Community Care Facilities

Investigation can be conducted over the phone. The frequency of follow-up with the facility for outbreak updates will be at least bi-weekly, but more frequently as needed and determined by Outbreak Management Branch (OMB) MD.

Inform the facility that they will be included on a public outbreak notification list posted on the LAC Public Health website until the facility demonstrates that there are no new cases at the facility for at least 14 days and outbreak is resolved.

Note: All staff in CCLD licensed adult and senior care facilities who are fully vaccinated and eligible for bivalent booster doses should receive their recommended booster doses. The bivalent booster dose is not mandatory; however it is the best defense against the currently circulating strains of COVID-19. If a fully vaccinated staff member has been subsequently infected with COVID-19, they may defer receiving the booster dose up to 90 days after clinical diagnosis or first positive test. Staff in DCFS facilities are not required to be fully vaccinated or boosted, but they are highly recommended to do so.

Additional Guidance and Resources:

• Guidance for Community Care Facilities
• Bed Positioning Guidance
• Information for Health Facilities

Low-Risk Community Care Facilities:

These are short- or long-term residential facilities that meet any one of the following descriptors:

• Residential facilities for adults licensed by the California Community Care Licensing Division (CCLD) including Residential Care Facilities for the Elderly (RCFEs) and Adult Residential Facilities (ARFs). For facility types see: www.cdss.ca.gov/inforesources/community-care/ascp-centralized-application-units. See below for separate definition of DCFS-affiliated congregate care facilities.
• Residential behavioral health treatment facilities, such as substance use or mental health treatment facilities.
• Group homes for adults not licensed by the State, which provide housing and assistance with activities of daily living or other need.

High-Risk Community Care Facilities:

Facilities that provide caregiving services primarily to residents with at least two or more of the following:

• Residents older than 65 years of age.
• A memory care unit or at least 25% residents with dementia or severe mental illness diagnosis.
• Provide medical care to residents who are non-ambulatory.
• Serve residents that require regular direct on-site medical care.

DCFS-affiliated congregate care facilities

• CCLD-licensed residential facilities caring for minors age 6 through 17 and non-minor dependents age 18 through 21 in out-of-home care, including Short-Term Residential Therapeutic Programs, Community Treatment Facilities and Transitional Shelter Care Program Facilities.

Emergency shelters for isolation for DCFS-affiliated youth diagnosed or suspected of COVID-19 and for quarantine of youth contacts of confirmed COVID-19 cases

• Small apartments where individual youth or youth from the same household are housed for short term stays due to isolation or quarantine needs.
• Supervision is provided 24 hours daily onsite by disaster service workers in 8 to 12 hour shifts with staff sleeping onsite and providing assistance with meals, bathing, recreation, etc.

1. Always encourage all staff and residents to follow physical distancing and adhere to hand hygiene guidance as much as possible.
1. Signage should be posted to reinforce frequent hand washing, cover your cough, and maintain physical distancing.
2. Provide accurate and updated Public Health materials to facility- including posters, handouts, etc. available at http://publichealth.lacounty.gov/acd/ncorona2019/printmaterials.htm.
2. Ensure indoor masking at the facility for staff and visitors (well-fitting masks for visitors and, medical grade (surgical mask) or N-95 for caregivers).
1. Source control is required by all staff and visitors in all indoor resident areas, common or shared areas, walkways, or where residents and/or staff congregate, with exceptions listed for visitation and group activities/communal dining.
2. Staff working alone in closed areas do not need source control unless they are moving through common spaces where they may interact with other staff or residents.
3. Medical grade surgical/procedure masks should be worn by any resident that is confirmed or suspected to have COVID-19 who is around others.
4. All residents should be encouraged to wear masks when outside their room. This includes residents who regularly leave the facility for care (e.g. hemodialysis patients).
5. Residents who, due to age or underlying cognitive or medical conditions, cannot wear masks, outside their room should not be forcibly required to wear masks and should not be forcibly kept in their rooms. However, masks should be encouraged as much as possible. Children under 2 should not be required to wear masks.
6. When staff are in resident rooms, residents should cover their noses and mouths as much as possible. Residents can use tissues for this or masks.
3. Increase environmental cleaning throughout the facility to 3 times a day (if possible) with emphasis on high touch surfaces and objects such as doorknobs, bannisters, countertops, faucet handles, and phones, particularly in the unit where case(s) were located. Use EPA-registered cleaning agents and follow the label directions.
4. Identify a mechanism for the facility to obtain SARS CoV-2 samples and to send these specimens from the facility to a commercial clinical laboratory. If a facility is unable to obtain DPH recommended SARS CoV-2 testing through a commercial laboratory or does not have clinical staff on site to administer the test, see Testing Recommendations below.
5. Response testing should be initiated following the detection of a positive case. Refer to Community Care Facilities guidance.
6. Plan for ways to continue essential services if on-site operations are reduced temporarily.
   
