VARIANCE TO STAGE 2 OF CALIFORNIA’S ROADMAP TO MODIFY THE STAY-AT-HOME ORDER COVID-19 VARIANCE ATTESTATION FORM FOR County of Los Angeles May 18, 2020 Background On March 4, 2020, Governor Newsom proclaimed a State of Emergency because of the threat of COVID-19, and on March 12, 2020, through Executive Order N-25-20, he directed all residents to heed any orders and guidance of state and local public health officials. Subsequently, on March 19, 2020, Governor Newsom issued Executive Order N-3320 directing all residents to heed the State Public Health Officer’s Stay-at-Home order which requires all residents to stay at home except for work in critical infrastructure sectors or otherwise to facilitate authorized necessary activities. On April 14th, the State presented the Pandemic Roadmap, a four-stage plan for modifying the Stay-at-Home order, and, on May 4th, announced that entry into Stage 2 of the plan would be imminent. Given the size and diversity of California, it is not surprising that the impact and level of county readiness for COVID-19 has differed across the state. On May 7th, as directed by the Governor in Executive Order N-60-20, the State Public Health Officer issued a local variance opportunity through a process of county self-attestation to meet a set of criteria related to county disease prevalence and preparedness. This variance allowed for counties to adopt aspects of Stage 2 at a rate and in an order determined by the County Local Health Officer. Note that counties desiring to be stricter or move at a pace less rapid than the state did not need a variance. In order to protect the public health of the state, and in light of the state’s level of preparedness at the time, more rapid movement through Stage 2 as compared to the state needed to be limited to those counties which were at the very lowest levels of risk. Thus, the first variance had very tight criteria related to disease prevalence and deaths as a result of COVID-19. Now, 11 days after the first variance opportunity announcement, the state has further built up capacity in testing, contact tracing and the availability of PPE. Hospital surge capacity remains strong overall. California has maintained a position of stability with respect to hospitalizations. These data show that the state is now at a higher level of preparedness, and many counties across the state, including those that did not meet the first variance criteria are expected to be, too. For these reasons, the state is issuing a second variance opportunity for certain counties that did not meet the criteria of the first variance attestation. This next round of variance is for counties that can attest to meeting specific criteria indicating local stability of COVID-19 spread and specific levels of county preparedness. The criteria and procedures that counties will need to meet in order to attest to this second variance opportunity are outlined below. It is recommended that counties consult with CDPH COVID-19 VARIANCE ATTESTATION FORM cities, tribes and stakeholders, as well as other counties in their region, as they consider moving through Stage 2 Local Variance A county that has met the criteria in containing COVID-19, as defined in this guidance or in the guidance for the first variance, may consider modifying how the county advances through Stage 2, either to move more quickly or in a different order, of California’s roadmap to modify the Stay-at-Home order. Counties that attest to meeting criteria can only open a sector for which the state has posted sector guidance (see Statewide industry guidance to reduce risk). Counties are encouraged to first review this document in full to consider if a variance from the state’s roadmap is appropriate for the county’s specific circumstances. If a county decides to pursue a variance, the local health officer must: 1. Notify the California Department of Public Health (CDPH), and if requested, engage in a phone consultation regarding the county’s intent to seek a variance. 2. Certify through submission of a written attestation to CDPH that the county has met the readiness criteria (outlined below) designed to mitigate the spread of COVID-19. Attestations should be submitted by the local health officer, and accompanied by a letter of support from the County Board of Supervisors, as well as a letter of support from the health care coalition or health care systems in said county. 1 In the event that the county does not have a health care coalition or health care system within its jurisdiction, a letter of support from the relevant regional health system(s) is also acceptable. The full submission must be signed by the local health officer. All county attestations, and submitted plans as outlined below, will be posted publicly on CDPH’s website. CDPH is available to provide consultation to counties as they develop their attestations and COVID-19 containment plans. Please email Jake Hanson at Jake.Hanson@cdph.ca.gov to notify him of your intent to seek a variance and if needed, request a consultation. County Name: County of Los Angeles County Contact: Dr. Muntu Davis Public Phone Number: (213) 288-8768 Readiness for Variance The county’s documentation of its readiness to modify how the county advances through Stage 2, either to move more quickly or in a different order, than the California’s roadmap to modify the Stay-at-Home order, must clearly indicate its preparedness according to the criteria below. This will ensure that individuals who are at heightened risk, including, for example, the elderly and those with specific co-morbidities, and those residing in long-term If a county previously sought a variance and submitted a letter of support from the health care coalition or health care systems but did not qualify for the variance at that time, it may use the previous version of that letter. In contrast, the County Board of Supervisors must provide a renewed letter of support for an attestation of the second variance. 1 2 CDPH COVID-19 VARIANCE ATTESTATION FORM care and locally controlled custody facilities and other congregate settings, continue to be protected as a county progresses through California’s roadmap to modify the Stay-at-Home order, and that risk is minimized for the population at large. As part of the attestation, counties must provide specifics regarding their movement through Stage 2 (e.g., which sectors, in what sequence, at what pace), as well as clearly indicate how their plans differ from the state’s order. As a best practice, if not already created, counties will also attest to plan to develop a county COVID-19 containment strategy by the local health officer in conjunction with the hospitals and health systems in the jurisdiction, as well as input from a broad range of county stakeholders, including the County Board of Supervisors. It is critical that any county that submits an attestation continue to collect and monitor data to demonstrate that the variances are not having a negative impact on individuals or healthcare systems. Counties must also attest that they have identified triggers and have a clear plan and approach if conditions worsen to reinstitute restrictions in advance of any state action. Readiness Criteria To establish readiness for a modification in the pace or order through Stage 2 of California’s roadmap to modify the Stay-at-Home order, a county must attest to the following readiness criteria and provide the requested information as outlined below: • Epidemiologic stability of COVID-19. A determination must be made by the county that the prevalence of COVID-19 cases is low enough to be swiftly contained by reintroducing features of the stay at home order and using capacity within the health care delivery system to provide care to the sick. Given the anticipated increase in cases as a result of modifying the current Stay-At-Home order, this is a foundational parameter that must be met to safely increase the county’s progression through Stage 2. The county must attest to: o Demonstrated stable/decreasing number of patients hospitalized for COVID-19 by a 7-day average of daily percent change in the total number of hospitalized confirmed COVID-19 patients of <+5% -OR- no more than 20 total confirmed COVID-19 patients hospitalized on any single day over the past 14 days. Los Angeles County reported a 7-day average of daily percent change in the total number of hospitalized cases as -1%. 7 Day Average Hospitalization with Daily Percent Change (day over day) in Los Angeles County Date # confim_cases_hosp 5/24/2020 5/23/2020 5/22/2020 5/21/2020 5/20/2020 5/19/2020 5/18/2020 1443 1440 1490 1491 1506 1517 1531 % change 0% -3% 0% -1% -1% -1% -1% prev_date 5/23/2020 5/22/2020 5/21/2020 5/20/2020 5/19/2020 5/18/2020 5/17/2020 3 # prev confirm_cases_hosp 1440 1490 1491 1506 1517 1531 1549 CDPH COVID-19 VARIANCE ATTESTATION FORM *Source: California Department of Public Health COVID-19 Tracking Tool, the Reddinet HAvBED data, and the COVID-19 Hospital Daily Assessment Poll data from the California Hospital Association (CHA) o 14-day cumulative COVID-19 positive incidence of <25 per 100,000 -OR- testing positivity over the past 7 days of <8%. The County of Los Angeles reports a 7-day testing positivity rate of 6.7% and a 14-day cumulative COVID-19 positive incidence rate was 98.7 (10,148 cases based on COVID-19 episode date; Population 10,278,834) per 100,000. Date 7 Day Average Positivity Rate Collection date daily_tests daily_positive %_pos 5/18/2020 16942 989 5.8% 5/19/2020 11844 747 6.3% 5/20/2020 8921 693 7.8% 5/21/2020 8357 589 7.0% 5/22/2020 8606 590 6.9% 5/23/2020 4119 273 6.6% 5/24/2020 2875 223 7.8% 61664 4104 6.7% *Data is from electronic laboratory reports, provider reports, and manually entered laboratory reports from the cities of Pasadena and Long Beach and County of Los Angeles Departments of Public Health NOTE: State and Federal prison inmate COVID+ cases can be excluded from calculations of case rate in determining qualification for variance. Staff in State and Federal prison facilities are counted in case numbers. Inmates, detainees, and staff in county facilities, such as county jails, must continue to be included in the calculations. Facility staff of jails and prisons, regardless of whether they are run by local, state or federal government, generally reside in the counties in which they work. So, the incidence of COVID-19 positivity is relevant to the variance determination. In contrast, upon release, inmates of State and Federal prisons generally do not return to the counties in which they are incarcerated, so the incidence of their COVID-19 positivity is not relevant to the variance determination. While inmates in state and federal prisons may be removed from calculation for this specific criteria, working to protect inmates in these facilities from COVID-19 is of the highest priority for the State. o Counties using this exception are required to submit case rate details for inmates and the remainder of the community separately. 4 CDPH COVID-19 VARIANCE ATTESTATION FORM We are not using this exception. • Protection of Stage 1 essential workers. A determination must be made by the county that there is clear guidance and the necessary resources to ensure the safety of Stage 1 essential critical infrastructure workers. The county must attest to: o Guidance for employers and essential critical infrastructure workplaces on how to structure the physical environment to protect essential workers. Please provide, as a separate attachment, copies of the guidance(s). Los Angeles County distributed a guidance document to all businesses with essential workers that described safety practices and requirements for structuring the physical environment to protect essential workers. Since April 10, 2020, the County has required Essential Businesses to implement a Social Distancing Protocol. The "Social (Physical) Distancing Protocol" that must be implemented and posted must demonstrate how the following infection control measures are being implemented and achieved, as applicable: a) Limiting the number of people who may enter into the facility at any one time to ensure that people in the facility can easily maintain a minimum six (6) foot physical distance from others, at all times, except as required to complete a business activity or transaction. Members of a single household or living unit may stand or move together but must be separated from others by a physical distance of at least six (6) feet. b) Where lines may form at a facility, marking six (6) foot increments at a minimum, establishing where individuals should stand to maintain adequate Social (Physical) Distancing, whether inside or outside the facility. c) Providing hand sanitizer, soap and water, or effective disinfectant at or near the entrance of the facility and in other appropriate areas for use by the public and employees, and in locations where there is high-frequency employee interaction with members of the public (e.g., cashiers). Restrooms normally open to the public shall remain open to the public. d) Posting a sign in a conspicuous place at all public entries that instructs the public not to enter if they are experiencing symptoms of respiratory illness, including fever or cough, to wear face coverings, and to maintain Social (Physical) Distancing from one another. e) Providing for the regular disinfection of high-touch surfaces, and disinfection of all payment portals, pens, and styluses after each use. All businesses are encouraged to also offer touchless payment mechanisms, if feasible. f) Providing cloth-face coverings to employees and contracted workers whose duties require close contact with other employees and/or the public. g) Requiring that members of the public who enter the facility wear a facecovering, which reduces the risk of “asymptomatic” or “pre-symptomatic” transmission to workers and others, during their time in the facility. h) Adhering to communicable disease control protocols provided by the 5 CDPH COVID-19 VARIANCE ATTESTATION FORM Los Angeles County Department of Public Health, including requirements for cleaning and disinfecting the site. See protocols posted at www.publichealth.lacounty.gov/media/Coronavirus/ Guidance is available for essential workplaces available in the following locations: LA County: www.publichealth.lacounty.gov/media/Coronavirus/ Pasadena: https://www.cityofpasadena.net/public-health/health-order/covid-19/ Long Beach: http://www.longbeach.gov/health/diseases-andcondition/information-on/coronavirus/ o Availability of supplies (disinfectant, essential protective gear) to protect essential workers. Please describe how this availability is assessed. We are utilizing California Department of Public Health COVID-19 Tracking Tool, the Reddinet HAvBED data, and the COVID-19 Hospital Daily Assessment Poll data from the California Hospital Association (CHA) and are identifying the percentage of hospitals that have 15+ days of available PPE, including N95 masks, other masks, eye protection, face shields, gloves, and gowns. As of 5/24/20, 84% of LA County hospitals had adequate N95 supply, 79% had adequate supply of other masks, 72% had adequate eye protection, 77% had adequate face shields, 64% had adequate gloves, and 53% had adequate gowns. • Testing capacity. A determination must be made by the county that there is testing capacity to detect active infection that meets the state’s most current testing criteria, (available on CDPH website). The county must attest to: o Minimum daily testing capacity to test 1.5 per 1,000 residents, which can be met through a combination of testing of symptomatic individuals and targeted surveillance. Provide the number of tests conducted in the past week. A county must also provide a plan to reach the level of testing that is required to meet the testing capacity levels, if the county has not already reached the required levels. On 5/26/2020, The County Los Angeles reports the total number of tests conducted in the past 7 days was 148,835 (over population of 10,278,834), which is approximately 2.07 tests per 1,000 residents per day. o Testing availability for at least 75% of residents, as measured by the presence of a specimen collection site (including established health care providers) within 30 minutes driving time in urban areas, and 60 minutes in rural areas. Please provide a listing of all specimen collection sites in the county and indicate if there are any geographic areas that do not meet the criteria and plans for filling these gaps if they exist. If the county depends on sites in adjacent counties, please list these sites as well. 6 CDPH COVID-19 VARIANCE ATTESTATION FORM Los Angeles County attests to testing availability for more than 75% of residents, as measured by 30 minutes driving time in urban areas, and 60 minutes in rural areas. See list below of all testing locations, which includes hospitals, urgent care clinics, outpatient clinics, and drive-thru and pop-up clinics. Testing is also available at shelters and encampments for persons experiencing homelessness. • Alexandria Care Center • Antelope Valley Mall • Ararat Convalescent Hospital • Baldwin Hills Crenshaw Plaza - Drive Thru Only • Bellflower City Hall • Beverly Hills Carmel Assisted Living • Bonnie Brae Convalescent Hospital • Brier Oak on Sunset • Brookdale Senior Living • Buena Ventura Post-Acute Care Center • Cabrillo High School- Long Beach • Carbon Health - Echo Park - Walk-Up Only • Carson/Torrance • ChapCare on Lake Avenue- Pasadena • Charles R. Drew Campus • Country Manor Healthcare • Country Villa North Rehabilitation and Wellness Centre • Country Villa Sheraton • Crenshaw Christian Center - Drive Thru Only • Culver West • Dodger Stadium drive-thru testing • East, Country Villa • East LA College • Foothill Retirement • Granada Hills Convalescent • Grancell Village of the Jewish Homes for the Aging • Grand Park Convalescent Hospital • Hansen Dam Recreation Center - Drive Thru Only • Hollywood Premier • Hotchkin Memorial Training Center - Drive Thru Only • Jordan High School- Long Beach • Joyce Eisenberg Keefer Medical Center • Kedren Community Health Center - Walk Up Only • Kei Ai Los Angeles Health Center • Kennedy Post Acute • Kingsley Manor Care Center • La Brea Rehabilitation Center • Lincoln Park - Drive Thru Only • Longwood Manor Convalescent Hospital • Lynnwood • Long Beach City College-Pacific Coast Campus • Long Beach City College- Veteran’s Stadium • Mid Wilshire Healthcare Center • Mugunghwa Silvertown • Northridge Care Ctr. • Northridge Fashion Center - Drive Thru Only • Northridge Hospital Medical Center • Pomona Fairplex Gate 17 7 CDPH COVID-19 VARIANCE ATTESTATION FORM • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • o Rehab Center of Beverly Hills Rose Bowl Testing Site- Paadena Sakura Intermediate Care Facility San Gabriel Valley Airport Santa Clarita Sherman Oaks Health & Rehab Solheim Senior Community South Bay Galleria St. John of God Retirement & Care Center Sunray Healthcare Center Tarzana Health & Rehabilitation Center The Forum The Meadows Post-Acute UHRC UHRC 39TH STREET UHRC 3rd and Rose UHRC Alvarado UHRC CABRITO UHRC CIVIC CENTER UHRC GLOBE UHRC GOWER UHRC Harbor City UHRC Oakwood UHRC PENMAR UHRC SELMA UHRC Sepulveda UHRC VENICE BOARDWALK VA Parking Lot 15 (at corner of Constitution and Davis) - Drive Thru Only Veterans Home - West LA Villa Scalabrini Virgil Rehabilitation & Skilled Nursing Center West Covina - AltaMed Medical and Dental Group West Hills Health and Rehab Center West Valley - Drive Thru Only West Valley Post-Acute Windsor Terrace Healthcare Center Please provide a COVID-19 Surveillance plan, or a summary of your proposed plan, which should include at least how many tests will be done, at what frequency and how it will be reported to the state, as well as a timeline for rolling out the plan. The surveillance plan will provide the ability for the county to understand the movement of the virus that causes COVID19 in the community through testing. [CDPH has a community sentinel surveillance system that is being implemented in several counties. Counties are welcome to use this protocol and contact covCommunitySurveillance@cdph.ca.gov for any guidance in setting up such systems in their county.] o 8 CDPH COVID-19 VARIANCE ATTESTATION FORM Los Angeles County attests to having a COVID-19 Surveillance Plan. LA County has been conducting community wide testing at hospitals, mobile testing sites, skilled nursing facilities, jails and shelters. Local health jurisdiction testing and surveillance guidance and updates are provided to health care providers and facilities as needed. Currently we are testing on average 18K people a day representing more than 5% of the population monthly including an effort to test all SNF residents and staff. As mentioned above, LA County positivity rate is 6.6% and is being monitored and reported daily. Efforts are being made to increase testing going forward, including reintegrating mobile sites into the healthcare system. We have a plan for testing contacts if cases are identified at worksites, congregate facilities as well as the medical care system and supporting SNFs to do their own testing. We will embed teams with outreach workers to test persons experiencing homelessness to do testing in shelters and encampments and an effort will be made to make sure our FQHCs have access to testing to increase testing among communities especially hard hit by COVID. We are also working closely with jails and prisons to do testing. We report all case and electronic lab reporting (ELR) data to CDPH daily by noon. Case data include demographic characteristics, clinical characteristics, known hospitalization data and data related to deaths. ELR data include ordering and performing facility, specimen characteristics, collection data, and result data. • Containment capacity. A determination must be made by the county that it has adequate infrastructure, processes, and workforce to reliably detect and safely isolate new cases, as well as follow up with individuals who have been in contact with positive cases. The county must attest to: o Enough contact tracing. There should be at least 15 staff per 100,000 county population trained and available for contact tracing. Please describe the county’s contact tracing plan, including workforce capacity, and why it is sufficient to meet anticipated surge. Indicate which data management platform you will be using for contact tracing (reminder that the State has in place a platform that can be used free-of-charge by any county). On 5/26/2020, the County of Los Angeles has a total of 1759 contact tracers, 17.1 staff per 100,000 county population, which exceeds the 15 per 100,000 requirement. o Availability of temporary housing units to shelter at least 15% of county residents experiencing homelessness in case of an outbreak among this population requiring isolation and quarantine of affected individuals. Please describe the county’s plans to support individuals, including those experiencing homelessness, who are not able to properly isolate in a home setting by providing them with temporary housing (including access to a separate bathroom, or a process in place that provides the ability to sanitize a shared bathroom between uses), for the duration of the necessary isolation or quarantine period. Rooms acquired as part of Project Roomkey should be utilized. 