Hospital services to both the citizens within the District and the region, and the costs and
benefits of the Kaweah Delta medical facilities located in four out-of-District, bordering,
communities – Dinuba, Exeter, Lindsay and Woodlake. It then describes the legal feasibility,
and the processes, by which Kaweah Delta’s out-of-District service area citizens could
participate in District governance and operations.
Included in the summarized data from the study is the following:
•

The cost of Kaweah Delta’s operation and maintenance of the four rural health clinics,
and the revenues therefrom, are:

Dinuba
Exeter
Lindsay
Woodlake
TOTAL

12 Months Revenues and Costs
Cost
Income2
$1,348,000
$1,492,000
$8,206,000
$11,476,000
$721,000
$1,217,000
$857,000
$1,289,000
$11,132,000
$15,474,000

Visits
14,460
105,860
11,370
11,980
143,670

The amount of the revenues from each facility is determined by the fees required to
be charged for each service by public and private health care insurance. Kaweah Delta
provides the maximum patient services allowable within these reimbursable charges.
These facilities reduce the need for over-usage of core Kaweah Delta Urgent Care and
emergency room and Hospital facilities and provide revenues in compensation for
such services.
Rural health care clinic users benefit by having nearby health care; the Hospital and
emergency room benefit by reduction in their usage. It should be noted that Kaweah
Delta proposes to continue to provide these clinics whether or not District
consolidations or District boundary-change annexations take place.

2

•

Fifty-two percent of the Hospital’s inpatients are from within the current District
boundaries; 24% are from nearby, bordering, smaller communities. The balance of
the 48% of the 2,391,000 total inpatients (24%) are patients from elsewhere
attracted by local doctors and high-quality Hospital facilities and services.

•

Kaweah Delta’s assessed value tax base is $13,215,046,432. The corresponding tax
base for the rural health clinic-served community areas is $4,411,000,000,
approximately 33% as much.

Net patient revenues; estimated, 2018

Boundaries Study
Kaweah Delta Health Care District

May 2019
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 Executive Summary

3

•

Kaweah Delta’s annual tax-based revenues, including existing bond repayments, are
approximately $4,343,799 in 20173.

•

The legal processes for Districts’ consolidation, or annexations, are relatively simple
and are regulated by the Tulare County Local Agency Formation Commission (LAFCo)
to fully assure that such changes are made only in accord with the wishes of the
residents of any affected area. They can be initiated, for District consolidations, by
District Board agreements, or for annexations, by citizen petition. Such changes must
be based upon mutually decided and LAFCo approved agreements.

CA State Controller’s Office, 2017

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 5

 Kaweah Delta Emergency and Urgent Care Facilities

SECTION 1 - KAWEAH DELTA EMERGENCY AND URGENT CARE FACILITIES
1.1 - Facilities within the District Boundary
The Hospital emergency room revenues were approximately $40,610,000 in 2018;
corresponding expenses were $40,957,000.4
The Visalia Urgent Care, and ”Prompt Care” facilities’ revenues were approximately
$13,040,000, the corresponding costs were $8,860,000, in 2018.3
Patients that utilize the Kaweah Delta HCD as a healthcare provider are scattered throughout
the region. Based on location, patients may travel considerable distances for care. Kaweah
Delta is the largest provider of care in these communities. However, the breakdown by
community in Table 1 shows which communities utilize the District facilities most
frequently.
Table 1
Kaweah Delta’s Visalia Emergency/Urgent Care Facilities Market Share, 2017
Community
Visalia
Dinuba/Cutler/Orosi
Exeter
Woodlake
Lindsay
Three Rivers

Market Share
78.8%
45.1%
80.6%
82.8%
48.2%
61.9%

Source: OSHPD Inpatient Data Set Calendar Year 2017

Appendix A provides residence location-related information regarding emergency
department (emergency room, urgent care and prompt care) usage by patients using these
facilities.5

1.2 - Facilities Outside the District Boundary
1.2.1 - DINUBA
Kaweah Delta HCD operates a rural health care clinic located at 355 Monte Vista Drive in
Dinuba (Figure 2). It serves 14,400 patients annually in the Dinuba, Cutler, and Orosi
communities. The costs of, and revenues from, such services are $1,700,000 and $1,990,000
annually. The clinic is located within the boundaries of Alta Hospital District.
The Alta Hospital District contains approximately 50,602 people (with a registered voter
population of approximately 14,038). The assessed value of the properties in the District is
4
5

Estimated by extension of 9 months revenues
Kaweah Delta Health Care District, Steven Collings, Analyst, March 2019

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 6

 Kaweah Delta Emergency and Urgent Care Facilities
$2,660,999,263. Of the total population with Alta Hospital District, 47.0% resides in Dinuba,
26.9% in Cutler-Orosi, and 26.1% in the remaining unincorporated rural areas.
Even though their hospital closed years ago, the Alta Hospital District is still an active District
and still collects property taxes. Consolidation of that District and of Kaweah Delta Health
Care District could be effected by action of the two District Boards.

