so i'll do the next couple of slides and we'll switch back and forth but one of the things we wanted to talk about as we've previously discussed, that we have both a legal and ethical responsibility to treat individuals in the least restrictive setting. and over the years have made a number of investments in less are restrictive interventions and where these investments are ebb and flow depending on the te needs of the population but it provides urgent care, the healing center beds, and straight medicine. we completely agree with the conservativeship offices that the primary reduction in conservativeships is related to the implementation of 5270, but some secondary reasons why this might be the case is the implementation of other innovative programs in our community, including outpatient treatment which launched in 2015 and we've had reduction,

including hospitalization and jail contacts and the goal of this program is to get ahead of a crisis to cry for cuyahog cri. wovwe've worked around this and implemented thresholds, including the mobile therapy vans, as well as engagement therapy specialists. this graphic is something sure i'm sure everyone is familiar with at this point, since we use it as a representation of our system of care and again, just to reiterate that our focus is on voluntary services and leases restrictive options and conservativeship and locked facilities are an important tool

and part of our system of care for vulnerable individuals who meet the legal standards. i think what's important to note is that individuals aren't stuck at any of the levels of care. recovery and wellness is not a linear journey, but our goal to get people back to the less restrictive option for them. >> so we heard about the correction to the very important caseload comparison that's in the vla report and that's a huge relief for me to know that, thank you, supervisor stephanie, for requesting an amendment to the report be made and i think it's important for all of you, for our policy makers at the local level, the state level as well as the community to have accurate data points. and it was a concern for me because that data point has been cited in multiple newspaper articles, tv news, radio, even

cqed forum. and so i know that policy makers want the correct information and i think it's an interesting question about caseload size, what is the appropriate caseload size and one thi thing i can sa, administrators of these programs, we don't have baseline levels of standards. there aren't standards. there isn't reliable data behind this state report that's published by the department of healthcare services. we don't have state-wide reports that actually provide information so that we can do cross-county comparisons and i think that is really a disservice to all of us and i will just mention, i am on the boar for the state-wide association that represents public co conservators.

we have another bill that was mitted in the last legislative cycle supported with csac and to request state funding for the county operations of the programs. and there is not a home for the office of the public conservator at the state level which is unusual for programs we operate locally and that's because there is no dedicated funding for the public concouldn' conservator p. part of the budget proposal that is going forward is that the association would assist the state with data collection efforts moving forward and i wanted to highlight that proposal because i think any support we can provide would be really helpful. i think it's a very important proposal. so again, this was a survey that we did, a point in time survey,

and i'm grateful they accepted the information we provided and we have saved these caseload standards through inquiry to colleagues. i will tell you that some of my colleagues are concerned about having their caseload numbers published. it is public information. but the concern, because there's a lot of attention and a lot of messages around caseload size and so, i was great approximately that thesgratefulo agree there are strong variations in the ways that counties operate their programs. for example, just from the relationships that i have with other counties, i know that in some counties, the conservatorship is dropped if the individual is not in a

locked facility. we operate our program in a different way and trying to b tailor this. >> this is apples and apple's comparison from each county? >> no, our office collected this by connecting directly with our colleagues in other counties. >> so we know how they came up with their numbers? >> tcon numbers and total caseload at the time, in july of 2019, it would include all individuals who were under a temporary conservatorship, as well as individuals under a permanent conservatorship at that moment in time. i can tell you, we rounded down and i can tell you in san francisco, we currently have 617 individuals who are under either a tcon or a permanent

conservatorship. >> and how is the data any different from permanent conservatorship? >> sorry? >> the per ten thousand numbers basically similar for permanent conservatorships? >> for the other conservatorships. >> we have 5.2 for san ma da mao and these are including temporary or permanent conservatorships? >> correct. >> do temporary and permanent follow each other in the different counties or would we see differences if we were looking at only temporary or only permanent? >> i only antidotally know in some counties they're doing far more temporary conservatorships than permanent conservatorships. >> and if we were looking at permanent, our numbers might be better?

