ADDITIONAL MATERIALS 04.e (9034) VARIANCE TO STAGE 2 OF CALIFORNIA’S ROADMAP TO MODIFY THE STAY-AT-HOME ORDER COVID-19 VARIANCE ATTESTATION FORM FOR County of Santa Cruz 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 Packet Pg. 13 of 142 ADDITIONAL MATERIALS variance opportunity are outlined below. It is recommended that counties consult with cities, tribes and stakeholders, as well as other counties in their region, as they consider moving through Stage 2 04.e (9034) 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 Santa Cruz County Contact: Gail Newel, MD, MPH Public Phone Number: 831-454-4242 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 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 Packet Pg. 14 of 142 ADDITIONAL MATERIALS example, the elderly and those with specific co-morbidities, and those residing in long-term 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. 04.e (9034) 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. Packet Pg. 15 of 142 ADDITIONAL MATERIALS The County of Santa Cruz has epidemiologic stability of COVID-19 in its jurisdiction. Although the daily and weekly new case rate has steadily risen in the last two weeks, the prevalence of COVID-19 cases remains relatively low and can be swiftly contained. An anticipated outcome of further progression into Stage 2 and increased testing is a likely increase of positive cases. The County has prepared for, and continues to build, the capacity to meet this anticipated growth in cases. The County has sufficiently flattened the curve, increased healthcare surge capacity, monitors local conditions, and remains prepared to modify its Shelter-in-Place Order, if and when necessary, in order to protect the public health of its community. 04.e (9034) Since April 13th, 2020, the County has had fewer than 5 laboratory confirmed COVID-19 hospitalizations per day, meeting the target of no more than 20 total confirmed COVID-19 patients hospitalized on any single day over the past 14 days. Despite the minimal impact on our hospitals, Santa Cruz County has worked to continuously communicate with our hospitals and clinical partners to prepare in the case of a COVID-19 surge through weekly calls, regular reports disseminated to providers, and epidemiologic surveillance. County epidemiologists will continue to monitor our hospital capacity. Hospitalization data comes from the daily CDPH hospital survey and the Snowflake database. Date 05/13 05/14 05/15 05/16 05/17 05/18 05/19 05/20 05/21 05/22 05/23 05/24 05/25 05/26 05/27 05/28 COVID-19 Cases in the Last 14 Days 34 33 33 32 34 36 36 43 48 48 53 59 58 XX XX XX COVID-19 Hospitalizations per Day 1 1 1 1 1 2 1 3 4 4 4 4 4 4 XX XX It is worth noting the County is monitoring epidemiologic stability and hospital surge through local disease modeling as well, see Attachment B, https://www.santacruzhealth.org/HSAHome/HSADivisions/PublicHealth/Communicable DiseaseControl/CoronavirusHome/LocalCOVID-19ForecastModels.aspx. Through a collaboration with the University of California at Santa Cruz, County of Santa Cruz epidemiologists have developed and implemented a time discrete, stochastic SEIR (Susceptible, Exposed, Infected, Resistant) model. The model provides projections and a most likely estimate for the number of daily COVID-19 hospitalizations in the future. The model helps County staff monitor when hospitals could see surge and the magnitude of that surge. This information is shared publicly on the County’s COVID-19 website, internally, and with partners. For more information about the SEIR model works, please visit https://github.com/jpmattern/seir-covid19. Packet Pg. 16 of 142 ADDITIONAL MATERIALS o 04.e (9034) 14-day cumulative COVID-19 positive incidence of <25 per 100,000 -OR- testing positivity over the past 7 days of <8%. 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. Since the outset of the COVID-19 pandemic, the prevalence of COVID-19 in the County of Santa Cruz has remained relatively low, although as expected, increases have been seen following lifting several elements of Shelter in Place orders in early May. The County of Santa Cruz Health Officer implemented Shelter-In-Place Orders along with other Bay Area counties on March 16th, 2020, after identifying community spread of COVID-19. As of submission of this attestation, May 29th, the County has a total of 205 positive cases (data calculated through CalREDIE). In the last 14 days, the County identified 58 new laboratory confirmed COVID-19 cases. Assuming a population of 273,999, the threshold for the County to progress through Stage 2 is an incidence of less than 68 new cases over the last 14 days (see below). Threshold___ = X 100,000 Residents Population of Santa Cruz County 25_ = 100,000 X 273,999 25*(273,999) = 100,000X 25*273,999 = 68.5 100,000 The County’s low prevalence, based upon data as of May 29th, is reinforced by our ability to meet the State’s indicators, as follows: Indicator 1 – Less than 5 confirmed COVID-19 patients hospitalized on any single day over the past 14 days (less than the 20-patient threshold). Indicator 2 – an incidence of 58 cases over the last 14 days (less than the 68 threshold). Packet Pg. 17 of 142 ADDITIONAL MATERIALS It is worth noting that the County has no State or Federal prisons in its jurisdiction. Therefore, when considering both the above indicators and the broader context, the County has epidemiologic stability in its jurisdiction. • 04.e (9034) 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). On March 16th, the County of Santa Cruz Health Officer, Dr. Gail Newel, issued a Shelter In Place (SIP) order (see Attachment C http://santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Shelter%20in%20Place%20Or der%20March%2016%202020.pdf?ver=20200318), which includes guidance for employers and essential critical infrastructure workplaces for the protection of essential workers. Subsequent updates to the SIP were released on: • March 31st (see Attachment D, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PHO%20Order% 20Extending%20SIP%2020200331.pdf); • April 29th (see Attachment E, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PHO%20Order% 20Extending%20SIP%20Effective%20May%201%202020.pdf?ver=20200430); • May 6th (see Attachment F, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Health%20Orde r%20May6%20signed%20by%20GN%20and%20JH.pdf?ver=20200506); and • May 26th (see Attachment G, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/May%2026%20P HO%20Order.pdf?ver=20200526). The intent of the SIP is to ensure that the maximum number of people shelter in their places of residence to the maximum extent feasible to slow the spread of COVID-19 and mitigate the impact on delivery of critical healthcare services to those in need. All Health Officer orders, including the SIPs, are posted publicly at: https://www.santacruzhealth.org/HSAHome/HSADivisions/PublicHealth/Communica bleDiseaseControl/CoronavirusHome/PublicInformation.aspx The guidance included in this order include the following protections for essential workers: − Shelter in place for all county residents, except for essential activities as defined by the SIP. − Essential businesses are directed to maximize the number of employees who work from home. Packet Pg. 18 of 142 − − o ADDITIONAL MATERIALS Social Distancing Requirements, which include:  Wearing a Face Covering in compliance with the April 23, 2020 Health Officer Order Generally Requiring Face Coverings (see Attachment H, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PHO%20Ord er%20Face%20Coverings%20April%2024.pdf?version=042320);  Maintaining at least six-feet of physical distance from individuals who are not part of the same household or living unit (except to the limited extent necessary to provide care, including childcare, adult or senior care, care to individuals with special needs, and patient care);  Frequently washing hands with soap and water for at least 20 seconds, or using hand sanitizer that is recognized by the Centers for Disease Control and Prevention (CDC) as effective in combatting COVID-19;  Covering coughs and sneezes with a tissue or fabric or, if not possible, into the sleeve or elbow (but not into hands); and  Avoiding all social interaction outside the household when sick with a fever or cough. Requirement for all businesses and governmental entities to complete the Social Distancing Protocol, which is included in the SIP as “Appendix A”. This protocol can be found on the county’s public website (see Attachment I, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Appendix-ASocial-Distancing-Protocol%20March%2031%202020%20FINAL.pdf) The protocol covers the following:  Signage at each public entrance of the facility to inform all employees and customers that they should: avoid entering the facility if they have a cough or fever, maintain a minimum six-foot distance from one another, sneeze and cough into a cloth or tissue or, if not available, into one’s elbow, and not shake hands or engage in any unnecessary physical contact.  Measures to protect employee health, including but not limited to symptom checks before coming into the workspace, ensuring adequate availability of cleaning supplies, and distributing a copy of this protocol to all employees.  Measures to prevent crowds from gathering, including but not limited to limiting the number of customers in the business establishment and implementing protocols to reduce crowds and lines.  Measures to keep people at least six feet apart, including but not limited to placing markings six feet apart in customer line areas, separating order areas from delivery areas, and providing employee direction to maintain at least six-feet distance from customers and each other.  Measures to prevent unnecessary contact, including but not limited to preventing people from self-serving food items, prohibiting customers to bring their own reusable items from home, and providing contactless payment systems.  Measures to increase sanitization, including but not limited to ensuring easy access to disinfectant supplies, including hand sanitizer and/or soap and water, and implementing processes for regular cleaning of highcontact surfaces. 04.e (9034) Availability of supplies (disinfectant, essential protective gear) to protect essential workers. Please describe how this availability is assessed. Packet Pg. 19 of 142 ADDITIONAL MATERIALS As noted above, the County of Santa Cruz’s Health Officer order to Shelter In Place includes guidance for essential businesses to ensure availability of supplies to protect essential workers. The County has distributed guidance for medical and non-medical essential businesses to develop contingency protocols of Personal Protective Equipment (PPE) and Personal Protective Measures (PPM). The County has also maintained a supply of PPE and PPM for businesses to request when they have difficulty obtaining supplies through their usual routes of procurement. Businesses can request and receive up to a 2-week supply of PPE and/or PPM. 04.e (9034) The County’s PPE Utilization and Distribution Guidance for Medical and Health Personnel can be found as Attachment J, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PPE%20Guidance%20F inal%204-16-20.pdf − The accompanying request application can be found here: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PPERequest_DO C02.pdf?ver=20200525 The County’s PPM Utilization and Distribution Guidance for Non-Medical Personnel can be found as Attachment K, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PPM%20Guidance%20 FINAL%204-16-20.pdf − The accompanying request application for PPM can be found here: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/PPM%20Reques t%20Application%20EOC%20Logs%20050720%20Typable%20Version.pdf • 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. The County of Santa Cruz has approximately 273,999 residents, requiring a testing capacity of 412 tests per day when using the state’s readiness criteria of 1.5 tests per 1,000 residents (273,999/1,000*1.5 = 412). The County has adequate and growing testing capacity in its jurisdiction. In May, the County was able to significantly expand its testing capacity with the opening of one of the State’s 86 new mass testing sites. With the addition of this OptumServe testing site (which is operating close to 90% capacity), the County has reached the ability to throughput 570 tests per day. This number includes testing available at healthcare facilities and the County’s three inpatient facilities. Packet Pg. 20 of 142 ADDITIONAL MATERIALS SANTA CRUZ COUNTY- CAPACITY FOR AMBULATORY TEST SITES (UPDATED AS OF MAY 21, 2020) PROVIDER ORGANIZATION Current Daily Capacity 100 Site Address Population Served Hours of Operation 610 Fredrick Street Santa Cruz, CA 95062 Dignity Health patients Mon-Fri 8am-5pm KAISER PERMANENTE SCOTTS VALLEY 30 Kaiser Permanente members Mon-Fri 1pm-4:30pm KAISER PERMANENTE WATSONVILLE 30 5615 Scotts Valley Drive Scotts Valley, CA 95066 1931 Main Street Watsonville, CA 95076 Kaiser Permanente members Mon-Fri 1:30pm-4:30pm SUTTER HEALTH/PAMF SANTA CRUZ URGENT CARE SUTTER HEALTH/PAMF WATSONVILLE URGENT CARE COUNTY HEALTH CENTERWATSONVILLE 40 2025 Soquel Avenue Santa Cruz, CA 95065 550 S. Green Valley Road Watsonville, CA 95076 Mon-Sun 8am-5pm 40 1430 Freedom Blvd, Suite D Watsonville, CA 95076 Sutter Health/PAMF patients, General public Sutter Health/PAMF patients, General public General public COUNTY HEALTH CENTER-SANTA CRUZ 40 General public Mon, Wed-Fri 8am-5pm Tues 8am-8pm PLANNED PARENTHOOD 25 1080 Emeline Avenue Santa Cruz, CA 95060 398 S Green Valley Road Watsonville, CA 95076 Planned Parenthood patients Tues and Thurs 12 pm to 1 pm SALUD PARA LA GENTE 40 General public Mon-Sat 8:30am-5:30pm Sun 8:30am-12:30pm SANTA CRUZ COMMUNITY HEALTH CENTERS 25 204 East Beach Street Watsonville, CA 95076 21507 E Cliff Drive Santa Cruz, CA 95062 General public Mon-Thur 8am – 8 pm, Fri 8am – 4 pm CABRILLO COLLEGE STUDENT HEALTH CENTER 10 Cabrillo College students, faculty and staff Mon-Thurs 8am-5pm UC SANTA CRUZ COWELL STUDENT HEALTH CENTER 20 Parking Lot J, Cabrillo College 6500 Soquel Drive, Aptos CA 95003 1156 High Street Santa Cruz, CA 95064 UC Santa Cruz students Mon-Fri 8am-5pm OPTUMSERVE AT RAMSAY PARK COMMUNITY TESTING 132 1301 Main Street Watsonville, CA 95076 Public Wed-Sun 7am-7 pm DIGNITY HEALTH MEDICAL GROUP 40 04.e (9034) Mon-Sun 8am-5pm Mon-Thurs 7:30am-6:30pm Fri 7:30am-5pm Packet Pg. 21 of 142 TOTAL - ESTIMATED AMBULATORY CAPACITY 572 ADDITIONAL MATERIALS *** Note: Does not include hospital testing of patients or mobile specimen collection team capacity. 04.e (9034) The County utilizes a tiered testing strategy, making testing readily available for all symptomatic individuals, asymptomatic case contacts, asymptomatic healthcare workers and first responders, then all persons living or working in the County. In addition, the County is developing a mobile surveillance testing program for staff and residents in congregate living facilities, agricultural workers and those unable to leave their place of residence. Date 05/22 05/23 05/24 05/25 05/26 05/27 05/28 Daily Count of Tests Conducted 152 207 226 231 247 10* XX In the past week, 1,073 were completed in the County (note, this number does not include negative test results not yet reported, resulting in an under-count). 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. The below map illustrates the current 13 testing sites currently available to the public in the County of Santa Cruz and the driving time to a specimen collection site, by geography. These sites establish testing access for residents well within the state established driving times from all locations in the County. Packet Pg. 22 of 142 ADDITIONAL MATERIALS 04.e (9034) The 13 listings below represent the specimen collection sites available and is available to the public as an interactive GIS map on the County website. https://www.santacruzhealth.org/HSAHome/HSADivisions/PublicHealth/Communicable DiseaseControl/CoronavirusHome/SAVELivesSantaCruzCounty/GetTested.aspx Packet Pg. 23 of 142 ADDITIONAL MATERIALS o 04.e (9034) 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.] Packet Pg. 24 of 142 ADDITIONAL MATERIALS Our surveillance strategy is one focused on ensuring we have a robust system for assessing the severity and spectrum of disease across our county. Building on our foundation of testing and tracing capabilities, our surveillance framework borrows from the work of the Center for Infectious Disease Research and Policy (CIDRAP) and centers around the following four “rights” – 1) right populations; 2) right test; 3) right interpretation; 4) right actions. 04.e (9034) With an infrastructure designed to facilitate rapid identification and response, we have the diagnostic capabilities to facilitate testing of individuals at early onset of symptoms. We also have the capacity to test asymptomatic individuals at higher risk of exposure. Through our mobile specimen collection teams, we will possess the ability to deploy testing in several sites across the county. This capability will allow for ongoing surveillance of individuals in higher risk settings and timely response for any outbreaks needing immediate attention. Through a focused surveillance approach, we will be able to accomplish the following objectives: − Detect COVID-19 infections among vulnerable populations at higher risk of disease − Continue case investigation and contact tracing efforts to slow transmission − Identify disease clusters requiring special intervention − Understand COVID-19 transmission trends in our communities Surveillance Overview The County of Santa Cruz Public Health Division maintains the ongoing capability to collect, track, analyze, and report patient (case) information as part of its role in responding to infectious diseases that fall under Title 17 Section 2500 of the California Code of Regulations and emerging threats, such as COVID-19. A main component of our COVID-19 surveillance plan is to bolster existing surveillance processes and systems and implement new methods of targeted surveillance testing (as referenced above). • Provider Reporting Suspected and confirmed cases of COVID-19 are required by Title 17 Section 2500 of the California Code of Regulations to be immediately reported by medical providers to the County of Santa Cruz Public Health Division. The Disease Control Branch uses provider reporting (via the County of Santa Cruz COVID-19 Confidential Morbidity Report) and laboratory reports to initiate case and contact investigations for every known case of COVID-19. Disease Control also requests that providers and congregate settings report suspected cases associated with vulnerable populations to investigate more immediately. Public Health Division staff work with local providers to improve the accuracy, completeness, and timeliness of reporting. Reports are entered into the California Reportable Disease Information Exchange (CalREDIE), which is a statewide confidential and secure system, via Electronic Lab Reporting or manual entry. Reports are evaluated by the County of Santa Cruz Public Health Division staff based on the Counsel of State and Territorial Epidemiologists’ (CSTE)’s nationally standardized surveillance case definition. • Laboratory Testing Testing capacity continues to increase at multiple sites throughout the County (as referenced in other sections in this document). Diagnostic testing of symptomatic individuals and close contacts is available as ordered providers. Testing of asymptomatic individuals (beginning with healthcare workers) is available through the OptumServe community testing site. Prioritization of populations for testing will Packet Pg. 25 of 142 ADDITIONAL MATERIALS continue to be evaluated and communicated to the public as we analyze and assess local epidemic trends and mitigation needs. 04.e (9034) Targeted Surveillance Testing will occur in a tiered approach, beginning with staff and residents of skilled nursing facilities (SNFs) in accordance with CDPH AFL-2053. County Public Health is partnering with the University of California, Santa Cruz to targeted surveillance testing at SNFs. As local epidemiologic trends and vulnerable populations are identified, targeted surveillance testing will expand to meet these needs (e.g., shelters, farmworker communities, long-term care facilities, jails, college dorms, other essential workers, etc.) • Case Investigation and Contact Tracing Case interviews are a source of rich information regarding risk, exposure, and demographics, from which epidemiologic trends can be identified for intervention. Interview and other investigation information is entered into CalREDIE (for cases and their contacts) and analyzed for reporting. As warranted, exposure notices are issued to raise awareness among those potentially exposed. Public Health Nurse investigators and Epidemiologist surge staffing has been implemented and will continue to be expanded, as indicated by the magnitude of the local epidemic. When available, the County Public Health Division will transition to the statewide contact tracing database for contact information. • Cluster Identification & Monitoring Through reporting, case interviews and contact tracing, clusters may be identified, in accordance with CDPH guidance and definitions. Disease Control epidemiologists and investigating public health nurses will collaborate to characterize the cluster, report to the Health Officer, confer with CDPH, and implement containment efforts, as indicated. Clusters of public health importance (e.g., a case in a skilled nursing facility or homeless shelter, increasing cases in farm worker communities, etc.) will warrant cross-divisional efforts to increase testing, containment, and mitigation interventions. • Hospital Census The County Public Health Division receives daily data from the California Department of Public Health (CDPH) hospital census survey through Snowflake. The Division reviews the number of in-use and available acute care beds, intensive care unit beds, and ventilators for COVID and non-COVID patients daily. The Division also monitors the hospital census survey data on PPE stock at each hospital as well. Skilled Nursing Facility (SNF) data are received daily from the Region II Regional Disaster Medical Health Specialists (RDMHS) and include census, COVID-19 cases, and PPE availability at each of our 7 SNFs. • Syndromic Surveillance Our syndromic surveillance system began in 2015 as a collaboration between the County of Santa Cruz Health Services Agency and the Santa Cruz County Health Information Exchange to create a timely and accurate data repository through BioSense. The County Public Health Division uses BioSense to monitor COVID-19 like symptoms, chief complaints, and discharge diagnoses from emergency department data submitted by our major hospitals (Dominican and Watsonville Community Hospital) and by our Palo Alto Medical Foundation (PAMF) urgent care sites. Packet Pg. 26 of 142 • ADDITIONAL MATERIALS Data Analysis Data will be extracted from the above systems and analyzed in R Studio. Basic descriptive statistics, such as counts, rates, and proportions, will comprise most of the statistical analyses. However, when appropriate, forecasting, regression, and other statistical tests will be utilized. 04.e (9034) Surveillance data of known cases, including demographics, exposure sources, trends among new cases, etc. will be updated daily and analyzed for trends, as indicated. Any noticeable spike or case(s) of public health concern will warrant immediate attention. Other indicators, disease modeling, syndromic surveillance, and metrics outlined in other areas of this form will be reviewed on a weekly basis. Overall analysis of the local epidemic will produce metrics not only related to relaxing shelter-in-place, but also triggers for tightening shelter-in-place orders. • • Information Dissemination Surveillance data has been and will continue to be disseminated through the weekly provider reports, daily updates to our website and data dashboards, and provided internally through situation- status reports for every operational period. When possible, County Public Health Division staff also present and share data with stakeholders and other response partners at various meetings. • Plan Review and Adjustments As CDC and CDPH develop and release new guidance, County Public Health will iterate its containment and mitigation approach to align with evidence-based practices and local epidemiologic trends. 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). The County of Santa Cruz meets this criterion by virtue of our ability to date to contact each positive case within 24 hours and case contacts within 48 hours. This has been possible because of the willingness and dedication of our Communicable Disease Unit. We recognize the need to expand our team for longterm sustainability, and are actively training additional contact tracers and managers. In the next few weeks we will be meeting and exceeding the recommended number of contact tracers. The County is adding to its team of existing case investigators and contact tracers to include redeployed county employees, promotoras (community health workers), students who are working towards a certification or license in the health care field and need work experience in order to complete their requirements, and community volunteers. Packet Pg. 27 of 142 ADDITIONAL MATERIALS We do not currently meet the target 41 contact tracers, based on the readiness criteria of 15 per 100,000 (273,999/100,000*15 = 41). However, by June 5, 43 contact tracers and case investigators will be trained, which includes 28 individuals newly trained via the State’s new Virtual Training Academy. Additional trainees in the pipeline will add more contact tracers in the middle of June. The County will continue to recruit and screen volunteers for a 3rd wave of additional contact tracers. 04.e (9034) The County has kept abreast of case investigation by contacting each positive case within 24 hours of receiving the positive result. Contact tracing occurs with each positive case, even though the County is currently experiencing a surge in cases that is challenging existing staff. Onboarding is occurring now with newly trained contact tracers and case investigators to support surges in cases. The County currently uses the CalREDIE system for primary data management and intends to onboard and transition to the State’s contact tracing platform when made available to theCounty. 