Transcripts For SFGTV BOS Government Audits And Oversight Committee 20220721

Good morning we are in the meet bing [bad audio echo] meet ing [bad audio echo] [audi issue] do i dare try to proceed or do we need to take a break . No audio. Technical issues. This neat meeting the july 21, 22 meetingly of government audit and Oversight Committee im supervisor dean preston chair. Joined by vice chair connie chan and supervisor mandelman. Clerk is jessica perkson and want to thank sfgovtv for staffing the meetings. Board of supervisors are now convennes hybrid meeting for in person and online comment and Public Comment via phone. The board real lieses it is essential. First comment taken on each item. Those in person allowed speak first then those who are waiting on the phone line. Watching on channel 26, 28, 78 or 99 the Public Comments number is stream access code 2493 392 7760. You will heart meeting discussion and muted and in listening mode when your item come up and comment is called those in person lineup to speak near the podium and those on the phone line sdiel star 3 to be added to the speaker line if you mean are on the phone turn down your tv. You may submit comment in writing. E mail to the government audit and oversight clerk at jessica perksins. 4156550001 item 5 a resolution mem ranldz update of understanding with the joint powers board Transportation Authority. San in teo Transit District and city and county of San Francisco related to the upon governance off joint powers board. Member who is can wish to comment lineup to speak. Remote call the number 4156550001, access code 2493 392 7760. And press upon pound twice. You will press star 3 to enter the line a prompt indicate you raised your hand. Wait until the system indicates you have been unmuted. Thank you, madam chair and madam clerk and we have with us president walton who is the sponsor of this item. And want to turn the floor over to him. Thank you president and colleagues for take this out of order this is to approve the memorandum of understanding with the peninsula upon joint powerhouse board. Santa clara transportation and district and the city and county of San Francisco rolling to governors of the joint powers board when we voted we promised we would have a process to reach governance agreement and required the work to address our governance concerned. This is that result. We have been working on caltrain governors now for over 3 years since i have been on the board of supervisors and serving on the jpb and we did as a body the jpb did consider various governance models and adopted the term sheet on march 30 of 22. Lead to the mou we have before us the jpb pass the mou on june 23. Passod june twoochlt sfhta passed this week and the vta is set to pass on august fourth. Mou will allow the jpb to increase oversight for caltrain and ensure caltrain and the executive director has the independence and the team needed to operate the railroad as we embark on electricification it is Ambitious Goals as we get on prepandemic levels. I want to thank deputy City Attorney innes. My colleagues for working with me and the jpb governance effort and jpb colleagues and to our cta chair supervisor mandelman and peskin worked closely with us in the caltrain board to get to agreements and move things through. We do have with us today one of our sfmt aboard of directors steve the chair of the jpb. I know that director heminger will provide insight to the mou. So chair heminger, what you like to add we will love to hear from you and appreciate you being here this morning. Thank you, president walton i want to check if supervisor mandelman wait . Welcome. Supervisor, the agreement before you today has a history. Like most agreements do and actually the history on this guess back when Abraham Lincoln was president i will start more recently. In 1980, because at that point the southern pacific railroad, which was running that service those years decided to get out of the passenger business and start focusing only on freight. And at that point, we were looking around for somebody to run the railroad since sp was going to back out. State decide to do so in its role as a transportation entity. But i think the state quickly discovered that building a highway is in the the same as running a railroad. So at the upon end of the 80s. We were at a point where the local agencies needed to step up and that is what they d. The 3 counties formed a joint Powers Agreement and that is essentially the way we have been upon governed since. At the time they took over the service they we also had an opportunity to buy the rightofway for the public. And all of you know, about rightofway and how precious it is. And in the case of this peculiar rightofway, it is easily the most valuable transportation asset in our region. And fortunately, we were able to put together the funds to do it. Most came from a state bond measure the voters approved but there was a reporter for a local match. And at the time of the 3 part nerts only san matteo was willing to put cash down on the barrel head, which meant in order for the transaction to go through. They had to advance funds not only for its share but shares of 2 partners in San Francisco and santa clara. There was an expectation created. I had an agreement passed to try to structure a repayment plan. That eventually resulted in 30 Million Dollars being provided to sam trans but left 20 million short. And that is one thread that makes its way in the agreement that is before you today. To finally pay up on that dent. And also to pay what i would characterize a late fee. Because the debt was not paid not only in whole but not paid according to the schedule we had agreed to. So, that is one thread as i said that i think is in in agreement. The other thread and supervisor walton had a lot to do with this one, is the fact that we really and when i say. We i referred to San Francisco and santa clara county. We felt that the role that san mateo played in advancing the funds they were given the opportunity to be the managing agency for this service essential low as long as they wanted to. That left the other 2 counties in the position of irrelevant not having a lot of fluents over things you would think arc a board would have. And as a result of supervisor walton, we were able not to long ago, to get our own lawyer hired. We were able to get our own auditor hired. The most important step was to get the 8 to hire our own executive director, which is something that every organization i know about has. One of the responsibilities. Thats the other thread. I would characterize this agreement as a classic quid pro quo agreement. Where each party gives something and gets something. What the 2 book end counties get is that higher level of accountability. And what san mateo gets, finally, is that being discharged and also the late fee being paid to acknowledge the fact they have been waiting for the money for a long time. I conclude by saying, that as the board chair this year as supervisor walton indicated; i have been working on this during my whole tenure that was true of my predecessor and her predecessor. This has been enormously preoccupying for the board t. Is important to have a shape of the table when you need to they hog up the oxygen in the room that is happening here. It is vitalally important we get this agreement behind us and turn our attention back to the real business of our board, which is first of all to find 70 of riders, which we still have not found because caltrain is doing much worse than muni, for example in terms of current versus prepandemic ridership. And the fact that caltrain has under way 2 billion Dollars Program to electrify that service i characterize the second great investment by the public in that corridor. First of all by acquiring the right of way and secondly, now electrifying the line which is something we have to do to all of our infrastructure in the country to deal with climate change. But we are really out ahead of the pack i would say here in the San Francisco pel anyone slut. By getting that done for caltrain. Thanks for bearing with the history lesson. I think the history is relevant and i would be happy to answer questions if you have them, supervisors. Thank you. Supervisor mandelman. Thank you chair preston i want to say thank you to president walton, and commissioner heminger. For all of your work on this. I have been part of a few of the meetings along the way as commissioner heminger said this has been going on for arc while and i think pretty important for 3 counties to get to a resolution as we try to make the case for federal funding for projects like downtown extension and many other projects that the region wants and needs. And i had understood one of the Major Concerns that the m. D. Federal government had has been challenging around governors. The jpb. So, the fact that we have gotten everybody godding heads and got to tees peace is a testament to the seriousness of folk and it is desire to come together and work through difficult issues and im grateful. Thank you. Vice chair chan thank you, chair preston for my own understanding and if you could help me, where are we in the approval process of this mou . We are i think supervisor may have mentioned we are most. Way through we have 5 boards that have to approve this tells you how complicated the governors structure is. And you would be the fourth the fifth would be vta in early august. We are in the home stretch, supervisor. Nicely done, thank you. Thank you, i want to echo the thanks to you chair heminger and our president. President walton, thank you this has been i will say there is a lot of work we do in public view and a lot of work we do that is in the so visible to the public. I know you and your office put in time and energy this representing the city on this. It is important. Unless you have additional comments, lets open up Public Comment. Thank you, mr. Chair. Members of the public who wish to speak and join nothing person may line up to speak. If you are joining us remote call 4156550001 enter access code 2493 392 7760. Once connected press star 3 to enter the line. For those in the queue continue it wait until you have been unmuted that will be a queue to begin. Im seeing no in person and 8 upon listening and one in our queue. Can you put that caller forward . Good morning, commissioners i would like to thank director heminger and director walton on the caltrain for getting us [inaudible]. My only comment this morning is i support approving this mou. The thing im correspond moving forward is going along the same lines in casting this proposal of governors in concrete amending the jpb. And past performance and for the future. Moving forward must be consider changing the [inaudible]. I want all the supervisors to be very alert and making sure that nothing happens that we may regret after 10 years down the road. Thank you. Thank you for sharing your comments. I will double check we dont have combeblgs. That was the final caller thank you, Public Comment on this item is closed. And seeing no one else on the roster thank you president walton for your leadership and perhaps supervisor mandelman as chair of our Transportation Authority you would like to make a motion to sends this resolution to the full board with recommendation as a Committee Report . Wonderful on the motion to sends this to the board as a report. Vase chair chan. Aye member mandelman. Aye. And chair preston. Aye. You have 3 ayes. Thank you. Motion passes. Madam clerk call items 1 and 2 together. Agenda item 1 a hearing on the 202122 civil grand Injury Report shovel ready best practices and collaboration to improve the Capitol Construction program. And 2, responding to the judge on recommendations contained in the upon 2122 civil grand jury report and impelementation of accepted findings and recommendations through Department Heads and the annual budget. Members. Public who wish to comment may lineup to speak or if you are joining remote call 4156550001 enter access code 2493 392 7760 press star 3 to enter the line. Prompt will indicate you raised your hand wait until you have been unmuted then begin comments. Thank you, and colleagues, we added these items to the agenda in order to sends the boards upon response to the superior court and philadelphia our duty to civil grand jury and under statutes my staff has been in touch with the Mayors Office and other diameters regarding todays date over the past weeks. After we added this to the agenda we received request to continue these items to allow departments to better prepare and identify speakers that can answer questions about the facts that are set forth in the conclusions in the grand jurys report which touch to many departments. The Mayors Office was the only executive office to require to submit a responsibles to the civil grand jury it makes sense to continue this to be able to ask the remaining departments questions about the civil grand jurys finding and a better understanding of their perspectives. That would be in the interest of the public and help the board better prepare responses to the findings and recommendations of the civil grand jury. Apologies who was hope to weigh in on the merits today. But want to thank the civil grand jury for the flexibility and understanding and want to