Figure 2
Dinuba Rural Health Care Clinic
Monte Vista Drive, Dinuba
The current taxation rate in the Kaweah Delta District for all Hospital costs, including
repayment of existing bond issues, is $0.018094 per $100 of assessed value. If a similar tax
rate on Alta Hospital District ratepayers was applied, it would result in annual revenues of
approximately $481,000. However, in the event of District consolidation, the assumption of
existing capital facilities bonded costs by the Alta ratepayers may be waived by mutual
consent of District Boards.
Perhaps typical of small Districts when their hospital is closed, Alta Health Care District had
tax-based revenues of approximately $467,000 in 2017/2018, with expenditures of $14,000
for Health Care Grants and $117,000 for general and administrative costs (annual Financial
Report for Year Ended June 30, 2018).

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 7

 Kaweah Delta Emergency and Urgent Care Facilities

1.2.2 - EXETER
Kaweah Delta HCD operates a rural health care clinic located at 1014 San Juan Avenue in
Exeter (Figure 3). It serves 105,860 patients annually. The costs of, and revenues from, such
services are $8,206,000 and $11,476,000 annually. The clinic is located within the
boundaries of Exeter District Ambulance.
The Exeter District Ambulance contains 15,294 people (with a registered voter population
of 5,665). The assessed value of the properties in the District is $1,220,648,355; 69.8% of the
population resides in Exeter, 30.2% in surrounding unincorporated areas.
The current taxation rate in the Kaweah Delta District for all Hospital costs, including
repayment of existing bond issues, is $0.018094 per $100 of assessed value. A similar tax
rate on Exeter District Ambulance ratepayers would result in annual revenues of
approximately $220,000. Again, assumption of existing bonded costs is not required to be
transferred to new ratepayers brought into Kaweah Delta HCD.

Figure 3
Exeter Rural Health Clinic
1014 San Juan Avenue, Exeter
1.2.3 - LINDSAY
Kaweah Delta HCD operates a rural health care clinic located at 839 N. Sequoia Avenue in
Lindsay (Figure 4). It serves 11,370 patients annually. The costs of, and revenues from, such

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 8

 Kaweah Delta Emergency and Urgent Care Facilities
services are $721,000 and $1,217,000 annually. The clinic is located within the boundaries
of Lindsay Local Hospital District.
The Lindsay Local Hospital District contains 20,083 people (with a registered voter
population of 5,502). The assessed value of the properties in the District is $987,860,159;
65.6% of the population resides in Lindsay, 34.4% in the surrounding unincorporated area.
The current taxation rate in the Kaweah Delta District for all Hospital costs, including
repayment of existing bond issues, is $0.018094 per $100 of assessed value. A similar tax
rate on Lindsay Local Hospital District ratepayers would result in annual revenues of
approximately $179,000. As before, assumption of existing bonded costs is not required to
be transferred to new ratepayers brought into Kaweah Delta HCD.

Figure 4
Lindsay Rural Health Care Clinic
839 N. Sequoia Avenue, Lindsay
1.2.4 - WOODLAKE/THREE RIVERS AREA
The Woodlake, Three Rivers and adjacent valley and foothill areas are served by a Kaweah
Delta rural health care clinic located at 180 E. Antelope Avenue in Woodlake (Figure 5). It
serves 11,980 patients annually. The costs of, and revenues from, such services are $857,000
and $1,289,000 annually.

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 9

 Kaweah Delta Emergency and Urgent Care Facilities
This area contains approximately 15,281 people (with a registered voter population of
approximately 6,028). The assessed value of the properties in the area is $1,335,023,308;
49.9% of the population resides in Woodlake, 14.3% in Three Rivers and 35.8% in the
unincorporated valley and foothill areas of this region.
The current taxation rate in the Kaweah Delta District for all Hospital costs, including
repayment of existing bond issues, is $0.018094 per $100 of assessed value. A similar tax
rate on Woodlake, Three Rivers, valley and foothill area ratepayers would result in annual
revenues of approximately $242,000. If annexation of these areas were proposed, the
District would need to state in its proposal if the new territories annexed would be required
to contribute to the existing bond repayment or not.

Figure 5
Woodlake Rural Health Care Clinic
180 E. Antelope Avenue, Woodlake

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 10

 Data Summary

SECTION 2 - DATA SUMMARY
The data collected for this report has been divided into various study areas to provide insight
into the distribution of residents, registered voters, and the overall assessed value of
property. These categories were chosen due to their potential impact on various future
actions of the District such as District consolidation or establishment of a bond assessment
through the Proposition 218 process.
The study areas are:
•

Kaweah Delta Health Care District

•

•

Alta Hospital District
o Dinuba
o Cutler/Orosi
o Balance of District

Lindsay Local Hospital District
o
Lindsay
o
Balance of District

•

Northeast County Area
o
Woodlake
o
Three Rivers Community
Services District (CSD)
o
Valley Area
o
Foothill/Mountain Area

•

Exeter District Ambulance
o Exeter
o Balance of District (including a
portion of Farmersville)

2.1 - Population
The total population for all the study areas is 252,090 residents. The Kaweah Delta HCD has
approximately 60% (150,830 residents) of that population, three times as many residents
as the next most populated study area, Alta Hospital District (50,602 residents).
Populations of each subarea are shown in Table 2. A population density map is provided as
Figure 6.

