Transcripts For SFGTV BOS Public Safety Neighborhood Services Committee 20220814

Providing via comments via telephone. Public access is essential and well be taking Public Comment as follows. First Public Comment will be taken on each item on this agenda. Those attending inperson will be able to speak first and then well take those calling online. Public comment callin numbers across the stream. When connected be in listening only when your item of interest comes up, and public calls, those joining us inperson should call star3 to be added to the speaker line. Please remember to turn down your tv. You may submit Public Comment in writing. You can email them to myself. Aye. Chair march. Aye. March, aye, two ayes. Thank you, madam clerk can you please call yellow light number 1. Clerk yes, item number 1 is a hearing at the conditions Psychiatric Services unit at San Francisco General Hospital and Psychiatric Services and requesting the department of Public Health sul Crisis Response team to report. Members wishing to provide comment may line up to speak or if youre joining us remotely, please call the public number. Then pound and pound again, once connected meeting, youll be prompted to the line. Please wait until we take Public Comment on this item and when the system indicates that youve been unmuted, that will be your cue to start speaking. Thank you, for all your leadership on really addressing our Mental Illness. And thank you for calling for this special meeting today. The floor is yours. Thank you, chair for making time for this hearing today. The state of pes is not going back as long as ive been on the board, membersed of this board have heard troubling stories and statistics coming out of pes. I remember touring pes on my first year on the board and troubled numerous time when pes was on diversion. The concerns helped drivein conclusion of the proposal that is now four years old for a crisis diversion facility to be included when it was passed in 2019. So i was not surprised but troubled to read back in april in the examiner that conditions are still challenging alt psych emergency and still a capacity problem and staff, there still is or was in april in under staffing problem. There have been positive developments over the last four years of some initiatives that were intended to take pressure. The opening of summer rise as drug sobering facility was thought to be an intervention that might relief pressure on psych emergency as i know that opening of door urgent care years earlier had been an intervention to try to relief some of the pleasure on psych emergency. Im concerned about, you know, psych emergency one because we need a facility. For people who need emergency Psychiatric Care. Who wre see far too often not getting that care on the streets. So we need a place where people can go. So if were not able to accommodate that in San Francisco, thats a problem. If folks are having to go to ghs, we heard from other hospitals that that creates challenges for them there. But we think that the conditions within terms of pressure and staff throughout our response our Behavior Health response who have behavioral needs. How were doing on facilities that do relief pressure at pes. And by folks who need the saoet and take a place who takes a psychiatric emergency. Thats what were going to try to do here today. I want it thank everybody who participated today for all of your help not only scaoepg yourself but all the people in your office. Unless chair thats anything, we will start with a presentation from our director of Behavioral Health dr. Hillary and dr. Mark leaery on behalf of dph. Thank you, chair mar and supervisor mandleman. There should be a presentation coming up soon. There it is, great. Next slide please. Thank you for coming to talk about our emergency services. Staffed by a psychiatric during the 247 hours. We provide emergency assessment and treatment of Mental Health and Substance Abuse and triaage of medical conditions when they arise. We provide linkage to followup services which is crucial. And we received voluntary and involuntarily patients in pes. As supervisor handleman mentioned, people are brought in voluntarily or by police. To reduce the risk of infection in our congregate setting. Next slide please. We have psychiatrist and psychiatric Nurse Practitioners onsite 247, we have psychiatric nurses and license tech who are staffing one staff to four patient level at all times. We have psychiatric social workers who focus on linkage for our patient. Psychiatric occupational therapist provide life skills assessment in pes along with group settings. And then finally were excited about the hiring of a Patient Navigator for pes which is in process right now. Next slide please. I want to emphasize that pes has been open throughout the city throughout the open pandemic. At the beginning of the pandemic with the support of our hospital leadership, we pivoted to have all psychiatric patients who are coming to the campus for care to be arriving at our csfgd the Emergency Department for covid clearance. This technically true, its really a technicality what that read is on the emergency network, that is the communication that lets the ems rigs and Law Enforcement units that they need to go directly to the gsfd and not bring patients to pes. So we dont want patients arriving at pes unscreen and have to bring to that congregate setting. Sol once patients arrive in the ed, they are triaaged and treated by a pes psychiatrist who is onsite in the ed16 hours a day from 7 00 am to 7 p. M. , overnight thats a chaired responsibility between pes and ed. We also have the behavioral emergency Response Team as well as pes support team that helps us with patients in the ed before they get over to pes. And as a result of that process, about onethird of the criminal patients are discharged directly from the ed. And then the other twothirds are transfers to pes after theyve been covid cleared or any other medical concern that they may be present with. I want to emphasize that pes has been open for the city throughout the covid pandemic, weve been opening 82 of the time for an immediate transfer once the patient has been covid clear. 18 of the time waoefn closed to that transfer process and patients have had to wait until a space opens in pes. As a point of comparison, prepandemic, we were on condition red, true condition red in pes 35 to 30 of the time. So were actually doing well with this process, i believe. Once patient arrive in pes and are treated assessed and treated we provide linkage to care and this is a look at what is happening here in 2022 year to date, 18 of people who come are admitted for acute in hospitalization. Most of those depending on their insurance coverage. 5 are discharged and admitted to the res pid either on campus or valencia. As you know Behavioral Health urgent care unit. And finally 65 of the patients are discharged without patient referrals including kids management. There have been a number of, im sorry next slide please. Next slide please. One more slide, sorry about that. There have been a number of renovations in linkage between pes for example. 120 increase in discharge medications both psycho petric, between 2021 and 2022. The dph behavioral bridge and services team, the best Team Provides link an managers who actually tom to pes to enhance the linkage process. Dph Behavioral Health has helped to strengthen partnership 360 to provide detox for our patients leaving dps and their Alcohol Treatment Program residential program. We also are making increase intensity Case Management referral to transitional age youth, acute linkage our city wide linkage and reducing residivism program. And finally wanted to give you a picture of what happens when patients leave our inpatient unit at San Francisco general. And you can see here 127 patients or 31 are discharged home. 18 are discharged against medical advise. And this is a group of patients who are voluntarily man holds and are released by court, by commissioner of the court from their legal hold and choose to leave the hospital. Can we stop there for a second. Sure. Thats 72 people where dps is recommending against release and theyre still being released . Thats right. Over between august of 21 and march of 22. Thats interesting, thats interesting statistic, okay. Ill be happy to expand on that. So 12 are discharged, crisis residential, 8 are transferred to our Medicine Service, one of the benefits of being codependent. 8 are discharged to the humming bird psych respid program. 6 go to shelter, 4 go to Residential Care facility or care and board facilities. 4 of patients decline referrals. 3 go to residential Treatment Facility those are longer term residential Treatment Facilities as opposed to the shortterm adus. And very small numbers, 1 go to psychiatric skilled nursing, transitional housing and Residential Care for the elderly. And sadly, the very last bar there, we only get about 1 patient a year into the state hospital. Actually, can i ask a question on this one too. Sure, chair mar. Do you know how much ~ i assume youre speaking the facilities, i dont have numbers on that. I think we could get that data for you. Thank you very much, happy to answer any questions. That was it . Im asking, if that was the presentation. Yes. And then dr. Cunnings is going to speak. I have things to ask but maybe we should have dr. Cunnings and then have you come whack. Back. Okay, thank you. Good morning, supervisors thank you for inviting us to talk about this important topic. And ill just wait a moment for the slides to come up again. Just one note at the to many that ill make. Were working collaboratively with dr. Leaery to strengthen in whatever ways we can both the incoming need for care as well as the discharge related care, knowing that pes, neither pes nor Community Base can stand or stand alone. Soy share with you today some of the work that weve been doing, in that regard, you are familiar with pieces of it and weve tried to put the context here how we are interacting and supporting the work at zuckerberg. So ill speak first about alleviating the demand, followup treatment and i know that you all were interested in our hiring update as well. Next slide. Zoo let me speak about the coverage about alleviating demand either by preventing crisis or innovating early and in community with crisis. I know you all know about our street Crisis Response teams in the month of june alone, skiter engaged with 226 clients. And between november 2020 and june 2021, skiter engaged with more than 5,000 clients. The outcome has resulted in fewer than 15 of clients who needed transport to the hospital. I want to acknowledge my colleagues at the Fire Department with whom this program is in partnership. To our urgent air as already mentioned, directly admits clients from pes who need further stabilization and connects them to next levels of care for example, the acute divert units and residential programs and so forth. In fiscal year, in the current fiscal year, or last fiscal year, apologies, approximately 1600 clients were admit withed an average daily admission of 4. R5 client. Finally outside of the Behavioral Health with whom but is also an Important Program is whole person integrated care which operates urgent care and sampling of one month, ten percent of clients that they say had an urgent Mental Health episode which they were addressed in that setting. Next slide please. Also as dr. Leaery mentioned, humming bird, or im actuallyto see if this is both humming bird, 433 admissions for overnight stay. A majority of humming bird clients were being referred by pes or the medical emergency room as well as zuckerberg inpatient unit for further stabilization. You can see the further specifics in the table before you. Next slide. Also as you know, there have been a number of resent openings and efforts under way to improve Behavioral Health services, all of which in part