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. The County of Santa Cruz exceeds the state threshold for temporary housing units by more than double, thanks to a multi-part strategy that includes existing shelter space, hotel rooms through Project Roomkey and expanded congregate shelter capacity. Based on the most recent Point-In-Time count from 2019 of 2,167 people experiencing homelessness (sheltered or living unsheltered) in Santa Cruz County, the 15% threshold equates to the ability to shelter 325 people (2,167 x 15% = 325). As of May 29th, the capacity to shelter individuals is 721: • Existing shelter capacity (after reducing capacity to accommodate for effective physical distancing) = 380 • Expanded congregate shelter capacity (including County Fairground) = 159 • FEMA Trailers = 30 • Motel/Hotel capacity, through Project Roomkey = 152 Isolation and Quarantine for individuals experiencing homelessness is available as individual rooms with private bathrooms in hotels through Project Roomkey and are held vacant and ready to deploy in case of need. On-demand sheltering for individuals who otherwise cannot safely do so is available at additional hotels, as clinically recommended by public health nurse case investigators. Mitigation plans in congregate shelters include: shared bathrooms cleaned three or four times each day; physical distancing measures in place; facial coverings are required; symptom and temperature screening protocols are implemented daily; a containment protocol is developed and tabletop exercises conducted regularly for staff preparedness. Packet Pg. 28 of 142 ADDITIONAL MATERIALS Shelter and Care is operated by the County’s Human Services Department, who manage a comprehensive shelter referral process to support this plan, which can be found here: https://santacruzhumanservices.org/Home/COVID-19HomelessServicesInformation • 04.e (9034) 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. Packet Pg. 29 of 142 ADDITIONAL MATERIALS The County of Santa Cruz has three inpatient facilities in its jurisdiction: Dominican Hospital (DH), Watsonville Community Hospital (WCH), and Sutter Maternity and Surgery Center (SMSC). Signed letters of support and preparedness are attached from the three facilities, Attachments L, M and N. The facilities have substantial capacity, including ICU beds, ventilators, and adequate PPE available to handle standard health care capacity, current COVID-19 cases, and potential surge due to COVID-19. COVID-19 patients make up a small percentage of local hospital census in Santa Cruz County. Each facility has been engaged in individual planning and have performed activities to prepare for a surge of patients. These activities include the suspension of elective surgery, implementation of triage stations and tents, and planned expansion and conversion of idle sections of hospitals to expand inpatient and ICU capacity. Ventilators in storage have been refurbished and additional PPE has been acquired. Detailed information regarding an All County Facilities Coordinated Surge Plan can be reviewed in Attachment O. For more information on disease modeling for hospital surge, please refer to the Epidemiologic Stability Metric Section within this document. 04.e (9034) Dominican Hospital Licensed Inpatient Licensed Surge Beds Ventilators Meets Beds Beds ICU +35%? 222 188 24 57 35 Yes The average census at DH is 120 beds or 54% capacity. Based on this figure, they can easily meet 135% (surge of >35% = 120*35%=42 surge beds). DH has strategized several different ways to meet surge capacity. DH will expand their ICU by changing short stay and outpatient/surgical beds into ICU or Med-Surg beds as needed. Their staffing strategies include moving all staff to 12-hour shifts, “uptraining” (occurred in March) nurses to increase ICU nursing capacity, use of creative staffing configurations, and use of registry, travelers, and contracts. Watsonville Community Hospital Licensed Inpatient Licensed Surge Beds Ventilators Meets Beds Beds ICU +35%? 106 106 6 20+ 15 Yes The average census at WCH is 25 beds or 24% capacity, which is lower than preCOVID census of 40 beds (surge of >35% = 25*35%=7 surge beds). Due to their low average census, WCH could easily manage an additional 40 patients more than the current census number. WCH has strategized to call in staff who are off due to low census or call in their per diem staff. They also report to have four beds adjacent to their ICU that could be converted to ICU beds, and they could also convert 3-4 PACU beds to ICU beds. Their biggest challenge would be obtaining the staffing needed to open beyond the initial surge of 40 patients. Aside from the strategies mentioned, WCH reported they could extend shifts short term and use travelers to staff their facility. Sutter Maternity and Surgery Center Licensed Inpatient Licensed Surge Beds Ventilators Meets Beds Beds ICU +35%? 28 16 0 20 1 Yes Of the 28 licensed beds noted in the CDPH report, 16 are med-surg and 12 are perinatal. SMSC would expect to increase surge capacity only by using their medPacket Pg. 30 of 142 ADDITIONAL MATERIALS surg capability. SMSC reported to increase by 20 med-surg beds by: doubling up rooms and by turning their surgical suites into step down beds. They plan to increase their staff by increasing shifts to 12-hour shifts, closing elective surgeries and use the surgical staff to provide care for the surge patients. SMSC recently trained their surgical staff to prepare them to care for patients in a step-down environment. As an alternative, SMSC also has the capacity to draw from the large Sutter Hospital system for additional staff. 04.e (9034) Monitoring Hospital Readiness All three in-patient hospitals are part of the County’s healthcare coalition. Each week, partners engage in discussions to provide updates and ask about their capacity and PPE inventory. In addition to these weekly, verbal check-ins, hospitals enter data required by CDPH as a daily survey via Snowflake. This data is monitored by the Medical Health Operational Area Coordinator (MHOAC) and an epidemiologist to ensure capacity and readiness for acute care, ICU, and ventilator COVID-19 surge. The plots to the left are monitored and updated daily. They display the number of COVID-19 patients and non-COVID-19 patients hospitalized in acute care, are on ventilators, or in the ICU, as well as what a 35% increase in COVID-19 patients would look like. As shown above, County hospitals can manage a 35% surge due to COVID-19 and still provide regular patient care. Packet Pg. 31 of 142 o ADDITIONAL MATERIALS 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. 04.e (9034) The hospitals have established relationships with well-recognized medical supply vendors. Hospitals have been working with these vendors since the onset of the pandemic to ensure adequate PPE supply for healthcare providers and ancillary staff. County hospitals also have PPE conservation plans in place and report PPE status or needs to the MHOAC. When the hospitals are unable to source necessary equipment through the normal vendors, facilities submit a resource request with the County MHOAC to request additional supplies. The County has also developed an Allocation of Scarce Resources portion within the MHOAC to guide standardize the approach to PPE distribution and prioritization of resources to healthcare stakeholders. Dominican Hospital DH is following CDC guidance for PPE contingency and crisis strategies including using face masks beyond the manufacturer-designed shelf life during patient care. They attempt to order through their normal vendors and will order through the MHOAC if needed. Their biggest challenge is testing capacity due to lack of reagent supplies for their in-house equipment, and delayed results coming from outside labs. Watsonville Community Hospital WCH reported they are following CDC guidance for conserving PPE. Their facilities Director has been proactive in ordering PPE from their vendors to close the gap between their needs and their ability to receive delayed PPE orders. Sutter Maternity and Surgery Center SMSC reported to be updating their PPE plan as they have expanded their capability by fit testing their staff. Instead of relying solely on PAPRs for their staff, getting staff fit tested allows staff to utilize an N95 mask. They state they are working closely with their corporate resources, providing daily inventories and monitoring. PPE is typically ordered through their primary vendors, internal corporate resources, or from the MHOAC if needed. Inventories Current County PPE Inventory N95 Masks 107,714 Procedure Face Masks Shields 186,150 64,428 Gowns Gloves 113,708 185,200 Current Hospital PPE Inventory Dominican Hospital N95 Masks >= 15 Days Other Masks >=15 Days Eye Gowns Gloves Protection >= 15 >= 15 >= 15 Days Days Days Date Last Updated 05/27/2020 Sutter >= 15 Days >= 15 Days >= 15 Days >= 15 Days >= 15 Days 05/27/2020 Watsonville Community Hospital >= 15 Days >=15 Days >= 15 Days >= 15 Days >=15 Days 05/27/2020 Packet Pg. 32 of 142 ADDITIONAL MATERIALS • 04.e (9034) 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. The County of Santa Cruz has been working closely with our community partners throughout our COVD-19 response to protect our most vulnerable community members. On March 20, the County of Santa Cruz Health Officer issued a no-visitation order at residential health care facilities throughout the County, (see Attachment P, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/SCC%20PHO%20 ORDER%20Re%20Visitors%20in%20Res%20Heatlhcare%20Facilities.pdf). The no-visitation order has since been extended indefinitely and covers all visitation other than end-of-life situations to further protect SNF residents. The County of Santa Cruz Communicable Disease Unit (CDU) and Emergency Preparedness staff engage SNFs in ongoing on-site visitations with facility assessments that include: infection prevention and controls; preparedness plans; isolation and quarantine protocols; staffing readiness and contingency plans; personal protective equipment (PPE), and supply chain integrity. Strategies for improvement are provided to each facility when needed. Technical assistance is provided to each facility with robust support and will continue in the event of an outbreak from the Department Operations Center (DOC) Logistics Section and the Medical Health Operation Area Coordinator (MHOAC) for resource requesting and Emergency Preparedness for planning, training and testing response protocols. These supports are ongoing (see press release COUNTY COMPLETES COVID-19 READINESS ASSESSMENT OF SKILLED NURSING FACILITIES dated April 23, 2020, Attachment Q, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/SNF.Assessments.04232020.pdf) County Public Health staff also maintain communication with SNFs through regular emails, weekly calls with SNF Medical Directors on Friday afternoons, weekly calls with SNF administrators on Monday afternoons, and ad hoc calls as any issue arises. Collaborative planning meetings with local healthcare providers resulted in development of the Emergency Response Plan for Skilled Nursing Facilities (see Attachment R), which guides how the County addresses urgent matters at SNFs. Additionally, SNFs are represented within three groups in the HSA DOC Operations Section – Community Recovery Branch, Disease Control Branch, and the Preparedness Branch, which further enables the County to closely support facilities providing care to these vulnerable populations. The County is working vigorously to implement sufficient testing capacity to conduct expanded outbreak investigations, expanded contact tracing and community-wide testing through the launching of OptumServe that began on May 6, 2020. Packet Pg. 33 of 142 ADDITIONAL MATERIALS 04.e On May 8, 2020, CMS published an interim final rule requiring SNFs to report COVID-19 facility (9034) data to the CDC and to notify residents, residents' representatives, and families of residents of when there are COVID-19 positive residents or healthcare workers in the facility. Per CDPH AFL 20 – 43.2 dated May 13, 2020, the report must include, but is not limited to, the following: • Suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19 • Total deaths and COVID-19 deaths among residents and staff • Personal protective equipment (PPE) and hand hygiene supplies in the facility • Ventilator capacity and supplies in the facility • Resident beds and census • Access to COVID-19 testing while the resident is in the facility • Staff shortages • Other information specified by the Secretary County staff monitor these data, as provided by CDPH, and support local SNFs when deficiencies are reported. 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. All seven SNFs participate in the CDPH daily poll where data regarding COVID-19 including PPE inventory are documented. The County receives and reviews the daily polls for compliance with the requirement of having >14-day supply of PPE on hand prior to receiving state supplies. The names and contacts of the seven County SNFs are: Name of Facility Address City County Valley 919 Watsonville, Santa Cruz Convalescent Freedom CA Hospital – Blvd. Watsonville Watsonville Nursing 535 Auto Watsonville, Santa Cruz Center – Center Dr. CA Watsonville Pacific Coast 1935 Wharf Capitola, Santa Cruz Manor Rd. CA th Driftwood 675 24 Santa Cruz, Santa Cruz Healthcare Center Ave. CA Santa Cruz Santa Cruz Post1115 Santa Cruz, Santa Cruz Acute Capitola Rd. CA Hearts and Hands 2990 Soquel Post-Acute Care Ave. and Rehab Center Watsonville Post- 525 Auto Acute Center Center Dr. Phone (831) 722-3581 Point of Contact Loralie Yzerman (831) 724-7505 Emily Perez, DON (831) 476-0770 Marise Goetzl (831) 475-6323 Kathleen Lovato Lance Bailey, Adm. Edna Keener, DON Rusty Grenier, Adm. Bobby Singh (831) 475-4055 Santa Cruz, Santa Cruz (831)479-9000 CA Watsonville, Santa Cruz (831)742-7505 CA Lucila Tinoco From the most recent daily poll available (05/26/2020), all SNFs report adequate PPE supplies and no urgent needs. All the above SNFs have at least 8-14 days of N95s, surgical face masks, Packet Pg. 34 of 142 ADDITIONAL MATERIALS 04.e and eye protection. All seven SNFs are expecting at least one shipment of PPE supplies from (9034) FEMA to supplement and bolster the >14-day supply requirement. • 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. A Supplemental Order was issued by the Health Officer of the County of Santa Cruz taking effect on May 8, 2020 (see Attachment F), in order to enter Stage 2 with the Governor. This order allowed curbside pickup and delivery from select retailers consistent with those described by the Governor, as well as manufacturing and logistics to support those retailers. A related press release was also issued: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/SIP.Modifications.05062020.pdf A new Health Officer Order was issued on May 26, 2020 (see Attachment G), aligning the County of Santa Cruz with the Governor’s Roadmap through all four stages. The May 26 order brought the County into alignment with the State through Early Stage 2 Low Risk Workplaces with modifications, including office-based businesses (when telework is not possible), select services as defined, outdoor museums, open gallery spaces, and other public spaces with modifications. In addition, this order allowed the opening of in-store retail and religious and cultural services, all with modifications, aligning with the Governor’s Roadmap changes of May 25, 2020. Related FAQ’s and a press release were also issued: - FAQs: https://www.santacruzhealth.org/Portals/7/pdfs/coronavirus/COVID-19_FAQ_526-20_English.pdf (see Attachment S) - Press Release: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/HealthOrder.05262020.pdf (see Attachment T) A Supplemental Order will be issued on the same date as the Variance Attestation Application to the State, to take effect upon approval and posting of the application by the State. This Supplemental Order will allow the opening of restaurants, barbershops and hair salons, with modifications according to the guidance at https://covid19.ca.gov/pdf/guidance-dine-in-restaurants.pdf and https://covid19.ca.gov/pdf/guidance-hair-salons.pdf and the associated checklists. Related FAQ’s and press release are planned. In addition to the orders described above, an Order Generally Requiring Face Coverings was issued on April 23, 2020 (see Attachment H), Additionally, a Social Distancing Protocol is attached to the April 29, 2020, Health Officer Order as Appendix A (see Attachment I), which is to be completed, implemented and posted at each public entrance of every business and governmental entity. This Social Distancing Protocol has been in effect in the County since March 31, 2020, and includes measures to protect the public and employees at each posting facility. The County of Santa Cruz, in collaboration with the Santa Cruz Community Foundation, has established an Economic Recovery Council (see website Packet Pg. 35 of 142 ADDITIONAL MATERIALS 04.e (9034) https://www.santacruzhealth.org/HSAHome/HSADivisions/PublicHealth/ CommunicableDiseaseControl/CoronavirusHome/SAVELivesSantaCruzCounty/ EconomicRecoveryCouncil.aspx) consisting of 13 Council members plus leaders from the local Chambers of Commerce. The Council members are respected leaders in the business community, representing a variety of industry sectors throughout the County. The Economic Recovery Council meets weekly with County leadership, including Public Health officials, to plan for the reopening of local business. Each member meets separately with a workgroup for their business sector, following State guidelines and developing plans for their particular sector. No Stage 3 or 4 businesses or activities will be allowed until approved by the State. Schools will await further guidance from the State, and will not open without this. • 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. • 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. Packet Pg. 36 of 142 ADDITIONAL MATERIALS See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U 04.e (9034) 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? See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Testing Section 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? See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Contact Tracing Section 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? Packet Pg. 37 of 142 • • • • • • • • ADDITIONAL MATERIALS 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? 04.e (9034) See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Congregate Living and Vulnerable Populations Section 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 SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Protecting the Vulnerable section 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? See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Acute Care Surge section Essential Workers • How many essential workplaces are in the county? Packet Pg. 38 of 142 • • • ADDITIONAL MATERIALS 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? 04.e (9034) See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Essential Workers section 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? See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Special Considerations 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? 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? See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Community Engagement 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? Packet Pg. 39 of 142 ADDITIONAL MATERIALS See SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap, Attachment U, Relationship to Surrounding Counties 04.e (9034) 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. Packet Pg. 40 of 142 ADDITIONAL MATERIALS 04.e (9034) I, Gail Newel, MD, MPH, hereby attest that I am duly authorized to sign and act on behalf of the County of Santa Cruz. I certify that the County of Santa Cruz 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 Containment Plan is submitted for the County of Santa Cruz, 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 Gail Newel, MD, MPH Signature Position/Title Health Officer, County of Santa Cruz Date May 29, 2020 Packet Pg. 41 of 142 ADDITIONAL MATERIALS 04.e (9034) Attachment A Place Holder for signed Board of Supervisors Letter of Support Packet Pg. 42 of 142 ADDITIONAL MATERIALS 04.e (9034)  Attachment B COVID-19 Information & Updates Santa Cruz County HSA Home ▸ Coronavirus Home ▸ Local COVID-19 Forecast Models Local COVID-19 Model Forecasts and Data Analyses Note: The information on this page is updated every Wednesday What is Disease Modeling? Disease models make forecasts about what could happen. They show us how a disease might spread in a community. These forecasts help us to plan for different situations. Just like weather forecasts, disease models are not perfect. And like weather forecasts, disease models are most accurate for forecasting the near future. Because COVID-19 is a new disease, we learn more about it all the time. We adjust our forecast models as we learn. You can see Santa Cruz County’s modeling code for yourself here. How to read the model: For the actual number of hospitalizations in the past, we use the blue dots. To look at the future, we use the dark blue line and the light blue area. The dark blue line is the most likely number of hospitalizations in the future. Since models are not perfect, the light blue wider area shows the range of likely hospitalizations. Why We Forecast Hospitalizations We all rely on our hospitals to take care of us when we are very ill. If a hospital gets too full, it doesn’t have enough space or staff to care for everyone. Packet Pg. 43 of 142 ADDITIONAL MATERIALS So, it is important to keep track of how many people are staying in a hospital at one time. It is also important to use our forecasts to predict 04.e (9034) when hospitals might get too full. When our hospitals start to get too full, we need to take actions to slow the spread of COVID-19. Tracking and forecasting how many people are in our hospitals help us SAVE Lives in our community. Interested in more COVID-19 models? Many models exist online to help answer questions about COVID-19. Since every model is based on a set of assumptions, it is helpful to review other models to compare projections, trends, and methods. Each model will likely show different results. For more information, we recommend visiting https://www.cdc.gov/coronavirus/2019-ncov/covid-data/forecasting-us.html. Additional COVID-19 Analyses While disease modeling is helpful for planning, additional analyses help us understand the spread of COVID-19 in our community relative to others. One way to understand this is through doubling-time. Doubling-time is the time it takes for the total case-count to double. A higher doubling-time reduces the impact of COVID-19 to the health care system and suggests a slower spread of COVID-19. How to read the plot: The plot shows COVID-19 rates and the average doubling-time since the 10th COVID-19 case, for each California County. The COVID-19 rates are calculated as the number of cases per 100,000 residents in each county. This helps account for different population sizes when comparing COVID-19 spread across California. How is Santa Cruz County doing in comparison to other CA counties? Santa Cruz County has a lower total case-count and a higher average doubling-time compared to many other counties. As testing capacity for COVID-19 increases across California, we are likely to see an initial increase in COVID-19 cases and decrease in doubling-time. Monitoring case-counts while we work to increase our ability to detect COVID-19 helps us SAVE Lives in Santa Cruz County. Terms Of Use Privacy Statement Packet Pg. 44 of 142 Attachment C ADDITIONAL MATERIALS 04.e (9034) County of Santa Cruz I HEALTH SERVICES AGENCY '11/Y.TA. c,\l.u ""'·-=- POST OFFICE BOX 962, 1080 Emeline Ave., SANTA CRUZ, CA 95061-0962 TELEPHONE: (831) 454-4000 FAX: (831) 454-4488 TDD: Call 711 Public Health Division ORDER OF THE HEALTH OFFICER OF THE COUNTY OF SANTA CRUZ DIRECTING ALL INDIVIDUALS LIVING IN THE COUNTY TO SHELTER AT THEIR PLACE OF RESIDENCE EXCEPT THAT THEY MAY LEAVE TO PROVIDE OR RECEIVE CERTAIN ESSENTIAL SERVICES OR ENGAGE IN CERTAIN ESSENTIAL ACTIVITIES AND WORK FOR ESSENTIAL BUSINESSES AND GOVERNMENTAL SERVICES; EXEMPTING INDIVIDUALS EXPERIENCING HOMELESSNESS FROM THE SHELTER IN PLACE ORDER BUT URGING THEM TO FIND SHELTER AND GOVERNMENT AGENCIES TO PROVIDE IT; DIRECTING ALL BUSINESSES AND GOVERNMENTAL AGENCIES TO CEASE NONESSENTIAL OPERATIONS AT PHYSICAL LOCATIONS IN THE COUNTY; PROHIBITING ALL NON-ESSENTIAL GATHERINGS OF ANY NUMBER OF INDIVIDUALS; AND ORDERING CESSATION OF ALL NONESSENTIAL TRAVEL DATE OF ORDER: MARCH 16, 2020 Please read this Order carefully. Violation of or failure to comply with this Order is a misdemeanor punishable by fine, imprisonment, or both. (California Health and Safety Code§ 120295, et seq.) UNDER THE AUTHORITY OF CALIFORNIA HEALTH AND SAFETY CODE SECTIONS 101040, 101085, AND 120175, THE HEALTH OFFICER OF THE COUNTY OF SANTA CRUZ ("HEALTH OFFICER") ORDERS: 1. The intent of this Order is to ensure that the maximum number of people self-isolate in their places of residence to the maximum extent feasible, while enabling essential services to continue, to slow the spread of COVID-19 to the maximum extent possible. When people need to leave their places of residence, whether to obtain or perform vital services, or to otherwise facilitate authorized activities necessary for continuity of social and commercial life, they should at all times reasonably possible comply with Social Distancing Requirements as defined in Section 10 below. All provisions of this Order should be interpreted to effectuate this intent. Failure to comply with any of the provisions of this Order constitutes an imminent threat to public health. 