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EDMUND G. BROWN JR.
Governor

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


May 6, 2022


TO:
Local Public Health Department Staff, Shelter Operators, Others

SUBJECT:
Infection Control Guidance for Clients in Congregate Shelters, Including Shelters for People Experiencing Homelessness



Updates as of May 6, 2022:

 

People experiencing homelessness and other clients in congregate shelters are high risk for COVID-19 infection. This population is also at higher risk of having serious disease and complications, especially those who are older and have chronic medical conditions. Homeless shelters and other shelters where individuals have close contact with one another indoors (congregate shelters) are especially vulnerable to outbreaks of COVID-19.

Local health departments should ensure that congregate shelters in their jurisdictions are informed about best practices and recommended COVID-19 mitigation measures. When responding to suspected or confirmed cases of COVID-19 in congregate shelters, local health departments should implement recommended physical distancing and required masking measures, increase ventilation to the extent possible, vaccinate willing clients and staff who are unvaccinated, have not completed a primary series, or are not boosted if booster-eligible, and refer appropriate clients for treatment with recommended post-exposure prophylaxis.

The following recommendations are intended to assist congregate shelter operators to mitigate the risk from COVID-19 infection for clients and visitors. When possible, the use of alternative housing sites or non-congregate settings should be considered in lieu of congregate shelters.

Please see the November 3, 2021 CDC guidance for detailed information: Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19).

In the workplace, employers are subject to the Cal/OSHA COVID-19 Prevention Emergency Temporary Standards (ETS) and should also refer to Cal/OSHA FAQs, or in some workplaces the Cal/OSHA Aerosol Transmissible Diseases (ATD) Standard (PDF), and should consult those regulations for additional applicable requirements.

Local health jurisdictions may be more restrictive than this statewide guidance in determining recommendations and requirements based on local circumstances or during certain situations that may require more restrictive requirements (for example, during active outbreaks).

Planning

  • Encourage all staff, volunteers and clients of congregate shelters to have completed a primary series and booster dose if the individual is eligible. See Interim Guidance for Health Departments: COVID-19 Vaccination Implementation for People Experiencing Homelessness for more information.
  • Homeless shelters must consult the July 26, 2021 State Public Health Officer Order for specific requirements for homeless shelters.
  • Consult CDPH mask guidance (and any local requirements for masking in homeless shelters).
  • Post signs at entrances and in strategic places providing instruction on hand hygiene, cough etiquette (PDF), required mask wearing, and physical distancing.
  • Minimize the number of staff and volunteers who are unvaccinated, incompletely vaccinated, or not boosted if booster-eligible who have face-to-face interactions with clients with respiratory symptoms or who are in isolation for COVID-19 infection.
  • Staff and volunteers who do not interact closely with symptomatic or isolated clients and do not clean client environments do not need to wear personal protective equipment (PPE) aside from complying with masking requirements.
  • All shelters should have plans for how to provide isolation or quarantine for clients when needed per CDPH Guidance for Local Health Jurisdictions on Isolation and Quarantine of the General Public
  • If the shelter cannot safely provide on-site isolation or quarantine, there should be a plan for non-congregate housing off-site (e.g., isolation in a designated hotel).

Prioritization of non-congregate housing for clients

When isolation and quarantine cannot be provided safely on-site, non-congregate housing resources, such as Project Roomkey, should be prioritized first for those who test positive for current COVID-19 infection (regardless of vaccination status or prior infection), for isolation. Non-congregate housing should also be prioritized for:

  • Those who need to be quarantined following an exposure.
  • Those who are at high-risk for severe COVID-19 infection or medical complications should they become infected, such as people over 65 or those who have underlying health conditions that increase the risk of severe COVID-19 infection.