support and ideally minimize or mitigate the demand on Crisis Services including pes and so here you have humming bird valencia which was open as you know, 2021, therefore 20 beds for overnight beds. Summer rice which newly opened last month, a drug soebing center for people experiencing intoxication or mental crisis due to drugs. This is intended to be a safe place to rest, stabilize and importantly connect people to on Going Services. This program is still in the process of ramping up in its early weeks. There are currently 12 beds or Spaces Available with the intent to expand to 20. Further, it is currently open 12 hours a day naending to move to 24 7 in the next few weeks. In the first weeks of its launch, summer rise, has served 230 clients. It has proven to be an Attractive Service for our folks in the community. As you already mentioned, supervisor mandelman, we are working on unit. This service will be a crisis unit capable of providing up to 23 hours of care. Next slide. I now want to transition to ways in which Behavioral Health on services are aiming to support pes discharges through pes base program city side has two social workers when its city wide stabilization programs to provide discharge planning support and coordination. As dr. Leaery mentioned it is well integrated into the pes work flow, these are folks with expertise throughout the city and they provide direct referrals to our Case Management bridge teams. The next paragraph discusses our office of coordinated care which has been newly launched in the last month. This office provides followup for individuals specifically around, who have been served by skiter teams, Response Teams and have been placed on 5150s. Additional our expanded team also provide bridge Case Management for individuals who are being discharged from acute levels of care including pes, including patient psychiatry unit. So this is a new resource that has come online supporting hospital and pes discharges. Let me move on to the next slide. As you also know were aiming to open new and Residential Care beds. So far in 2021, 89 beds were open and additional 89 beds have opened as of july 2022. You can see the range of types of beds that have been opened. And we are anticipating an additional 70 beds to open by the end of the summer as our program capacitys grow and new programs open. By the end of the summer, this will get us to approximately 250 of the 400 beds open goal specified in hmsf. The next program that will open shortly is 46 beds at a site called victorias place, this will be rehabitative care. I know you had answers about planning and bed planning that the dph is undertaking. Were aiming to complete a second bed stabilization by the end of 2022. As you know we need to update the original plans. We are also updating our realtime times. We expect well be ranking the wait lines online in the coming months and that will enable us to know what is going on currently and help with planning both near term and longer term. Next slide. And finally, i just wanted to share with you, hiring update that as you know, under the emergency initiative, we undertook a process of expediting hires for the services that will serve people of the tenderloin and beyond. You can see here that our work has continued aggressively to filet needed informations both preexisting to back fill vacancies across our systems of care as well as to fill positions enabled by the new programming under prop c and mhs. In total we have hired, either on boarded or the process of selecting candidates for approximately 400 workers across our systems of care in Behavioral Health as well as whole person integrated care. And that is my last slide, were happy to take questions. Thank you, i have a few. And i guess, maybe wub way do this is go through the more interesting slides. Can we go back to the first presentation on the linkage . Let me pull up the slide that says linkage renovations. There we go. And so linkage is important well, dr. Leaer tell us why linkage is important. Well linkage is very crucial when patients present in a crisis. What is going to determine their ultimate recovery and ability to live with, psychiatric condition is their followup. So thats a crucial part of what we try to do and what our Mental Health system does to be able to link patients so that they can relatively after they leave, they can have an appointment with a Mental Health provider that is appropriate for their need. And i dont know whether this is a question for dr. Or leaery or kunings or somebody else who is not in the chamber today. One of the thing that has had to have happening, i assume its still happening, but had been happening prepandemic, was that a relatively small number of folks were generating a lot of visits to pes and a lot of need for and i think even for more extended stays in patients. One of the findings was that a large number of people were being discharged without a referral for services. And that was a disputed figure by the way from pes. But it looks like, you know, a majority of folks are at least getting a referral. But im curious about well a couple of things, im curious about the nature of the referrals. In some cases, it looks like you have the case managers there and so the work is already kind of begun. Xwu im curious about the flavor, how many folks are still living, better than nothing probably but its not ideal. And im curious if you have a sense of how many, how many are getting the percentage. And also is this problem a relatively small number of folks and not on going and how do you measure that . Im not sure if thats a leaery question, its a larger system. However you wraunt to address that. I dont have figures in terms of patients that get out of pes. That warm hand off that is meeting them. S tl s still a small number of residents that return. Are you, are you not boss . So how are you thinking about that process . One is how were managing discharges in general. And inadequate kind of referral. And for that reason, we are collaborating with our new office of core teams to make systems so that there is more than a piece of paper about the effectiveness of several or coordination process and were intending were set ising up data systems, we Just Launched the teams in the last weeks to measure that and to improve upon that. That handing people paper for referral who may not be in the moment asking for treatment or motivated is not enough for note vacation. As we know in the Behavioral Health world, multiple motivational, encouraging contacts overtime does produce desired behavior change including promoting treatment and engaging in care. Second point is frequent utilizer and the way were thinking this from a population point of view, is we in the new budget, people who have had a 5150, we know they have presented for involuntarily care after some crisis or adverse event. And we want to prioritize them as a group that could benefit from a more intensive followup and offers of care and engagement of care in order to prevent the next crisis. And highly stressful environment where people are trying to get this stuff done to start collecting data about which type of referral somebody may be getting. So that people can run the numbers so we can analyze this. So by creating a longer term process of converting to epic to single electronic Health System that includes document referrals, includes if referrals are followed through with both for the management team. My fear about System Solutions and this has been error hed we have spend a long time setting up systems to measure and eventually spit out reports that are going to help us learn and then move on things. On some of these basic questions about what is working, what is not, do you feel thats something that were going to start to get this year . I think my goal our goal is to start putting data as we know it, everything is in order to act. We act on the best data we have and as it evolves, we can change direction. So i think its this year, yes. Are they dealing with the same people over and over again. I feel like weve demonstrated, there is a monthly dashboard, were track the number of people served, what happens to them, we are aiming to avert entire levels of care. Were aiming to link to non crisis levels of care and those data are as we have them are available in the monthly dashboard. Do you want to . I guess to address whether the cycling problem is Getting Better or worse and whether these are impacting. In pes when we looked in detail at the highest users of sick emergency, the people that come back, dozens of times a year to the ed or pes, what weve seen is that these individuals have serious Substance Use disorder. In combination with a psychiatric disorder as well. But it seems to be what leads them to return on multiple times. Weve taken different approaches with these individuals, we always try to link them with intensive Case Management. Were some weve locked in long term treatment. Some with housing conservativeship that you initialed. About thes been challenging. We always try to engage patients in Substance Abuse treatment. And sometimes thats possible and sometimes, because of individual youre able to cooperate and sometimes not. Those are the main challenging that we see to the extent that we have and ink that will be able to link these individuals. As dr. Cunnings mentioned, these are relapsing conditions by nature and we often times we need to try to engage the patient before its success when it is. With a with a Substance Use disorder. I mean, has it worked . Theyve remained well others have done the same thing and done well but then been discharged to a lower level voluntarily seteding. Again we expect relapse as part of the condition. There is a slide about the folks who were discharged against what the doctors were ordering or suggesting. Right. So that suggests that youre trying to get 5250 holds or conservativeship and youre getting denied. But those are almost all individuals that have come on a 5150, then we place them after 72 hours on a 5250 the 14day hold and at that point, they have a right to a Court Hearing within four calendar days. And they received treatment and often or significantly improved. We testify in front of the judge try to convince the judge that they need to be in the hospital. And most of the time the judge agrees with. 72 times of the year the judge doesnt. Right. I dont think there is a problem there with the way the hearing system is set up. Were not doing enough voluntarily hold to people. Would you be seeking more 5250s if you had more space . No. Okay, let me see if i have anything else. Was that the state of our Public Health emergency hires . And so what is the, what is the staffing situation in psych emergency . What is going. Im going to differ to my nurse colleagues to answer that question. They are on the zoom. Do we have the people to address the staffing challenges. Hi, sorry, i was unmute. Hi, this is karen hill for the department of Public Health. So we, we have some staffing challenges for for some of the positions. We have rns that have some staffing challenges. However were in the process of filling two vacancies that we have. Those positions should be filled fairly soon. The other areas were seeing, Behavioral Health in pes does constitute some staffing challenges that were working diligently with our recruiters. As well as other Community Base information to enhance that applicant pool. We continue to extend offers. Which has ended, we still have vacancies under that emergency order that were extending offers. Can you step up, im a little confused. Are you saying you have two nursing vacancies but those are well under way to being filled . Or did i misunderstand . They are reviewing those applicants currently to be able to extend offers fairly soon. Okay, so from the perspective of dph, we dont have a staffing problem . As far as the current vacancies, as far as the current vacancies