9 CDPH COVID-19 VARIANCE ATTESTATION FORM Los Angeles County is working in collaboration with the City of Los Angeles and homeless service providers throughout the County to implement strategies to prevent and mitigate the spread of COVID-19 among unsheltered people experiencing homelessness (PEH). To date, we have established and continue to build out motel/hotel options (through Project RoomKey) for medically vulnerable PEH totaling 4,700 units. The County has established medical sheltering for COVID+, suspect, or exposed individuals who are unable to safely isolate and currently have 791 occupiable units available at five motel/hotel locations. Additionally, the Department of Public Health’s Environmental Health team conducted inspections at over 300 homeless shelter facilities. There are 983 beds among existing shelter capacity that can and currently function as isolation beds. In addition, there are 295 City trailers that may be accessed. This totals 6,769 units that may be occupied. Given that a 2019 survey found 45,000 unsheltered persons experiencing homelessness, the County can attest that it currently has sufficient temporary housing units to shelter 15% of this population, who may require isolation and quarantine. In June, a medical sheltering hotel location may be discontinued, which would decrease the percent to 14.4% of the population. • Hospital capacity. A determination must be made by the county that hospital capacity, including ICU beds and ventilators, and adequate PPE is available to handle standard health care capacity, current COVID-19 cases, as well as a potential surge due to COVID-19. If the county does not have a hospital within its jurisdiction, the county will need to address how regional hospital and health care systems may be impacted by this request and demonstrate that adequate hospital capacity exists in those systems. The county must attest to: o County (or regional) hospital capacity to accommodate COVID-19 positive patients at a volume of at a minimum surge of 35% of their baseline average daily census across all acute care hospitals in a county. This can be accomplished either through adding additional bed capacity or decreasing hospital census by reducing bed demand from non-COVID-19 related hospitalizations (i.e., cancelling elective surgeries). Please describe how this surge would be accomplished, including surge census by hospital, addressing both physical and workforce capacity. Los Angeles County attests that hospitals have substantial capacity to meet the current number of COVID-19 positive patients and the ability to surge up to 50% of their normal capacity. Los Angeles County EMS Agency MHOAC monitors hospital capacity on a daily basis. Eighty (80) hospitals operating in the county participate in the Hospital Preparedness Program (HPP) which has provided enhanced disaster planning, preparedness and equipment. The County Departments, Health Services (DHS), Emergency Medical Services (EMS) Agency and Public Health (DPH), have consistently monitored and communicated with the licensed acute care facilities throughout the County. Hospital bed capacity for 70, 9-1-1 receiving hospitals is tracked and posted on the EMS Agency and DPH web sites daily. COVID-19 admissions have consistently decreased since mid-April 2020. This data demonstrates excess bed capacity throughout the system with the ability of the hospitals to surge, if necessary, to approximately 40-50 percent. The 70 9-1-1 receiving hospitals have a total licensed non-ICU bed capacity of 17,000 and the ability to surge within the hospital an additional 11,400. Their ICU bed capacity of 2,500 can be surged to 4,069. There are 10 CDPH COVID-19 VARIANCE ATTESTATION FORM 2,320 ventilators within the hospital system and an additional 3,211 that could be brought into use as needed. In addition to the surge capacity within the facilities, hospitals have identified areas for non-traditional bed and care, such as tent structures, hard shell mobile facilities and area such as out-patient surgical centers. Following “Disaster Plans”, hospitals demonstrated the ability to rapidly create surge capacity. In discussion with the hospitals, there is agreement that the recent experience has enabled the hospitals to rapidly repeat and re-institute the process to create capacity as needed. The Disaster Resource Center (DRC) program established in Los Angeles County, allow hospitals and the EMS Agency to support each other and move, loan and share equipment and supplies. The established system of communication between hospitals and the EMS Agency, ReddiNet, allows for hospitals to communicate needs and the ability to handle EMS 9-1-1 ambulance transports, allowing for emergency department personnel to regroup and adjust to the demands of incoming patients. Through experience of treating COVID-19 patients, hospitals have modified their processes and locations of care to conserve personal protective equipment and staff utilization. Policies for screening and testing patients and staff have been put into place. Patient are triaged and directed to areas of care for symptomatic and asymptomatic areas to limit patient and employee exposure. Hospitals have expanded their capacity to cohort patients in ICU, telemetry and wards. Staffing expansion is addressed through cross training existing staff, reallocation of staff from closed departments, new hires, registry and reactivation of retired employees. Our hospital systems have the ability to move staff, equipment and supplies to sister facilities experiencing a greater impact. Link to hospital data and bed capacity: http://file.lacounty.gov/SDSInter/dhs/1070690_HospitalLicensedBeds03-25-20.pdf o County (or regional) hospital facilities have a robust plan to protect the hospital workforce, both clinical and nonclinical, with PPE. Please describe the process by which this is assessed. Each hospital in LA County determines the type of PPE their clinical and nonclinical personnel need to wear depending on risk of exposure using CDC and LA County Public Health PPE guidelines. All hospitals in LA County have established relationships with medical supply vendors and they have been working with these vendors to procure PPE since the onset of the Covid-19 outbreak. The major vendors LA County hospitals are using are Cardinal Health, Owens Minor, Medline, and Grainger. Due to the shortage of PPE at the onset of the pandemic, LA County hospitals promptly recognized the need to implement PPE conservation strategies using CDC guidelines. LA County assessed the PPE burn rate for hospitals to determine allocation and distribution strategy for the operational area. After making this determination, the LA County EMS Agency MHOAC decided to take a proactive approach and distribute all PPE in its disaster cache based on a data dependent allocation methodology rather than wait for hospitals to submit resource requests. The same proactive 11 CDPH COVID-19 VARIANCE ATTESTATION FORM approach was implemented on subsequent PPE received from the State and the federal government. Recently, some PPE has become more available in the marketplace as evidenced by PPE vendor solicitations submitted to the EMS Agency and new procurement avenues set in place through cooperative programs. Hospitals protect workforce through: o Test of all patients o Screening and, as needed, testing employees o Conversion of spaces to COVID Positive patient care areas o Limiting access o Dedicated staff o Access to labor pool PPE Distributed to hospitals as of April 28, 2020 PPE Amount Unit of Measure N95 Masks 5,318,555 Each Surgical Masks 894,590 Each Face Shields 203,592 Each Gowns 85,580 Each Gloves 84,000 Each Respiratory Kits • 172,304 Each Vulnerable populations. A determination must be made by the county that the proposed variance maintains protections for vulnerable populations, particularly those in long-term care settings. The county must attest to ongoing work with Skilled Nursing Facilities within their jurisdiction and describe their plans to work closely with facilities to prevent and mitigate outbreaks and ensure access to PPE: o Describe your plan to prevent and mitigate COVID-19 infections in skilled nursing facilities through regular consultation with CDPH district offices and with leadership from each facility on the following: targeted testing and patient cohorting plans; infection control precautions; access to PPE; staffing shortage contingency plans; and facility communication plans. This plan shall describe how the county will (1) engage with each skilled nursing facility on a weekly basis, (2) share best practices, and (3) address urgent matters at skilled nursing facilities in its boundaries. 12 CDPH COVID-19 VARIANCE ATTESTATION FORM Los Angeles County attests to ongoing work with Skilled Nursing facilities within Los Angeles County. As the CDPH District Office in LA County, as authorized under CDPH/County Standard Agreement No. 19-10042 for health care facility inspections, the LA County Health Facilities Inspection Division (HFID) will continue to adhere to all CDPH guidance and mandates to help SNFs, including conducting Infection Control Assessment and Response (ICAR) surveys of SNFs with residents and/or staff with COVID-19. The ICAR survey has six areas to assess: visitor restriction; education, monitoring, and screening of healthcare personnel (HCP) and residents; ensuring availability of PPE and other supplies; ensuring adherence to recommended infection prevention and control practices, and communicating with the health department and other healthcare facilities. LA County will continue to monitor and advise on their outbreak status and the increasing numbers of cases and deaths related to COVID-19. To address any identified concerns during the ICAR survey on-site visits and the daily call monitoring, DPH will continue virtual assessment and tours of SNFs. In addition to investigating complaints and resuming federal recertification surveys as directed, LA County will also review and verify that SNFs located in the County are implementing their mitigation plans through on-site visits every six to eight weeks. LA County will ensure that the mitigation plan includes regular testing of residents and staff; hiring and retaining an Infection Control Preventionist; ensuring vendor contracts are in place to replenish/replace PPEs; securing necessary staff by implementing staffing contingency and crisis strategies plan; ensuring dedicated space that would allow for the separation of infected residents and healthcare workers; and having in place a method for daily communication with staff, residents and family regarding the status and impact of COVID 19. The visits will also identify unsafe practices that have or are likely to cause harm to patients. When DPH finds evidence of violations, it initiates enforcement actions, including calling an immediate jeopardy situation, which may result in a State issued civil penalty. LAC DPH is working to conduct facility-wide COVID-19 diagnostic testing for all residents and staff for the 381 SNFs in Los Angeles County (including Long Beach and Pasadena). Such testing allows the identification of all COVID-19 infected persons, including those who are asymptomatic, to facilitate more effective cohorting and greatly lower the risk of exposure and transmission to other residents and staff within the facility. This strategy also has the dual benefit of reducing illness within facilities and mitigating the risk of further transmission to facility staff, who live in the community. LAC DPH is also prioritizing prevention interventions such as infection control, including hand hygiene, correct use of personal protective equipment, cohorting infected residents and staff, and developing dedicated COVID-19 units. Infection preventionists would complement the existing public health infrastructure by providing additional education to public health investigative staff, SNF staff, and SNF residents. The goal with this education would be to build local expertise within the SNFs so that they can better manage the current COVID-19 crisis, but also develop skills and infrastructure that can better prepare facilities to manage the day to day issue of antibiotic-resistant bacteria and future emerging pathogens. Critical PPE will continue to be provided to the SNF sites as needed and available. 13 CDPH COVID-19 VARIANCE ATTESTATION FORM See guidance and plan for long term care facilities: http://publichealth.lacounty.gov/acd/docs/nCoVLTCGuide.pdf o Skilled nursing facilities (SNF) have >14-day supply of PPE on hand for staff, with established process for ongoing procurement from non-state supply chains. Please list the names and contacts of all SNFs in the county along with a description of the system the county must track PPE availability across SNFs. There are 381 Skilled Nursing Facilities (SNF) in Los Angeles County. A list of all facilities can be found in Attachment 1: List of SNF. On May 26, the County Board of Supervisors directed county departments to design publicly available dashboards for each individual SNF to report COVID metrics, including PPE supply. As of 5/26/20, the following data were available for all SNFs in LA County: 33% have adequate PPE (defined as more than 14 days). • Breakdown by type: o 47% have adequate N95s o 48% have adequate face masks o 49% have adequate eye protection o 33% have adequate gowns o 45% have adequate gloves The County continues to procure PPE from commercial vendors and assess PPE supply chains (see Attachment 2: Time Critical Work Plan to Optimize Personal Protective Equipment Supply). The County has sufficient availability of resupply for order from commercial vendors for face masks, gloves and eye protection. The County is facing issues with vendor-reduced stock for gowns and N95 respirators. With newly established contracts directly with manufacturers, the County will have sufficient amounts of gowns by mid-June and N95 respirators by August 2020. The County has a 3-point plan in place to ensure SNFs have access to adequate PPE supply by the end of June 2020: 1. Continue PPE Distribution to SNFs with Supply Shortages: The County regularly distributes emergency PPE supply to SNFs that are in urgent need (<5 days supply), and organizes distribution events for SNFs facing shortages. The next PPE distribution event for SNFs is scheduled for June 4, 2020. SNFs with shortages will receive a 14-day supply of face masks, eye protection and gloves. Any available gowns and N95s at this time will also be distributed. The following distribution event for SNFs is scheduled for June 18, 2020, at which time a 14day supply of gowns and N95s will be distributed. 2. Provide Vendor/Pricing Resources to SNFs: The County has been providing vendor/pricing information to SNFs so they are well positioned to procure their own PPE supply as commercial supply chains open up. The County is proactively following up with SNFs that face repeated shortages and troubleshooting barriers with facilities’ management. The County will continue 14 CDPH COVID-19 VARIANCE ATTESTATION FORM to update its vendor/pricing information and distribute to SNFs, and advise all facilities to stockpile their own 30-day supply for future emergencies. 3. PPE Supply and Usage Tracking System: To support the County’s effort to ensure SNFs have a 14-day supply of PPE on hand, the County is tracking PPE availability across SNFs using the California Department of Public Health survey data and has provided facilities with information on optimizing personal protective equipment during PPE shortages. Additionally, the County is developing its own online data system using Nintex to collect PPE inventory and calculate burn rates for all long-term care facilities. On May 26, the County Board of Supervisors directed county departments to design publicly available dashboards for each individual SNF to report COVID metrics, including PPE supply. A list of all facilities can be found in Attachment 1: List of SNF. Additionally, the County is procuring PPE to stockpile 30-day supply for SNFs and other long-term care facilities that it supports. This local County cache will be used as an emergency supply after facilities exhaust their 30-day supply. • Sectors and timelines. Please provide details on the county’s plan to move through Stage 2. These details should include which sectors and spaces will be opened, in what sequence, on what timeline. Please specifically indicate where the plan differs from the state’s order. Any sector that is reflective of Stage 3 should not be included in this variance because it is not allowed until the State proceeds into Stage 3. For additional details on sectors and spaces included in Stage 2, please see https://covid19.ca.gov/industry-guidance/ for sectors open statewide and https://covid19.ca.gov/roadmap-counties/ for sectors available to counties with a variance. The County of Los Angeles reopening plan aligns with the State’s reopening plan. The County has moved into Stage 2 alongside the State. The County allowed in-store retail, manufacturing, related logistics, and places of worship to resume operations contingent upon operating within State guidelines. Following successful attestation, businesses within accelerated Stage 2 will be permitted to reopen if and when they have implemented appropriate health and safety measures in accordance with an appropriate facility-specific reopening plan. These businesses include: Hair Salons, Barbershops, Dine-in restaurants. The County will continue to provide County required protocols for reopening. Reopening of Stage 2 businesses is contingent upon their readiness to implement and comply with sector-specific guidance. • Triggers for adjusting modifications. Please share the county metrics that would serve as triggers for either slowing the pace through Stage 2 or tightening modifications, including the frequency of measurement and the specific actions triggered by metric changes. Please include your plan, or a summary of your plan, for how the county will inform the state of emerging concerns and how it will implement early containment measures. 15 CDPH COVID-19 VARIANCE ATTESTATION FORM Los Angeles County attests it has sufficient metrics that will serve as triggers for slowing the pace through Stage 2 or tightening modifications. Metrics focus on two questions: 1) How capable are we of slowing the spread and 2) How effective are we in slowing the spread? 1. How capable are we of slowing the spread? • Daily number of available ICU beds, past 3-day average o Target: past 3-day average number of available ICU beds has not decreased over the past 14 days and accounts for at least 10% of total ICU bed capacity • Daily number of available ventilators, past 3-day average o Target: past 3-day average number of available ventilators has not decreased over the past 14 days and accounts for at least 20% of total ventilator capacity • Percentage of hospitals that have 15+ days of available PPE, including N95 masks, other masks, eye protection, face shields, gloves, and gowns o Target: at least 80% of hospitals have 15+ days of available PPE • Daily number of COVID-19 diagnostic tests per 1,000 residents o Target: at least 1.5 tests per 1,000 residents per day, or 15,000 tests per day, have been done over the past 7 days • Daily percentage of new and pending COVID-19 cases that have same-day follow-up investigation o Target: at least 90% of new and pending COVID-19 cases have same-day follow-up investigation over the past 7 days 2. How effective are we in slowing the spread? • Daily number of deaths, past 7-day average o Target: 7-day average number of deaths has not increased over the past 14 days • Daily number of deaths, past 7-day average, by race/ethnicity and area poverty level (equity measure) o Target: the magnitude of disparity in 7-day average number of deaths has not increased across race/ethnic or poverty groups over the past 14 days • Daily number of hospitalized COVID-19 patients, past 3-day average o Target: the 3-day average number of hospitalized patients has not increased over the past 14 days. • Percentage of skilled nursing facilities with 1 or more COVID-19 cases reported in the past month that have offered testing to all residents and staff o Target: at least 90% of skilled nursing facilities with one or more COVID-19 cases reported in the past month have offered testing to all residents and staff Los Angeles County will monitor metrics continuously and to assess conditions. If assessment identifies emerging concerns, Los Angeles will notify the state of circumstances and consult regarding mitigation strategies. See LA County DPH Website for latest recovery dashboard: http://www.publichealth.lacounty.gov/media/Coronavirus/covid19_recovery_dashboard.htm • COVID-19 Containment Plan Please provide your county COVID-19 containment plan or describe your strategy to create a COVID-19 containment plan with a timeline. 