thank supervisor mandelman who will take the lead on the work on this. And so, which that open this item up for Public Comment and we can hear from a motion to continue after. Thank you, mr. Chair. Member who is wish to speak on the continuance and in person may lineup now. If you are remote call 4156550001 enter access code 2493 392 7760 and then star 3 to enter the speaker line. Checking with our 9 people listening and zero in the queue. Mr. Chair. Thank you, Public Comment is closed. Id like to make a motion it condition items 1 and 2 to our meeting on september 15th. On that motion to continue the items to september 15th vice chair chan . Aye. Member mandelman. And chair preston. Aye. You have three ayes. Thank you the motion passes. Item 3 . Item 3 is a hearing on the citys sponse on the monkeypox vire. Efforts to vaccinate at risk groups against monkeypox and coordination with Public Health and cdc and requesting the d. Public hasnt to report. Member who is wish to comment may lineup to speak or if you are remoted call the line 4156550001 and enter access code 2493 392 7760 then press star 3 to enter the speaker line. Thank you madam clerk. This item is know sponsored by supervisor mandelman i want to thank him for his leadership on this issue and for moving swiftly its the board and working with advocates and making sure we can have this hearing before we break for our recess in august. Time is of the essense. Im looking forward to the presentations and supervisor upon mandelman, do you have opening remarks . I dpo and thank you chair preston for making time for this hearing so we could get to it before the august recess employees i want to thank did cohen from public will health for being here as well as drr tammy ear from the aids found a recollection and folks from the [inaudible] and from the hiv caucus who have been leading the effort to try to get more public attention and urgency around the response to monkeypox. Thank you. We are here today because gay and bisexual men and transfolks in the United States are being failed by our Public Health institutions and the cdc and hhs. And i thought i would share 2 stories about folks who are familiar to most of us. And experiences they have had trying to get vaccine in San Francisco. So this morning at 5 50 a. M. , our own hans how of the Housing Stability Fund Oversight Committee, and other organizations and civic commitments; got himself in line outside general hospital. And after a wait of 3 hours was able to get the first of the 2 dose of vaccine that will immunize him from monkeypox. The problem is, the 3 our wait is you know in the Early Morning is not great. But in fact, probably waited for 12 hours for this vaccination he had been at general 3 times prior waiting for hours each day and each day being told when he got to talk to somebody they had run out of vaccines for that day and welcome to come back the next time of our own tom who folks may remember from my office and is now of k with equality california alerted after pride weekend he had been to a party there were folk who is tested positive for monkeypox. He called all of the numbers that are website directs to you call to make an appointment to get a vaccination and never heard back from any of those numbers. And he was alerted not by d ph tweet but gay twitter. That he could get vaccines on a day at a place and as many [inaudible] and are doing, got himself in a line and able to access a vaccine between 14 days of exposure. Sadly not with help from our local department of Public Health. And he has learned from gay twitter that the second dose may not be coming that is in the communityed him he has an appointment. Our own tom is not quite sure that is going on with his second dose. These are 2 people with extraordinary access who have been involved in City Governments. You know we are talking upper percentile of ability to access Public Services and their frustration is great. I can only imagine how great the frustration and feelings of powerlessness are for thousands of other folk who is ought to be getting the vaccine. Now this is in the the 1980s. And joe biden is not Ronald Reagan and monkeypox although very unpleasant and not something anyonement system not hiv. But this is an eerily familiar experience for the Queer Community especially for longterm survivors of the early ugly days of the aids crisis and the terrible federal response another thing peculiar around monkeypox this is the tail end of another pandemic where the response was quite differents. Federal government vaccinated 40 Million Dollars for covid19 within 3 months after first shots. And today they are planning to fully vehicle nay 3. 5 Million People for monkeypox by the middle of next year the crisis is now and although that is an improvement from the plan they rolled out a mont ago they talked about 2 million doses the end of next year. They are moving in the right direction du inadequate to a crisis now. We have nearly 6 million may be more transfolk in the United States that is assuing the monkeypox stays within the Queer Community. There is no reason to think it may spread out. This is a travesty. The department of Public Health at our press Conference Last Week said as an Immediate Response we need 35,000 doses that is in the enough but we need them. As of this week, months after the first case of this out break in may, we received 8,000 doses. So, this should have been a preventible Public Health crisis. Experts warning about the spread of monkeypox beyond west africa for a dkdz. The fda approved a vaccine that would not exist without 2 billion dollars of taxpayer money that went in the development and manufacturing of the vaccine. Despite that investment, the trump and Biden Administrations stop filed enough to vaccinate 28 thousand not the millions they should have ordered and today we move so slowly in accessing the vaccines. In some way we dont have representatives from the government here for this hearing. We be speculating. I think it is important to understand when the federal response is the best hay can do to a pox virus or if they responded with less urgency than the capacity they v. If it is the best we can do this raises troubling questions about our pandemic play book and to effectively respond to other viruss we may see become prevalent. If it is a less urgent response it would be great ton why, who made the decision not to responded. And i am no Public Health expert. We have a couple here today. But it does seem to me that it would have been preferable if the federal government used the resources to over due the initial response to monkeypox and nip it in the bud. Instead they have done the bear minimum dragged along each step and turned out to be a whoafully inadequate response where we have Significant Community spread. 55 cases on tuesday alone. We need an urgent response now and it is playing with our federal government the government is not a war footing around monkeypox and that is in the acceptable. Im sympathetic to and grateful for the responsibles of the local Healing Department. I think the stories i shared earlier indicate that even here local low in San Francisco there is room for improvement and we need to improve quickly. Local leaders in our Public Health world have been doing everything to i think that they can to get vaccines out the communication has been weak. I think that department of health putting out criteria and going further and being clearer and making more sense than the governments criteria to saying that sex workers are a prior for vaccination that men who have sex with men and active are a priority. Like these are Good Development it is. The stories that people not hearing that is going on about social modia communication telling people vaccines are available they are not. They communicate to folks quickly when they are available and where. And making people going through the ritual each day they get up earlier to lineup in the colder and darker Early Morning to have some shot at getting a vaccination seems not a great way. I want to thank the aids foundation i went by on sunday they distributed 300 vaccine in a humane way there were not lines around the block they got everybody one who made an appointment and thousands on a wait being list. At least it spares people waiting in the line. So, i think we have stuff to explore today. Love to hear first from Doctor Stephanie cohen with the department of Public Health and thank you for being here. Thank you for the opportunity to present today. Im Stephanie Cohen the medical director of city clinic and hiv prevention in the decease prevention control branch in the Population Health division. I will wait for colleagues to pull up slides. Thank you for your opening remarks. Good morning. There we go. Here you see an over viewpoint epidemiology of monkeypox in the new out break it is spread outside of countries to mull pull locations throughout the world that had never previously seen monkeypox cases. The figure on the left shows the number of cases with blue bars. You see the rise. The red line represents each new country with the first case. Over all, as of july 19th there were 13, 340 confirmed cases worldwide. 1800 in the United States. With california heavily impacted. With 266 case. You see San Francisco within california is one of the most heavily impacted jurisdictions with 141 case as of july 19th. This is in the a new disease but the first time it spread in countries at once. I will review epidemiology of case as of july 18th. As you see, most people who have hamonkeypox in San Francisco between 25 to 54. With the Largest Group 35 to 44 year olds. Next slide. This slide shoes the break down of case by race and compared to the race of the total San Francisco population. You see that certain groups are already impacted. For instance hispanic or latin x made up 29 and represent 15 of the population. Whites represented 47. 7 of cases and 41 of the total pol lagz and black, 7 in 5 of total population. Next slide. In terms of gender identity almost all cases item in men with a small number in transmen. This mirrors the epidemiology we see throughout the state and nationally. Also mirorth national and state wide epidemiology most cases have been gay or gay identified but not all. Next slide. Early on, sfd ph had an Incident Management Team priorities out lined here. Include establishing and maintaining readiness for delivering medical countermeasures. Maintaining an equity and evidence based approach throughout. Surveillance and monitoring. And lastly, and i know you touchod this critical importance. Ensuring effective and accurate messaging to providers, organization and communities. Supervisor mandelman also covered this topic around federal response to vaccines. I think it is critical to know that vaccines are the most effective tool to fight this virus and the best way to protect people. Unfortunately, the federal response has been slow and bottle neckd and the supply is limited. And way out stripped by need and demand. The process which should occurs the gentleman distributes to state Health Departments and then allocated bite california Public Health to counties the department of health and Human Services distributed 144,000 doses and there are more coming but need to come quicker. And we are doing advocacy at the federal level around this issue as our Community Activists and local and state politicians. As of july 15th, we had requested 35,000 dose. We knew early on the need and this is not the full need this is the early prioritized need. And as you noted, we have received 7, 743 doses. They have almost all been allocated out to the distribution Vaccine Distribution network we established. And as of july 20th, over 34 huh human have made their way in peoples arms. The additional 4,000 were received yesterday. So they will be provided to Community Members and patients and individuals over the next 7 days we expect that allocation to be used up. Next slide. Many appeal in San Francisco need protection offered bite Monkeypox Vaccine and should have access. Now the priority population is gay, bisexual, transpeople and other men who have skeks where men and multiple sex partners. Sex partners are also a priority. We know that this expansion of Eligibility Criteria will create more demand and we are already unable to meet the demand before the expansion of the criteria but felt this was critical step to take we need to get the vaccine to communities experiencing higher infection rates. As we noted, given the current limitations of supply there will be individuals who are emeligible but not able to receive it yet. And that is extremely traumatic for patients who know they want the vaccine and prosecute active and taking care of health and believe mow we are working hard to address this and get the vaccines to the communities. On the strategy to efficient low distribute vaccine is to establish a Network Within the d. Public health and throughout our systems of care. We continue is important to have geographic diverse idso there are multiple places people can get the vaccine to have the vaccine across all of our health systems. Offer drop in options that are better for you some and ensure we have appointment options. We are working on establishing venue base and pop up events like you