that we have right now, just the two pes rns those are vacancies that we currently have and in the process of being filled. As far as staffing shortages. Go ahead. And or chris anne can probably answer that. Hi, good morning, supervisors can you hear me . Oh great. Im that, i am the nursing director kathy blue is on vacation and im here with christina and we can try to answer some of our questions. In terms of challenges, i will say that staff has been a challenge and planned and unplanned absences. So when these absences occur, we use per diem. As well as opt license and geriatric conditions and per diem staffing. For the census. We have used as a said per diem staff. Of one of the things that nurse manager said to me when we were talking about the staffing, said the staff are really dedicated to the unit and they tend to stay and help when there are unplanned absences in terms of filling that void. Okay, so you have low 20s ftes, two vacancies within that vacancies. You rely on per diem to augment those vacancies and it gets a lot worse when people have to stay out longer. Why the reliance on per diem. Per diem has always been part of the model. I think its part of our model that we have Civil Service staff and then our per diem staff. Okay, all right. So lets go back to the existing services. Response team, pull that one up. Are we asking for the slides to come up. We are asking for the slides to come up. Can the slides come up, it looks like its slide 10. There we go. Between 10 and 11 and 12, we see various services that have been stood up that conceivably might have an impact on demand, i mean you can see response traemz if theyre engaging with more folks identifying more need in the community and increasing demand for psych emergency. But other, or you can see situations being resolved in the community and then not, you know, not leading to a 5150 which would reduce demand. Curious to see and that may be more dr. Leaery, do you think any of that happening . What is the impact of these additional facilities . Do we have anyway at all of thinking about or measuring how that, what that is doing to demand for pes . I think we, this is something that we want to measure and look at. I think what has been challenging in this door, a door was preexisting, humming bird potrero was preexisting. You heard about some of the staffing and other challenges because of unplanned absences. And that may as well as the economic and other drivers leading to what were seeing on the streets to either discharge or from the patient psychiatry unit in order to create more flow for duel urgent care to increase xas ilt and flow. So from the early examples prior to the early year and pandemic form part of the basis for what the recommended precrisis. So my hope is that now that the pandemic is stabilizing, as we open services to look at demand and ps and elsewhere to understand impact and understand diverse and non acute non Crisis Services. Yeah, because were doing a lot. Absolutely for, i think absolutely i think, to address some of the challenges that were talking about in terms of demand for pes services and surely there is some side of people that could be diverted somewhere else. Creates a place where we are more comfortable on the way out. As a way to get a set of folks who are going through psych emergency a lot somewhere else. And you know, the model for the soebing center that prevailed that i think was its more like people walking in the door and well see how it plays out. But we can keep putting these things online and not knowing how theyre impacting. And we should bring them online but we should not do it that way. To know what stable means and what stable staffing means. And, light other sectors of kaelgt dare experiencing recruitment difficulties with some of our analytic capacity. So my strong commitment is to try to address the affective both on the need of acute care but really importantly to promote functioning and helping folks be healthy and living their best lives. We have not seen significant numbers of patients. Summer rise was we have not seen them. That has not been an outcome. Ttsz hard to tell but that has been our experience. That weve had, and that seems like a problem if we think there is a need. To all the people out there who are not doctors or nurses or crisis out reach people. Although they had opened additional psych beds, he said that he was really proud of is 7 acute crisis facility that they had opened up. And i said over what period of time, and he said oh since i was elected and when was that, 2018. How many beds . Between 10 and 30. So thats moving quite a bit faster than we are. And it does not feel like were set up to stand up this piece. Along the timeline that we need as i felt about placement throughout the system. Do you want to respond to that. No, we need to go as fast as we can. But you have the structures, i feel like supervisor ronen asking these questions, is there a need for strike team that is like the real state person . Rather and maybe we can bring when we have to acquire something and byway, we have to do one year rfp. Tell us a little bit about what the update. Summarize, psych emergency and other emergency, what are reactually thinking about . What do we need one . Do we need 10 what are your thoughts about that model and our need for it . And then the next question is, how do we, how do we get you the resources to actually get that done . And then we can evaluate if that works. Many questions, happy to try to answer. I share your and many peoples sense of urgency. Let me start there. I think weve made a lot of movement and variety of strategies to open the Residential Care and treatment side of the plan. And i have my numbers in the notes, have expected to open a significant number of new beds with more to come by the end of summer. So additionally in the budget this year, we did request new staff to support the infrastructure in the way thats youre describing for Residential Care team or residential residential order of care in order as well as other staff in order to haste en the steps that you described. So i would just say, we are, so we have some new resources based on part on some of the conversation thats weve had with you and supervisor ronen and thanks to the mayor. And our complex project in particular. And this is a complex project it required the diversion unit. Required psych acquisition which requires innovation. To have a nonprofit provider provide services there. In order to do the things that were aiming for. Do we need more door . I heard Different Things. I heard door was utilized at points like. I dont think our data can pour with that understanding about their utilization. And if door relief, you know 5150 is a door. When people get 5150 to an acute crisis. Its a state ~ 5150 in san diego apparently, that is how that works and that is what provides relief too. Thaoz facilities mean many Different Things to many people and then it moved forward and something happens and its interesting, you know, Linkage Center was interesting. What many thought it was going to be. Im happy to go back to san diego and try to understand their approach. Im still trying to understand our approach. Im not sure that there is a consensus that that would help. Would it help psych emergency . I think we believe it would. We believe it will also be able to intervene. You got a head shake over there and when you said it would, you got one of these. I think there may be a need for dps to figure out what to do. So we have some time. Number one, as we are undergoing rfp writing process, working with the iwg, i will just say, i didnt see the head shaking, but i want to reiterate that were in close collaboration between the different parts of dph with the hospital in order to use all the Information Available to meet the needs of both what is happening on the street, aiming to as well as what is happening in the hospital. Given the pace that we have seen in the last several years and in which the ideas seem to take this meander path and result in something, well there may not be, there is a consensus form but its not what some number of folks thought they were getting at the front end and given the time and energy that has been put in the exercises. The Linkage Center was many months and millions and millions of dollars that some set of folks thought it was going to be a place where people were going to be taken instead of taking drugs and turned out to be a experience not exactly the way we would want to run that. I have deep concern about where dph is going on this Behavioral Health facility. If it has a clear plan to solve the problem and the to get us the facilities that we need and what the facilities look like. I look to you to solve that, and to relief the pressure around the folks that are cycling through in psychosis because of the meth theyre using, its not outdoor and based on the way youre describing the crisis facility, its not the crisis facility either. So i have concerns. Im happy to continue talking about it, im not sure, were three weeks into the summer rise program, i feel like, i dont think we know the impact yet. We were not fully open, its not 24 7, i my understanding again some of this predates me, it has huge closely from the original intent what has changed in the city is change drug pattern with the use of fentanyl. It was important to you and the city. As well as accommodating for changing what the landscape is here. Im saying, i dont think were trying to divert from the details. Happy to understand if that is not your impression so. Im confident that for some of the people that were involved in the Traffic Force the goal was to provide a facility that would divert people who were, what we call a 5949 and a half, and i think the summer rise is fantastic, its great. We will use and probably use more. Accept when i was paying attention to door, we would never take its just, its a different level of care. Thats cool. We need those. But if there is a problem, we need to solve psych emergencys problem. So the crisis diversion unit that is not about resolving the problem, might worth doing but its not part of this hearing. It isnt part of the hearing, were intending to solve the problem of people in crisis giving them the best possible opportunity for excellent care and linkage to on Going Service to see prevent the next crisis. Part of that is trying to avert an unneeded ps administration. Admission. I think were also aware that the need to have deep expertise and the ability to take care of folks who are severely intoxicated as well as other Mental Health challenges. I think my last question is on the expanding residential and Outpatient Health treatment. Slide which has a 23bed interest. What is our board and care goal . . O. This is derived from the original bed Optimization Study which i know is precovid and a number of years ago. And i think as i mentioned, were waiting on data to see if this is meet our goal. I think the other goal just to also say our other goal is to help people transition to higher level of care and to lower level of care when needed. So i know that many of my colleagues who predated me were really intent on helping people transition to potentially lower levels of care. So while there is a wait time at a current state, i think that part of the goal is not only how many we can admit but how many folks we can transition to more Community Base or lower levels of care. Yeah, this is not, i mean this does not have to, im glad for the slide and im always glad to hear about that and its not really again, the subject of the hearing which is pes, but, that bullet referring to a board and care goal is what drives me nuts. Suggests to me about driving nuts. Of any sort of Behavioral Health goals. That study three years old now, you know, kind of analysis of what do we think it would take to address our flow needs. I dont know what number, it came up with as the