COVID-19 vaccination verification

  • When feasible, shelter operators should assess the COVID-19 vaccination status of all clients and assist them with initiating or completing COVID-19 vaccination and boosters, if recommended. Shelters should not decline entry to clients based on vaccination status.
  • Shelter operators in shelters where healthcare services are provided may enroll in the California Immunization Registry (CAIR) to confirm client COVID-19 vaccination status. To apply for access, go to: CAIR Enrollment Website.
  • See the CDPH Guidance for Vaccine Records Guidelines & Standards for options for individuals to provide proof of vaccination.

Clients who are children

  • Children may be sheltered with other household members during their isolation and quarantine periods.

Sleeping areas

  • Mats/cots/beds for clients who are not experiencing COVID-19 symptoms should be arranged so that clients lie head-to-toe relative to each other and are distanced as feasible.
  • For clients with symptoms consistent with COVID-19, testing should be conducted as soon as possible, and such clients should be isolated until test results are known. If such clients cannot be placed in individual rooms, ensure physical distancing from asymptomatic clients.
  • No physical distancing is required between members of the same household, regardless of COVID-19 vaccination status.

Common areas

  • Encourage dining and other group activities to take place outdoors as much as possible; this is especially true for dining since masks must be removed for eating or drinking.
  • When possible, practice physical distancing in indoor common areas among clients, staff, and volunteers who are unvaccinated, have not completed a primary series, or not boosted if booster-eligible, or whose vaccination status is unknown, including:
    • Seating in shared indoor dining areas.
    • Essential indoor group activities.
  • Members of the same household can sit together indoors without distancing but should be distanced from other individuals to the extent possible.
  • Deliver food or stagger mealtimes to reduce crowding in shared dining areas.
  • Stagger the schedule for use of common areas such as kitchens, living spaces, and recreation areas.
  • Create a staggered bathing schedule to reduce the number of people using the facilities at the same time.
  • Educate clients and staff on basic infection control measures for respiratory infections, including hand hygiene, respiratory hygiene, and cough etiquette.
  • Follow the Centers for Disease Control and Prevention (CDC) cleaning and disinfection guidelines for community facilities, and cleaning facilities if someone is sick.
  • Place signs throughout the facility with reminders about hand hygiene, required masking, cough etiquette, and reporting any symptoms to staff.

Ventilation

Face coverings

Masking by staff, volunteers, and clients is currently required per CDPH mask guidance (and may also be subject to local requirements), regardless of COVID-19 vaccination status or prior infection, unless sleeping, bathing/showering, or eating/drinking.

Shelters should ensure that a supply of masks is available to distribute to anyone who arrives without one and should supply respirators (N95, KN95, KF94) or surgical masks to clients or visitors if feasible, to provide better protection.

Cleaning protocols

Handling waste:

  • Wear gloves.
  • Handle trash bags by their empty upper sections and do not hold against body.

Doing laundry:

  • Wear a well-fitting mask while handling dirty laundry.
  • Handle dirty laundry with a minimum of agitation to help prevent the generation of potentially contaminated lint aerosols.
  • Launder items using the warmest appropriate water setting for the items and dry items completely.
  • Dirty laundry that has been in contact with an infectious person can be washed with the laundry of other people.
  • Clean and disinfect hampers or other carts for transporting laundry according to guidance above for hard or soft surfaces.

COVID-19 symptom screening and screening testing in congregate shelters

Screening clients for COVID-19 signs and symptoms:

  • Anyone reporting one or more symptoms of COVID-19 (that cannot be explained by a pre-existing condition) or has a measured temperature of 100.4°F/38°C or higher should be isolated and tested for COVID-19 infection.
    • Antigen or PCR testing can be performed. However, persons infected with SARS-CoV-2 within the prior 90 days should have antigen testing.
  • Symptom screening should be performed daily if staffing capacity allows.
  • Designate a limited number of staff members to conduct screening.
  • PPE should be used when screening clients.
    • PPE should include a respirator at least as effective as an N95 filtering facepiece respirator, eye protection (goggles or disposable face shield that fully covers the front and sides of the face), and a single pair of disposable gloves.
    • Gowns are not routinely required for staff performing screening of asymptomatic people, however, gowns should be worn when screening symptomatic people. See the CDC’s Personal Protective Equipment: Questions and Answers for additional information.
  • In addition to regular symptom screening, encourage clients who develop symptoms to report those symptoms to designated staff members as soon as possible.
  • Clients may be screened with a COVID-19 symptom questionnaire (PDF).

