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State Public Health Officer Order 

Amending the Order of August 26, 2021

Since Thanksgiving, the statewide seven-day average case rate has increased by 410% and the number of COVID-19 hospitalized patients has increased by 63%.In addition, the recent emergence of the Omicron variant (it is estimated that approximately 70% of cases sequenced, nationally, are Omicron and rapid increases are occurring globally) further emphasizes the importance of vaccination, boosters, and prevention efforts, including testing, are needed to continue protecting against COVID-19.

Although COVID-19 vaccination remains effective in preventing severe disease, recent data suggest vaccination becomes less effective over time at preventing infection or milder illness with symptoms, especially in people aged 65 years and older. Early data also suggest the increased transmissibility of the Omicron variant is two to four times as infectious as the Delta variant, and there is evidence of immune evasion. Recent evidence also shows that vaccine effectiveness against COVID-19 infection is decreasing over time without boosters. Boosters have been available in California since September 2021.

Given the greater transmissibility of the Omicron variant, the risk of outbreaks in long-term care settings is of particular concern given the medical vulnerability of residents in such settings. Furthermore, based on the experience from prior COVID-19 surge periods during which high morbidity and mortality was experienced by residents and staff within such long-term care settings, the impact of such facility outbreaks may be devastating.

Based on the emergence of Omicron, additional statewide facility-directed measures are necessary to ensure we protect the particularly vulnerable populations in long-term care settings. Accordingly, amendments to the original State Public Health Officer Order of August 26, 2021, to make boosters mandatory and to require additional testing of visitors eligible for boosters who are not yet boosted, are necessary at this critical time.

Introduction from Original State Public Health Officer Order issued August 26, 2021

The COVID-19 pandemic remains a significant challenge in California. COVID-19 vaccines are effective in reducing infection and serious disease. At present, 63% of Californians 12 years of age and older are fully vaccinated with an additional 10% partially vaccinated. California is currently experiencing the fastest increase in COVID-19 cases during the entire pandemic with 18.3 new cases per 100,000 people per day, with case rates increasing ninefold within two months. The Delta variant, which is very highly contagious and possibly more virulent, is currently the most common variant causing new infections in California.

Unvaccinated persons are more likely to get infected and spread the virus, which is transmitted through the air. Most current hospitalizations and deaths are among unvaccinated persons. Thanks to vaccinations and to measures taken since March 2020, California's health care system is currently able to address the increase in cases and hospitalizations. However, additional statewide facility-directed measures are necessary to protect particularly vulnerable populations. Hospitals, skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and adult and senior care residential facilities serve uniquely vulnerable populations where COVID-19 outbreaks can have severe consequences including hospitalization, severe illness, and death.

Vaccinations have been available in California from December 2020 to the present, and from January 1, 2021, to July 27, 2021, a total of 9,371 confirmed COVID-19 outbreaks and 113,196 outbreak-related cases were reported to CDPH. The two most common settings for these outbreaks were: Residential care facilities (22.5%) and SNFs (9.8%). There have been over 4,000 outbreaks in residential care facilities, over 2,000 outbreaks in SNFs, and over 450 outbreaks in hospitals in California to date. Recent outbreaks in such settings have frequently been traced to unvaccinated staff members, demonstrating the risk of unvaccinated persons in these settings.

While there is currently a significant increase in the community transmission of COVID-19 in California, vaccination against COVID-19 is the most effective means of preventing further infections, transmission, and outbreaks. As we respond to the dramatic increase in cases, transmission prevention measures must be increased for the protection of the patients and residents in the facilities referenced in this Order. This can be done by reducing the risk that visitors to these facilities are bringing COVID-19 from the community and introducing it into these settings. Requiring well-fitting face masks for all visitors is an important step for source control. An emphasis on vaccination and testing should also contribute to reduction of transmission risk in these high-risk settings.

COVID-19 remains a concern to public health and, in order to prevent its further spread in hospitals, SNFs, ICFs, and adult and senior care residential facilities, the following limited and temporary public health requirements are necessary at this time.

I, as State Public Health Officer of the State of California, order:

I. This Order applies to the following facilities:

A. General Acute Care Hospitals,

B. Skilled Nursing Facilities (SNFs),

C. Intermediate Care Facilities (ICFs), and

D. Adult and Senior Care Residential Facilities licensed by the California Department of Social Services.

II. The Order applies only to visitation in facilities identified in this Order. Visitation shall be permitted only in accordance with this Order.

A. General Acute Care Hospitals must either: (1) verify visitors are fully vaccinated, or (2) for unvaccinated or incompletely vaccinated visitors, verify documentation of a negative SARS-CoV-2 test.

B. Skilled Nursing Facilities, Intermediate Care Facilities and Adult and Senior Care Residential Facilities (licensed by the California Department of Social Services) must either: (1) for indoor visitation, verify visitors are vaccinated, have had all recommended doses based on Table A below and provide evidence of a negative SARS-CoV-2 test within one day of visitation for antigen tests, and within two days of visitation for PCR tests; OR (2) permit only outdoor visitation for those that do not meet all the requirements in Section B (1). For outdoor visitation, visitors must provide evidence of a negative SARS-CoV-2 test within one day of visitation for antigen tests, and within two days of visitation for PCR tests.

