SANTA ANA (CNS) — Orange County Health Care Agency officials Friday reported six more people have succumbed to COVID-19 and 209 more have been diagnosed with coronavirus. 

The death toll now stands at 1,281 and the cumulative number of cases is at 54,118 since the pandemic began.

Four of the six reported dead on Friday were skilled nursing facility residents. Since the pandemic began, 461 of the deaths were skilled nursing facility residents and 89 lived in assisted living facilities.

Orange County CEO Frank Kim said he was concerned to see the case rate rise above 200.

"I'm concerned," Kim said. "I want to see those numbers smaller. The general trend is a slow, steady rise in case loads. We're not seeing any significant particular industry sector that is causing it. It's generally throughout the community."

The reporting of COVID-19 fatalities comes from multiple hospitals and the Orange County coroner's office and are often delayed, so the six deaths happened over the past few weeks. But the Orange County Health Care Agency has reported 67 fatalities since Sunday, following 77 last week.

The deadliest day for the county since the pandemic began remains Aug. 3, when 19 people died. The last day of double-digit deaths was Aug. 31, when 10 people died.

"When you see a surge of cases, the unfortunate second shoe to drop in our community and in communities across the country is deaths, which is a lagging indicator," said Dr. Matthew Zahn, the medical director of the county's communicable disease control division.

The deaths are "overwhelmingly related to the surge in cases a couple of months ago," Zahn said. "Our hospital and ICU numbers (since then) have really gone down, which is really important."

Hospitalizations jumped from 158 on Thursday to 175, with the number of patients in intensive care inching up from 45 to 48. The county has 34 percent of its intensive care unit beds available and 67 percent of its ventilators. The change in 3-day average for hospitalized patients rate increased from 5.4 percent on Thursday to 6.8 percent.

The positivity rate, which is reported each Tuesday, stands at 3.1 percent, the same as last week, but the daily case rate per 100,000 people went up from 3.6 to 4.4, which is higher than the cutoff of 3.9 to qualify for the state's orange tier.

It means the county will remain in the red tier for at least another two weeks, but there is hope the trend will continue and that the county will be able to move into to the orange tier by mid-October.

Last Thursday's and Friday's numbers put the county over the top, said Dr. Clayton Chau, the director of the Health Care Agency and the county's chief health officer.

"We've had a few days of uptick in numbers, small but significant to affect our tier system," Chau told the Orange County Board of Supervisors on Tuesday. Chau said it appears that Labor Day gatherings led to the increase. 

One of the thorniest problems is young adults renting out vacation residences for parties, Kim said Monday.

Students returning to school don't appear to have been an issue, Zahn said.

"At this point, we see really minimal activity," Zahn said. "What we've seen so far is quite encouraging."

Kim said the increase in cases amounts to about 30 diagnoses a day. Officials have not seen anything in particular fueling the slight increase. 

County Supervisor Lisa Bartlett said there is concern about a seesawing back and forth between the red and orange tiers because if the county has to step back a tier, that locks it into place for at least three weeks even if the metrics match a less-restrictive tier.

State officials were expected on Friday to announce new guidelines for mass gatherings, but did not do so. The mass gatherings include theme parks, concerts and sporting events. The expectation was that those types of activities will not be allowed until a county moves up to the least restrictive tier of yellow, which could take months.

Orange County Board Chairwoman Michelle Steel criticized the state for "dragging its feet" on issuing reopening guidelines for theme parks like Disneyland in Anaheim and Knott's Berry Farm in Buena Park.

"We need these parks to reopen not for our children and tourists but our businesses and communities that rely on them," Steel said. "I am disappointed at the lack of progress California has made in this and every other area while other governments have made safe reopenings of their theme parks. California continues to delay and this has resulted in the loss of 28,000 jobs. All of this could have been avoided."

The OCHCA reported that 881,030 COVID-19 tests have been conducted, including 10,569 reported Friday. There have been 48,734 documented recoveries.

To qualify for the orange tier, the positivity rate must be 2 percent - 4 percent, and the case rate per 100,000 must be 1 percent - 3.9 percent.

Moving to the orange tier means retail businesses could operate at full capacity, instead of 50 percent as required in the red tier. Shopping malls could also operate at full capacity, but with closed common areas and reduced food courts, just as in the red tier.

The orange tier boosts capacity for churches, restaurants, movies, museums, zoos and aquariums from 25 percent capacity to half capacity. Gyms and fitness centers could boost capacity from 10 percent to 25 percent and reopen pools.

The orange tier also allows family entertainment centers like bowling alleys and wall-climbing to open indoors to 25 percent capacity.