2. All individuals currently living within Santa Cruz County (the "County") are ordered to shelter at their place of residence. To the extent individuals are using shared or outdoor spaces, they must at all times as reasonably possible maintain social distancing of at least six feet from any other person when they are outside their residence. All persons may leave their residences only for Essential Activities, Essential Governmental Functions, or to operate Essential Businesses, all as defined in Section 10. Individuals Packet Pg. 45 of 142 ADDITIONAL MATERIALS 04.e (9034) experiencing homelessness are exempt from this Section, but are strongly urged to obtain shelter, and governmental and other entities are strongly urged to make such shelter available as soon as possible and to the maximum extent practicable (and to utilize Social Distancing Requirements in their operation). 3. All businesses with a facility in the County, except Essential Businesses as defined below in Section 10, are hereby required to cease all activities at facilities located within the County except Minimum Basic Operations, as defined in Section 10. For clarity, businesses may also continue operations consisting exclusively of employees or contractors performing activities at their own residences (i.e., working from home). All Essential Businesses are strongly encouraged to remain open. To the greatest extent feasible, Essential Businesses shall comply with Social Distancing Requirements as defined in Section 10 below, including, but not limited to, when any customers are standing in line. 4. All public and private gatherings of any number of people occurring outside a household or living unit are prohibited, except for the limited purposes as expressly permitted in Section 10. Nothing in this Order prohibits the gathering of members of a household or living unit. 5. All travel, including, but not limited to, travel on foot, bicycle, scooter, motorcycle, automobile, or public transit, except Essential Travel and Essential Activities as defined below in Section 10, is prohibited. People must use public transit only for purposes of performing Essential Activities or to travel to and from work to operate Essential Businesses or maintain Essential Governmental Functions. People riding on public transit must comply with Social Distancing Requirements as defined in Section 10 below, to the greatest extent feasible. This Order allows travel into or out of the County to perform Essential Activities, operate Essential Businesses, or maintain Essential Governmental Functions. 6. This Order is issued based on evidence of increasing occurrence of COVID-19 within the County and throughout the Bay Area, scientific evidence and best practices regarding the most effective approaches to slow the transmission of communicable diseases generally and COVID-19 specifically, and evidence that the age, condition, and health of a significant portion of the population of the County places it at risk for serious health complications, including death, from COVID-19. Due to the outbreak of the COVID-19 virus in the general public, which is now a pandemic according to the World Health Organization, there is a public health emergency throughout the County. Making the problem worse, some individuals who contract the COVID-19 virus have no symptoms or have mild symptoms, which means they may not be aware they carry the virus. Because even people without symptoms can transmit the disease, and because evidence shows the disease is easily spread, gatherings can result in preventable transmission of the virus. The scientific evidence shows that at this stage of the emergency, it is essential to slow virus transmission as much as possible to protect the most vulnerable and to prevent the health care system from being overwhelmed. One proven way to slow the transmission is to limit interactions among people to the greatest extent practicable. By reducing the spread of the COVID-19 virus, this Order helps preserve critical and limited healthcare capacity in the County. 7. This Order is issued in light of the existence of 11 cases of COVID-19 in the County, as well at least 258 cases of confirmed cases and at least three deaths in adjacent Bay Area counties as of 5:00 p.m. on March 15, 2020, including a significant and increasing number of suspected cases of community transmission and likely further significant increases in transmission. Widespread testing for COVID-19 is not yet available but is expected to increase in the coming days. This Order is necessary to slow the rate of spread and the Health Officer will re-evaluate it as further data becomes available. 8. This Order also is issued in accordance with, and incorporates by reference, the March 4, 2020 Proclamation of a State of Emergency issued by Governor Gavin Newsom, the March 4, 2020 Declaration of Local Health Emergency Regarding Novel Coronavirus 2019 (COVID-19) issued by the Health Officer, the March 10, 2020 Resolution of the Board of Supervisors of the County of Santa Cruz Ratifying the Order of the County Health Officer to Shelter in Place Page 2 of 6 Packet Pg. 46 of 142 ADDITIONAL MATERIALS 04.e (9034) Declaration of a Local Health Emergency, and the March 10, 2020 Resolution of the Board of Supervisors of the County of Santa Cruz Proclaiming a Local Emergency. 9. This Order comes after the release of substantial guidance from the Centers for Disease Control and Prevention, the California Department of Public Health, the County Health Officer and other public health officials throughout the United States and around the world, including a variety of prior orders to combat the spread and harms of COVID-19. The Health Officer will continue to assess the quickly evolving situation and may modify or extend this Order, or issue additional Orders, related to COVID-19. 10. Definitions and Exemptions. a. For purposes ofthis Order, individuals may leave their residence only to perform any of the following "Essential Activities." But people at high risk of severe illness from COVID-19 and people who are sick are urged to stay in their residence to the extent possible except as necessary to seek medical care. 1. To engage in activities or perform tasks essential to their health and safety, or to the health and safety of their family or household members (including, but not limited to, pets), such as, by way of example only and without limitation, obtaining medical supplies or medication, visiting a health care professional, or obtaining supplies they need to work from home. 11. To obtain necessary services or supplies for themselves and their family or household members, or to deliver those services or supplies to others, such as, by way of example only and without limitation, canned food, dry goods, fresh fruits and vegetables, pet supply, fresh meats, fish, and poultry, and any other household consumer products, and products necessary to maintain the safety, sanitation, and essential operation of residences. iii. To engage in outdoor activity, provided the individuals comply with Social Distancing Requirements as defined in this Section, such as, by way of example and without limitation, walking, hiking, or running. 1v. To perform work providing essential products and services at an Essential Business or to otherwise carry out activities specifically permitted in this Order, including Minimum Basic Operations. v. To care for a family member or pet in another household. b. For purposes of this Order, individuals may leave their residence to work for or obtain services at any "Healthcare Operations" including hospitals, clinics, dentists, pharmacies, pharmaceutical and biotechnology companies, other healthcare facilities, healthcare suppliers, home healthcare services providers, mental health providers, or any related and/or ancillary healthcare services . "Healthcare Operations" also includes veterinary care and all healthcare services provided to animals. This exemption shall be construed broadly to avoid any impacts to the delivery of healthcare, broadly defined. "Healthcare Operations" does not include fitness and exercise gyms and similar facilities . c. For purposes of this Order, individuals may leave their residence to provide any services or perform any work necessary to the operations and maintenance of "Essential Infrastructure," including, but not limited to, public works construction, construction of housing (in particular affordable housing or housing for individuals experiencing homelessness), airport operations, water, sewer, gas, electrical, oil refining, roads and highways, public transportation, solid waste collection and removal, internet, and telecommunications systems (including the provision of essential global, national, and local infrastructure for computing services, business infrastructure, communications, and web-based services), provided that they carry out those services or that work in compliance with Social Distancing Requirements as defined this Section, to the extent possible. Order of the County Health Officer to Shelter in Place Page 3 of 6 Packet Pg. 47 of 142 ADDITIONAL MATERIALS 04.e (9034) d. For purposes of this Order, all first responders, emergency management personnel, emergency dispatchers, court personnel, and law enforcement personnel, and others who need to perform essential services are categorically exempt from this Order. Further, nothing in this Order shall prohibit any individual from performing or accessing "Essential Govermnental Functions," as determined by the governmental entity performing those functions. Each governmental entity shall identify and designate appropriate employees or contractors to continue providing and carrying out any Essential Govermnental Functions. All Essential Governmental Functions shall be performed in compliance with Social Distancing Requirements as defined in this Section, to the extent possible. e. Forthe purposes of this Order, covered businesses include any for-profit, non-profit, or educational entities, regardless of the nature of the service, the function they perform, or its corporate or entity structure. f. For the purposes of this Order, "Essential Businesses" means: 1. Healthcare Operations and Essential Infrastructure; 11. Grocery stores, certified farmers' markets, farm and produce stands, supermarkets, food banks, convenience stores, and other establishments engaged in the retail sale of canned food, dry goods, fresh fruits and vegetables, pet supply, fresh meats, fish, and poultry, and any other household consumer products (such as cleaning and personal care products). This includes stores that sell groceries and also sell other non-grocery products, and products necessary to maintaining the safety, sanitation, and essential operation of residences; m. Food cultivation, including farming, livestock, and fishing; 1v. Businesses that provide food, shelter, and social services, and other necessities of life for' economically disadvantaged or otherwise needy individuals; v. Newspapers, television, radio, and other media services; vi. Gas stations and auto-supply, auto-repair, and related facilities; v11. Banks and related financial institutions; v111. Hardware stores; 1x. Plumbers, electricians, exterminators, and other service providers who provide services that are necessary to maintaining the safety, sanitation, and essential operation of residences, Essential Activities, and Essential Businesses; x. Businesses providing mailing and shipping services, including post office boxes; x1. Educational institutions-including public and private K- 12 schools, colleges, and universities- for purposes of facilitating remote learning or performing essential functions, provided that social distancing of six-feet per person is maintained to the greatest extent possible; xu. Laundromats, drycleaners, and laundry service providers; xiii. Restaurants and other facilities that prepare and serve food, but only for delivery or carry out. Schools and other entities that typically provide free food services to students or members of the public may continue to do so under this Order on the condition that the food is provided to students or members of the public on a pick-up and take-away basis only. Schools and other entities that provide food services under this exemption shall not permit the food to be eaten at the site where it is provided, or at any other gathering site; xiv. Businesses that supply products needed for people to work from home; xv. Businesses that supply other essential businesses with the support or supplies necessary to operate; xvi. Businesses that ship or deliver groceries, food, goods or services directly to residences; Order of the County Health Officer to Shelter in Place Page 4 of 6 Packet Pg. 48 of 142 xv11. xvm. xix. xx. xx1. ADDITIONAL MATERIALS 04.e (9034) Airlines, taxis, and other private transportation providers providing transportation services necessary for Essential Activities and other purposes expressly authorized in this Order; Home-based care for seniors, adults, or children; Residential facilities and shelters for seniors, adults, and children; Professional services, such as legal or accounting services, when necessary to assist in compliance with legally mandated activities; Childcare facilities providing services that enable employees exempted in this Order to work as permitted. To the extent possible, childcare facilities must operate under the following mandatory conditions: 1. Childcare must be carried out in stable groups of 12 or fewer ("stable" means that the same 12 or fewer children are in the same group each day). 2. Children shall not change from one group to another. 3. If more than one group of children is cared for at one facility, each group shall be in a separate room. Groups shall not mix with each other. 4. Childcare providers shall remain solely with one group of children. g. For the purposes of this Order, "Minimum Basic Operations" include the following, provided that employees comply with Social Distancing Requirements as defined in this Section, to the extent possible, while carrying out such operations: 1. The minimum necessary activities to maintain the value of the business's inventory, ensure security, process payroll and employee benefits, or for related functions. 11. The minimum necessary activities to facilitate employees of the business being able to continue to work remotely from their residences. h. For the purposes of this Order, "Essential Travel" includes travel for any of the following purposes. Individuals engaged in any Essential Travel must comply with all Social Distancing Requirements as defined in this Section below. 1. Any travel related to the provision of or access to Essential Activities, Essential Governmental Functions, Essential Businesses, or Minimum Basic Operations. 11. Travel to care for elderly, minors, dependents, persons with disabilities, or other vulnerable persons. 111. Travel to or from educational institutions for purposes of receiving materials for remote learning, for receiving meals, and any other related services. 1v. Travel to return to a place of residence from outside the jurisdiction. v. Travel required by law enforcement or court order. / v1. Travel required for non-residents to return to their place of residence outside the County. Individuals are strongly encouraged to verify that their transportation out of the County remains available and functional prior to commencing such travel. 1. For purposes of this Order, residences include hotels, motels, shared rental units and similar facilities. J. For purposes of this Order, "Social Distancing Requirements" includes maintaining at least sixfoot social distancing from other individuals, washing hands with soap and water for at least twenty seconds as frequently as possible or using hand sanitizer, covering coughs or sneezes (into the sleeve or elbow, not hands), regularly cleaning high-touch surfaces, and not shaking hands. 11. Pursuant to Government Code sections 26602 and 41601 and Health and Safety Code section 101029, the Health Officer requests that the Sheriff and all chiefs of police in the County ensure compliance with and enforce this Order. The violation of any provision of this Order constitutes an imminent threat to public health. Order of the County Health Officer to Shelter in Place Page 5 of 6 Packet Pg. 49 of 142 ADDITIONAL MATERIALS 04.e (9034) 12. This Order shall become effective at 12:01 a.m. on March 17, 2020 and will continue to be in effect until 11 :59 p.m. on April 7, 2020, or until it is extended, rescinded, superseded, or amended in writing by the Health Officer. 13. Copies of this Order shall promptly be: (1) made available outside the offices of the County of Santa Cruz at 701 Ocean Street, Santa Cruz, CA 95060; (2) posted on the County Health Services Agency website (www.santacruzhealth.org); and (3) provided to any member of the public requesting a copy of this Order. 14. If any provision of this Order or the application thereof to any person or circumstance is held to be invalid, the reminder of the Order, including the application of such part or provision to other persons or circumstances, shall not be affected and shall continue in full force and effect. To this end, the provisions of this Order are severable. IT IS SO ORDERED: Gail Newel, MD Health Officer of the County of Santa Cruz Dated: March 16, 2020 APPROVED AS TO FORM: 6/, lo to )L) Order of the County Health Officer to Shelter in Place Page 6 of 6 Packet Pg. 50 of 142 ADDITIONAL MATERIALS Attachment D 04.e (9034) County of Santa Cruz HEALTH SERVICES AGENCY POST OFFICE BOX 962, 1080 Emeline Ave., SANTA CRUZ, CA 95061-0962 TELEPHONE: (831) 454-4000 FAX: (831) 454-4488 TDD: Call 711 Public Health Division ORDER OF THE HEALTH OFFICER OF THE COUNTY OF SANTA CRUZ DIRECTING ALL INDIVIDUALS LIVING IN THE COUNTY TO CONTINUE SHELTERING AT THEIR PLACE OF RESIDENCE THROUGH MAY 3, 2020; AND PROVIDING FURTHER CLARIFICATION AND LIMITATIONS DATE OF ORDER: MARCH 31, 2020 Please read this Order carefully. Violation of or failure to comply with this Order is a misdemeanor punishable by fine, imprisonment, or both. (California Health and Safety Code § 120295, et seq.; Cal. Penal Code §§ 69, 148(a)(1)) UNDER THE AUTHORITY OF CALIFORNIA HEALTH AND SAFETY CODE SECTIONS 101040, 101085, AND 120175, THE HEALTH OFFICER OF THE COUNTY OF SANTA CRUZ (“HEALTH OFFICER”) ORDERS: 1. This Order supersedes the March 16, 2020 Order of the Health Officer directing all individuals to shelter in place (“Prior Shelter Order”). This Order clarifies, strengthens, and extends certain terms of the Prior Shelter Order to increase social distancing and reduce person-to-person contact in order to further slow transmission of Novel Coronavirus Disease 2019 (“COVID-19”). This Order shall become effective at 11:59 p.m. on March 31, 2020 and will continue to be in effect until 11:59 p.m. on May 3, 2020, or until it is extended, rescinded, superseded, or amended in writing by the Health Officer. All individuals, businesses and government agencies in the County of Santa Cruz (“County”) are required to follow the provisions of this Order. 2. The intent of this Order is to ensure that the maximum number of people shelter in their places of residence to the maximum extent feasible to slow the spread of COVID-19 and mitigate the impact on delivery of critical healthcare services to those in need. All provisions of this Order must be interpreted to effectuate this intent. Failure to comply with any of the provisions of this Order constitutes an imminent threat and menace to public health, constitutes a public nuisance, and is punishable by fine, imprisonment, or both. 3. All individuals currently living within the County (including all cities within the County) are ordered to shelter at their place of residence. They may leave their residence only for Essential Activities, Essential Governmental Functions, Essential Travel, to work for Essential Businesses, or to perform Minimum Basic Operations for non-essential businesses, all as defined in Section 12. 4. When people need to leave their place of residence for the limited purposes allowed in this Order, they must strictly comply with Social Distancing Requirements as defined in Section 12.j, except as expressly provided in this Order. Packet Pg. 51 of 142 ADDITIONAL MATERIALS 04.e (9034) 5. All businesses with a facility in the County, except Essential Businesses, as defined in Section 12.f, are required to cease all activities at facilities located within the County except Minimum Basic Operations, as defined in Section 12.g. For clarity, all businesses may continue operations consisting exclusively of owners, employees, volunteers, or contractors performing activities at their own residences (i.e., working from home). All Essential Businesses are strongly encouraged to remain open. But Essential Businesses are directed to maximize the number of employees who work from home. Businesses that include an Essential Business component at their facilities alongside non-essential components must, to the extent feasible, scale down their operations to the Essential Business component only; provided, however, that mixed retail businesses that are otherwise allowed to operate under this Order may continue to stock and sell non-essential products. Essential Businesses must follow industry-specific guidance issued by the Health Officer related to COVID-19. All Essential Businesses are encouraged to prepare, post, and implement a Social Distancing Protocol at each of their facilities at which they are maintaining operations, as reflected in Appendix A. 6. All public and private gatherings of any number of people occurring outside a single household or living unit are prohibited, except for the limited purposes expressly permitted in this Order. Nothing in this Order prohibits members of a single household or living unit from engaging in Essential Travel or Essential Activities together. 7. Except for the purpose of Essential Travel, as defined below in Section 12.h, all travel is prohibited, including but not limited to, travel on foot, bicycle, scooter, motorcycle, automobile, or public transit. People may use public transit only for purposes of performing Essential Activities or to travel to and from work to operate Essential Businesses, maintain Essential Governmental Functions, or to perform Minimum Basic Operations at non-essential businesses. Transit agencies and people riding on public transit should comply with Social Distancing Requirements, as defined in Section 12.j, to the greatest extent feasible. This Order allows travel into or out of the County to perform Essential Activities, operate Essential Businesses, maintain Essential Governmental Functions, or perform Minimum Basic Operations at nonessential businesses. 8. This Order is issued based on evidence of increasing occurrence of COVID-19 within the County and throughout the Bay Area, scientific evidence and best practices regarding the most effective approaches to slow the transmission of communicable diseases generally and COVID-19 specifically, and evidence that the age, condition, and health of a significant portion of the population of the County places it at risk for serious health complications, including death, from COVID-19. Due to the outbreak of the COVID-19 disease in the general public, which is now a pandemic according to the World Health Organization, there is a public health emergency throughout the County. Making the problem worse, some individuals who contract the virus causing the COVID-19 disease have no symptoms or have mild symptoms, which means they may not be aware they carry the virus and are transmitting it to others. Because even people without symptoms can transmit the infection, and because evidence shows the infection is easily spread, gatherings and other interpersonal interactions can result in preventable transmission of the virus. This public health emergency has substantially worsened since the County issued the Prior Shelter Order on March 16, 2020, with a significant escalation in the number of positive cases, hospitalizations, and deaths, and increasing strain on health care resources. At the same time, evidence suggests that the restrictions on mobility and social distancing requirements imposed by the Prior Shelter Order are slowing the rate of increase in community transmission and confirmed cases by limiting interactions among people, consistent with scientific evidence of the efficacy of similar measures in other parts of the country and world. The scientific evidence shows that at this stage of the emergency, it remains essential to continue to slow virus transmission as much as possible to protect the most vulnerable, to prevent the health care system from being overwhelmed, and to prevent deaths. Extension of the Prior Shelter Order and strengthening of its restrictions are necessary to further reduce the spread of the COVID-19 disease, preserving critical and limited healthcare capacity in the County and advancing toward a point in the public health emergency Packet Pg. 52 of 142 ADDITIONAL MATERIALS where transmission can be controlled. This Order is necessary to slow the rate of spread, and the Health Officer will re-evaluate it as further data becomes available. 04.e (9034) 9. This Order is issued in accordance with, and incorporates by reference, the March 4, 2020 Proclamation of a State of Emergency issued by Governor Gavin Newsom, the March 4, 2020 Declaration of a Local Health Emergency Regarding Novel Coronavirus 2019 (COVID-19) issued by the Health Officer, the March 10, 2020 Resolution of the Board of Supervisors of the County of Santa Cruz Ratifying and Extending the Declaration of a Local Health Emergency, and the March 10, 2020 Resolution of the Board of Supervisors of the County of Santa Cruz Proclaiming a Local Emergency. 