board and care number in that point in time. But that was not the result of thoughtful analysis and how many board and beds we have lost and likely to lose. I mean, the way this should be done is figure out how many board and care beds we need and figuring out a way to get them in San Francisco or close. That is not what the bed optimization was. And optimization is so not needed and this is a part of that. Heard. All right, thank you. Thanks. I think we have our partners the pes ucsf coming up next, unless ive got it wrong. No i got it right. Hello, thanks for having us. Im maria raven im chief of emergency medicine at ucsf. So, a lot of this relevant to us. I was going to give a little overview if you can put up the slides. We obviously dont have a pes, but we do see a lot of psychiatric patients. So you can go to the next slide. So we have a partnership with the city colocated on tele graph hill. There is a depiction of that. Today all the theyre all ucsf faculty. We have a regular collaboration between psychiatry and dph Behavioral Health group. Grant coal facts, is a, i cannot see the line by ~ former ucsf. He was in faculty, i just didnt want to get that wrong. And susan airelectric graduated from the ucsf school of medicine, so really close ties there. You can go to the next slide please. And so currently our, pronounced heights, langley Psychiatric Hospital also known as lppi and then of course our partners, cgsg. Go to the next slide please. So our bed capacity is growing. Our Emergency Department beds are going to go from 43, slaoully thats a slight over count to 71. And from currently what we have is 4 behavioral designated treatment rooms to a total of 8. And then of course we have the new psychiatry building and theyre seeing close to 6 3000 visits a year. So i want today give you a sense of what our department has seen. So in quarter 1 of 2022, we saw 485 Behavioral Health patients come through the Emergency Department and we design these on a people on a 5150 hold who arrived on a hold or put on a hold. Who we put on a 24hour involuntarily department hold. That does not income pus every behavior that we see but it does incompass the group that are more severely ill. Their average length of state in our Emergency Department was 25. 7 hours. We can stay on that path ride. Of those 221, which is about 45 were either admitted or transferred. So times we have to admit to our inpatient Medicine Service for two reasons fpt one they have a coexisting issue, maybe there is an overdose and there is a concern about medical impacts, they need monitoring. But often their stay is too long. So when theyre with us, up to 72 hours, there is nowhere else we can send them then we admit them to our patience on a 5150. If they are admitted to the hospital, theyre average length of stay is 14 days in the hospital. And then about 55 are discharged meaning that their hold is ultimately released. And i will say there, we actually discharge a lot of people to door, so that is a resource for us. It allows us to discharge. Our Emergency Department staffing is like california ratio, one nurse to every four patients fpt we also have security that are staixed in the area of our Emergency Department where we have our psychiatric folks who are on 5150 holds and we have one Security Guard for every four patients that are on 5150s and we have a Nurse Practitioner and a dedicated parttime, and fulltime psychiatric social worker. So at lppi, they have 6 to 1 nursing ratio staffing. And you can go to the next one. This is just about people talking about administration or transfer that we were talking about. Just 3 months quarter one 481 patients of the ones admitted or transferred, 39 went to langley porter. One that should be admitted and 26 were transferred to other psychiatric facilities in the city. The problem we encounter are primarily with their experience. And then addition, if patients have serious behavioral problem thats theyve exited in thed past at an inpatient site its hard tore place them as well. You can go to the next slide. So were trying to work to better align so were functioning more as a unit that views all of our patients as having access to similar resources. And i appreciate the collaboration from dr. Cunnings and dr. Leaer ion that. And were attempting to increase our staffing. Because we give the care on holds. So were moving towards increasing our staffing that is specific to our psychiatric Emergency Department patients and were hoping that that will allow us to treat patients earlier and hopefully be able to discharge more patients from the Emergency Department as opposed to having to transfer them to other facilities. You can go to the next slide. Thats all i have, so if you have questions, ill be happy to take them. I dont have any questions. Thank you for your presentation. the last presentation is from Mariam Molina with sfpv. Good morning, can you hear me. Yes. Thank you. My name is mario molina, im the coordinator for the San Francisco Police Department and i oversee the reports and training for the sfpd. We would like to thank you for presenting in this hearing. I think this is a very important topic and were delighted to present to you the work that the men and women of sfpd do every day especially when it comes to engaging with our populations that have been subject to illness. My goal is to give you overview for what the Police Department has. So this is a procedure for Police Officer where he encounters commit to headlight. If the officers get this dispatch or they may be, my own view a person in practice and. So the first thing they do is conduct an assessment. Officer mr. Determine if they fall in the category of 5150 or institution cost. If they have detrimental to themselves. Interview with witnesses and family members and contact 911 and considered by the individual. And he vent actually they will get to the individual and engage in a conversation whether he or she meets the criteria. Based on the situation is. The he or she will be transported to an Emergency Department. Those who dont decide, they will contact dispatch, they will contact dispatch and safety as write a letter. If answer is yes, the person will be transported. If the answer is no, they will go to the next available er where the person can go to. Now if the officers will divert to person, the two opgs that we have as of right now, is the clinic in the west side clinic. So well transport and well have to pass their process. Usually they do not take people who are agitated or assaultive. If the person is not appropriate for the clinic, they will be referred to Something Else. Based on whatever transpired during the interview. Use of force policy we have to contact our supervisor to answer to the location. And just to give you a guide of how long it takes for the officers to go through the process. If the person is agitated or assaultive, officers will jump in the ambulance with the medic and their partner will follow the ambulance where they go. Oncing they get there, they will talk about the reasons why the person was detained. If there is not an emergency, they will come back and have the report. Book accordingly. And they either contact me through the crisis line through the crisis unit. We have a good working relationship. They will contact me and will get everything who work with the Police Department and we need to do if we need to do a followup. Next slide please. So just to give you a glimpse. We had adoption on Mental Health dimension when i took over the program in 2016. Upwards of 4,000 plus 5150s. As we move forward, we saw 3426, 2020, 2088. 2021, 2082. Were at 1442. Training crisis intervention. Whether its caused by drugs or organic Mental Health issue. A lot of the consumers that we encounter in the streets of San Francisco are considered a diagnosis. Theyre self medicating themselves and health concerns. And we see that every day in San Francisco and ill get to that in the presentation on how we can help. Now when we break it down to the time of day, we pretty much even. In the past, directly from the previous, and data that i collected, activity in the evening hours. But right now as it stands in the last two years, its pretty much even across the board. Pretty much the same numbers of the week. Next slide. Next slide. So this is the people that we encounter. Females are 646. [audio muffled] the previous numbers were for Mental Health issues. And this is actually the individuals that the officers contacted. Next slide. Just to give you a glimpse of the continues to do when responded to do with people in crisis. In 2019 went to 16,542. 2020, 521. And you can follow the rest of the costs. We see until the end of the year last year. The difference that we have for service was 2033. So we hoping that theyre now implement in 2007 that those numbers will go down. At the beginning was very, later on because they move on and they pretty much operational, we meet every quarter, i think but we discuss cases in situations at least twice a week. So give you idea, this year, we have gone through 7723 calls in the First Six Months of 2022. Next slide. I just want to thank supervisor mar for putting this because it gives us an opportunity to talk about different areas as a way of improvement in working with our partners, private hospitals. So with the concerns that we have when a person gets taken to the hospital for Mental Health evaluation, we fill out a state form. The state form has a section for Law Enforcement what we ask this staff to to notify. And the reason that we have that is because there may be some followup that needs to be done by the department. And we dont have the information to follow. It says notify the Police Department when the person is released or prior to being released. Sometimes we get information and sometimes we dont. And sometimes we get the information at the time the person is being released. And sometimes its too late. Thats something that we need to improve and we communicate with pbs and private hospitals. I know mental headlight is protected by hippa by we have to have a better way. I think the Police Department has improved on how we collect data and im willing to put whatever information is needed to do follow ups. From the time we see it, when i communicate with private hospitals, it seems like everybody is working on their own. Theyre not talking to each 00 were seeing the same populations, were over latching on services. Were dealing on the same individuals on a daily basis. I get it, its hippa but we still need to communicate without violating any hippa restrictions. For instance i have access to dashboard that gets populated every 24 hours with the name, on information on the person that has been detained by the officers. And im working to get thing the hospital that the person is getting to. I do that on a request of dph. My understanding, that there is no communication between private hospital and San Francisco on how they respond to data tracking. I know there is the avatar system and there is Community Sharing information but, those systems are as good as the people that are putting in the information themselves. I dont want people treatment and diagnosis, its not about that, its about connecting people to treatment and lower the efforts. Because were dealing with the same individuals on a daily basis. Theyre willing to provide training and learn about other agencies and what the limitations are. So i think so far, i have a good working relationship with dps and saint francis. We have a Cat Working Group which is composes of public defenders office. We used to have ucsf but they stopped coming about two years ago when the pandemic hit. We need every month for a period of two hours. I share with the civilians and whoever is group. The use of force, and the Police Department only to headlight calls. And we discuss policy training and ways to improve our relationship with each other. I invite