referenced supervisor mandelman, that was successful. And role time accurate messaging to the community when special where vaccines are available. Second low t is critical we distribute the vaccines we are allocated quickly. Speed is urgent you noted and to build immunity as rapidly as possible and to demonstrate to the state and the cdc, we have the infrastructure in place to get the vaccines out to our community and to illustrate the deep demands we have here in San Francisco and the need. We are also prioritizing Health Equity by partnering with Community Based organizations doing out reach to those impacted by monkeypox virus and may not necessary low have access to information and make sure they are also linked to vaccine. We are bodiesing on lessocks learned from the community during other challenges such as covid and hiv. Next slide. Testing has been another challenging facet in the response. It is getting better. The current state is that the test is performod a lesion or swab the people tested are those with a rash. There are other tests in the pipeline that might be effective, swabbing athletes or rectums they are not available yet. When this epidemic started the only Testing Available was the states lab and several other california sponse networks that created air bottle neck and slow turn around. As of july 11 we have several commercial labs lab corp and quest and the San Francisco department of Public Health was able to receive on july first and within a short time frame complete validation and launched testing at our lab on july 12. The Public Health lab has the capacity to do 188 tests per day and have been able to leverage their covid tools including the extraction robots. Our goals with testing to make sure well is low access and faster time and electronic transmission of results important for providers and patients. There is an antiviral treatment which is also limited. And in that currently only a few providers prescribe it and they are the indication current evercurrently is it tree the most serious cases. This is because this medication is admit fda approved for monkeypox and requires administrative process for use it available under, investigational new drug protocol. We are doing advocacy at the federal level around this issue we need more access to this treatment. In addition, we are work to support bringing providers on board who can go through this process and able to prescribe the medication to patients. Community and out reach and education is an absolutely core and critical part our response and using a multipronged strategy to engage the community and provide information this includes Community Meetings engage being Community Based organizations. Festivals, fairs and gatherings. Social media, Public Service announcements, paid advertising and information distribution. We have don out reach and presentations to date at over 20 Community Groups and organizations including but in the limited to the left you see here. We were active at sf pride. Releasing Public Service announcements out reach and distribution of materials. Making on stage announcements. Flyering and releasing paid advertising during pride. We work to ensure the word gets out and kept informed of the situation we face. There is a list of some of the things we have done or sending 2,000 e mails. Flyering throughout the city. Direct out reach and dance parties ensureings materials are translated in multiple languages. Working on notifications and sending out a weekly news letter to Community Groups. In terms of paid advertising we have been working with organizers and advertisers to build awareness and have launched Advertising Campaigns in the bar and placed billboard in key thorough fares in San Francisco. For the latest information on monkeypox, the public and community can go to our sfgov monkeypox website and finds information and other materials on the tool kit page there is opportunity to request a presentation if a Community Group would like that and we will be posting real time after it accurate moving updated on our twitter regarding the ever changing situation with vaccine access. Thank you for your time and im happy to take questions. If i could, thank you doctor cohen and for all your work. I have a few. Again you are a local Public Health official not the federal government. But well is a feeling i think for, lot of wcfs the [inaudible] the you have described supply chain issues being the cause of the inability to get an appropriate supply of vaccine to San Francisco. But i cant help but think that this is a choice by someone. To not prioritize this. Given how rapidly we were able to not just distribute and discover a covid vaccine. We have one we dont have enough of it in the United States and dont have enough in San Francisco. So what is going on . You know i share your same questions and concerns around this. I think that some reveals concerning issues with National Level pandemic preparedness. There was an overly optimistic view that this viral infection could be controlled by vaccination strategy which would not require the same quantity of dose. I think early on as we saw in europe it was clear that would not be the kachls i dont know there was enough pivoting around that soon enough. And i think well is you know has been news around issues with the factory where the vaccines are in europe and inspection and clearance processes there. It seems like well is failures in full pull levels that need to being dissected as you said we should have had vaccines out in large quantities the beginning of june. Is it clear to you who is in charge of this at the federal level who is supposed to be getting these vacs eastbounds to us in a more pyle timely way . This is not my area but i know that the government the. Strategic National Stock pile has been controlled by several agents and that created xhoungz and management challenges and i believe now will be over seen by a new federal agency. And in terms of in notion that someone this miss apprehension or wrong idea that somebody had this will be easily control and did in the need more vaccines the numbers in San Francisco seem troubling and seem reminiscent of the days. Covid19 pandemic in termless of the low but going up. Are you seeing 55 new case in a day seems a lot. And i mean are we spreading into, haare you seeing with the numbers and what is that telling you about how much will get it in the next week or month. The numbers are concerning i hesitate to draw comparisons to covid19 this virus is different it is in the have the capacity to spread that quickly to that 19 people. But it is spreading quickly within Sexual Networks and a sexualy associated infection through close contact and rise in numbers is concerning. Currently in europe and the u. S. The spread has remained within gay, bi and transcommunities. I think as it continues to grow it could spread to other communities as well. It has not happened yet in the new global out break. We got shipment of 4,000 this week. Do you have an indication had the next shipment will come. Joy dont. But we can we will keep you and the public informed when we have that information. I think we are trying to hope for the best and plan for the worse around allegations well keep everyone updates. We are on our seats. You want to jump in. A quick clarification on the number of cases and im curious the numbers you were begin during your presentation and apologies, when they go through. Do we have how many new cases like yesterday. Right. We are updating the Public Information twice a week on numbers of cases. I believe the case counts were through the 19th. Yes. Why do you know what the numbers are looking each day over the last we are looking each day at numbers they are increasing each day. Some of this is because of the shift to faster turn around testing there was a bag log of cases or samples collect read prior to july 11th that had not been tested when the lab came on board they did several handled collected over the prior several weeks. There was mike an extra bump dollar because of that. But that is not to under 78 the fact that case increase. Do we know yesterdays count. I dont want to misspeak i have seen it but would like to confirm before. Sharing. Thank you. Can you explain that is going on with second doses and people who have appointments for a second dose. Are they able to get this second dose . Yes, thank you. Absolutely we do intend that everyone will receive a second dose the guidance now from the state is to prioritize first doses to ensure we get as many people a first dose as possible had we have the supply to give the second doses they will be begin beaut working on this is all been unfolding the last 24 hours we need to message out and make it clear for folk who is had their first dose what to expect. This would be a delay of the second dose and delay for a short time. Appointment i have to get my second dose say i dont know. Im not sure when your first doses started. If it were next week. Is it likely that appointment is going to get cancelled in joy think now we are asking our vaccinators to prioritize first dose by not giving your second dose will be someone with no immunity who has the opportunity to achieve protection we will message out about that. We will hear from doctor how the aids foundation is dealing with that. In terms of the folk who is got vaccination fist they deposit an appointment this might noting real. Thats correct. I want to thank you for you said the challenges and the expanding the eligibility to prioritize sex work and men having sex with men and people seeking vaccines, the reality is the folks knew they needed to get it before and we had an unfair system if people were willing to get in a line they were getting the vaccine regardless. I think it made sense to acknowledge reality and for folk who is are at risk the risk is greater if you are a sex worker or sexualy active person if you are across the room from machine in a party that seems that was a good thing and glad we god ahead. Now we have the cattle call approach. Will d ph change that. I know if i want the vaccine i have to get there an hour earlier tomorrow. We are working every day to improve the process and make sure the public has information how to get vaccines. We dont want anyone wastes time in line or under going the stress of wait nothing line and not able to receive a vaccine. The changes occurred in the last few days with kaisers no allocation they opened their vacs evens to kaiser members and nonmembers by appointments. And we have distributed to a Broader Network of clinical sites and partner and appreciate our partnerships with cbos the San Francisco Aid Foundation. Every vac nayerments more doses and their supply is in the meeting their demand. I think that having more supply is going to be critical. To get this address the current are raising. But in the meantime. Well continue to have appointment based options. Like through kiez and through the clinics on the website as well as the drop in option for people who are not able to make an appointment. Second question the inability to get a call back from any of the numbers. So i think this is also improving it does require resource. I will say for city clinic we had like 600 voice mails. It was everyone was inunidated. We are trying to pool in resources to make sure people get call back its is frustrating had they are calling multiple places leaving multiple voice mails they are scared andment a vaccine. It is a bad look for San Francisco and i mean i do i have been grateful for you know much of what the upon department of public healing has been doing the communications have been poor. And i think not only we have been giving out Bad Information but we have been making worse telling people to call the numbers where at least the folks im talking to not getting called back. That is anecdotal. If you have data, thats great. I think that those numbers on the website are not helpful. And i think for people who are im not sure how we will communicate with people whose appointments not honored. It is a bad look, i think to have people showing up for appointments that have been cancelled and not given notification of that. So how are you beefing up or over see changing how the social Media Communications happen so we are communicating in a timely way and not relying on gay twitter much. Well, i think we can talk with the team to give you detailed specifics i am hearing the feedback and there are efforts to try to address it and ensure the information out is accurate and real time. The drop in clinic was stood up over night. They did in the know how many dose they would have until they received them. I think having more advanced awareness for everyone helps with that plan and communication and really trying to figure out how to do it better every day through Quality Improvement and process improvement so people be not waiting in line for powerhouse in the wee hours of the day this is not guilty a criticism of you. My impression of you are great and appreciate this presentation but i want to community through to you the department of Public Health although the response of the federal government has been so bad that everybody looks better. D ph has done strong things, i do think the inability to return the phone calls, having people