10. This Order is issued in light of evidence that the Prior Shelter Order has been generally effective in increasing social distancing, but that at this time additional restrictions are necessary to further mitigate the rate of transmission of COVID-19, to prevent the health care system from being overwhelmed, and prevent death. This Order comes after the release of substantial guidance from the Centers for Disease Control and Prevention, the California Department of Public Health, and other public health officials throughout the United States and around the world, including an increasing number of orders imposing similar social distancing requirements and mobility restrictions to combat the spread and harms of COVID-19. The Health Officer will continue to assess the quickly evolving situation and may modify or extend this Order, or issue additional Orders, related to COVID-19, as changing circumstances dictate. 11. This Order is also issued in light of the March 19, 2020 Order of the State Public Health Officer (the “State Shelter Order”), which set baseline statewide restrictions on non-residential business activities effective until further notice, as well as the Governor’s March 19, 2020 Executive Order N-33-20 directing California residents to follow the State Shelter Order. In certain respects, this Order adopts more stringent restrictions than the State Shelter Order. This is necessary to address the particular facts and circumstances in this County. Without this tailored set of restrictions that further reduces the number of interactions between persons, scientific evidence indicates that the public health crisis in the County will worsen to the point at which it may overtake available health care resources within the County and increase the death rate. Also, this Order enumerates additional restrictions on non-work-related travel not covered by the State Shelter Order, including limiting such travel to performance of Essential Travel or Essential Activities, and sets forth Social Distancing Requirements for all individuals in the County when engaged in activities outside their residences. Where a conflict exists between this Order and any State public health order related to the COVID-19 pandemic, the most restrictive provision controls. 12. Definitions and Exemptions. a. For the purposes of this Order, individuals may leave their residence only to perform the following “Essential Activities.” But people at high risk of severe illness from COVID-19 and people who are sick are strongly urged to stay in their residence to the extent possible, except as necessary to seek or provide medical care or Essential Governmental Functions. Essential Activities are: i. To engage in activities or perform tasks important to their health and safety, or to the health and safety of their family or household members (including pets), such as, by way of example only and without limitation, obtaining medical supplies or medication, or visiting a health care professional. ii. To obtain necessary services or supplies for themselves and their family or household members, or to deliver those services or supplies to others, such as, by way of example only and without limitation, canned food, dry goods, fresh fruits and vegetables, pet supply, fresh meats, fish, and poultry, and any other household consumer products, products needed to work from home, or products necessary to maintain the habitability, sanitation, and operation of residences. iii. To engage in outdoor recreation activity, including, by way of example and without limitation, walking, hiking, bicycling, and running, in compliance with Social Distancing Packet Pg. 53 of 142 ADDITIONAL MATERIALS iv. v. vi. vii. 04.e (9034) Requirements. Outdoor recreation activity at parks, beaches, and other open spaces must be in conformance with any restrictions on access and use established by the Health Officer, government, or other entity that manages such area to reduce crowding and risk of transmission of COVID-19. Such restrictions may include, but are not limited to, restricting the number of entrants, closing the area to vehicular access and parking, or closure to all public access. Outdoor recreation activity is subject to the following further restrictions: 1. Sports or activities that include the use of shared equipment, such as basketball, tennis, pickleball, or disc golf may only be engaged in by members of the same household or living unit. 2. Use of shared facilities for recreational activities outside of residences, including, but not limited to, golf courses, rock parks, climbing walls, pools, spas, shooting and archery ranges, and gyms, is prohibited and those areas must be closed for recreational purposes. 3. Use of high-touch equipment in recreational areas including, but not limited to, playgrounds, and outdoor gym equipment is prohibited. Such equipment shall be closed to public access and reflected as such by posted signage. To perform work for an Essential Business or to otherwise carry out activities specifically permitted in this Order, including Minimum Basic Operations, as defined in this Section. To provide necessary care for a family member or pet in another household who has no other source of care. To attend a funeral with no more than 10 individuals present. To move residences, but only if it is not possible to defer an already planned move, if the move is necessitated by safety, sanitation, or habitability reasons, or if the move is necessary to preserve access to shelter. b. For the purposes of this Order, individuals may leave their residence to work for, volunteer at, or obtain medically necessary services at “Healthcare Operations,” including, without limitation, hospitals, clinics, COVID-19 testing locations, dentists, pharmacies, blood banks and blood drives, pharmaceutical and biotechnology companies, other healthcare facilities, healthcare suppliers, home healthcare services providers, mental health providers, or any related and/or ancillary healthcare services. “Healthcare Operations” also includes veterinary care and all healthcare services provided to animals. This exemption for Healthcare Operations shall be construed broadly to avoid any interference with the delivery of necessary healthcare. “Healthcare Operations” excludes fitness and exercise gyms and similar facilities. c. For the purposes of this Order, individuals may leave their residence to provide any services or perform any work necessary to the operation and maintenance of “Essential Infrastructure,” including airports, utilities (including water, sewer, gas, and electrical), oil refining, roads and highways, public transportation, solid waste facilities (including collection, removal, disposal, and processing facilities), cemeteries, mortuaries, crematoriums, and telecommunications systems (including the provision of essential global, national, and local infrastructure for internet, computing services, business infrastructure, communications, and web-based services). d. For the purposes of this Order, all first responders, emergency management personnel, emergency dispatchers, court personnel, and law enforcement personnel, and others who need to perform essential services are categorically exempt from this Order to the extent they are performing those essential services. Further, nothing in this Order shall prohibit any individual from performing or accessing “Essential Governmental Functions,” as determined by the governmental entity performing those functions in the County. Packet Pg. 54 of 142 ADDITIONAL MATERIALS e. For the purposes of this Order, a “business” includes any for-profit, non-profit, or educational entity, whether a corporate entity, organization, partnership or sole proprietorship, and regardless of the nature of the service, the function it performs, or its corporate or entity structure. f. 04.e (9034) For the purposes of this Order, “Essential Businesses” are: i. Healthcare Operations and businesses that operate, maintain, or repair Essential Infrastructure; ii. Grocery stores, certified farmers’ markets, farm and produce stands, supermarkets, food banks, convenience stores, and other establishments engaged in the retail sale of unprepared food, canned food, dry goods, non-alcoholic beverages, fresh fruits and vegetables, pet supply, fresh meats, fish, and poultry, as well as hygienic products and household consumer products necessary for personal hygiene or the habitability, sanitation, or operation of residences. The businesses included in this subparagraph (ii) include establishments that sell multiple categories of products provided that they sell a significant amount of essential products identified in this subparagraph, such as liquor stores that also sell a significant amount of food. iii. Food cultivation, including farming, livestock, and fishing; iv. Businesses that provide food, shelter, and social services, and other necessities of life for economically disadvantaged or otherwise needy individuals; v. Construction, but only of the types listed in this subparagraph below: 1. Projects immediately necessary to the maintenance, operation or repair of Essential Infrastructure; 2. Projects associated with Healthcare Operations, including creating or expanding Healthcare Operations; 3. Affordable housing that is or will be at least partially income-restricted, including multi-unit or mixed-use developments; 4. Public works projects if specifically designated as an Essential Governmental Function by the lead governmental agency; 5. Shelters and temporary housing, but not including hotels or motels; 6. Projects immediately necessary to provide critical non-commercial services to individuals experiencing homelessness, elderly persons, persons who are economically disadvantaged, and persons with special needs; 7. Construction necessary to ensure that existing construction sites that must be shut down under this Order are left in a safe and secure manner, but only to the extent necessary to do so; and 8. Construction or repair necessary to ensure that residences and buildings containing Essential Businesses are safe, sanitary, or habitable to the extent such construction or repair cannot reasonably be delayed; vi. Newspapers, television, radio, and other media services; vii. Gas stations and auto-supply, auto-repair (including, but not limited to, for cars, trucks, motorcycles and motorized scooters), and automotive dealerships, but only for the purpose of providing auto-supply and auto-repair services (and not, by way of example, car sales or car washes). This subparagraph (vii) does not restrict the on-line purchase of automobiles if they are delivered to a residence or Essential Business; viii. Bicycle repair and supply shops; ix. Banks and related financial institutions; x. Service providers that enable residential transactions (including rentals, leases, and home sales), including, but not limited to, real estate agents, escrow agents, notaries, and title companies, provided that appointments and other residential viewings must only occur virtually or, if a virtual viewing is not feasible, by appointment with no more than two visitors at a time who reside within the same household or living unit and one individual Packet Pg. 55 of 142 ADDITIONAL MATERIALS xi. xii. xiii. xiv. xv. xvi. xvii. xviii. xix. xx. xxi. xxii. xxiii. xxiv. xxv. xxvi. xxvii. 04.e (9034) showing the unit (except that in person visits are not allowed when the occupant is still residing in the residence); Hardware stores; Plumbers, electricians, exterminators, and other service providers who provide services that are necessary to maintaining the habitability, sanitation, and operation of residences and Essential Businesses; Arborists, landscapers, gardeners, and similar service professionals necessary to maintain the habitability, sanitation, operation of businesses or residences, or the safety of residents, employees, or the public (such as fire safety or tree trimming to prevent a dangerous condition); Businesses providing mailing and shipping services, including postal boxes; Educational institutions—including public and private K-12 schools, colleges, and universities—for purposes of facilitating remote learning or performing essential functions, provided that social distancing of six-feet per person is maintained to the greatest extent possible; Laundromats, drycleaners, and laundry service providers; Restaurants and other facilities that prepare and serve food, but only for delivery or carry out. Schools and other entities that typically provide free food services to students or members of the public may continue to do so under this Order on the condition that the food is provided to students or members of the public on a pick-up and take-away, or delivery basis only. Schools and other entities that provide food services under this exemption shall not permit the food to be eaten at the site where it is provided, or at any other gathering site; Funeral home providers, mortuaries, cemeteries, and crematoriums, to the extent necessary for the transport, preparation, or processing of bodies or remains; Businesses that supply other Essential Businesses with the support or supplies necessary to operate, but only to the extent that they support or supply these Essential Businesses. This exemption shall not be used as a basis for engaging in sales to the general public from retail storefronts; Businesses that have the primary function of shipping or delivering groceries, food, or other goods directly to residences or businesses. This exemption shall not be used to allow for manufacturing or assembly of non-essential products or for other functions besides those necessary to the delivery operation; Airlines, taxis, rental car companies, rideshare services (including shared bicycles and scooters), and other private transportation providers providing transportation services necessary for Essential Activities and other purposes expressly authorized in this Order; Home-based care for seniors, adults, children, and pets; Residential facilities and shelters for seniors, adults, and children; Professional services, such as legal, notary, or accounting services, when necessary to assist in compliance with non-elective, legally required activities; Services to assist individuals in finding employment with Essential Businesses; Moving services that facilitate residential or commercial moves that are allowed under this Order; Childcare facilities providing services that enable owners, employees, volunteers, and contractors for Essential Businesses, Essential Governmental Functions, or Minimum Basic Operations to work as allowed under this Order. Children of owners, employees, volunteers, and contractors who are not exempt under this Order may not attend childcare facilities. To the extent possible, childcare facilities must operate under the following conditions: 1. Childcare must be carried out in stable groups of 12 or fewer (“stable” means that the same 12 or fewer children are in the same group each day). 2. Children shall not change from one group to another. Packet Pg. 56 of 142 ADDITIONAL MATERIALS 04.e (9034) 3. If more than one group of children is cared for at one facility, each group shall be in a separate room. Groups shall not mix with each other. 4. Childcare providers shall remain solely with one group of children. g. For the purposes of this Order, “Minimum Basic Operations” means the following activities for businesses, provided that owners, employees, and contractors comply with Social Distancing Requirements as defined this Section, to the extent possible, while carrying out such operations: i. The minimum necessary activities to maintain and protect the value of the business’s inventory and facilities; ensure security, safety, and sanitation; process payroll and employee benefits; provide for the delivery of existing inventory directly to residences or businesses; and related functions. ii. The minimum necessary activities to facilitate owners, employees, and contractors of the business being able to continue to work remotely from their residences, and to ensure that the business can deliver its service remotely. iii. Any additional social distancing measures being implemented (see the Centers for Disease Control and Prevention’s guidance at: https://www.cdc.gov/coronavirus/2019ncov/community/guidance-business-response.html). h. For the purposes of this Order, “Essential Travel” means travel for any of the following purposes: i. Travel related to the provision of or access to Essential Activities, Essential Governmental Functions, Essential Businesses, or Minimum Basic Operations. ii. Travel to care for any elderly, minors, dependents, or persons with disabilities. iii. Travel to or from educational institutions for purposes of receiving materials for remote learning, for receiving meals, and any other related services. iv. Travel to return to a place of residence from outside the County. v. Travel required by law enforcement or court order. vi. Travel required for non-residents to return to their place of residence outside the County. vii. Travel to manage after-death arrangements and burial. viii. Travel to arrange for shelter or avoid homelessness. ix. Travel to avoid domestic violence or child abuse. x. Travel for parental custody arrangements. xi. Travel to a place to temporarily reside in a residence or other facility to avoid potentially exposing others to COVID-19, such as a hotel or other facility provided by a governmental authority for such purposes. i. For purposes of this Order, “residences” include hotels, motels, shared rental units and similar facilities. Residences also include living structures and outdoor spaces associated with those living structures, such as patios, porches, backyards, and front yards that are only accessible to a single family or household unit. j. For purposes of this Order, “Social Distancing Requirements,” means: i. Maintaining at least six-foot social distancing from individuals who are not part of the same household or living unit (except to the limited extent necessary to provide care, including childcare, adult or senior care, care to individuals with special needs, and patient care); ii. Frequently washing hands with soap and water for at least 20 seconds, or using hand sanitizer that is recognized by the Centers for Disease Control and Prevention as effective in combatting COVID-19; iii. Covering coughs and sneezes with a tissue or fabric or, if not possible, into the sleeve or elbow (but not into hands); and iv. Avoiding all social interaction outside the household when sick with a fever or cough. Packet Pg. 57 of 142 ADDITIONAL MATERIALS 04.e (9034) 13. Government agencies and other entities operating shelters and other facilities that house or provide meals or other necessities of life for individuals experiencing homelessness should take appropriate steps to help ensure compliance with Social Distancing Requirements. For additional guidance, government agencies should refer to the Centers for Disease Control and Prevention Interim Guidance Responding to Coronavirus 2019 (COVID-19) Among People Experiencing Unsheltered Homelessness. (https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/unsheltered-homelessness.html). 14. Pursuant to Government Code sections 26602 and 41601 and Health and Safety Code section 101029, the Health Officer requests that the Sheriff and all chiefs of police in the County ensure compliance with and enforce this Order. The violation of any provision of this Order constitutes an imminent threat and menace to public health, constitutes a public nuisance, and is punishable by fine, imprisonment, or both. 15. Copies of this Order shall promptly be: (1) made available at the County offices at 701 Ocean St, Santa Cruz, CA 95060; (2) posted on the County Public Health Department website (www.santacruzhealth.org); and (3) provided to any member of the public requesting a copy of this Order. 16. If any provision of this Order or its application to any person or circumstance is held to be invalid, the remainder of the Order, including the application of such part or provision to other persons or circumstances, shall not be affected and shall continue in full force and effect. To this end, the provisions of this Order are severable. IT IS SO ORDERED: _______________________________ Gail Newel, MD Health Officer of the County of Santa Cruz Dated: March 31, 2020 Approved as to Form: _______________________________ Office of the County Counsel Attachments: Appendix A – Social Distancing Protocol Packet Pg. 58 of 142 ADDITIONAL MATERIALS 04.e (9034) %XVLQHVV QDPH )DFLOLW\ $GGUHVV $SSUR[LPDWH JURVV VTXDUH IRRWDJH RI VSDFH RSHQ WR WKH SXEOLF %XVLQHVVHV PXVW LPSOHPHQW DOO DSSOLFDEOH PHDVXUHV OLVWHG EHORZ DQG EH SUHSDUHG WR H[SODLQ ZK\ DQ\ PHDVXUH WKDW LV QRW LPSOHPHQWHG LV LQDSSOLFDEOH WR WKH EXVLQHVV Signage: ☐6LJQDJH DW HDFK SXEOLF HQWUDQFH RI WKH IDFLOLW\ WR LQIRUP DOO HPSOR\HHV DQG FXVWRPHUV WKDW WKH\ VKRXOG DYRLG HQWHULQJ WKH IDFLOLW\ LI WKH\ KDYH D FRXJK RU IHYHU PDLQWDLQ D PLQLPXP VL[ IRRW GLVWDQFH IURP RQH DQRWKHU VQHH]H DQG FRXJK LQWR D FORWK RU WLVVXH RU LI QRW DYDLODEOH LQWR RQH¶V HOERZ DQG QRW VKDNH KDQGV RU HQJDJH LQ DQ\ XQQHFHVVDU\ SK\VLFDO FRQWDFW ☐6LJQDJH SRVWLQJ D FRS\ RI WKH 6RFLDO 'LVWDQFLQJ 3URWRFRO 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0+0 1 (>35) County Warehouse Reserve (Days) 30 30 30 30 30 Packet Pg. 92 of 142 ADDITIONAL MATERIALS 04.e Attachment (9034) County of Santa Cruz HEALTH SERVICES AGENCY POST OFFICE BOX 962, 1080 Emeline Ave., SANTA CRUZI CA 95061-0962 TELEPHONE: (831) 454-4000 FAX: (831) 454-4488 TDD: Call 711 Public Health Division FURTHER ORDER OF THE HEALTH OFFICER OF THE COUNTY OF-SANTA CRUZ DIRECTING RESIDENTIAL HEALTHCARE FACILITIES TO RESTRICT ACCESS BY ALL NON-ESSENTIAL PERSONS EFFECTIVE DATE OF ORDER: April 10, 2020 Please read this order carefully. Violation of or failure to comply with this Order constitutes a misdemeanor punishable by ?ne, imprisonment. or both. (California Health and Safety Code 120295, et seq.) UNDER THE AUTHORITY OF CALIFORNIA HEALTH AND SAFETY CODE SECTIONS 101040, 101085, AND 120175 ET SEQ., THE HEALTH OFFICER OF THE COUNTY OF SANTA CRUZ ORDERS: 1. As of 12:01 am. on April 10, 2020, all Residential Healthcare Facilities, as de?ned in paragraph 2 below, shall exclude from entry or access to its premises. any non?essential persons including, but not limited to, visitors of residents-at any Residential Healthcare Facility. Sections 3 and 5 below describe eXCeptions to this prohibition. This Order will continue to be in effect until the March 4, 2020 Proclamation of the Governor referenced in paragraph 8 is rescinded or until this Order is rescinded, superseded, or amended by the Health Of?cer in writing. 2. For the purposes of this order, a Residential Healthcare Facility (or ?Facility?) is: a. Any Skilled Nursing Facility, Intermediate Care Facility, Residential Care Facility, Residential Care Facility for the Elderly or Continuing Care Retirement Community licensed or certi?ed by the State of California; or Any congregate living health facility that operates 24 hours a day, 7 days a week, including congregate living homes for the developmentally disabled, residential treatment facilities, sober living environments, substance use disorder treatment centers, residential hospice care, residential healthcare rehabilitation facilities, residential treatment facilities or other group homes that provide residents with some degree of medical, therapeutic, support (including for substance use disorder) or services in support of the activities of daily living, eating, bathing, dressing and other basic?self?care). Packet Pg. 93 of 142 ADDITIONAL MATERIALS 04.e (9034) . Facilities that are not considered Residential Healthcare Facilities or that are otherwise exempt from this Order include: hospitals, surgery centers, birthing centers, nonresidential day programs, and any other nonresidential facility. . For the purposes of this order, ?non-essential personnel? are employees,contractors, or members of the public who do not perform treatment, maintenance, support, or administrative tasks deemed essential to the healthcare or other primary mission of the Facility. For the purposes or this Order, ?premises? includes without limitation the buildings, grounds, facilities, driveways, parking areas, and public spaces of the Residential Care Facility. . It is the intention of the Health Of?cer to permit residents to receive visitors when they are at the end of their life. Therefore, in limited circumstances, the Facility may authorize visitation by non-essential visitors when a Facility resident is at the end of their life. The determination as to whether any particular situation ?ts within this exception may be made by any person designated in the license as an Administrator or Medical Director of the Facility where the individual is a resident; the highest-ranking staff person employed by the Facility or their designee; or any licensed physician. This exception is intended to apply to visitors such as family members, close friends, those providing services or support of a religious nature, legal representatives and ?duciaries. The Facility must continue to comply with risk mitigation measures established in these limited circumstances, including limiting, as much as possible, contact with-any other resident of the Residential Health Care Facility. The Facility shall make reasonable efforts to facilitate non-physical contact between residents, where such efforts will not otherwise interfere with the healthcare or other primary mission of the Facility. 7. The Facility shall discourage and limit non-essential resident movement onto and off of Facility premises where feasible. In all situations, the Facility shall make every effort to comply with the ?Shelter in Place? Order issued by the Health Of?cer on March 31, 2020 and referenced by its full title in paragraph 8 below. 8. This order is being issued on the basis of scienti?c evidence and best practices as currently available to prevent the spread of the virus to the residents at the Facility and to prevent any cases of ?om occurring at the Facility to protect those residents ?om avoidable risk of serious illness or death resulting from exposure to The age, physical condition, and health of a signi?cant majority of residents of these Residential Healthcare Facilities places those residents at high risk of experiencing serious health complications from infection, including death. This order is issued in accordance with, and incorporates by reference, the March 4, 2020 Proclamation of a State of Emergency issued by Governor Gavin Newsom, the March 4, 2020 Declaration of a Order of the County Health Of?cer Restricting Visitors to Residential Healthcare Facilities Page 3 of 3 Packet Pg. 94 of 142 ADDITIONAL MATERIALS 04.e (9034) Local Health Emergency Regarding Novel Coronavirus 2019 (COVID-19) issued by the Health Of?cer, the March 10, 2020 Resolution of the Board of Supervisors of the County of Santa Cruz Ratifying the Declaration of a Local Emergency, the March 10, 2020 Resolution of the Board of Supervisors of the County of Santa Cruz Proclaiming a Local Emergency, and the March 31,. 