16 CDPH COVID-19 VARIANCE ATTESTATION FORM LAC DPH will work with the County Board of Supervisors, League of Cities, County Public Health Commission, County Prevention Taskforce, County Department of Health Services, County Department of Mental Health, and the Hospital Association of Southern California (HASC) to finalize the Containment Plan. Our containment plan will be finalized by June 5th and posted on our website. While not exhaustive, the following areas and questions are important to address in any containment plan and may be used for guidance in the plan’s development. This containment plan should be developed by the local health officer in conjunction with the hospitals and health systems in the jurisdiction, as well as input from a broad range of county stakeholders, including the County Board of Supervisors. Under each of the areas below, please indicate how your plan addresses the relevant area. If your plan has not yet been developed or does not include details on the areas below, please describe how you will develop that plan and your timeline for completing it. Testing • • • • • Is there a plan to increase testing to the recommended daily capacity of 2 per 1000 residents? Is the average percentage of positive tests over the past 7 days <8% and stable or declining? Have specimen collection locations been identified that ensure access for all residents? Have contracts/relationships been established with specimen processing labs? Is there a plan for community surveillance? The Los Angeles County current 7-day average of daily testing volume is over 2.0 per 1,000 residents. The average percentage of positive tests over the last 7 days is less than 8% and declining. Los Angeles County has developed a plan to sustain and increase testing that moves us from an early approach that has relied on drivethrough test sites to a strategy that is integrated into the established health care system and increases access to the most vulnerable populations. Los Angeles County has advanced from initially being able to support less than 100 tests per day performed by its public health laboratory to where today more than 10,000 tests are collected at a wide range of sites throughout the County and are performed by a wide range of laboratories. More than 40 public testing sites are available to members of the community throughout Los Angeles County. This means that a testing site is within a 15-minute drive of every member of the community. Even so, barriers to testing access remain to some residents. As a result, the County is exploring how to integrate tests into existing health care systems or providing testing in ways that will increase access to hard-toreach communities. For example, the County Department of Health Services is expanding testing within its Ambulatory Care Network and partnering with Federally Qualified Health Centers to increase testing in our most vulnerable populations. Both the city and county of Los Angeles have established multiple contracts with local laboratories to support and expand the needed testing capacity. These laboratories have been closely reviewed to assure that have been granted EUA for the tests they are using and to ensure that they are in compliance with all reporting 17 CDPH COVID-19 VARIANCE ATTESTATION FORM requirements. This approach has been very effective at greatly increasing the available of thousands of tests with reasonable turn-around-times to support the most important needs within the County. LAC Public Health has developed a surveillance plan, to include a virtual network of sentinel surveillance laboratories, a series of seroprevalence surveys, as well as expanded surveillance testing in Skilled Nursing Facilities. Please see the section on “Surveillance” for more information on these activities. Contact Tracing • • • • How many staff are currently trained and available to do contact tracing? Are these staff reflective of community racial, ethnic and linguistic diversity? Is there a plan to expand contact tracing staff to the recommended levels to accommodate a three-fold increase in COVID-19 cases, presuming that each case has ten close contacts? Is there a plan for supportive isolation for low income individuals who may not have a safe way to isolate or who may have significant economic challenges as a result of isolation? For the County, there are 1759 contract tracers. See Attachment 3: Contact Tracing Plan. The County has resources to isolate and quarantine individuals who are not able to do so on their own. Living and Working in Congregate Settings • How many congregate care facilities, of what types, are in the county? • How many correctional facilities, of what size, are in the county? • How many homelessness shelters are in the county and what is their capacity? • What is the COVID-19 case rate at each of these facilities? • Is there a plan to track and notify local public health of COVID-19 case rate within local correctional facilities, and to notify any receiving facilities upon the transfer of individuals? • Do facilities have the ability to adequately and safely isolate COVID-19 positive individuals? • Do facilities have the ability to safely quarantine individuals who have been exposed? • Is there sufficient testing capacity to conduct a thorough outbreak investigation at each of these facilities? • Do long-term care facilities have sufficient PPE for staff, and do these facilities have access to suppliers for ongoing PPE needs? • Do facilities have policies and protocols to appropriately train the workforce in infection prevention and control procedures? • Does the workforce have access to locations to safely isolate? • Do these facilities (particularly skilled nursing facilities) have access to staffing agencies if and when staff shortages related to COVID-19 occur? 18 CDPH COVID-19 VARIANCE ATTESTATION FORM How many correctional facilities, of what size, are in the county? • There are 5 correctional institutions in LA County. • Correctional institutions and estimated population include: o Los Angeles County Jail - 12000 o Juvenile Detention - 606 o Federal Correctional Institution – Terminal Island – 1118 o Federal Correctional Institution – Metropolitan Detention Center - 587 o California State Prison, Los Angeles - 3188 How many homelessness shelters are in the county and what is their capacity? There are 322 shelters and interim housing sites with 14, 686 beds. What is the COVID-19 case rate at each of these facilities? • Los Angeles County Jail – 7.1 % • Juvenile Detention – 1.65% • Federal Correctional Institution – Terminal Island – 65.1% • Federal Correctional Institution – Metropolitan Detention Center • California State Prison, Los Angeles – 3.98% Is there a plan to track and notify local public health of COVID-19 case rate within local correctional facilities, and to notify any receiving facilities upon the transfer of individuals? • LA County DPH notifies receiving congregate facilities of the COVID-19 status of the person being transferred. • LA County DPH is notified when individuals released from correctional institutions are transferred to a congregate facility. Do facilities have the ability to adequately and safely isolate COVID-19 positive individuals? Yes, across the 300+ sites we identified 983 beds within existing homeless shelter capacity. We have over 1,000 individual medical sheltering units available for COVID, suspect, and exposed PEH. Do facilities have the ability to safely quarantine individuals who have been exposed? Yes. Congregate settings encompass a wide spectrum of settings ranging from board and cares to shelters, residential substance use settings, residential mental health settings, interim housing, etc. As a result, there is variability in their abilities to quarantine exposed individuals. Based on our outreach to 500+ sites across the county, most settings have at least some ability to cohort individuals and quarantine exposed individuals, with limitations mainly being based on their physical structure (room set up, # of bathrooms, etc). We conducted technical assistance for these settings to optimize their ability to minimize transmission risks within their specific settings in order to achieve a shared understanding of how to use their space optimally with respect to infection control. Is there sufficient testing capacity to conduct a thorough outbreak investigation at each of these facilities? Yes. Do long-term care facilities have sufficient PPE for staff, and do these facilities have access to suppliers for ongoing PPE needs? See above. Do facilities have policies and protocols to appropriately train the workforce in infection prevention and control procedures? Yes. Does the workforce have access to locations to safely isolate? Yes. 19 CDPH COVID-19 VARIANCE ATTESTATION FORM Do these facilities (particularly skilled nursing facilities) have access to staffing agencies if and when staff shortages related to COVID-19 occur? Yes. See attached plans and guidance documents below: • http://publichealth.lacounty.gov/acd/docs/nCoVLTCGuide.pdf • http://www.publichealth.lacounty.gov/media/Coronavirus/guidances.htm#congregateliving This includes: o congregate living facilities o Residential substance use settings o Persons experiencing homelessness o Correctional and detention facilities • http://www.ph.lacounty.gov/acd/procs/b73/B73Index.htm This includes: o Healthcare associated institutions and SNFs o Community residential congregate living settings o Congregate settings associated with people experiencing homelessness (sheltered and unsheltered) o Correctional and detention facilities Protecting the Vulnerable • • Do resources and interventions intentionally address inequities within these populations being prioritized (i.e. deployment of PPE, testing, etc.)? Are older Californians, people with disabilities, and people with underlying health conditions at greater risk of serious illness, who are living in their own homes, supported so they can continue appropriate physical distancing and maintain wellbeing (i.e. food supports, telehealth, social connections, in home services, etc.)? See the following: o Racial, Ethnic and Socioeconomic Data and Strategies Report: http://publichealth.lacounty.gov/docs/RacialEthnicSocioeconomicDataCOVID19.pdf o Mitigation plan (Attachment 4) Acute Care Surge • • • • Is there daily tracking of hospital capacity including COVID-19 cases, hospital census, ICU census, ventilator availability, staffing and surge capacity? Are hospitals relying on county MHOAC for PPE, or are supply chains sufficient? Are hospitals testing all patients prior to admission to the hospital? Do hospitals have a plan for tracking and addressing occupational exposure? We are tracking this using California Department of Public Health COVID-19 Tracking Tool in association with the California Hospital Association and the Reddinet HAvBED COVID-19 Hospital Daily Assessment Poll Data. Essential Workers • How many essential workplaces are in the county? 20 CDPH COVID-19 VARIANCE ATTESTATION FORM • • • What guidance have you provided to your essential workplaces to ensure employees and customers are safe in accordance with state/county guidance for modifications? Do essential workplaces have access to key supplies like hand sanitizer, disinfectant and cleaning supplies, as well as relevant protective equipment? Is there a testing plan for essential workers who are sick or symptomatic? Is there a plan for supportive quarantine/isolation for essential workers? See guidance and information for essential workers and workplaces. http://www.publichealth.lacounty.gov/media/Coronavirus/guidances.htm#business Mitigation plan. Various materials have been developed to address availability of supplies for essential workers, including: 1. Guidance for cloth face coverings: http://publichealth.lacounty.gov/media/coronavirus/docs/protection/Guida nceClothFaceCoverings.pdf 2. Infographic on cloth face coverings: http://publichealth.lacounty.gov/media/coronavirus/docs/protection/FaceC overingsInfographic.pdf 3. Cleaning in group settings: http://www.publichealth.lacounty.gov/media/Coronavirus/docs/protection/ GuidanceCleaning-English.pdf 4. Cleaning and disinfection Matrix: http://www.publichealth.lacounty.gov/media/Coronavirus/docs/protection/ CleaningMatrix.pdf 5. Steps for handwashing: http://www.publichealth.lacounty.gov/media/Coronavirus/docs/protection/ GuidanceHandwashing-English.pdf 6. Guidance for workplace managers: http://www.publichealth.lacounty.gov/media/Coronavirus/guidances.htm#b usiness List of vendors that can be accessed to procure supplies is attached and available on our COVID-19 website. Special Considerations • • Are there industries in the county that deserve special consideration in terms of mitigating the risk of COVID-19 transmission, e.g. agriculture or manufacturing? Are there industries in the county that make it more feasible for the county to increase the pace through Stage 2, e.g. technology companies or other companies that have a high percentage of workers who can telework? No, not at this time. Community Engagement • • Has the county engaged with its cities? Which key county stakeholders should be a part of formulating and implementing the proposed variance plan? 21 CDPH COVID-19 VARIANCE ATTESTATION FORM • • Have virtual community forums been held to solicit input into the variance plan? Is community engagement reflective of the racial, ethnic, and linguistic diversity of the community? Yes. We hold regular telebriefings with elected officials and city managers, business sectors, and community-based organizations. We also work with CBOs serving or representing specific racial and ethnic groups to get feedback. Live briefings are also conducted in Spanish and Armenian with weekly media availability for Korean and Chinese media outlets. The County translates its guidance documents into the following languages: • Spanish • Traditional Chinese • Simplified Chinese • Korean • Armenian • Tagalog • Arabic • Farsi • Russian • Japanese Relationship to Surrounding Counties • • • • Are surrounding counties experiencing increasing, decreasing or stable case rates? Are surrounding counties also planning to increase the pace through Stage 2 of California’s roadmap to modify the Stay-at-Home order, and if so, on what timeline? How are you coordinating with these counties? What systems or plans are in place to coordinate with surrounding counties (e.g. health care coalitions, shared EOCs, other communication, etc.) to share situational awareness and other emergent issues. How will increased regional and state travel impact the county’s ability to test, isolate, and contact trace? All surrounding have already been granted a variance. The Southern California Health Officers meet weekly to get updates and to discuss and address issues. In addition to your county’s COVID-19 VARIANCE ATTESTATION FORM, please include: • • • Letter of support from the County Board of Supervisors Letter of support from the local hospitals or health care systems. In the event that the county does not have a hospital or health care system within its jurisdiction, a letter of support from the relevant regional health system(s) is also acceptable. County Plan for moving through Stage 2 All documents should be emailed to Jake Hanson at Jake.Hanson@cdph.ca.gov. I, Muntu Davis, hereby attest that I am duly authorized to sign and act on behalf of County of Los Angeles. I certify that County of Los Angeles has met the readiness criteria outlined by CDPH designed to mitigate the spread of COVID-19 and that the information provided is true, accurate and complete to the best of my knowledge. If a local COVID-19 22 CDPH COVID-19 VARIANCE ATTESTATION FORM Containment Plan is submitted for County of Los Angeles, I certify that it was developed with input from the County Board of Supervisors/City Council, hospitals, health systems, and a broad range of stakeholders in the jurisdiction. I acknowledge that I remain responsible for implementing the local COVID-19 Containment Plan and that CDPH, by providing technical guidance, is in no way assuming liability for its contents. I understand and consent that the California Department of Public Health (CDPH) will post this information on the CDPH website and is public record. Printed Name Dr. Muntu Davis Signature Position/Title County Health Officer Date May 28, 2020 23 List of Skilled Nursing Facilities (5/27/20) Facility Affinity Healthcare Center Alameda Care Center Alamitos Belmont Rehabilitation Hospital Alcott Rehabilitation Hospital Alden Terrance Convalescence Hospital Alexandria Care Center Alhambra Healthcare and Wellness Centre,LP All Saints Healthcare Angels Nursing Health Center Antelope Valley Care Center Ararat Convalescent hospital Ararat Nursing Facility Contact Name Galeck, Mark Avila, Katherine Rualo, Christine Contact Phone 818-335-9998 818-843-1771 562-522-2337 Contact Email Administrator@AffinitySNF.com Fac52don@longwoodmgmt.com crualo@alamitosbelmont.com Green, Curtis Vodicska, Steven 626-627-7002 213-382-8461 admin@alcottrehab.com FAC09ADMIN@LONGWOODMGMT.COM Teroganesyan, Lusine Jimenez, Michelle 323-660-1800 lusine.TerOganesyan@alexandriacc.com 626-282-3151 Administrator@alhambrahc.com Sensible, John Paul Recto, Evelyn Skiba, Thomas Karapetian, Christine Kechichian, Margarita Johnson, Wacy Rivera, Daniel Robison, Michelle B Ruiz, Emmanuel 818-982-4600 x103 213-484-0784 760-807-0685 818-720-8319 Jpsadm@allsaints-subacute.com evelyn@caravanoperations.com avcc.administrator@antelopevalleycarecenter.com christinek@ararathome.org 818-837-1800 or 818-4458068 208-351-1611 626-445-2170 562-865-5218 818-798-4044 margaritak@ararathome.org 626-863-1758 mmonnier@abh.org 562-424-8101 wwilliams@ensignservices.net 818-246-5677 sxpetrosyan@marinerhealthcare.com 323-756-8191 alexisw@avalonvillahealthcare.com Arbor Glen Care Center Arcadia Health Care Center Artesia Christian Home Inc Astoria Nursing and Rehab Center Atherton Baptist Home - Sam Monnier, Mary B. West Atlantic Memorial Healthcare Williams, Wilestela Center Autumn Hills Healthcare Center PETROSYAN, SHUSHAN Avalon Villa Care Center Washington, Alexis wjohnson@ensignservices.net Drivera@arcadiahcc.com micheller@achome.org mruiz@astorianrc.com Facility Baldwin Gardens Nursing Center Bay Crest Care Center Beachwood Post-Acute & Rehab Beacon Healthcare Center Bel Tooren Villa Convalescent Hospital Bel vista healthcare center Bell Convalescent Hospital Bellflower Post Acute Berkley East Convalescent Hospital Berkley valley Convalescent hospital BERKLEY WEST COVALESCENT HOSPITAL Beverly west healthcare Bixby Knolls Towers Healthcare & Rehab Bonnie Brae Skilled Nursing Brentwood Health Care Center Briarcrest Nursing Center brier Oak on Sunset Brighton Care Center Broadway by the Sea Broadway Healthcare Center Broadway Manor Care Center Brookdale northridge Brookdale San dimas Brookfield healthcare center Contact Name Levine, Keith Contact Phone 818-284-7780 Contact Email keith@baldwingardens.net Carlin, Andrea Novitsky, Anton 310-371-2431 310-451-9700 andrea.carlin@genesishcc.com anovitsky@plum.com Lords, Trevor Daiz, Richard 626-483-7556 562-867-1761 tlords@beaconhealthcarecenter.com richard_Daiz@lcca.com Nelson, Clark Andresen, Shelly Barrett, Lauren Pyper, Benjamin 562-494-5001 626-627-7719 562-925-2274 925-344-1060 brad.jacobsen@belvista.com andresenshelly4900@gmail.com administrator@bellflowerpa.com bpyper@aspenskilledhealth.com Davis, Francisco 818-786-0020 frank.davis@berkleyvalley.com Pyper, Benjamin 925-344-1060 bpyper@aspenskilledhealth.com Aguilos, Robert Barrett, Karin Jean 323-938-2451 562-715-6624 administrator@beverlywesthc.com pat.holt@rhf.org cayton, Marlo Ashcroft, Jona Pashapour, Irene Drake, Brett Gunnell, Dean Demurjian, Chia Alaverdayn, Ermine Varsenik Keshishyan Kneedy-Cayem, Kara Howell, David Thompson, Tiana 323-428-3369 310-828-5536 323- 663-3951 626- 798-9124 909-938-2532 626-285-2165 818-246-7174 818-886-1616 909-394-0304 marlo@bbch1.com jashcroft@brentwoodnursing.com irene.pashapour@briaroakonsunset.com brett@brighton1836.com dgunnell@broadwaybythesea.com chia.demurjian@broadwayhcc.com fac26admin@longwoodmgmt.com vkeshishyan@brookdale.com kara.kneedy-cayem@brookdale.com 562-869-2567 323-268-0106 dhowell@ensignservices.net administrator@BuenaVenturaRehab.com Facility Buena Ventura Post Acute Care Center Burbank healthcare AND REHAB CENTER Burlington Convalescent hospital California healthcare and rehab center California Post Acute California Post Acute Camellia Garden Care Center Canyon oaks nursing and rehab center Casa Bonita convalescent hospital Casitas Care Center Catered manor nursing center Centinela Skilled Nursing & Wellness Centre Century Villa, Inc Chandler convalescent hospital Chatsworth Park Health Care Center Chino valley healthcare center Contact Name Tellez, Alexandra Contact Phone 818-843-2330 Contact Email fac53admin@longwoodmgmt.com DISTEFANO, DAN 213-381-5585 fac01admin@longwoodmgmt.com Ramos, Lina 818-988-2501 fac95ipn@longwoodmgmt.com Dhawan-Desai, Vandana Oscherowitz, Eli Oscherowitz, Eli Arlante, Nelida Nagy, Jason 818-988-2501 fac95admin@longwoodmgmt.com 818-919-0395 818-919-0395 626-798-6777 818-887-7050 administrator@capostacute.com narlante@camelliagardenscc.com jasonnagy@lifegen.net Escontrias, Richard 909-599-1248 fac29@admin@longwoodmgmt.com Valdivia, Rosa Saulietis, Nora Mobasser, Mohsen 818-368-2802 562-426-0394 310-674-3216 rvaldivia@casitascc.com nsaulietis@covenantcare.com Administrator@centinelanursing.com Silver, June Diebold, Cory Ly, Sonia J. 310-672-2012 818-240-1610 818-882-3200 june.silver@centuryvil.com administrator@pacificparkhc.com sly@chatsworthparkcare.com Orquia, Juanita 909-628-1245 fac38admin@longwoodmgmt.com Clara Baldwin Stocker Home Claremont Care Center Claremont Manor Care Center Clear View Convalescent Center Clear view sanitarium COAST CARE CONVALESCENT CENTER McDonald, Don Arellano, Carla Japenga, Diana Kooner, Sandeep 626-962-7151 909-593-1391 909-971-6154 310-538-2323 donmcdonald@clarabaldwinstocker.com caarellano@ensignservices.net djapenga@frontporch.net skooner@clearviewcare.com Towns, Mark Invencion, Janice 310-538-2323 626-337-7229 drtowns@msn.com edwinraquel@gmail.com Facility College Vista Post-Acute Colonial care center Colonial Gardens Nursing Home Community care center Country Manor Healthcare Country Oaks Care Center Country villa bay vista healthcare center Country villa Belmont heights healthcare Country Villa Claremont Healthcare center Country Villa East Nursing Center Country Villa Los Feliz Nursing Center Country villa mar vista nursing center Country Villa North Convalescent Center Country Villa Pavilion Nursing Center Country Villa Rehabilitation Center Country Villa Sheraton Nursing and Rehabilitation Country villa south Convalescent center Country Villa Terrace Nursing Center Country Villa Westwood Convalescence Center Country Villa Wilshire Contact Name Navarro, Jessica Esguerra, Rubie Let E Stephens, Kent Contact Phone 323-257-8151 562-432-5751 Contact Email admin@collegevistacare.com fac34admin@longwoodmgmt.com 562-949-2591 blown1969@hotmail.com O'Connor, Barbara 626-357-3207 818-899-0251 909-622-1067 562-634-4693/964-6907 © boconnor@chms.us dsd@countrymanorhealthcare.com admin@countryoakscenter.com Administrator@CVBayVista.com Venturina, John Maguet, Ryan Larzaro, Lisa Warren, Calvin Arias, Christina Valencia, John 562-597-8817 909-624-4511 Administrator@cvbelmontheightshc.com administrator@cvclaremonthc.com Administrator@CVEastNursingCenter.com Brian,Marc 323-734-1101 323-666-1544 Montag, Memphis 310-397-2372 administrator@cvmarvistanc.com Conti, Mary J 323-734-9122 info@NorthPalmsRehab.com Villaluz, Raymund P. 323-939-3184 administrator@cvpavilionnc.com GANS, BARRY 213-484-9730 barry.gans@losangelesrehabwc.com Lindongan, Mathew Avi (Avraham), Saada Villaluz, Raymond 818-892-8665 310-839-5201 Miller, Corey 323-653-3980 310-826-0821 Javier, John 323-653-1521 administrator@cvlosfeliznc.com matthew.lindongan@northhillshc.com asaada@snfoperations.com or administrator@cvsouthnc.com administrator@cvterracenc.com administrator@westwoodhwc.com Administrator@CVWilshireNC.com Facility Convalescent Center Courtyard Care Center Covina Rehabilitation Center Crenshaw Nursing Home Culver West Health Center Del Amo Gardens Care Center Del Mar Convalescence Hospital Del Rio Convalescent Center Del Rio Gardens Care Center Downey community health center DOWNEY CARE CENTER DREIER’S NURSING CARE CENTER Driftwood Healthcare Center Eastland Subacute and Rehabilitation Center Edgewater Skilled Nursing Center Eisenberg village EISENHOWER HEALTHCARE CENTER El Encanto Healthcare and Habilitation Center El Monte Convalescence Hospital El Rancho Vista Health care center elmcrest care center Emerald terrace convalescent hospital Contact Name Contact Phone Contact Email Bagsic, Jonah Velazquez, Amy Garcia, John Sanchez, Jamie Wauke, Brent Hovey, Alexandra 562-494-5188 818-632-4986 323-933-1560 310-390-9506 310-378-4233 626-288-8353 jbagsic@courtyardcarecenter.com fac49admin@longwoodmgmt.com fac02admin@longwoodmgmt.com jsanchez@CulverWest.com info@delamogardens.com admin@delmarhospital.com Siregar, George Siregar, George Peterson, John 562-927-6586 562-927-6586 562-862-6506 george.siregar@vdelrio.com george.siregar@vdelrio.com jpeterson@downeycommunity.com Raul Renteria Haedrich, John 562-528-1553 818-242-1183 x407 rrenteria408@gmail.com info@nursing-care.com Weiss, Jonathan Fugate, Karen 310)793-3000/323)481-8441 626-444-2535 jweiss@snfoperations.com fac66admin@longwoodmgmt.com Chapman, Jonathan 562-434-0974 jchapman@edgewaterrehab.com Kennings-Glass, Kathleen Turney, Christopher 855-227-3745 Smadar.jal@jha.org 626-798-9133 cturney@eisenhowerhealthcare.com Calvo, Kenneth 626-336-1274 Kenc@eehc.org Telles, Jesse 626-442-1500 jtelles@pipeline.com