in line for hours and not giving them an appointment option are unforgivable and d ph needs to fix it. Those are my comments. Thank you doctor, for your work and your presentation i did have a question for a littles more collar ifkdz on the supply vaccine supply issues and may be you can provide more information. I think one thing i want to be clear on is it is the federal government distribution is that our sole ability to obtain vaccine or is there any other whether through private companies through other countries and is there anything else we could do outside of our efforts to pressure the federal government to ramp up had they give to california. Excellent question. My mondaying is currently, yes, the federal government is the only supplier and there is one manufacturer. Whether there are conversations going on around off patten allowing other companies to produce the vaccine, i dont know. It seems they should be going of now there is one manufacture and it is all through federal government. To the states. Thank you. And then the my understanding the process from federal government to states and states distribute to the counties. Just looking at that next step, any concerns or issues around how the decisions being made from the state level in terms of distribution. And where we sit as a city in terms of number of cases risks and the share of shed light on how the decisions made at the state level and which counties what and whether concerns with the amount coming from the state. Sn state has an allocation formula that i believe is based on monkeypox case rates. Continuing to test and demonstrate the burden of disease we have in San Francisco is important for that. It takes in accounts the rate of early syfilous among men in the jurisdiction and have a high rate in San Francisco. So those 2 factorers i think the 2 most important factors in determining the allocation. The state expected the vaccines allocated are administered. The ability to get the vaccine out quickly is important for future allocation fist jurisdictions receive vaccine and dont give them that could affect future allocations. It is a reasonable approach. Some of the challenges with it are you know people are not confineed one jurisdiction people work, play and move around the area. There are people from other counties getting vaccinated here and San Francisco in other counties. There is a bit of that to take into account in terms of how much we should be receive being especially if we are vaccinated people from elsewhere. And to follow up on that, i dont have a great sense of how the surrounding counties are doing in terms of wait times and lines. There ability to administer the second doechls im curious if the situation is similar. I understand some folks could arc veil themselves of taxiing in neighboring county. Is it looking better admit neighboring counties or the same . We have the highest case rate of the bay area counties currently. And i think we have an Incredible Community that is proactive and health care seek. I think our community is showing up in a way that is important. I dont than we seen that in all the bay area counties. I think that as cases rise in other counties than i will experience similar imbalances with supply and demand. Id like to say we are better in San Francisco but i think everyone is struggling with the same issues throughout the bay area. To clarify what im getting its. There was a time had it came to covid vaccines you could not get one here but you could work in the oak land and go and get your vaccine there. And it was fluid. There were different times we faired differently than other countries. People sometimes came here. Im trying to understands for someone watching this and at risk and trying to get vaccines or a second dose, whether it is an option it for them if they have the ability to travel to be looking in the options or whether the waits that we are seeing here are the same waits that they would be face figure they were to go to other counties. I thank you from my understanding at this point there are similar challenges throughout the bay. I dont know of other counties that established the time of mass drop in vaccination clinic this is we have. Thank you. Vice chair chan . Thank you, chair preston. This is the question that i am just trying to have a better understanding. Is this you know i understand seeing just the slide that talked about getting the word out. I and i think that has been true. Sometimes through our City Government in a situation hawe never felt before and this is the pandemic and or any type of emergency. I think that folks who have cultural or language challenges always get left behind with in this case, Public Health information. And you know supervisor mandelman is right, if the example in folks he mentioned are when we would consider upper percentile who have Excellent Knowledge and direct access to the information and about getting vaccine and transmission and Public Health information. But i have to sill im not seeing that amount in terms of language. And i thank you data that released, shows that the desparity among the Latino Community as limp my concern is that, we are already having challenges getting the vaccine and distributed. People are wait nothing line. They are call nothing and not getting calls back. That desparity will be further in my opinion, among those who english is not their first language. They may or may not already under a lot of pressure, and for them to try to say, i am at high risk population. I need this. I i just have not got a lot of concern and we node to fix that. But help me understand if we have a strategy now in place to fix that . Thank you. Thank you, that is critical. We are putting equity at the search and the strategy is partnerships with cbos wee just started building on partnerships we had throughout covid and hiv to work with cbos that work with the communities to pull people in for vaccines they are not knocking on the door who will not have access to the information. Cbos do direct out reach to clients to link them to vaccines. Can you mention the specific list of cbos you are talking about . I think i dont have the full list here but we can certainly send it to you. I would love to. I think that is just for follow up. And but also i think we can, too, play a part. I think that another part is like supervisor mandelman mentioned in the gay twitter. That is what like this is the only place that folks get information. Again, that is another part of like further divide on the Digital Divide in San Francisco and thats the only place people get information, this is dangerous. And im going to say this out loud, too. It is like i think there is part of it like i look to the partner of public healing to prioritize making sure that the most impacted populations are prioritized for vaccination. I do want to suggest and recommend had ph be mindful in the messaging and the way that it is distributed that not to also create a stigma this is cast upon our lbgtq community and to really urge the public in general, to be made aware to share that information. Respectfully. And that goes back how critical for d ph be the one in distribute the information and fast. And the effectively like efficiently now tow misinformation dont spread. So thats really my concern now. So, i would appreciate with a response and a follow up with the list of cbos. Thank you. Thank you. Thank you. Vice chair chan i had a question you fauked in your presentation the demographics of who is track monkeypox and who what groups are prioritized in terms of out reach and vaccines. What i did not see if you are tracking the demographics of folks who are receiving the vaccine . Yes, that is absolutely critical we are working on setting up the Data Exchange with the california adult if immunization registry to provide that as we did with covid it requires an mou and froesz get it in the adult registry thats where we will pull that data on racial, ethnic, age and gender break down to ensure we are achieving equity is the most person goal. When do we expect to get of the first data . We with can report back after the hearing. We have the data for vaccines within d ph the challenges for external partners is where we get it through care. Thank you. Vice chair chan. I think that one more note i want to add is im trying to understand between the learned lessons from pandemic that we just literally still in the midst in my opinion and we are in a different stage of it. I just im just im just kinds of stumble on the fact that we still having a hard time getting data sharing from private health care and Service Providers on the critical issue. I want to put it out there and wishing that d ph will consider to replicate another model, a system we can get this going. Thank you. Thank you vice chair chan. Supervisor mandelman. Thank you, colleagues. Thank you doctor cohen. I think we are ready for tyler. Thank you. And thank you to our partners at aids foundation we are grateful for your work. And i want to thank doctor and everyone at the Aid Foundation for all the w they have been doing from the early days sounding the alarm. Calling for town halls and having town halls. Getting information and vaccine in arm in a humarine way that makes sense. A true resource through all of this. And so welcome doctor trimere. Thank you if you could bring up my slides employmenting to thank you, supervisor mandelman for todays hearing for your leadership. For you and supervisor dorseys resolution. And also a shout out to senator wiener for you their leadership. Picture it, we are in a Public Health crisis impacting gender and transgender men and folk in our community there is a public failure this community is left on their own to advocate for one another and educate each other and bring awareness to an issue and fight for access to the health care they need and deserve. No im not talking about 1982, im talking about modern day monkeypox. And while we cannot draw a correlation with the earliest days of the hiv epidemic in terms of the severity, we can draw a correlation in the lack of urgency that he is occurring when a Public Health crisis is impacting a group of people that have long had medical trauma that long been stilling in typesd and politicized in our country. Know we are in a moment with organizations like San Francisco aids found agsz recognizing the 40 years of service this year are well positioned to respond to the monkeypox issue in our community. And we are hoping each day that be receiving more vaccine in the community but in the hands of trusted Community Partners who had relationships with community and are able to offer vaccination and testing in a low barrier and culturally affirming way. We have seen an incredible demand for access to information for people to talk to about their concerns and fierce as monkeypox continued to pred. In our community. And become to the early days of foundation had our First Program was a hot line, we launched a new monkeypox hot line which now some respecting 12 calls per minute from the day we operated. Answering the questions of fear and wondering when they will be getting access it a vacs sxeen hato do if they do have symptom in our community. To be responsive and answer the questions, we have been partner to get information in the community and the best ways to help folks understands what monkeypox is and when to do if they have questions. Lunched a virtual town hall with our colleagues at San Francisco department of health. And hundreds attendsed ask question and educated. So much so we are working on launching a Spanish Language version that will be announced soon. We are continuing to receive questions about where hay can get more information about vaccines, how they learn more about transmission. Prevention and vaccination. Next slide. As my colleague talked b we have just seen a tremendous growth of monkeypox in our community but this is only a snapshot of what we believe Community Spread to truly be because of the delay in our ability to test up front and now in aware knows of the community when and how to access testing our assumption the spread is further than we know in this snapshot. We node to continue to do anything we can to reduce the bureaucratic barrier in place to access testing and treatment and access vaccination. You saw the data for california and coming out of San Francisco department of health but we wanted give you a snapshot what we have done with limited supply of vaccine as well as our testing efforts in the community. Starting with testing in diagnose this is our data as of july 20. We tested 52 individuals. As of the 17th. And 20 were positive. 6 negative and 26 are pending results. Looking at the demographics, however, 49 of those we have tested are black or other people of color in a break down of 18 latin. 14, Pacific Islander and 5 from the black community the personals of commune based organizations having resources to reach those who have been further from access in the health care space. 98 men. And ages between 23 and 66. Of the demographics of those tested positive for monkeypox data which we are collecting at San Francisco aids foundation, 65 black, indigenous. 35 latin. 25 ap i and 5 black. Among our vaccinations through the clinic in the castro, we vaccinated 761 people. Will including 460 people who attended the events this past sunday. 