2020 Order of the Health Of?cer of the County of Santa Cruz Directing all Individuals Living in the County to Continue Sheltering at Their Place of Residence Through May 3, 2020; And Providing Further Clari?cation and Limitations (the latter being known as the ?Shelter in Place Order of March 31, 2020?). 9. This Order is not intended to restrict any ?rst responder access to Facility premises. Further, this Order is not intended to restrict local, state or federal of?cers, investigators, law enforcement or medical personnel from carrying out their lawful duties on the premises of a Facility. 10. If any subsection, sentence, clause, phrase or word of this Order or any application of it to any person, Facility, structure or circumstance is held to be invalid or unconstitutional by a decision of a court of competent jurisdiction, then such decision will not affect the validity of the remaining provisions or applications of this Order. 11. Copies of this Order be posted and provided by the Residential Healthcare Facility as follows for the duration of this Order: (1) posted at all public entrances to the Facility; (2) provided to each resident; (3) provided to any authorized decision maker if not the resident; (4) provided to the designated Long-Tenn Care Ombudsperson for the County; and (5) offered to anyone who visits the Facility seeking to Visit. IT IS SO ORDERED: Gail Wet MD Dated: April 9, 2020 Hea Of?cer of the County of Santa Cruz APPROVED AS TO FORM: Scan, Of?ce of the ??ounty Counsel Order of the County Health Of?cer Restricting Visitors to Residential Healthcare Facilities Page 3 of 3 Packet Pg. 95 of 142 ADDITIONAL MATERIALS 04.e (9034) County of Santa Cruz HEALTH SERVICES AGENCY POST OFFICE BOX 962, 1080 Emeline Ave., SANTA CRUZ, CA 95061-0962 TELEPHONE: (831) 454-4000 FAX: (831) 454-4488 TDD: Call 711 Public Health Division Press Release For Release: Immediately Date: April 23, 2020 Contact: Jason Hoppin, County Communications Officer Phone: (831) 454-3401 COUNTY COMPLETES COVID-19 READINESS ASSESSMENT OF SKILLED NURSING FACILITIES Santa Cruz County, CA - The County of Santa Cruz Public Health Division has completed assessments of local skilled nursing facilities and continues working closely with them to prevent the spread of COVID-19. Through site visits, needs assessments and guidance, Public Health staff have supported skilled nursing facility operations and is prepared to direct additional public health resources to local facilities should an outbreak occur. While there are currently no known cases among skilled nursing facility residents within Santa Cruz County, the presence of medically-vulnerable individuals living in close quarters have made skilled nursing and long-term care facilities highly susceptible to outbreaks of COVID-19. On March 20, Health Officer Dr. Gail Newel issued a no-visitation order at residential health care facilities throughout Santa Cruz County. The order has since been extended indefinitely and covers all visitation other than end-of-life situations. In early April, Public Health developed a seven-member team of Communicable Disease Unit staff to coordinated and complete on-site assessments of each of the seven skilled nursing facilities within Santa Cruz County. This team worked with skilled-nursing staff on reviewing the facility’s capacity for isolation and quarantine of residents, reviewing their process for managing staff and/or residents with COVID-19, and ensuring each facility had policies in place to prevent the spread of COVID-19. “The success of our local COVID-19 response is dependent on the readiness of our healthcare facilities,” says Michelle Meszaros, the lead Public Health Nurse for the skilled nursing facility assessments. Packet Pg. 96 of 142 ADDITIONAL MATERIALS 04.e (9034) The Centers for Disease Control has urged all long-term care facilities to act now to prevent the spread of COVID-19, including taking measures to address asymptomatic and pre-symptomatic transmission such as screening essential personnel prior to entering the facility. All skilled nursing facilities have COVID-19 prevention protocols in place, including the use of face coverings by staff and residents in common areas, routine screening of staff and residents for fever and respiratory illness, increased environmental cleaning, and adhering to physical distancing guidelines. “We are heartened by the proactive engagement of our skilled nursing facilities, and look forward to ongoing collaboration,” Meszaros said. “We are in this together.” State and federal guidance on safe operations for skilled nursing facilities is available at https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/COVID.19_Guidanc eFor_SNF_HAI%20WebinarFINAL_03.13.20.pdf and https://www.cdc.gov/coronavirus/2019ncov/hcp/long-term-care.html. ### Packet Pg. 97 of 142 ADDITIONAL MATERIALS 04.e (9034) Emergency Response Plan for Skilled Nursing Facilities 5/27/20 Background The Emergency Response Plan for Skilled Nursing Facilities is intended to document and quantify the activities and discussions to date, provide an inventory of expected surge resources, and coordinate the optimal utilization of those resources during crisis conditions. Planning and Mitigation Activities to Date Each facility is subject to all licensing requirements through the California Department of Public Health. In addition, the Santa Cruz County Public Health Department also conducts facility assessment and site visits specific to protocols, equipment and training relative to infection control and the care of COVID-19 positive patients. In an attempt to limit exposure, SNFs currently restrict visitors. Nevertheless, SNF employees commonly work in multiple facilities and the potential for introduction of the COVID virus into this environment is most likely through this route. This creates significant vulnerability for this at-risk patient population given that the virus could be readily transmitted within and between facilities. Given that there is a possibility of the virus being transmitted prior to any symptomatic stages, careful use of PPE, including source masking and handwashing are critical to reduce the risk of spread. SNF Capacity There are seven (7) Licensed Skilled Nursing Facilities in Santa Cruz County with a combined capacity of 725 patients. Facility Name Driftwood Healthcare Center Hearts and Hands, Post-Acute and Rehab Santa Cruz Post Acute Pacific Coast Manor Valley Convalescent Hospital Watsonville Nursing Center Watsonville Post-Acute Center Address 675 Avenue 2990 Soquel Ave 1115 Capitola Road 1935 Wharf Road 919 Freedom Blvd 535 Auto Center Drive 525 Auto Center Drive 24th City Santa Cruz Santa Cruz Santa Cruz Capitola Watsonville Watsonville Watsonville Capacity 92 144 149 99 59 87 95 Packet Pg. 98 of 142 ADDITIONAL MATERIALS 04.e (9034) Potential Scenarios 1. Outbreak within a SNF Once a positive case is identified within a SNF, the Public Health Department will work with the facility to ensure that the previously established infection control plans are being adhered to. This may include consolidating patients into a predesignated cohort ward/wing and assigning medical personnel to work exclusively in that area. Given the disruption to the patient, every attempt should be made to safely care for the patient in their usual location. However, if an outbreak becomes evident it may become necessary to relocate patients to another SNF where isolation can be more readily attained. This will require careful coordination between nursing facilities and will be determined by nearby capacity, ability to adhere to infection control plans, and availability of transportation services. 2. Staffing Emergency Within a SNF There have been instances nationwide and in California when there is a sudden lack of staffing following identification of a COVID-19 case(s) in a skilled nursing facility. In some cases, the staff are reporting illness themselves, and in others they apparently are concerned about the prospect of illness and fail to report for their shift. This condition can develop with very short notice creating an emergency condition where residents may have a delay in care with adverse consequences. Again, emphasis should be placed on keeping patients in their place of usual care, provided that an emergency team can be quickly deployed. The advantage of keeping patients in place as opposed to evacuation, is that patients generally do better when they can stay in their usual surroundings. Also, moving patients with COVID-19 creates exposure risk to transporting personnel and to the destination personnel. Finally, evacuation requires a large number of ambulance resources that may not be available due to system volumes. Sources of emergency team members can be from neighboring SNFs, Santa Cruz County Medical Reserve Corps, California Health Corps, and EMTs and Paramedics. • • • Neighboring SNFs: There may be preidentified reserve personnel from neighboring SNFs who are willing to deploy on short notice. The advantage of these personnel is that they live locally, are accustomed to providing care in this setting and are familiar with Santa Cruz County. Medical Reserve Corps: This team includes physicians, nurses and other allied health professionals who live locally and may be able to rapidly deploy. California Health Corps: This is a large body of health professionals who have registered with the State of California and have shown willingness to deploy where needed. They may not live locally and may take some time to arrive. Packet Pg. 99 of 142 ADDITIONAL MATERIALS • 04.e (9034) EMTs and Paramedics: Local Optional Scope of Practice authority from the Emergency Medical Services Agency has been granted, allowing these personnel to operate in a static medical setting such as an Alternate Care Site or care facility. While these personnel are not generally deployed in a static health care environment, they are able to meet most healthcare needs with just in time training. More importantly, they have the clinical training and experience to recognized when a patient may need a higher level of care. Short notice staffing emergencies will be allocated 911 resources as needed with a plan in place for immediate backfill of units, ambulance strike teams from neighboring counties as necessary, and state staffing resources and the incident progresses. If staff cannot be attained in a timely manner, and the patients are at risk, then evacuation of the facility may be necessary. Evacuation should be to another SNF that has capacity however the Alternate Care Site and emergency departments are less desirable locations. Conclusion Skilled Nursing Facilities regularly care for a subgroup of patients that are particularly vulnerable to COVID-19. A large number of Santa Cruz County patients are residents of these facilities and are not easily accommodated elsewhere, especially when our healthcare facilities are projected to be overwhelmed at the same time. In the event of a staffing crisis at a SNF, all efforts to bring a healthcare team to that SNF under short notice, should be attempted. Evacuation should be a last option. Packet Pg. 100 of 142 ADDITIONAL MATERIALS 04.e (9034) MAY 26, 2020 MODIFICATION TO SHELTER IN PLACE ORDER FREQUENTLY ASKED QUESTIONS (FAQs) The County Health Officer is issuing an order on May 26, which will be in effect the following day, aligning the County more closely with the State Shelter-in-Place order. This will allow certain limited operations to resume, including in-store retail, churches and office workspaces. In addition, the County is expected to request an attestation letter from the Board of Supervisors on June 2 allowing Santa Cruz County to apply for a Stage 2 variance allowing certain other businesses to reopen. For more information on the variance process, see below. When does the new Health Officer order go into effect? The new order goes into 11:59 p.m. on May 26, 2020. Do I still need to stay at home? Mostly, yes. The Governor’s Stay at Home order is still in effect. Non-essential travel is prohibited. Stay local! You may leave home to work, to support local businesses as allowed and to engage in outdoor recreational activities. Gathering in groups outside of your household is still not allowed, even outdoors, except for church and other limited reasons. People over 65 and those with underlying medical conditions should stay home as much as possible. Does this order allow more entities and businesses to open? Yes. In addition to curbside retail (and supporting manufacturing and logistics), which is allowed under the Health Officer’s May 6 order, the following businesses and operations will be allowed, with modifications, once the new Order goes into effect: • • • • • • • In-store retail Offices (when telework not possible) Outdoor Museums, Galleries and other Public Spaces with Modifications Limited Personal Services Childcare for all children of working or volunteering parents Churches Political gatherings Packet Pg. 101 of 142 ADDITIONAL MATERIALS 04.e (9034) Limited personal services include car washes, pet grooming (previously allowed for the health of the animal), and landscape gardening. It does not include nail salons or massage services (for other than medical purposes), which are included in Stage 3. What is the Social Distancing Protocol? The Social Distancing Protocol is designed to limit the spread of COVID-19 by protecting the health and safety of employees and the public when visiting businesses and governmental entities. Under local Health Officer orders, all operations must also follow and post the Social Distancing Protocol, which incorporates much of the State guidance for businesses. This Protocol is also known as Appendix A, and can be here found in English and Spanish. What are Social Distancing Requirements? The Social Distancing Requirements are the five basic elements to protect the safety and health of Our community. • • • • • Maintaining at least a six-foot physical distancing from individuals who are not part of the same household or living unit (with exceptions for necessary care); Frequently washing hands with soap and water for at least 20 seconds, or using hand sanitizer that is recognized by the Centers for Disease Control and Prevention as effective in combatting COVID-19; Covering coughs and sneezes with a tissue or fabric or, if not possible, into the sleeve or elbow (but not into hands); Avoiding all social interaction outside the household when ill; and Wearing a Face Covering in compliance with the April 23, 2020 Order of the Health Officer Generally Requiring Face Coverings. Some businesses will be allowed to operate “with modifications.” What does that mean? Businesses allowed to operate under State and local orders must follow sector specific guidance, which for specific sectors may be found here, or below. In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. How can I prepare my retail business to safely reopn to protect my staff and customers? Guidance for shopping centers, destination retail, strip malls and swap meets can be found here, with a checklist available here. . In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. How can I prepare my office to safely reopen to protect my staff and customers? Office workspaces will be allowed to open once the May 26 Order goes into effect, though telework is strongly encouraged where possible. It is also important to note that reopening offices does not allow gatherings of non-staff members to occur. Packet Pg. 102 of 142 ADDITIONAL MATERIALS 04.e (9034) Guidance on safely reopening offices can be found here. A checklist can be found here. . In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. How can I prepare an outdoor museum to safely operate? State guidance on outdoor museums can be found here. A checklist can be found here. . In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. How can I prepare my manufacturing facility to safely operate? State guidance on manufacturing facilities can be found here. A checklist can be found here. . In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. How can I prepare my car wash, pet groomer or other low-risk personal services business to safely operate? These kinds of retailers should follow the state guidance for retail establishments, found here. . In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. When do Stage 3 businesses open? The State will determine this. The May 26 Order aligns the County with the Governor’s orders to reopen through Stage 4. The State has not yet given a timeline for when Stage 3 businesses would be allowed to open. How does this order impact temporary beach closures? It does not. Between 11 a.m.-5 p.m., beaches remain closed unless traversing the sand to engage in water activities such as surfing, swimming, kayaking, boogie boarding etc. Outside those hours, beaches are open for recreation only. Sitting, lying, standing, sunbathing, sight-seeing, picnicking, and all other non-exercise, passive, or sedentary activities on beaches remain prohibited and may result in a citation. How does this order impact construction? This order removes local restrictions and guidance on construction. Construction businesses still must comply with social distancing requirements and face covering orders, as well as state guidance. They must complete, implement and post Appendix A at each construction site and at each public entrance to their facilities. Packet Pg. 103 of 142 ADDITIONAL MATERIALS 04.e (9034) How does this order impact golf course operations? This order removes local restrictions and guidance on golf courses and driving ranges. Golf courses still must comply with social distancing requirements and face covering orders, as well as state guidance. . In addition, each business must complete, implement and post Appendix A, Social Distancing Protocol, at each public entrance to their facilities. Are charter fishing boats allowed to operate in the County of Santa Cruz? Yes, charter fishing boats may operate and take out passengers, subject to the following conditions: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ The charter fishing boat shall only allow residents of the County of Santa Cruz to be passengers on the boat. These restrictions do not apply to the crew or staff of the charter fishing company. Residency of all passengers shall be verified by the crew prior to boarding and documented in the company’s reservation system. The purpose of the charter fishing is for fishing for the purpose of the sale or consumption of fish. The number of people aboard the boat shall be limited such that at least 6-feet of social distancing between passengers and crew is maintained. Passengers holding fishing rods are subject to the same minimal social distancing requirements at all times. Restrooms shall be sanitized after each use. The boat and all equipment that has contact with the passengers or crew shall be washed and/or sanitized after each use or trip. The shared handling of fishing equipment or fish is prohibited. Hand sanitizer shall be made available to all passengers and crew throughout the boat and at each rod station. Prior to boarding, passengers are required to wait on the dock at least six feet apart and shall not board the vessel until the captain or crew instruct them to. Charter fishing companies shall encourage the use of contactless means of payment. Passengers shall not shake hands, share food or drinks, or engage in any unnecessary physical contact. The crew shall be informed of these requirements prior to boarding, and when possible, at the time the reservation is made. All crew and passengers are required to wear face coverings. Rails, counters, and seating areas shall be cleaned frequently to maintain sanitary conditions. Passengers shall disembark one at a time as instructed by the Captain or crew. When does the order end? It ends July 1, 2020. Packet Pg. 104 of 142 ADDITIONAL MATERIALS 04.e (9034) VARIANCE PROCESS What does the variance allow? With the County meeting State requirements for a variance, our intent is to request one from the State. If the variance is approved, the County will be allowed to move into Late Stage 2, pending further Health Officer orders, to specifically allow the following sectors to open: • Dine-in restaurants (with modifications) Guidance for restaurants wishing to resume dine-in service will be required to follow State guidelines to protect the health and safety of staff and customers. Those guidelines can be accessed here, while a checklist for dine-in service can be found here. Does the variance allow schools to reopen? Yes, schools are included in Late Stage 2. State guidance for reopening of schools and childcare is expected in early June, and will guide local decisions about how and when to reopen schools. Does the variance allow all sectors to reopen? No. Very few sectors are allowed to reopen through the variance process. The following are NOT included in Stage 2 of the Resilience Roadmap and will not be allowed until the State removes restrictions: • • • • • • • • • Personal services such as nail salons, tattoo parlors, gyms and fitness studios Hospitality services, such as bars, wineries, tasting rooms and lounges Entertainment venues, such as movie theaters, gaming, gambling, arcade venues, pro sports, indoor museums, gallery spaces, and zoos Community centers, public pools, playgrounds, and picnic areas Nightclubs Concert venues Festivals Theme parks Hotels/lodging for leisure and tourism What does the County have to do to seek a variance? A county that has met certain criteria in containing COVID-19 may consider increasing the pace at which they advance through Stage 2, but not into Stage 3, of the Resilience Roadmap. As part of this process they must analyze and prepare a group of plans and documents to present to the State for consideration. Initiating the process involves two steps: 1. Notify the California Department of Public Health (CDPH) and engage in a phone consultation regarding the county's intent to seek a variance. This has been completed. 2. Certify through submission of a written attestation to CDPH that the county has met the readiness criteria designed to mitigate the spread of COVID-19. Attestations should be submitted by the local Public Health Officer, and accompanied by a letter of support from the County Board of Supervisors and letters of support from local hospitals or health care systems. Packet Pg. 105 of 142 ADDITIONAL MATERIALS 04.e (9034) What are the required readiness criteria? The County must meet certain criteria relate to epidemiological data, essential worker protections, testing availability, containment capacity, hospital readiness and protections for vulnerable residents. This requires collaboration with local health care providers, homeless services providers and skilled nursing facilities among others. At this time, the County meets the criteria and the Public Health Division intends to request support from the Board of Supervisors on June 2, 2020. For updates on our progress on these metrics, go to www.santacruzhealth.org/savelives. What else is required to obtain a variance? The State also requires various documentation related to readiness criteria, as well as the following plans: • • • Sectors and timelines plan. The County must provide detail on how we intend to move through Stage 2. This includes which sectors and spaces will be opened, in what sequence, and on what timeline, as well as notations on difference from state orders. This plan does not include sectors that are part of Stage 3. Adjustment triggers plan. The County must provide metrics that would serve as triggers for either slowing the pace through Stage 2 or tightening modifications, including details on what actions we would take if those triggers are met, including containment measures. Stage 2 plan. The County must provide a plan to move through opening sectors and spaces that are part of Stage 2 under the Resilience Roadmap. This plan may not include Stage 3 sectors. If the State approves the variance, can all Stage 2 businesses reopen? Not quite. The variance grants the Health Officer authority to reopen these businesses. The Health Officer must take additional action in order to allow activities under Stage 2 to resume. What else is the State asking for? The State is requiring a broad COVID-19 Containment Plan. The Plan should include, but is not limited to: 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 <7% 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? 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? Packet Pg. 106 of 142 ADDITIONAL MATERIALS • • 04.e (9034) 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? PROTECTING THE VULNERABLE • • • • • • • • • 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? Do facilities have the ability to safely isolate COVID-19 positive individuals? Do facilities have the ability to safety 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 these facilities (particularly skilled nursing facilities) have access to staffing agencies if and when staff shortages related to COVID-19 occur? 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? ESSENTIAL WORKERS • • • • • How many essential workplaces are in the county? 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? 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? COMMUNITY ENGAGEMENT • Has the county engaged with its cities? Packet Pg. 107 of 142 ADDITIONAL MATERIALS • • • 04.e (9034) Which key county stakeholders should be a part of formulating and implementing the proposed variance plan? 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? 