everybody in the meeting to attend these meetings. Thats best way to engage with each other. It would be fantastic. And finally identifying additional treatment. We have access to more, we have access to the west side clinic. If i want to take somebody to the humming bird, i have to see if they can get somebody to coming bird. The Police Department does not have all access. And come in fact, we definitely need to have a better way of communicating what is available to officers on the street. Unfortunately when we talk about the Mental Health, we talk about the individual and the numbers are but we forget the families. When somebody is in crisis, its the entire family in crisis. We had a different perspective, just see the person and i know a lot of individuals have the right to services to note a notable to treatment. I get all of that. But as an officer and speaking on the men and women of San Francisco that wear the uniform every daycious we see the other side too. Im glad that this is being discussed. I think its way way overdue that we need to talk about how can we serve on only the individual but the families that are suffering out there. Next slide. Thats it. There you go. Thank you, lieutenant molina. Did you have a request. Yes, thank you so much for that informative presentation and really just for all of the Important Role that sfpd plays as a key First Responder to residents experiencing extreme current headlight and psychiatric crisis as we continue to struggle to build out our a more comprehensive and ineffective system of care. I did have a question about calls for service chart, im trying to understand the data, if you can bring that slide back up. And i want to understand how it reflects. And the overdose Response Team. And people are calling 911. So that call gets designated meaning the officer has to respond repeatedly. And the person is in position. So the officer who respond accordingly, meaning that the person is not attacking anybody. One person communicates with the person and the another person is secondary if there is a need to display less lethal which is a bean bag. If the person has committed a crime, then they will be violated for the Mental Health. They will be taken to pes or sited or arrested based on what the victim is telling us. Got it. Got it, they require response. Perhaps check on well being, 9 10 or any of the other ones . I know they talk about the being assigned to the wellness team. So far we have not seen that. As you can see, we have received over 12,000 of the calls. It can be a person laying down to the sidewalk may be intention so it can be a medical it can be a police person. It could be anything. Got it, got it, thank you, thank you lieutenant molina. I also have questions about the calls for service chart. So the codes are assigned by pdm or pd . The codes are assigned by, i learned this in 1994 when i went to the police academy, theyreby the code. But the assignment of some something is coded, as a 5150 Mental Health is that because the 911 call receiver and dem felt this was a case that required 5150 detention and therefore called it a 5150 . Usually those calls are from clinicians, that will call 911 and say, i need an officer for 5150. So its just a radio call. So its not all 5150 calls and some calls for Something Else turn into a 5150 . And how many 5150s we do. Can we go back and look at that. Those are the ones. So im trying to understand the decline and the world is crazy and similarly, i can see that spilling into 2021 but it looks like the trend towards 5150s is continuing. And i have two questions about that. And another question, its a good thing if were getting care to people in some mechanism other than a 5150, its another thing if were not intervening with people that need a detention. What do you think is going on . Is it my version of a good thing or a bad thing or a little bit of both . I would say its a great thing. Because our offices are doing more assessment on the calls. As i said, what were seeing a lot in the streets of San Francisco is chemical induced psychosis because the person has substance or is reacting to the substances. So the same thing, similar to somebody who is on an organic Mental Health illness. What were seeing is an increase in ams. Officers determine its more of a medical call. We believe the person is in immediate need of medical care. Majority are duel diagnosis. The numbers have increased while the numbers of Mental Health detention have decreased. I understand that youre under a lot of pressure to reduce the 5150 Mental Health detention and from one view point that unquestionably a good thing. But i do think this required, you talked about the siloization of our different responses. It is way too hard for people to get 5150s i know from family members of friends, and from the system not 5115ing and getting them into a hospital bed looks like failure to families of particularly young people with Mental Illness that means it falls on somebody, trying to understand what is happening as the criminal justice recedes and is anyone taking that place . You know, its not clear to me and a lot of San Franciscoians that were getting help to people when were not 5150ing them. May i address that. Sure. When i took the over the program, the San Francisco was averaging about 7,000 5150s, that includes were not the only one ones doing. Clinicians are able to do 5150s and when appropriate, so there is different entities that come to this play, right that are able to do that. So its not so much that theyre doing it but the criteria. But nothing thats changed between . No, but we have to make sure that we have a probably cause to do so. That the person is in fact a danger to self and others. So if i meet that criteria, i can use that to detain the person. We want to make sure that that is happening. What im seeing in the difference. We hear about the 51 people and public defender to the hearings. So people that have those hearings which is the right to have, im entitled to a representation to the defenders office. We deal with the families that brings that had somebody who is mentally in their homes or hotels. And sometimes were required to provide information in writing. Ive been here 5 times and so far its only been hard time. Its been challenging. Say that again. It is very challenging for us to come back to the families and to come to the families. Are you saying that that is that we, that in San Francisco we usuallily do not allow police to testify to the judges making the decision about 5150 . And thats a decision made by whom . I have no idea who makes the decisions. But were not sometimes were not, pref to those, were told that the person is going up tore a rehearing and whatever is discussed there is discussed there and then the person is released and we have to be with the individual over and over again. Thats why im asking for training and more collaboration so they can see our ride. And not to interrupt, this is my last question because i think we need to move on. What are the four forums for currently available for to you talk with folks in dph about issues like this. Asked dph to hire four clinicians to work with the San Francisco Police Department. So i have access to clinicians from the department of health. I have a good communication with them. Its very frustrating to continue to have people over and over again. And just the offices in the streets because as a privileger when you contact a consumer Mental Health your intentions are to connect people for followup. You wonder why this is happening. Thank you, lieutenant molina, my sper perception is that there are not enough collaboration from pdh and trying to full back what had been Public Health interventions. I understand there is hippa restrictions but ive seen it this play out in my districts and im hoping that folks in the department are thinking about how to collaborate. I would like to invite april flown if she wants to add anything. We didnt ask you to put together a presentation, maybe the one question, are you in fact doing 5150s at this point . And do you have any observations . What would be relevant, anybody you got your however minutes you want. Thank you, im chief of operations for Fire Department i oversee our street teams. Which is our high division. I dont have a power point but i can speak to some of your questions. Yes, street crisis is doing 5150s and we have a hold about 6 of the time. Our Community Captains have holds. Can you remind me of your second question. What are you xaoeshsing . One flt things that i heard from some are reluctant to 5150s. And lieutenant molina was talking about the need to take people. One of the steps is thed majority of intervention resolve on the sidewalk. And kind of that declining 5150. Bad way to look at it is that person who was in crisis, is where they are we still havent really addressed their problem, we just got them down for this hour or this day or whatever. Do you feel a lack of appropriate places to take people. I will say, i want to speak to some destination that probably does off load from pes, but street crisis primarily transports, so theyre not left in the sidewalk, theyre going to a non emergency situation urgent care summer rise and humming bird. That person was either placed on hold or Community Identified a key medical issue that needed attention. Street wellness, they transport to summer rise and shelter. Our ambulance transport to another center. Speaking to the people that we see more in crisis. They have severe Substance Use, psychiatric illness and medical conditions. And i want to preface by saying the line providers are doing the best decision that they can with the limited resources for these people, but its not always what meets their needs so we see them over and over again. I look a look at some of the most users in the last 5 years, and they dont have a illness that will allow us to go for conservativeship. The five individuals have had 1781 transport and that does not capture the entire number. Actual numbers is about 4,000 thats about 2 Million Dollars in transport. Of those five, two have died and two are in a program. One of them was conserved but it ended up being dropped because of a lack of placement options. And the 5th one is a psychiatric facility. I want it thank you for that. And im saddened that dr. Kunings had to leave, because they dont call Substance Use disorder as an basis for conservativeship but it it does call out alcohol use disorder. With folks with disorder issues can cost a large of amount of number without, some of these folks did get help. One of our highest use is affective disorder. Last five years, 732 transports. And hes in map right now. He does not have the supporting underlying psychiatric diagnosis. Required. Yes. Ops requires a diagnosis. If theyre considered in ama because they have not received medical advises. Now that we know theyre being through the Emergency Department before they go through victim emergency and they wait a long time. These numbers will be really important to look at so we can evaluate. In terms of that, 82 of the time that the pes is opened through the Emergency Department that is not something that my staff report, they report a different, theyre not going to be as specific numbers but they report that most of the time when they call pes theyre not able to transfer patients over. A way to collaborate is to look, because its truly their only for the period of time that they need covid clearance. Im curious where that ties in. We have a large number of clients who will up to the Emergency Department for pro tesing and diagnosed related but theyre not on a 5150. If they cleared it before. Theyre likely to go out of the system. So there is a whole different bucket of clients. So those are some areas that i think clarification would be important. I also want to give, my second point, i want to give some context to the experience of large staff