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State of California—Health and Human Services Agency
California Department of Public Health

AFL 18-09
January 12, 2018

General Acute Care Hospitals (GACH)

Requesting Increased Patient Accommodations Including Medical
Surge Tent Use

AUTHORITY:     Government Code (GC) section 8558, California Code of Regulations (CCR), Title 22, sections 70129, 70217, 70805, 70809

All Facilities Letter (AFL) Summary
  • This AFL supersedes AFL 09-39, H1N1 Response, and AFL 06-33, Replacement of AFL 04-28, Increased Patient Accommodations.
  • This AFL outlines requirements for requesting a temporary program flex for increased patient accommodations, such as medical tents, during a disease outbreak or an unexpected event such as a disaster or mass casualty incident.

The California Department of Public Health (CDPH), Licensing and Certification Program (L&C), has the authority to grant program flexibility from regulatory requirements as long as statutory requirements are met. Requests for a program flex must include justification for the program flex and supporting documentation that patient care will not be compromised.

Health care emergencies or unforeseen events, such as an infectious disease outbreak, a disaster or mass casualty incident (generally related to a natural or human-caused disaster) may lead to a rapid influx or “surge” in patients. Facilities may request temporary approval with a program flex for an increase in patient accommodations, surge tent use, or space conversions related to these emergencies. Program flex requests are not long-term solutions for chronic problems, such as emergency department overcrowding.


Patient Accommodation Standards:

Title 22, CCR, section 70809 states:

    (a) “No hospital shall have more patients or beds set up for overnight use by patients than the approved licensed bed capacity except in the case of a justified emergency when temporary permission may be granted by the Director or his designee.

    (b) Five percent of a facility's total licensed bed capacity may be used for a classification other than that designated on the license. Upon application to the Director and a showing that seasonal fluctuations justify, the Director may grant the use of an additional five percent of the beds for other than the classified use.

    (c) Patients shall not be housed in areas which have not been approved by the Department for patient housing and which have not been granted a fire clearance by the State Fire Marshal, except as provided in paragraph (a) above.”

 GACHs must request and receive L&C approval prior to using more beds than their licensed capacity. Facilities seeking an alternate use of beds, pursuant to section (b) above, must provide documentation of seasonal fluctuations to justify the alternate use. GACHs must continue to provide services in compliance with all applicable laws and regulations.


Approved Space Conversions and Tent Uses:

Title 22, CCR, section 70805 states “spaces approved for specific uses at the time of licensure shall not be converted to other uses without the written approval of the Department.” Use of GACH property for any purpose other than those approved at the time of licensure constitutes a conversion of space and requires L&C approval.

CDPH will authorize the use of tents if the GACH has obtained written approval from the local fire authority for tent use.

CDPH will authorize surge tents for use as waiting rooms, to conduct triage and medical screening exams, and provide basic first-aid and outpatient treatment that meets applicable rules and regulations. Any other use will require additional CDPH approval.

To receive approval for surge tent use, GACHs must contact their L&C District Office (DO), explain the situation, and justify the use of tents.

A GACH must obtain Office of Statewide Health Planning and Development (OSHPD) approval if the proposed tents will use any utility hookup that originates in or passes through any hospital building. For assistance with questions or concerns regarding OSHPD approval of tents, please contact Nanci Timmins, Chief Fire & Life Safety Officer, at (213) 687-4959, or by email at


Nurse to Patient Ratio Requirements:

L&C has no mechanism for "suspending" or "waiving" regulations which represent the minimum standards providers are required to meet at all times. The nurse to patient ratios, at Title 22, CCR, section 70217, are the same as all other regulations. If a hospital has an alternative means of meeting the intent of the regulations, then the hospital can request program flexibility in accordance with Title 22, CCR, section 70129.


Submission Process for Request for Temporary Program Flexibility:

A facility seeking an approval for increased patient accommodations in response to a disease outbreak or an unexpected event, such as a disaster or mass casualty incident, that requires surge tent use or space conversions must contact the DO immediately with a request for advance approval to implement the proposed program flex. GACHs should not assume that the request will be approved until, at a minimum, it is verbally authorized by an L&C representative. L&C will confirm approval through a fax or email sent to the GACH. Please use the “Temporary Permission for Program Flexibility for Increased Patient Accommodations,” form CDPH 5000 A (PDF), to request approvals.

During normal business hours (8:00 a.m.-5:00 p.m.) contact the local L&C DO.

For after-hour requests, or if the local L&C DO is non-operational due to emergency or a disaster, follow the process below:


For facilities outside Los Angeles County:
State Office of Emergency Services Warning Center: (916) 845-8911.
Ask that they notify the CDPH duty officer.


For facilities in Los Angeles County:
Los Angeles County Operator: (213) 974-1234.
Ask that they notify the on-call Health Facilities Inspection Division supervisor.


In a declared emergency CDPH will issue guidance to inform facilities about any temporary changes authorized during the emergency.

L&C will periodically contact GACHs to get status reports on their program flex during the period of the emergency. Please notify your local L&C DO when tent use is discontinued and the tent is taken down. If a facility fails to comply with the agreed upon terms and conditions, L&C may revoke the program flex.

If you have questions about this AFL, please contact your local L&C DO. Contact information for your local DO is located at:



Original signed by Jean Iacino

Jean Iacino
Deputy Director


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