Boundaries Study
Kaweah Delta Health Care District

May 2019
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 Data Summary
Table 2
Study Areas Population Estimates
Study Area
Kaweah Delta Health Care District
Alta Hospital District
Within Dinuba
Within Cutler or Orosi
Balance of District
Exeter District Ambulance
Within Exeter
Balance of District
Lindsay Local Hospital District
Within Lindsay
Balance of District
Northeast County Area
Within Woodlake
Within Three Rivers CSD
Valley Area
Foothill/Mountain Area
TOTALS

Total
Population
150,830
50,602
23,772
13,610
13,220
15,294
10,520
4,774
20,083
13,167
6,916
15,281
7,631
2,182
3,725
1,743
252,090

% of
Total
59.8%
20.1%
9.4%
5.4%
5.2%
6.1%
4.2%
1.9%
7.9%
5.2%
2.7%
6.1%
3.0%
0.9%
1.5%
0.7%
100.0%

Source: American Community Survey 2017

2.2 - Registered Voters and Participation Rates
The total number of registered voters within the study areas is 99,684. The Kaweah Delta
HCD has approximately 69% (68,451 voters) of the total registered voters within the study
areas, five times as many registered voters as the next highest study area, Alta HCD (14,038
voters).
With respect to the voting participation rate in the last primary election of the corresponding
study areas, Exeter Ambulance HCD has the highest participation rate of all the study areas
(49.4%). Kaweah Delta HCD the third (35.3%), Alta HCD the lowest (28.4%).
If participation rates are low in a study area, it can be assumed that it may be less likely that
the served community would wish to garner votes to legitimately protest any reorganization
action, such as a consolidation or annexation. Due to the fact that 50% of the registered
voters within an area would need to file a written protest to a consolidation proposal to effect
termination of Board-agreed consolidation, or 25% to require a public vote, it seems unlikely
that areas with an election participation rate below 40% would effectively organize and
garner support to challenge Board-desired consolidation. The protest provisions and
processes for reorganization are discussed further in Section 3.

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 12

 Data Summary

Figure 6
Population Distribution within Study Areas

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 13

 Data Summary
Registered voter counts and primary election participation rates are shown in Table 3. A map
of the location of 2018 primary election voters is provided as Figure 7.
Table 3
Registered Voters and Voter Participation Rates within Study Areas

Study Area

Registered
Voters

Kaweah Delta Health Care District
Alta Hospital District
Within Dinuba
Within Cutler or Orosi
Balance of District
Exeter District Ambulance
Within Exeter
Balance of District
Lindsay Local Hospital District
Within Lindsay
Balance of District
Northeast County (no district)
Within Woodlake
Within Three Rivers CSD
Valley Area
Foothill/Mountain Area
TOTALS

68,451
14,038
7,337
2,461
4,240
5,665
3,371
2,294
5,502
3,109
2,393
6,028
2,201
530
1,341
1,956
99,684

% of
Total
68.7%
14.1%
7.4%
2.5%
4.3%
5.7%
3.4%
2.3%
5.5%
3.1%
2.4%
6.0%
2.2%
0.5%
1.3%
2.0%
100.0%

Voted in
2018
Primary
Election
24,129
3,986
1,797
617
1,572
2,796
1,676
1,120
1,928
1,068
860
2,798
588
284
828
1,098
35,637

% of
Total
67.7%
11.2%
5.0%
1.7%
4.4%
7.8%
4.7%
3.1%
5.4%
3.0%
2.4%
7.9%
1.6%
0.8%
2.3%
3.1%
100.0%

2018 Primary
Participation
Rate
35.3%
28.4%
24.5%
25.1%
37.1%
49.4%
49.7%
48.8%
35.0%
34.4%
35.9%
46.4%
26.7%
53.6%
61.7%
56.1%
100.0%

Source: Statewidedatabase.org

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Kaweah Delta Health Care District

May 2019
Page 14

 Data Summary

Figure 7
2018 Primary Election Voter Distribution within Study Areas

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Kaweah Delta Health Care District

May 2019
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 Data Summary

2.3 - Assessed Valuation of Properties
Assessed valuation of properties within the Study Area were gathered from Tulare County
through the Tulare County Assessor’s Office and GIS Departments. The total assessed
valuation of property was organized by each study area and summarized. This valuation
information may be used to calculate distribution of assessments related to existing health
care facilities operation and maintenance and to a future bond measure.
The total assessed valuation for all the study areas is $19.4 billion. The Kaweah Delta HCD
has approximately 68% ($13,215,046,432) of the total valuation, five times as much
assessed valuation as the next largest study area, Alta Hospital District ($2,660,999,263).
The assessed valuations of each study area are shown in Table 4. An assessed value map is
provided as Figure 8.
Table 4
Assessed Valuation within Study Areas
Study Area
Kaweah Health Care District
Alta Hospital District
Within Dinuba
Within Cutler or Orosi
Balance of District
Exeter District Ambulance
Within Exeter
Balance of District
Lindsay Local Hospital District
Within Lindsay
Balance of District
Northeast County Area
Within Woodlake
Within Three Rivers CSD
Valley Area
Foothill/Mountain Area
TOTALS