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? How will increased regional and state travel impact the county's ability to test, isolate, and contact trace? Packet Pg. 108 of 142 ADDITIONAL MATERIALS 04.e (9034) County of Santa Cruz HEALTH SERVICES AGENCY POST OFFICE BOX 962, 1080 Emeline Ave., SANTA CRUZ, CA 95061-0962 TELEPHONE: (831) 454-4000 FAX: (831) 454-4488 TDD: Call 711 Public Health Division Press Release For Release: Immediately Date: May 26, 2020 Contact: Jason Hoppin, County Communications Officer Phone: (831) 454-3401 NEW HEALTH ORDER ALLOWS CERTAIN ACTIVITIES TO RESUME Santa Cruz County, CA - Santa Cruz County Health Officer Dr. Gail Newel has issued a new Health Order allowing early Stage 2 activities to proceed and aligning the County with any future State action to remove restrictions under the statewide Stay at Home order. The Order will allow office workspaces, in-store retail, religious services and cultural ceremonies, manufacturing, limited personal services, protests and outdoor museums to resume, effective 11:59 p.m. on Tuesday. All businesses and operations must continue complying with Social Distancing Protocols and Order to Wear Face Coverings, as well as sector-based guidance available from the State on the covid19.ca.gov/roadmap website. “As we move forward with these changes, I want to caution everyone that COVID-19 is still present in our community. Anyone who is 65 years old or older, as well as those who are medically vulnerable, should continue sheltering in place,” Newel said. “I urge all members of our community to help those who need to shelter by continuing to offer help and check in.” Telework is strongly encouraged where possible, but office spaces may open by following State guidance on safely reopening, found here. A checklist can be found here. Childcare is now allowed for children of workers and volunteers in all open sectors, not just essential services. Guidance on childcare facilities can be found here. In-store retail operations should follow State guidance for retail establishments, found here. In addition, retailers are required to follow and post local guidance under the Health Order known as Appendix A, available in English and Spanish. Low-risk personal services such as car washes and pet groomers should also follow guidelines for retail operations, and follow and post Appendix A. Packet Pg. 109 of 142 ADDITIONAL MATERIALS 04.e (9034) Under new guidance from the State, in-person religious services, cultural ceremonies and funerals may resume, with attendance limited to 25 percent of a building’s capacity or 100 persons, whichever is fewer. Congregants must comply with Social Distancing Protocols. State guidance for places of worship and cultural ceremonies can be found here. Political protests may also resume, limited to 25 percent of the relevant area’s capacity or 100 persons, whichever is fewer. Protesters must comply with Social Distancing Protocols. Additional information on protests is available here. State guidance on manufacturing facilities can be found here. A checklist can be found here. State guidance on outdoor museums can be found here. A checklist can be found here. While the State is allowing in-store retail to proceed, dine-in restaurants are still considered a late Stage 2 activity subject to State approval of a variance allowing those activities to move forward. The County has initiated the variance process, with an application expected to be submitted June 2 pending approval by the Board of Supervisors. A review may take up to one week. If approved, local Health Officers must implement a new Order allowing late Stage 2 activities to resume. While the Order announced today allows the immediate implementation of any future changes to the State Shelter-in-Place order, the County may not allow activities and operations that conflict with State rules. The County wishes to remind the public that gatherings of any kind outside your immediate household remain high-risk until case counts reduce, and should be avoided except as allowed above. The Order maintains language on daily beach closures between 11 a.m.-5 p.m., as well as language restricting patronage at local hotels, motels and vacations rentals, including asking lodging owners to maintain a log of the purposes customers are staying at local lodging establishments. The Order will expire July 1, 2020. For local information on COVID-19, go to www.santacruzhealth.org/coronavirus, call 211 or text “COVID19” to 211211. Residents may also call (831) 454-4242 between the hours of 8 a.m. and 6 p.m., seven days a week. ### Packet Pg. 110 of 142 ADDITIONAL MATERIALS 04.e (9034) Attachment U SAVE Lives Santa Cruz County COVID-19 Containment Plan: Implementing California’s Resiliency Roadmap Packet Pg. 111 of 142 Introduction ADDITIONAL MATERIALS 04.e (9034) The County of Santa Cruz began pro-active steps early in the emergence of COVID19. Recognizing that there was potential for wider global spread, the County of Santa Cruz Health Services Agency first activated the Department Operations Center (DOC) on February 28, 2020. On March 4, 2020, the Public Health Officer issued a Declaration of Public Health Emergency, followed by Social Distancing Guidelines released on March 13, 2020. On March 16, 2020, the Public Health Officer issued the county’s first Order for all residents to Shelter in Place, just days before California’s first statewide Stay At Home Order. Amendments to local orders were made on April 29, 2020 and May 6, 2020, to align local orders with changing state orders and significantly lifting many areas of restrictions such as construction, real estate, landscaping, and curbside retail. Most recently, the local Health Officer issued a May 26, 2020 Order, allowing Stage 2 activities reopened statewide to proceed and aligning the County with any future State action to remove restrictions under the statewide Stay at Home order. The County of Santa Cruz did not meet the Variance criteria first issued by the state on May 8, 2020 and would not meet several of those criteria now. Now that the state has significantly loosened several elements of the criteria, the County of Santa Cruz now meets the minimum criteria to apply for a Variance to accelerate through Stage 2 of California’s Resiliency Roadmap. Although increasing case counts are concerning, we are far more prepared today, compared to early in the pandemic, to respond to the epidemiology, health care, and public health demands that may result from increased transmission. Table 1 below shows the epidemic curve, with an increase in cases approximately three weeks following early May modifications to Health Orders that lifted some restrictions. Table 1: May 27, 2020 Epidemic Curve for the County of Santa Cruz Packet Pg. 112 of 142 ADDITIONAL MATERIALS 04.e (9034) Overview of SAVE Lives Santa Cruz County SAVE Lives Santa Cruz County (SAVE Lives) is a plan to monitor and mitigate the impacts of COVID-19 during the reopening of communities as a result of the lifting of the State’s Stay At Home and the local Shelter In Place Health Officers’ Orders. COVID-19 impacts every corner of the community. Working with partners throughout the County of Santa Cruz, we have developed a framework to safely move forward that protects residents, aligns with State public health authorities and the governor’s Resilience Roadmap, and is based on measurable objectives to increase community resiliency. The SAVE Lives website can be found here: www.santacruzhealth.org/savelives. Recognizing the challenge COVID-19 poses to the community, SAVE Lives Santa Cruz County is a partnership between the County of Santa Cruz and Community Foundation Santa Cruz County, designed to facilitate a community-based plan for moving forward. It is based on four principles:  SLOW THE SPREAD - Until a vaccine and human immunity are in place, we must use the tools we have to slow the spread of COVID-19 and protect lives. These include: o Physical distancing measures o Expanding public health testing, case investigation, contact tracing and isolation and quarantine capabilities o Expanding healthcare capacity and PPE availability  ADAPT AND ADJUST – We recognize ongoing changes are necessary to minimize harm. These include: o Modifying physical distancing measures for schools, businesses, and community o Maintaining and monitoring testing, contact tracing, isolation, and quarantine capacities o Maintaining and monitoring health system capacity  VACCINATE AND TREAT - Once a vaccine and treatments are available, we must: o Develop a vaccination plan to coordinate equitable, risk-based distribution o Increase capacity for mass vaccination and dispensing o Implement agreements with private and public partners to coordinate vaccination plans and serve as dispensing sites o Ensure ability to access and administer therapeutics to meet the demand  ELEVATE READINESS - COVID-19 will change the way we function as a community. Our task includes: o Elevating readiness for the next public health emergency o Strengthening Public Health infrastructure and workforce o Evaluating and improving Public Health information systems Packet Pg. 113 of 142 ADDITIONAL MATERIALS 04.e (9034) SAVE Lives was developed by aligning four significant state and national frameworks: 1. California’s Roadmap to Reopening 6 Indicators to Modifying Stay At Home Orders (Released April 14, 2020) 2. California’s Resilience Roadmap: 4 Stages to Reopening (Released April 28, 2020) 3. Johns Hopkins University’s “Public Health Principles for a Phased Reopening During Covid-19: Guidance for Governors” 4. Resolve to Save Lives (RSL), “COVID-19 Playbook”, a global health initiative outlining an adaptive response to the COVID-19 pandemic. It is important to note that although the federal government released phased guidelines for reopening America, there are no federal orders and states have discretion to determine reopening criteria and timelines, based on relevant state, regional and local data. State and federal guidelines call for physical distancing, diligent personal hygiene practices, and recommendations to stay home when sick. Overview of Frameworks California’s Six Indicators On April 14, 2020, California provided six indicators to be used as a framework for making decisions in modifying the Stay-at-Home order: • • • • • • The ability to monitor and protect our communities through testing, contact tracing, isolating, and supporting those who are positive or exposed The ability to prevent infection in people who are at risk for more severe COVID-19 The ability of the hospital and health systems to handle surges The ability to develop therapeutics to meet the demand The ability for businesses, schools, and childcare facilities to support physical distancing; and The ability to determine when to reinstitute certain measures, such as the stayat-home orders, if necessary. California’s Resilience Roadmap Four Stages On April 28, 2020, the state unveiled Resilience Roadmap Stages, a framework for a stepwise opening of lower risk to higher risk workplaces as supported by epidemiology, public health and health system capacity and preparedness. According to the state, during Stage 2, counties may choose to relax stricter local orders at their own pace. Following Stage 2, once a statewide COVID-19 surveillance system is made possible through testing, further regional variations could be supported. Packet Pg. 114 of 142 ADDITIONAL MATERIALS 04.e (9034) Johns Hopkins Bloomberg School of Public Health “Public Health Principles for a Phased Reopening During Covid-19: Guidance for Governors” This framework provides high-level risk assessments for organizations and specific settings in seven categories: • Nonessential businesses • Schools and childcare facilities • Outdoor spaces • Community gathering spaces • Transportation • Mass gatherings • Interpersonal gatherings Each of these categories is assessed along three dimensions: • Contact intensity • Number of contacts • The degree to which the activities are considered to be modifiable (through mitigation measures such as enabling people to remain 6 feet apart) to reduce risk Resolve to Save Lives This global health initiative outlines an Adaptive Response Approach to the COVID19 pandemic in its “COVID-19 Playbook”. Packet Pg. 115 of 142 ADDITIONAL MATERIALS 04.e (9034) Table 2: Resolve to Save Lives Adaptive Response Guiding principles of this framework are summarized in the following Key Approaches: • Use data to drive decisions and share data with the public • Respect, protect, and promote human rights of all communities and all sectors of society • Adapt general approaches to the national, subnational, and local contexts to maximize public health benefit and minimize economic and social harms • Engage communities, learning from them and enlisting them to lead and implement programs Essential activities are organized into the following categories: • Coordinated response o Establish a functional, adequately funded, and interconnected incident management structure o Clearly communicate evidence-based information through multiple means o Daily briefings from a trusted source on case counts, countermeasures, recommendations, and outlook • Box the virus in (Disease control) Packet Pg. 116 of 142 ADDITIONAL MATERIALS o Implement individual (hand/cough/illness) and environmental hygiene o Test widely and maintain timely and accurate surveillance  Report cases and deaths within 24 hours  Utilize syndromic surveillance (e.g. influenza-like illnesses (ILI), severe acute respiratory infections (SARI) as early signals  Ensure and publicly report rapid turnaround times of laboratory tests  Test suspected cases and clusters rapidly after identification  Isolate all infected people in safe and suitable places  Identify and trace contacts quickly and as completely as possible, expanding the circle when transmission is found  Quarantine contacts and address the social, medical, and practical needs of individuals so they can remain in quarantine without hardship • Safely manage COVID-19 cases o Equip and protect healthcare workers with appropriate controls and prevent health care worker infections o Provide for supplemental oxygen and other essential care to the greatest extent feasible to support seriously ill patients, including ventilator support as feasible o Provide social, economic, and emotional support for patients o Facilitate the development of diagnostics, therapeutics, and vaccines • Turn on and off physical distancing measures when appropriate o Make informed decisions based on potential impact, surveys, and objective assessments o Implement and assess adherence to physical distancing (e.g., cancellation of gatherings) and hand/cough/illness hygiene measures o Monitor for violence, social disruption, and other negative impacts of physical distancing o Assess and implement as indicated quarantine of travelers and restrictions on travel • Maintain non-COVID-19 essential health services o Maintain vaccination, maternal and child health, behavioral health, and care of chronic conditions • Essential societal services o Ensure security and access to basic provisions, power, water, internet, media, and financial services 04.e (9034) The County of Santa Cruz Public Health Division studied the alignment of each of the four frameworks above, adapting the Resolve to Save Lives recommendations and incorporating California’s indicators across Epidemiology & Surveillance, Health Care, and Public Health areas related to COVID-19. The Matrix below maps Criteria and Metrics to locally available Data Sources and Analysis. This approach will provide data to inform when and how to employ Triggers for Modification. Packet Pg. 117 of 142 ADDITIONAL MATERIALS 04.e (9034) Table 3: Matrix Aligning Resolve to Save Lives and State Criteria with Local Data Matrix for Re-opening from Shelter-in-Place: Criteria, Metrics, Data Source, and Analysis Adapted from “When and How to Reopen After COVID-19” published by Prevent Epidemics, a project of Resolve to Save Lives Area & Indicator Criteria Metric Data Sources / Collection tools Analysis tool Epidemiology (CA #1, 2, 6) Decreasing cases with increased testing (or stable testing with decreasing positivity) and increasing case doublingtime as per model projections for at least 14 days. Case and lab counts (and/or proportion of positive lab results) trends over time Epi: CalREDIE Modeling: Double-time graphs Epi: R Modeling: Epidemiologist Stan/Python Epidemiology (CA #6) Decline in the observed and projected daily death rate for at least 14 days Death count and decreasing trend over 14 days Epi: CalREDIE and Vital Records Modeling: Daily-death rate graph Epi: R Modeling: Epidemiologist Stan/Python Epidemiology (CA #1, 2, 6) Steady decrease in ILI in syndromic surveillance for at least 14 days. % and/or decreasing trend of ILI BioSense; Sentinel provider from PAMF/Sutter BioSense Population flu reports More discharges than admissions for COVID-19 for at least 14 days. Health: ReddiNet and CDPH # of COVID-19 dashboard admissions; # of COVID- Epi: Hospital Excel, R 19 discharges Admit/Discharge of Known Cases in CalREDIE Health Care (CA #6) Data: ReddiNet and CDPH dashboard; EMS responder app for self-assessment Modeling: ICU model projections Consider: Known Cases in ICU Health Care (CA #3, 6) Ability – including staffing – to double number of ICU patients from current and projected census. # of ICU patients; # ICU beds at capacity; ICU staffing availability Health Care (CA #2, 3, 6) Sufficient PPE for all health care workers even if cases double. # of PPE in stock; # ReddiNet and CDPH current hospitalizations dashboard Health Care (CA #1, 3, 6) Ensure baseline capacity in general health services exists and can continue within model projections (may include expansion of telemedicine) Y/N questionnaire in ReddiNet Public Health (CA #1, 2, 6) Confirm that CDU capacity remains supported to conduct contact tracing for all cases % of cases interviewed CalREDIE and Internal and contacts elicited for Tracking Spreadsheet tracing Public Health (CA #1, 2, 3) Designated facilities for nonhospitalized COVID-infected people who cannot be safely cared for at home # of isolation and (e.g., because of space constraints, quarantine sites; # of homelessness, medically vulnerable beds at each site household members, or otherwise) Data: ReddiNet and CDPH dashboard Modeling: Hospital model projections Reports from EOCs and Shelter Team Responsible for Analyzing Epidemiologist MHOAC/ Epidemiologist Data: CDPH dashboard MHOAC/ Modeling: Epidemiologist Stan/Python Excel, CDC burn rate MHOAC/ Epidemiologist Data: Excel Modeling: MHOAC Stan/Python R, Excel Epidemiologist Excel ACS and Shelter branch under Ops Public Health (CA #2, 5, 6) Partnering with law enforcement or partner agency: Demonstrated ability to convey physical distancing recommendations that change behavior in most residents # citations/documented Police reports; Community issues related to reports known to County physical distancing in agencies the community Pending Law DOC Public Health (CA #5, 6) Consider neighboring counties' shelterin-place policies – (to either align and/or to protect our county) Existing policies in neighboring counties Email; weekly call Health Officer ABAHO communication Packet Pg. 118 of 142 ADDITIONAL MATERIALS 04.e (9034) Triggers for Modification These guidelines are intended to be informative, not rigid, and to be interpreted based on patterns of data evident as well as public health system capacity. No single element will serve as an automatic basis for action. Furthermore, it should be noted that as communities progress along stages of reopening, there is an inherent and unknown amount of risk. The state will be notified when any single trigger is reached. Tailored modification will be needed when one or more criteria in at least 2 of 3 sections are met. Table 4: Triggers for Adjusting Modifications Timeline A new Health Officer Order was issued on May 26, 2020, aligning the County of Santa Cruz with the Governor’s Roadmap through all four stages. The May 26 order brought the County into alignment with the State through Stage 2 Low Risk Workplaces with modifications, including office-based businesses (when telework is not possible), select services as defined, outdoor museums, open gallery spaces, and other public spaces with modifications. In addition, this order allowed the opening of in-store retail and religious and cultural services, all with modifications, aligning with the Governor’s Roadmap changes of May 25, 2020. Packet Pg. 119 of 142 ADDITIONAL MATERIALS A Supplemental Order will be issued on the same date as the Variance Attestation Application to the State, to take effect upon approval and posting of the application by the State. This Supplemental Order will allow the opening of restaurants, barber shops and hair salons, with modifications according to the guidance at https://covid19.ca.gov/pdf/guidance-dine-in-restaurants.pdf and https://covid19.ca.gov/pdf/guidance-hair-salons.pdf and the associated checklists. 04.e (9034) In addition to the orders described above, an Order Generally Requiring Face Coverings was issued on April 23, 2020, Additionally, a Social Distancing Protocol is attached to the April 29, 2020, Health Officer Order as Appendix A, which is to be completed, implemented and posted at each public entrance of every business and governmental entity. This Social Distancing Protocol has been in effect in the County since March 31, 2020 and includes measures to protect the public and employees of each posting facility. No Stage 3 or 4 businesses or activities will be allowed until approved by the State. Regarding schools, the county Health Officer will await further guidance from the State and will not reopen this sector without state alignment. Testing The County has been working with partners to steadily increase testing capacity. With the addition of the OptumServe testing site, the County of Santa Cruz has reached throughputs of 570 tests per day, which is significantly above its target of 412 tests per day when using the state’s capacity of 1.5 tests per 1,000 residents and also meets the target of 2.0 tests per 1,000 residents per day. Further, the County has a coordinated testing strategy, to prioritize testing for all symptomatic individuals, asymptomatic healthcare workers and first responders. The OptumServe specimen collections site has allowed access to testing for all asymptomatic adults living or working in the County. The county is currently developing a surveillance testing program for residents in congregate care facilities, with discussions underway with University of California Santa Cruz for possible utilization of its lab for specimens collected by mobile specimen collection teams. The table below includes the various venues for County of Santa Cruz residents to access testing, which includes the plan for mobile testing units. Packet Pg. 120 of 142 ADDITIONAL MATERIALS 04.e (9034) Table 5: County of Santa Cruz Planned Testing Venues While the county has robust equipment available for testing, it continues to experience various challenges in terms of specimen collection and processing, primarily due to supply limitations (swabs, viral transport media, reagents), and staffing. We are currently exploring all supply chains to secure regular supplies for test collection kits to support plans for a new community testing site in North County and the mobile specimen collection teams who will have the capacity to deploy on a daily basis. A portion of these kits will be used to increase the ability of the FQHCs (particularly the County Health Services Agency Clinics) to test people who are symptomatic. In the coming weeks, we intend to implement the recommendations in the recently issued AFL 20-53, which outlines surveillance and response-based testing for our 7 Skilled Nursing Facilities. We estimate a demand of 3,000 tests per month to implement the guidance. The County’s ability to meet its plan for testing capacity could further constrain baseline challenges independent of the AFL. The County is currently planning mobile specimen collection teams and accessing the CZ BioHub lab at University of California San Francisco as an additional lab resource. Table 6: Test Sites and Capacity COUNTY OF SANTA CRUZ - CAPACITY FOR AMBULATORY TEST SITES (UPDATED AS OF MAY 21, 2020) PROVIDER ORGANIZATION DIGNITY HEALTH MEDICAL GROUP Current Daily Capacity 100 Site Address Population Served Hours of Operation 610 Fredrick Street Santa Cruz, CA 95062 Dignity Health patients Mon-Fri 8am-5pm Packet Pg. 121 of 142 KAISER PERMANENTE SCOTTS VALLEY 30 KAISER PERMANENTE WATSONVILLE 30 SUTTER HEALTH/PAMF SANTA CRUZ URGENT CARE SUTTER HEALTH/PAMF WATSONVILLE URGENT CARE COUNTY HEALTH CENTERWATSONVILLE 40 40 1430 Freedom Blvd, Suite D Watsonville, CA 95076 COUNTY HEALTH CENTER-SANTA CRUZ 40 PLANNED PARENTHOOD 25 SALUD PARA LA GENTE 40 SANTA CRUZ COMMUNITY HEALTH CENTERS 25 CABRILLO COLLEGE STUDENT HEALTH CENTER 10 UC SANTA CRUZ COWELL STUDENT HEALTH CENTER 20 OPTUMSERVE AT RAMSAY PARK COMMUNITY TESTING TOTAL - ESTIMATED AMBULATORY CAPACITY ADDITIONAL MATERIALS 5615 Scotts Valley Drive Scotts Valley, CA 95066 1931 Main Street Watsonville, CA 95076 Kaiser Permanente members Mon-Fri 1pm-4:30pm Kaiser Permanente members Mon-Fri 1:30pm-4:30pm 2025 Soquel Avenue Santa Cruz, CA 95065 550 S. Green Valley Road Watsonville, CA 95076 Sutter Health/PAMF patients, General public Sutter Health/PAMF patients, General public General public Mon-Sun 8am-5pm 1080 Emeline Avenue Santa Cruz, CA 95060 398 S Green Valley Road Watsonville, CA 95076 General public Mon, Wed-Fri 8am-5pm Tues 8am-8pm Planned Parenthood patients Tues and Thurs 12 pm to 1 pm 204 East Beach Street Watsonville, CA 95076 21507 E Cliff Drive Santa Cruz, CA 95062 General public Mon-Sat 8:30am-5:30pm Sun 8:30am-12:30pm General public Mon-Thur 8am – 8 pm, Fri 8am – 4 pm Parking Lot J, Cabrillo College 6500 Soquel Drive, Aptos CA 95003 1156 High Street Santa Cruz, CA 95064 Cabrillo College students, faculty and staff Mon-Thurs 8am-5pm UC Santa Cruz students Mon-Fri 8am-5pm 132 1301 Main Street Watsonville, CA 95076 Public Wed-Sun 7am-7 pm 572 *** Note: Does not include hospital testing of patients or mobile specimen collection team capacity. 