   1. Restrict group activities, field trips, and communal dining in accordance with Community Care Facilities guidance. For youth in DCFS-affiliated congregate care facilities, communal dining can be maintained as long as youth are assigned to cohorts appropriately by COVID status/exposure status and groups are small and stable.
   2. Staff may eat together in staff breakrooms or a separate designated area, but physical distancing of six feet or more between persons, as well as wearing medical grade (surgical masks) unless eating, must be enforced at all times while eating. Maintaining physical distancing should determine how many staff members can be in the room at the same time, depending on the size of the room. Wipes should be provided for staff to clean up after finishing their breaks.
7. Plan for employee absences and create a back-up/on-call system.
8. Immediately implement symptom screening for all staff, visitors, and, if feasible, residents.
1. Every individual entering the community care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) regardless of reason, should be asked about COVID-19 symptoms and exposure to a COVID-19 positive person. An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately.
2. Records are to be kept of screening.
3. Facilities should limit access points and ensure that all accessible entrances have a screening station.
4. Anyone with a fever (100.4° F or 38° C) or symptoms (fever, chills, cough, shortness of breath, new loss of taste or smell, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) should not be admitted entry.
9. Restrict all volunteers and non-essential personnel (e.g. barbers) during an outbreak.
10. Post a notification letter at the entrance of the facility and community area.
11. Visitors are allowed to visit with the following restrictions. See (see Community Care Facilities Guidance):
1. Those with fever symptoms, or close contact with a COVID positive person should not be permitted to enter the facility at any time (even in end-of-life situations).
2. Post signs explaining visitor restrictions.
3. Set-up alternative methods of visitation such as through videoconferencing through Skype or FaceTime.
4. Those visitors that are permitted should be screened for fever and respiratory symptoms, must wear a mask while in the building, and should restrict their visit to the resident’s room or other location designated by the facility. They should also be reminded to frequently perform hand hygiene and to practice physical distancing while in the facility.
5. Visitation should follow guidelines in the Community Care Facilities guidance. Indoor and in-room visitors are no longer required to show proof of vaccination or negative test results.
12. For youth in DCFS-affiliated congregate care facilities, there are several important considerations concerning visitors and visitation:
    1. Court mandated visits may involve visits to youth onsite at the facilities or visits offsite. Legally these visits supersede HOO mandates for isolation and quarantine.
       • For youth who are COVID positive and finishing their isolation period, the facility needs to request that the DCFS social worker assigned to the youth request postponement of the court mandated visit until the isolation period is over.
       • For youth who were exposed to a COVID-positive individual and are under quarantine in the yellow zone, the facility needs to request that the DCFS social worker assigned to the youth request postponement of the court mandated visit until the isolation period is over.
       •  For youth residing in a facility with an open outbreak but who are not under isolation or quarantine orders (youth in the GREEN ZONE), visitations should be allowed to proceed.
    2. Onsite and off-site family visits that are not court-mandated should also be allowed or postponed according to the distinctions above. Youth in the RED and YELLOW zones should postpone visits until after their isolation/quarantine terms have been completed. Youth in the GREEN ZONE can continue to have visits if so approved by the facility staff and the assigned DCFS case-worker.
13. Provide education and job-specific training to staff regarding COVID-19, including:
1. Signs and symptoms.
2. Modes of transmission of infection.
3. Correct infection control practices and personnel protective equipment (PPE) use.
4. Staff sick leave policies and recommended actions for unprotected exposures (e.g., not using recommended PPE, an unrecognized infectious patient contact).
5. How and to whom COVID-19 cases should be reported.
14. Ensure that your facility has the capacity to isolate residents with COVID-19 and quarantine residents who are close contacts of a COVID-19 case.
15. Establish a COVID-19 area within the facility, if possible:
1. The COVID-19 area (Red Zone) is for residents who have confirmed COVID-19 and must have a designated bathroom. The area must be physically separated from the area for those who do not have COVID-19. If not possible to separate physically because the facility is structured to have individual resident apartments or rooms with their own bathrooms, all that is needed is appropriate signage outside the apartment or room designating the color status of the resident and the appropriate PPE needed to care for that resident, along with a PPE cart for that room.
2. All staff, equipment, and common areas should be kept separate as much as possible.
3. LAC DPH does not recommend transferring patients to hospitals unless they require higher level of care and does not recommend transfer between facilities unless the facility is unable to isolate cases adequately.
16. Facility should accept back COVID+ patients ready to be discharged from acute care hospitals in accordance with Interfacility Transfer Rules.
17. The facility should consult with the District Public Health Nurse IDPHN)/Outbreak Investigator (OI) assigned to the facility regarding closure of the facility to new/returning admissions.
18. Have a resident and family notification process for when a case of COVID-19 is identified.
19. Have the ability to identify residents who could be discharged to home in the event of COVID-19 introduction to the building.
20. As much as possible, have employees work at only one facility in order to reduce interfacility spread of COVID-19.
21. For any transfers out of the building, notify EMS and the receiving facility of possible exposures.
22. Cancel and re-schedule all upcoming non-essential medical appointments or consider telemedicine routine care appointments when available.
23. All care-giving staff that provide direct resident care in these facilities are considered similar to healthcare personnel (HCP).
24. All caregivers should wear a medical grade face mask (or N-95) while they are in resident care areas, walkways, and common or shared areas where residents and/or staff may congregate.
25. For all resident encounters, caregivers should at minimum wear a mask (medical grade, surgical mask, or higher). If resident is unable to cover nose/mouth (i.e. practice source control), caregivers should also use eye protection for that encounter. Full PPE (N-95 respirator, gloves, gown, and eye protection) is recommended while providing care to a resident in the Yellow or Red zones. For conservation of PPE, please refer to CDC guidance (www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html).

