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

AFL 21-14.2
October 6, 2022

Intermediate Care Facilities/Developmentally Disabled (ICF/DD)
Intermediate Care Facilities/Developmentally Disabled – Habilitative (ICF/DD-H)
Intermediate Care Facilities/Developmentally Disabled – Nursing (ICF/DD-N)
Intermediate Care Facilities/Developmentally Disabled – Continuous Nursing (ICF/DD-CN)

Visitation Guidance for ICF/DD-H-N-CN Facilities During the Coronavirus Disease-2019 (COVID-19) Pandemic
(This AFL supersedes AFL 21-14.1)


All Facilities Letter (AFL) Summary

  • This AFL notifies all ICF/DD-H-N-CN facilities of the 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 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effective September 17, 2022, the visitation requirements outlined in the August 26, 2021 Public Health Order (PHO) are rescinded.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.  

NOTE: This AFL is no longer in effect and is for historical purposes only.

Please refer to the most recent CDC guidance. ​


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 48percent 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 facility 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 ICF/DD-H-N-CN 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

Visitation can be conducted through different means based on a facility's structure and clients/residents' needs. Visitation can be conducted in resident rooms, dedicated visitation spaces, and outdoor areas. Facilities should communicate infection prevention and control (IPC) requirements to visitors. Visitors, residents, and HCP must also continue to follow current CDPH Masking Guidance to protect themselves and others.

The following recommendations mitigate the risk of COVID-19 transmission and are consistent with current CDC guidance for congregate settings such as ICF/DD-H-N-CN. These recommendations should be followed except where they prevent a necessary accommodation.

  • Screen and triage all visitors, upon entry to the facility in accordance with current CDC guidance for signs and symptoms of COVID-19 and/or exposure within the prior 14 days to another person with COVID-19.
  • All visitors must wear a well-fitting face mask (medical mask, also called surgical masks or double masking is recommended) upon entry and at all times while in the facility unless eating or drinking and perform hand hygiene.
  • Visits should be conducted with an adequate degree of privacy and should be scheduled at times convenient to visitors (e.g., outside of regular work hours).
  • All visitors must maintain physical distancing from other visitors from different households, as well as from facility staff and clients/residents; circumstances when visitors may interact without physically distancing from the client/resident they are visiting are outlined below.

Additionally, for facility/staff:

  • Facility staff must, regardless of their vaccination status, wear a face mask for source control and maintain physical distancing from visitors.
  • Routinely clean and disinfect frequently touched surfaces in the facility and designated visitation areas after each visit.
  • Post instructional signage throughout the facility on COVID-19 signs and symptoms, IPC precautions, other applicable facility practices (e.g., use of face covering or mask; specified entries, exits, and routes to designated areas; hand hygiene).

When accommodations to meet the specific needs of a resident prevent implementation of a protective measure during visitation, additional levels of protection should be addressed in a person-centered manner such as:

  • Touch-based communication may be necessary for clients/residents with combined hearing and vision impairment. Increased use of touch-based communication may necessitate higher levels of hand hygiene, respiratory protection and/or other protections.
  • When communicating with individuals who are deaf or hard of hearing, staff and visitors should use a clear mask or cloth mask with a clear panel.

Visitors who are unwilling to adhere to the recommended principles of COVID-19 infection prevention or who have tested positive for COVID-19 should not be permitted to visit in person or should be asked to leave. Under such circumstances, facilities must offer alternatives for remote (skype, etc.) or telephone visitation.

Outdoor Visitation

Outdoor visits pose a lower risk of transmission because of increased space and airflow; therefore, outdoor visitation is preferred and 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. 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 and staff monitoring of infection control guidelines.

Outdoor visits may be conducted without face masks and physical distancing and include physical contact (e.g., a brief hug, holding hands), regardless of vaccination status.

To ensure the protection of visitors and clients/residents, CDPH recommends the following:

  • Facilitate routine visitation unless weather considerations (e.g., inclement weather, excessively hot or cold temperatures, poor air quality), an individual's health status (e.g., medical condition(s) or COVID-19 status) make these options untenable.
  • Consider limiting the number of individuals visiting per resident at the same time based on the size of the space.

