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

AFL 22-07.1
October 6, 2022

Skilled Nursing Facilities

Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities (SNFs)
(This AFL supersedes AFL 22-07)

All Facilities Letter (AFL) Summary

  • This AFL notifies SNFs of updated California Department of Public Health (CDPH), Centers for Medicare and Medicaid Services (CMS), and Centers for Disease Control and Prevention (CDC) guidance for improving their infection control and prevention practices to prevent the transmission of COVID-19, including guidance for visitation.
  • This AFL provides CDPH guidance for group activities and communal dining.
  • This AFL revision announces that, effective September 17, 2022, the visitation requirements outlined in the August 26, 2021 Public Health Order (PHO) are rescinded. Visitors are no longer required to show proof of vaccination or a negative test to have indoor visitation. Visitors must continue to comply with CDPH Masking Guidance while visiting in these indoor healthcare settings and should continue to maintain all current infection prevention practices to continue protecting these most vulnerable populations.  


Since the start of the pandemic, CDPH has led with science and data to better understand COVID-19. California has seen a dramatic increase in the percentage of Californians that are fully vaccinated and boosted. At present, 80 percent of Californians 12 years of age and older have completed their primary series of COVID-19 vaccines, and 48 percent have received their first booster dose. Vaccines for children 5–11 years of age have been available since October 2021.

While further expanding visitation opportunities for SNF residents, CMS and CDPH continue to require that visits are conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents.

The Omicron subvariants have shown immune escape and increased transmissibility, and while unvaccinated individuals still have higher risk of infection, previously infected, vaccinated, and boosted persons have also been infected. Consequently, mandated testing of unvaccinated visitors is not effectively preventing disease transmission as with the original COVID-19 virus and prior variants earlier in the pandemic. 

On August 11, 2022 and August 24, 2022, the CDC issued updated guidance, indicating that screening testing is no longer recommended in general community settings; therefore, in accordance with the PHO rescinded September 15, 2022 and effective September 17, 2022, the indoor visitation requirements for SNFs are rescinded. Visitors no longer need to provide proof of vaccination or show documentation of a negative SARS-CoV-2 test when visiting. Visitors must continue to comply with CDPH Masking Guidance while visiting in indoor settings and should continue to maintain all current infection prevention practices to continue protecting these most vulnerable populations. 

General Visitation Guidance

Facilities may conduct visitation through different means; however, facilities must adhere to the core principles of COVID-19 infection prevention (PDF) at all times. Visitation should be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life. SNFs must also enable visits to be conducted with an adequate degree of privacy and should be allowed at times convenient to visitors (e.g., outside of regular work hours).

SNF residents and health care personnel (HCP) must continue to follow current CDPH Masking Guidance to protect themselves and others, including wearing a mask, avoiding crowds and poorly ventilated spaces, covering coughs and sneezes, washing hands often, and following guidance for personal protective equipment use and SARS-CoV-2 testing.

Any visitor entering the facility, regardless of their vaccination status, must adhere to the following:

  • All visitors must be screened for fever and COVID-19 symptoms and/or exposure within the prior 14 days to another person with COVID-19; if a visitor has COVID-19 symptoms or has been in close contact with a confirmed positive case, they must reschedule their visit, regardless of their vaccination status.
  • All visitors must wear a well-fitting face mask with good filtration (N95, KF94, KN95, or surgical masks are preferred over cloth face coverings) and perform hand hygiene upon entry and in all common areas in the facility; 
  • If personal protective equipment (PPE) is required for contact with the resident due to COVID-19 positive isolation status (including fully vaccinated visitors), it must be donned and doffed according to instruction by HCP.
  • Facilities should limit visitor movement in the facility, regardless of the visitor's vaccination status; for example, visitors should not walk around the hallways of the facility and should go directly to and from the resident's room or designated visitation area.

Visitors who have tested positive for COVID-19 should not be permitted to visit or should be asked to leave if they are still within their isolation period (within 10 days of their positive test). Under such circumstances, facilities must offer alternatives for remote (Skype, etc.) or telephone visitation. Staff should provide monitoring for those who may have difficulty adhering to core principles, such as children.

Indoor, In-Room and Large Communal Space Visitation Requirements

Facilities shall allow indoor in-room visitation for:

  • All residents regardless of vaccination or COVID-19 status.

Indoor in-room visitation shall meet the following conditions:

  • Indoor visits must be conducted with both the resident and visitor wearing a well-fitting face mask. Regardless of vaccination status, the resident and visitor  do not need to physically distance and can include physical contact (e.g., hugs, holding hands) but must wear a well-fitting face mask while in the resident's room unless eating or drinking.
  • Visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of the roommate's vaccination status.
  • Visitors should be provided personal protective equipment (gloves, gown, eye protection and N95 respirator) and instructed in a N95 respirator seal check for visitation of residents in isolation areas.