40 04.e (9034) Mon-Sun 8am-5pm Mon-Thurs 7:30am-6:30pm Fri 7:30am-5pm Packet Pg. 122 of 142 Contact Tracing ADDITIONAL MATERIALS 04.e (9034) The County of Santa Cruz values contact tracing as an essential component of containing new clusters of COVID-19 and community reopening. Over 100 individuals expressed interest with the Volunteer Center of Santa Cruz and through the Medical Reserve Corps to become trained in contact tracing and support public health efforts. The County’s current plan to expand its team of existing contact tracers include redeployed county employees, promotoras (community health workers), students who are working towards a certification or license in the health care field and need work experience in order to complete their requirements, and community volunteers. About half of our target number of 41 contact tracers will come from existing staff and the other half will be community volunteers. We do not currently meet the target of 15 tracers per 100,000 population. However, by June 5, 43 contact tracers and case investigators will be trained, which includes 28 individuals newly trained via the State’s new Virtual Training Academy. Additional trainees in the pipeline will add more contact tracers in the middle of June. The County will continue to recruit and screen volunteers for a 3rd wave of additional contact tracers. While the County has kept abreast of case investigation and contact tracing to date, we are currently experiencing a surge in cases that is challenging existing staff. Aside from contact tracers, efforts are also being made to secure administrative and supervisory staff needed with expanded testing and resultant case investigations. The County is in the process of expanding contact tracing staff to the recommended levels; however, our recent surge in cases is challenging our current capacity. Additional contact tracers will be onboarded in waves. By June 1 we will increase our capacity by 30%, onboarding 20 more people in training in late May. We are recruiting staff to be reflective of community racial, ethnic, and linguistic diversity, and are organizing the contact tracing teams accordingly. • • • • • • 15 currently trained staff, 9 of which are bilingual in Spanish 26 additional people are on our list to be trained by June 4, of which 6 are bilingual in Spanish 14 people are pending enrollment; 2 are bilingual in Spanish, 1 is bilingual in Farsi, 1 is bilingual in Japanese 10 students are in process of being identified 10 promotoras are in process of being identified Volunteers continue to voice interest and are being screened for the contacttracer role Individuals who are unable to safely isolate or quarantine in their own homes may be offered on-demand sheltering. Collaboration between the County’s Public Health Division and Human Services Department (HSD) is critical to this plan’s success. HSD’s Shelter and Care Branch arranges rooms via contracts with local hotels. On-demand sheltering is offered when clinically recommended by public health nurse case investigators. Services and support needs are assessed during case investigations Packet Pg. 123 of 142 ADDITIONAL MATERIALS and prior to placement, which includes food, linens, and connections to primary care. Collaborations are also in place with the farm worker community, including the regional Growers Shippers Association, who have made isolation and quarantine hotel spaces available to farmworkers. 04.e (9034) With the recent detection of four family clusters last week, all related to Mother’s Day weekend gatherings, the Communicable Disease Unit (CDU) is currently investigating 36 new positive cases and their contacts. Although the County currently has sufficient case investigation and contact tracing staff, the recent increase in cases required us to activate surge plans for case investigation and contact tracing, including immediate onboarding of newly trained contact tracing and case investigation staff. Training for contact tracing staff includes completion of the Statesupported Virtual Academy and shadowing an experienced disease investigator. Congregate Settings and Vulnerable Populations Skilled Nursing Facilities Understanding the risk associated with all congregate settings, the Department Operations Center (DOC) developed a Congregate Setting branch in its ICS early in the incident response, adding the county jail settings and shelters to plans to prevent and mitigate COVID-19 transmission in high-risk settings. The County of Santa Cruz Communicable Disease Unit (CDU) engaged the SNFs in on-site visitations with facility assessments that included: infection prevention and controls; preparedness plans; isolation and quarantine protocols; staffing readiness and contingency plans; personal protective equipment (PPE) and supply chain integrity. Strategies for improvement were provided to each facility when needed. Technical assistance has been provided to each facility with robust support from the DOC Logistics Section and the Medical Health Operation Area Coordinator (MHOAC) for resource requesting and the Preparedness Branch for planning, training, and testing response protocols. These supports are ongoing and described in an April 23, 2020 Press Release (Attachment Q). The County also maintains communication with its SNFs through regular emails and weekly Health Care Coalition calls, for all health care facility partners, in addition to weekly COVID-19 Response for Skilled Nursing Facilities Facilitated Discussion calls, limited to SNFs. Collaborative planning meetings with local healthcare providers resulted in development of the Emergency Response Plan for Skilled Nursing Facilities, which guides how the County addresses urgent matters at SNFs. Additionally, SNFs are represented within three groups in the HSA DOC Operations Section – Community Recovery Branch, Disease Mitigation Branch, and the Preparedness Branch, which further enables the County to closely support facilities providing care to these vulnerable populations. The County is working vigorously to implement sufficient testing capacity to conduct expanded outbreak investigations, expanded contact tracing and community-wide testing through the launching of OptumServe that began on May 6, 2020. Packet Pg. 124 of 142 ADDITIONAL MATERIALS On May 8, 2020, CMS published an interim final rule requiring SNFs to report COVID-19 facility data to the CDC and to notify residents, residents' representatives, and families of residents of when there are COVID-19 positive residents or healthcare workers in the facility. Per CDPH AFL 20 – 43.2 dated May 13, 2020 the report must include, but is not limited to, the following: • Suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19 • Total deaths and COVID-19 deaths among residents and staff • Personal protective equipment (PPE) and hand hygiene supplies in the facility • Ventilator capacity and supplies in the facility • Resident beds and census • Access to COVID-19 testing while the resident is in the facility • Staff shortages • Other information specified by the Secretary 04.e (9034) All seven SNFs participate in the CDPH daily poll where data regarding COVID-19 including PPE inventory are documented. The County receives and reviews the daily polls for compliance with the requirement of having >14-day supply of PPE on hand. The names and contacts of our seven SNFs are as follows: Table 7: County of Santa Cruz Skilled Nursing Facilities Information Name of Facility Address City County Valley 919 Watsonville, Santa Cruz Convalescent Freedom CA Hospital – Blvd. Watsonville Watsonville Nursing 535 Auto Watsonville, Santa Cruz Center – Center Dr. CA Watsonville Pacific Coast 1935 Wharf Capitola, Santa Cruz Manor Rd. CA Driftwood 675 24th Santa Cruz, Santa Cruz Healthcare Center Ave. CA Santa Cruz Santa Cruz Post1115 Santa Cruz, Santa Cruz Acute Capitola Rd. CA Hearts and Hands 2990 Soquel Post-Acute Care Ave. and Rehab Center Watsonville Post- 525 Auto Acute Center Center Dr. Phone (831) 722-3581 Point of Contact Loralie Yzerman (831) 724-7505 Emily Perez, DON (831) 476-0770 Marise Goetzl (831) 475-6323 Kathleen Lovato Lance Bailey, Adm. Edna Keener, DON Rusty Grenier, Adm. Bobby Singh (831) 475-4055 Santa Cruz, Santa Cruz (831)479-9000 CA Watsonville, Santa Cruz (831)742-7505 CA Lucila Tinoco Packet Pg. 125 of 142 ADDITIONAL MATERIALS The County’s Public Health Division has reviewed each SNFs COVID-19 infection control plans; those plans will be reviewed on regular intervals as required through the COVID Mitigation Plan in the AFL 20-52 issued by CDPH on May 11, 2020. The SNFs in the County of Santa Cruz have relied heavily upon the HSA DOC Logistics Section to procure PPE and to build their inventory to the required >14 days cache. This has been necessary because other healthcare settings, such as hospitals, have been given higher priority for PPE to use in urgent care during the COVID-19 pandemic. Most vendors have prioritized existing customers and hospital orders above those of SNFs. This along with the severe global supply chain shortages, resulted in orders placed by SNFs being unable to be filled by the supplier or the delivery being significantly delayed. Further complicating matters is that suppliers have also cancelled orders due to the diversion of PPE to other states where confirmed cases and fatalities due to COVID-19 are significantly higher. 04.e (9034) The Preparedness Branch of the HSA DOC Operations Section developed a Vendor list for SNFs with the names of private suppliers and has requested that SNFs identify their non-government suppliers and repeatedly place PPE orders with those vendors as needed. If orders are cancelled, they have been advised that they should resubmit on a weekly basis as supply chain restoration has been an erratic process. To avoid duplication of work and resources, the County is using the mechanism implemented by the State to track PPE availability across SNFs in its jurisdiction. As stated above, this polling is tracked locally to ensure that SNFs are reporting their numbers and both the state and local public health are informed on their status. In addition to the daily polling reports, the County has advised the SNFs of the imminent delivery of (2) one week’s supply of PPE to each facility from FEMA. SNFs have been informed that they are required to ensure that this additional supply be maintained to ensure that they are above the minimum of >14 days’ supply. Delivery of the FEMA shipments is expected within the next two weeks (see Table 8). Packet Pg. 126 of 142 ADDITIONAL MATERIALS Table 8: FEMA PPE Expected Deliveries to SNFs (information received May 10, 2020) 04.e (9034) Eye 7DOS 7DOS Protection Masks Gloves 7DOS Gowns Status (Pending Projected Shipment/Shipped/ Shipment Date Delivered) 95062 57 538 2500 598 20-21 May 0 Santa Cruz CA 95010 47 590 2700 498 20-21 May 0 SANTA CRUZ Santa Cruz CA 95062 46 634 2900 480 20-21 May 0 525 AUTO CENTER DRIVE WATSONVILLE Santa Cruz CA 95076 35 328 1500 364 20-21 May 0 WATSONVILLE NURSING CENTER 535 AUTO CENTER DRIVE WATSONVILLE Santa Cruz CA 95076 38 355 1700 397 20-21 May 0 DRIFTWOOD HEALTHCARE CENTER - SANTA CRUZ 675 24TH AVENUE SANTA CRUZ Santa Cruz CA 95062 42 505 2300 446 20-21 May 0 VALLEY CONVALESCENT HOSPITAL 919 FREEDOM BLVD WATSONVILLE Santa Cruz CA 95076 28 384 1800 296 20-21 May 0 7 0 0 0 293.18478 3334 15400 3078.44 0 0 Provider Name Address City County SANTA CRUZ POST ACUTE 1115 CAPITOLA ROAD SANTA CRUZ Santa Cruz CA PACIFIC COAST MANOR 1935 WHARF ROAD CAPITOLA HEARTS & HANDS, POST ACUTE CARE & REHAB CENTER 2990 SOQUEL AVENUE WATSONVILLE POST ACUTE CENTER 0 State ZIP Code 0 The County developed and presented a virtual Microsoft Teams Tabletop Exercise (TTX) for SNFs and Congregate Shelter representatives and staff that was offered on two dates and made available through video recording. The CDU maintains a dedicated line for clinical questions related to COVID-19 that SNFs and other Congregate Living representatives and staff have utilized frequently in their readiness planning and action steps. Weekly conference calls shall continue with dedicated Emergency Preparedness staff providing ongoing support to those caring for our vulnerable residents. SNF representatives and staff are connected with CAHAN and have been informed through multiple channels on how to access local, state and CDC information and tools designed for the health and care of the populations that they serve. Corrections The County of Santa Cruz Sheriff’s Office oversees three correctional facilities. The Main Jail has a capacity of 319 inmates, and two other facilities, Roundtree, and Blaine Street, have a capacity of 96 inmates and 32 inmates, respectively. The Sheriff’s Office worked closely with the Health Services Agency and Public Health Divisions to assure plans and protocols were in place for screening of staff and inmates, reduced census, limiting visitation, assuring sufficient PPE and environmental strategies, and more. Shared planning processes include a protocol for corrections to immediately notify the Communicable Disease Unit in the event of a positive case in an inmate or staff, including the notification of receiving facilities should a transfer be required. The Health Officer and District Attorney both signed an order allowing release of lowlevel offenders. As a result, census is less than half of capacity in all County correctional facilities. In addition, newly incarcerated are place in a quarantine Packet Pg. 127 of 142 ADDITIONAL MATERIALS ward for 14 days prior to entering the general inmate population. Finally, all persons entering a County correctional facility are temperature checked and screened for symptoms prior to entering. Visitors have been limited to clergy and legal counsel since mid-March. As a result of early planning and aggressive implementation, there have been no COVID-19 cases in the jail population. 04.e (9034) Homeless Shelters The County of Santa Cruz and partner cities have established a task force to oversee homeless services during the COVID-19 pandemic, focused on minimizing the spread of the disease by isolating sick and vulnerable individuals and supplementing existing services impacted by the outbreak. Led by the County of Santa Cruz Human Services Department, the task force consists of staff from the County and cities of Santa Cruz and Watsonville, as well as community based organizations’ experts brought in to help secure facilities to shelter both sick and well individuals experiencing homelessness, as well as a range of services needed to support the operation of those facilities. The CDU, as part of its role in the Congregate Setting Branch, followed the same plans and protocols designed to provide SNF consultation, site visit and technical assistance, in partnership with the Human Services Division DOC. This collaborative planning ensures that homeless individuals experience safe shelter and services to ensure their health and the health of the community at large. The Human Services DOC is tasked with implementing and overseeing all facets of the local pandemic response within the homelessness community. Hotel/motel capacity of 152 rooms has been secured and will be prioritized to house COVID-19-positive homeless patients who are recuperating, homeless individuals with significant COVID-19 exposure in need of quarantine, and medically vulnerable and elderly homeless individuals. These facilities are one pillar of the task force’s four-pillar plan, which also includes expanded sheltering capacity, expanded hygiene infrastructure and direct outreach to homeless individuals. The County and partner cities, including Santa Cruz and Watsonville, are nearing completion of a plan to expand overall sheltering capacity to replace capacity diminished by the County Health Officer’s Shelter in Place order, which limits the number of beds available in existing shelters due to distancing requirements. The City of Santa Cruz has also worked with the Salvation Army and hired Downtown Streets Team members to bring on additional site monitors to facilitate ongoing safe and client-focused operations at the Armory. Resources at the Housing Matters campus on Coral Street are being reconfigured to accommodate more shelter capacity and resource centers for increased health assessments. County outreach workers, including Homeless Persons Health Project Staff, have received training on symptoms and care of individuals with COVID-19. Resources at the Housing Matters campus on Coral Street are being reconfigured to accommodate more shelter capacity and resource centers for increased health assessments, and County Packet Pg. 128 of 142 ADDITIONAL MATERIALS outreach workers, including Homeless Persons Health Project staff, have received training on symptoms and care of individuals with COVID-19. 04.e (9034) With new shelter locations recently expanded in response to COVID-19, there are currently 23 shelters in the County of Santa Cruz, including hotels reserved for homeless, with a total capacity of 721 individuals, with 521 individuals currently sheltered in these locations. The county recently experienced its first COVID-19 cluster associated with a shelter, with 10 out of 27 residents testing positive, for a case rate of 37%. According to our shared plans, the positive individuals were immediately isolated in hotels reserved for isolation and quarantine, and FQHC partner Salud Para La Gente assisted in surveillance testing of all residents. All congregate facilities have the ability, through partnerships with the county, to safely and adequately isolate COVID-19 positive individuals and quarantine those who have been exposed. Each facility was supported by CDU to have policies and protocols to appropriately train the workforce in infection prevention and control procedures. Should any congregate facility experience an outbreak, plans to deploy on site testing would be triggered. We currently have sufficient staffing, lab, and testing supply materials. In terms of PPE, the county has taken a tiered approach to assuring sufficient PPE, including PPE only being provided to priority staff and settings, and Personal Protective Measures or PPM (face coverings and non-medical grade protection) being made available to residents and volunteers. Supply chains have begun to restore, making PPE and PPM more available, and the County has an ongoing robust PPE and PPM donation effort. Through a network of county, local partner and state programs healthcare workers have access to low and no cost location option to safely isolate if needed. Additionally, the County EOC and DOCs have identified Medical Reserve Corps, Disaster Service Worker, and extra help lists of individuals able to deploy if and when staff shortages related to COVID-19 occur. Protecting the Vulnerable One of the main incident objectives during the County’s COVID-19 response has been to “use an equity lens in all decision making.” Public Health staff embody this objective throughout the pandemic response, through ensuring communication is accessible, suitable and available to various populations, collaborating with community partners that work closely with specific vulnerable groups, and support approaches that are culturally and linguistically appropriate. All public materials are developed with literacy and educational level in mind. Additionally, the County is adding an Equity Officer to the DOC organizational structure to support the inclusion of equity throughout the incident. Materials, including the County COVID-19 website, are made available in Spanish (English and Spanish are the County’s threshold languages). Outreach and education have included radio PSAs in English and Spanish, and interviews with Packet Pg. 129 of 142 ADDITIONAL MATERIALS Spanish language news outlets. The Pajaro Valley community, which includes the southern part of the County of Santa Cruz, is home to a majority of our County’s Hispanic/Latino community. Engagement with the Pajaro Valley includes regular stakeholder meetings with local community-based organizations (CBOs) and providers. A newly formed task force organized by leaders from Pajaro Valley CBOs, in partnership with SAVE Lives, are focusing to ensure COVID-19 messaging aligns with the cultural norms and language requirements of the community, that social services and resources are readily available to any who need them, and with a focus on the farm worker community, Mixtec, and Spanish speaking populations. 04.e (9034) Older adults are supported through collaborations with the Human Services Department (HSD) and County Emergency Operations Center (EOC), including securing restaurants to participate in the Great Plates program: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/GreatPlates.05052020.p df Guidance for Home Health Care agencies was disseminated to help the continued support of elderly home-bound individuals. https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/COVID%20Guideline %20Home%20Health%20Care.pdf Additionally, guidance and messaging for older adults and high risk populations was disseminated, including the COVID-19 Guidance for Older Adults and High Risk Populations in the County of Santa Cruz: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/COVID19%20%20Guidelines%20for%20Older%20Adults%20and%20High%20Risk %20Populations_eng.pdf Services continue for vulnerable populations, primarily through remote and telephonic or telehealth methods. This has included well-check calls from the local Medi-Cal Managed Care Plan, Central California Alliance for Health (CCAH), for hundreds of their high-risk Medi-Cal beneficiaries, continued case management and care coordination services for eligible patients of FQHCs in the county, and provision of behavioral health services through telehealth for the seriously mentally ill population (see Behavioral Health Division FAQs on Telehealth services https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Co%20BH% 20Telehealth%20FAQ%20Vol3.pdf). Additionally, educational resources to support mental health for the general population in these challenges times have been shared widely via social media and the website: https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/SCC%20Mental% 20Health%20Tips%20%26%20Resources%20ENG%20Coronavirus.pdf Acute Care Surge Background The expected surge of patients associated with the COVID-19 pandemic threatens to overwhelm the County inpatient capacity in the coming months. The Public Health Division has had ongoing discussions with our healthcare partners with respect to their plans and preparations for this expected surge of patients. It is clear from these discussions that optimal preparation will require a collective effort of all our Packet Pg. 130 of 142 ADDITIONAL MATERIALS health care facilities to identify and implement any opportunities to expand and coordinate care throughout our County. 04.e (9034) The All County Facilities Coordinated Surge Plan is intended to document and quantify the activities and discussions to date, provide an inventory of expected surge resources, and coordinate the optimal utilization of those resources during crisis conditions. Planning Activities to Date Each of the three inpatient facilities in Santa Cruz have been engaged individual planning and have performed activities to prepare for a surge of patients. These activities include the suspension of elective surgery, implementation of triage stations and tents and planned expansion and conversion of idle sections of the hospital to expand inpatient and ICU capacity. Ventilators in storage have been refurbished and additional PPE has been acquired. An Alternative Care Site (ACS) was developed but demobilized when hospitalization numbers remained low. The ACS supplies and plan have been stored and remain ready to redeploy, if needed. Inpatient and Intensive Care Capacity Total County of Santa Cruz inpatient capacity, ICU capacity and ventilators are listed in Table 9. Table 9: County of Santa Cruz Inpatient Capacity Total Beds ICU Beds Ventilators DCH 279 35 35 WCH 126 13 15 Sutter 28 0 1 ACS 40 0 0 Total 473 48 51 Latest median projections (5/24/20) suggest < 10 peak COVID-19 hospitalizations by June 15. Current doubling time is estimated at 20 days. The models, however, give a broad range of possibilities that may be far higher or lower than the projected median. Under the most likely scenario, there will be sufficient total inpatient capacity within our County. Table 10, below, shows individual hospital capacity and resources. Expanding ICU capacity In the event of an unanticipated surge in cases, ICU capacity is the most likely critical resource to constrained by capacity. There are several options to consider, each of which may be necessary: 1. Transfer patients to out of county hospitals: During non-crisis periods, transfer to other hospitals is routine when the patient’s needs exceed local capacity or capability. However, given the widespread nature of this event, there is a high likelihood that out of county hospitals will also be beyond capacity and not be able to accept a critical patient. Transportation to distant counties and even neighboring states may be necessary but again, availability remains uncertain. Packet Pg. 131 of 142 ADDITIONAL MATERIALS 04.e (9034) 2. Acquire additional ventilators Additional ventilators might be available from state or national stockpiles. Also, WCH may have a supply of disposable ventilators that could employed. Anesthesia machines, if not otherwise in use, may be used as emergency ventilators. Currently ventilators are difficult to acquire, and the common practice of renting ventilators from a supply house is no longer an option due to high demand. There is a national effort to produce and acquire more ventilators. Even if additional ventilators could be acquired locally, there is also the need for medical specialists to manage these. Typically, this requires ICU level nursing, respiratory therapy, and an intensivist physician at a minimum. Workforce expansion using just-in-time training and statewide medical workforce resources may be necessary. 3. Institute Scarce Ventilator Allocation Strategies Each hospital should use a standardized assessment for the need for intubation and ventilation. Some patients, when faced with the prospect of being on a ventilator, may choose to decline that intervention. Others, while hypoxic to the extent that intubation would be considered prudent during normal situations, may tolerate careful observation, oxygen supplementation, BiPAP, and other respiratory care under crisis standards of care. Clinicians at all facilities should coordinate crisis standards of care to ensure consistent allocation strategies that are intended to maximize population outcomes. Expanding General Inpatient Capacity Current projections suggest that we will have sufficient general inpatient capacity, however these same models show a lower probability that demand will far exceed current capacity. Should it become necessary, there are several options for further expanding inpatient capacity. 1. Transfer patients to out of county hospitals: The same conditions relative to transfer of ICU patients as described above may also apply to general admissions as well. Fortunately, the State of California has temporarily acquired Seton Medical Center in Daly City for the purpose of expanding inpatient capacity and this may be an available option. 2. Expand the Alternate Care Site The ACS currently sited and planned could comfortably accommodate 40 patients and be quickly activated. It could be expanded to up to 70 patients, if necessary. Additional Alternate Care Sites could also be stood up at other locations in the county, but this would require another set of staffing. Additional staffing may be available through the California Health Corps. 3. Institute a lower threshold for home care When there is no longer any inpatient capacity at local hospitals, ACS or within any reasonable distance, it may become necessary, under crisis standards of care, to consider home care for a wider range of patients. Clinicians should consider the Packet Pg. 132 of 142 ADDITIONAL MATERIALS trajectory of the illness, the presence of comorbidities, and the degree of support at home when making admission decisions under scarcity conditions. Generally, patients who are appropriate for hospice care should not be admitted. 04.e (9034) Our partners have done a tremendous job preparing for this extraordinary event. We are hopeful that the Public Health measures instituted last month continue to flatten the curve and increase the likelihood that our healthcare capacity will exceed the expected surge. However, responsible planning dictates that we prepare for the unexpected. The All County Facilities Coordinated Surge Plan (Attachment O) is a work-in-progress and multiple revisions are expected as this event progresses. Table 10: Surge Capacity Tracking Dominican Community Hospital (5/24/20) Current Census Surge Licensed + Total (Other + Capacity Surge Capacity COVID) (%) All Beds 222 + 57 279 116 + 1 162 (138) Facility ICU Beds 24 + 6 30 18 + 1 11 (58) Ventilators 34 34 1+0 33 (>35) On Hand (Days) County Warehouse Reserve (Days) N95 Masks >14 30 Other Masks >14 30 Gloves >14 30 PPE Gowns >14 30 Face >14 30 shields/Eyewear Facility PPE Watsonville Community Hospital (5/24/20) Current Census Surge Licensed + Total (Other + Capacity Surge Capacity COVID) (%) All Beds 106 + 23 129 19 + 4 106 (460) ICU Beds 13 13 2+0 11 (360) Ventilators 15 15 0+0 15 (>35) On Hand (Days) County Warehouse Reserve (Days) N95 Masks >14 30 Other Masks >14 30 Gloves >14 30 Gowns >14 30 Face >14 30 shields/Eyewear Sutter Maternity & Surgery Center of Santa Cruz (5/24/20) Licensed + Total Current Census Surge Packet Pg. 133 of 142 Surge Facility PPE All Beds Ventilators N95 Masks Other Masks Gloves Gowns Face shields/Eyewear Capacity 16 + 10 26 1 0 On Hand (Days) >14 >14 >14 >14 >14 ADDITIONAL MATERIALS (Other + Capacity COVID) (%) 5+0 21 (420) 0+0 1 (>35) County Warehouse Reserve (Days) 30 30 30 30 30 04.e (9034) Essential Workers County of Santa Cruz essential workplaces include, but are not limited to, Environmental Health Division permitted restaurants, gas stations, agricultural industrial businesses, and schools. The number and identity of permitted essential workplaces are on record with the Environmental Health Division. In addition, government workplaces include the County, four cities and special districts. The County has four health systems (Dignity, Sutter, Kaiser and Watsonville Community Hospital), seven SNFs, four Federally Qualified Health Center systems, and a number of primary care and dental groups and providers. Local and State Health Officer Orders provide requirements for essential businesses to operate in a manner that reduces the spread of COVID-19. Shelter In Place Orders require every workplace to post Appendix A – Social Distancing Protocols (Attachment I), to assure workplace safety measures are in place. Information and Guidance on the County’s main COVID-19 page is provided, which includes federal, local, and state guidance for essential and nonessential workplaces, FAQs, and resources for workers such as signage and educational materials. These documents have been distributed through regular provider updates, in the field, online, via e-mail distribution lists and through traditional and social media. Environmental Health Specialists conduct inspections and educate employers and management on sector specific and general guidance to prevent COVID-19. Links to the following local guidance documents are included below: • • COVID-19 Guidance for County of Santa Cruz Homeless Service Providers https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/COVID19%20Guidance%20for%20Santa%20Cruz%20County%20Homeless%20Services %20Community%20-%20Updated%203-22-2020.pdf County of Santa Cruz Agriculture Resource Guide https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/AG%20Resources -Eng-Sp.pdf Packet Pg. 134 of 142 • • • ADDITIONAL MATERIALS Food Facility Operators FAQs https://www.santacruzhealth.org/Portals/7/pdfs/Coronavirus/Food_Facility_Op erators_FAQ.pdf COVID-19 Guidance for Home Health Care Agencies https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/COVID%20Guidel ine%20Home%20Health%20Care.pdf Potential Employee Exposure to Coronavirus FAQs https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Critical%20Worker %20Exposure%20FAQs%205-20-20.pdf 04.e (9034) In addition to Health Officer Orders, local protocols and guidance, the County has referred Stage 1 businesses and employees to sector specific guidance at https://covid19.ca.gov/industry-guidance/. Future State guidance will be provided for other sectors of commerce and society such as schools. Medical and non-medical essential businesses can purchase cleaning supplies and disinfectants from vendors or directly through retail outlets. The County Emergency Operations Center (EOC) and Health Services Agency Public Health DOC maintain an inventory of available supplies for county essential workplaces, congregate settings, and health care facilities. The Medical Health Operational Area Coordinator (MHOAC) receives and tracks personal protective equipment and other health and medical resources for the first responder and health care community. The EOC manages personal protective measures (nonmedical grade such as face coverings), sanitizer, cleaning and disinfectant resource requests for shelters and other essential workplaces. PPE and PPM Guidance, as well as PPE and PPM Resource request forms are available on the County Coronavirus website. The County of Santa Cruz Testing Plan includes guidance for testing of sick or symptomatic essential workers. Symptomatic essential workers are encouraged to contact their healthcare provider for health advice and guidance. Symptomatic workers may be referred to health facilities that also collect specimens for COVID-19 testing such as hospital emergency departments. An open letter to all state defined Stage 1 essential workers was shared widely to encourage asymptomatic essential workers to utilize the OptumServe testing site. The County Health Services Agency FQHC clinics performs viral testing, in addition to hospital and commercial labs, and can provide testing with results within 24 hours for certain essential workers, through organizational agreements, with first responders and law enforcement. Prompt identification and isolation is essential to preventing further spread of the virus and keeping our essential workplaces operating. Based on local experience, nearly all essential workers can quarantine and isolate at home. Essential health care workers that cannot quarantine or isolate at home may request assistance with temporary lodging through the MHOAC or EOC. Health care providers caring for essential workers who cannot isolate at their residence are referred to the state program for low and no cost hotels stays for health care workers, or they may contact the EOC to request assistance with placement. Packet Pg. 135 of 142 ADDITIONAL MATERIALS Any essential worker identified as unable to isolate at their residence is provided isolation at a predetermined alternative shelter site or hotel. Food, social services, housekeeping, and transportation are provided at no cost to each participating individual. 04.e (9034) Special Considerations Agriculture The “Communication and Education for Farmworkers during COVID-19” workgroup meets on a weekly basis and is co-facilitated by County Public Health and the County of Santa Cruz Agricultural Commissioner. The work group is comprised of agencies that serve the farmworker population in Watsonville, which is primarily Latinx. The representatives include individuals from community-based organizations, the school district, food bank, safety net clinic(s), the State of California Employment Development Department, faith-based groups, the City of Watsonville, and the Farm Bureau. The weekly meetings provide an opportunity for County Public Health and the Agricultural Commissioner to provide updates on COVID-19 issues such as testing availability, face covering distributions, isolation housing and any other emerging issues. In addition, community representatives provide updates on outreach and education efforts conducted in Watsonville, and the Pajaro Valley, to prevent the spread of COVID-19 among the farmworker population. A shared Google Drive was created by County Public Health to ensure participating agencies have access to educational materials and to avoid duplication of efforts. Recently, Salud Para La Gente, Watsonville’s largest safety net clinic, presented a comprehensive framework to prevent the spread of COVID-19 among farmworkers. In upcoming meetings, the workgroup will explore how the strategies in the framework can be applied. Tourism The County of Santa Cruz has long been a travel destination, with tourism a major contributor to the economy. While the County has gradually begun to reopen, and will plan to follow the Governor’s Roadmap, local restrictions will be kept in place to disincentivize non-essential travel. These include daily beach closure from 11 am to 5 pm, as well as restricting all beaches and adjacent parkways for recreational activity only (see Press Release, Attachment V, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/BeachRestrictions.04292 020.pdf) . Sitting, lying and gathering in groups are prohibited on all beaches and adjacent parkways, as are beach paraphernalia such as chairs, loungers, coolers, umbrellas and shade structures. These measures have proven to be effective in decreasing travelers from outside of the County while still allowing residents to access the beaches for recreational activities. The Santa Cruz Beach Boardwalk, a major travel destination, remains closed. In addition, local Health Officer orders require hoteliers and short term vacation rental owners to keep ledgers of travelers along with reason for essential travel, and must present the ledgers on demand for law enforcement purposes (see Attachment W, FAQ from May 1st SIP Order, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Updates%20to%20the% Packet Pg. 136 of 142 ADDITIONAL MATERIALS 20SIP%20Order%20FAQ.pdf?ver=20200406). As travel increases due to the lifting of Stay at Home orders, the County will see an influx of travel from other regions and will be prepared to coordinate testing, isolation, and tracing with other jurisdictions as needed. The County of Santa Cruz looks forward to welcoming tourists and other non-essential travelers in the future, when deemed safe. Until then, the County is confident that the precautions put into place at both the state and local level will allow the County to adequately monitor and screen for an increase in COVID-19 transmission. 04.e (9034) Community Engagement During the COVID-19 pandemic the Board and cities have been apprised of the local data and progress towards the State’s variance criteria through the County Health Officer Dr. Gail Newel, Deputy Health Officer Dr. David Ghilarducci and Health Services Agency Director/Incident Commander Mimi Hall. The County Administrative Office has coordinated weekly meetings between the mayors of each of city within County of Santa Cruz (Scotts Valley, Santa Cruz, Capitola, and Watsonville) and our Public Health DOC leadership. Public Health hosts and participates in multiple recurring meetings to ensure regular communication with the public. This includes hosting a weekly press conference with a live stream on social media, participating in a weekly “Community Partner” call hosted by the local EOC, hosting a weekly call with local healthcare executives, and partnering with a local nonprofit, Health Improvement Partnership, to have a weekly “Clinicians Resource Call” with Public Health staff and a well-respected local infectious disease physician. The County of Santa Cruz, in collaboration with the Santa Cruz Community Foundation, has established an Economic Recovery Council (see website https://www.santacruzhealth.org/HSAHome/HSADivisions/PublicHealth/ CommunicableDiseaseControl/CoronavirusHome/SAVELivesSantaCruzCounty/ EconomicRecoveryCouncil.aspx) consisting of 13 Council members plus leaders from the local Chambers of Commerce. The Council members are respected leaders in the business community, representing a variety of industry sectors throughout the County. The Economic Recovery Council meets weekly with County leadership, including Public Health officials, to plan for the reopening of local business. Each member meets separately with a workgroup for their business sector, following State guidelines and developing plans for their particular sector. Relationship to Surrounding Counties The County of Santa Cruz is situated between counties with differing COVID-19 experiences. Although considered part of the greater Bay Area, the County is geographically divided from our neighboring counties to the north, Santa Clara and San Mateo. These two counties were impacted early in the pandemic, and have significantly higher case prevalence than does Santa Cruz. Both have large urban areas with economic sectors attracting international travel. To the south and east lie Packet Pg. 137 of 142 ADDITIONAL MATERIALS the counties of Monterey and San Benito, with large rural areas and agriculturebased economies, both with prevalence and case rates similar to Santa Cruz. 04.e (9034) The County of Santa Cruz has been actively engaged with neighboring counties through the Association of Bay Area Health Officers (ABAHO), representing 13 local health jurisdictions throughout the greater Bay Area. These Health Officers have met regularly since January to respond to COVID-19, and continue to connect through twice weekly conference calls. Additionally, they share documents and exchange ideas via Slack, a team messaging app. ABAHO has been at the forefront of developing and issuing standardized Shelter in Place orders. These orders have been widely credited for early success in disease containment. In the County of Santa Cruz in particular, the Shelter in Place order was issued very early in the County’s COVID19 experience, which is likely a major contributor to the County’s low disease prevalence and rates to date. Three counties lie adjacent to the Monterey Bay – Santa Cruz, Monterey and San Benito. These counties have a long tradition of collaboration as a tri-county region. This has continued during COVID-19, with frequent conversations between County Administrative Officers as well as Public Health officials. An ongoing weekly conference call between Santa Cruz and Monterey County public health leadership has been established, with a particular emphasis on the agricultural community in the Pajaro Valley, which overlies the shared border. All counties in the region have case rates lower than those of the State overall. Hospitalization rates are low or decreasing. Most of the case rates are low, with San Mateo being an outlier at 5 per 10K. In preparation for this attestation, the Health Officer for the County of Santa Cruz has communicated directly with health officials in each neighboring county. San Benito was approved for a variance by the first set of criteria on May 12 and immediately entered into full Stage 2 (except schools) with good response to date. Monterey recently submitted a variance attestation and also plans to immediately enter into full Stage 2 (except schools). Santa Clara County plans to stay in lockstep with the central Bay Area counties, with a stringent Shelter in Place order and no plans to apply for a variance. San Mateo County is following the Governor’s Roadmap through the four stages, and does not plan to apply for a variance. The leadership of the County of Santa Cruz understands how critical ongoing collaboration and open communication is to maintaining the health and safety of the region. As travel increases due to the lifting of Stay at Home orders, the County will see an influx of travel from other regions and will be prepared to coordinate testing, isolation, and tracing with other jurisdictions as needed. County epidemiologists have longstanding relationships with their counterparts in neighboring counties regarding cross-jurisdictional communicable disease investigations. The County of Santa Cruz epidemiology team participates actively in the ABAHO epidemiology group weekly conference calls. Packet Pg. 138 of 142 ADDITIONAL MATERIALS The County of Santa Cruz has long been a travel destination, with tourism a major contributor to the economy. While the County has gradually begun to reopen, and will plan to follow the Governor’s Roadmap, local restrictions will be kept in place to disincentivize non-essential travel. These include daily beach closure from 11 am to 5 pm, as well as restricting all beaches and adjacent parkways for recreational activity only (see Press Release, Attachment V, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/BeachRestrictions.04292 020.pdf) . Sitting, lying and gathering in groups are prohibited on all beaches and adjacent parkways, as are beach paraphernalia such as chairs, loungers, coolers, umbrellas and shade structures. These measures have proven to be effective in decreasing travelers from outside of the County while still allowing residents to access the beaches for recreational activities. The Santa Cruz Beach Boardwalk, a major travel destination, remains closed. In addition, local Health Officer orders require hoteliers and short term vacation rental owners to keep ledgers of travelers along with reason for essential travel, and must present the ledgers on demand for law enforcement purposes (see Attachment W, FAQ from May 1st SIP Order, https://www.santacruzhealth.org/Portals/7/Pdfs/Coronavirus/Updates%20to%20the% 20SIP%20Order%20FAQ.pdf?ver=20200406). 04.e (9034) The County of Santa Cruz looks forward to welcoming tourists and other non-essential travelers in the future, when deemed safe. Until then, the County is confident that the precautions put into place at both the state and local level will allow the County to adequately monitor and screen for an increase in COVID-19 transmission. The County is cautiously optimistic that a gradual and phased reopening, with constant vigilance for the health and safety of all County residents, will permit a successful new equilibrium during this challenging time, and allow parts of the County’s social and economic sectors to resume activities under the safeguards recommended by experts in pandemic control. Packet Pg. 139 of 142 ADDITIONAL MATERIALS 04.e (9034) Press Release For Release: Immediately Date: April 29, 2020 Contact: Jason Hoppin, Communications Manager Phone: (831) 454-3401 ADDITIONAL BEACH ACTIVITY LIMITS DURING PEAK HOURS Due to overwhelming weekend beach crowds that undermined State and local Shelter-in-Place orders, the County of Santa Cruz is implementing new rules to limit beach activity during peak usage hours. As part of an updated Shelter-in-Place order, Santa Cruz County Health Officer Dr. Gail Newel is expected to issue new restrictions limiting daily beach activities. While beaches remain available only for recreational activities to promote physical and mental health, beginning this weekend, beaches will off-limits for all activities between the hours of 11 a.m.-5 p.m. “Despite warnings against travelling to Santa Cruz County for beach access and against congregating on beaches, local law enforcement spent the weekend responding to numerous issues all along our coastline,” Sheriff Jim Hart said. “Unfortunately, these actions are necessary to protect the health and welfare of our most vulnerable residents. The Sheriff’s Office, the police departments and State Parks will do everything we can to support the Health Officer and enforce her revised order.” Previous limits on beach activities such as lying, sitting, standing, sunbathing, sightseeing and other non-exercise related activities remain in place. No umbrellas, barbecues, coolers, beach chairs, shade structures, tents or other equipment will be allowed at any time. Water-based activities such as surfing, paddleboarding, boogie boarding, swimming, snorkeling and kayaking will not be impacted by the order. Beaches may be traversed to participate in these activities. Additionally, facilities adjacent to beaches such as parkways, sidewalks and trails will remain open. Non-beach areas of local parks are unaffected by the order, though they remain subject to restrictions put in place by State and local jurisdictions. The order will remain in effect until revised by the Santa Cruz County Health Officer. For local information on COVID-19, go to www.santacruzhealth.org/coronavirus, call 211 or text “COVID19” to 211211. Residents may also call (831) 454-4242 between the hours of 8 a.m. and 6 p.m., seven days a week. Packet Pg. 140 of 142 ADDITIONAL MATERIALS 04.e (9034) UPDATES TO THE SHELTER-IN-PLACE (SIP) ORDER What is different in the May 1st Santa Cruz County Order from the March 31ST Order? • All essential businesses will be required to follow minimum basic safety precautions, including physical distancing and face covering requirements, and post health and safety information (Appendix A). • Allows non-emergent healthcare services in accordance with State directives and guidance, including elective surgeries and other services which may have been delayed. Healthcare facilities must comply with State guidance around Personal Protective Equipment and other measures. • Permits construction in accordance with State directives and guidance, with proper physical distancing protocols (Appendix B). • Permits real estate transactions in accordance with State directives and guidance. • Permits individuals to move to a new residence; however, if moving into or out of Santa Cruz County, individuals are strongly encouraged to self-quarantine in their new residence for 14 days. • Permits landscaping and gardening, tree trimming, and other outdoor services. • Permits wholesale and retail nurseries, and other businesses that support outdoor services. • Allows the use of golf courses and driving ranges with documented protocols that are outlined Appendix C of the revised order. • Allows stable groups of 12 or fewer children for recreational or educational purposes. Such activities must be carried out in stable, “closed” groups of 12 of fewer, as described in the Order. • Outdoor recreational areas and activities with high-touch equipment or that encourage gathering such as team sports, pools and playgrounds will not be permitted to return at this time. • Adds those who manufacture, distribute, sell, rent, lease, repair or maintain vehicles and other transportation equipment as essential businesses, with social distancing requirements. • Includes fabric and craft stores as an essential business for purposes of supplying materials to create face coverings and other personal protective equipment (PPE). Packet Pg. 141 of 142 ADDITIONAL MATERIALS 04.e (9034) What does the modified SIP order say about beaches? • Beaches will be closed 11:00am – 5:00pm, but may be traversed during these hours for the purposes of water sports. • Beach parkways will remain open for use during these hours, as will the water. • Outside of these hours, beaches are only open for recreational activities to promote physical and mental health, such as walking, running, cycling and water sports. • At no time will sitting, lying, standing, sunbathing, sightseeing, and other non-exercise activities be allowed at beaches. No umbrellas, shade structures, tents, barbeques and grills, coolers, beach chairs, or other conveyances for sitting or lying will be allowed on the beaches. What does the modified SIP order say about hotels and vacation rentals? • Although nothing has changed in the order about hotels and vacation rentals, clarifications are made: o Hotels, motels, inns, bed and breakfasts, vacation rentals, RV parks, campgrounds, and any other short-term lodging businesses are prohibited from providing accommodations to any individual unless that individual is: ▪ Present in the County for the purpose of performing services for an Essential Business o ▪ Performing services at Health Care Operations, ▪ Providing an Essential Governmental Function ▪ Providing care for a sick individual. Lodging staff is required to keep a written record of the purpose of the guest’s stay that is consistent with the terms of the Order and have it available should law enforcement request to see it. o Lodgers, business owners, and business operators are all subject to citation for violation of these restrictions. Packet Pg. 142 of 142