    Note: The rationale for mask and eye protection is to try to prevent caregiver exposure. Medical grade or surgical masks can be worn for an extended period but should be discarded after they become saturated with moisture.

26. If unsafe for residents to eat unsupervised (e.g., prone to aspiration) or cannot feed themselves, or if staffing is insufficient to support one to one feeding, residents may eat outside their rooms as long as physical distancing guidelines can be followed. See Community Care Facilities guidance for more details.
27. Designate caregivers who will be responsible for caring for suspected or known COVID-19 residents. Ensure they are trained on the infection prevention and control recommendations for COVID-19 and the proper use of PPE.
28. If staffing scarcity requires staff to work with COVID-19 positive and negative residents, staff should be careful to change required PPE between patients, and adhere to donning and doffing recommendations (www.publichealth.lacounty.gov/acd/docs/CoVPPEPoster.pdf), though N95 and face shields may be worn throughout the day consistent with CDC PPE conservation contingency strategies (www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html). If staff must care for residents in multiple Zones, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between Zones.
29. In an outbreak situation, admission of new residents (new admissions) and returning residents (readmissions) should be permitted unless closure is approved by the Area Medical Director (AMD). This rule applies to DCFS-affiliated congregate care facilities as well as other CCFs.
30. The decision to close to admissions should be recommended only after a number of factors have been considered. Consider closing the facility to admissions if some or all of the following are concerns:
    1. Inadequate infection prevention & control concerns from licensing
    2. Concerning rates of adverse outcomes including hospitalizations and deaths
    3. Evidence of concerning viral transmission based on response testing of residents
    4. Inability to cohort residents per protocol:
    • Inability to effectively quarantine new admissions and readmissions
    • Inability to effectively dedicate COVID and non-COVID areas and staff in the facility
    5. Lack of effective infection control practices as evidenced by a virtual or on-site infection control visit
    6. Inadequate supply of PPE.
    7. Staffing shortages or inability of current staff to properly care for COVID-19 positive residents are reported.