Facilities shall also accommodate visitation in large communal indoor spaces for residents who are not in isolation:

Indoor spaces used for visitation such as a lobby, cafeteria, activity room, physical therapy rooms, etc. should be arranged to accommodate physical distancing between visitor-resident groups. Facilities should assess the maximum number of resident-visitor groups that can be accommodated while maintaining physical distancing between groups in communal indoor spaces designated for visitation; when the maximum is reached, visits will need to be conducted in the resident's room (if appropriate) or outdoors (preferably).

During indoor large communal space visits between residents and visitors, regardless of vaccination status, both the resident and visitor must always wear a well-fitting face mask unless eating or drinking while in designated spaces for visitation. These visits may be conducted without physical distancing and include physical contact (e.g., hugs, holding hands).

Continuing Outdoor Visitation Requirements

All facilities must continue to allow outdoor visitation options for all residents, regardless of vaccination status. Outdoor visits pose a lower risk of transmission due to increased space and airflow; therefore, outdoor visitation should be offered unless the resident cannot leave the facility, or outdoor visitation is not possible due to precipitation, outdoor temperatures, or poor air quality. When providing outdoor visitation facilities should facilitate visits on the facility premises (e.g., visits on lawns, patios, and other outdoor areas, drive-by visits, or visit through a window) with physical distancing between visitor-resident groups, and staff monitoring of infection control guidelines.

Outdoor visits between residents and all visitors do not need to be conducted with face masks and may include physical contact (e.g., hugs, holding hands).

Other Visitation Options in Addition to Outdoor and Communal Spaces

In addition, to maximize visitation opportunities and keep residents and families connected, facilities are encouraged to:

  • Offer alternative means of communication for people who would otherwise visit, including virtual communications (phone, video-communication, etc.).
  • Assign staff as primary contact to families for inbound calls and conduct regular outbound calls to keep families up to date.
  • Offer a phone line with a voice recording updated at set times (i.e., daily) with the facility's general operating status, such as when it is safe to resume visits.
  • Create/increase listserv communication to update families, such as the status and impact of COVID-19 in the facility.

Communal Dining and Group Activities:

Communal activities and dining may occur in the following manner:

  • Residents who are not in isolation may eat in the same room without physical distancing, regardless of vaccination status.
  • Residents who are not in isolation may participate in group/social activities together without face masks or physical distancing, regardless of vaccination status.

Facilities should consider, in consultation with their local health department, reimplementing limitations on communal activities and dining based on the status of COVID-19 infections in the facility, e.g., when one or more cases has been identified in facility staff or residents.

Residents Who Leave and Return to the Facility

Residents taking social excursions outside the facility should be educated about potential risks of public settings and reminded to avoid crowds and poorly ventilated spaces. They should be encouraged and assisted with adherence to all recommended infection prevention and control measures, including source control, physical distancing, and hand hygiene. If they are visiting friends or family in their homes, they should follow the source control and physical distancing recommendations for visiting with others in private settings as described in CDC Guidance on Minimizing the Impact of COVID-19 on Communities.

Non-essential Personnel/Contractors

Non-essential personnel/contractors (e.g., barbers, manicurists/pedicurists), who comply with universal face mask requirements of the facility, may enter the facility and provide services to residents in appropriate spaces (outdoors, if feasible, or indoors in a well-ventilated area where physical distancing can be maintained between residents).

Additional Considerations for Pediatric Residents

  • Visitors are essential for the mental health and developmental needs of pediatric residents. Visitation must be permitted for pediatric residents.
  • Involve Child Life workers, parents, legal guardians, or authorized representatives in planning the facility visitation program and the most developmentally appropriate visitation program for each resident, including residents who may not have family who can visit. The visitation program shall provide routine and ongoing visitation to meet each resident's developmental and medical needs. 
  • Visitors may include parents, legal guardians, or authorized representatives of the pediatric resident and family, regardless of age. Child visitors must be able to observe the required infection control practices, (e.g., source control, hand hygiene, physical distancing) and should be accompanied by an adult visitor.
  • Visitors may also include educational instructors, special education aides, and physical, speech or other therapists and service providers who are referenced in a resident's Individualized Education Plan, Section 504 Plan, Individualized Program Plan, or Community Placement Plan.
  • Extended periods of physical contact may be allowed between the pediatric resident and visitors.

Required Visitation

All facilities must comply with state and federal resident's rights requirements pertaining to visitation. Facilities should follow CDPH and local public health department guidance when implementing visitation policies. Failure to facilitate visitation, without adequate reason related to clinical necessity or resident safety, would constitute a violation of resident's rights and the facility would be subject to citation and enforcement actions.

If you have any questions about this AFL, please contact your local district office.



Original signed by Cassie Dunham

Cassie Dunham

Deputy Director



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