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Reporting LAHAN Alerts

Sites and Settings Associated with

People Experiencing Homelessness (PEH)

B73 COVID-19 - Procedural Guidance for DPH Staff

Sites and Settings Associated with People Experiencing Homelessness

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Outbreak Definitions:

Under Title 17, Section 2500, California Code of Regulations all suspected outbreaks are reportable. COVID-19 outbreak definitions are determined based on risk of transmission in particular sites, and are as follows:

Congregate residential sites associated with PEH such as shelters, encampments, or recuperative care centers:

At least 3 confirmed cases of COVID-19 in residents or staff within a 14-day period.

Outdoor congregate areas other than encampments (e.g., Safe Parking sites):

At least 3 confirmed cases of COVID-19 in residents or staff from 3 different households within a 14-day period.

Semi-congregate or non-congregate residential sites associated with PEH such as Single Room Occupancy housing, Tiny Homes, Project Roomkey or Project Homekey housing or shelters for which the layout is discrete apartments:

At least 3 confirmed cases of COVID-19 in residents or staff from 3 different households within a 14-day period.

Non-residential sites providing homeless services such as hygiene centers, food distribution centers, case management or other access centers for PEH:

At least 3 confirmed cases of COVID-19 in clients or staff within a 14-day period.

Medical shelters for isolation of persons diagnosed with COVID-19 (e.g., Isolation/Quarantine (IQ) sites):

At least 3 confirmed cases of COVID-19 in staff within a 14-day period. Residents are not included in the outbreak definition because IQ sites are specifically for isolation due to COVID-19.

Retroactive Outbreaks:

Outbreaks that are 14-28 days old may be opened for CFS investigation if either of the 2 following criteria are met

  1. There is a COVID death at a facility
  2. There is evidence of high transmission (>30% attack rate in residents/staff in 14 days have tested positive for COVID-19)

The ACDC MD to review the outbreak with ACDC RN before opening outbreak. In deciding whether or not to open an outbreak, the ACDC MD would review the facility's response (e.g what percentage of staff/residents were tested when cases were identified). The PEH MD would also review if there was any recent history of an outbreak at that facility. 

Epidemiologic Data for Outbreaks

  1. Confirm etiology of outbreak using laboratory data.
  2. Recommend all symptomatic residents or staff be tested for COVID-19.
  3. Determine the onset date of the outbreak. The onset date of the outbreak is the date of the first laboratory-confirmed case. Given the incubation period of SARS CoV2s is 14-days, the outbreak investigation should include investigation of cases occurring 14 days prior to the onset date that initiated the investigation.
  4. If earlier cases are found, investigation of prior cases should continue until a first index case can be determined, and the  outbreak onset date should be updated to reflect the new findings.
  5. Complete the line list for the site (see Report Forms) after each round of testing, and final list prior to outbreak closure.
  6. Include everyone who was exposed at the site on the line list, whether or not they are tested. Consider infectious period of each case: 2 days before symptoms or test date if asymptomatic until isolation ends. Once a case enters isolation, exposure from that case can be considered to have ended. In residential settings, exposures may be difficult to ascertain, and all the residents and staff who were working may be considered exposed.
  7. The line list includes identifying information including demographics, addresses, entry and exit dates, and health information. Please refer to accompanying instructions on the line list.
  8. Note entry and exit dates of residents and staff in and out of the facility during the outbreak period.
  9. Obtain site floor plan, if appropriate.
  10. Continue surveillance for new cases until no new cases are identified for at least 2 weeks from last exposure or until site meets outbreak closure criteria. Last exposure refers to the last date a person with COVID-19 was at the site while infectious.
  11. If  new cases are identified within one incubation period (i.e., 14 days) of the date that the last case was identified, assess for epi linkages and ongoing transmission and determine if further testing is necessary.
  12. Ensure epidemiologic data documented in IRIS and in line lists are consistent. Upload forms and line lists into IRIS.
  13. Complete COVID-19 OUTBREAK FORM: PEOPLE EXPERIENCING HOMELESSNESS (PEH) SETTINGS form at the conclusion of investigation (see Report Forms).
  14. Create an epi-curve, by date of onset. Only put those that meet the case definition on the epi-curve. (Optional, but recommend for complicated or extensive outbreaks)