127 vaccine doses is the amount we still have on hand. Although we are filling those from our wait list and continue to ask for moreax cells to vaccine. We have an extremely limited supply you heard today. Of the vaccine. We are distributing our dose of vaccine as soon as we receive them by scheduling appointments rather than people wait nothing lines and filling the appointments from our wait list. The wait list one of the only wait list admit city. This slide say there is are over 4800 people on the wait list this morning tla there are 5, 300 waiting on our wait list who deemed eligible under the previous eligibility and as we learned today it has expanded. And anticipate getting an influx of phone calls and requests for the wait list. A quick over view of the vaccination. We are reaching people at the highest risk. Documenting exexposures from the pride parties we heard about. Being gay and bi transmen and women and many trying to gain access of vaccines at the partner cites. Racial equity sehigh in mind as we think about Vaccine Equity and he majority diagnosed and vaccinated have been individual this is is because we are a trusted culturally competent prosecute viedzer for gay and bimen in the community. You look here at the image you see a break down of over all demographics of those we are vaccinating. Leaning back in to the number of folks we have been able to reach. This vaccine demographic slide will further show you over 80 of those have been gay and by sexual men, 9 transgender or nonbinary and 65 between ages of 25 and 44. We have been working with San Francisco department of health. We have been proud to increase our coordination and communication, although we still have a long way to go in being able to get messaging out in the communities of keep have been trying to arc line with equity transgenders and provide the lessons we are learning at San Francisco aids foundation to the department of health so they can think about that as they allocate to the community. We are happy to see the expanded eligibility. But again, this will only cause a long are backlog and lines. And more frustration with our communal. But we are happy to see that as we are responding that San Francisco department of health has offered their staff to help address the hot line calls we receive at San Francisco aids foundation. We have several recommendations and requests. Back up one. There we go. Obviously, vaccines. We need them and need them now. We have been requesting for our general operations western our Sexual Health clinics still needs to operate to address the Sexual Health needs of our community and incorporate monkeypox vaccinations 200 vaccines a week for general operations and have been asking 1,000 doses to begin to launch from 2 to 4 large events for priority communities that may not have the 8 to take time off and wait in lines or in phone trees. We are conditioning to advocate for equity and he out reach in access to vaccines. Excited seat eligibility has been increased we need to ensure in that increasad eligibility the folk vs access to sites and hours and they are getting the access they need and deserve. We are hope to see a strong are community dash board with demographics on testing beyond when we know who we are test nothing our clinic including testing, diagnose and vaccination. And that we will be able to partner more closely on communities lead fest positive messaging on prevention and exposure this window is too late. For when we have needed to be doing in the community there are efforts to educate folks. In the abcents of a biomedical response, we need Harm Reduction focused out in the community immediately. Especially as we continue throughout street festival season. There are appointment slots made available. So you are not wait nothing line. But coordination has been an issue. For example, we received qr codes to get to priority communities for the vaccination clinicings at San Francisco general in morning but did in the receive them until after 6 p. M. Last night making impossible to get the appointment base system out in the handses who may not be able to stand in line. We are requesting a meeting on the coordination of communication and Community Engagement that includes per ins who are trusted out in the community to create the set of messaging. And foiblely just that we have we do have some concern about the especiallys we head in the street festival season the allocations from the state. The state of california has to think about the state in entirety im biassed. But i myself am a black, gay man living with hiv for 18 scombroers high risk for monkeypox and myself and many members of my team working every day have not yet received vaccines ourselves. We near a moment of crisis. We near a moment where the federal government has again failed us. And we need to do everything in our power to be responsive to the needs of our communities. We understand that there is a federal supply chain issue. We understand that supply chain goes to the state and also understand this we are in a very short windso now where the threat is happen being daybyday in an increased way and have several events the community will attends within the weeks ahead and need to get vaccines out in the arms of folks. For those who are listening today, we are hoping you will continue to help us demand action. We have been collecting signatures in the voices of those who want to help us prevent the further spread monkeypox. This is something you can do as we responded. And foiblely to thank all of the Community Members that have been sharing information among themselves and our Community Activists waiting in line, sharing information and taking action. Thank you for your efforts. Thank you, doctor. I have a few questions. Swon so your huge wait list has built up with the prior criteria. I did notice left night when i went to sign up with the new criteria you cant do that. Right now on your website. What is your think burglar what the aids foundation will be able to a dam new criteria. We have now have a morning monkeypox meeting i never thought i would say, we do. Every morning at 9 a. M. We mote to discuss what happened in the left 24 hours and determine what updates we node to make. We are changing both the criteria in the sign up wait list today on our website and through the form you fill out. I look forward to joining the other 20,000 people. You can be 5, 301. Exciting. And do you have thoughts on why it has been, you have been able to do this. You return phone calls you are able to set up appointment for 5,000 folks. Any thoughts yet city has not been able to do this. I think it is we all have things that demand our time. But i think it it is a responsibility as Public Health officials and Community Organizations to prioritize the crisis happen nothing our community. I think we have seen efforts of the city to do so. But i do think that we have been much more in a position we have redirected efforts. We have said to our staff that right now monkeypox is a crisis in our community. And that who i we have other crises occurring we need to pause efforts and beat the curve of new spread in our community. We have a team of folks that is in the doing their current jobs they are aing the hot line or preparing for a clinic. And we hope to see the same effort and repriorityingization happening at the city. One of the things the aids foundation and other aids organizations have done in the preprep days was help folk think about risk and how to manage risk. And im wondering how you are, this is i should have asked to Public Health as well. How are i mean i have been free lancing some in tv appearances suggesting to folks they might want to consider going in the summer until they have been vaccinated thinking about activities and dialing down. Or just at least thoughtful about it and not doing unintentionally doing things that are risky. That is about as sex positive as i can get about communicating that, for folks, in are you how are you trying to community . We are coming up on the door. There are circuit parties. Folks are taking shirts off and making out. You know. And you know and then there is the plain old garden variety sexual activities of gay, bi, and transfolks. Had are we communing to people about what they ought to be think burglar this summer if they have not been vaccinated. We received a lot of question in this very similar vein via our town hall. I encourage folks to visit our website where we responded to all of the questions that dmam through asked question documentful we are an organization that recognizes that we cant tell people just to abstain or dial back tell fill something in folks we dont want to shame people for behavior the way they and a half gats but want to make sure they are prepared for the best way to navigate the current crisis. That could mean ensurure trial to dial up the conversation you have with part nirsz. If you go it a dance party thinking about what what you will wear perhaps it is long sleeve. Cleave jones was asking me should we tell people to keep their shirts on. We know how this is spread from skin to skin contact it is likely based on what we have seen tkdz be spread in those ways. The parties are going to happen and i think it is a real thing to been what you will wear in the moments. We are working on a new cam upon pain roll out before the next set of festivalos how folks remain safe going to the events. Great. Thank you. I will say one thing you asked around second dose. Which is we will just be unable to responded unless we receive more vaccination at San Francisco aids foundation. Thank you. Thank you. Unless there are other questions i like to open up for Public Comment. Thank you mr. Chair. Members who wish to speak and join nothing person line up to speak along the windows now. For those remote call 4156550001 and enter access code 2493 392 7760 then press star 3 to enter the speaker line. Continue to wait until the system indicates you have been unmuted to begin. Fst person come forward. Good afternoon, thank you for having this hearing im joe swies speaking here today was informative. Thank you to d ph and all our Community Organizations for hard work. I understand that this is a failure on the federal level. But i cant help but wonder that it has been a disappointing response on state and local areas. Like to see the success on the cbo sides. Dont understand why the process be the limited vaccines we have is inclusive of people who can afford to take the day off and go to a walk up and defend on friends when is is working and not. I explored the website and went through the clinics that sfgov. Org they redirect you back to voice mail and and general walk up and it is extremely disorganized. I think we deserve better the best Success Stories are in new york, sacramento and l. A. All counties have limited vaccines i would like to encourage that the city and the department of health take in consideration what they do when further supplies come. If we got 100 thousand tomorrow it would still be exexcusive press that would benefit a now to start. New york and l. A. I see on so social media updates and i love to see that here. Thank you. Gary mc coy my capacity at senior cochair with [inaudible] and other capacities, too. They talk to me in various ways. Thank you for prioritizing this hear and thank you supervisor mandelman the first in the community to speak up on this issue. That we have internal numbers that are made public twice a week is a problem. Need to be more transparency. Dash boards that are updated darryly. We need to know populations and demographics most impacted receiving the vaccination and treatment. Goals in the d ph today was great. We need to know when they will start. Almost 91 of them have been implemented yet. We need access in impacted communals. Should leverage the same partners we had for covid being vaccinations. We need an appointment system for foams that work or other commitments. Stand nothing hours in line does that the work for a majority of the population impacted. After years of a pandemic and fair season coming up we node to act quickly. We have the infrastructure and covid play book and need to use it. Thank you for sharing your comments. Hello supervisors, noise to be back, thank you very much for holding this hearing. Tom i will do a bit with my equality california hot than gay man in San Francisco hat on. As equality california work to improve local, state and federal response to monkeypox. I think hear in San Francisco we are luck tow have lbgtq representatives like supervisor mandelman and scott wiener among the most vocal officials in the United States. In demanding a response at all levels to the public healing crisis. Thank you to our lbgtq lead and House Speaker pel lose and he mayor who are calling on hhs and the cdc to respond to this crisis with urgency terequires. And to provide San Francisco and california and communities across the state with the vaccines and Testing Capacity necessary to at this point turn the tide away from a full blown Public Health crisis. It feels as though begin the slow response we missed moment and dealing with this for a language time. Unfortunately. But thank you to leaders now San Francisco