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

September 28, 2021

All Californians

Adult Care Facilities and Direct Care Worker Vaccine Requirement

​The COVID-19 pandemic remains a significant challenge in California. COVID-19 vaccines are effective in reducing infection and serious impacts including hospitalization and death. At present, 69.34% of Californians 12 years of age and older are fully vaccinated with an additional 8.26% are partially vaccinated. California continues to experience high-levels COVID-19 cases with 21.1 new cases per 100,000 people per day, with case rates currently tenfold higher as compared to June 2, 2021. The Delta variant is highly transmissible and causes more severe illness. In fact, recent data suggests that viral load is roughly 1,000 times higher in people infected with the Delta variant than those infected with the original coronavirus strain, according to a recent study.  The Delta variant is currently the most common variant causing new infections in California.

Unvaccinated persons are more likely to get infected and spread the virus, which is transmitted through the air. Most current hospitalizations and deaths are among unvaccinated persons. California's hospital and health care delivery system is strained. Additional statewide directed measures are necessary to protect particularly vulnerable populations, and ensure a sufficient, consistent supply of workers in high-risk care settings. These measures can improve vaccination rates in these settings, which ensures that both the individuals being served as well as the workers providing the services, are protected from COVID-19.

Adult and senior care facilities, and settings within which direct care and services are provided, as identified in this order, are high-risk settings where COVID-19 transmission and outbreaks can have severe consequences for vulnerable populations resulting in hospitalization, severe illness, and death. Further, the settings in this order share several features. There is frequent contact between staff or workers and highly vulnerable individuals, including elderly, chronically ill, critically ill, medically fragile, and people with disabilities. In many of these settings, the consumers and residents are at high risk of severe COVID-19 disease due to underlying health conditions, advanced age, or both.

Among 19,830 confirmed COVID-19 outbreaks throughout the pandemic, 47% were associated with the health care, congregate care, and direct care sector. The top industry settings are adult and senior care facilities and in-home direct care settings (22%) where increasing numbers of workers are among the new positive cases and recent outbreaks in these types of settings have frequently been traced to unvaccinated individuals.

Vaccination against COVID-19 is the most effective means of preventing infection with the COVID-19 virus, and subsequent transmission and outbreaks. As we respond to the ongoing pandemic, all workers in adult and senior care facilities and in-home direct care settings must be vaccinated to reduce the chance of transmission to vulnerable populations.

For these reasons, COVID-19 remains a concern to public health and, in order to prevent its further spread in adult and senior care facilities and in-home direct care settings, new public health requirements are necessary at this time.
NOW, THEREFORE, I, as State Public Health Officer of the State of California, order:

1. All individuals in subdivisions (a) through (e) must have the first dose of a one-dose regimen or the second dose of a two-dose regimen by November 30, 2021.

a. All workers who provide services or work in Adult and Senior Care Facilities licensed by the California Department of Social Services; 

b. All in-home direct care services workers, including registered home care aides and certified home health aides, except for those workers who only provide services to a recipient with whom they live or who are a family member of the recipient for whom they provide services;

c. All waiver personal care services (WPCS) providers, as defined by the California Department of Health Care Services, and in-home supportive services (IHSS) providers, as defined by the California Department of Social Services, except for those workers who only provide services to a recipient with whom they live or who are a family member of the recipient for whom they provide services;

d. All hospice workers who are providing services in the home or in a licensed facility; and 

e. All regional center employees, as well as service provider workers, who provide services to a consumer through the network of Regional Centers serving individuals with developmental and intellectual disabilities, except for those workers who only provide services to a recipient with whom they live or who are a family member of the recipient for whom they provide services.

2. All workers who are eligible for the exceptions outlined in subdivisions (b), (c), and (e) of section (1) must only provide services to a single household. If the worker provides services across multiple households, then the exception does not apply, and the worker must adhere to the provisions of this Order. 