Ragini Kaur 562-942-7019 administrator@elranchovista.com White, JD Mendoza, Cristina 951-323-6460 213-385-1715 jd.white@providencegrouphc.com Msmilow@emeraldtch.com Facility Fidelity health care Fireside Health Care Center Flower villa, inc Foothills Heights Care Center Fountain View Subacute and Nursing Center Four seasons healthcare & wellness center ,LP Garden crest rehab center GARDEN VIEW POST-ACUTE REHABILITATION Gardena convalescent center GEM Transitional Care Center Gladstone care and rehabilitation center Glendale Transitional Care Center Glendale Healthcare Center Glendale Post Acute Center Glendora Canyon Transitional care unit Glendora Grand Inc GLENHAVEN HEALTHCARE Glenoaks Conv. Hospital Glenridge Center Golden Cross Health Care Golden State Colonial Healthcare Center Good Shepard Health Care Central of Santa Granada Hills Convalescent Hospital Grancell village of the Jewish Contact Name Alex Chua Nunez, Janees Ndiyob, Ted Jannat, Shahrzad Carlin, Andrea Contact Phone 323-456-9224 310-393-0475 x211 310-652-3030 626-798-1111 323-461-9961 Contact Email achua@fidelityhcc.org jnunez@firesidecare.com tedn@flvil.com administrator@foothillops.com Andrea.Carlin@GenesisHCC.com Pastor, Emmanuel 818-985-1814 mannypastor@yahoo.com Ice, Carol Francis, Arthur R 332-6638281 707-287-8441 626-962-7095 admin@gardencrestweb.com gardenviewcarecenter@gmail.com Weiss, Jonah Ruiz, Emmanuel Bautista, Christian Ryan Groch-Tochman, David Caballero, Jennifer Michel Seifert Roberts, Jason 310-532-9460 818-798-4044 626-505-5204 jweiss@gardenaconvalescentcenter.com mruiz@astorianrc.com administrator@gladstonecare.com 310-409-8207 Dagroch-tochman@marinerhealthcare.com 818-246-5516 310-310-5146 909-230-1455 jennifer.caballero@glenadalehcc.com michel.seifert@glendalepac.com jroberts@glendoratcu.com Mauga, Donovan Marks, Carrie L Le Vine, Henry Abigail Gonzalez Arevalo, Jose Marks, Carrie L 626-331-0781 818240-6720 818-427-4470 818-240-4300 626-290-0391 6)791-1948/379-4198 © 818-763-8247 c:818-4274470 310-451-4800 donovan.mauga@glendoragrand.com carrie@caravanoperations.com chlevine@yahoo.com abigail.gonzalez@rescare.com joe@goldencrosshealthcare.com carrie@caravanoperations.com 818-891-1745 administration@ghcarecenter.com 818-774-3314 james.mackay@jha.org Abacan-Agulto, Isidra Hibarger, David L Mackay, James administrator@goodshepherdhcc.com Facility homes Grand Park Convalescent hospital Grand Valley Healthcare Center Green acres healthcare center GREENFIELD CARE CENTER OF GARDENA Greenfield Care Center of South Gate Griffith Park Healthcare Center Guardian Rehabilitation Hospital Harbor Post Acute Care Center HARBOR VIEW BEHAVIORAL HEALTH CENTER Hawthorne healthcare & Wellness Center, LP Heritage Manor Heritage Rehabilitation Center HIGH VALLEY LODGE Highland Park Skilled Nursing & Wellness Centre Holiday Manor Care Center Hollenbeck Palms Hollywood Premier Healthcare Center Hollywood Presbyterian medical center D/P SNF Huntington Drive Health and Rehabilitation Center Huntington Park Nursing Contact Name Contact Phone Contact Email Schmukler, Yehuda 323-350-7772 yschmukler@hotmail.com Garcia, Alfred Orquia, Juanita Tg, Jonathan 818-786-3470 626-280-2293 310-329-9929 alfredg@grandvalleyhcc.com fac23admin@longwoodmgmt.com admin@gccsouthgate.com Jose, Kimberly 323- 564-7761 admin@gccsouthgate.com RUCIRETA, VINCENT Delgado, Glennie s 818-845-8507 323-931-1061 Glendale045@aol.com glennied@guardianrehab.com Villanueva Domingo, Angelica Thomas-Bland, Shannon Herrera-Shipe, Rusmine Ethington, Gregory C Martinez, Roy Bolten, Joel M. Esquer, Albert Duane Kunz,Scott #7678 Shockley, Morris Oscherowitz, Eli 310-320-0961 hcc.administrator@harborcarecenter.com 562-591-8701 sbland@hvcbh.com 310-617-1126 310-679-9732 administrator@hawthornehc.com 626-573-3141 admin.hm@mpowercom.net 310-320-8714 818-352-3158 323-254-6125 roy.admin@heritagerehabcenter.com jbolten@highvalleych.com administrator@highlandparknursing.com 818-341-9800 323-263-6195 818-919-0395 ait@danyonvistapa.com mshockley@holpalms.com administrator@serranopostacute.com Agoncillo, Jose Antonio Morris, Monica 626-445-2421 joseantonio.agoncillo@huntingtondrivehhc.com 213-631-6197 administrator@huntingtonhcc.com Martin 323-589-5941 mlumingkewas@convenantcare.com Facility Center Contact Name Lumingkewas Contact Phone Contact Email Hyde park healthcare center Imperial Care Center Moyle, Kenny Bellantuoni, Gemma M Dharwadkar, Rahul K Gewirtz, Chonoch Rob, Takami 323-753-1354 818-980-8200 info@hydeparkrehab.com Fac47admin@longwoodmgmt.com 310-679-1461 fac42admin@longwoodmgmt.com 562-943-7156 323-261-8108 csalviejo@imperialhcc.com samin@inifnity-care.com Rimando, Jenny Marie A Guevarra, Marydes 310-677-9114 JMTAbella@marinerhealthcare.com 909-623-7100 administrator@pamonavalleyrc.com Reylon Tiples, NHA Seifert, Michael J 562-427-8915 562-868-4767 rtiples@iccare.org fac59admin@longwoodmgmt.com Chazanow, Samuel 626-289-4439 administrator@ivycreekhc.com Imperial crest health care center Imperial Healthcare Center Infinity Care of East Los Angeles Inglewood Health Care Center Inland Valley Care and Rehabilitation Center Intercommunity Care Center Intercommunity healthcare center Ivy Creek Healthcare & wellness center Joyce Eisenberg Keefer Medical Center Kei-Ai Los Angeles Healthcare Center Kei-ai Southbay healthcare center Kennedy post acute care center KINGSLEY MANOR CARE CENTER La Brea Rehabilitation Center La Crescenta Healthcare Center lA PAZ geropsychiatric center Lake Balboa Care Center Lakeview Terrace Jeffery Gall jeffrey.gall@jha.org Teshima, Janie 818-757-4402 949-233-7765c Nordfelt, Spencer 310-532-0700 snordfelt@aspenskilledhealth.com URENA, MONICA Rushforth, Shaun D 323-651-0043 323-906-3301 administrator@kennedypostacute.com Srushforth@frontporch.net Pena, Hugo Isayan, Sona Meyer, Michael Aldunate, Jose Weaver, DJ 310-971-1768c 818-236-3400 323-578-0894c 310-709-8491 323-810-8167c administrator@labrearehab.com sxisayan@marinerhealthcare.com mmeyer@telecarecorp.com jaldunate@lakebalboacare.com dj@lakeviewsnf.com janieT@aspenskilledhealth.com Facility Lakewood Healthcare Center Lancaster healthcare center Landmark Medical Center LAs Flores Convalescent Hospital Laurel park behavioral health center Lawndale Healthcare and Wellness Centre LEGACY HEALTHCARE CENTER Leisure Glen Post Acute Care Center Lighthouse Healthcare Center LITTLE SISTERS OF THE POOR Live oak rehabilitation center Lomita post acute care center Long Beach care center Contact Name Enriquez, Alice Galang, Nichole Campos Kilby, Rosemary Langevin, Chris Contact Phone 562-869-0978 661-942-8463 909-593-2585 Contact Email Administrator@lwhealthcare.com nichole.galang@desertcanyonpostacute.com r.kilby@landmarkmedicalcenter.net 310-323-4570 clangevin@lflores.net Chiara, Tracy 909-622-1069 tracy.chiara@genesishcc.com Mobasser, Mohsen 949-600-3446 Administrator@lawndalehc.com Upthegrove, Amie Artyunyan, Mary 626-798-0558 818-247-4476 medrec@legacysnf.com administrator@leisureglenrehab.com Strother, David McCarthy, Marguerite Fugate, Karen Fortin, Wayne Siregar, Christopher 323-564-4461 310-548-0625 david@lhcarecenter.com mssanpedro@littlesistersofthepoor.org 626-289-3763/562-7-3831c 310-325-1970 562-4266141/909-3623270c 818-919-0395 fac33admin@longwoodmgmt.com wfortin@lomitacare.com christopher.siregar@lbccenter.com Long Beach healthcare center Long Beach Memorial Medical Center Long Beach Post Acute Oscherowitz, Eli Longwood manor convalescence hospital Los Angeles Community hospital LOS PALOS POST-ACUTE CARE CENTER Lotus care center Lynwood healthcare center Maclay Healthcare center Gedyon, Makda 310-874-9593 562-591-7621/562-9777219c 323-935-1157/323-354-2221 Olga Meza Alegre, Nestor (323) 251-1866 310-832-6431 olga.meza@altacorp.com nalegre@lpconv.com Cuaresma, Roland Ta, Johnathan Dscherowitz, Eli 323-292-0748 310-537-2500 818-919-0395 administrator@lotuscarecenter.com johnathan.ta@lynwoodhcc.com eli@beecanhealth.com Jeff Hovespian Munoz, Carlo G eli@beecanhealth.com jhovespian@memorialcare.org administrator@lbpostacute.com fac05admin@longwoodmgmt.com Facility Magnolia gardens convalescent hospital Manchester Manor Cvlt Hospital Maple Healthcare Center Marina pointe healthcare and subacute MARLORA POST ACUTE REHABILITATION HOSPITAL Marycrest Manor Mayflower Care Center Mayflower gardens Convalescent hospital Maywood Skilled Nursing & Wellness Centre Meadow Behavioral Health Center Memorial Hospital of Gardena snf Mesa Glen Care Center Mid-Wilshire Health Care Center Mirada Hills Rehabilitation Mission Care Center Monrovia Gardens Healthcare Center Monrovia Post Acute Monte Vista grove homes Monte Vista. Healthcare center Montebello care center Monteito heights healthcare & wellness center Monterey Healthcare & Wellness Centre, LP Contact Name Zepeda, Rosario Contact Phone 818-360-1864 Contact Email sac03admin@longwoodmgmt.com Jackson, Ethan 323-753-1789/909-2131787c 213-255-0265/213-747-6371 310-391-7266/310-2100240c 562-494-3311 administrator@manchestermanorch.com 310-838-2778 626-579-1602 661-943-3212 admin@marycrestculvercity.com sayers@longwoodmgmt.com craig.oltman@rhf.org Rosman, Shimon 323-560-0720 Administrator@maywoodHC.com McLearie, Wendy 310-391-8266 wendy.mclearie@meadowbrookbac.com Stevens, Steven Latterell, Kyle JONES, ALFRED H 310-532-4200/909-2709663c 951-565-7438 213-483-9921 sstevens@avantihospitals.com administrator@r66postacute.com ajones@midwilshirehcc.com Kuizon, Kristina Hatch, Mo Tiffany Austin 562-947-8691 626-607-2400 626-358-4547 kristina_kuizon@lcca.com mohatch@ensignservices.net tiffany.austin@monroviahcc.com Oscherowitz, Eli 818-919-0395 eli@beecanhealth.com Herbert, Deborah Lazo, Genesis Hernandez, Gwendy Henry, Carl 626-796-6135 626-359-8141 323-724-1315 323- 223-3441 DHerbert@mvgh.org genesis.lazo@montevistahcc.com Gwendy.Hernandez@montebellocc.com administrator@montecitohc.com Kauffman, Joshua 626-280-3220 jkauffman@snfoperations.com Ekekeulu, Chima Nguyen-Hone, Jen De La Cruz, Josefina M Flora Azinge Ayers,Shannon Altman, Craig chima.ekekeulu@maplehcc.com jenh@aspenhealth.com jo-c@marlora.com Facility Monterey Park Convalescent Hospital Montrose Healthcare Center Contact Name Ethington, Gregory C Carrera, Rogelio Contact Phone 626-280-0280 Contact Email admin@montereyparkcare.com rcarrera@longwoodmgmt.com Ovsepyan, Romela 818-441-4709 818-2493925 818-248-6856 Montrose Springs Skilled Nursing & wellness Center Motion Picture and TV Hospital Mount San Antonio Gardens Mountain View convalescent hospital New Vista Nursing and rehabilitation center New vista post acute care center North Valley Nursing Center North Walk Villa Convalescent Hospital Northridge Care Center Norwalk meadows nursing center Norwalk skilled nursing & wellness center Oak park Healthcare Center Olive vista behavioral health center Olympia Convalescent Hospital OSAGE HEALTHCARE & WELLNESS CENTER Pacific care nursing center Pacific Palms Healthcare Pacific Post- acute Pacific villa, inc Pacifica Hospital of the Valley Robert Jensen Atilano, Lisa Anthony Pham 855-760-6783 909-399-1200 818-367-1033 robert. jensen@mptf.com latilano@the-gardens.org Apham@chms.us Perez, Jean 818-352-1421 x200 jean.perez@newvistanursingrehab.com Perez, Mary 310-477-5501 mary.perez@newvistapostacute.com Navarro, Jessica Lawler, Emelyn 818-352-1454 562-921-6624 admin@northvalleynursingcenter.com emelyn_lawler@lcca.com ALEMI, DAUD Eileen Baltazar 818-881-7414 562-864-2541/323-637-0259 Fac32Admin@longwoodmgmt.com administer@norwalkmeadows.com Paver, Phillis 818-334-0924 administrator@norwalkwc.com Reinhold, Amanda Gecse, Crystal 818-262-1440 909-437-4712 admissions@oakparkhc.com crystal.gecse@shandinhillsbhc.com Kim, Don Morgan, Ranita (ask for East Building) Rama, Vann Haering, Lance De Jesus, Walter Estavillo, Evangeline 213-487-3000 310-674-3216 adon@olympiacc.com don@osageHCC.com 714-213-6851 562-433-6791 909-641-1096 562-595-1731 vannr@pacificcarenc.net lancehaering@pacificpalmshealthcare.com admin@pacificpostacute.com evangeline.estavillo@pacificvil.com Parra, Jim 562-242-8162/818-252-2281 jparra@pacificahospital.com administrator@verdugovalleywc.com Facility Palazzo post acute Palos verdes health care center Panorama Gardens Nursing Paramount Convalescent Park Avenue Healthcare & Wellness Center Parkwest Healthcare Center Pasadena care center Pasadena Grove healthcare center Pasadena Meadows Nursing Center Pasadena park healthcare and wellness Penn mar therapeutic center Pico Rivera healthcare center Pilgrim Place Health Service Center Pine Grove Healthcare & Wellness Center, LP Playa del Rey center Pomona Vista Care Center Primrose post acute Providence Holy Cross Medical Center D/P SNF Providence Little Company of Mary Providence Little Company of Mary PROVIDENCE ST. ELIZABETH CARE CENTER Ramona Nursing & Rehabilitation Center Contact Name Oscherowitz, Eli Caro, John Gamero, Alicia Melander, Spencer Ramos, Emmanuel Contact Phone 818-919-0395 310-784-5440 818- 893-6385 562-634-6877 909-623-0791 Contact Email administrator@serranohealth.com carolomita@aol.com agamero@ensignservices.net admin@paramountconvalescent.com administrator@pomonahc.com Pelaez, Rose Padama, Anthony 818-708-3533 562-340-2009 assistantadministrator@parkwestrehab.com Admin@PasadenaCareCenter.com Turney, Chris cturney@eisenhowerhealthcare.com Bartolone, Rhea 626-798-9133 626-283-4592 Gruman, Zev 626-463-4105 administrator@pasadenaparkhc.com Dimla, Dolores Crowell, Caroline Rodas, Richard 626-401-1557 562-948-1961 909-399-5592 dorid@pennmartc.com fac58admin@longwoodmgmt.com rrodas@pilgrimplace.org Magsila, Luke A 626-285-3131 Administrator@PineGroveHC.com Urbina, Christian Andal, Nancy Lee, Samuel 323-346-8993 909-623-2481 951-505-0255 christian.urbina@genesishcc.com don@pomonavistacarecenter.com samlee@plum.com Angie Torres (818) 496-4633 angietorres@providence.org Oliveras, Sherry 310-732-6729 sherry.oliveras@providence.org Shepherd, Holly Baker, Jeremy 818-980-3872 310-303-6107 holly.shepherd@providence.org jeremy.baker@providence.org Hyer, Michael 626-442-5721 mhyer@ramonarehab.com Administrator@PasadenaMeadows.com Facility Regency oaks post acute care center RINALDI CONVALESCENT HOSPITAL Rio hondo subacute & nursing’s center Riviera Health Care center Rose Gardens Healthcare Center ROSE VILLA HEALTHCARE CENTER Rosecrans care center Royal care skilled nursing center Royal Crest Health Care Royal gardens healthcare Royal oaks care center Royal oaks manor _ Bradbury oaks Royal Palms Post Acute Royal Terrace Health care ROYAL VISTA CARE CENTER Royal Wood Care Center Saint Vincent Healthcare San Fernando post acute hospital San Gabriel Convalescent center San Gabriel valley medical center San Marino Manor Contact Name Cantore, Lourdes Contact Phone 562-498-3368 Contact Email administrator@regencyoaksrehab.com Keawekane, Scott 818-360-1003 skeawekane@RinaldiCares.com Pagela, Karen 323-724-5100 karen.pagela@genesishcc.com Sonia Cardenas Rosales, May Lisa 562-806-2576 626-797-2120 scardenas@rivierahealthcare.com administrator@rosegardensubacute.com Howell, David 562-925-4252 dhowell@ensignservices.net ESTANDARTE, NOEL N Peralez, Jon 310-323-3194 NEstandarte@Rosecranscc.com 562-427-7493 jperalez@covenantcare.com Silverio, Olivia Oscherowitz, Eli Stevens, Lisa Pierce, Meg 626-915-5621 818-919-0395 310-963-6410 818-720-8636 royalcresthc@gmail.com administrator@RoyalGardenHealth.com LisaT@Granadapostacute.com meg.pierce@humangood.org Oscherowitz, Eli Ocherowitz, Eli Nicolas, Brenda Garcia, Gigi Bautista Jr., Cipriano Galit, Mannie 818-919-0395 818-919-0395 626-289-5365 310-326-9131 626-512-2595 administrator@royalpalmshealth.com administrator@royalterracehealth.com brenda.nicolas@royalvistacare.com lisa.lazaro@genesishcc.com junbautista1019@gmail.com 818-899-9545 jcatama@goldenlegacycare.com De La Llana, Manuel 626-280-4820 fac24admin@longwoodmgmt.com Inmabi, Anthony Elbert, Michael (or Yolanda) 323-422-6013 626-446-5263 Anthony.Innabi@ahmchealth.com administrator@sangabrielpa.com Facility Santa Anita Convalescence Hospital SANTA CLARITA POST ACUTE CARE CENTER Santa Fe Convalescent hospital SANTA FE HEIGHTS HEALTHCARE CENTER LLC Santa Fe lodge Santa Monica Convalescent Center Santa Monica Convalescent Center ll Santa Monica Health Care SANTA TERESITA MANOR Seacrest Convalescent hospital Seaport 17th cate center Shadow Hills Convalescence Hospital Sharon care center Contact Name Harvey, Steve Contact Phone 626-579-0310 Contact Email davids@gshci.com Kim, Henry 661-259-3660 hkim@santaclaritapa.com Ramirez, Rubin Perez, Roberto 562-424-0757 310-639-8111 hugop@santafech.com administrator@santafeheights.com Brewer,Shannon Batac, Madelin 626-448-4248 213-880-7764 sayers@longwoodmgmt.com mbatac@smconvalescent.com Batac, Madelin 213-880-7764 mbatac@smconvalescent.com Torres, Belinda Maltonado,Veronica Alegre, Nestor Yang, Andrew Santa Isabell, Angel 310-829-4301 626-633-2342 310-833-3526 310- 829-5411 818-352-4438 BTorres@marinerhealthcare.com snfadmin@santateresitainc.com nalegre@scconv.com info@seaport17.com none@dhs.ca.gov Ianieri, Holly holly.ianieri@sharoncarecenter.com Sherman oaks health and rehabilitation center Sherman village healthcare center Shoreline healthcare center Haas, Steven 310-569-2282 323-6552023 818- 986-7242 Posada, Elvira 818-766-6105 face46admin@longwoodmgmt.com Ortiz Luis, Sheila 562-494-4421 ext. 201 Sierra View Care Center Kwok, Whitney (or Ditto) Aguirre, Vernon 626-960-1971 soluis@ensignservices.net; contactshoreline@ensignservices.net admin@sierraviewcarecenter.com 323)665-1185/714)732-1168 Administrator@skylinehc.com Laws, Jay (John) Farag, Nabil Miller, Julie Matt Flake 562-698-0451 323-257-7518 x221 626-399-0358 562-868-9761 socalpostacute@gmail.com Jfarag@solheimsenior.org southpas2000@yahoo.com mflake@ensignservices.net SKYLINE HEALTCARE CENTER LOS ANGELES SoCal Post Acute Care Solheim Senior Community South Pasadena care center Southland fac98admin@longwoodmgmt.com Facility ST. ANDREWS HEALTHCARE St John of God Retirement and care Stoney Point Healthcare Center Studio city rehab center Sunny Village Care Center Sunnyside Nursing Center Sunnyview Care Center Sunray healthcare center Sunset Manor Convalescent Hospital Sylmar Health and Rehabilitation Center Tarzana health & rehab center Temple City Healthcare Temple park convalescent hospita The Californian - Pasadena Convalescent The Canterbury The Earlwood The Ellison John transitional care Center THE GARDENS OF EL MONTE The grove post acute center Meadows Post Acute The Orcard - Post Acute Center The Rehabilitation Center of Santa Monica The Rehabilitation Center of Beverly Hills The Rowland Contact Name Chivi, Nathaniel COSICO, JOHN P Contact Phone 323-731-0861 323-731-0641 ext. 11539 Mason, Tim shouhed, Heather Pinoliar, Reynaldo Dahl, Shane Wudneh, Alem Rafael Salinas, Stuart 818-882-8233 818-605-9768 626-576-1032 714-724-1975 323-735-5146 323-734-2171 626-443-9425 Contact Email sahc.administrator@standrewshealthcare.com jcosico@stjog.org; usaprov-office@sbcglobal.net; Rbaciarelli@stjog.org Mruiz@jshci.com fac06admin@longwoodmgmt.com rey.pinoliar@sunnyvillagecc.com administrator@sunnysidenursing.com fac22admin@longwoodmgmt.com AArevalo@sunrayhc.com admin@sunsetmanorcare.com Friedman, Bernard 818-834-5082 x5082 bernardf@sylmashrc.com Scantlebury, Ingrid Figueroa, Joanne Zemel, Elliot (Rensel) Pages, Luis 818-939-8724 626-443-3028 213-380-3210 idscantlebury@savasc.com eden@caravanoperation.com auralterron@hotmail.com 626-739-5114 ext.15 Luis.Pages@californianch.com Hone, David L Villaluz, Robert Carlson, Shane 310-265-5100 310-371-1228 661-494-8600 dhone@thecanterbury.org Robert.Villaluz@GenesisHCC.com shane.carlson@pursuehealthllc.com Chondala Yanguba Kim, Henry Jennifer Haas Huefner, Mathew K. Gordillo, Fredie 626-443-1351 818-361-0191 480-686-2856 562-693-7701 323-782-1500 x1504 chondalay@elmontegardens.com hkim@thegrovepa.com administrator@themeadowspa.com mhuefner@ensignservices.net fredie.gordillo@rehabcenter.com Jeffrey Huang 310-255-2800 carentar@marinerhealthcare.com Kalomas, Anthony 626-967-2741 tkalomas@aol.com Facility Topanga terrace Torrance Care Center West inc. Torrance Memorial Medical Center Totally kids speciality healthcare_sun valley Two Palms Nursing Care Center University park healthcare center Valley Palms Care Center Valley vista nursing transitional care lock Van Nuys Health Care Vermont Healthcare Center Vernon Healthcare Center VETERANS HOME OF CALIFORNIA - WEST LOS ANGELES Victoria Care Center View Heights convalescent hospital View park convalescent center Villa Elena healthcare center VILLA GARDENS HEALTH CARE UNIT Villa Scalabrini Special Care VILLA SERENA HEALTHCARE CENTER Virgil rehabilitation and skilled nursing center Vista Del Sol Care Contact Name Hever, Leeron Lara, Susan Candace Millek Contact Phone 818-883-7292 310-370-4561 310-784-4924 Contact Email lhever@topangaterrace.com susan.lara@torrancecare.com candace.millek@tmmc.com Michelle Nydam/Samantha Melendez Fessenden, Martha Geraldine Tutor 818-252-5863 626-798-8991 213-595-7385 don.rn@totallykidssvsh.com; administrator@totallykidssvsh.com tmfess@yahoo.com geraldine.tutor@universityparkhcc.com Ruby Padua Martinez, Jorge A. 818-983-0103 818-763-6275/818-471-8187 rnunezpadua@valleypalms.com administrator@valleyvistanursing.com Mejia, Norma Tilney, Isabel Hicks,Leslie McGuire, Kevin 818-997-1841 310-328-0812 626-629-6167 424-832-8238 norma.mejia@carecenteronhazeltine.com ITILNEY@VermontHC.com Administrator@VernonHC.com kevin.mcguire@calvet.ca.gov Farage, Peter Jones, John 626-962-1043 323-757-1881 admin@thevictoriacarecenter.com jjones@viewheights.com Gooden, Amber Arrevalo, Armondo Digerness, Paula 323- 295-7737 562-714-0476 626-786-8063 fac12admin@longwoodmgmt.com a.arrevalove@progressivecarecenters.com pdigerness@frontporch.net Afshar-Tavana, Ardeshir Jenkin, Eden A. 818-768-6500 ardy@villascalabrini.com 562-437-2797 eden@caravanoperations.com Sosing, Victorio 323-665-5793 vsosing@virgilrehab.com Lym, Teresa 626-524-5330 don@vistadelsolcare.com Facility Wellsprings Post-Acute Center W. Covina Healthcare Center West Haven Healthcare West Hills Health and Rehabilitation Center West Valley Post Acute Western Convalescence Hospital Westlake convalescent hospital Whittier hills health care center Whittier nursing and wellness center, inc Whittier pacific care center Windsor Care Center of Cheviot Hills Windsor Convalescent center of north long WINDSOR GARDENS CONVALESCENT CENTER OF HAWTHORNE Windsor Gardens convalescent center of Long Beach Windsor gardens convalescent hospital Windsor Gardens Health Center WINDSOR MANOR Windsor Palms Care Center of Artesia Windsor Terrace Healthcare Center Woodland care center Woodruff Convalescent Center Contact Name Reyes, Rafael A Vidales, Miguel Dess, Mary Donohoe, Mark Contact Phone 661-948-7501 626-962-3368 626-962-4461 818-456-2982 Contact Email Administrator@WellspringsPAC.com miguel.vidalesjr@westcovinahcc.com memphis@caravanoperations.com fac56admin@longwoodmgmt.com Aguinaga, Edwardo Camanag, Emma 818)348-8422/590-0783 323-737-7778 edward.aguinaga@westvalleyhc.com fac07admin@longwoodmgmt.com Perez, Emma C Kim, Jesse Sona Bhatia 213-484-0510 562-947-7817 562-693-5618 eperez@wechospital.com jkim@ensignservices.net sona@whittiernursingwellness.com Ayers, Ramona G Tom 562-693-5240 626-252-1667 310-836-8900 Hurtado, Miguel 562-428-4681 fac20admin@longwoodmgmt.com jehuang@windsorcares.com; info@windsorcares.com mhurtado@windsorcares.com