1. All ill persons (residents or staff) with symptoms suggestive of respiratory illness should be presumed to have COVID-19 and SARS-CoV2 testing should be done.
1. For suspected or confirmed residents, immediately mask and initiate quarantine/isolation. Use face covering if mask is not available. If possible, initiate contact and droplet precautions and eye protection (mask, gloves, face shield/goggles, disposable/washable gown).
2. Symptomatic/confirmed staff should be asked to go home immediately and seek care as appropriate. Immediately mask the staff and isolate in room with door closed if need to remain on premises.
3. In the case of two or more unknown respiratory cases in 72 hours at facility, encourage testing of routine respiratory pathogens including influenza testing if appropriate to establish alternative diagnosis.
2. Facilities should initiate contact investigation around each confirmed case (staff or resident) to identify all close contacts (staff and residents) during the infectious period of the case(s).
   • NOTE: Resident cases are NOT considered outbreak-associated if:
     • They were admitted as a known case.
     • Their specimen collection date was within 90 days of a prior positive result.
     • Their symptom onset or specimen collection date was on or prior to their 7th day of residency in the facility. Symptom onset or specimen collection date (whichever is earlier) is considered day 0.
     • Their symptom onset or specimen collection date was 3 or more days after being discharged from the facility. Symptom onset or specimen collection date (whichever is earlier) is considered day 0.
     • Their only positive test is not considered confirmatory (e.g., an unsupervised antigen test).
   • NOTE: Staff cases are NOT considered outbreak-associated if: 
     • They did not work for 5 or more days before their symptom onset or specimen collection date. Symptom onset or specimen collection date (whichever is earlier) is considered day 0.
     • They did not work for 10 or more days after their symptom onset or specimen collection date. Symptom onset or specimen collection date (whichever is earlier) is considered day 0.
     • Their specimen collection date was within 90 days of a prior positive result.
     • Their specimen collection date or symptom onset date occurred prior to the first resident case or after the outbreak was considered over per DPH guidance.
     • Their only positive test is not considered confirmatory (e.g., an unsupervised antigen test).
3. Facilities need to report all COVID-19 positive cases within 24 hours to LAC DPH using the REDCap POCT form: https://redcap.link/si8uv987, or by phone at (213) 240-7941, or by fax at (213) 482-4856. After being assigned an Outbreak Investigator, the Facility should report additional cases and deaths to that person. See the Community Care Facilities Guidance for more details.
4. Document all staff and resident case and contacts on the COVID-19 Line List for Congregate Residential Settings for Resident and Staff.
5. Designate areas in your facility for the placement of suspected (Yellow Zone) and confirmed (Red Zone) residents. Refer to the Community Care Facilities Guidance.

Note: The actual isolation area will depend on each building but define the area by your local workflow (e.g. the unit the resident is located would be a logical decision).