Screening testing for clients

  • Consider performing screening testing at admission and/or regularly, on all or a sample of clients, particularly when community rates are high.
  • Local health departments may have guidance on screening testing in shelters.
  • The State of California offers resources to set up and operate testing sites. Shelters may apply for testing resources at the State of California website.

New client intake:

  • New client intakes to a shelter should be screened for symptoms on admission. If asymptomatic, they can immediately join the regular population.
  • New client intakes may have screening testing on admission or according to the regular screening cadence in the facility.

Screening testing for staff and volunteers:

See the State Public Health Officer Order for Health Care Workers in High-Risk Settings for any requirements for diagnostic screening testing of staff and volunteers.

Isolation of clients with acute respiratory illness or confirmed COVID-19

  • Clients with symptoms of COVID-19 should be moved to a private area of the facility for isolation and be tested as soon as possible.
  • If the client has severe symptoms, arrange for the client to receive immediate medical assessment and care as appropriate.
  • Clients who test positive for SARS-CoV-2 may follow CDPH Guidance for Local Health Jurisdictions on Isolation and Quarantine of the General Public.
  • In a county with high community levels of COVID-19, consider continuing isolation and retesting in 1-2 days if a symptomatic client tests negative with an antigen test, particularly if tested during the first 1-2 days of symptoms.
  • If clients who test positive for SARS-CoV-2 cannot be safely isolated on-site, it is recommended that they be placed in non-congregate housing, if available. See CDC Guidance for Shared or Congregate Housing for additional information.
  • If infected clients cannot be housed separately, they may be isolated as a cohort in a large and well-ventilated on- or off-site space with a separate bathroom and a door that can be closed to other clients.
  • Symptomatic clients who have not been diagnosed with COVID-19 should not be cohorted with clients with known SARS-CoV-2 infection.
  • Symptomatic clients should wear a surgical mask, if available, or other well-fitted mask with multiple layers.
  • Shared items used by infected/symptomatic clients should be cleaned thoroughly before use by another client.
  • Notify the local public health department of new cases of respiratory illness or fever among clients and any clusters of respiratory illness or fever in clients or staff.

Identification, testing, and quarantine of close contacts

Follow CDPH Guidance for Local Health Jurisdictions on Isolation and Quarantine of the General Public recommendations for testing and quarantine of clients following an exposure.

Identification:

Testing:

  • Close contacts should be tested as recommended in CDPH Guidance for Local Health Jurisdictions on Isolation and Quarantine of the General Public
  • Close contacts who develop COVID-19 symptoms should be isolated and tested as soon as possible.
  • Due to the potential for rapid transmission of COVID-19 within congregate settings, broader testing beyond immediate close contacts, e.g., location-based or facility-wide, may be appropriate in response to an identified case of COVID-19 infection in a shelter.

Quarantine:

  • Asymptomatic clients who need quarantine should be placed in non-congregate housing, if available, during their quarantine period.
  • If non-congregate housing is not available, such clients may be quarantined as a group (cohorted) in the shelter separate from other clients if space allows; frequent testing should be considered for the exposed group.
  • Quarantine (separation from others) should be implemented only when clients are present in the high-risk setting; quarantined clients may leave the shelter (or non-congregate housing) during their quarantine period.
  • If COVID-19 symptoms develop, the client should be isolated and tested as described in the "isolation of clients with acute respiratory illness or confirmed COVID-19" section above.

Outbreaks

  • Shelters experiencing an outbreak as determined by the local health department may continue to admit new clients if there are available beds in areas where no COVID-19 positive clients are being isolated.
  • Shelter operators may need to make internal decisions to pause new admissions due to key staffing shortages.

Additional Resources



Originally published on November 22, 2021