gay man hat on. I saw and i think San Francisco in the 80 ave. Pioneered a National Model for response to the aids crisis. We had a model to response to the covid crisis. And we are not with the monkeypox health crisis. You shared my story. It is unforgivable i find out i dont have a second appointment because of this hearing. It is unforgivable people are getting vaccines today who saw yesterday they could not if they did not get there before 6 a. M. But get them now because friends are posting we need d ph to share that information the city nodes to lead in the response. Thank you for sharing your comments. Good morning surprises im santiago a queer gender nonconforming person. Im here to demand culturally competent focused service for my community. Im witnessing every day misinformation. Lack of educational material in other language and snow ball affect of stigma causing in my lesbian, gay, bisexual, transgender queer questioning and asexual communities. As these people may be sex workers or frightened undocumented families. A couple weeks back i told i may have exposed monkeypox after calling 4 clinics including my primary care dwr told there was a shortage of vaccines a week later i was able to receive my first vaccine and yet it took 2 weeks for mow to receive the monkeypox pc r lab results. Still, i dont have a second appointment. For my second dose. And during this time i was isolated unable to passport my team. I felt powerless. I can imagine the challenges someone else may experience knowing i have ocsesz and work in the community. My Latin X Community is hit hard. 30 of monkeypox cases are latin x. We need to change this and act fast. Under an hour at work we put on a list over 70 people that were queer, transpeople of color and yet we dont have the demand to give them the vaccines we need to change this. Thank you. Hello good afternoon, supervisors. Thank you for giving me the plat furthermore to talk about this issue at hand at our public Healing Department and community. Im joannea a queer nonbinary fell i work at [inaudible] as an hiv wellness coordinator. Im here to advocate for the Latin X Community and thegand everdemand for vaccines to be accessed. The population i work with is in a vulnerable state with spread monkeypox in San Francisco and lack of vaccines for high risk. As know hiv coordinator i had little to no information begin to me bite department of Public Health of california. San francisco and the cdc. I also want to point out most of the information i had to seek was all in english and limited for people that are monolingual. This is an unacceptable display of action on d phs part when communities are hit hard. Work nothing my community with high risk individuals put mow at risk for monkeypox as i assist in hiv tests. Support groups and lbgtq healing fair events i live in an lbgtq household and reasonable informed there is a possible monkeypox exposure. I looked clinics and denied access to vaccines i was not a man or considered high risk this. Is a disregard to slowing the spread of monkeypox and preventing higher cases from forming. Thank you for your time today and listen to my testimony i want to share a question with you all. Now we have a high cases in more than any state. Apologies we have to cut you off. We are having everybody at 2 minutes. Next speaker. Hello, supervisors thank you for the opportunity to speak today im curtis work nothing the tenderloin makered and cochair. But im also a gay man live nothing San Francisco. Im a long time survivor of hiv over 35 years and you know, i cant help but feel this feels similar to where we inform the 80s. I continue is a different set of circumstances. It feels reminiscent. The poor response and state response and city response. I cant help but ask myself would the response be different if it was not confine in the the gay communities. If there were in the hetero~ sexual community would there be no urgency . I dont know if that is true. I like to think in the world we live in this is not trough. You see what is going on the nation on issues around lbgtq community it probably is true. It is a problem. I have people in calling me. Friends calling mow and senior i work with in the community and folk in low income folks trying to get information about monkeypox if they should get tested. You know, mow because there is in access to information the messaging is not communicated. They dont know how to access the informing. You know im not a health care professional. I gotta say i want in the loom people call me i am well informed i did in the find out the changes until i heard the hearing today. I fit the criteria today. I got here and heard it here. Thats sad, right. I money we need to do better and ramp up our efforts as a city and state and the nation. Thank you. Good morning board of supervisorpt im andy stone at huge thank you to supervisor mandelman and the supervisors for bring thanksgiving important issue up. I have a lot of things to say. The first thing is you know thank you for all your advocacy with the state and federal government. California is the top 2 states impacted now. Numbers of monkeypox cases are the highest in the nation and inside california, San Francisco has a third of new case of monkeypox. We need to advocate to increase access and that must happen quicker. I want toed say thank you to d ph expanding the eligibility to include gay, bi and transgender men and 6 with men and folks that had more than one Sexual Partner in the last 14 days and sex workers. I have a couple of things to say ensure equity increasing transparency for Public Health we need information more quickly about who is getting diagnosed, tested and treed for monkeypox and transparency who is most risk including where the cases of monkeypox are currently being arc rising. For example in lettin x, gay and male community. We node to make sure we are doubling down on efforts to ensure folk vs access to vaccines and work with more lbgt, latin x to get vaccines in arms and make sure people are not wait nothing line for hours to be turned away and come back day after day to be turned away again this is helping folk who is have the ability to take off work or work remotely. Thank you. Thank you for sharing your comments. Next speaker. Good afternoon. Im harry Border Patrol im 77 yearsol im here to speak so stigma. It is is cheer that the country is not going to Pay Attention to homosexuals. They did not in the 80s the hiv spread quickly because of that and not going to do it this time unless we press hard against what is termed the conversationive view in the country. We will not get the vaccines unless there are major push and invite and you beg you to screen it and know that that is when you are up against. Everyone cells w off and im sure they will do a great job however. Stigma is going to be the ball rolling do you want hill that will crush this and am spread like the hiv virus did in the early 80s. Please, have that under everything you say. Is that we are going to be discriminated against because of who we are im a white man inside im rainbow colored. Get them all and help them all. Thank you. Thank you for your comment the that is the ends of in person speakers. Can we have the First Virtual caller . Im mike market and i am resident of districted 8. Thank you for having this hearing. I appreciate it. I urge to you expand access to Monkeypox Vaccine and improve communication strategy as well as develop solutions and model new york and l. A. [inaudible] my store sein the unique a gay man who live in a house with other gay men. Im at high risk. Last week i visited sf general and turned away. This week the information is confusing. I took yesterday off of work to go to berkeley for the vaccine the fact i had to go to a bath house recreational in a different county for health care need system insxan insulting. That line was full of desperate people from San Francisco. It was a fridged and white crowd i waited 5 showers was lucky. Many were turned away and many from San Francisco. Im fridged i know that many folks dont have that luxury to driveway to Arlington County over the possibility of receiving basic health care the city can sthofl robberedless of federal distribution. Pop ups are great for distributing toed not health care. I received a positive test result 5 days after the test putting me out of high risk to my community i did everything i could with resources i had access and i felt powerless. This feels similar. I e mailed the mayor, supervisor mandelman and others and received no response we must do better we cant keep get thanksgiving wrong. Thank you. Thank you for sharing your comments. Next speaker, please. We have 11 listen and 3 in the queue to provide Public Comment. Can you put the next call are forward . That was an unattended line. We will circle back to that one. Good morning supervisor preston, channel and machine man im Steven Torres a cochair of the castro cultural district. Thank you supervisor mandelman for your advocacy. Delay and slowing response to monkeypox distressing and unnecessary. Traumas of the past and [inaudible] and it is behalfling after covid pandemic. What is distressing with the limited vaccines no efforts made prior to pride celebrations to mitigate the spread and protect our communities. We along with the lbgtq [inaudible]. We applaud the efforts of San Francisco aids foundation. [speak fast] and education and understanding of the virus moon primary care providers. We have concerns and information distribution nonenglish Speak Community and the cbo. [inaudible] comprehensive state and municipal out reach in response to guide expose the infected with individuals similar to those in place for covid19 should be in accomplice with low barrier testing on state and municipal levels. Thank you. Thank you for sharing your comments. Next speaker, please good afternoon irs sproos im ben i anxiety calling as a member of the lbgtq democrat iing club. I urge you to continue to apply pressure at every government level to not abandon our community. And not accept a vaccine only approach mitigating monkeypox. We need to demand better of our agencies to use the science and tools that are available to increase access to testing. To increase access to antiviral medicine. And increase Community Level engage am that is not just sends being an e mail to your existing e mail list. We have gone over 2 years being told that individual responsibility the get us out of covid we are in the 7th surge of another variant this is in the acceptable. We need an organized, robust public healing infrastructure and strategy implemented yet that does not rely on individual responsibility to the abandonment. I urge you to demand better of everyone in a position to ask for and receive more resources. If we dont stop the Trans Mission of the virus in the lbgtq Community Tell spread to other xhounlts we must act now. Thank you very much. Thank you for sharing your comments. I will check with our operations to see if we have another caller. That completes the queue. Public pents on this item is closed. Thank all the Public Commentsers special just ensure supervisor mandelman has arc additional robbers. I want it say that i think the point made by a lot of commenters is an important one. Upon we all recognize there are the supply chain issues. Those dont explain some of the shortcomings we heard about in terms of appointment waits and lack of communication. In terms of i dont understand yet aids foundation can answer a question about the percentage of people in the demographic break down who get the the vaccine and commends them of their Community Based organizations for being so on Top Television and having that data i dont understand yet department of public healing kent do that daily. That we account not get answers to that. I think that it has been suggested by a number of folks both in Public Comment and outside there be a dash board that d ph makes available that gives role tame information that is essential. I will i think agree with the many commenters said that despoit this different from the 80s and aids in many way nas mandelman said that i agree with the sentiment we would see we not in10ingally but we would see a different response if this were impacting a different community. Hetero~ sexual folks. Whatever the intentions here that is a reality i challenge anyone to dispute. I think that while we all have a shared frustration with the federal response and we all Work Together t push the feds i have no doubt d ph is doing that i want to echo Public Commenters about the need for d ph to up the response. This is a disconnect tuck burglar a lot of the attempts to Center Equity in our response. And the fact this if you cant ford to spends hours upon hours online which is by definition is going to favor the least marginalized not the most. So we have to address that. In a proactive way. Thank you, supervisor mandelman for your leadership and bring this not committee and your work in raising Public Awareness and sounding the alarm thank you chair preston. I concur everything you just said. I think have been united and have been worked well with the department of Public Health and calling on the federal government to get their act together i think d ph needs to get its act together and the stories we hear