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

AFL 21-35
September 17, 2021

Adult Day Health Centers (ADHCs)

Guidance for In-Center Services and Operation of ADHCs during the Coronavirus Disease 2019 (COVID-19) Pandemic


All Facilities Letter (AFL) Summary

  • This AFL provides guidance for ADHCs to operate and safely return to in-center services during the COVID-19 pandemic. This guidance includes the following:
    • Safety Protocols
    • Isolation
    • Participants Rights​
    • Transportation
    • Vaccination
    • Testing
  • This AFL also provides recommendations for group activities when all participants are fully vaccinated. 

NOTE: This AFL is no longer in effect and is for historical purposes only​

Please refer to the most recent CDC guidance. ​


The California Department of Public Health (CDPH) is providing guidance for ADHCs to safely return to in-center services. This AFL also provides COVID-19 mitigation strategies in accordance with the CDC's Guidance for Adult Day Services Centers. ADHC's should promote and engage in preventive behaviors that reduce the spread of COVID-19 and maintain healthy operations and environments at ADHC facilities.

General Guidance and Safety Protocols

CDPH recommends all ADHC's continue to follow CDC recommended safety protocols:

  • Participants and visitors should stay home and refrain from entering the ADHC when any of the following occurs, regardless of vaccination status:
    • Tested positive for, have symptoms of, or undergoing evaluation (such as pending viral test) for COVID-19.
    • Recently had close contact (less than 6 feet for a cumulative total of 15 minutes or more over a period of 24 hours, or direct physical contact) with a person with COVID-19 during the prior 14 days.
  • Staff who have tested positive for, have symptoms of, or undergoing evaluation (such as pending viral test) for COVID-19 should stay home and refrain from entering the facility.
  • Fully vaccinated staff/health care personnel (HCP) (i.e., ≥2 weeks following receipt of the second dose in a 2-dose series, or ≥2 weeks following receipt of one dose of a single-dose vaccine) with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure. Work restrictions for fully vaccinated HCP populations with higher-risk exposures should still be considered for HCP who have underlying immunocompromising conditions (e.g., organ transplantation, cancer treatment), which might impact level of protection provided by the COVID-19 vaccine, and for fully vaccinated HCP who have traveled (excluding essential work related travel) when quarantine and work restrictions would apply to any traveler.
  • Conduct health screening for all participants, visitors and staff. Anyone entering the facility, regardless of their vaccination status, must:
    • Be screened for fever and COVID-19 symptoms and/or exposure within the prior 14 days to another person with COVID-19
    • Consider virtual health checks for employees and participants (for example, symptom and temperature screening) before they arrive at the center, in accordance with state and local public health authorities and your occupational health services (if applicable).
    • Before collecting health-related information from staff or participants, center administrators should comply with requirements of Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • Wear appropriate face mask (medical masks, also called surgical masks, or double masking is recommended) at all times in the ADHC; exceptions for when fully vaccinated participants may not wear masks during group activities are described below under "Group Activities":
    • Wearing masks may be difficult for participants with sensory, cognitive, behavioral issues, disabilities, or dementia. Staff should provide necessary support to participants who have trouble remembering to put on a mask, keeping it on, and removing it when needed. Staff should consider wearing masks that are clear/transparent so that participants can see the staff's mouth.
  • Wash hands often with soap and water or with hand sanitizer containing at least 60% alcohol.

Modify Layouts

  • Arrange tables and chairs to allow for physical distancing. People from the same household and/or participants who are all fully vaccinated can sit together without physical distancing; otherwise, space seating at least 6 feet apart. Provide visual cues such as tape or chalk to guide spacing.
  • Increase access to handwashing stations or hand sanitizer dispensers at key locations.
  • Minimize traffic in enclosed spaces, such as elevators and stairwells. Ensure that limiting the number of participants and physical distancing can be maintained in shared rooms, such as television, game, or exercise rooms, or rooms for shared worship services.

Group Activities

Activities should be encouraged but modified to help prevent the transmission of COVID-19 in the facility. The following are, in part, CDC recommendations:

  • Fully vaccinated participants may participate in group/social activities together without face masks or physical distancing; if any unvaccinated participants are present during the activity, then all participants in the group activity should wear a well-fitting face mask for source control and should physically distance from others.
  • Alter schedules, such as staggering meal and activity times, and creating pods (that is, forming small groups that regularly participate at the same times) and do not mix with individuals in other groups.
  • Prioritize outdoor activities over indoor activities when possible.
  • Clean tools, materials, and computer or other equipment before and after the participant has finished using them, or at least daily.
  • Avoid holding any in-person events that include people who are not staff in the ADHC. If an event is held, follow COVID-19 event considerations​.
  • Determine maximum group size, ensuring it is in conformance with your local health department guidelines.
  • Ensure that the group size is no larger than the space available to maintain physical distancing between each person present, as applicable.
  • Consider assigning cohorts to a specific room for their use for the program day.
    • Limit and discourage the rotational use of multiple rooms by one group, if another space is required and conditions allow consider moving cohort outside.
  • Shorten activity time to reduce exposure.
  • Schedule types of activities that allow for staff and participants to wear a face covering during the activity and when moving to and from the activity.
  • Create a sign-up sheet for each activity to control the number of clients. Sign-ups should be handled by staff to avoid cross contamination by multiple clients touching the same paper/pen/screen.


