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

AFL 21-31
August 12, 2021

General Acute Care Hospitals

Visitor Limitation Guidance at General Acute Care Hospitals (GACHs)

All Facilities Letter (AFL) Summary

  • This AFL consolidates the California Department of Public Health's (CDPH's) visitation guidance into a single set of recommendations for GACHs.
  • This AFL also provides updated visitation guidance based upon CDC's updated healthcare infection prevention and control recommendations in response to COVID-19 vaccination for non-long-term care facilities (e.g., General Acute Care Hospitals, Acute Psychiatric Hospitals).
  • The Public Health Order related to visitors in the acute health care setting issued August 5, 2021 becomes effective August 11, 2021. This AFL requires hospitals to develop and implement processes for verifying the vaccination status of acute care visitors and for obtaining and tracking documentation of results of SARS-CoV-2 diagnostic testing from visitors who are unvaccinated or incompletely vaccinated.
  • Skilled nursing facilities should continue to refer to AFL 20-22.9, the various kinds of intermediate care facilities should continue to refer AFL 21-14.1, and all other health care facilities should refer to AFL-20-38.7 for visitation guidance.

On August 5, 2021, the State Public Health Officer issued an order pertaining to "Requirements for Visitors in Acute Health Care and Long-Term Care Settings."  As more transmissible variants of the SARS-CoV-2 virus circulate in California, COVID-19 cases are rising rapidly in California and the vast majority of cases are occurring in unvaccinated individuals. Despite the availability of safe and highly effective COVID-19 vaccination, many individuals remain unvaccinated and are at high risk of acquiring COVID-19 and exposing hospital patients or health care personnel. In an ongoing effort to ensure patient safety and to minimize the spread of COVID-19 among vulnerable individuals, CDPH is requiring GACHs to develop and implement processes for verifying the vaccination status of acute care visitors, and for obtaining and tracking documentation of SARS-CoV-2 diagnostic test results of acute care visitors who are unvaccinated or incompletely vaccinated. Visitors who are unvaccinated or incompletely vaccinated must show documentation of a negative SARS-CoV-2 test that occurred within 72 hours before each visit. Visitors who test positive for COVID-19 should not be permitted to visit or should be asked to leave. Under such circumstances, facilities must offer alternatives for remote (skype, etc.) or telephone visitation.

Options for Providing Proof of Vaccination

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

  • Covid-19 Vaccination Record Card (issued by the Department of Health and Human Services Centers for Disease Control & Prevention or WHO Yellow Card[1]) which includes name of person vaccinated, type of vaccine provided, and date last dose administered); OR 
  • a photo of a Vaccination Record Card as a separate document; OR 
  • a photo of the client's Vaccination Record Card stored on a phone or electronic device; OR 
  • documentation of COVID-19 vaccination from a healthcare provider; OR  
  • 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.

Visitors may access their digital vaccination record by using the CDPH Digital COVID-19 Vaccine Record website.

In the absence of knowledge to the contrary, GACHs may accept the documentation presented as valid. Facilities must have a plan in place for tracking verified visitor vaccination status. Documentation of the verification must be kept on file at the facility and made available upon request by CDPH or the local public health department for one year following the end of the public health emergency.

Unvaccinated or Incompletely Vaccinated Visitors

Visitors of acute health care that are unvaccinated or incompletely vaccinated must show documentation of a negative SARS-CoV-2 test where the specimen collection occurred within 72 hours before each visit and for which the test results are available at the time of entry to the facility. Visitors may choose antigen or molecular (e.g., PCR) testing to satisfy the testing requirement. Any molecular 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. GACHs can offer to conduct onsite testing of visitors if practical per facility testing capacity but are not required to do so. For purposes of this AFL, a person who accompanies a patient to an outpatient appointment is not a visitor in acute health care.

Visitors who are visiting a patient in critical condition, when death may be imminent, are exempt from the vaccination and testing requirements, however, must comply with all infection control and prevention requirements applicable for indoor visits. For purposes of this AFL and in emergent situations, parent or guardian visitors of pediatric patients, a support person for a labor and delivery patient, and support persons for a patient with physical, intellectual, developmental disability, or cognitive impairment are considered visitors who are visiting a patient in critical condition. For subsequent visits following the emergent situation and as soon as reasonably possible, these visitors must comply with the vaccine verification or applicable testing requirements within 72 hours.

For purposes of this AFL, the terms "visitor" and "support person" are used interchangeably.


CDPH recommends that hospitals in all counties allow all patients to have up to two visitors from the same household at the same time, provided physical distancing can be accomplished and visitors comply with hospital visitor guidelines.

In addition, CDPH continues to recommend up to two visitors or support persons not necessarily from the same household at the same time, provided physical distancing can be accomplished, for specific patient groups to ensure support for their mental health and well-being:

  • Pediatric Patients
  • Labor and Delivery Patients
    • In addition to the support person(s), CDPH recommends that a doula, if desired by the patient, be permitted to be present if prior arrangements have been made with the hospital and the doula complies with hospital PPE and infection control guidelines.
  • Patients at End-of-Life
  • Patients with Physical, Intellectual, and/or Developmental Disabilities and Patients Cognitive Impairments
  • Surgery Patients
    • CDPH recommends that up to two visitors be permitted until the patient is taken into prep (provided physical distancing can be accomplished), and up to two visitors when the patient is in recovery and preparing for discharge. Visitors may use waiting rooms it they are set up to maintain distancing between individuals and groups, and wear appropriate facial covering at all times in the waiting room.

Visitors do not need to be designated in advance by the patient. Unvaccinated visitors returning from international travel should quarantine and not visit the hospital until quarantine is completed; fully vaccinated visitors, however, do not need to quarantine after travel.

Each visitor, regardless of their vaccination status, should be screened for fever and COVID-19 symptoms; must wear a well-fitting face mask (medical masks, also called surgical masks, or double masking is recommended) upon entry and at all times within the facility; must wear other personal protective equipment (PPE) as appropriate while in the patient's room; and must physically distance from healthcare personnel and other patients/residents/visitors that are not part of their group at all times while in the facility. Facilities should also limit visitor movement in the facility. For example, visitors should not walk around in hallways of the facility and must go directly to and from the patient's room.

On April 27, 2021, CDC released updated healthcare infection prevention and control recommendations in response to COVID-19 vaccination. Visits between fully vaccinated visitors and fully vaccinated patients may be conducted without physical distancing and may include physical contact (e.g., a hug, holding hands) and eating together, while alone in the patient's room (no other patients, visitors, or health care personnel are present). All visitors must wear a well-fitting face mask at all times in the facility including when in the patient's room regardless of vaccination status unless eating or drinking.

CDPH supports efforts to ensure that new nurses and other professionals coming into the healthcare workforce are able to obtain necessary clinical experience. CDPH encourages students obtaining their clinical experience be permitted to enter the facility if they meet the CDC guidelines for healthcare workers to maintain the workforce needed during this pandemic. Hospitals may allow volunteers in the facility in compliance with their internal policies

Additionally, CDPH strongly encourages acute care facilities to create ways for patients to have frequent video and phone call visits. If shared devices are used for video calls facilities should ensure appropriate infection control measures are in place. For additional visitation guidance applicable to SNFs, please see AFL 20-22.9 and for guidance applicable to the various kinds of ICF/DD facilities please see AFL 21-14, and all other health care facilities should refer to AFL-20-38.7 for visitation guidance.

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



Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director

[1] People 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).

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