are horrible and i think both of the other members have noted. We are not distributing the vaccine the limed supply we get equally that makes people have confidence in San Francisco city gentleman. And that needs to change. So im going to request or make a motion request and make a motion that we continue this hearing to the call of the chair i think it is likely we will need have future hearingos this. Thank you, supervisor mandelman we will support that and to be clear, whenever you want it back we will make that happen. Unless there are further comments or questions. Call the roll on the motion to recommend this or call of the chair, vice chair chan. Aye. Member mandelman. Aye. Chair preston. Aye. Thank you, the motion passes. Please call item 4. Item 4 today a hear to receive an update to the assistant district attorneys plan to address the hand hygiene documentation. Infection prevention and control by the center for medicare and Medicaid Services result nothing a loss of laguna honda arc creditedation and medicare and Medicaid Program funding and a plan for reinstate am of the programs bite federal dead line and requesting the department of Public Health to report. Members may line up to speak or remote call 4156550001 access code 2493 392 7760 then star 3 to enter the queue. I program will indicate to raise your hand. Thank you, madam clerk. And want to welcome our presenters to the item and also thank supervisor melgar for sponsoring this. And for her leadership. We had an initial conversation at the full board and a committee approximate but looking forward it getting our updates and just appreciate your leadership and your tome put, lot of time i will turn it over to you supervisor melgar. Thank you for scheduling the hearing so quickly. Gifrn the growing concerns about the status of laguna honda hospital, i want to clarify the goals of the hearing. We picked up the legislation that was introduced by supervisor peskin and transferred over to us. So we could schedule it quickly but not talking about hygiene or hand washing well concentrate on the closure plan. So, i have a 3 main goals for the hearing. And i hope that you will agree the first is clarify some of the conflicting information we have been hearing about the implementation of the closure and patient transfer plan to get clear answers about who is being prioritized for transfer and whether there is discretion in the transfer of the frail, high risk patients. Provide insight on patient rights. Refuse transfer and relike. Clarify misleading information provided to patient and families that may be cohearsing them to accept transfers despite occurrence. Identify the appeal sxroesz what consequences if any there are to the city. And identify what the city bottom line is. Pertaining to however how far we are willing to go with cms in relocating parents that may not survive. So as we know, this i didnt cal Health Institution is in crisis the hospital lost the a creditation by medicare and medicaid. In april. We have been on a parallel path to recertification. Part of the arrangement with cms to continue receiving funding for medicare and medicaid parents extended september 13 of 22 laguna honda submitted a closure and patient relocation and transfer fan approved. This plan was told to us by mr. Pickens. Thank you for being here. At our committee of the whole. On may 24 of 2022 we discussd that and regain certification. We can cope our hospital continuing to serve the patients that need it. Well is much to discuss about the recertification plan, we can address that at the full board on september 13th hearing we agreed tochlt todays hear being will be folk ulgsed on the status of the relocation and transfer plan. Of near low 600 patients that are still there. We were under the impression that if laguna honda hospital work in good faith to a Social Security the patientings help identify proper place am for discharges and transfer that we could and we would have fulfilled our commitment as was in the closure plan we agreed to. That that we would continue to receive medicare and medicaid payment. While we inspectly worked on the recertification. The hospital has followed through on assessing every patient at laguna honda the staff had made thousands of calls now. To local facilities skill nursing beds. 56 discharges and relocations. And yet. We are getting mixed messages from cms whether we are doing enough we are not aggressive enough in moving people out. There has been the understanding that we are we were understood this from mr. Pickens at our committee of the whole that we were prioritizing the discharge and relocation of patients based on level of need. We were moving out those with lower levels of care first. And this has not been what we had been hearing. We heard of acute patients offered treasure and some have been transferred. For patients now who have been transferred have died. That we are aware of. 2 of them were elderly we than there is high risk there is truly no rational for n this nor a moral excuse. We must ask how far we are willing to go to meet the terms of the this agreement with cms. At the expense of the lives and the health of our citys most acutely vulnerable patients. Many of whom will like low not survive this transfer. Today we will hear from the d. Public healing and laguna honda hospital leadership. We have a special guest, former City Attorney and former supervisor remy who has been a long time champion in rebuilding laguna honda hospital, has been i advocate during this time of crisis and one of our best willing minds in the city. We have theresa on stand by who represents the workers at laguna honda hospital and jill nielson from the department of disability and aging to discuss the role of the Public Guardian 2 of the patients who had passed were in public conservatorship and many are still at our hospital. We have that obligation as a city. We have as well mr. Pickens again, thank you for being here and continuing to keep us informd and getting to the very heavy and important issues. So through the chair, i would like to ask mr. Pickens to come up. I do apologize my cosponsor supervisor peskin got late in the day he is in the able to join us we will go into the hearing. Mr. Pickens if you could come up and make your presentation. Before mr. Pickens begins supervisor mandelman . I want to thank supervisor melgar for calling for this hearing. I have been following the news from laguna honda with great concern. To me in the thick of the fight over the a creditation and potential closure of city college, this is reminiscent where it feels to me like a crediting body is forcing really bad out come at the local level without taking responsibility. For those out come. I think this what is happening to folk who is are being turned out of laguna honda in some cases to die in other cases to be sent it homeless shelters is an embarrassment to the Biden Administration. I am i say this as a generally supporter. Supporter of the Biden Administration laguna honda is the upon count ropes largest Skilled Nursing facility. San francisco is the only county that tried to bear the responsibility of operating a facility like this. It is an essential provider of Skilled Nursing care to a host of people but the major plagues now for people under conservatorship to land in San Francisco. And to be turning folks out of that institution into eithered far poorer, less careful institutions or to homeless shelters is awful. And there is i think a notion from some folk in San Francisco in administration, we cannot make too much noise for forethat cms will punish us. I am a rogue member of this board of supervisors and im not part of the administration and feel more liberateed say that what is happening here is absolutely wrong. And the Biden Administration the department of health and Human Services are doing a bad thing to San Francisco. I want to thank supervisor melgar for calling for this hearing. Thank you you are in the rogue we all fell this way. Thank you for those words. Thank you i will say that i i know folks are work being hard but it is important to step become at supervisor mandelman and melgars comments do and recognize the tragedy unfolding here. You know i say this as someone with 2 dkdzs of defending against e visions and marched with People Holding a huge banner this says, e vision equals death. And when you see people displaced especially seniors and others with Significant Health issues displaced from their homes we are seeing this, this is happen nothing the most well managed way and folks are trying to mitigate damage their is no mitigating the impact on the most vulnerable members of our city by this and it is not too late for the federal government to make to stop these out come. And this impact. I will be joining with you supervisor mandelman and melgar in any and every possible way. I agree, were not the ones had are directly administering figure out the plan and work with the regulators we in this committee are an oversight body that calls a foul when we see one. Next for combrur leadership. Unless have you comments we will welcome mr. Pickens. Good afternoon and thank you. And members of the board. Im joined this afternoon by doctor hag dltd away she is here to help me keep to track and answer questions. She is the colead for the laguna honda closure plan. And so is well up to speed on the plan. Again thank you for this opportunity to come before and you provide this update. Before i begin todayy presentation id like to clarify my credentials. When i was here before i referred to doctor pickence by a couple of the your colleagues and want to clarify im not a medical physician. I am a Lifelong Health care add administrator with a batch lors if Public Health and masters in Health Care Administration from school of Public Health and tropical medicine and certified in health care management. The premiere credentialing association of health care professionals. Thank you for this opportunity for the doctor and i to present an update to the laguna honda closure lan. Laguna honda providing Quality Health care to San Francisco for more than 150 years. This was demonstrated when laguna honda successful low protected patients during the pandemic where the Hospital Experiences the lowest death rates and highest vaccination rates. Was ash worrieded best practice for covid killer in the nation. After several inspections last year and early this year, the Federal Center for medicare and Medicaid Services, cms, terminated laguna honda participation in the medicare and Medicaid Programs. Findings were addressed related to the use of elicit substances. However, unfortunately when they restate your named for the final visit they found additional issues and due to the time clock in terms of the federal revving ligz for compliance, laguna honda did not have sufficient time to address and remedy the new issues leading to dessertification in may. As a result of the dessertification of laguna honda cms is requiring that the hospital close and transfer or discharge all patients by september 13th of 22. It is important to emphasize that we at the start recognized how traumatic and significant a type of closure or transfer would be for the patients at laguna. In that regard, laguna and city leadership works with our partners many of which were in the dc area to develop and prosecute pose to cms that rather then and there implement a closure transfer plan that we establish said recertification mile stones be met that would show how lagowna remedy those deficiencies and come become to compliance with cms so we would not implement the closure planner transfer patients. Cms reject third degree proposal. We were then instructed to develop a closure plan per cms rules. We developed a closure plan and presented to cms that was realistic based upon the size of the patient preponder lithe at laguna and the complexity of the patients we care for. We proposed that if we are forced to go through a closure relocation press we would need an 18 month process to complete. In order to go it in the most efficient and safe process for patients. Cms reyekt third degree 18 mont closure plan and required we go on a 4 month closure plan from may to assessment. With the possibility of additional 2 months. We rescue noise how traumatic this process. Locked at calculations we know because we care for nel every day. Look the at the availability of nursing and beds within San Francisco and california. And informed cms as a local expert who takes care of patients, this is how long it would take. They reject today and said now you must do it in 4 months. Therefore we submitted the plan. Changed the plan we submitted and come plied with the directive it must be 4 month and they approved that plan. It is important this in that plan while we did not get the 18 months we did say we would make our best efforts to implement this 4 month plan, which we knew was not present but were forced to dom that is when we have done since. We made our very best effort and also kept cms and the California Department of Public Health informed on a weekly basis of our progres employed cloclosure plan is prescribed and required by med killer and Medicaid Services and the California Department of public healing who serves a subcontractor to cms. We were and continue