Henderson, Donna 310-675-3304 dhenderson@windsorcares.com Amini, Reza H. 562-422-9219 Lupercio, Alejandro 323-937-5466 Ruber, Nurit 818-985-5990 ramini@windsorcares.com; lbcadmin@windsorcares.com alupercio@windsorcares.com; lacadmin@windsorcares.com VNHADMIN@Windsorcares.com Duarte, Yvette Hagar, III, James P 818-660-4658 562-412-7366 Yvette.Duarte@humangood.org JHagar@windsorcares.com Stern, Charles E 818-787-3400 Simcha A. Cyrulnih Hodomo, Henry 562-309-7049 714-423-3030 cstern@windsorcares.com; teradmin@windsorcares.com simcha.cyrulnih@genesishcc.com wconvalescent@aol.com Facility Woods Health York healthcare & wellness center Contact Name Wasley-Fairley, Suzanne Mejia, Lienna Contact Phone 951-553-1982 818-645-2854 Contact Email sfairley@livingathillcrest.org; info@livingathillcrest.org administrator@yorkhcwc.com List of Skilled Nursing Facilities Associated with Hospitals Facility Contact Name Contact Phone Contact Email DEPARTMENT OF STATE HOSPITALS - METROPOLITAN EAST LOS ANGELES DOCTORS HOSPITAL D/P SNF DAHLGREN, RONALD GILLETTE, LEWIS SMITH NEVINS, SHARON HAZEL, SANDY EMANATE HEALTH HOSPICE HUNN, JEAN (626) 859-2263 EMANATE HEALTH INTER-COMMUNITY HOSPITAL, D/P SNF ENCINO HOSPITAL MEDICAL CENTER GLENDALE MEMORIAL HOSPITAL AND HEALTH CTR. D/P SNF GOOD SAMARITAN HOSPITAL D/P SNF GREATER EL MONTE COMMUNITY HOSPITAL D/P SNF PRESBYTERIAN INTERCOMMUNITY HOSPITAL D/P SNF HOWARD, MELISSA HOPPING, JAMIE (626) 915-6215 CBRAINERD@MAIL.CVHP. ORG MALBARECE@EMANATEH EALTH.ORG SEAVER, ROGER CLYMER, GENEVA CHESTER, SANDRA ADAMS, DANIEL BOYDSTON, RUSSELL (818) 502-2201 JASON.BLACK@DIGNITYH EALTH.ORG ITO, BEVERLY J O'ROURKE, KATHLEEN PHELPS, RONALD DAVEY, RONALD WALLMAN, GERALD CARMEN, ROBERT G (323) 263-9655 ALHAMBRA HOSPITAL MEDICAL CENTER D/P SNF CATALINA ISLAND MEDICAL CENTER D/P SNF SAINT FRANCIS MEDICAL CENTER D/P SNF SAKURA INTERMEDIATE CARE FACILITY SHERMAN OAKS HOSPITAL SOUTHERN CALIFORNIA HOSPITAL USC VERDUGO HILLS HOSPITAL D/P SNF WEST COVINA MEDICAL CENTER D/P SNF WHITE MEMORIAL MEDICAL CENTER D/P SNF WHITTIER HOSPITAL MEDICAL CENTER D/P SNF (626) 570-1606 (310) 510-0700 (562) 863-7011 CHRISTOPHER.BLEBU@D SH.CA.GOV (626) 579-7777 (562) 698-0811 (310) 900-8261 (818) (310) (818) (626) 981-7111 836-7000 790-7100 338-8481 MARYPADAMA@VERITY.O RG BITO@ASPENSKILLEDHEA LTH.COM Los Angeles County Department of Public Health      TIME CRITICAL WORK PLAN TO OPTIMIZE PERSONAL PROTECTIVE EQUIPMENT SUPPLY Los Angeles County Department of Public Health Facilities, Certain Healthcare Facilities, and Service Providers I. INTRODUCTION Personal protective equipment (PPE) is a vital element of protecting healthcare workers (HCW) and other service providers that perform direct care for and routinely have prolonged, close direct contact with people with possible or confirmed COVID-19 infection or their bodily fluids. PPE is not required, however, for employees or visitors of healthcare facilities that do not perform direct patient care or enter the room(s) of patients.1 For COVID-19, currently recommended PPE includes gloves, gowns, eye protection, and respiratory protection. CDC recommends that a facemask should be used by people who have COVID-19 and are showing symptoms such as cough. This is to protect others from the risk of getting infected. PPE shortages are currently posing a tremendous challenge to healthcare facilities across the nation. The Los Angeles County Department of Public Health (DPH) provides services to over 4000 facilities, including long-term healthcare facilities (Long-Term Care: intermediate care facilities, skilled nursing facilities and congregate health living facilities; non-LTC: hospice care and dialysis center), residential care, senior living facilities, homeless and domestic violence shelters and laboratory testing centers, in addition to the needs of those within the Department of Public Health (Attachment 1). Many of these facilities are experiencing severe PPE supply shortages and requesting assistance from DPH and other County agencies. DPH is continuously working to secure additional deliveries of PPE supplies from state and national stockpiles and supply chains and will prioritize their distribution to them to facilities as they are received. II. OBJECTIVE Protection for HCWs, healthcare facilities, and service providers responding to COVID-19 is the highest priority. This work plan is intended to maintain the highest level of                                                               CDPH “Use of Personal Protective Equipment during COVID-19 Outbreak”, April 14, 2020. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID19/UseofPersonalProtectiveEquipmentduringCOVID19.aspx   1   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 1 of 1  Los Angeles County Department of Public Health      appropriate protection while also optimizing the PPE supply, and provide the best available guidance for extending the use of PPE given current global shortages. The process and recommended strategies presented in this work plan were developed using available information and guidance documents from the World Health Organization (WHO), U.S. Centers for Disease Control and Prevention (CDC), California Department of Public Health (CDPH), other local health departments, and in consultation with DPH’s medical and public health experts and facility stakeholders. A summary of stakeholder feedback received through consultations with facility stakeholders is provided below. Additional stakeholder input and feedback on this work plan is welcome, and DPH will continue to update and revise its recommendations, as appropriate. III. OPTIMIZING PPE USE Strategies to optimize PPE begin with implementation of an appropriate hierarchy of controls for occupational exposures, as shown below: Source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html DPH places emphasis on measures to appropriately minimize PPE through implementation of initial levels within the hierarchy of controls. The WHO has emphasized that the current global stockpile of PPE is insufficient, particularly for masks and respirators; and the supply of gowns and goggles is also soon expected to be insufficient. Similarly, PPE supply shortages are being experienced at both the national and local levels.   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 2 of 2  Los Angeles County Department of Public Health  IV.     STAKEHOLDER INPUT DPH contacted internal and external agency representatives regarding the prioritization and distribution of PPE to inform this process going forward. Overall, some of the challenges encountered were: - Unclear communication to facilities regarding who to contact for PPE supply - Facilities contacted multiple agencies with the same PPE request, and this may have resulted in facilities receiving multiple shipments - Point of delivery locations were crowded with suboptimal parking and traffic flow capacity - Facilities did not pick up their PPE supplies at the designated location and time - Lack of PPE supplies to distribute, so minimal supplies is being divided among many facilities based on bed capacity - Orders take several weeks to fill due to overseas shipments required. - No existing data system to connect requests with inventory data, or run assessments on PPE usage. The stakeholder conversations were instrumental in identifying opportunities and potential solutions going forward: V. Identify clear communication channels and present a unified front to maintain these communication channels for facilities to request PPE Aside from bed capacity, other key public health risk factors should be used to prioritize PPE, including outbreak status and high-risk populations. Work with stakeholders to stagger pick-up times so delivery locations are not overwhelmed. Verify correct contact information for facilities prior to pick-up. Identify and deploy a real-time data system that can integrate with the warehouse data system and produce dashboard reports. Provide resources on PPE usage and optimization to facilities and providers. SUPPLY CHAIN LOGISTICS The first step to effectively managing available PPE supply is to understand current PPE inventory, supply chain, and utilization rate, in addition to PPE optimization strategies that are already being deployed. DPH will implement a system that assesses stock levels and utilization rates daily, with projected exhaustion rates updated at least once per week. DPH will collect information on supply chain status for over 4000 facilities, and will prioritize collecting supply chain status for those facilities considered highest priority because they meet one of these criteria:   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 3 of 3  Los Angeles County Department of Public Health  - - -     Facilities with HCWs performing aerosol-generating procedures; Facilities with a current outbreak2 of COVID-19, and with positive cases among HCWs or residents; Facilities with HCWs delivering direct services and who come in close contact with clients, defined as client interactions where HCWs are within 6 feet of clients for at least 10 minutes; and Facilities with high percentage (>50%) of HCWs and/or residents in high risk categories, including older adults 65 years and older, people with certain chronic health conditions, and pregnant women. Facilities that are implementing crisis capacity steps for sparing PPE. The sections below provide specific details on how the supply chain status will be assessed and updated regularly, how facilities can request supplies when needed, and supply distribution logistics. A. Supply Chain Assessment Supply chain status for individual facilities will inform system-wide status for each type of PPE, and inform the level of contingency and crisis strategies needed (see Section V). Supply chain status will be assessed and described using these definitions3: - No shortage: Adequate stock on hand with no current or expected changes in daily practice, and sufficient availability of resupply for order from commercial vendors. - Vendor reduced stock: Limited or no availability of resupply for order from commercial vendors. This includes vendor determination that a product is on allocation (distribution restrictions that may include placing limitations on quantities sold, orders on hold or backordered, or limiting release to emergency-only use). - Facility reduced stock: Reduced stock on hand in healthcare facility, referring to PPE conforming to established standards of care. Reduced stock represents approximately 50% or less, compared to normal stock levels on hand. - Facility contingency stock: Reduced stock on hand causing changes in daily practice but without significant impact on care delivered, patient safety, or HCW safety. Contingency stock levels represent approximately 25% or less, compared to normal stock levels on hand.                                                              2  Outbreak defined as: residential congregate facility – 3 or more cases; SNF/LTC/Assisted Living – 1 case; other  work sites – 5 or more cases (or 3 or more if vulnerable cases); Persons experiencing homelessness – 1 case  3  Colorado Department of Public Health and the Environment, March 2020. https://cha.com/wp‐ content/uploads/2020/03/Mask‐and‐PPE‐sparing‐optimizing‐supply.pdf    FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 4 of 4  Los Angeles County Department of Public Health  -     Facility crisis stock: Reduced stock on hand causing changes in daily practice that are not commensurate with established standards of care. Facility stock out: Complete absence of PPE (exhaustion of disposable supplies after all available measures for alternate use have been applied; exhaustion of supplies needed to disinfect re-usable PPE; etc.) Further detail for assessment of supply chain can be described according to the geographic spread of shortages: - Sporadic: Limited numbers of facilities impacted. - Local: Impact in 1 service planning area (or approximately 10% of Los Angeles County). - Regional: Impact in more than 1 but less than 5 services planning areas (approximately half of the service planning areas in Los Angeles County). Widespread: Impact in more than half of the service planning areas. To gain a rapid understanding of current supply chain status while more detailed information is collected, the DPH point person for each type of facility was asked to define qualitatively any urgent PPE supply needs. The qualitative assessment of PPE supply across the DPH-assigned healthcare facilities and service providers as of May 7, 2020, was: 1. 2. 3. 4. 5. Gloves: Stock out (Regional) Gowns: Stock out (Regional) Eye Protection: Crisis stock (Widespread) Respiratory Protection – surgical mask: Contingency stock (Widespread) Respiratory Protection – N95 respirators: Crisis stock (Widespread) For a more thorough assessment of supply chain status at each facility, DPH staff will establish a PPE Tracking Center, Management Database, and Procurement Team: PPE Tracking Center: Each of the PPE Area Leads, listed below in Section V.b. PPE Supply Requests, will be asked to gather information from facilities on the type of PPE shortage and identify which facilities. DPH staff will enter this information into the PPE tracking database so it can be used to review their current strategies for optimizing PPE and identify any training or other outreach needs. DPH staff and PPE Area Leads will proactively follow-up with facilities that meet the highest priority criteria to inquire about PPE shortages, steps they are taking to optimize PPE supply, and their access to the commercial PPE supply. Staff will   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 5 of 5  Los Angeles County Department of Public Health      inquire about PPE utilization rate and any shortages; collect other information to determine its risk ranking and offer guidance/reference materials. A standard script and questionnaire will be provided to staff to guide these phone calls. PPE Management Database: Currently, there is no existing database or information collection system to gather information on PPE shortages at DPH. DPH will begin tracking PPE shortages to continually inform its guidance and recommendations for extending PPE use. Initially, information on PPE shortages will be entered into a database and used to guide immediate actions. Dependent on identifying an IT solution, a real-time inventory tracking system can be created to facilitate electronic submissions through a web-based form.** This will allow more informed forecasts to be calculated through available resources such as the CDC’s burn rate calculator: https://www.cdc.gov/coronavirus/2019ncov/hcp/ppe-strategy/burn-calculator.html **It is important to note that real-time tracking and assessment of PPE shortages and utilization is dependent on identifying and deploying an integrated data system. Various options are currently being explored and will be presented to DPH leadership and agency partners for consideration. PPE Procurement: DPH will enter PPE orders into the centralized County Operational Area Response and Recovery System (OARRS), track these orders and provide estimate arrival dates. One DPH staff person will work closely with the County Emergency Operations Center Logistics’ procurement team to submit, track and receive orders. B. PPE Supply Requests Facilities experiencing urgent PPE shortages (less than 5 days’ supply) should submit requests via email to the PPE Area Lead for their facility type: Facility Type Residential Treatment Facilities Domestic Violence Shelters Enhanced Behavior Support Home, Adult Residential Facility for Persons with Special Health Care Need Residential Care Facilities for the Elderly, Residential Care Facilities for Chronically Ill,   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      PPE Area Lead Gary Tsai gstai@ph.lacounty.gov Angela Boger aboger@ph.lacounty.gov Tamara Rodriguez, tamara.rodriguez@dds.ca.gov Claire Matsushita, Claire.matsushita@dss.gov Page 6 of 6  Los Angeles County Department of Public Health    Social Rehabilitation Community and Continuing Care Retirement Community Skilled Nursing Facilities, Congregate Living Healthcare Facilities, Intermediate Healthcare Facilities Housing and Service Providers for People Experiencing Homelessness   Dorothy de Leon ddeleon@ph.lacounty.gov Gayle Fraser-Baigelman GFraserBaigelman@dhs.lacounty.gov Note: EMS is providing PPE to Skilled Nursing Facilities and coordinating closely with DPH’s PPE  Coordinator to prioritize their needs.    The PPE Area Leads will communicate critical PPE needs to the PPE Management team, and the PPE Management team will prioritize facilities that meet one or more of the following criteria: - Facilities with HCWs performing aerosol-generating procedures; - Facilities with a current outbreak4 of COVID-19, and with positive cases among HCWs or residents; - Facilities with HCWs delivering direct services and coming in close contact with clients, defined as client interactions where HCWs are within 6 feet of clients for at least 10 minutes; - Facilities with high percentage (>50%) of HCWs and/or residents in high risk categories, including older adults 65 years and older, people with certain chronic health conditions, and pregnant women; and - Facilities that are implementing crisis capacity steps for optimizing PPE. In communication materials, DPH will provide the email address, dphppecoordinator@ph.lacounty.gov, as a resource to help answer questions about the PPE request process for urgent needs and refer providers to the appropriate PPE Area Lead. To assist the PPE Area Leads with gathering information about PPE shortages, DPH has created a standard form that can be emailed directly to providers. DPH will normally provide a status update within 23 days and provide the PPE Area Leads with pick-up location information to distribute to facilities in their network. Immediate delivery will be made in case of sudden increase in outbreak, as long as stockpile is available, within a realistic timeline for receiving PPE.                                                              4  Outbreak defined as: residential congregate facility – 3 or more cases; SNF/LTC/Assisted Living – 1 case; other  work sites – 5 or more cases (or 3 or more if vulnerable cases); Persons experiencing homelessness – 1 case    FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 7 of 7  Los Angeles County Department of Public Health      C. Distribution Center Logistics DPH has a warehouse facility to receive and store PPE supply as it becomes available from state and national stockpiles and from commercial vendors from across the globe. An onsite Agency Administrator is assigned to staff the central warehouse and perform the following tasks: - Manage delivery and pick-ups/drop-offs of PPE to the warehouse, and from the warehouse to designated Point of Delivery locations across the County. DPH facilities, health care facilities, and service providers will pick up supplies at the Point of Delivery locations. - Report daily inventory of PPE available at the warehouse. - Report estimates of how long the warehouse supply of PPE will last based on projected need, as determined via current inventory and a system-wide utilization rate (e.g., < 7-day supply, 7 – 14-day supply, 15 – 30-day supply, > 1-month supply).  VI. DEVELOP AND DISSEMINATE GUIDANCE DURING PPE SHORTAGES Information from the supply chain assessment will directly inform the extent of PPE sparing measures needed (see Decision Matrix attachment). The CDC’s conventional, contingency and crisis strategies are outlined below and, in consultation with medical and other clinical experts, will be refined to apply to DPH facilities, healthcare facilities and service providers. Once finalized, the contingency and crisis capacity steps drafted below will be rapidly disseminated directly to DPH’s facility, healthcare facility and service provider staff. Step 1: Conventional Strategies Before contingency and crisis strategies can be determined and implemented, the following conventional strategy steps must be accomplished, in accordance with CDC guidance: 1. Understand PPE inventory and supply chain 2. Understand PPE utilization rate 3. Communicate with state and federal agencies regarding identification of additional supplies 4. Understand whether facilities are already implementing conventional engineering and administrative control measures to the fullest extent possible, including: a. Reducing face-to-face HCW encounters with patients by bundling care activities to minimize room entries and service delivery via telehealth. b. Excluding all HCWs not directly involved and essential in the patient’s care.   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 8 of 8  Los Angeles County Department of Public Health      c. Excluding visitors to patients with known or suspected COVID-19. d. Limiting or prohibiting visitors at facilities with known or suspected COVID-19. e. Prohibiting visitors at facilities housing residents who are highly vulnerable to COVID-19. f. Using alternatives to N95 respirators, where appropriate and feasible, including other classes of filtering facepiece respirators, elastomeric halfmask and full-face piece air purifying respirators or powered air purifying respirators (PAPRs). g. Cohorting patients. Step 2: Contingency Capacity Steps Given the expected PPE shortages, DPH has requested all facilities to review and immediately implement the CDC contingency capacity strategies to help optimize PPE supplies. The trigger for implementing contingency capacity steps is when the supply chain faces facility contingency (defined as approximately 25% or less of what is normally kept in stock). Specifically, DPH will provide contingency capacity guidance below to its own facilities, healthcare facilities and service providers. - - - - Eye Protection: o Shift eye protection supplies from disposable to re-usable devices. o Implement extended use of eye protection, with proper donning, doffing, and reprocessing. Gowns: o Shift gown use towards cloth isolation gowns. o Consider the use of coveralls. o Use of expired gowns beyond the manufacturer-designated shelf life for training. o Use gowns or coveralls conforming to international standards. Surgical Facemasks o Selectively cancel elective and non-urgent procedures and appointments for which a facemask is typically used by HCW o Remove facemasks for visitors in public areas. o Implement extended use of facemasks o Restrict facemasks to use by HCWs and symptomatic patients. rather than by patients for source control. N95 Respirators   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 9 of 9  Los Angeles County Department of Public Health      o Temporarily suspend annual fit testing5 o Extending the use of N95 respirators by wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Step 3: Crisis Capacity Steps – Stock Running Low When PPE supplies are running low and the tracking of supply stock indicates facility crisis (defined as reduced stock on hand results in changes to daily practices that do not commensurate with standards of care), the following crisis capacity steps will be advised: - - - - Eye Protection o Use eye protection devices beyond the manufacturer-designated shelf-life during patient care activities. o Prioritize eye protection for select activities. o Consider using safety glasses that have extensions to cover the side of the eyes. Gowns o Extend use of gowns (disposable or reusable) o Re-use of cloth isolation gowns o Prioritize gowns for specific activities. Surgical Facemasks o Use surgical facemasks beyond the manufacturer-designated shelf life during patient care activities. o Implement limited re-use of surgical facemasks. o Prioritize surgical facemasks for selected activities. N95 Respirators o Limit use of N95 respirators for HCW providing direct patient care during aerosol-generating procedures in any patient who is COVIDpositive, person under investigation or unknown COVID status. o Use of N95respirators beyond the manufacturer-designated shelf life for healthcare delivery. o Use of N95respirators under standards used in other countries that are similar to NIOSH-approved respirators. o Limited re-use of N95 respirators                                                              5  In March 2020, OSHA issued new temporary guidance regarding the enforcement of OSHA’s Respiratory  Protection Standard. The guidance gave OSHA field offices enforcement discretion concerning the annual fit  testing requirement as long as HCP have undergone an initial fit test with the same model, style, and size.    FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 10 of 10  Los Angeles County Department of Public Health      o Use of additional N95respirators beyond the manufacturedesignated shelf life for healthcare delivery that have not been evaluated by NIOSH. o Prioritize the use of N95 respirators and facemasks by activity type. o Follow CDPH instructions to have N95 respirators submitted for decontamination and returned for reuse. Step 4: Crisis Capacity Steps – When No PPE is Available Additional options when no PPE are available include: - Gowns: o As a last resort for care of COVID-19 patients, the following pieces of clothing can be considered, however none of these can be considered PPE. Preferable features are long sleeves and closures that can be fastened and secured.  Disposable laboratory coats  Reusable patient gowns  Reusable laboratory coats  Disposable aprons  Rubber or comparable material raincoats, which can be disinfected after each use.  Combinations of clothing - Surgical Facemasks o Exclude HCWs at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients o Designate convalescent HCP for provision of care to known or suspected COVID-19 patients. o Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask. o Consider use of expedient patient isolation rooms for risk reduction. o Consider use of ventilated headboards o HCWs use of homemade masks - N95 Respirators o Exclude HCWs at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients o Designate convalescent HCW for provision of care to known or suspected COVID-19 patients o Expedient patient isolation rooms for risk-reduction o Ventilated headboards   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 11 of 11  Los Angeles County Department of Public Health  VII.     ORGANIZATIONAL CHART FOR WORK PLAN IMPLENTATION Katie Butler  DPH PPE Coordinator  PPE Deputy  Coordinator Akiko Tagawa Carrie Tayour,  Eleanor Flowers DPH Logistics Chief PPE Data  Management Unit PPE Outreach and  Education Unit Mike Contreras,  DPH Warehouse  Agency Administrator Mike Jordan Pablo Valadez, Senior  Deputy, DPH Agency  Administrator Araceli Santana,  Warehouse Systems  Analyst Stakeholder  Coordination Unit Alla Kalencich Gayle Baigelman,  Data Systems Lead Homeless Providers Claire Matsushita,  Developmental  service facilities Nicole Mayer, PPE  Request Email  Monitor Tamara Rodriguez,  Social Service  facilities  DPH Logistics Section Chief submits PPE orders  for the Department needs.  Nwamaka Oranusi,  These orders are then entered into the  prioritization system and fulfilled based  according to priorities at the time the order is  placed  Long‐term Care  facilities Gary Tsai,  Residential SUD  Facilities Angela Boger,  Domestic Violence  Facilities   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 12 of 12  Los Angeles County Department of Public Health  VIII.     WORK FLOW FOR PRIORITIZING PPE AND DISTRIBUTING PPE TO >4,000 FACILITIES Step 1: DPH provides PPE Area Leads with guidance on how to prioritize PPE distribution and optimize use of PPE. PPE Area Leads are critical to ensuring facilities are using PPE in accordance with CDC and DPH guidelines. DPH staff will provide support through phone and in-person consultation, as necessary, for high-risk facilities. Step 2: DPH requests PPE Area Leads to report any urgent PPE needs (less than 5 days supply) and send requests to the PPE Management Unit (Carrie Tayour) and PPE Lead Coordinator (Katie Butler). Step 3: PPE Management Unit records the request and enters into the database and screens urgent requests for those that require follow-up calls. Step 4: PPE Management Unit recommends requests for approval and PPE Lead Coordinator approves requests before they are sent to the Warehouse Center. Step 5: Warehouse Center confirms the order and delivery location with the PPE Area Lead. Step 6: Warehouse Center pulls inventory from the floor to fill orders, and coordinates pick-up/delivery of the supplies. Note: If any other DPH staff member receives a request for PPE, the facility should be referred to the Area Lead for their facility type. A referral sheet will be provided to the liaison unit and others, as relevant.   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 13 of 13  Los Angeles County Department of Public Health      Facility Decision Matrix and Communication Strategy for Optimizing PPE Supply  Supply Chain Status PPE Sparing Measures  Communication Strategy*   What is the supply chain status  for each type of PPE? No shortage Vendor reduced stock None None Contingency for N95s None for other PPE types Refer to online resources Facility reduced stock                    (50% less than needed) Contingency  Guidance document Facility contingency  stock      ( 25% less than  needed) Contingency Guidance document Facility crisis stock  (changing standard of  care) Crisis Health alert to staff Facility stock out Crisis plus additional  adminsitrative controls Health alert to staff *In addition to the communication methods listed, DPH will offer consultations through phone and email communications across all supply chain scenarios.   FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 14 of 14  Los Angeles County Department of Public Health      Attachment 1: Tiered Prioritization Table for PPE Supplies by Sector and Their Servicing Agency    Tier 1                                  Tier 2       Tier 3             Tier 4           Sector  Health Care  Workers                                  Public Safety       Service  Providers             City, County,  Special  District and  Critical  Infrastructure           Prioritization ‐ Highest to Lowest  Category  Serviced By       Hospitals   Clinics  EMS Provider Agencies (Fire Departments and Private  Ambulance Companies)  Public Health   Long Term Care Facilities  Skilled Nursing Facilities  Ambulatory Surgery Centers   Dialysis Centers  Urgent Care     Home Health and Hospice  Doctor Offices  Residential Care / Adult and Senior Care Facilities     Law Enforcement  Children, Family and Social Services     DHS  DHS  DHS  DPH  DPH  DHS  DHS  DHS  DHS  DHS  DHS  DPH    CEOC  CEOC    Homeless Shelters  Residential Treatment Facilities  DV Shelters  Board and Care      DPH  DPH  DPH  DPH    Continuity of Government  Continuity of Operations  Critical Infrastructure Sections (Energy, Water)  CEOC  CEOC  CEOC    FOR OFFICIAL USE ONLY‐ DO NOT DISTRIBUTE  Last Revised: 5/7/2020      Page 15 of 15  Los Angeles County Department of Public Health Contact Tracing Plan Introduction In the fight against Coronavirus 2019 (COVID-19), contact tracing is a core communicable disease control strategy to prevent transmission of the virus from infected persons to those who are susceptible. Contact tracing is the effort to identify every person who has been in close contact with someone with a communicable disease in order to quarantine those that have been exposed and prevent further transmission of the disease. In the absence of a vaccine or an effective treatment for COVID 19, isolation of those who are infected (cases) and quarantine of those who have been in contact with a case (contacts) is one of the most effective public health tools available. Los Angeles County Department of Public Health (DPH) has a team of personnel who conduct case investigation and contact tracing in the management of various communicable diseases, such as COVID-19. However, as the numbers of diagnosed COVID-19 cases have increased, the scale of work required has expanded beyond the capacity of the available workforce, requiring the expansion of the pool of workers to support the efforts required to investigate cases and trace contacts. Included in this report is an overview of DPH’s plan for contact tracing and monitoring for COVID-19, as well as the plan to rapidly onboard, train, and deploy thousands of new workforce members to support the effort. Overview of DPH’s Plan for Expanding Contact Tracing and Monitoring Since the initial response to COVID-19, DPH has been aggressively involved in case investigation and contact tracing. As the number of new cases has grown to over 500 diagnosed each day, DPH has focused its case investigation and contact tracing efforts on those in settings with the highest risk of rapid spread and negative health outcomes. These high-risk settings include, but are not limited to, hospitals, skilled nursing facilities and other health care settings, correctional institutions, and other congregate residential facilities. Furthermore, DPH has expanded its pool of contact tracers to allow staff with the highest level of experience to focus on those in high risk settings, while a new pool of staff has been trained and is focusing on contact tracing for all others. Key principles of DPH’s contact tracing: • Interview each case, elicit a list of close contacts, and provide education and information. • Interview contacts and provide education and information. • Isolate the case and quarantine contacts: 5/11/2020 Page 1 of 6 Los Angeles County Department of Public Health Contact Tracing Plan • o Issue a health officer order to the case to require isolation for a minimum of 10 days after symptom onset or the date of the specimen collection with positive results. o Issue a health officer order to the contact to quarantine for 14 days after the last day of exposure to the case. Monitor contacts for the development of symptoms: o Conduct passive daily monitoring for symptoms for 14 days after the last day of exposure and attempt to have at least two telephonic interviews with the contact during the 14-day quarantine period. o If symptoms appear during the quarantine period, the contact is considered a presumptive case and is managed accordingly. The following definitions are used for close contacts and infectious period: • Close contact: household members, intimate partners, caretakers and individuals with any of the following exposures during the infectious period: o Presence within 6 feet of the case for more than 10 minutes, or o Unprotected contact with the case’s body fluids or secretions. • Infectious period: o Those with symptoms: 48 hours before symptom onset and up until 10 days after symptoms first appear and at least 3 days after fever is gone and respiratory symptoms have improved. o Those without symptoms: 48 hours before specimen collection date and up until 10 days after the specimen collection date. DPH has developed various documents related to isolation of cases and quarantine of contacts, which are posted on the DPH website at www.publichealth.lacounty.gov. Key documents used by DPH contact tracers include: • Cases: o Health Officer Order for the Control of COVID-19 Public Health Emergency Isolation Order o Home Isolation Instructions for People with COVID-19 • Contacts: o Health Officer Order for the Control of COVID-19 Public Health Emergency Quarantine Order o Home Quarantine Guidance for Close Contacts to COVID-19 5/11/2020 Page 2 of 6 Los Angeles County Department of Public Health Contact Tracing Plan Contact Tracing Plan - Onboarding of Surge Staff DPH anticipates an ongoing rise in the number of confirmed COVID-19 cases that will reach or exceed 2500 cases a day. In anticipation of a rise to this level, DPH projects needing approximately 2500 additional staff to support surge response in contact tracing. This projection is based on the following information: • Each case interview takes approximately 45 minutes to complete, • Each contact interview takes approximately 30 minutes to complete, • Each case identifies approximately 8 close contacts during their infectious period. • Based on current data from completed interviews, 38% of the cases identify working or living in a high-risk setting, resulting in deployment of specialized staff to conduct more detailed outbreak investigations, which is much more extensive and time consuming. • These activities need to occur 7 days a week, requiring different shifts or workers. # of contacts (8 contacts/ case) 1,000 1,500 # of case interview staff needed (10 cases/ staff) 100 150 2,000 2,500 200 250 # of new cases • • Total # of staff 8,000 12,000 # of contact interview staff needed (15 contacts/ staff) 540 800 16,000 20,000 1,070 1,400 1,270 1,650 640 950 An additional 450-600 staff are needed to support institutional investigations which average 300 facilities per day. An additional 280 staff will be needed to manage/supervise interview teams and investigation teams at a ratio of 1 supervisor / 8 staff. In response to the need for additional staff to support the expected surge in contact tracing, the following efforts are underway: • LA County DPH Workforce: o DPH has trained and assigned over 400 DPH staff to support expanded contact tracing needs. This is in addition to the hundreds of staff supporting high risk setting contact tracing and investigations. • LA County Workforce Support: o DPH submitted a request to the County Emergency Operations Center (EOC) on May 1, 2020 to request approximately 2,000 County personnel to support the contact tracing efforts over the next 6 months. o This option is seen as the most rapid and viable option of immediate support since county workforce members have already been live-scanned and can quickly be given access to the technology platform developed to manage contact 5/11/2020 Page 3 of 6 Los Angeles County Department of Public Health Contact Tracing Plan • • • tracing efforts. Additionally, it’s optimal to tap into our countywide Disaster Service Worker (DSW) pool, as many County workers have taken the DSW oath to serve Los Angeles County during an emergency. A plan has been developed to quickly onboard County employees to this role, including completion of HIPAA training requirements. Last week, this strategy was piloted with 150 County Library staff and lessons learned are being incorporated into the overall onboarding plan. State Staffing Resources: o California State is planning to redirect State staffing resources and hire additional staff to have up to 10,000 staff available to support local health jurisdictions in contact tracing efforts. o DPH has submitted a request for 2,500 staff through this effort. It is unclear whether this staffing support will be made available, and DPH is attempting to solicit clarification from the state. Federal Resources: o DPH has received $289 million in additional funding from the CDC through an augmentation to our ELC grant that will support contact tracing and other core functions including surveillance, enhanced lab capacity, electronic reporting, and testing. DPH is working with the CEO and DHS to submit budget forms to CDC. This is a multi-year grant that can support activities through 11/18/22. Volunteer Resources: o DPH has been working with EOC, DHR and other county partners to explore how other agencies could be rapidly onboarded to support contact tracing staffing needs. Promising efforts are underway with nursing schools and the Peace Corp. o The primary challenges with use of volunteers is lack of reliability with scheduled hours, access to technology solutions, security concerns, and training time required to properly onboard. DPH is working to identify solutions for each of these challenges. All contact tracing workforce members will need to meet certain requirements before they can be assigned to contact tracing. Draft Job Action Sheets have been developed to provide an overview of the role and associated duties (Appendix A). Contact tracing is a specialized skill and staff assigned to this role need to be adequately trained. A detailed curriculum is being developed to include live webinar sessions, as well as various web-based self-learning modules to assure that staff receive the necessary knowledge and skills to properly perform this new role (Appendix B). DPH is working with CDPH to leverage trainings resources the State is planning to develop for the self-learning modules over the next two weeks. 5/11/2020 Page 4 of 6 Los Angeles County Department of Public Health Contact Tracing Plan Contact Tracing Plan- Information Technology Systems Strategy DPH has been utilizing a virtual call center and cloud-based systems since early March 2020 to manage case investigations and the issuance of quarantine and isolation orders. This solution replaced a burdensome manual process and has been successful at simplifying the data collection process and automating several key data processing steps. A workgroup met over the past two weeks to identify a systems strategy to support contact tracing efforts and the related surge in staff. The strategy is based on information gathered from current interview team leads, CDPH, CDC and vendor partners. DPH will use the following approach: 1. Implement contact tracing workflows to support the full end-to-end work process from contact elicitation through to completion of the daily monitoring of contacts. 2. Staff will begin utilizing current contact elicitation and interview forms beginning the week of May 4th, 2020. Surge staff onboarded during the next two weeks will continue to leverage the current solution. 3. Additional technology enhancements will be implemented to support the contact tracing process including: a. Complete the integration of data to/from the Integrated Response, Investigation and Surveillance (IRIS) system, the technology platform used to manage communicable disease investigations; b. Expanded contact tracing interview form; c. Daily monitoring surveys that can be distributed via Short Message Service (SMS) or similar channels; d. Implementation of new security roles to enhance routing to teams investigating high-risk situations (e.g., skilled nursing facilities, correctional, etc.); e. Portal to streamline onboarding of surge staff; and f. Integration with tools to streamline address/email lookups for the issuance of quarantine orders, in cases where contact information cannot be located. Challenges and Next Steps The most significant challenges to the rapid expansion of contact tracing efforts are the ability to identify and onboard large numbers of staff and volunteers as well as overcoming technology barriers to assure that the key principles of contact tracing can be performed seamlessly and 5/11/2020 Page 5 of 6 Los Angeles County Department of Public Health Contact Tracing Plan swiftly to identify new contacts and support meaningful data collection. Public Health anticipates augmentation of staff resources discussed above and will continue in its efforts to plan to rapidly onboard and train staff and to develop technology solutions to optimize overall systems performance. Public Health will continuously monitor its performance to enhance the effectiveness of its efforts to isolation cases and quarantine contacts so as to protect as many persons as possible from infection with SARS-CoV-2 virus. 5/11/2020 Page 6 of 6 Appendix A CONTACT TRACING DIVISION LEADER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health MY ROLE: Contact Tracing Division Leader I SUPERVISE: Contact Tracing Team Leader I REPORT TO: Case and Contact Interview Branch Director JOB DESCRIPTION • Provide daily supervision to assigned Contact Tracing Team Leaders. • Receive contact cases from Case and Contact Interview Branch Director through a web-based, secure platform. • Distribute contact cases evenly to Contact Tracing Team Leaders who will evenly assign cases to their team of Interviewers. • Perform quality assurance checks on completeness of interviews. • Assure Contact Tracing Team Leaders are providing quality assurance checks with interview teams. • Assure all scripts, policies, and procedures provided by Los Angeles County Department of Public Health (LAC DPH) are followed. • Assure Team Leaders and Interviewers are complying with LAC DPH training regarding confidential information related to personal information. • Communicate questions, comments, concerns, and/or feedback to the Case and Contact Interview Branch Director (e.g., system issues). • Regularly check in with assigned Team Leaders as a group as well as individually in order to relay updates and coach Team Leaders on best practices. REQUIRED MATERIALS AND EQUIPMENT  Laptop or desktop computer with a microphone  Internet Access / WiFi (if working off the County network)  Amazon Web Services (AWS) Connect account  AWS Connect training guide  Microsoft Customer Relationship Management (CRM) account  Microsoft CRM system training guide  DPH Contact Tracing Standard Operating Procedure  Training materials needed to perform duties (DPH website resources, etc.)  Training certificates; proof of completion • Communicate to assigned Team Leaders any changes around quarantine procedures, testing resources, contact monitoring procedures, steps to County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING DIVISION LEADER-ROLE DESCRIPTION (Draft: 5/4/20) Page 1 of 3 CONTACT TRACING DIVISION LEADER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health • • • • follow if symptoms develop, guidance’s on social distancing and infection control to assure they’re providing up to date and accurate information to contacts. Demonstrate the ability to professionally and effectively manage a team of Team Leaders during a time of crisis and distress. Apply sound critical thinking and judgement skills. Counsel Division Leaders on resources available to manage emotional and mental stress. Must be flexible to work on weekends. JOB DUTIES Training Workspace Set-up Software Installation  Complete the Day 1 and Day 2 DPH Contact Tracing Training Program.  Assure all Team Leaders and Interviewers complete the required training.  Collect all course completion certificates from your Division Team Leaders and Interviewers; submit to the LAC DPH Division of Organizational Development and Training.  Organize Division structure; identify Team Leaders (1 lead for 4- 5 Interviewers)  Submit staffing roster to Case and Contact Interview Branch Director for review.  Submit Division staff list complete with names and email addresses of all Team Leaders and Interviewers to Case and Contact Interview Branch Director for Amazon Web Service (AWS) Connect account set-up.  