>> possibly. >> better, like more -- >> larger? >> actually, our per ten thousand number in the report, in the department of healthcare service's report is reported at.9, so it's a very significant difference. i also want to highlight that we are actively working on correcting the data that we are sending up to the public healthcare services. i wanted to take today also as an opportunity to correct in the report what was written, that staffing challenges have directly impacted our caseload numbers. it is true back -- prior to three years ago, the office of the public conservator was

managed by the public health. we reclassified all of the our deputy conservators and supervising deputy conserv conss and we're now able to manage the list and we are almost at almost full-staffing capacity. we just received authority to hire for the two new ftes in this past budget and we were grateful and actively moving to hire those positions. i suspect that we will have individuals occupying those positions within the next four to eight weeks. >> supervisor mandelman, i appreciate you highlighting this is a complex issue and we need a portfolio of complex services to move the needle for individuals in our community is we certainly

agree that conservatorship should be a part of that discussion. we also appreciate the ability to collaborate with the board of supervisors and the mayor's office to partner on a behaviour health proposal that would make intentional and significant investments to better position us to meet the needs of the population, which includes in the permanent funding we know of 212 beds that will be opening up that are funded to move forward with. and in addition to the conversation about evaluation, that's something we've partnered closely with the department of aging and adult services and we are looking to move forward with health and emergency services and should able to have data within the next six months. i think it will be important to look at the immediate impacts of conservatorship and then, also, the long-term impacts for individuals who remain on counties but who are ncountycony

fare in the community. >> we don't have that information already? >> so we have a lot of data and what we need to do is match that data with information from the office of conservatorship services so we can better understand the more holistic impact on an individual. we certainly have that on a dp side and the office of conservatorship offices has that on their side but the matching to look at the impact, i think, is what is most pressing. >> keep going. >> we are already working on the vla's recommendation that we update our memorandum of understanding between the department of public health and human service's agency and we have a very engaged group that includes the city attorney's office, the doctors from zuckerburg san francisco general hospital, san francisco health

network, behavioral health services, and i think it is an opportunity for us to not only address the data-sharing issue that needs to be documented and resolved, but it provides us with an opportunity to really clarify roles and responsibilities moving forward. so we're excited that that process is already underway. and apologies for the lengthy presentation. i promise a brief one. but i did want to say that we are very focused on the future and on moving forward. the office of the public conserve tor itor is working foa conservatorship unit. the new resources will allow us to do that. and we hope to grow the numbers of clients that we have that are living in community-based settings. and, of course, we already are working on the implementation of the housing conservatorship

program, and the department of public health coordinated the first working-group meeting last week. and we are doing everything we can to expedite the implementation of the pilot program. we know that it's going to be an important new tool for us and then we really hope to allows us to protect and assist more individuals. thank you very much for your time didn't we'll be happy to answer any questions you might have. >> supervisor walton. >> thank you chair, and thank you both for the press. i do have juspresentation.i havd you may have heard my concerns about conservatorship in the past and who are we conserving and you may not have this new but would love to see the ethnic break-down of people we have in our current sf?

do you have that now? >> i do and i can tell you that i know our african-american citizens are overrepresented when you look at the presentation. when you do and evaluation projects, you look at a cohort, a certain time period and the last break-down that we looked at, african-american made up to close to 0% o 20% and the majory are white males over the age of 60. but we see there are disparities. the islanders population is underrepresented when we look at their population here, the greater population in san francisco. the latino population is about -- is fairly well represented, appropriately represented in terms of the way their representation in san francisco.