members. Best way for me to do that is through what we have an a a system, its a form that we encourage our nurses to fill out if theyre, if theyre in a staffing situation or clinical situation where they feel circumstances are not ideal for patient care or in some areas violate ratios, violate some of the tenants that are decide to protect the patients and staff. If you will indulge me, i would like to read some comments. And this is all new, because my system has been[audio statically] some of these comments are from the ground nurses in the psychiatric Emergency Department. Short staff patients have been here for over 100 hours, while two officers were observing. We have testing because of accuity. Were at full capacity with patients waiting. Triaage as well as monitoring one to one patience. Nursing being able to not take breaks of shortages. No mnas, charge nurse sitting on a one to one patient. These are a somewhatering of comments. And from our in patient unit, full patient load, test patient could not get the attention that they required. One to one coaching but there are none to do so. Cover all patients and complete rounds. Accuity is high. I have over 50 of these that has been submitted in the last four months. And our and reason i bring it back here is because, when was discussing the fact that we have two rn vacancies, two rns is sufficient to solve the types of working conditions that these people are reporting. No coaches no mnas no security presence. So if your staff are under staff, then youre pulling all of your nurses from their regular duties to do all the ansary. Its very concerning to me. Adding to that i was interested to see the presentation from ucsf. Emergency department has neither of those and we oftenpdf station in the Emergency Department. We also do not provide security. I love that number. One Security Guard for four 5150 clients. And that is is to be paid further in october. Which means were at risk to having zero in our department. So the working conditions are of significant concern. Which leads me to my point. We heard about the trouble that theyre having to find qualified staff to work in this department. We had multiple conversations to try to indicate that we are in an endless loop at this point. We have inadequate staffing which means the staff overtime on the regular, they dont get their break. We have no one to help us out so theyre working much much harder than people at other institutions. Add on to that, that the county is one of the institutions that is not offering sign off bonus for the staff. Weve talked about that time, its standard to offer sign on bonus. So we cannot get experienced staff. The staff we have is so much more and so much harder for the population that they leave which just continues to end the cycle so were really struggling to get out. And if you add to that working conditions that are low on staff and low on security, youre never going to get ahead. We have to figure out a way to break this cycle. Just want to be honest about that. Im happy to answer any questions that you have. Im sorry to ramble on quickly, ive been listening for a while i wanted to get that. Thank you, president , and i do not have any questions, i have concern for the conditions that youre describing and you know, particularly the concern for the safety of folks working in the emergency room and psych emergency and the availability of some of the other Case Management and services to folks going to the er. Unless chair mar, do you have any questions . I have a followup question to lieutenant molina if youre online. Im here. Great. This is just a followup question around the calls for service chart and im looking at particularly the 800 code call code for mentally disturbed person which is the largest number of calls. Its been a constant number, it really has not gone down in the last few years. Im wondering why that is with the implement of skert. Skert is responding to the blevel calls. Yes, so basically, going back and looking at the data, the 800 calls. We average about 10 to 11,000 a year. Those were between the Police Department and Fire Department as of june 22, this year was fully implemented. Those calls have been transferred to the Fire Department. So i have not seen any changes yet because it just happened last month. The Police Department still carry the heavy load on that. Okay, thats all. Before we go to Public Comment. I do want to thank our private hospital who have been helpful in thinking of this hearing. If we have questions, we have available from the Hospital Council michele coalman from Dignity Health alex, from sutter Melissa White and lee anne mendes and from kaiser alex wong. We engaged with them, primarily, two things, one is on the theory that when when folks are sent, that impacts. And i do think and we have not been able, we had enough to talk about, that we have not gotten deep into the role of private hospitals of addressing the shortages that we have. I think that is a shortage of beds. I want to invite anyone from any of the aforementioned hospital or Vice President coleman to add anything but nobody had been obligated. And this meeting has gone already for two and a half hours and chair mar has been patience. This is mitchell with council. I dont want to step in front of my members and they can speak if they would like to, but i would like to say generally as todays hearing illustrates, providing Psychiatric Emergency Services is the huge complex challenge for the entire delivery system. San francisco are committed to meet the health. We appreciate the conversations with you and look forward to continued conversations. Thank you ms. Coleman, if anyone else wants to weigh in feel free and also feel free not to. Mr. Chair i think were ready for Public Comment. Lets go to Public Comment. Clerk anyone who would like to speak, you can line up. And for those joining us zoom. Enter the meeting id. We have our first speaker at the podium please proceed. Hi, ive been homeless over 20something years. I wanted to know why, can everybody else get section 8 and mine was taken back each and every time . Im at the goode hotel where im called the snitch, i dont do drugs, i do smoke weed. I was suppose to stab somebody and this guy was talking about out out out. They call the police every day on me and make false police report. They have something in my room that scares me. Im called bitches and mother fuckers, everywhere i go. The tv was taken apart and hooked to security downstairs. So i know they are looking at me, so i unplug the tv, right now, i look like im crazy but i would rather be some place else. Can you put me some place elsewhere im safe . I walked in and i was given a permanent section 8 by has sean and ms. Grande. What is wrong with me . Can somebody please help me . What do i need to do . Do you know how hard it is to go around in circles . Im 52 for being called a snitch and poison. I did not do that to myself can you imagine what my inside looks like . Can you please help me out . Clerk thank you so much for your comments. Seeing no other speakers here in person, we will go to the remote call in system line. It does appear we have three in the queue, mr. Adkins if you can please put the first one through. Speaker im alex im the public manager that provides Substance Use disorder and variety of other sevensers for our californians but mainly in San Francisco. We are one of the places that previously for detax. And providers are also experiencing staff issues. And another relevant issue is nonprofit workers are paid less than their counterparts with the city of San Francisco. So when we talk about when we have staffing issues, a de tox bed does not mean anything when we dont have staff. This is definitely that needs to be addressed. And would help alleviate some of the staffing issues which could in turn help. Thank you. Thank you for your comments. Lets have the next caller please. Speaker hi im scott chang. I currently work as a emergency physician at pomona and ive been practicing medicine here for the last nine years. And the Psychiatric Care in the city has been the worse since ive been here. And you know, some of the perspective from boots on the ground, i worked at heather at the general and i want today talk about what happens when these patients come in with these Substance Use, Mental Health patients come in. Its not like they come m and they get seen and get discharged. Theyre combative the meth, they cannot come prehence, they have to be sedated and and there is not a Single Person that works in the hospital who has not been kicked or spit. You know, it takes a toll, these are every bed that these patients occupy is a bed that cant be used for your grandmother who may have had a stroke, somebody who gets in a car accidents. It, it dis strakts from the rest of the flow of the department. And even after theyre sober these patients go through what we call meth bomb shells, they haveweve had patients who had 1,000 hospital visits in the previous 12 months. At what point do we say that the 5150 is not working and we have to go to resource to see conservativeship to address the issue. There has to be a point between one, 5051 and 1,000 5150s. Clerk thank you so much for your comments apologies for cutting you off but were set ising the timer for two minutes. May we have the next speaker please. I have been involved in this issue for almost 35 years. Since then it has been, one year after another its been worse and worse and worse. We sently we had a person that was 5150 but he was ranting, he smelled, he smells like hes dying. He has a big wound of the face. The crisis team and police team were there and he refused. We had him in the state before. I went over the next day and talked to him and he had agreed to have a shower. A haircut and to have somebody look at his wound. I found a program but i could not find a vehicle without calling police or fire. It is been 5, we have looking for just a van to take him and i told him we would bring him back. This is the first step in the way to approach some of the mentally ill and its being ignored. We had a Wonderful Program called into the hot program and the hot program does not work. Bring back the map program. If you really want to find out what is happening, talk to us in the field every single day. We have found out that all of these extra groups that you have and a few others that did not stick, there is no communication. There has to be a better way. Clerk thank you so much for your comment. Speakers time is expired apologies for cutting you off were setting the time at two minutes. Can we get the next caller please. Speaker hi my name is julie im from the emergency emergency at San Francisco general. And thank you so much for having this hearing. Its, many people its long overdue. I wanted to thank sfp and the emergency room about one minute walk and pds. So i imagine, frustrating to have these people on billions unable to connect the two together. The staff are getting beaten and addressed and having a hard time. Thank you so much scott. Thank you. Its still very hard to help somebody and then they punch in the face or drag you by the hair its really rough. I wish the board would come back and get into psych emergency and see what is happening for a few minutes. Its been really rough for the staff and there is been zero offer of differential or any sort of bonus for people who have been suffering that for the past two years. But nursing and other staff in the hospital, and all of the staff has not gotten one extra thank you. And differential for triaage who sit there for three hours watching this tragedy, is heart breaking. And i have some day soon we can meet with supervisor. Clerk thank you so much for your comments. Speakers time is expired. Apologize for cutting you off. Mr. Adkins do we have any other callers left . Madam clerk, there are no further callers in the queue. Clerk mr. Chair. Thank