ADHCs should consider CDC recommendations to isolate and transport staf​f and participants​ who have symptoms while at the ADHC:

  • Plan to have an isolation room or area (preferably with access to a dedicated restroom) you can use to isolate a sick participant or staff member. Ensure that isolated participants are wearing masks, are at a distance of 6 feet or greater from others and remain under supervision.
  • Staff should isolat​e people who begin to have symptoms from others. Prepare a list of all individuals who have been in clo​se contact with sick participant(s) or staff member(s).
  • Notify an emergency contact regarding the sick person's symptoms and arrange safe and accessible transportation home. Arrange emergency transport to a healthcare facility for participants or staff with severe symptoms (PDF).

Participant COVID-19 Vaccination

COVID-19 vaccination is a critical step in the recovery from the pandemic. ADHCs should also monitor the CDC's Coronaviru​s Disease 2019 (COVID-19) webpage for additional guidance as it becomes available.

ADHCs may encourage COVID-19 vaccinations for participants and families:

  • The Pfizer-BioNTech, Moderna, and Janssen (Johnson and Johnson) COVID-19 vaccine trials have demonstrated that the COVID-19 vaccine is safe and effective.
  • The COVID-19 vaccine is available at no out-of-pocket cost.
  • Post-vaccine signs and symptoms are usually:
    • Mild to moderate in severity
    • Occur within the first three days of vaccination
    • Resolve within 1-2 days of onset
    • Less frequent and less severe in adults older than 55 years

Participants Rights and COVID-19 Vaccinations

ADHCs must keep in mind the importance of adhering to participant​ rights  throughout the COVID-19 vaccination period, including the right to receive or reject medical care or health related services. Participants who refuse to be vaccinated may not be denied participation in any ADHC activity or service available to any other participant solely based on the decision to not receive the vaccine. Participants who are unvaccinated or incompletely vaccinated must always wear a mask unless they are eating or drinking.

Staff Vaccination Requirement

Pursuant to the August 5, 2021 Public Health Order, ADHC staff/HCP who are not exempt are required to be vaccinated. In an ongoing effort to ensure patient safety and to minimize the spread of COVID-19 among vulnerable individuals, CDPH is requiring all HCP who provide services or work in healthcare facilities to receive COVID-19 vaccination. HCP must have completed the vaccination series of either the first dose of a one-dose regimen or their second dose of a two-dose regimen by September 30, 2021. HCP may be exempt from the vaccination requirements only upon providing the operator of the facility a written declination, signed by the individual stating either of the following: (1) the worker is declining vaccination based on Religious Beliefs, or (2) the worker is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reason. Please see AFL 21-34 for additional information related to the vaccine mandate.

Staff COVID-19 Testing and Masking Requirements

CDPH is requiring health care facilities to develop and implement processes for verifying the vaccination status of all HCP, and for obtaining and tracking documentation of weekly SARS-CoV-2 diagnostic screening testing of all HCP who are unvaccinated or incompletely vaccinated. Staff cannot opt to regularly test instead of getting vaccinated. Testing will be an alternate means for satisfying the August 5 Public Health Order only for those who are granted an exemption pursuant to the Order.

ADHCs must make their best efforts to comply with the vaccine verification and testing requirements in this AFL, as soon as reasonably possible, with full compliance no later than August 23, 2021. ADHCs can also implement additional infection control policies beyond these requirements, as some already have. For additional information about the testing requirements, see AFL 21-29.

ADHCs must strictly adhere to current CDPH Masking Guidance. To the extent they are already applicable, ADHCs must also continue to adhere to Cal/OSHA's standards for Aerosol Transmissible Diseases (ATD), which requires respirator use in areas where suspected and confirmed COVID-19 cases may be present, and the Emergency Temporary Standards (ETS) that requires all unvaccinated workers be provided a respirator upon request. For additional information about masking requirements see AFL 21-29.


ADHCs should follow the CDC guidance for transporting participants​:

  • Schedule and stagger drop off or pick up times for participants to avoid crowding.
  • Encourage physical distancing among staff and participants at the entrance and exit during these drop off and pick up times with use of visual cues like tapes and signs.
  • Fully vaccinated participants may be seated together without physical distancing in transport vehicles; otherwise, seat participants at least 6 feet apart while in transport vehicles.
  • Create participant pods (keeping small groups together) to limit mixing and create distance between passengers (for example, skip rows) when possible.
  • Require mask wearing and encourage physical distancing among staff and participants at the entrance and exit during these drop off and pick up times with use of visual cues like tapes and signs. 

If you have any questions about infection prevention and control of COVID-19, please contact the CDPH Healthcare-Associated Infections Program via email at or

Please remember to immediately report suspected and confirmed cases of COVID-19 to your local public health department (PDF) and your district office.



Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director



  • CDC Guidance for Adult Day Services C​enters​

[1] Health Care Personnel refers to all paid and unpaid individuals who work in indoor settings where (1) care is provided to patients, or (2) patients have access for any purpose. This includes HCP serving in health care or other health care settings who have the potential for direct or indirect exposure to patients or SARS-CoV-2 airborne aerosols. HCP include, but are not limited to, nurses, nursing assistants, physicians, technicians, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the health care facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the health care setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel).

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