>> the majority of percentage, do we know if that's long-term or short-term? >> whether they've been on conservatorship for a long-neve? i do not have that but i would be happy to provide that to you. >> supervisor walton, in terms of demographics of who we see, those numbers are fairly consistent with whom we see as a department. >> how does this work for individuals in custody or for youth? >> how does it work for individuals in custody? so for adults in custody, we do work with the jail, the psychiatric service's division within the jail and we are conserving individuals while they are in jail and we are trying to move them out of jail as quickly as we possibly can. >> i would add that it's rare that individuals who are on an existing lps conservatorship are

brought into custody. i think we're successful there, but there are individuals who certainly are seen in custody who would benefit from being on a conservatorship and the jail is able to make those referrals. >> what about you? >> we are not conserving individuals under the lps act under the age of 18 and, actually, the age breakdown between 18-24 only makes us 2% of our lps caseload. >> thank you. >> thank you for your presentation, for your work. at the start of this, let me ask you some specific kinds of questions about the charts but at the beginning of this, i talked, i think, about the mismatch between san francisco, the reasonable expectation we would have a mechanism in place that is not incarceration for

taking care of folks who can't take care of themselves. the sense that is conservatorship in the public's mind. and the reality that other than conservatorship honestly, there aren't a lot of other ways to deprive people of their autonomy and liberty, short of incarceration. and so, the question i'm going to get to, and may ask for dr. leery's thoughts, as well. but whether we think we are conserving everyone who is potentially eligible under current law and how far off of that we think we might be and how we would begin to think about that question, we've talked about it. and then, there's a hint -- nobody wants -- i understand neither of your departments really wants to bite on this, but there i is the idea, think,

that the lack of placements is somewhat in some set of ways depressing -- maybe congressingg the conservatorships. and if we had placements, we would be conserving a far larger number. and i want to think about what we think that's doing. and then the last sort of big difficult question above your pay grade, but i'll ask you to answer is, you know, what changes in the lps law, san francisco should be advocating for? and that's potentially a question for dr. leery, as well before i get to those hard, challenging questions, i'm going to ask some smaller, i hope, not as challenging questions.

so there's the chart on page 4. i think it's appeared in different places and i'm looking at page 4 of the vla report. and, basically, the chart that describes the decline in dis-loaincaseload. i know you described an increase in caseload and i want to thank everywhere who has been doing the work. and i think in recognition of the crisis we're facing, herculean efforts, to refer people when it's appropriate and pursue the case and do the work to actually get the conservatorship sustained. but before -- up to 2017-'18, it looks like, you know, starting in 2012-'13, there were 820 and by 2017-'18, we were down to 45. is it your understanding that that is attributable to the

30-day holds? >> yes. >> you think that's about the 30-day hold? >> back in 2012, the hospitals were using the temporary conservatorship process to be able to hold that cohort of individuals that need 30 to 45 days to recover. they didn't have any other mechanism to keep them in the hospital on an involuntary basis and so what would happen is we would -- just point out, i was not working in my current role at the time, but from talking with my colleagues, what i've heard is that the temporary conservatorship, which is really a seemless process, we submit the petition to the court and the court reviews the petition in camera and then the temporary conservatorship is granted. our office is granted the authority to do our full investigation to determine

whether the permanent conservatorship is appropriate. the tcons were submitted to keep people and they would recover and be determined no longer to be gravely disabled and they would be discharged with community service referrals. >> so i'm skeptical of that answer because of the chart on -- and maybe i'm misreading or misunderstand but if you look at the chart on page 6, that breaks out permanent versus temporary conservatorships. and there is certainly a decline in temporary conservatorships. although, it doesn't actually track that establishment of the 30-day holds. and the decline in permanent, you know, is significant. from 2012-'13 to 2013-'14, there's a halving of that number

and percolates in the 40s and then in '17-'18 something happens and then i believe what's going on is the political pressure around what's going on on our streets is building and we are starting to really -- and maybe some of the work around the high users of multiple systems and the work that dph is doing didn't there's leadership in the office of the public conservator figuring out if there's more people who would qualify for a permanent and it goes up. but that doesn't -- i mean, that explanation that we found another way of meeting the needs of people who need permanent conservatorships, i don't accept. i don't think that's right and i don't think that's what happened. i think the 30-day hold may have played a role, but i think there were other things going on during that period. i tend to think it was probably around the lack of placements and i tend to think there may