Total
Parcels
51,072
13,013
6,041
2,373
4,599
5,800
3,344
2,456
6,148
2,924
3,224
8,174
1,832
1,483
1,920
2,939
84,207

%
Parcels
60.7%
15.5%
7.2%
2.8%
5.5%
6.9%
4.0%
2.9%
7.3%
3.5%
3.8%
9.7%
2.2%
1.8%
2.3%
3.5%
100.0%

Assessed Value
$13,215,046,432
$2,660,999,263
$1,188,396,485
$309,461,788
$1,163,140,990
$1,220,648,355
$602,026,922
$618,621,433
$987,860,159
$454,274,342
$533,585,817
$1,335,023,308
$245,796,305
$312,660,449
$370,419,649
$406,146,905
$19,419,577,517

%
Value
68.1%
13.7%
6.1%
1.6%
6.0%
6.3%
3.1%
3.2%
5.1%
2.3%
2.7%
6.9%
1.3%
1.6%
1.9%
2.1%
100.0%

Source: Tulare County GIS and Assessor’s Office
Note: Approximately $759 million (3.9% of all assessed value for government facilities within the study areas) was
removed from the total assessed property value, as it does not contribute to bond repayment.

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 16

 Data Summary

Figure 8
Property Assessed Value Distribution within Study Areas

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Kaweah Delta Health Care District

May 2019
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 Data Summary

2.4 - Community Facilities Financing
It is currently envisioned by Kaweah Delta that the total amount(s) and timing, of bond issue
financing for essential new Hospital facilities would be significantly less than previously
contemplated; that maximum feasible usage of other financing sources would be employed.
In view of that assumption, data is presented here regarding calculated costs to homeowners
and other taxpayers for bond issues of $50, $75 and $100 million dollars. These bond issue
amounts, and the tax impacts thereof, might have to be repeated at some significantly later
date if facilities construction is planned on an as-needed basis.
Tables 5 and 6 provide data for quick estimation of approximate bond issue-related costs for
residential properties within Kaweah Delta only. (Approximate estimation of equivalent tax
rates for various study area-related District boundary combinations can be made based on
the assessed values in Table 4.) Table 6 specifically shows the variation of assessed values
through the study area and provides insight as to the level of how much of an assessment
may be within the corresponding community.
Table 5
Cost Impacts, Residential Properties –
Bond Issues for Hospital Facilities (Kaweah Delta only)6
Bond Issue
Amount
$50,000,000
$75,000,000
$100,000,000

$100,000
Assessed
Value
$20.57
$30.86
$41.14

$125,000
Assessed
Value
$25.71
$38.57
$51.43

$175,000
Assessed
Value
$36.00
$54.00
$72.00

$200,000
$250,000
Assessed
Assessed
Value
Value
$41.14
$51.42
$61.72
$77.15
$82.29
$102.86

Table 6
Median Single-family Home Assessed Values7
Community
Kaweah Delta Health Care District
Alta Hospital District
Exeter District Ambulance
Lindsay Local Hospital District
Woodlake
Three Rivers

6
7

Median Assessed Value
$201,721
$135,592
$160,573
$119,786
$105,622
$189,801

Assuming 3 ½ bond interest rate, 30-year bond
Tulare County Assessor Records

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 18

 Data Summary
The required capital recovery ‘rate’8 (.05437) remains the same regardless of the assessed
value upon which the capital recovery factor, at 30 years and 3 ½% interest is based.
Within the existing Kaweah Delta District boundaries, the recovery factor will apply to the
total assessed value of the District, $13,215,046,432.
Should Kaweah Delta Health Care District, for example, consolidate with Alta Hospital
District, which has an assessed value of approximately $2,659,000,000, the combined
assessed value of the two Districts would create a 20.1% increase in total assessed value.
The corresponding rate reductions enabling the same bond repayments of $50,000,000,
$75,000,000 or $100,000,000 bonds would be in the order of a 20% reduction in Kaweah
Delta costs. Multiple alternative scenarios are shown in Table 7 in the event the District were
to consolidate or annex other districts or areas.
It is critical to note that bond-based tax rates and resulting assessments relate not only to
homeowner costs but to major taxpayers such as industries and farms. It will be incumbent
upon Kaweah Delta, and to any cooperating District to fully involve such taxpayers in
planning for District boundary adjustments.
Although there are a number of alternative consolidation/annexation combinations, an
example of cost reduction would be the consolidation or annexation of all the study areas.
The total assessed value base for bond repayment by all study areas would be
$19,419,577,517; the resulting rate reductions would be in the order of 32% of Kaweah Delta
costs.

8 The capital

recovery factor is the uniform payment to be received for a set number of years such that the total
present value of all these equal payments is equivalent to a payment amount at a specific interest rate.