to be directed boy cms and cdph to strict low adhere to the plan that they approved that 4 months was a pot of additional two months extension. It is important to note this we meet weekly with cdph and cms and in the meetings, we are told that we are not moving fast enough nor having enough discharges to meet their september 13th deadline for transferring and closure. As i shared when they approved that plan they also said that if we are successful in the impelementation they would consider an additional two months of funding. Beyond september 13th that would take us until november 13th. And they have made it clear that additional 2 months is upon our successful impelementation of their closure plan. It is important to note because of the clause we put in the plan about making our best efforts we have continually asked to define what they considered to be appropriate progress. You are require topside transfer and close by september 13th. It is important to note that within the cms, rowels and regulations of the California Department of public healing and the California Department of Health Care Services, that there is for the protection of patients an Appeals Press that is very prescriptive and gives rights to appeals recommendations. Id like to point out that again, we recognized how traumatic and significant the closure and transfer process was going to be. And we are every day. With our patients, family and our staff. It is traumatic for all of them. For many cases patients and our staff have been together for year and sometimes decades. Again we more a wagz in the of our making in terms of closure transfer plan but imposed upon us and doing our best to meet the obligations that are required urn that plan. Cms cover most of the costs for care that occurs at laguna honda hospital. And in addition to providing the funding, through cms the California Department of Health Care Services or dhcf is a responsible payor on behalf of cms in california they partnered with the California Department of public healing as we try to implement this closure plan. Areas of concern obviously is the significant cost of care at laguna honda. Currently, it it the operating costs of laguna 550 thousand dollars per day. That equals to 200 Million Dollars a year operating budget in order to cover the upon expenses of our patients. And with this in minds, if the fact that cms has made it clear that the initial 4 month fund and approximate terrible low the additional two month is all predicated upon our ability to satisfy them that we are implementing the closure and transfer plan. And so, this has been foremost in one of the things that have been driving the processes that we have been going through to date. Cms um is has reported thap we that they feel we are not being aggressive enough in implementing the compla know you know puts us in a difficult position because we we first of all have to advocate for safety of our patients. And those who are there mou and also have the obligation to look out for the longterm viability and success of laguna. And one of those is knowing just the cost involved of maintaining of that many Skilled Nursing bed and that are ned in the San Francisco. And we are aware that while we nevermented to implement this plan. In order to sustain the financial viability of laguna, we have done everything we can to comply with the ask from cms and though we have transferred our discharged 56 of the over 600 residents obviously we are a long way from getting from 600 to zero by september 13th. But again we are making our best efforts to do that. As i mentioned before, we asked to clarify for us and really give us bench marks and just hard quantifiable information in terms of what would they consider to satisfying progress showing we are making best efforts and good faith efforts to impelement the plan. Again to date we have not received clarity under you are required implement the plan saying you must transfer or close by september 13th. I do want to acthanking we heard from families and member of commune that there was confusion over a requirement that patients must pay for care after july 15th. The issue of payment beyond when parents may decline a transfer is one this we have raised with cms in order to get clarity to be more clear to patients and families. In terms of what their options are. Again, we have not receive third degree clarity. But we have clarified for our social work and staph working with patients that beginning july 15th that no patient will be should be told this their care will not be paid because we are waiting for this clarity from cms and the state. The appeal process, i mentioned early on that part of the cms and cdph press for had a facility moves toward closure and transfer, has built in the process an appeals process by which patients are notifyed appeal. This appeal process is not run by laguna honda but run by the state of california. It is important to note that on may 16th, after the cms dessertification each of the patients at laguna received the required 60 day nithat laguna would close as was required by cms rules. And that they would be referred and transferred to an appropriate facility. This initial 60 day notification included information about the patients appeal right and that notification. To be more specific the notification included that the patients if they no longer needed nursing facility care the patient would be recommended for discharge to a nonSkilled Nursing level of care a home or a Community Based care. Like a Residential Care center ownership board and care. Or other facility. It is important to note that no patients have or will be discharge friday laguna if they still require Skilled Nursing care. They will be transferred or offered air transfer to an appropriate facility that identified to meet their needs based upon the comprehensive multidisciplinary assessment done and required as part of a closure plan. It is important to note that no patient has been required move before july 15th. There have been transfer and discharges occurred before july 15th they were been based on agreement of the patient or decision maker. Wanted to point that out. In termings of dates. Before july 15b a patient had the rit to dpe cline a place am. However we were highwayly encouraging patients to accept in the transfers or beds they were offered because we felt the longer a patient waited the greater the likelihood the bed minot be available in the future and go to a facility further. Away from San Francisco. In terms of the july 15th date it is important to note Going Forward from july 15th, as we best as we have been instructed by cms, we have been told the only way a patient can stop the relocation process is to actually file an appeal. They can decline a referral and we asked cms how many times a patient get its decline a referral before filing the appeal and if the patient declines the referral will cms and the state pay for care . We asked this of the state and cms and not provide an answer. You know we are committed to dog all we can to keep our patients, their family and staff informed. But it is difficult for us to dot best j. W. We can when we dope get clear information back from cms and the state. But we are as best we have information we share it and we will always look for opportunity to improve how we communicate that information. We provided to patients Contact Information about support for transfer relocation. And even for the appeals process. They have been provided with a San Francisco longterm care program, phone number 4157519788. And we have vincent a longterm opbuds person and when has an office at laguna and readily and often interacting with residents daily. In addition to vincent we provided residents and fells with the condition tact information from the state longterm care opbuds person and it is 9162470300. And in addition to those numbers patients provided the longterm care crisis line that number is 18002314024. And it is is available 24 7. So again the will appeal process suspect state department of service. By no means we discourage patients to file appeals. You know the appeal right is there for a reason and we encourage everyone to exercise the rights they are afforded to the greatest extent they feel is necessary for their case. And we are still waiting clarity from cms on Unanswered Questions how many times can a patient decline a referral. Before cms will decide they will no longer pay for the care. Because of that it will tell us hainformation we can xhoukt to a patient as to whether or not they would person low become responsible for the bill or not. Again, we are hoping that the cms indicated they hope to get back with answers the end of this week and as we get that informing we will share it with the board and with our patient and Decision Makers. We are committed to providing stressful time. And this flow chart shows the thoughtful and thorough possess we are employing as per of the closure plan. When i came to the committee i referenced that exhaustive Patient Assessment process. You recall i mentioned this the Patient Assessment involved i multidisciplinar care team the nurses. Activity therapist and dieticians come together with the patient and family members or Decision Makers to determine that the nodes of the patient are so that they know which type of bed and which facility to find for that patient. In our closure plan that we presented cms, we designated three groups of patients. 1, 2 and 3. Again, knowing our patients best we felt this it was important that we prioritize which patients we would identify for a transfer and relocation first. We proposed and started focusing on those patients who had no longer had skill needs and discharged to the community or other places. And had begun so we would safety more highly high needs patients those with more Health Conditions to a later process. However, a couple week miss the closure process, we were told this we were not moving fast enough. And rather than help us on those lower needs patient and groups 1, this we had to focus on all groups at the same time. Because from cmss position they felt if we waited for higher level patients we would run out of time and not able to move them before the date. At this point, we are transferring and assessed all patients and looking for beds for all priority groups. To give an over view of the discharge approximate closure plan, i mentioned before all patients receive their first notification 60 dayos may 16th. At that point, the patient assess ams were done. Because that was the first, first stage of beginning to try and identify beds for patients. We mentioned before and it is scene on the weekly dash board we published we make a thousand calls a week calling the 2,000 facilities around california trying to find beds for each patient hos node that level of care. And as beds are found, we send a packet over to the facility presenting our patient for consideration for the mission. They look to so, do they have the facility and program its meet the needs and if so, they inform us and then we take that information to the patient and the Family Decision make and present it as an option and they either have the option to accept it or they can decline it. And at this point, after july 15th if than i decline it they also have the option to file an appeal to ask that the state adjudicate their referral and discharge notification. It is also person it mention this in addition to finding additional Skilled Nursing beds for patients and still need skill nursing care, some of our patients are discharged to the community. That can be to home or can be to a board and care facility. And sometime its is to a navigation center. I will give stats toward the end. One thing you know laguna honda serves all populations of an fran. That includes the homeless population. And sometimes individuals who are homeless have medical conditions or injuries that result in needing Skilled Nursing care and so they will end up the laguna honda. But hopefully once they received the care special rehab and it is time for them to be discharged; unless we identified a housing opportunity for them. Sometimes they are referred to the citys homeless response system through the navigation centers. We are working with the department of homelessness and housing service. For some of the patients. I think that i will look go through the stats 3 of the 56 patients have gone to shelter and navigation. It is not the best option we hope for. In terms of do we sf silltate that discharge versus someone has a higher skill need. We focused on those community discharges. Those are coming through now. That we are seeing. Also supervisor melgar you mentioned the death of the patients that had been transferred and id like to acknowledge that information and to extend our deepest sympathies to their friend and families. And ulc not care teams at laguna who for some took care of them for many years. I emhad in todays presentation i was able to articulate the fact that we acknowledge the very real risk. Transfer trauma. And in fact, in our closure plan, we specific low reserved it. And in california there is a statute requirement if it transfer tuma has to are part of your planning process. In this assessment press we talked about and if you want more specifics, doctor