have been changes which inn in church that lead people to refer fewer folks. this is wild speculation but do you have any thoughts about that? i'm not trying to play a fam gaf gotcha. >> i don't know any provider working with the vulnerable adults who we work with would say we don't need more placements at all levels of care. the born in care crisis playing out on our streets in san francisco is integral to place individuals in community-based settings and keep them this sanfrancisco which would be ideal to placed them in their home county and we're not always able to do that because of lack of placements. i really appreciate your deep nuance understanding of this time period. i don't have all of the answers

personally and i can understand the frustration that you may have. i think what i want you to know, supervisor, and what i want the entire board to know is that we are extremely focused on improving our collaboration and finding every innovative way to support individuals today and moving forward. >> right. and i appreciate that. i also appreciate that every dph staffer that comes before this committee is in a nearly impossible position because you're explaining decisions made by people who were not you is there has been transition and change and you're trying to do the best you can with what you've got. but from our perspective, people who allocate resources and decide kind of -- and our asked by our constituents on a daily basis what the hell is doin goi. we have to figure out what the hell is going on.

and plainly, you know, we're -- it seems plain to me -- again, i'm a lay person in this, like my of my constituents, but it seems plain to me that people should be conserved who aren't. so getting to the more, like, theoretical aspects of this. and one of the things that sb1045 and 40 were get after was, you know, the need, the problem around this person and there's like a lot of this person, who can stabilize at general, probably get stable -- either gets temporarily stabilized in pes or stabilizes over a period of weeks, but that person either never get as conservatorship or gets a conservatorship extheand then stabilizes but we have a belief or our system is built around

the idea we push people to the least restrictive setting. my biased is coming out here. i'm wondering whether we are making a mistake and maybe compelled by the law, but making a mistake in pushing people, you know, into less restrictive environments that they're not ready for, too fast. and do we feel like we don't have the legal tools? this goes to, is this is change in state law that we need? you know, are we not keeping these people under more supervision and keeping conservatorships going longer because we don't have the legal tools and need to change the law or because we don't have the resources and need more resources? or is it a combination of both? if there were changes in state law around grave disability and the definition of that, have you thought about what that would

look like? >> i can respond to changes in state law. over the past couple of years, there been multiple bills that went forward that were focused on updating the definition of grave disability. l.a. county put forward a change to the definition of grave disability which really brings in the concept of sort of informed consent. and triking t tritryingtrying tg the priors witprovidingthe prove flexible. in my understanding, but that they primarily failed because they did not have funding packages attached to them. counties across the state, and again, this is my antidotal knowledge based on working with the state association, counties are operating these programs on

an absolute shoestring and that's why the budget proposal that i've referenced earlier is critically important. i mean, we have three programs that do not have designated state funding for the county operations. in san francisco, we are lucky. we know that. we have additional resources that our colleagues across state do not have. so i think that we already have some of the bills and they've been introduced. what we need to do is make sure that they pass at the state level and that they're funded appropriately because in order to actually implement them, it will cost the state and counties quite a bit of money. there's investments not just with staffing but the investments on the placement and treatment side. the state audit that campbell referenced earlier was a tremendous opportunity. we had state opportunities with us for three weeks and i am really, really looking forward to the recommendations that they

will be publishing, that we should have those recommendations by march. and i know that there's a lot of policy makers at the state level waiting, as well. i really urge the board of supervisors, if i may, to be working in tandem, in conjunction with the rest of the state. we operate under state law and because these are such huge issues involving civil protections and civil rights, i think it's a weighty enough topic that the state needs to take the lead there and we can take the lead by helping to partner and be a voice up in sacramento for bills we think are worthwhile. >> i completely agree and i think we're all hopeful in this audit will help to inform legislative change at the state level. a couple of things i wanted to remark on is certainly the psychiatrist thinks an individual is gravely disabled, it would be unethical for them not to move forward with a