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Kaweah Delta Health Care District

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 Data Summary
Table 7
Median Single-family Assessed Values9 and Related Bond Issue Costs
Median
$50,000,000
Assessed
Bond Issue
Value
No Consolidation
Kaweah Delta Health Care District

$201,721

$41.50

$75,000,000
Bond Issue

$100,000,000
Bond Issue

$62.25

$83.00

With Kaweah Delta + Alta Hospital District Consolidation
Kaweah Delta Health Care District
Alta Hospital District

$201,721
$135,592

$34.54
$23.22

$51.81
$34.83

$69.08
$46.44

With Kaweah Delta + Exeter District Ambulance Consolidation
Kaweah Delta Health Care District
Exeter District Ambulance

$201,721
$160,573

$37.99
$30.24

$56.98
$45.36

$75.98
$60.48

With Kaweah Delta + Lindsay Local Hospital District Consolidation
Kaweah Delta Health Care District
Lindsay Local Hospital District

$201,721
$119,786

$38.61
$22.93

$57.92
$22.93

$77.22
$45.86

With Kaweah Delta + Woodlake, Three Rivers, and Unincorporated Area Annexation
Kaweah Delta Health Care District
Woodlake
Three Rivers CSD
Valley Area
Foothill Area

$201,721
$105,622
$189,801
$82,779
$149,653

$37.69
$19.73
$35.46
$15.47
$27.96

$56.53
$29.60
$53.19
$23.20
$41.94

$75.38
$39.47
$70.93
$30.93
$55.92

With Kaweah Delta + All Areas Consolidation/Annexation
Kaweah Delta Health Care District
Alta Hospital District
Exeter District Ambulance
Lindsay Local Hospital District
Woodlake
Three Rivers CSD
Valley Area
Mountain Area

9

$201,721
$135,592
$160,573
$119,786
$105,622
$189,801
$82,779
$149,653

$28.24
$18.98
$22.48
$16.77
$14.79
$26.57
$11.59
$20.95

$42.36
$28.47
$33.72
$25.15
$22.18
$39.86
$17.38
$31.43

$56.48
$37.96
$44.96
$33.54
$29.57
$53.14
$23.18
$41.90

Tulare County Assessor Records

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Kaweah Delta Health Care District

May 2019
Page 20

 Consolidation/Annexation Law and Procedures

SECTION 3 - CONSOLIDATION/ANNEXATION LAW AND PROCEDURES
There are multiple scenarios by which Kaweah Delta HCD could add territory into its District.
The Cortese-Knox-Hertzberg Local Government Reorganization Act of 2000 (CKH) governs
the provisions related to district boundary reorganizations. These provisions are
administered locally by Tulare County Local Agency Formation Commission (LAFCo). The
recommended reorganization processes available through the Tulare County LAFCo are as
follows:
•
•

Consolidation of two or more hospital districts; and
Annexation of new territory not within an existing hospital district.

Each one of the two reorganization processes are subject to various provisions of
notification, public hearing, and possible election before registered voters and/or property
owners within the territory affected. Each process is articulated in more detail within this
section.
District dissolution with subsequent annexation is another process for reorganization.
However, it is not recommended given perceived negative attitudes regarding dissolutions
and could provide to be difficult to garner support.
All procedural information related to the consolidation of districts was obtained from the
California LAFCo (CALAFCo) White Paper “The Metamorphosis of Special Districts: Current
Methods for Consolidation, Dissolution, Subsidiary District Formation and Merger.”
Annexation information was obtained from Tulare LAFCo’s Local Policies and Procedures
Manual.

3.1 - Consistency with LAFCo Policy
The preamble of CKH contains a number of legislative findings and declarations that serve
as a general guide for LAFCo and their purpose for being. The first and main declaration is
that it is the policy of the state to encourage orderly growth and development, as essential
to the social and economic well-being of the State.
The Legislature has also found, and declared within CKH, that a single multipurpose
governmental agency, such as City, is accountable for community service needs and financial
resources and, therefore, may be the best mechanism for establishing community service
priorities especially in urban areas. Nonetheless, the Legislature recognizes the critical role
of many limited purpose agencies, such as health care districts, especially in rural
communities. The Legislature also found that, whether governmental services are proposed
to be provided by a single-purpose agency, several agencies, or a multipurpose agency,
responsibility should be given to the agency or agencies that can best provide government
services.
The issue of consolidation or further annexation of underserved areas with any of the
hospital districts and service providers must be consistent with the policy guidance of CKH
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 Consolidation/Annexation Law and Procedures
and LAFCo’s mandate to provide service accountability to residents. Kaweah Delta HCD is
providing services to residents both inside and outside of its boundaries, some of which are
within other districts which are not providing services. Therefore, it is reasonable to
consider Kaweah Delta HCD as the best agency to continue providing such services,
consistent with LAFCo’s general mandates and principles.

3.2 - Consolidation
Under CKH, "District Consolidation" means the uniting or joining of two or more like special
districts into a single new successor special district.10 The proceedings for a consolidation of
special districts must be conducted according to the principal act of the district to be formed,
in this case the Local Health Care District Law (Health and Safety Code Sections 32000 to
32492).