C. All visitors may use either PCR testing or antigen testing. Any PCR or antigen test used must either have Emergency Use Authorization by the U.S. Food and Drug Administration or be operating per the Laboratory Developed Test requirements by the U.S. Centers for Medicare and Medicaid Services

Table A:

California Immunization Requirements for Indoor Visitation

D. Pursuant to the CDPH Guidance for Vaccine Records Guidelines & Standards, only the following modes may be used as proof of vaccination:

1. COVID-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card) which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR
2. a photo of a Vaccination Record Card as a separate document; OR
3. a photo of the client's Vaccination Record Card stored on a phone or electronic device, OR
4. documentation of COVID-19 vaccination from a health care provider; OR
5. digital record that includes a QR code that when scanned by a SMART Health Card reader displays to the reader client name, date of birth, vaccine dates and vaccine type.

In the absence of knowledge to the contrary, a facility may accept the documentation presented as valid.

E. For unvaccinated, incompletely vaccinated, or booster-eligible visitors who have not yet received their booster dose:

1. In General Acute Care Hospitals, unvaccinated or incompletely vaccinated are eligible for indoor visits only if they can show documentation of a negative SARS-CoV-2 test where the specimen collection occurred within 2 days if using PCR or 1 day if using antigen testing before each visit and for which the test results are available at the time of entry to the facility. Unvaccinated or incompletely vaccinated visitors with history of COVID-19 within the prior 90 days may provide documentation of recovery from COVID-19 and release from isolation in lieu of testing.
2. In Skilled Nursing Facilities, Intermediate Care Facilities and Adult and Senior Care Residential Facilities (licensed by the California Department of Social Services) unvaccinated, incompletely vaccinated, or booster-eligible visitors who have not yet received their booster dose are eligible only for outdoor visitation if they can show documentation of a negative SARS-CoV-2 test where the specimen collection occurred within 2 days if using PCR or 1 day if using antigen testing before each visit and for which the test results are available at the time of entry to the facility. Such persons must also wear a well-fitting face mask (a surgical mask or respirator) and physically distance from facility personnel and other patients/residents/visitors that are not part of their group at all times during the visit. If a resident is not able to leave their room or otherwise meet with visitors outdoors, the visitation may take place indoors, even for visitors who cannot provide vaccine verification or a negative test; however, these visits cannot take place in common areas, or in the resident's room if the roommate is present, and the visitor must wear a well-fitted mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) and the resident must wear a well-fitting face mask at all times and physically distance.
3. For visitors who visit for multiple consecutive days in all settings covered by this Order, proof of negative test is only required every third day (meaning testing is only required on day one, day 4 and day 7, and so on).

F. Facilities must have a plan in place for tracking verified visitor vaccination status or documentation of a negative SARS-CoV-2 test. Records of vaccination verification or documentation of a negative SARS-CoV-2 test must be made available, upon request, to the local health jurisdiction for purposes of case investigation.

G. Facilities can offer to conduct onsite testing of visitors if practical per facility testing capacity but are not required to do so.

H. A patient attending an outpatient appointment and a person who accompanies a patient to an outpatient appointment in a support capacity is not a visitor in acute health care.

I. The following visitors are exempt from the vaccination and testing requirements of this Order:

1. Visitors who are visiting a patient in critical condition, when death may be imminent.
2. In emergent situations, parent or guardian visitors of pediatric patients, a support person for a labor and delivery patient, support persons for a patient with physical, intellectual, developmental disability, or cognitive impairment and a person visiting for bonding visits including in-room stay with a newborn and hospitalized parent. For subsequent visits following the emergent situation and as soon as reasonably possible thereafter, but no longer than 72 hours, these visitors must comply with the vaccine verification or applicable testing requirements.

For such persons the requirements of Section III, below, will still apply.

III. Mask, personal protective equipment, and physical distancing requirements:

A. All visitors must:

1. wear a well-fitting face mask (a surgical mask, double masking or a respirator is recommended) at all times during any visitation at the facility;
2. wear any other personal protective equipment (PPE) while in the patient's or resident's room that facility personnel deem appropriate to the situation; and
3. physically distance from facility personnel and other patients/residents/visitors that are not part of their group at all times during any visitation at the facility.

IV. Definitions: For purposes of this Order, the following definitions apply:

A. "Fully Vaccinated" means individuals who are considered fully vaccinated for COVID-19: two weeks or more after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization), or two weeks or more after they have received a single-dose vaccine (Johnson and Johnson [J&J]/Janssen). COVID-19 vaccines that are currently authorized for emergency use:

By the US Food and Drug Administration (FDA), are listed at the FDA COVID-19 Vaccines webpage.

By the World Health Organization (WHO), are listed at the WHO COVID-19 Vaccines webpage.

B. "Incompletely vaccinated" means persons who have received at least one dose of COVID-19 vaccine but do not meet the definition of fully vaccinated.

C. "Unvaccinated" means persons who have not received any doses of COVID-19 vaccine or whose status is unknown.

D. "WHO Yellow Card" refers to the original World Health Organization International Certificate of Vaccination or Prophylaxis issued to the individual following administration of the COVID-19 vaccine in a foreign country

V. The Terms of this Order supersede any conflicting terms in any other CDPH orders, directives, or guidance. This Order is not intended to revoke or withdraw any prior orders.

VI. This Order shall take effect on January 7, 2022, at 12:01 am. Facilities must be in full compliance at that time. This Order will remain in effect until February 7, 2022, and CDPH will continue to assess ongoing conditions during this time to determine any further updates.

VII. The terms of this Order supersede the August 26, 2021 Requirements for Visitors in Acute Health Care and Long-Term Care Settings.

VIII. This Order is issued pursuant to Health and Safety Code sections 120125, 120140, 120175,120195 and 131080 and other applicable law.

Tomás J. Aragón, M.D., Dr.P.H.

Director & State Public Health Officer

California Department of Public Health