conservatorship, regardless of constraints and options. that being said, we, of course, support the investments that are being made in treatment options so that we do have more of that. i think the other thing that's happened over recent years, that we've seen and was part of the catalyst for the housing conservatorship was the increase of met methamphetamine and that stabilization and it's deteriorating and i appreciate the opportunity, because i think it will make a significant difference. >> for a very, very small number, but yes. >> but very important individuals. and the other thing that i think you were commenting on is regarding the court's interpretation of grave disability and the way it is worded currently in the institution's code is nuanced and up for interpretation.

and so i think that having more clarity at the state level of what it means to be gravely disabled would be incredibly helpful because i think that is likely to impact a psychiatrist moving forward with conservative, depending on how the court interprets that. the other thing that think is important and related to these investments that we have is -- and we look at this across our system of care not just with conservatorships or facilities but to the point of are we moving people into lower levels of care too soon? is increasing our capacity and flow to move people back to restrictive levels if that's needed but giving people the opportunity to be successful at those lower levels of care? >> i wanted to ask about this little wrinkle in lps that to read it allows for establishment of lps conservatorship based on

chronic inebriation but it is my perception that we don't do much of that. my office keeps a list of people we hear about, how my constituents cannot understand how this person is still out there. i'm thinking of a 72-year-old man, who has been hospitalized more times than anyone can count, who everyone sees often with sores on his body, bleeding, going into stores and restaurants over years, ok? and the response i got fro froma doctor at dph, well, he might be reaching the point he might be appropriate for a conservatorship. well, the non-dph, non-city hall

san francisco response so that is that's insane. if that person were my uncle, my father, anybody in my life, i would want that person to be taken care of and we are completely failing. the underlying issue, there's probably dementia and who knows what other issues, but he is a chronic alcoholic and so, taking that -- we're not talking about a specific person, but -- except i sort of am. but why are we not able to use chronic eknee briation even though the law calls it out? >> it's do to chronic alcohol or mental illness. >> so when that person gets describegetsstabilized and by te

was taken in before a court under a petition for a conservatorship, he's not exhibiting grave disability that moment, even though is a chronic inebriate, the fact the language is in the statue, that presents us from making the case for conservatorship? the individual has to meet the same threshold of grave disability. but one thing i'll say, ang gelcandgelca and i did discuss , the individuals who have alcohol use as a primary use disorder, have an overarching, major mental illness. in addition, they may be using alcohol and additional substances, as well.

we have 4,000 in san francisco whsan franciscowho have an alcod we know the vast majority use alcohol and may use additional substances, too. you highlighted dementia and the way that our regulatory systems treat individuals who lack capacity, is that we have a divide between those with mental illness and those who have a cognitive impairment, deteriorating type of dementia and we do see -- in effect, i was involved in one case on the public guardian side and we were working to protect an individual who is a chronic inebriate. he is definitely, by all accounts, everyone agrees gravely disabled due to chronic

alcoholism. but when he is an acute setting, he gains the institutional sobriety. he still has a very significant level of impairment, but the impairment is due to a cognitive impairment. for this individual that i'm thinking of, it's no longer due to a serious illness. we have been working to move towards a conservatorship for this individual on the probate side, as well. so that may be in many instancee get thavedata -- but one may bee intervention that's more appropriate. >> it was reality we have so many people cycling through jail and psych emergency and i have a

number of these folks who get picked up and maybe make it through, say, get into behavioral health court or drug court or simply through a hospitalization get stabilized and never reach the point where we petition for a conservatorship for them and i think your understanding is that we probably couldn't because even if they have an underlying mental illness, the role substance use plays in their illness is such that they can be stabilized and not be appropriate for a conservatorship by the time they are brought before a judge. so senator weiner came up with sb1045 and it was suggested that that was the wrong way to do it, the 85150 or some number of