1. Case(s) should be isolated in single-person room(s). Move roommates into other rooms within the isolation area, if possible. Otherwise, cohort case(s) together in a separate room with the door closed and a dedicated restroom.
2. Cohort staff (keep the same, limited number of staff caring for the Red Zone residents and ensure they do not interact with residents/staff in other zones, as much as possible).
3. Move suspected residents into the Yellow Zone.
6. Designate a Yellow Zone, if possible, for residents who have been identified as contacts to case(s) at your facility.
1. Residents should use masks or face coverings. If possible, initiate contact, droplet, and eye protection precautions in the Yellow Zone.
2. Place asymptomatic residents identified as close contacts in the Yellow Zone regardless of vaccination status.
3. Post signage of your Yellow Zone.
4. Cohort staff as much as possible to minimize transmission.
7. Residents in the Yellow and Red Zones should:
1. Have visitors only as allowed in the Community Care Facilities Guidance and should have limited contact with staff and other residents. See above for special considerations for court-mandated visitation for youth in DCFS-affiliated congregate care facilities.
2. Stay in a separate room as much as possible and away from residents who are vulnerable to severe illness related to COVID-19. Individuals vulnerable to severe illness related to COVID-19 include those who are age 65 and above, or with underlying medical conditions such as chronic lung disease or moderate to severe asthma, chronic heart disease, diabetes, end stage kidney or liver disease or weakened immune systems such as cancer patients, those on immunosuppressive therapy and HIV/AIDS.
3. Use a separate bathroom.
8. Quarantine in the Yellow Zone ends 10 days from the last day the resident was in close contact with a laboratory confirmed case (see Community Care Facilities guidance for exceptions). For youth in DCFS-affiliated facilities, quarantine in the Yellow Zone ends 10 days from the last day the resident was in contact with a laboratory confirmed case (see Community Care Facilities guidance for exceptions).
9. If Yellow Zone residents develop symptoms of respiratory illness (fever and cough or shortness of breath), then SARS-CoV2 testing should be done and they should be moved to the Red Zone if positive. If negative, they should stay in the Yellow Zone until their quarantine period is over and symptoms have resolved.
10. If, during the quarantine period, there is contact with a person with suspected or confirmed COVID-19 the quarantine period will have to restart.
11. Continue to monitor all residents for fever and respiratory symptoms (i.e. cough, sore throat, shortness of breath) until 14-days after the last COVID-19 exposure at facility. Last COVID-19 exposure at facility is until the last COVID-19 case (staff or resident) is placed under isolation. Any breach in isolation of COVID-19 case would constitute an ongoing exposure at facility and monitoring period will need to be extended additional 14 days from that time.
12. Special situations for facilities to consider:
1. For residents receiving dialysis outside of the facility, notify their dialysis center and request that they be dialyzed in “isolation.”
2. Consider substituting nebulizers for metered dose inhalers.
13. Instruct the facility to notify District Public Health Nurse (DPHN) assigned to the facility immediately if any resident or staff report fever or respiratory symptoms.
14. Notify DPHN immediately if any caregivers or resident contact tests positive for COVID-19.

