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

AFL 20-74.1
July 22, 2021

Skilled Nursing Facilities

Coronavirus Disease 2019 (COVID-19) Recommendations for Personal Protective Equipment (PPE), Resident Placement/Movement, and Staffing in Skilled Nursing Facilities
(This AFL supersedes AFL 20-74)

All Facilities Letter (AFL) Summary

  • This AFL provides recommendations for PPE, resident placement/movement, and staffing based on the residents' COVID-19 status.
  • This revision updates the chart of recommendations to clarify when eye protections must be used and to align with the latest CalOSHA requirements no longer allowing extended use and reuse of respirators.  

Facilities should first ensure confirmed COVID-19 positive residents are placed on the dedicated COVID-19 positive unit ("red" area) and then evaluate exposure status of other residents in the facility. Facilities should group residents into three separate cohorts, accordingly:

  • COVID-19 positive for the duration of the resident's isolation period: "red" area
  • COVID-19 exposed within the last 14 days: "yellow-exposed" status
    • In general, all residents on the unit or wing where a case was identified in a resident or healthcare personnel (HCP) are considered exposed and should remain in their current rooms unless sufficient private rooms are available. Avoid movement of residents that could lead to new exposures, for example, moving a resident into a room where one of the new roommates is subsequently found to have unidentified asymptomatic infection.
  • COVID-19 negative without known exposure within the last 14 days and recovered residents who have completed their isolation period: "green" status

The COVID-19 positive cohort should be housed in a separate "red area" (building, unit or wing) of the facility and have dedicated HCP who do not provide care for residents in other cohorts and should have separate break rooms and restrooms if possible.

Prioritize private rooms for new admissions ("yellow-observation") and for symptomatic residents ("yellow-PUI") while test results are pending.

Except for the designated COVID-19 positive unit ("red" area) and the observation area or rooms for newly admitted residents ("yellow-observation" area), the color-designations are not necessarily fixed, static locations; rather, the colors define the residents' exposure status and the necessary PPE for HCP. For example, early in an outbreak, the entire facility outside the "red" area might be considered "yellow-exposed;" as individual buildings/units/wings achieve two sequential negative rounds of response testing, those buildings/units/wings may become "green" status.

Refer to the "COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category" (PDF) for a chart of the COVID-19 recommendations.

If you have any questions about this AFL, please contact the Healthcare-Associated Infections Program via email at



Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director


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