5150s because you could put it in the law the way chronic inebriation is but that's doing us no good at all. i'm concerned sb1045 was way too small for the scope of the problem and we should be expanding it. but it seems like insofar as adding substance abuse like alcohol, it may not get us very far. >> i think what's important about that, an individual doesn't need to be placed on a 5150 but needs to be on an inpatient unit and that goes through a court process. >> under traditional lps. >> under traditional lps, right. so i think what housing county enforces iconservatorship enfort cycling in and out.

while it's important to account for others, it just adds that into lps. >> unless there are more questions, i want to get dr. leery up here for a second. but i do want to thank you for all of the work you do everyday and i want to implore you to use every tool in your toolbox to reach as many people as the current law allows to continue doing the outreach in the work and to encourage them to refer everywhere appropriate to work with the city attorney's office and do everything we can to push the limits of what we can get away with, actually. like i noticed that the petitionone of these charts shows a number of permanent conservatorships and this is on page 6, temporary conservatorships and the number

that were declined. we asked for and they were declined and we went from 12, and then one this '14-'15 and that success and that you have lined -- the system is not recommending people for conservatorship who judges are determining that's not a good idea. but i wonder if there might be some folks who would benefit, who should be conserved, who are not having to go with the court around having folks denied and make that case -- some harder cases. i know the cases you're doing are hard and take a ton of work. but we want to encourage you to get as many people into care and we should be advocate for changes in state law and whatever the governor comes up with lps reform, please let our offices now what we should be advocating for.

thank you. >> thank you. >> and then dr. leery, can you come up for a moment? so tell us who you are and what you do and why you've shown up today. >> i'm mark leery, the interim chief of psychiatry at san francisco general. i've worked there 30 years at the locked in-patient units and psych emergency and city-wide case management and the jail psychiatric program. i want to thank you for your deep interest in this issue and the way that you're looking at it in such ad manner. >> i think we're in actually, a moment with opportunity because we're approaching it in different ways but i think it's

not every member of the board, and certainly the mayor who all want to try to make progress on these issues. so i want to talk with you about the beds and kind of the choke points in the system and what's hard and why people are stuck. and one of the things that i understand, from prior conversations with you and from these reports and the conversation we have been having is that we do not have enough locked subacute beds for the need. that means people get stuck in jail. they get stuck at general, in acute care. and we just don't have enough and i'm wondering if you could tell us if you have any idea what the additional need is for locked subacute beds to create more flow out of pes, to free up

people, more flow out acute psych unit at general and out of jails and actually meet the city's needs and maybe be able to conserve more folks who need a conservatorship and shouldn't be returned to the streets until they're in better shape. >> well, i would start off by saying, i agree that absolutely, we don't have enough locked subacute beds for the patients that we have in san francisco. and it's a difficult number to -- to answer the question of how many we need, i'm not sure that i can do that, not being a statistician or epidemiologist but i can offer a good place to start. in recent months, we've had often about 20 people on our acute locked-in patients at sanfrancisco general waiting for lock subacute care. and that's just the one time, a

snapshot, on any given time. and as you saw from the report, they wait an average of 51 days. so if you multiplied the 20 patients times the fraction of a year 20 days is, it would come out to about 120, 125, something like that. so that would be, think, a reasonable estimate. we might not need that many. we might need more. it's hard to tell, but it's clear we need more beds at every level of care and i think we always want to emphasize people getting treatment at the least restrictive setting they can be successful at. so we need beds at every level and that's a crucial point but

things like supportive hotels and supported housing. but the biggest choke point, people that need lock subacute care, there aren't other options to creatively put together to treat them successfully. people that are less severely ill, we can be more creative and different options can be successful. but i think ultimately, the lock subacute treatment bees are the biggest choke point. >> do you know the cost of those beds. >> i don't. >> they are quite expensive, quite necessary, but even as i said, even just the mayor's proposal to expand our st. mary's capacity by 14 beds in this last year's budget was something people were coming