Mask PUI(s)/confirmed case(s). Rapidly separate PUIs or cases whenever possible in an area that is isolated from the rest of the facility (ideally with a designated bathroom) or refer them to a medical shelter (IQ site). All PUIs should be tested for COVID-19. The latest isolation guidelines can be found here.

Cases who are staff should stay home for the duration of isolation.

Call 911 for anyone with severe symptoms. Notify emergency medical staff of COVID-19 suspicion.

Shelters are subject to the Aerosol Transmissible Diseases (ATD) standard. Follow Airborne Precautions in addition to Standard Precautions for all interactions:

    1. Practice physical distancing in indoor common areas.
    2. Perform hand hygiene before and after all patient contact and contact with potentially infectious material.
    3. Wear a well-fitting mask, with eye protection and/or gloves, depending on the planned interaction.
    4. Carry a plastic waste bag for collection of used or contaminated PPE to dispose of in designated location. Biohazard disposal is not necessary.


In congregate settings, accurate exposure histories and contacts may be difficult to determine, and all residents may be considered exposed.

Quarantine of close contacts is no longer required. Masking and testing instructions can be found here.


Work Considerations

  • Staff who are close contacts may continue to work as long as they do not develop symptoms or test positive. It is strongly recommended that they test upon identification (but not earlier than 24 hours after exposure), and if negative, on Days 3 and 5.
  • Staff who are close contacts must wear a well-fitting mask around others for 10 days.
  • If staff develop symptoms after returning to work, they must be excluded from the workplace and should test as soon as possible. If staff test positive, they follow the isolation instructions for cases. 



  1. Contact with the site should be made on the same day the outbreak investigation is opened. A testing strategy should be communicated with the site and a site visit should be made within 24 hours. Testing strategy may depend on CDC COVID-19 Community Levels.
  2. Follow-up with the site weekly, or more frequent as determined by the CFS physician.
  3. Inform the site that they will be included in a public outbreak notification list posted on the LAC Public Health website until no new cases at the facility for at least 2 rounds of mass testing. Outbreaks may close at the discretion of the physician lead and closure criteria may change when community transmission rates are elevated. 4. Post a notification letter at the entrance of the shelter and community areas.
  4. Post a notification letter at the entrance of the shelter and community areas.
  5. Send notification letter to the facility with the name and contact information of the assigned Public Health Nurse.
  6. Targeted testing may be recommended, on a case-by-case basis, if testing resources are limited and transmission appears more limited.
  7. Request expedited testing through the DPH Testing Logistics Team and the Community Testing Team, as appropriate.
  8. Testing at the facility may be conducted by partner organizations, however DPH remains the lead for testing in an outbreak setting and should attempt to arrange for testing to occur within 48 hours of outbreak opening. If no partner organization is scheduled to do testing within that timeframe, request for a DPH Community Testing Team unless the field teams will perform testing themselves.
  9. When partner organizations are conducting the outbreak testing, follow up on all test results and include in the line list for outbreak management.
  10. Retesting of persons who are known to be positive in the past 90 days is discouraged. Testing should be done only on those who are symptomatic.
  11. Notify ACDC PEH team within 24 hours of identification of any of the following:
      1. There is a COVID-19 death at a facility. Death reporting form must be filled out and submitted to ACDC (See Forms).
      2. There is evidence of high transmission (>30% attack rate in residents/staff in 14 days)

Additional guidance and resources:


  • Emphasize importance of early detection and isolation of cases.
  • Reinforce good hand hygiene and post signage as reminders.
  • Promote masking, practice social distancing throughout the setting, and increase ventilation and air filtration.
  • Emphasize respiratory etiquette (cover cough and sneezes, dispose of tissues properly).
  • Encourage clients/residents, staff, and volunteers to stay up to date with all COVID-19 vaccines (fully vaccinated and received a booster dose or fully vaccinated and not yet booster eligible).