3.2.1 - INITIATION BY KAWEAH DELTA HCD AND ANOTHER SUPPORTIVE DISTRICT
Consolidation may be initiated by the legislative bodies of two or more like special districts.
In order to start the consolidation process, the districts must adopt "substantially similar''
Resolutions of Application to consolidate the districts.11 The Resolutions of Application
must:12
•
•
•
•
•
•

State the proposal is made [pursuant to Part 3 of Division 3 of the Act [(§ 56650 et~.)];
State the nature of the proposal and list all proposed changes of organization;
Set forth a description of the boundaries of the affected territory accompanied by a
map showing the boundaries;
Set forth any proposed terms and conditions;
State the reason or reasons for the proposal; and
State whether the proposal is consistent with the sphere of influence of any affected
district.

Following adoption of the “substantially similar” Resolutions of Application, an application
that contains the following items13 must be filed with the Local Agency Formation
Commission (LAFCo):
•
•
•
•

A resolution of application initiating the proposal (with the above-mentioned
information);
A statement of the nature of the proposal;
A map and description acceptable to the LAFCo Executive Officer of the boundaries of
the subject territories for each proposed change of organization or reorganization;
Any data and information that may be required by any regulation of the Commission;

Government Code Section 56030
Government Code Section 56853(a)
12 Government Code Sections 56654 and 56700
13 Government Code Section 56652
10
11

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 Consolidation/Annexation Law and Procedures
•
•

Any additional data and information that may be required by the executive officer
pertaining to any of the matters or factors which may be considered by the
commission; and
The names of the officers or persons, not to exceed three in number, who are to be
furnished with copies of the report by the executive officer and who are to be given
mailed notice of the hearing.

Lastly, a Plan for Services must also be provided as part of the application to LAFCo. This
Plan for Services must contain the following information:14
•
•
•
•
•
•

An enumeration and description of the services to be extended to the affected
territory;
The level and range of those services;
An indication of when those services can feasibly be extended to the affected
territory;
An indication of any improvement or upgrading of structures or other conditions the
local agency would impose or require within the affected territory if the change of
organization or reorganization is completed;
Information with respect to how those services would be financed; and
Possible increase in governing Board size of a consolidating District, and potential redrafting of in-District boundaries for Board members.

3.2.2 - LAFCO REVIEW AND PROTEST PROVISIONS
It is important to note that LAFCo may change the terms of the consolidation set forth in the
districts' proposal.15 However, after any material modification to any of the terms of the
consolidation proposal, LAFCo must provide mailed written notice of the change to the
districts and cannot move forward on the consolidation for 30 days following that mailing
without the districts' written consent.16 During this 30-day time period, either district may
file a written demand with the LAFCo Executive Officer, demanding that LAFCo make
determinations only after notice and hearing on the proposals. If no written demand is made
by either district, LAFCo may make those determinations without notice or a hearing.
However, LAFCo cannot make any changes that would delete or add districts to the proposed
consolidation without the written consent of the applicant districts.17
Upon receiving the districts' proposals to consolidate, LAFCo must approve, or conditionally
approve, the consolidation unless LAFCo receives a protest petition from the statutorily
mandated number of landowners/voters required to submit the consolidation to an election,
as described below.18 If a conflicting proposal is submitted to LAFCo within 60 days of the

Government Code Section 56653(b)
Government Code Section 53853(b)
16 Government Code Section 56853(b)
17 Government Code Section 56853(c)
18 Government Code Section 56853(a)
14
15

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 Consolidation/Annexation Law and Procedures
submission of the proposal to consolidate, LAFCo cannot approve the proposal to consolidate
until it considers the conflicting proposal.19
LAFCo will order consolidation subject to confirmation of the voters, if it receives protests
meeting the voter/landowner requirements20. Since the District is not a landowner-voter
district, Government Code Section 57077.2(b)(1) sets forth the following protest threshold:
A. In the case of inhabited territory, protests have been signed by the following:
i.

ii.
iii.

At least 25% of the number of landowners within the territory subject to the
consolidation who own at least 25% of the assessed value of land within the
territory;
At least 25% of the voters entitled to vote as a result of residing within, or
owning land within, the territory; or
At least 50% of such voters.

A 25% protest requires LAFCo to submit a consolidation to the voters as calculated pursuant
to Government Code Section 57077.2(b)(1), the election will be held within the territory of
each district ordered to be consolidated.21 LAFCo's resolution must provide the question to
be submitted to the voters, specify any consolidation terms and conditions, and state the vote
required to confirm the consolidation. The election procedures and requirements are set
forth in Government Code Section 57125 et seq.
If an election is held and the majority of voters within the territory of any district vote against
the consolidation, LAFCo must adopt a certificate of completion terminating proceedings.22
However, if the majority of the voters in both districts ordered to be consolidated vote in
favor of consolidation, the LAFCo Executive Officer must execute a certificate of completion
confirming the order of consolidation.23
If the number of protests does not reach either of the 25% thresholds described above, no
election is required to be held and LAFCo must execute a certificate of completion upholding
the consolidation and making the requisite filings.24
If a 50% protest is received, no election will be held, and LAFCo will terminate the
proceedings.
A flowchart that delineates the procedures of the consolidation process is provided as Figure
9.25