Confirm your AWS Connect account has been created and setup as instructed for yourself and your Team Leaders; contact the Case and Contact Interview Branch Director if help is needed.  Review and familiarize yourself with the AWS Connect training guide provided during your Day 2 training session.  Assure your workspace or home office space is set up and ergonomically safe.  Submit Staffing Roster of Contact Tracing Team Leaders and Interviewers for Customer Relationship Management (CRM) access.  Confirm CRM access has been granted for yourself and your Team Leaders; set up appropriate settings in CRM as instructed.  Complete paperwork for vCMR access.  Obtain access to Case and Contact Interview Branch Microsoft Teams page; review Teams page.  Distribute training materials to Interviewers, as needed. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING DIVISION LEADER-ROLE DESCRIPTION (Draft: 5/4/20) Page 2 of 3 CONTACT TRACING DIVISION LEADER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health Contact Division Supervision Quality Assurance  Supervise a team Division Leaders.  Assign contacts to Team Leaders; assure even distribution.  Monitor Team Leader issues with use of the web-based, secure CRM platform.  Ensure accurate use of the scripts, policies and procedures provided by Los Angeles County Department of Public Health (LAC DPH) when conducting the contact interview.  Assure team members are conducting a symptom check and referring contacts for testing and providing them with instructions for quarantine.  Assure team members are providing education on basic information regarding disease transmission and LAC DPH isolation and quarantine information.  Monitor and document how many interviews are conducting per shift across the division and provide an update to Case and Contact Interview Branch Director at the end of each shift.  Lead morning, afternoon, and evening team check-in meetings, as needed.  Hold a full team debrief at the end of the week.  Report what is working well and areas of improvement needed to the Case and Contact Interview Branch Director.  Assist with training new Team Leaders, as needed.  Disseminate new materials to your Team Leaders as updates are made.  Maintain daily communication with Case and Contact Interview Branch Director on assigned activities and tasks.  Perform other duties as required or assigned. NOTES: County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING DIVISION LEADER-ROLE DESCRIPTION (Draft: 5/4/20) Page 3 of 3 CONTACT TRACING INTERVIEWER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health MY ROLE: Contact Tracing Interviewer I REPORT TO: Contact Tracing Team Leader I SUPERVISE: N/A JOB OVERVIEW • Call and communicate in a professional and empathetic manner with household and nonhousehold close contacts of COVID-19 patients. • Inform contacts of their encounters with a confirmed positive case and track contacts in case of symptom onset. • Conduct the contact interview by phone following scripts, policies and procedures provided by Los Angeles County Department of Public Health (LAC DPH). • Comply with LAC DPH training regarding confidential information related to personal information. • Provide contacts with information about quarantine procedures, testing resources, contact monitoring procedures and steps to follow if symptoms develop. • Provide contacts information and guidance on social distancing as well as methods for preventing infection. • Maintain a professional, positive attitude and work ethic. • Demonstrate the ability to interact professionally with culturally diverse individuals during a time of crisis and distress. • Apply sound critical thinking and judgement skills. • Must possess proficiency with computers and software programs. • Must possess the ability to type and enter information into a computer-based platform. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING INTERVIEWER - ROLE DESCRIPTION REQUIRED MATERIALS AND EQUIPMENT  Laptop or desktop computer with a microphone  Internet Access / WiFi (if working off the County network)  Amazon Web Services (AWS) Connect account  AWS Connect training guide  Microsoft Customer Relationship Management (CRM) account  Microsoft CRM system training guide  DPH Contact Tracing Standard Operating Procedure  Training materials needed to perform duties (interview script, DPH website resources, etc.)  Training certificates; proof of completion (Draft: 5/4/20) Page 1 of 3 CONTACT TRACING INTERVIEWER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health • Must be flexible to work on weekends. • Demonstrate the ability to work independently. • Bilingual skills are a plus. JOB DUTIES Training Workspace Set-up Software Installation  Complete the Day 1 and Day 2 DPH Contact Tracing Training Program; provide your Contact Tracing Division Leader with course completion certificates to be tracked by the DPH Division of Organizational Development and Training.  Assure your workspace or home office space is set up and ergonomically safe.  Confirm your Amazon Web Service (AWS) Connect account has been created and setup as instructed; contact your Team Leader if help is needed.  Review and familiarize yourself with the AWS service guide provided during your Day 2 training session.  Confirm Customer Relationship Management (CRM) access has been granted; set up appropriate settings in CRM as instructed.  Review your CRM training and interviewer guides provided during your Day 2 training session.  Review the DPH Contact Tracing Standard Operating Procedure, interview scripts, policies, and procedures in preparation to begin your contact interviews. Contact Interviews Rapport Building Data Entry  Receive COVID-19 case contact assignments from Case Interviewers within the Case and Contact Interview Branch.  Contact Tracing Interviewers should aim to conduct approximately 15 contact interviews per 7-hour shift and provide an update to the Contact Tracing Team Leader at the end of each shift.  Using AWS Connect, call COVID-19 case contacts and inform them of their encounter with a confirmed positive case.  Use the web-based, secure CRM platform to document all contact interview data collected.  Obtain basic demographic and minimal clinical history needed by the LAC DPH to identify high risk individuals and settings.  Ensure use of the scripts, policies and procedures provided by Los Angeles County Department of Public Health (LAC DPH) when conducting the contact interview.  Conduct a symptom check; if needed, refer them for testing according to established protocols, and provide them with quarantine instructions.  Provide education on basic information regarding disease transmission and shared LAC DPH isolation and quarantine information.  Maintain daily communication with Team Leader on assigned activities and tasks. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING INTERVIEWER - ROLE DESCRIPTION (Draft: 5/4/20) Page 2 of 3 CONTACT TRACING INTERVIEWER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health  Perform other duties as required or assigned. NOTES: County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING INTERVIEWER - ROLE DESCRIPTION (Draft: 5/4/20) Page 3 of 3 CONTACT TRACING TEAM LEADER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health MY ROLE: Contact Tracing Team Leader I SUPERVISE: Contact Tracing Interviewer I REPORT TO: Contact Tracing Division Leader JOB DESCRIPTION • Provide daily supervision to a team of 4-5 Contact Tracing Interviewers. • Assigns cases to interviewers, considering caseload and other factors, as appropriate. • Perform quality assurance checks on completeness of interviews. • Assure team members are following all scripts, policies, and procedures provided by Los Angeles County Department of Public Health (LAC DPH). • Assure team members are complying with LAC DPH training regarding confidential information related to personal information. • Communicate questions, comments, concerns and/or feedback to the Contact Tracing Administrator (e.g., system issues). • Regularly check in with team as a group as well as individually in order to relay updates and coach interviewers on best practices. • Communicate to team members any changes around quarantine procedures, testing resources, contact monitoring procedures, steps to follow if symptoms develop, guidance on social distancing and infection control to assure they’re providing up to date and accurate information to contacts. • Demonstrate the ability to professionally and effectively manage a team of interviewers during a time of crisis and distress. • Apply sound critical thinking and judgement skills. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING TEAM LEADER-ROLE DESCRIPTION REQUIRED MATERIALS AND EQUIPMENT  Laptop or desktop computer with a microphone  Internet Access / WiFi (if working off the County network)  Amazon Web Services (AWS) Connect account  AWS Connect training guide  Microsoft Customer Relationship Management (CRM) account  Microsoft CRM system training guide  DPH Contact Tracing Standard Operating Procedure  Training materials needed to perform duties (DPH website resources, etc.)  Training certificates; proof of completion (Draft: 5/4/20) Page 1 of 3 CONTACT TRACING TEAM LEADER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health • Counsel team members on resources available to manage emotional and mental stress. • Must be flexible to work on weekends. JOB DUTIES Training Workspace Set-up Software Installation  Complete the Day 1 and Day 2 DPH Contact Tracing Training Program; provide your Contact Tracing Division Leader with course completion certificates to be tracked by the DPH Division of Organizational Development and Training.  Ensure all team members have completed all trainings.  Organize team structure and submit staffing roster to Contact Tracing Division Leader for review.  Assure your workspace or home office space is set up and ergonomically safe.  Submit staff list to Contact Tracing Division Leader with name and email addresses for Amazon Web Service accounts.  Confirm your Amazon Web Service (AWS) Connect account has been created for yourself and your team members; setup as instructed and contact your Division Leader if help is needed.  Review and familiarize yourself with the AWS service guide provided during your Day 2 training session.  Submit Staffing Roster for Customer Relationship Management (CRM) access to Division Leader.  Confirm CRM access has been granted for yourself and your team members; set up appropriate settings in CRM as instructed.  Review the DPH Contact Tracing Standard Operating Procedure, interview scripts, policies, and procedures in preparation to begin your contact interviews.  Complete paperwork for vCMR access.  Obtain access to Case Interview Branch Microsoft Teams page; review Teams page.  Distribute training materials to interviewers, as needed. Contact Interview Supervision Quality Assurance  Supervise a team of 4-5 Contact Tracing Interviewers.  Assign contacts to interviewers.  Monitor the number of interviews each Tracer conducts per day/week to ensure an even distribution of contact assignments.  Monitor team member issues with use of the web-based, secure CRM platform.  Ensure team member’s use of the scripts, policies, and procedures provided by LAC DPH when conducting the contact interview. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING TEAM LEADER-ROLE DESCRIPTION (Draft: 5/4/20) Page 2 of 3 CONTACT TRACING TEAM LEADER JOB ACTION SHEET COVID-19 Response for Los Angeles County Department of Public Health  Assure team members are conducting a symptom check and referring contacts for testing and providing them with quarantine instructions.  Assure team members are providing education on basic information regarding disease transmission and LAC DPH isolation and quarantine information.  Review all closed cases; ensure all required fields are completed.  Identify if cases are in a high-risk setting and disposition accordingly in CRM.  Monitor and document the number of interviews Contact Tracing Interviewers are conducting per shift and provide an update to your Contact Tracing Division Leader at the end of each shift.  Lead morning, afternoon, and evening team check in meetings, as needed.  Hold a full team debrief at the end of the week.  Report what is working well and areas of improvement to the Contact Tracing Division Leader.  Assist with training new interviewers, as needed.  Disseminate new materials to your interview team as updates are made.  Maintain daily communication with Contact Tracing Division Leader on assigned activities and tasks.  Perform other duties as required or assigned. NOTES: County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACING TEAM LEADER-ROLE DESCRIPTION (Draft: 5/4/20) Page 3 of 3 Appendix B CONTACT TRACER TRAINING DAY 1 - LIVE WEBINAR via WebEx (2 HRS) Training Module Module Description TRAINING PROGRAM OVERVIEW This module will provide an overview of the Department of Public Health (DPH) Contact Tracer Training Program by explaining training goals and objectives. DPH OVERVIEW This module will provide an overview of the Department of Public Health’s vision, mission, organizational structure and diverse programs. COVID-19 SITUATIONAL STATUS IN LOS ANGELES COUNTY This module will include: • An overview of the current COVID-19 situation in Los Angeles County • How to obtain up-to-date information by navigating the DPH website • Description of contact tracing CONTACT TRACING ROLES This module will explain the three (3) Contact Tracing roles within the DPH Case and Contact Interview Branch and how they work together. The module will also explain Job Action Sheets for the three roles. TOOLS & SYSTEMS This module will provide a brief overview of the tools and systems that the contact tracers will use. Detailed modules will be provided on Day 2. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACER TRAINING Program (Draft: 5/4/20) Time 10 minutes 10 minutes 30 minutes 45 minutes 15 minutes Page 1 of 4 CONTACT TRACER TRAINING NEXT STEPS Participants will be instructed to take the self-learning modules and return to the live webinar the next day. 10 minutes DAY 2 – LIVE WEBINAR via WebEx (2.5 HRS) Module Description Time REVIEW OF SELF-LEARNING MODULES This module will provide a review of the self-learning modules by summarizing and highlighting important points. 45 minutes MICROSOFT TEAMS DEMO A live demo of using the MS Teams will be provided. 15 minutes CRM SYSTEM DEMO A live demo of using the CRM system will be provided. 15 minutes AWS CONTACT DEMO A live demo of using the AWS Contact will be provided. 15 minutes PRACTICE ON CRM & AWS This module will provide an opportunity to practice using the CRM and AWS systems to enhance readiness in smaller breakout sessions. Training Module 1 hour DAY 3 – LIVE WEBINAR via WebEx (2 HRS) (3 HRS for Team Leads) Training Module Module Description REVIEW OF INTERVIEWING SKILLS This module will provide an opportunity to review the selflearning module of interviewing skills. PRACTICE INTERVIEWS This module will provide an opportunity to practice interview County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACER TRAINING Program (Draft: 5/4/20) Time 30 minutes 1 Page 2 of 4 CONTACT TRACER TRAINING by role playing in smaller breakout sessions. DPH CONTACT TRACING WORKFLOW This module will explain the contact tracing workflow and standard of operating procedure (SOP). TEAM LEADS TRAINING (Team Leads Only) This module will provide Team Leads supplemental training to help lead their teams. SHADOW INTERVIEWER This module will provide an opportunity to shadow an interviewer to enhance readiness. To be organized the Team Leads separately from the live webinars. hours 30 minutes 1 hour 2 hours WEB-BASED SELF-LEARNING MODULES (Days 1 & 2) Module Description Training Module PUBLIC HEALTH, EPIDEMIOLOGY, & COVID-19 101 This module will introduce the basic principles of public health and epidemiology as they relate to COVID-19. CONTACT TRACING 101 This module will explain the fundamentals and the importance of contact tracing. INTERVIEWING SKILLS This module will provide information on how to conduct contact tracing interviews including consideration of cultural sensitivity. UNDERSTANDING & COMMUNICATION ISOLATION & QUARANTINE This module will describe isolation and quarantine; and how to communicate about them. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACER TRAINING Program (Draft: 5/4/20) Time 1 hour 1 hour 1 hour 1 hour Page 3 of 4 CONTACT TRACER TRAINING CONFIDENTIALITY & HIPAA This training ensures that all employees and volunteers are informed of their duties to protect clients’ confidential information. The Health Insurance Portability and Accountability Act (HIPPA) is the United States legislation that sets data privacy and security provisions for safeguarding medical information. MICROSOFT TEAMS This module will provide instructions on how to use the Microsoft Teams. CRM SYSTEM This module will provide instructions on how to use the Customer Relationship Management (CRM) system to track contact tracing interviews. AWS CONTACT This module will provide instructions on how to use Amazon Web Services (AWS) to make phone calls for contact tracing. County of Los Angeles – Department of Public Health COVID-19 Response CONTACT TRACER TRAINING Program (Draft: 5/4/20) 1 Hour 15 minutes 1 hour 15 minutes Page 4 of 4 (t Ila-nu Jun-Lula. 2019 NOVEL CORONAVIRUS Community Mitigation Plan Summary May 1 5, 2020 For Official Use Only Record of Changes This page captures any substantive changes made to this document including the date, description, and rationale, and the name of the person who made the change. Any comments or recommendations for changes to this document should be emailed to eplanning@ph.lacounty.gov. Date 5/15/20 Version Changes 1.0 By Initial draft developed EPRD—Policy and Planning Unit For information regarding this document, please contact: Policy and Planning Unit Emergency Preparedness and Response Program Bureau of Health Protection Los Angeles County Department of Public Health (323) 246-6600 eplanning@ph.lacounty.gov For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 1 of 13 Introduction On December 31, 2019, the Wuhan Municipal Health Commission reported a cluster of 27 cases of atypical pneumonia in Hubei Province to the World Health Organization’s (WHO) China Country Office. The WHO issued a low-level notice six days later when the case count jumped to 44 informing the global community that the causative agent had not yet been identified, and that 11 of the cases were severely ill. On January 12, 2020, Chinese authorities identified the agent and publicly shared the genetic sequence, a novel coronavirus later named COVID-19. As cases and deaths mounted in China, one month later WHO declared the outbreak to be a Public Health Emergency of International Concern. Apprehension grew as cases were imported to surrounding countries in Asia and later to destinations in Europe, the Middle East, and the Americas. On March 11, 2020, WHO officially declared COVID-19 a pandemic, the second of this century. Situation In just five months, COVID-19 has rapidly spread to all but the most isolated corners of the globe (see Figure 1, depicting global incidence of cases within the last seven days). It has infected over 4 million persons, killed more than one-quarter million, and crushed advanced medical systems from Milan to New York City. Even as it has receded from China, resurgence has been seen in countries who had previously celebrated victories such as Germany, Japan and Singapore. Cases in the U.S. continue to climb in many states (see Figure 2, illustrating the cumulative prevalence of U.S. cases), and level off in others. States are beginning to relax and roll back restrictions across the country. The economic costs of responding to COVID-19 have been staggering. The U.S. unemployment rate more than quadrupled from a historic low of 3.5 percent in February of 2020 to 14.7 percent in April, with experts predicting it could exceed 20 percent in June. While states began to gradually reopen businesses in May after sheltering and shutdowns, barely more than half the U.S. adult population still had a job. Worse still, by the end of April, two national surveys found that more than one in five households in the U.S., and two in five households with mothers with children 12 and under, were food insecure. 