Protocol for Sheltered Settings (e.g. shelters, churches, indoor facilities)

  1. May admit new residents while doing initial assessments, including assessment of outbreak magnitude and environmental health evaluation if needed.
  2. Notify staff and residents of COVID-19 outbreak while maintaining patient privacy and request all to observe infection control measures across the facility.
  3. Initiate standard airborne precautions. Ensure that the site has sufficient mask supplies.
  4. Define an isolation area. Movement of residents within the facility should be thoughtful and aim to minimize transmission.
  5. A Department of Public Health Call Center has been established to assist healthcare providers, homeless service providers, street outreach teams, and law enforcement to find isolation beds for PEH. Call (833)-596-1009 from 8am to 8pm for bed availability.
  6. Rapidly move symptomatic PEH into an isolation area within current setting if possible (ideally in an area with a designated bathroom or to a medical shelter site/IQ site.
  7. Place clear signage outside all isolation areas for staff and clients to properly identify these areas.
  8. Designate a separate area for non-symptomatic PEH contacts who are high-risk (age over 50, chronic medical problem, pregnant). Consider placing high-risk clients in less densely crowded areas or in rooms with fewer than 10 beds.
  9. Review current status of all PEH to identify symptomatic residents and relocate to available isolation locations per protocol.
  10. Increase environmental cleaning throughout the congregate setting to three times a day with emphasis on high touch surfaces, particularly in the unit where the case was located. Ensure the use of an EPA registered disinfectant appropriate for SARS-CoV-2.
  11. Determine covid vaccination status of residents and staff. Provide vaccine education and offer referrals for COVID-19 vaccination to unvaccinated or incompletely vaccinated residents or staff.
  12. Clients who met the criteria and are unable to access oral COVID-19 therapeutics through their own provider or who do not heave health insurance can be referred to a Test to Treat program or the DPH Public Health Call Center/Tele-Health service, which provides testing, consultation, and prescriptions at 1-833-540-0473 open 7 days a week, 8:00 am-8:30 pm.
  13. Ensure adequate and easily accessible supplies for good hygiene, including:
    1. Tissues and trash receptacles
    2. No touch hand sanitizer dispenser near customer entrances if feasible
    3. Hand sanitizer with at least 60% alcohol
    4. Handwashing stations
    5. Soap
    6. Paper towels
  14. Initiate temperature and symptom checks at entry to the shelter. Initiate symptom checks daily for staff and residents.
  15. Discontinue all group events:
    • Serve meals "to go" if possible, or stagger dining times to decrease the size of the groups and maintain 6 feet of distance between diners.
    • If smaller group activities are medically necessary, keep the same group together to decrease the risk for virus spread.
    • Signage should be posted in the facility to reinforce frequent hand washing, cover your cough, and maintaining social distancing.
  16. Follow the LAC DPH Guidelines for COVID-19 Cases (Isolation) and Close Contacts.

Continuing admissions to shelters and other PEH facilities while under initial outbreak assessments

PEH sites under initial assessments may continue to accept new residents or readmissions. Consider closing the facility to admissions if any of the following are concerns:

  1. Inadequate infection prevention and control at the facility.
  2. Concerning rates of hospitalizations, deaths, or other adverse outcomes.
  3. High proportion of unvaccinated residents or staff.
  4. Concerning transmission rates based on response testing of residents.
  5. Inability to effectively cohort new admissions and readmissions from outbreak investigation cohort of residents. This would require facilities to have separate areas and separate staff.
  6. Shortage of staff or inability to designate staff for new admissions.
  7. Inadequate supply of PPE for residents and staff.

Additional guidance and resources:

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