3. Two-dose vaccines include: Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization. The one-dose vaccine is: Johnson and Johnson [J&J]/Janssen. All COVID-19 vaccines that are currently authorized for emergency use can be found at the following links:

a. By the US Food and Drug Administration (FDA), are listed at the FDA COVID-19 Vaccines webpage.

b. By the World Health Organization (WHO), are listed at the WHO COVID-19 Vaccines webpage. 

4. "Worker" refers to all paid and unpaid individuals who work in indoor settings where (1) care is provided to individuals, or (2) persons in care have access for any purpose.  This includes workers serving in residential care or other direct care settings who have the potential for direct or indirect exposure to persons in care or SARS-CoV-2 airborne aerosols. Workers include, but are not limited to, direct supportive services staff, hospice providers, nurses, nursing assistants, physicians, technicians, therapists, WPCS providers, IHSS providers, registered home care aides, certified home health aides, students and trainees, contractual staff not employed by the residential facility, and persons not directly involved in providing care or services, but who could be exposed to infectious agents that can be transmitted in the care setting (e.g., clerical, clergy, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, cosmetology, personal training and volunteer personnel).

5. “Employer” refers to an organization that employs and directs the worker in providing services. In the case of workers in a facility, the facility is the employer. In the case of certified home health aides and affiliated home care aides, the home health agencies and home care organizations are the employer.  

6. “Employer-Recipient” refers to the person receiving services from IHSS workers, WPCS workers, and independent registered home care aides.

7. Workers may be exempt from the vaccination requirements under section (1) only upon providing the employer or employer-recipient a declination form, 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 Reasons. 

a. To be eligible for a Qualified Medical Reasons exemption the worker must also provide to their employer or employer-recipient a written statement signed by a physician, nurse practitioner, or other licensed medical professional practicing under the license of a physician stating that the individual qualifies for the exemption (but the statement should not describe the underlying medical condition or disability) and indicating the probable duration of the worker’s inability to receive the vaccine (or if the duration is unknown or permanent, so indicate).  

8. If an employer or employer-recipient deems a worker listed above under section (1) to have met the requirements of an exemption pursuant to section (7), the unvaccinated exempt worker must meet the following requirements when entering or working in such facility or home:

a. Test for COVID-19 with either PCR or antigen test that either has 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. Testing must occur once weekly for such workers.

b. Wear a surgical mask or higher-level respirator approved by the National Institute of Occupational Safety and Health (NIOSH), such as an N95 filtering facepiece respirator, at all times while in the facility or home.

9. Consistent with applicable privacy laws and regulations, an employer must maintain records of workers’ vaccination or exemption status. If the worker is exempt pursuant to section (7), the employer as applicable also must maintain records of the workers’ testing results pursuant to section (8).  For IHSS workers, WPCS workers, and independent registered home care aides, the worker must maintain relevant records as provided in this section. 

a. The employer must provide such records to the local or state Public Health Officer, the California Department of Social Services, or their designee promptly upon request, and in any event no later than the next business day after receiving the request.

b. Employers and workers subject to the requirement under section (1) must maintain records pursuant to the CDPH Guidance for Vaccine Records Guidelines & Standards with the following information: (1) full name and date of birth; (2) vaccine manufacturer; and (3) date of vaccine administration (for first dose and, if applicable, second dose).

c. For unvaccinated workers: signed declination forms with written health care provider’s statement where applicable, as described in section (6) above. Testing records pursuant to section (8) must be maintained.

10. Nothing in this Order limits otherwise applicable requirements related to Personal Protective Equipment, personnel training, and infection control policies and practices.

11. Facilities covered by this Order, to the extent possible, are encouraged to provide onsite vaccinations, easy access to nearby vaccinations, and education and outreach on vaccinations. 

12. The July 26 Public Health Order will continue to apply.

13. This Order shall take effect immediately, and facilities and providers must be in full compliance with the Order by November 30, 2021.

14. This Order is issued pursuant to Health and Safety Code sections 120125, 120140, 120175,120195 and 131080 and other applicable law.

Tomás J. Aragón, MD, DrPH
Director and State Public Health Officer
California Department of Public Health