you, supervisor mandelman, can you for this. Do you have Closing Remarks . Im struck hearing from the different departments how many incredibly, how lucky we are in the city, to have so many dedicated folks at every level at every Department Working to try to meet the needs of our sickest and most Vulnerable People and yet i continue to feel that were not set up to address a challenge that we have seen now for many years. And i think weve done some good things. I think standing up the Response Team has been a positive thing. Each of the facilities that we talked about whether its the Linkage Center or Sobering Center or humming birds, each of these meets the need and valuable. But in terms of addressing, you know, the particular challenges posed by people suffering from serious drugs and alcohol addictions, you know, i think we are still a little bit of a square one. And i think we need to focus how to address that challenge that emerged at pes in the last five to ten years. And is a challenge and trying to walk down the street. I think what im going to request of this, i think pes is a very important i think i may want another visit. I would like to have more detail. I would like to continue this meeting. I would like to have more detail and a little more clarity on what they think that that might accomplish. So i will move that they continue this to the call of the chair. That sounds good to me. Madam clerk call the roll. Clerk with the order to continue. Mandelman. Aye. Clerk chair mar. Aye. Clerk two ayes. Madam clerk, call item number 2. Clerk [reading item 2] please wait until we take Public Comment. Mr. Chair for the record, we do have supervisor presspreston here as a third member of the committee. Thank you councilmember preston. The floor is yours. Thank you, chair marand supervisor mandelman. I want to thank you for your efforts specifically not just on vision zero but around increasing the transparency around fatalities to i will proof Street Safety and this is thating that we worked closely together leading on to our resolution announcement. And cosponsoring the request and i know interested in this issue as well. We introduced shortly after at that the 15th traffic fatality in the streets of San Francisco just this year. And it was right after this 7death in the month of may alone. Unless since the introduction, weve had not additional four traffic fatality. We all as supervisors and other in leadership get the heart breaking text at all hours of the day or night either from our colleagues at mta or Police Department or fire, whoever is responding. And then a aftermath of fatality. What is in the works in terms of improvement. What are the shortterm and long term plans. The public has a lot of these questions. We as supervisors also do. We spent quite a bit of time and communicate that back to constituents who have questions. There is a work that happens after at the departments and well be hearing from them momentarily. So my impression is not a back of hearing. To support victims and for departments to communicate with each other. A lot is happening what i noticed and what i think is impot us for this resolution. And often the details, often details what often occurs is there is tremendous misinformation out there. And you start to mayer from your Community Members around what happens what does not resemble what occured. And one of the things that that we have to do better that were all actually dealing with Accurate Information and that were sharing that in a transparent way for the public. That is in contrast to what a pretty orderly protocol thanks to a lot of great vision zero advocacy to who they are communicating behind closed doors and with each other. I think at the heart of vision zero is the idea that trafb fatalities and crashes and collisions are not he visitable and that we need to make sure that when a tragedy does occur somewhere in our city that were doing everything to ensure that that it never happens again. Some folks have asked why this is a resolution and not an ordinance. I want to be clear and well hear more from the departments. Its not created, its not a creature of an ordinance. The board adopted the vision zero policy in 2014. The protocols were implemented. And you know, we believe that part of that is really exploring doing a town hall of some kind. Well hear from other ideas presented as how we create that transparency. But i want to under store that the current protocol does not have any public facing disclosures or information xep for monthly reporting of the number and location of incidents on the vision zero website. And i think that really falls short of meaningful engaging the public. So we think a town hall and other information needs to be a part of the response. I want to thank mta, dph, sspd for their engagement leading up to the introduction and also to this hearing today. We did get a better from, from director on behalf of multiple organizations, departments with some proposed modifications. I responded with that letter with additional suggestions and changes. I hope we can get some clarity on what for after a traffic fatality. I also want to thank bike sf, and Bike Coalition in moving this forward and figuring out how we discuss and highlight these tragic deaths while also elevating the need for urgent street changes to prevent further fatalities and changes. With that accountser with that, i know we have mta, i would love to hear from. Okay, thank you so much. For working with me on this resolution and your leadership. I did want to add in highlight one tragic, tragic traffic fatality that happened in my district, it happened in january, it was one of far too many that happened this year. This was an at intersection in outer sunset that residents had expressed concerns about Traffic Safety about for years. There had been requested to add all white stop signs. My office even supported a request in 2020 to add allway stop signs at this intersection. All of them were not denied by mta traffic engineers. So tragically there was a fatal collision in january of this year. And a neighborhood leader was the victim of this fatality. That was very traumatic of this fatality. I do respond and they committed to actually to moving ahead as moving ahead with allway stop sign. I think this highlights better engage with the community to prevent these types of tragedies in the first place. There is a need for public process around the investigation and the response and so. Again thank you for working with us on this. Thank you, chair and supervisor preston. I really appreciate you all. For those who dont know, im joel ramos im the manager for the sfmta. Im joined by my colleagues on the vision zero coalition. Weve got commander sfpd, we got ricardo alea who is our engineer and our colleague and validsik is dialing in remotely from department of Public Health. And we extend our all of our gratitude to you all for calling this hearing. We certainly appreciate the urgency which with youre bringing this item to this committee. We share in your in your sense of gravity with the issue in getting our shared goals to getting to vision zero. We are here to talk about what we have done in the past. What our protocols have been and were going to convey what we plan to do in the future Going Forward thanks to your leader ship supervisor preston. We cant stress enough how grateful we are for the partnership we have with sfpd and Public Health. Were working very closely. Its clear that we need to do a better job at communicating exactly what the City Responses to each fatality and make that more reliable for the public so they can get a steady sense of what can be found out from the various agencies that are working on this together. Madam clerk, if you can chair the slides . I believe were ready to go. If you can advance to the first slide. Im going to sit down and let my colleagues step up and offer their respective roles in this process. And ana is going to speak through the teams link. And then my ricardo is going to talk about what we do some response. And ricardo is going to talk more about what were going to do Going Forward, if thats okay with you mr. Chair. I suppose its okay, chair mar. Yes, thank you. Thank you so much for having us, if i can introduce your esteemed Commander Call shall, thank you. Thank you. Good afternoon, i oversee the Collision Investigation Team whether its traffic collision investigative unit, our motorcycles better known as the four boys of solars. And some of our commercial Vehicles Community where they really map the intersection and the whole collision die graming. So ill quickly go over, i think youre familiar but so the public knows if theyre tuning in. Any call that come out, sfpd will go investigate injury collisions. Somebody has to have a minor complaint of pain. We do not investigate simple fender benders, but we will go and facilitate information. Fatal is severe crashes activate the traffic investigative unit. Those are investigators, these cased are treated and with a fatality will could be criminal charges up to and including homicide and vehicular manslaughter, if there is dui issues those cases are handled by investigators who work on criminal side with our technical people. So at a scene, we like to see the, we have officers trained higher and above. So for instance Early Morning hours where traffic is not working. The officers will handle those collisions. Next slide please. Will get notified by the Operation Center which includes all the leadership. We then with our resources sent out to the scene and then we get up dates. Either aye or one of my seen or leader ship people, we have a group text to alert them of the General Information so they can start the process from their end to respond. And then lastly an alert notification may be issued. For instance it may not be a Police Station that what happens between a vehicle and a pedestrian, two weeks whatever the case may be. It may be a crime that has been submitted. Committed. For instance somebody fleeing or under the influence. So a lot of those are not determined right away. But you should get the date and time of the collision, where it happened a brief summary and which Police Investigative units youre respond. So supervisor marmentioned out in avenue, that was a stolen vehicle, there was a lot of stolen items and that person fled the scene so we have multiple crimes in that case. What wound of happening, sfpd identified that person and it took us a while to track down that person criminally. So we do have a person that affects the community. So, that is it on how we get our information out to our partners. I assume questions will be asked at the end of the presentation. Thank you. If you, and chair mar, and supervisor preston, thank you for joining us as well. I should add that weve been able to work with the other supervisor thats are not been able to be here. Also ive been corrected were joined by seth pardono who is here to present inperson on behalf of the department of Public Health. Thanks for having us here, can i have the slide. Thank you very much. Going into a little bit of detail. This is a coordinated City Response within dph with collaboration with pd and the dph crisis counselors. If services are needed, they ask for a cell phone that is the point of contact. Pd report needed and priority is given to the family of the victim first if there is a driver who also requested dphs services and who may have been impacted. Serve as the cochair of Vision Zero Task force. Age of motum death, case number and whether we have next of kin information at the time and whether we have heard from the office of medical examiner, whether that next of kin has been contacted. Next slide please. Next, is previous months report. For example, the june includes data from may and so on. Dph prepares this monthly report, this is just the image here as an example of the first page its a threepage report. The