Government Code Section 56657
Government Code 57077.2(b)(1)
21 Government Code Section 57118(a)
22 Government Code Sections 57177.5(b) and 57179
23 Government Code Section 57177.5(a)
24 Government Code Section 57200
25 (San Diego Local Agency Formation Commission 2019)
19
20

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 Consolidation/Annexation Law and Procedures

3.2.3 - EFFECTS OF CONSOLIDATION
After the LAFCO Executive Officer files, the requisite certificate of completion, the
consolidated district succeeds to all the ''powers, rights, duties, obligations, functions, and
properties of all predecessor districts" which were consolidated to form a consolidated
district. Included in these rights and duties, a consolidated district becomes liable to all debts
of predecessor districts because it is as if the "consolidated district had been originally
formed under the principal act26," unless otherwise specified in the mutual proposal of the
agreed upon resolution of application to consolidate .
Finally, the effective date of the consolidation is the date set forth in LAFCO's resolution, so
long as it is neither earlier than the date the certificate of completion is executed, nor later
than nine months after an election in which the majority of voters approved the
consolidation.27 If LAFCo's resolution does not establish an effective date, the consolidation
is effective on the date the consolidation is recorded by the county recorder.28

Government Code Section 57500
Government Code Section 57202(a)
28 Government Code Section 57202(c)
26
27

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 Consolidation/Annexation Law and Procedures

Figure 9
Consolidation Process Flow Chart

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 Consolidation/Annexation Law and Procedures

3.3 - Annexation of Other Areas not within a District
"District Annexation" means the inclusion, attachment, or addition of territory to a special
district that was previously not within any like special district.29 Annexation of territory
would require outreach and discussion with the residents of the area to determine their
willingness to join the district. Approaching neighborhoods or communities that have a
centralized membership, such as a Board of Directors, Neighborhood Watch, Chamber of
Commerce or some other similar community-based organization, would likely be needed to
determine feasibility of annexation of a given area.

3.3.1 - ANNEXATION APPLICATION INITIATION AND LAFCO REVIEW PROCESS
For an annexation application, the petitioner, which may be the Kaweah Delta HCD, is
required to consult with Tulare County LAFCo about the proposal to determine legitimacy of
the boundaries proposed and any other issues which may arise as part of the application.
After a pre-consultation meeting, the District would submit an application that contains an
initiating resolution of the annexation, information regarding the proposal, a processing fee,
and any other required information that may have been required during the consultation
meeting. All the required information and documents for an application are listed below
(Tulare County LAFCo 2019):
•
•
•
•
•
•
•
•
•
•
•
•
•

Proposal Questionnaire
Map of Annexation Area
Legal Description of Annexation Area
CEQA Environmental Assessment
CEQA Environmental Finding
Department of Fish and Wildlife Notice of Determination receipt
Initiating Resolution/Petition
Plan for Services
A signed consent form for each assessment parcel providing consent
Non-refundable filing fee payable to Tulare County LAFCo
Evidence of completed pre-noticing (if applicable)
A signed Indemnification Agreement
A completed Financial Disclosure Statement

LAFCo staff would determine whether the application is complete, analyze the proposal to
see if it meets the requirements of CKH and LAFCo policy, write a staff report, and set a public
hearing or meeting date. At the scheduled meeting or public hearing, the Commission would
review staff analysis, receive oral and written testimony and adopt a resolution approving
or denying the proposed annexation with or without conditions.

29

Government Code Section 56017

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Kaweah Delta Health Care District

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 Consolidation/Annexation Law and Procedures
As part of the review of the annexation application, LAFCo considers the following factors:30
Pursuant to Government Code 57000 and unless the process can be waived, the Commission
is required to conduct “protest proceedings” to determine whether the proposal can be
ultimately approved without election (less than 25% protest), whether an election should
be held (greater than 25% but less than 50% protest), or whether the proposal must be
terminated due to majority protest (more than 50% protest).
If approved, LAFCO certifies that the change of organization is complete, has the change of
organization recorded by the County Clerk, notifies interested Local and State Agencies and
other interested parties of the change and files a Statement of Boundary change with the
State Board of Equalization (BOE). Changes that are filed with the BOE by December 1st
affect the property tax rate (if applicable) for the tax year beginning March 1st of the
following year. The BOE charges a filing fee that is based upon the size of the annexation.
This fee is paid by the applicant of annexation.
A complete flow chart of the annexation process is provided as Figure 10.31

30
31

Government Code Section 56668
(San Diego Local Agency Formation Commission 2019)

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 Consolidation/Annexation Law and Procedures

Figure 10
Inhabited Annexation Process Flow Chart

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Kaweah Delta Health Care District

May 2019
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 Analysis and Area-Related Recommendations

SECTION 4 - ANALYSIS AND AREA-RELATED RECOMMENDATIONS
4.1 - Potential Consolidation/Annexation Conditions
Districts, or areas considering consolidation or annexation should not be responsible for
taxes based on past Kaweah Delta bond issue repayment costs.
Agreements regarding consolidation or annexation should consider the possibility that a
percentage of the tax revenues from such actions be utilized, to the extent feasible, to expand
health care services in the participating communities.