after as an investment in incar ratioinincarceration or the wrog level of care. but you know, you can get more community beds for the price of a lock subacute bed but from my perspective and what i've heard from you, we need to make the lock subacute beds a priority this year. >> i would agree. lock subacute beds are less expensive than acute psychiatry beds. >> one other question, not exactly on topic here, but pes is on diversion how much of the time these days? in recent months about a third of the time, 35% of the time, which is way too much for our system. our goal is to never be on diversion. we want to accommodate anyone who needs emergency psychiatric care. >> it strikes me that, again,

our inability to get care for people on a longer-term base exist we're nobasis,we're not tn the wrong place. >> right, half of our visits to pes are return visits by people that have been there at least one time before. >> so when pes is on diversion, are they able to be seen at our other hospitals? because i know you and i have had this discussion before and i'm wondering where there might be issues with that. >> so it's far from an ideal situation. when we're on diversion, what happens is that police and ems will bring people that are placed on a 5150 to the nearest community hospital. >> to an er.

>> to the nearest community hospital, correct and no hospital -- we're the only psych emergency system. no other hospitals are equipped and they don't have the facilities to take care of someone on a 5150 over a period of time. as soon as we get off of diversion, which is not as often as we would like, then we bring those patients to esfg. >> did those hospitals at one time have the ability to take care of emergency psychiatric patients? it seems like there was a time there were bees at our community hospitals and now there are not? >> well, there definitely were acute inpatient beds at a number of the hospitals. st. maries had an adult unit and

mount zion had one and that closed. what would happen when they had units, i think often people would get admitted to an acute unit when all they needed was an emergency psychiatric visit, not inpatient hospital visit. if i could just -- i just want to underscore something that jill said about the communication. i think that we have a really great partnership with the office of the conservator and we have open communication -- the theconservators meet with us once a week i it's a good partnership and i want to underscore that. >> thank you, dr. leery, for your work is i want to encourage you to come to us as you see additional opportunities and i

hope that people are not self-regulating and not referring people for conservatorships when they think those are appropriate because they're concerned about the lack of placements. >> well, i mean, if i could address that, to be as real as possible about it, i think that i would underscore what angelica said, we keep them in pes as long as we have to, if it's clear-cut, we keep them in pes as long we need to. we admit them didn't they have to wait days, we do that, if it's a clear-cut case. but the lps law, as you know, is not precise in terms of what defined grave disability. and so, there's a huge gray area and if we mow tha know that we t have the inpatient bed capacity,

then we're less likely to admit someone or to refer them for a conservatorship, knowing that will put us in a position to treat the people with acute emergency conditions that we absolutely have to. >> you're in triage mode. >> yes. >> thank you for your interest. it sustains us, so thank you. >> thank you for your work and thanks to everyone at general. so with that, we'll open this up for public comment. if there are any members of the public who would like to speak on this item, please line to your right, our left. and seeing no public comment on this item, i will close public comment. and i will make a motion to have this hearing heard and filed and take this without jokes. objection. great.

mr. clerk, any other items before us today? >> that concludes or business for today. >> then we are adjourned.

valencia has been a constantly evolving roadway. the first bike lanes were striped in 1999, and today is the major north and south bike route from the mission neighborhood extending from market to mission street. >> it is difficult to navigate lindsay on a daily basis, and more specifically, during the morning and evening commute hours. >> from 2012 to 2016, there were 260 collisions on valencia and 46 of those were between vehicles and bikes. the mayor shows great leadership and she knew of the long history of collisions and the real necessity for safety improvements on the streets, so she actually directed m.t.a. to