17.4% of mothers with children under 12 reported their kids were not eating enough because they could not afford food in the prior month due to COVID-19. The rate represents a quadrupling of need from just two years prior, and it is nearly three times higher than the level of hunger reported for children during the Great Recession. Figure 1. Countries with Confirmed COVID-19* (WHO, 5-10-20) *Cases reported within the prior 7 Days For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 2 of 13 Figure 2. U.S. Cases (CDC, 4-28-20) Table 1. Key Facts (LACDPH, CDPH, CDC, WHO as of 5-11-20) Confirmed Cases Deaths Los Angeles County 30,204 1,422 California 67,936 2,718 U.S. 1,256,972 79,531 Global 3,866,642 270,118 Figure 3. Mapping COVID-19 Outbreak in California (Los Angeles Times, 5-11-20) For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 3 of 13 Key Disease Characteristics A. Clinical Presentation: signs and symptoms at illness onset vary, but over the course of the disease, most persons with COVID-19 will experience fever, cough, fatigue, anorexia, shortness of breath, sputum production, and myalgia. Chills, repeated shaking with chills, headache, sore throat, recent loss of taste or smell, and atypical presentations have also been described. B. Clinical Progression: severe disease can lead to bilateral pneumonia, acute respiratory distress syndrome, respiratory failure, acute liver injury, acute cardiac injury, acute kidney injury, secondary infection, septic shock, multiple organ dysfunction/failure, disseminated intravascular coagulation, rhabdomyolysis, and death. C. Risk Factors: • Age ≥ 65 years • Presence of underlying medical conditions, particularly if not well controlled, including: chronic lung disease or moderate to severe asthma, cardiovascular disease, diabetes, obesity with body mass index ≥ 40, liver disease, chronic kidney disease requiring dialysis, immunocompromised conditions, immune deficiencies, including cancer treatment, bone marrow or organ transplantation, poorly controlled HIV, prolonged use of corticosteroids • Living in a skilled nursing home, long-term care or other congregate living facility D. Transmission: • Primarily person-to-person via respiratory droplets • Secondarily via fomites in the environment around cases • Possible airborne especially during aerosol generating medical procedures E. Transmissibility: • Reproductive Number (Ro): 2 – 2.5 • Asymptomatic carrier: 25 – 50% • Median duration of viral shedding: 31 days • Most contagious: First week of infection F. Incubation: 2-14 days G. Severity • Mild Symptoms: Approximately 81% • Require Hospitalization: 5-14% • Require Intensive Care (+respiratory support): 5% • Require Ventilator Support = 1-2% • Case Fatality Rate: 1.3% H. Duration of Illness and Hospitalization • Median time from first symptom to dyspnea (labored breathing): 5 days • Median time from first symptom to hospital admission: 7 days • Median time from first symptom to acute respiratory distress syndrome: 8 days • Median time from symptom onset to ICU admission: 10.5 days • Median time from first symptom to discharge from hospital: 40 days For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 4 of 13 Assumptions • Non-pharmaceutical interventions, including widescale physical distancing and hygiene, and the rapid isolation of cases and quarantine of contacts, will remain the primary intervention until additional treatments and effective vaccines are widely available. • Extraordinary and historically unprecedented efforts have resulted in disease transmission slowing in Los Angeles County. However, its future course is still highly unpredictable. • The ongoing response will require sustained and concerted coordination across all levels of government, community, education, business, faith-based, community-based and nongovernmental based agencies. • Pressure to suspend restrictions on businesses and access to public places will grow. • Personal protective equipment, medications and other medical materiel will continue to be in short supply due to increased demand and supply chain interruptions. • Public information and media demands will remain high. • Congress will appropriate additional supplemental emergency funding for response as needed. Substantial CDC grant extensions, deferments, resource and personal redirections will be allowed. • Once vaccine to prevent COVID-19 and medications to treat the illness are available, the intervention will shift into mass vaccination efforts to prevent cases, and the rapid treatment of cases to reduce serious illness and death. At best, vaccine development from start to a finished product is likely to take 18 months (summer of 2021). Projections and Waves of Disease • Experts predict that the pandemic will likely continue until at least 60% to 70% of the population is immune. • It is anticipated that additional waves of cases at different heights and different time intervals (with high waves signaling major impact) will occur over the next 18 to 24 months throughout the U.S, including California and Los Angeles County, and will continue until sufficient population immunity is achieved. Figure 4 highlights possible COVID-19 pandemic wave patterns. • The timing and frequency of these waves will be influenced by various external factors. The local impact of these waves can be mitigated by the timing and strength of community mitigation actions in Los Angeles County. • Local epidemiological, laboratory, and surveillance data will indicate the rise and fall of each wave of cases in Los Angeles County. • Epidemiological, hospital admissions, and mortality data will indicate the impact (or strength) of each specific wave in Los Angeles County. Figure 4: Possible Pandemic Wave Scenarios for COVID-19 (CIDRAP, 4-30-20) For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 5 of 13 Purpose The purpose of this document is to establish the strategic direction and interventions needed to respond to COVID-19 in Los Angeles County. Goals • Slow transmission of disease • Minimize morbidity and mortality • Preserve healthcare, workforce, and infrastructure functions • Minimize social and economic impacts Objectives • Minimize potential spread and reduce morbidity and mortality of COVID-19 in communities. • Plan and adapt for disruption caused by community spread and implement interventions to prevent further spread. • Ensure healthcare system response is an integrated part of community interventions. • Ensure integration of community mitigation interventions with health system preparedness and response plans and interventions. Scope This document briefly summarizes the mitigation and suppression actions that LACDPH will undertake to respond to COVID-19 for the duration of the pandemic in Los Angeles County. Response Phases Because of the anticipated wave-like rise and fall of cases over the next 18 – 24 months, the response will need to be dynamic based on local conditions. Drawing from national guidance, this plan utilizes an adaptive framework to organize and direct the response operations in each mission for the duration of the pandemic. For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 6 of 13 Figure 5: Adaptive Response Current status Potential Fall/Winter Waves Source: Resolve to Save Lives, COVID-19 Playbook, 4-17-20 Missions: Summary Mission Epidemiology & Surveillance 1. 2. 3. 4. Public Health Laboratory & Testing Public Info & Warning Non-Pharmaceutical Interventions Mass Care Support 5. 1. 2. Objectives Identify, investigate, and report cases and contacts in a timely manner Track disease transmission, hospitalization, and deaths Monitor disease activity in community, healthcare, and congregate living settings Conduct routine and enhanced surveillance to inform public health interventions Enhance epidemiological activities to support decision-making Conduct laboratory testing of specimens Disseminate laboratory results 1. Disseminate key public information messaging to various audiences 1. Issue population protective actions to minimize community spread 2. Disseminate guidance on implementing protective actions 3. Build community capacity to follow public health guidelines and nonpharmaceutical interventions to protect the health of the population and prevent further community spread 4. Mitigate outbreaks in congregate settings 1. Support the sheltering of persons experiencing homelessness 2. Support the sheltering of persons without resources to safely quarantine and isolate For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 7 of 13 Mission Objectives 1. 2. 3. 4. Ensure adequate PPE Issue guidance to healthcare providers and healthcare settings Facilitate regulatory adjustments Support expansion of healthcare system to meet increased demand for services 1. Provide treatment medication to individuals with clinical manifestations of COVID-19 2. Provide preventive medications to persons susceptible and/or exposed to COVID-19 Healthcare Support Medical Countermeasures (MCM) Fatality Management Support 1. Support the proper management of fatalities 2. Support fatality management surge operations Community Recovery Support 1. Ensure that health and human service efforts of County agencies and private sector agencies are aligned with needs of individuals and communities 2. Protect the health of the population against longer-term negative health effects from mitigation and suppression response activities Mission-Specific Objectives and Strategies Epidemiology & Surveillance • • Objective 1: Identify, investigate and report cases and contacts in a timely manner o Strategy 1.1. Investigate all cases and issue isolation requirements o Strategy 1.2. Investigate all suspect cases and persons under investigation and issue isolation requirements until cleared by laboratory results o Strategy 1.3. Investigate all contacts and issue quarantine requirements o Strategy 1.4. Assess LACDPH’s electronic disease surveillance and investigation system to assure proper operation and connectivity to state and CDC reporting systems Objective 2: Track the disease transmission, hospitalization of symptomatic persons, and deaths due to COVID-19 o Strategy 2.1. ongoing Use existing health surveillance systems to define areas of possible and transmission o Strategy 2.2. Access data from State and/or Federal systems o Strategy 2.3. Access data from non-governmental or traditional surveillance systems For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 8 of 13 • • • Objective 3: Monitor disease activity in community, healthcare, and congregate living settings o Strategy 3.1 Implement a mobile device application and website to allow county residents to provide routine data after exposure, positive test, and development of symptoms to monitor disease progression and spread o Strategy 3.2. Collect and analyze aggregate daily counts of hospital admissions, ICU admissions, discharges, and deaths by age from hospitals, including counts of staff under isolation or quarantine orders o Strategy 3.3. Collect and analyze aggregate daily counts of isolated cases, quarantined contacts among residents and staff at congregate facilities Objective 4: Conduct routine and enhanced surveillance to inform public health interventions o Strategy 4.1. Establish an incident dashboard that provides a county-wide picture of trends and geographic and epidemiologic hotspots of new infections, hospitalizations, and deaths o Strategy 4.2. Establish a public-facing dashboard that clearly indicates LA County’s response status (e.g., mitigation, suppression, recovery) and the measures supporting this status that is simple for the public to understand Objective 5: Enhance epidemiological activities to support decision making o Strategy 5.1. Monitor impacts of mitigation activities (i.e., Safer at Home orders, nonessential business and school closures, and cancellation of mass gatherings) on the community o Strategy 5.2. Assess the impacts of healthcare surge activities (i.e., cancellation/deferment of elected surgeries, expansion of specialty beds, additional staffing) and monitor disruption in healthcare systems caused by COVID-19 (e.g., shortages of PPE or lab testing supplies) Public Health Laboratory & Testing • • Objective 1: Conduct laboratory testing of specimens for COVID-19 o Strategy 1.1. Conduct viral testing in the community o Strategy 1.2. Conduct antibody testing in the community Objective 2: Disseminate laboratory results o Strategy 2.1. Use existing reporting structures to disseminate laboratory results o Strategy 2.2. Develop new reporting structure to disseminate laboratory results to all partners Public Information & Warning • Objective 1. Disseminate key public information messaging to various audiences o Strategy 1.1. Create clear communications and public health messaging to provide accurate, appropriate and accessible information For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 9 of 13 o Strategy 1.2. Ensure information is disseminated in multiple mediums, multi-lingual formats, is user-friendly and is accessible to underserved populations o Strategy 1.3. Disseminate targeted messages to key stakeholders on protective behaviors and actions to minimize transmission o Strategy 1.4. Disseminate messages to public at large on protective behaviors and actions to minimize transmission o Strategy 1.5. Disseminate key public health messaging templates and media kits to ensure consistent sharing of information Non-Pharmaceutical Interventions • • • • Objective 1: Issue population protective actions to minimize community spread o Strategy 1.1. Issue emergency Health Officer orders, directives and declarations to protect health and minimize disease transmission o Strategy 1.2. Recommend policies to minimize community contact and reduce disease transmission Objective 2: Disseminate guidance on implementing protective actions o Strategy 2.1. Provide targeted guidance on how to implement protective actions to those at high-risk for COVID-19 o Strategy 2.2. Provide information on safe home isolation and quarantine practices o Strategy 2.3. Provide information to high-risk populations and key economic sectors and professions on how to implement emergency Health Officer orders o Strategy 2.4. Provide information on how to implement personal and environmental protective actions at home and work Objective 3: Build community capacity to follow public health guidelines and non-pharmaceutical interventions to protect the health of the population and prevent further community spread o Strategy 3.1. Advance community-based policies and program planning designed to stem the spread of disease and promote health, while addressing unintended consequences o Strategy 3.2. Collaborate with community partner organizations on mitigation planning and strategy development to address reducing social impacts during pandemic o Strategy 3.3. Ensure the inclusion of those most impacted by interventions and work in partnership to include them in decision-making Objective 4: Mitigate outbreaks in congregate settings (skilled nursing, long term care, assisted living, substance treatment recovery, homeless shelter, correctional facilities) o Strategy 4.1. Assess infection control measures o Strategy 4.2. Coordinate facility-wide testing at high-risk sites o Strategy 4.3. Issue facility corrective action plans o Strategy 4.4. Provide supplemental infection control training For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 10 of 13 o Strategy 4.5. Supplement PPE and staffing Mass Care Support • • Objective 1: Support the sheltering of persons experiencing homelessness o Strategy 1.1. Provide guidance on implementing personal and environmental protective measures to minimize transmission of COVID-19 at temporary shelters o Strategy 1.2. Educate shelter personnel on implementing personal and environmental protective measures to minimize transmission of COVID-19 at temporary shelters o Strategy 1.3. Assist in identifying and addressing other potential public health concerns in operating temporary shelters Objective 2: Support the sheltering of persons without resources to safely quarantine and isolate o Strategy 2.1. Provide guidance on implementing personal and environmental protective measures to minimize transmission of COVID-19 o Strategy 2.2. Educate personnel on implementing personal and environmental protective measure to minimize transmission of COVID-19 o Strategy 2.3. Assist in identifying and addressing other potential public health concerns in operating temporary shelters for quarantined or isolated individuals Healthcare Support • • • Objective 1: Ensure adequate PPE o Strategy 1.1. Analyze and forecast anticipated demands/needs o Strategy 1.2. Develop a coordinated system for PPE acquisition, prioritization, and distribution o Strategy 1.3. Coordinate the use of PPE decontamination units within the County o Strategy 1.4. Provide PPE sparing training o Strategy 1.5. Maintain close control of inventories and closely track resources Objective 2: Issue guidance to healthcare providers and healthcare settings o Strategy 2.1. Analyze disease impacts and needs in healthcare settings o Strategy 2.2. Communicate with healthcare providers and sectors o Strategy 2.3. Focus on high risk sectors and facilities (SNF and other congregate medical facilities) o Strategy 2.4. Provide training to healthcare sectors and facilities Objective 3: Facilitate regulatory adjustments o Strategy 3.1. Identify regulatory adjustments needed o Strategy 3.2. Advocate to state and federal health agencies For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 11 of 13 o • Strategy 3.3. Recommend policies modifying standards practices (i.e. telehealth, PPE sparing) Objective 4: Support expansion of healthcare system to meet increased demand for services o Strategy 4.1. Analyze and forecast anticipated demands/needs o Strategy 4.2. Coordinate need for alternate care services and/or alternate care sites o Strategy 4.3. Coordinate resource needs and requests with CDPH and Cal OES Medical Countermeasures • Objective 1: Provide treatment to individuals with clinical manifestations of COVID-19 o Strategy 1.1. Coordinate with hospitals to provide treatment medication to individuals with clinical manifestation of COVID-19 1 o • Strategy 1.2. Coordinate with hospitals to provide ventilators for COVID-19 patient care Objective 2: Provide preventive medications to persons susceptible and/or exposed o Strategy 2.1. Provide antivirals as a prophylaxis to close contacts of confirmed cases once FDA-approved for use o Strategy 2.2. Vaccinate persons susceptible and/or exposed once FDA-approved for use Fatality Management Support • • Objective 1: Support the proper management of fatalities o Strategy 1.1. Disseminate guidance on decedent handling o Strategy 1.2. Coordinate with EMS Agency to survey, analyze, and evaluate fatality management capacities of hospitals and other healthcare sectors. o Strategy 1.3. Coordinate with Medical Examiner/Coroner (ME/C) to survey, analyze and evaluate fatality management capacities of mortuary, funeral homes and other stakeholders. o Strategy 1.4. Update and share contact list of all mortuaries and funeral directors in LA County with ME/C o Strategy 1.5. Issue emergency Health Officer Orders (i.e., permits for disposition, expedited site selection, and restrictions on gatherings for funeral services) Objective 2: Support fatality management surge operations o Strategy 2.1. Identify and activate plans for receiving and processing death certificates in surge conditions o Strategy 2.2. Coordinate with ME/C to support temporary internment operations if needed; including site selection, expedited issuance of death certificates, and disposition permits There are no FDA approved MCM currently available for COVID-19. However, under an Emergency Use Authorization, the FDA has released a small quantity of Remdesivir to a limited number of hospitals. This unapproved drug will be used to treat COVID-19 patients hospitalized with severe disease under this EUA. For Official Use Only (FOUO) - Do Not Distribute Page 12 of 13 DRAFT: 5/14/20 1 o Strategy 2.3. Support Family Assistance Center operations as requested by County CEO Community Recovery Support • • Objective 1: Ensure health and human service efforts of County agencies and private sector agencies are aligned with needs of individuals and communities o Strategy 1.1. Identify populations at disproportionate risk for adverse health outcomes o Strategy 1.2. Ensure equitable access to services for vulnerable populations Objective 2: Protect the health of the population against longer-term negative health effects from mitigation and suppression response activities o Strategy 2.1. Assist in the continuity of essential health and human services to meet community needs o Strategy 2.2. Advance policies designed to stem the spread of disease and promote health, while addressing unintended consequences For Official Use Only (FOUO) - Do Not Distribute DRAFT: 5/14/20 Page 13 of 13 BOARD OF SUPERVISORS COUNTY OF LOS ANGELES 869 KENNETH HAHN HALL OF ADMINISTRATION LOS ANGELES, CALIFORNIA 90012 TEL: 213-974?5555 FAX: 213-974-1010 BARGER SUPERVISOR. FIFTH May 27, 2020 CHAIR OF THE BOARD The Honorable Gavin Newsom Governor, State of California 1303 10th Street, Suite 1173 Sacramento, CA 95814 Dr. Sonia Y. Angell State Public Health Officer and Director California Department of Public Health PO. Box 997377, MS 0500 Sacramento, CA 95899-7377 Dear Governor Newsom and Dr. Angell: On behalf of the Los Angeles County Board of Supervisors, I want to thank you for your leadership during the COVID-19 pandemic. The public health guidelines implemented by your of?ces have been instrumental in helping California ?atten the curve and to prevent local healthcare systems from being overwhelmed during this crisis. Most importantly, we appreciate the open dialogue, candor, and support provided to local jurisdictions throughout this difficult tlme. As you mentioned in your May 26 brie?ng, Los Angeles County?s size, scope, and budget is as large as many states in the Union. Our County covers more than 4,000 square miles, reaches seven distinct valleys and multiple urban centers, and is one of the most diverse in the nation. Given the overall size of the State of California, we appreciate that the State has considered local input and feedback. Los Angeles County has been, in our estimation, one of the most proactive and diligent counties in the State during this crisis, taking early and swift action to implement public health orders that have saved countless lives. The County?s hospitalization rate for cases has been decreasing for a straight and our positive test rate is dropping steadily. In addition, the County made tremendous early investments in testing with testing capacity far exceeding most urban counties in the State. We?ve also ensured sufficient personal protective equipment (PPE). Los Angeles County has completed a review of our health data and benchmarks, capabilities, and readiness to move beyond Stage 2 and has prepared comprehensive plans and public health guidance to assist our businesses and communities to enter the next stage. The Honorable Gavin Newsom Dr. Sonia Y. Angell May 27, 2020 Page 2 Our health of?cer?s attestation outlines epidemiological stability, protection of residents and essential workers, identi?cation and protection of at?risk and vulnerable populations, testing capacity, hospital capacity, and plans for accelerated reopening with appropriate safeguards built in as necessary. These plans are built from the work done locally, in concert with leaders of our communities and economic sectors including labor, business, non-pro?ts, and faith organizations, and expands on the County?s own Roadmap to Recovery. Los Angeles County has met the benchmarks and criteria identi?ed by the California Department of Public Health. The County has demonstrated an ability to protect our residents and essential workers and is well prepared to move forward at a faster pace than the State as a whole. Los Angeles County is one of only eleven counties statewide that has not yet received a variance from the State and granting variance to Los Angeles County will contribute to regional consistency. All of our surrounding counties have been granted a variance and including Los Angeles County will allow for economic and social equity throughout our region. Please accept this letter of support from the County?s Board of Supervisors as a complete endorsement of our health of?cer?s attestation and request for a local variance to California?s Resilience Roadmap. Sincerely, BARGER pervisor, Fifth District Chair, Board of Supervisors c: Los Angeles County Board of Supervisors Sachi Hamai, Chief Executive Of?cer Mary Wickham, County Counsel Celia Zavala, Executive Of?cer Dr. Barbara Ferrer, County Department of Public Health Dr. Muntu Davis, County of Los Angeles Health Of?cer May 27, 2020 Los Angeles County Board of Supervisors Sheila Kuehl Muntu Davis, M.D. Health Officer Los Angeles County Department of Public Health mudavis@ph.lacounty.gov Janice Hahn RE: Hilda L. Solis First District Mark Ridley-Thomas Second District Third District VARIANCE Fourth District Kathryn Barger Dear Dr. Davis, Fifth District Christina R. Ghaly, M.D. Director Hal F. Yee, Jr., M.D., Ph.D. Chief Deputy Director, Clinical Affairs Nina J. Park, M.D. Chief Deputy Director, Population Health 313 N. Figueroa Street, Suite 912 Los Angeles, CA 90012 Tel: (213) 288-8101 Fax: (213) 481-0503 www.dhs.lacounty.gov I am writing regarding our capacity to support the County of Los Angeles in seeking a variance to proceed to an expanded Stage 2 reopening. The four acute care hospitals operated by the Los Angeles County Department of Health Services (DHS), including Harbor-UCLA Medical Center, LAC+USC Medical Center, Olive View-UCLA Medical Center and Rancho Los Amigos National Rehabilitation Center, are prepared to accommodate a surge in COVID-19 patients of 35%, in addition to continuing to manage the acute care needs of non-COVID patients. The four DHS hospitals currently have sufficient personal protective equipment to protect our clinicians and employees. Sincerely, Christina R. Ghaly, M.D. Director CRG:mm www.dhs.lacounty.gov “To advance the health of our patients and our communities by providing extraordinary care”