1. DPH testing recommendations should be communicated to the facility administrator/manager or medical director.
1. For all community care facilities, response testing should be initiated if one COVID-19 positive individual (resident or staff) is identified. Refer to Community Care Facilities guidance.
2. For testing at DCFS-affiliated congregate care facilities, response testing is also recommended if one COVID-19 positive individual (youth or staff) is identified. If consent cannot be obtained for testing of the youth, youth should be placed in the Yellow Zone and monitored for 14 days.
3. Wider testing for early intervention may be considered in certain circumstances to help identify additional cases at a point in time and determine scope of outbreak at the facility. These include:
1. In high-risk Community Care Facilities.
2. Identification of contacts cannot be reliably conducted such that all residents are considered exposed (e.g. in a memory care unit).
3. AMD or designee determines broader testing is required after performing a transmission risk and infection control assessment.
4. For DCFS Emergency shelter facilities, response testing should be initiated if one COVID-19 positive staff is identified: mass testing should include all staff and non-COVID-positive youth who worked or resided in the apartment while the COVID-19 positive staff was infectious.
2. Response testing: If one COVID-19 positive individual (resident or staff) is identified, or more, PCR testing of all residents (excluding independent Continuing Care Retirement Communities-unless they have been in communal settings with other residents) and staff should be done every 3-7 days, regardless of vaccination status. This does not apply to individuals who have been positive for COVID-19 in the previous 90 days. Testing of all residents and staff may be discontinued after 14 consecutive days of negative testing (outbreak closure is dependent on 14 days without positive residents, however it is possible for the outbreak to be closed and for the facility to continue testing until they reach 14 consecutive days without any staff or resident cases due to the new CDSS PIN 22-16-ASC). For exceptions to this testing regimen, please see the Community Care Facilities guidance on response testing.
3. Exposure testing: asymptomatic staff and residents, regardless of COVID-19 vaccination status, and who have not been positive for COVID-19 in the last 90 days, should be tested not earlier than 2 days after exposure and, if negative, a second time between days 3-5 after exposure. Residents who are up to date with COVID-19 vaccines do not need to quarantine during this time. If a resident is not up to date with COVID-19 vaccines and needs exposure testing, they should quarantine and be tested not earlier than day 2 after exposure and can leave quarantine early after day 5 with a second negative test within 48 hours of leaving. If not performing a second test, quarantine ends after day 10.
4. Facilities should conduct their own testing if they can do so. The facility should first be referred to the Laboratories Providing Diagnostic Testing to find a lab—there are resources that provide onsite collection services. The facility should also be referred to the Community Care Facilities Testing Toolkit. If a facility is not able to find a lab for PCR testing with a turn around time of 48 hours or less, then antigen testing may be used for response testing in an outbreak situation. A positive test is generally confirmatory for COVID-19. A negative antigen or negative POC molecular test in a symptomatic person should be followed with a laboratory-based PCR test within 24 hours to confirm the negative result.
5. If the facility is unable to find a lab to do testing within 1 week, despite attempting to do so, facilities should be referred to DPH community testing (strike) team.
6. For symptomatic caregivers, ensure they are not working and recommend the following:
   1. Testing is recommended through their Primary Care Provider or through Los Angeles County https://covid19.lacounty.gov/testing/.
7. Requests for DPH strike team testing can be requested if facilities are unable to conduct targeted or wider testing on their own. However, requests will be prioritized by ACDC in communication with OMB based on risk and scope of outbreak, and consensus that testing will change management, as well as DPH capacity and resources for testing supplies and staff. Decisions for testing through DPH will be made on a case-by-case basis with the OMB MD. Retesting will be done by the facility when indicated.
   1. For an urgent need for testing outside of the priority, the request must come from the OMB Area Medical Director (AMD).

For more details, refer to CDC Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings.

1. If discontinuing isolation for symptomatic or asymptomatic cases in the Red Zone, facilities are advised to do the following:
1. Symptoms-based strategy:
   1. For those with symptoms: at least 1 day (24 hours) has passed since recovery, defined as resolution of fever without the use of antipyretic medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); AND
   2. For those with symptoms: at least 10 days have passed since symptoms first appeared if the patient has not been hospitalized and is not immunosuppressed. For symptomatic youth in DCFS-affiliated congregate care facilities, 10 days of isolation from the date symptoms first appeared is sufficient if criteria (i) has been met and the individual is not hospitalized or immunosuppressed.
   3. For those with symptoms: at least 20 days have passed since symptoms first appeared if the patient is immunosuppressed (actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose >20mg/day for more than 14 days, receipt of immunosuppressive medications [biologic agents, etc.] for treatment of autoimmune disease, or other cause of immunosuppression as determined by the patient’s primary physician).
   4. For those without symptoms: at least 10 days have passed since the date of positive test for patients who are not immunosuppressed. For asymptomatic youth in DCFS-affiliated congregate care facilities, 10 days of isolation from the date symptoms first appeared is sufficient if criteria (i) has been met and the individual is not hospitalized or immunosuppressed.
   5. For those without symptoms: if the patient is immunosuppressed (actively receiving chemotherapy for cancer, HIV with CD4 count <200, immunodeficiency disorder, prednisone dose >20mg/day for more than 14 days, receipt of immunosuppressive medications [biologic agents, etc.] for treatment of autoimmune disease, or other cause of immunosuppression as determined by the patient’s primary physician), the patient should be isolated for 20 days.
2. Testing should not be used as a sole criterion for being released from isolation or quarantine.
2. If transmission-based precautions have been discontinued, but the resident has persistent symptoms from COVID-19 (e.g., persistent cough), they should be placed in a single room, be restricted to their room, and wear a facemask (if tolerated) during care activities until all symptoms are completely resolved or at baseline.