Indoor Visitation

Facilities shall accommodate and support indoor visitation based on the following guidelines:

  • Indoor visits must be conducted with both the resident and visitor wearing a well-fitting face mask. Regardless of vaccination status, they 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.
  • Visitors must be willing to adhere to the recommended principles of infection prevention, including wearing a well-fitting facemask and maintaining physical distancing from other visitors from different households, facility staff and clients/residents. Staff should provide monitoring for persons who may have difficulty adhering to recommended principles, such as children.
  • Facilities should reasonably limit the number of simultaneous visitors per resident and limit the total number of visitors in the facility simultaneously, based on the size of the building and physical space.
  • Facilities may consider scheduling visits to help ensure all clients/residents are able to receive visitors.
  • Facilities should limit visitor movement in the facility, 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.
  • 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).
  • Where practical based on the size of the facility dedicated bathrooms solely for visitors should be clearly designated and communicated by staff to visitors. Exhaust fans should run continuously. When permissible, facilities should "consider ventilation system upgrades or improvements and other steps to increase the delivery of clean air and dilute potential contaminants," per CDC Guidance on Ventilation.

NOTE: For situations where there is a roommate and the health status of the resident prevents leaving the room, facilities should attempt to enable in-room visitation while adhering to the recommended principles of COVID-19 infection prevention.

Visitation in Communal Indoor Spaces that Allow for Physical Distancing

If outdoor visitation is not possible (e.g., inclement weather, poor air quality, resident inability to be moved outside, etc.), facilities shall accommodate visitation in communal indoor spaces such dining area, activity room, etc. where physical distancing can be maintained between the visitor and facility staff and other clients/residents they are not visiting. Facilities may need to rearrange these spaces or add barriers to separate the space to accommodate the need for visitation of multiple residents. 

During indoor large communal space visits, both the resident and visitor must always wear a well-fitting face mask unless eating or drinking. Regardless of vaccination status, these visits may be conducted without physical distancing and include physical contact (e.g., hugs, holding hands) while in designated spaces for visitation that maintain physical distancing between the visitor and facility staff and other residents they are not visiting.

Other Visitation Options in Addition to Outdoor and Communal Spaces

Clients/residents who are on transmission-based precautions for COVID-19 should only receive visits that are virtual, through windows, or in-person for compassionate care situations, with adherence to transmission-based precautions. However, this restriction should be lifted once transmission-based precautions are no longer required per CDC guidelines.

For clients/residents that are not able to have visitors because of their high-risk medical status, facilities are encouraged to implement one or more of the following options:

  • Offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.).
  • Creating/increasing listserv communication and website notifications to update families and caregivers, or outside HCPs, such as advising them not to visit when circumstances require.
  • Assigning dedicated staff as primary contacts to families and caregivers for inbound calls and conduct regular outbound calls to keep families and caregivers up to date.
  • Offering a phone line with a voice recording updated at set times (e.g., daily) with the facility's general operating status, COVID-19 infection status, and when it will be safe to resume visits.

Communal Activities and Dining

Communal activities and dining may occur in the following manner:

  • Clients/residents who are not in isolation may eat in the same room without physical distancing, regardless of vaccination status.
  • Clients/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 clients/residents.

Clients/Residents Who Leave and Return to the Facility

Clients/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.

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. Facilities should promote and may not restrict visitation without a reasonable clinical or safety cause, consistent with Code of Federal Regulations (CFR) requirements at 42 CFR 483.420(a) (PDF) ("Standard: Protection of clients' rights.") and 42 CFR 483.420(c) (PDF) ("Standard: Communication with clients, parents, and guardians.").

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.

Additional Considerations for Pediatric Facilities

  • 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.

CDPH understands the importance of maintaining contact with family and friends to clients/residents. We encourage facilities to monitor the CDC website for information and resources. 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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