4.2 - Existing Services
Existing services provided by Districts considering consolidation, such as the ambulance
service provided by Exeter District Ambulance, could conceivably be expanded to serve
other communities such as Woodlake, Lindsay, Three Rivers, and Cutler/Orosi.

4.3 - District/Community Approaches
It is critical that all Districts and potential service area governments representing possible
candidates for consolidation or annexation be openly and affirmatively contacted at an early
date.
Such contacts should include communities without rural health care services, and a
domesticated need for specific services or facilities.

Boundaries Study
Kaweah Delta Health Care District

May 2019
Page 30

 APPENDIXA

ER AND RURAL HEALTH CARE USAGE DATA

 

ER Rural Core
Analysis

Steven Collins
Analyst

MARCH 2019 (?Al Kaweall D6113.

MGPE THAN MEDICINE LIFE

 

 

Research Overview

- Objective:

For individuals who utilize the ED and Rural Health Clinics, where are
those patients coming from? How far are they traveling to reach the
loca?on?

Limiting to zip codes that had more than 5 individuals utilizing.
- Research Time Frame:
Individuals who utilized the ED or Rural Health Clinic in 7/18.

ED

Postal Code Count

 

93291
93277
93274
93292
93221
93223
93247
93257
93286
93618
93647
93235
93230
93615
93212
93256
93245
93267
93219
93272
93275
93227
93279
93278
93271

16,411
14J33

11,203
11756
1&335
2653
11608
2500
2253
L835
L400
L298
L202
691
623
533
507
477
429
399
365
359
348
286

 

 

Dislonce
Less than 5 Miles 40.62%
5 10 Miles 25.73%
10-15 Miles 12.01%
15-20 Miles 6.74%
2025 Miles 6.26%
25+ Miles 

 

Dinuba Rural Health Clinic


1 9
"3 John Muir 
Wilderness;

                 

 

Po?alCode Counl
93618 L349
93647 180 
93291 128 ?1
93277 114 .
93292 100 11
93654 96 
93615 81 
93221 75
93286 58
93247 46
93223 37
93274 37
93646 37
93631 25
93675 15
93235 15
93648 13
93257 13
93666 13
93662 12
93227 8
93657 7
93267 7 .

Giant Sequoia
National Monument

 

Distance Percent
Less Than 5 Miles 55.59%
5-10 Miles 14.35%
10-15 Miles 6.28%
15-20 Miles 12.55%
20?25 Miles 5.93%
25+ Miles 5.30% .

Hanlord
Lemoore?

Exeler Rural Health Clinic

 

Postal Code
93221 3.651
93277 1.940
93292 1 .935
93247 L835
93291 L776
93223 L615
93286 L397
93274 1.126
93257 L008
93235 272
93267 227
93618 199
93230 108
93271 86
93647 82
93244 72
93270 52
93615 47
93279 45
93265 43
93290 40
93256 39
93258 36
93275 33
93245 33

Distance Percent
Less than 5 Miles 29.41%
5 - 10 Miles 33.76%
10-15 Miles 22.37%
15?20 Miles 7.94%
20-25 Miles 2.60%
25+ Miles 3.91% .

 

 

 

Lindsay Rural Health Clinic

0 - ., - 1111;";
Sanger 0 ,4



 

Postal Code Count

93247 1,858 ?lma Read?e-
93257 30 

93221 19 1 9
93267 14 .. --Sequoi-
1 . 

1
1

     

Distance Percent
Less ihcm 5 Miles 57.87%
5?10Miles 13.31%
10-15 Miles 20.52%
15-20 Miles 5.95%
20-25 Miles 0.52%
25+ Miles 1.82% .

 
 

National Pa

93274
93277
93291
93292
93223
93286
93258 1
93270 14 
1
1

.499,

?2

0rd



93265 Corcor.
9361 8
93235 6 .

 

 

 

 

 

 

- - Seqnma -. ..
6 . 9

Woodlake Rural Health Clinic

130

     

0 

Giant Sequoia
National Monument

 

Poslol Code Coun?r
93286 L50l ?9??39
93292 206
93277 1 6
93274 1 7

93291 166

93221 1 9

1 5
1 2

93235
93257 Dislc: nce Perc enf

93247 66 . Less than 5 Miles 46.91%
93223 51 . a, 5 - 10 Miles 13.26%
93618 43 . 10-15 Miles 18.83%
93244 28 1520 Miles 8.47%
93647 27 20-25 Miles 5.54%
93271 27 25+ Miles 7.00% .
93230 24
93615 12
93267 11
93654 11
93245 8
93227 7
93278 6
6
6
6

 

93279
93290
93662

 

 

.mwnogmc?omc 

.zcm ?53: