>> chair mandelman: is the a.l.u. here? come on up. >> good morning, members of the board, officer solomson, a.l.u. unit. there are two letters of protest, zero letters of support. they're located in plot 558, which is considered a high crime area. they're in census track 162, which is considered a high

saturation area. alcohol liaison unit recommends approval on the following conditions: number one, sales, service and consumption of alcoholic beverages shall be permitted between the hours of 8:00 a.m. and 11:00 p.m. daily. number two, petitioners shall actively monitor their area under their control in an effort to prevent the loitering of persons on any property adjacent to the licenses premises as certified on their most recent ab-253 form. and no noise shall be audible at any nearby residents. i've just now spoken to them about agreeing to these conditions, and they have. >> chair mandelman: so the

conditions have been agreed to, and they're done. i don't see any questions or comments from colleagues. is the applicant here? come on up. if you want to. >> so we've accepted the conditions from john over there. the epicurean trader, we're a husband-and-wife run business, independently owned. our current markets are well reviewed and they're widely accepted in the neighborhoods in which we currently operate. in hayes valley, there are 5,296 residents in the

immediate vicinity of the location, as well there's location. since we've aunited states noed our plans to open the location, we've received overwhelming support from the hayes valley. we've designed the protection with the neighborhood in mind and feedback of the residents. we're dedicating a portion of the store to necessity needs. less than 5% of the total square footage is dedicated to alcohol. it is a small part of the business but a key part of the business. in order to provide essentials at a low price, we need to be able to sell shelf stable items at a high margin, which alcohol is one of those items. we're a very respected retailer. we have numerous locations and we've never had any problems selling alcohol, and we hope that you'll support our

location to open in hayes valley. thank you. >> chair mandelman: okay. seeing no questions from my of any colleagues, is there anyone who wishes to comment on this? if not, i'm going to close public comment. public comment is now closed. [gavel]. >> chair mandelman: well, i want to thank the a.l.u. for their work to get this within our 90-day deadline. i know this required a little bit extra, but i think at least one member of the board has expressed a strong desire for that. the a.l.u. will continue to respect the wishes of the city if we come in a little bit late. we are endeavoring to come in within that deadline. so thanks for all of your work. i understand that supervisor brown is in support of this item, and so i think we can

direct our clerk to prepare a finding of public convenience and necessity, that granting this license would serve public convenience and necessity. and so colleagues, can we forward that resolution to the full board with a positive recommendation without objection? we will do that. fantastic. thank you. mr. clerk, please call the next item. >> clerk: agenda item number two is consider hearing the transfer of a type 23 distilled wine, beer and liquor license to on the run market located at 4100 market, will serve the convenience and necessity of the city. >> chair mandelman: thank you. we are joined by supervisor fewer. >> supervisor fewer: thank you, chair mandelman. given the location of this residential area in a proximity

to an elementary school, a church, and a park, i feel it is important to have a thorough review and discussion about the conditions for this type 21 off sale general. i am questioning whether it is appropriate in this case to consider sales of liquor in bottles or containers that are less than one pint. the incidents of concern around liquor in the neighborhood previously have occasionally stemmed from the littering and consumption of these small bottles. i have also since been made aware that there are letters of protest from neighbors in proximity to establishment which is a consideration. i would respectfully like to request a continuancetor additional time to continue discussions with the a.l.u., a.b.c., and the applicant. >> chair mandelman: great. seeing that request, if my colleagues are okay, i think we will be inclined to grant it. but we do need to take public

comment on this item if there are members of the public that wish to speak on this item. i will close public comment. i will continue this until the next meeting of the public safety and neighborhood services meeting. >> clerk: and just to clarify, mr. president, that will mean it will be continued to april 18. >> chair mandelman: thank you. mr. clerk, call the next item. [agenda item read].

>> chair mandelman: great. supervisor stefani? >> supervisor stefani: thank you, chair mandelman. i want to start this hearing by telling you the genesis of why i called for this hearing. last year, i was on chestnut street in my district with my son, who at the time was 13 years old, and we saw an individual in distress. he was walking down the street with no pants, and looking drew garbage cans for food, and acting in a way that made me think that this person was in need for our help. so what i did was i called the non-emergency police number, and i waited. and they came out, and they made contact with this individual who complied.

and as the police were deciding what to do, they came up to me, and they said well, you know, you called it in. do you -- do you want to make a citizen's arrest for indecent exposure or something like that? i said absolutely not. this person does not need to go to jail. that's exactly what we do not need to happen. so after a series of questions, the police determined that i believe this person was a danger to himself. i don't know if to others at this point, but they ended up taking him to the hospital, to sf general on a 5150 hold. at that point, i don't know what happened because of hipaa laws, and you lose track of what's going on at that point. but the next day, i saw this individual on chestnut street with his hospital bracelet on almost in the same condition. so that, for me, what that said, i think when this person was taken to the hospital in

need of help, that somehow when he was released, something -- we missed an opportunity, that we, in part, i think failed this person not getting him the help that he needed. to see him back out on the streets one day later in the same condition for me was heartbreaking, and i want to do better. i want us as a city to do better. and i see this individual time to time in my district, and i don't know how to help him. and i want to learn how to help him. we talk a lot about coordinated entry in the city and county of san francisco, but we don't really talk a lot about coordinated exit. and when i'm talking about coordinated exit, i mean, what are we doing at the hospitals? we know that the homelessness crisis on our streets is not new information. we know for decades of thousands of people have lived

without homes or shelters, and biennial counts, the number of people living on our streets have been relatively stable. i believe that the number of people who are unhoused has worsened in recent times. i believe homeless residents, some with mental abuse and substance abuse issues are homeless as we know, and months or years of living on the streets only exacerbates these conditions and makes it worse for the individual. we know that nationally, america has been hit with an opioid epidemic. over 70,000 people have died nationally, and our city has not been immune to this. i think the doctors and physicians that pushed oxycontin on this country should be in jail. worse yet, san francisco has been affected by an increased use of methamphetamine. i believe as a society, we need

to do everything we can, everything we can to destigmatize mental health and substance abuse issues. treating these is an ongoing challenge and requires ongoing effort, but we must lead with services and treatment. all of these problems under lie the heartbreaking crisis that we are witnessing on our streets. thousands of people, many with physical, mental and substance abuse related health conditions who are struggling to survive are unhoused and in need of our help. our homelessness crisis is not just about homelessness, it is about mental health and substance abuse, as well. and i know this personally. i have a brother who is a heroin addict, and has been homeless in my hometown of merced. and i see how hard it is to help him.

i see how hard it is for my parents to help him. we try everything we can to help my brother, but he wants to use, and it's incredibly challenge. and i understand those challenges for families, and i understand those challenges for people who want to provide services to help individuals who are suffering. we know this crisis will not be solved overnight. we know it will take years of building new shelters and supportive housing, improving upon our services, and holding providers accountable. so i have three goals for today. first, i would like to understand the processes in which multiple departments coordinate and provide services to individuals with mental health and substance abuse issues with a focus on the 5150 process. and why i say the 5150 process is when i toured s.f. general, and i talked to the psychiatrists there, i learned

that 68% of p.e.s. admissions are homeless. second, i'd like -- i want to identify key points where departments interact or do not interact and could, such as when a person enters and exits psychiatric emergency services. again, a coordinated exit. third, i want to identify opportunities to improve the current coordination and services. are there ways we can leverage existing resources to provide more or better resources. are there points where we are losing people, where we can get them better services other than returning them to the streets? and i also want to understand what services could we be providing when people are leaving the hospital on a psychiatric hold? what are we lacking? where do we need to invest?

is it more mental health beds? is it step-down beds? is it treatment on demand? what is it because i know we want to figure that out. we all do, and i want to figure out how to provide that. i also want to be clear in this hearing. this hearing is not focused on sb-1045 and conservatorship. this hearing is about what happens when people living on our streets with substance abuse and mental health issues enter the hospital whether on a 5150 hold or for any other reason and how we can better help them. i want this conversation to be not preventing us to ever -- about preventing us to ever getting to skefsh to haveship because as long as we have people out on the streets suffering from mental health and substance abuse and physical issues, the more likely it is we have to consider conservatorship.

we have to figure out how better to coordinate services to make sure that happens. i think everyone can agree, and sb 1045 talks about eight 5150s. that's far too many for one individual, and we have to do everything in our power to help people the first time they need it. the hospital cannot be a revolving door that leads back to our streets. when we have an opportunity to help people, i believe we need to do everything we can to fix people at that point. we need more shelter and we need every effective services. we need every city department to be accountable and raise the bar in what we do. no city in california has figured this out, and we are all facing similar problems, but i think what we can do is continue to fight for change

and continue to demand that we do better. i think today can be a step in that change and i want to thank all of the representatives here and for my fellow committee members for being a part of this work. i do have -- i'm not sure if someone wants to speak, but i do have the leader of the san francisco foundation that's going to lead our presentation. >> hello. thank you for inviting me to speak. thank you. i'm dr. barry zephen. our team cares for people who experience homelessness who are at risk to dieing who are not getting their health needs met by other services. i'm going to present a case. the title of this case is it

takes a village. i'm using a supseudonym to protect his identity. john was on s.s.i. disability but somehow this was cutoff. he was homeless about before he came here and came "to get away from trouble." he was initially seen by street health worker shannon in october 2016 during civic center out reach. he was noted to be injecting into public and having several possessions, including electronics and several bicycles in various states of repair. he had a long history of bipolar disorder that had initially been diagnosed when he was an adolescent. he stated his goals were to get or drugs and visit his family

back east. he was among the first 20 patients in our low barrier buprenorphine pilot. over the next several months he had numerous police contacts and several periods incarcerated in jail. he is involved in community justice court. he had periods of depression, several medical and psychiatric emergency visits and two medical hospitalizations for serious skin and soft tissue infections. street medicine saw him frequently, often several times a week, initially only in the streets, but gradually more and more in our open access clinic. he had several short stays at shelters and navigation centers and somewhat longer and more successful time at humming bird place. he had extremely fractured

thoughts when he was in crowded social setting. he was assessed for housing by e.c.s. through the coordinated housing process and is receiving s.s.i. access through lawyers for homeless advocacy project. he was the first street medicine patient to receive the long acting injection form of buprenorfine. he is on the housing priority list, and with assistance, he is working through the complex process of obtaining permanent supportive housing. we are about to start treating

him for help tpatitihepatitis- goal of curing him. so what has changed? he still wishes to visit his family back east. now he has only one bicycle. he was not injecting drugs today and says he feels better than any time since he was a teenager. he is not blocking anyone's sidewalk with his possessions. he has not had psychiatric emergencies nor been admitted to hospital again. he speaks amazing that people think he is doing well. he is likely to need a good deal of support. the department of public health cares for thousands of people experiencing behavioral and homelessness issues each year. i've presented the case of one individual. street medicine works to

stablize those individuals who other services are not working for. i will pass it onto roland to talk about sfdph

from h.s.h. and h.s.a. and will provide you with an overview of the services we provide both individually and collectively as part of the process. i think it's important to note that a couple of years ago i didn't know my colleagues in h.s.h. and h.s.a., but because

of the crisis that we see on our streets, it's really forced us to get together and work collaboratively. this past summer, we had a retreat for all of our workers and form an action plan how we can help our citizens. between our three departments last year, we provided services to over 13,000 individuals experiencing homeless. our collective mantra is that no door is the wrong door. and actually, there shouldn't be any doors. it's really about seeing our clients where they are and many times, that's on the street. we -- when we encounter individuals on the street, that is done through a collaborative

approach by b.p.h., h.s.h. and h.s.a., led by dr. zephen, n nurse practitioners, psychiatrists, special physicians and peers who are out on the street providing real medical care to patients, and not only providing that care but linking them to more permanent types of medical care. we also have engagement specialists, and these are like a health care level individual, and oftentimes peers, people who had previously been homeless or addicted to substances and who are really out there and can realty to individuals -- relate to people that are out there on the street. the h.s.h., they have the homeless team, and that's the biggest team out there throughout the city in key neighborhoods where they're actively engaging individuals

on the street. and then our colleagues in h.s.a., they provide a very important component, which is making sure that individuals have access to benefits because those benefits can be the stablizing force that really keeps them on the right track. so how does this all come together? within the last 18 months, it's really come together in a couple of places. the most prominent one is hsoc, healthy streets operation center. that's where we combine with other departments like the police department, like the department of public works on an every day basis, and it's like an air traffic control. you mentioned the call to the non-emergency number, those calls come into hsoc. all the parties are at the table and really determines who's best to handle the call? it may involve some of our street specialists or street

medicine or e.m.s. 6 from the fire or it may involve the police department, depending on the nature of the call. our role is to provide medical and behavioral health services. h.s.h., our housing partners, and h.s.a., those benefits linking services. and then, the police. we're fortunate to have a police force that's out on the streets and actually have relationships with some clients, and so we rely upon them and to be their partners to support them in their out reach activities. we already talked about hsoc, but another way that we all come together is through what's called whole person care. whole person care is a program through the state of california's 1113 medicaid waiver that provided funding to counties in california to focus

on high utilizing populations. in san francisco, d.p.h., h.s.h., h.s.a., we've all come together the past two years in our whole person care program to again figure out how we can collaborate better to provide services. one of the things we -- i mentioned the retreat we did this past summer. one of the things that came out of that retreat was we need to have a better way in terms of who would get access to what services? i'd like to share this. this up side down triangle really represents the spectrum of services available in public

health. i want to highlight it includes both substance abuse services and mental health services. just to acclimate you to this gra graph, on the right-hand side, you see acuity. that is acuity from the lowest, all the way to the highest, which are locked mental health facilities. now dr. zephen provided you with a pretty illustrative case with what our workers encounter on a daily basis. but we wanted to give you more general overviews of how individuals are encountered and how we work together and collaborate. so in this scenario, it's a scenario of someone actively

using substances on the street. in many cases, someone like this, the call may come into hsoc or it may be one of the s.f. hot team members or an individual who encountered this on the street. often times, it's not one encounter, it's just that repetitive process. so for example, john may have been engaged over several weeks or months by annen gaejment specialist in attempting to refer him for treatment. he's finally decided he's ready for treatment, he right landev relationship with that engagement specialist, who will often walk john over or drive john over to a treatment access program. that's located at 1380 howard street, run by d.p.h. that's the place where all of

the substance abuse beds coordinated by d.p.h. is. those types of services include residential treatment. these are actually facilities, many of which are run by healthright 360. they're usually a 90-days, but it can go lessor more, depending on what the individual needs, and they can be placed there. in addition, while john is in that residential treatment center, h.s.h. is involved, and they're putting him through their coordinated entry process which then prioritizes where he is in the housing pipeline. >> chair mandelman: hold. supervisor ronen has questions and i have questions. >> supervisor ronen: thank you, chair mandelman.

so a couple of questions. so first of all, i know that 90 -- what i've been told is that 90% of individuals that are suffering from a mental health disease have also an accompany substance abuse addiction. that's what some providers have told me. that's an estimate of the figure. so are we talking about someone that has a substance abuse disease but not an accompany mental health? my understanding is they're offering co-occurring. >> and they're also trioccurring, so not mental health and substance abuse, but hypertension. >> supervisor ronen: when is the decision made to go into a

heath rig healthright 360 treatment program or conor house, where the emphasis is a little bit different, conor house, and, maybe progress, mental health being the primary disease, and healthright 3 healthright 360, substance abuse be the primary disease. >> if a person needs a mental health placement or substance abuse placement, they're in the same room, so they can determine which way that person needs to go. >> supervisor ronen: and is that a doctor who makes that determination? >> i'll have our director of public health answer that, but it's usually some type of social worker or clinician who is trained in what is the

priority, what is the clinical presentation of that person? they will review that and say based upon these criteria, you need this level of care. >> good morning, supervisors. so the assessment is done by a qualified practitioner, and that may be a clinical social worker or licensed family marriage therapist or nurse practitioner, and these individuals are all qualified to diagnose and assess treatment, so that is the structure at any given time. and also for our treatment access program, we have people that are certified in drug and alcohol counseling, which is a requirement for a long of the substance abuse treatment

provider dispalestine cipline, >> supervisor ronen: so after that decision is made, whether healthright 360 or progress or conor house decision is made, focused on treatment for the individual, how often is a bed available in one of those programs to immediately send a person there? >> so for mental health beds and substance abuse residential, there's -- there's detox and substance use residential treatment, and then, we also have recovery step down as another level. for mental health, if someone needs to go into a residential treatment or a mental health residential facility, that is actually processed through our transitions team, which they will do that assessment and they will make the determination of the acuity, the criteria. but also, a lot of time, people

may not go directly to there. they may go to an acute aversion unit. and someone can also go directly to the center, as well. they can go directly to healthright 360, and then, they send the authorization to us. we just want to make it more sort of accessible. so for substance abuse residential treatment, we usually actually have availability, and that is something that i think it's not known a lot of times. there -- the other day, when you had a hearing on -- for hsoc, we had number of residential treatment beds availab available. and it wasn't that we were holding them. there are a number of reasons that someone may not choose to go in. they may have different ways --

the person may show -- the assessment may show they don't meet the criteria, they may not want to go to detox. we want to make sure we always have beds available for substance abuse treatment, but i would say the pressure there is little bit less because it's really trying to make sure that we can get the person in. and then, the reason also sometimes those are less is because somebody may get in, but they're not mandated to stay in. or two days later, they won't stay there. for residential mental health, that is actually -- there is a list, and there's a wait, and there's not always immediate accessibility. >> supervisor ronen: what is that wait time? >> that one, i think our transitions team -- it could be weeks to months because again, depending on the location, as

well. >> supervisor ronen: what's the average wait time? >> i would say -- few months? >> supervisor ronen: so three months, do we know the exact wait time? >> we do because we have been tracking that in a residential setting. >> supervisor ronen: could we get it right now? could someone find that number right now? the other thing is i'm hearing two totally different things. so i want to clarify this, and i think that's the whole point of this meeting. any time one of my selself or colleagues tries to get into this subject matter, you talk to anyone in the city and you will hear a completely different story and emphasis. that's why i appreciate my colleague, supervisor stefani,

for calling this hearing. i feel it's incredibly needed, and i don't feel like we have a system that makes sense. so i heard from mr. pickens that everyone is assessed at the task level, and then, i hear from you that that is not the case. so you finally agree after many outreach attempts by the d.p.a. and hot teams engagement specialists. and i'd love to hear how they work together, but that's a whole other story -- that the person finally agreed to be assessed at t.a.p. and a nurse or a licensed clinical social worker has to make an assessment about whether the primary sort of need for this individual is a mental health disease or it's a substance abuse disease. and then -- and then, if it's

substance abuse, it's healthright 360, but for mental health, where do they go? >> for mental health treatment and substance abuse access, that is not where we would determine the placement for residential mental health. that is for figuring out what the needs are and assessing that for our different levels of care. >> supervisor ronen: wait, wait, wait. wait, wait, wait. sorry. can you clarify. you said they are triaged and referenced. >> the question is what level of service do they need? do they need an outpatient

level of assessment where they can come and go, or do they need residential treatment where they actually have to go and stay. so that decision -- that assessment is done at bhac -- >> supervisor ronen: bhac is t.a.p.? >> they are at the same location. they are located at 180 howard. it's kind of like air traffic control for mental and substance abuse programs. >> supervisor ronen: so the bhac-t.a.p. patients, they are being assessed by clinical workers or nurse practitioners. we need to treat the primary reason why the person is on the

street or not succeeding in society, and then, what happens to that person? >> the next question is, is there -- is this a housing issue or a treatment issue? >> so this person is experienci experiencing homelessness. so what's happening to this person? >> basically, we're trying to figure out what is the treatment option for them? do they need option, do they need case management? if they need housing -- >> supervisor ronen: okay. so let me try to make this easy. it is clear this person needs residential behavioral treatment bed, but there's a 90-day waiting list, although you don't have that number here today, which is frustrating, so you're going to get it for me. >> so that person would probably be referred to a navigation center to get them

off a street. >> b >>. >> supervisor ronen: but it's a person that's a schizophrenic who can't handle a 120 person room or -- what happens to that person? >> if they're -- >> supervisor ronen: okay. let's walk this through. >> or hummingbird, to help out the nav -- the nav center that exists is hummingbird, which is not nearly enough beds. >> supervisor ronen: okay. so i just want to understand. they are at t.a.p. it's determined that they have a mental health disease. the options are to go to p.e.s., hummingbird or they go

where? >> they could also go to urgent care, and after urgent care, they can decide if that person needs acute diversion, and they can go to housing for two weeks or plus, depending on their needs and what their needs are assess. and then, while they're there, they're continuously assessing what the next steps would be. >> supervisor ronen: okay. so let's say they go the urgent care route, which is probably the best route, 'cause there's a 12-day stablization crisis. but there's still no bed in the residential. where do they go? >> they're done with the a.d.u., and the question is where do they go next?

>> supervisor ronen: yes. >> i think there will be a conversation about where do they go next? we may be looking at stablization rooms, various options. residential treatment is one option. and again, we have to look at the condition of the person. not every person is presenting in a situation that are in a crisis. there are people who are also presenting in a crisis -- >> supervisor ronen: but they're homeless and schizophrenic and homeless and severe depression. >> people who are bipolar, the illness is one piece. there are people who have schizophrenia what a schizophrenia who are doing very well and very much productive. so you're talking about a very, very highly sort of acute and someone who's in a major crisis. that would be a different approach we would have versus

someone who has schizophrenia -- >> supervisor ronen: i'm just trying to understand the process. i'm trying to understand the person in your example who's been engaged by someone in your department, it's the person who's on the street. it's the person who every single person in this room has seen on the street countless times, who's talking to themselves, who needs help. it's the person that catherine stefani was talking about when she opened up this hearing. so that's who we're talking about we see every day on the streets of san francisco. where does this system breakdown? >> supervisor stefani: can i just interject real quick, supervisor ronen? >> supervisor ronen: sure. >> supervisor stefani: i understand where you get behind

we need to make sure we have enough resources. when the individual is at t.a.p. or bhac, and you're tlieitli trying to figure out -- they want help, and they want to get better. what we want to know as le legislators, what you need to do better. gosh, i wish there was really another mental health bed for this person into, gosh, i wish there was another residential treatment bed to get this person into so they don't have to go back onto the streets. your wish list to basically serve everyone that is coming through t.a.p. and bhac. >> i can tell you that since -- more hummingbird.

>> supervisor stefani: that's what we want to know. that's why i called this hearing. >> chair mandelman: can i jump in for a second? >> supervisor stefani: yes. >> chair mandelman: is hummingbird expanded? i think they are at 15.

>> yes. >> chair mandelman: and do you need a lot time? >> hummingbird is always full. >> chair mandelman: and you have a daytime at hummingbird. >> they treat people all day until 6:00. >> supervisor stefani: and just to follow up, it's not just about what the city and county of san francisco can provide, if what you need from us in terms of how we invest our dollars, but i want to know what can our other hospitals be doing? what can we step up to do? that's the information we need. what can we ask kaiser to do? what can we ask cpmc to do? i want to know what we need, and then how we can ask the other places to provide it.

>> we need more lsat, locked subacute treatment beds. >> chair mandelman: what does that mean? what is a locked subacute treatment bed? >> so it means the individual cannot come and go as they please. >> chair mandelman: so they would be inappropriate at s.f. general, and we would have a hard time justify keeping them there, but they don't have a place to go, and they can't be released on the street, and we also don't want to send them out of county. >> right. >> chair mandelman: that's the point of expanding the healing center with the eraf dollars does. i know that supervisor stefani has a few more questions, but i know that supervisor ronen

wants to follow up. >> supervisor ronen: yeah. instead of following the line that i started and i feel like i haven't gotten a lot of answers for, i'll follow up with what supervisor stefani said. so hummingbird is -- it's a navigation center. and granted, it's a navigation center that's focused on people with behavioral health conditions, but it's a temporary place for homeless individuals to be. it's not a treatment plan. it's not -- it's not the stablize -- it's not going to stablize the individual or get them to a place. so what's next for the person? what are the exits for humming bird? where are those people who fill those 29 beds every single

night go? >> so i would say it is a stablizing force, because number one, it gets people off the streets. >> supervisor ronen: no, no, i understand that. i'm looking for a path that -- you know, i believe that everyone can get well, and that everyone with the right set of circumstance can be somewhat reintegrated into society, maybe hold down a certain job, maybe living in a housing situation that isn't as restrictive as a residential treatment program. so i guess if that's where i'm starting from, that is my firm belief, what is our past in san francisco to get that person there, and, and it worries me.

while these are both very important, i don't believe that these are the two pieces that are going to get a person to reintegrate into society and no longer go through that cycle on the street of where they get to eight 5150s, etc. so i'm just looking for a vision from our departments that say here is our system, here's how it works, here's how you get from point a to being back in society and having a chance at a life again and off the street. and i have yet to understand or hear that