put a pilot of protected bike lanes from market to 15th on valencia street within four months time. [♪] >> valencia is one of the most used north south bike routes in san francisco. it has over 2100 cyclists on an average weekday. we promote bicycles for everyday transportation of the coalition. valencia is our mission -- fits our mission perfectly. our members fall 20 years ago to get the first bike lane stripes. whether you are going there for restaurants, nightlife, you know , people are commuting up and down every single day. >> i have been biking down the valencia street corridor for about a decade. during that time, i have seen the emergence of ridesharing companies. >> we have people on bikes, we have people on bike share,

scooters, we have people delivering food and we have uber taking folks to concerts at night. one of the main goals of the project was to improve the overall safety of the corridor, will also looking for opportunities to upgrade the bikeway. >> the most common collision that happens on valencia is actually due to double parking in the bike lane, specifically during, which is where a driver opens the door unexpectedly. >> we kept all the passengers -- the passenger levels out, which is the white crib that we see, we double the amount of commercial curbs that you see out here. >> most people aren't actually perking on valencia, they just need to get dropped off or pick something up. >> half of the commercial loading zones are actually after 6:00 p.m., so could be used for five-minute loading later into the evening to provide more opportunities or passenger and commercial loading. >> the five minute loading zone may help in this situation, but

they are not along the corridor where we need them to be. >> one of the most unique aspects of the valencia pilot is on the block between 14th street. >> we worked with a pretty big mix of people on valencia. >> on this lot, there are a few schools. all these different groups had concerns about the safety of students crossing the protected bikeway whether they are being dropped off or picked up in the morning or afternoon. to address those concerns, we installed concrete loading islands with railings -- railings that channel -- channeled a designated crossing plane. >> we had a lot of conversations around how do you load and unload kids in the mornings and the afternoons? >> i do like the visibility of some of the design, the safety aspects of the boarding pilot for the school. >> we have painted continental crosswalks, as well as a yield piece which indicates a cyclist to give the right-of-way so they

can cross the roadway. this is probably one of the most unique features. >> during the planning phase, the m.t.a. came out with three alternatives for the long term project. one is parking protected, which we see with the pilot, they also imagined a valencia street where we have two bike lanes next to one another against one side of the street. a two-way bikeway. the third option is a center running two-way bikeway, c. would have the two bike lanes running down the center with protection on either side. >> earlier, there weren't any enter lane designs in san francisco, but i think it will be a great opportunity for san francisco to take the lead on that do so the innovative and different, something that doesn't exist already. >> with all three concepts for valencia's long-term improvement , there's a number of trade-offs ranging from parking,

or what needs to be done at the intersection for signal infrastructure. when he think about extending this pilot or this still -- this design, there's a lot of different design challenges, as well as challenges when it comes to doing outreach and making sure that you are reaching out to everyone in the community. >> the pilot is great. it is a no-brainer. it is also a teaser for us. once a pilot ends, we have thrown back into the chaos of valencia street. >> what we're trying to do is incremental improvement along the corridor door. the pilot project is one of our first major improvements. we will do an initial valuation in the spring just to get a glimpse of what is happening out here on the roadway, and to make any adjustments to the pilot as needed. this fall, we will do a more robust evaluation. by spring of 2020, we will have recommendations about long-term improvements. >> i appreciate the pilot and how quickly it went in and was built, especially with the community workshops associated with it, i really appreciated that opportunity to give input.

>> we want to see valencia become a really welcoming and comfortable neighborhood street for everyone, all ages and abilities. there's a lot of benefits to protected bike lanes on valencia , it is not just for cyclists. we will see way more people biking, more people walking, we are just going to create a really friendly neighborhood street.

(roll call). executive director is present and at this time the commission respectfully asks that you silence all cell phones. >> thank you. there has been one change to the agenda, and that is we will be moving the long-term care coordinating council report to after the director's report and ahead of employee recognition. thank you. with that change, may i have a motion to approve the agenda. >> so moved. >> second. >> all in favor. any opposed. thank you. item 3. may i have a motion to approve the october 2, 2019 meeting minutes? >> so moved. >> second? >> second. any changes?