report will take us, if thats how long it takes us to confirm the information and ensure that the information is as correct as it can be at the time. Page one of the report includes the month tallies and year to date tallies that go back. The second page of the report is where we highlight the counts that may fall within our communities and other vulnerable populations such as seniors. And ayear trends. Do not reflect the freeways even if they occur within the county of San Francisco. However we do note in the footnote section of this report. Okay, i think that does it for dph, i look forward to your questions. Thank you. Good afternoon, im ri card a im the traffic engineer. Im going to talk about the role in fatality response. When we hear of a crash from the Police Department, we activate our rapid Response Team and the staff that is assigned will depend on location or the type of crash. Its usually very senior staff such as myself or senior engineers. We want to make sure that we have people that are experienced and make judgment calls pretty quickly after a fatality. And the process has greatly improved. But now we get very good communication and good collaboration, once we know of a fatality, we can talk to pc u staff. So again, we collaborate with the Police Department, their finding out information, sharing it with us. And based on the site review, well start recommendations about immediate changes that can be done. Sometimes there will be things that we can do in terms of maintenance. Sometimes there will be things that the intersection can have quick improvement. And then we also notify other agencies if they have other issues. We sometimes have things that can be repaired by other departments to street lights or we may contact public works if there is a tree or other infrastructure issue that may need attention. Sunlighting and those kind of factors. Next slide. Again when we look at the site, we look at patterns to see if this is safe pattern or unique incident that has not repeated itself. Sometimes this things are part of a pattern or some things that look to be a problem with the intersection that will increase the level of attention. Unique incidents that are not part of any previous history that the city could have use today prevent that particular incident. There are improvements, studies in a be pending. So the studies are notified and theyre brought on board to make sure that theyre aware of the urgency of the situation. Things such as new Traffic Signals and major facility outbreak. They may require funding those things can then be on the path. But also do they have any lessons for us about trends that can be addressed through other means or more globally through policy changes . Are we seeing an increase in wrecklessness. Are we having a certain design issues that should be fixed overall city side. We still had a fatal what can we do now. Speed enforcement which is something at the state level. Again the process is reacting to an event. Were trying to prevent these from happening again. But there is also a proactive Vision Zero Program that were all familiar that is looking at the data but overall other data that address other crashes before they happen. So were not just reacting to incidents and doing things the result of incidents, were not waiting for people to die sometimes people will be afraid. Were trying to prevent deaths from happening and using the data that with have and all the tools that we have deployment, deployment as quickly as and as efficiently as we can. So as mentioned before, staff has process but there is realization that the communication can be improved. That the public can look at. So i think this is a great proposal that has been brought forward. Uptodate reporting that updates the public on what has happened and what our city departments are doing as a result of a fatality including investigation from the Police Department, again the information that can be shared that is not going to interfere with the criminal investigation. Nothing that violates peoples privacy. And the fact that two private parties are basically involved or two or more parties can be involved. There may be investigations where such as hitandrun may be under investigation. So all of that information well be sharing in a report and m. P. A findings what have we done at the site. And then response has been initialed or completed. The reporting that we do, will also be discussed at our mta board. And they have an interest in this information. So far we present information as part of our directors report. And as part of the dialogue, we will be reactivating a process that we had started when vision zero started which is to post at the site a Public Notice that a fatal has happened and we will use that to get the Public Information or ability to access information about what happened and what the city is doing. So that public posting will require some resources. Ha concludes my presentation on the mt a role. Thank you so much, supervisor preston. Thank you, chair marand i want to thank mr. Lea and mr. Parto and community walsh for their work and presentations. Let me say just say, i think were im encouraged that were moving. I think there have been discussions but not a lot of Movement Towards a more transparent process and i think some of these things you laid out reflect, you know, hopefully a positive Movement Towards some new aspect of the protocol. But i want to make sure that that were clear on what were doing and proposed for changes. I dont know if we can go back to your slide, engineering rapid investigation was the title and you walked through the Different Things that are part of the investigation. Looking at other factors there, it is thank you. What if any of this currently is shared out with the public . There are things in the monthly and annual report. But it does not have this level of detail, im curious what if you can just is any of this communicated out . It depends on the incident. That is one of the proposal is to fix that and provide a place where there is a summary of what the mta has done or will do at an intersection. That has typically shared at our board, our director will sometimes share specific actions that have been taken following a fatality. Its a process where we long term, the feedback that where were getting from the supervisors or other members of the public, we may add to our response. When the department is not recommending, as part of vision zero, were always looking to make street improvements. Or they may be done as quarter project. But as far as the fatality, that is one thing that were proposing to fix. Thank you. It sounds like where other meeting where there is a regular or consistent presentation after a fatal. It would not have this level of detail but mike touched on some of these issues. Right. And this is part of a heart of the and i want to say this, this is part of the issue that done harm to the situation. I have found that there is a history to share. That people are engaged and improvement that have been made or in the works or plan for them. I think it does, not having the protocol of making the work that has been done or what is envisioned cleared to the public in any way, i think does a disservice to a lot of efforts that youre all undertaking behind the scenes. I just wanted to name that privacy and hippa and other privacy investigation as the commender referenced but that we get the other information out. So mr. Ramos sevensers the communications we had the letter from director out lieping the both the current proposals raising some concerns around holding a town hall style event. In rereading this, i want to focus on something that was significant for me. Im not sure if its for you or mr. Ramos, in the letter that we received, there is attachment, this is from directors, and the attachment is entitled current protocols after a fatal crash and it sets for a list of five things. And what i noticed unless i missed this in reading this multiple times, the fourth item on this list until the letter references a street Team Response and ill read it because, i think its pretty important because it, is says within two weeks of the crash, this is part of the description of the current protocol from director tongue land and cole fax. Within two weeks to provide respectful and out reach to the public at the crash site following a fatality. These one on one conversations with residents mer ants and commuters who live and work in the area. They acknowledge the fatality and taking action and engaged in solutions for eliminating traffic deaths. Does appear to be part of the actual november 2020 vision zero traffic protocol. There is nothing like that, but im looking at an attachment can you clarify for me what i just read to folks who commute buy to the Broader Community . That that is not something that we have been doing in the past two years. It was in the letter as part of the protocols but with a comment that its on hold because of funding. We all understand thats not happening now. This is the first time weve seen this. Im not sure by the a official protocol. It requires extra funding. And it was not aware that extra funding could not be aware in the future. This was extra relying on the team in our Planning Group at the mta. For us to go above and beyond what the basic response was. Has funding been refunded or thought to be undertaken. One is the posting so that is one aspect that based on what were recommending would now be would have to be funded. If were going to post every fatal site. To have Community Ambassador and to engage with the community, thats an additional cost that we would have to look at. And then it was discontinued, can you just shed light from the time period . Ill ask staff. I dont have them before me. But we can get that information. I would be curious why we have not request to fund it if there were no other issues. Were there issues other than funding. I think the Community Response part was not all fatal crashes it was reaction appropriate, where doing that would not be practical. Thank you, and just, you know, the short version of the letter and i should just say that for those who have not read it and wondering what im referring to. Inperson town hall event and then it outlines some proposed steps and i think in a nut shell are to have this much more robust report that actually sets forth a lot of the details that we were seeking to get through a town hall that that would be done in a public facing report that that would be easily accessible including a lot of these findings and recommendations and the status of cases subject to concerns. And then the other part, and you address this. The other part was suggesting quarterly supports to the mt a board in again, as satisfying some of that public facing side of this. To which that was not a in lieu provide that immediate update after a fate ability to the mta board and also quarterly provide more more in depth information. I dont want to speak about the board, one thing is we need to engage on the board. We were waiting for this hearing and the discussions to kind of evolve. These are the discussions that were hearing from the advocate and what kind of reporting they want to see with what frequency. They want to see more information often when were reporting to the board, we dont have all the details. We dont give out necessarily, all the pieces of information and what frequency we want to do as a way to make sure that this is something that were always bringing to their attention and their wellinformed on fatal trends and what the agency is doing. Thank you, i think that in addition to more comprehensive report that some level of direct engagement is really important. Are en kaournld that you have incorporated that into some of your, into your proposal. Why it was discontinued and during what period was done. Do you know what the cost of what youre proposing to implement that part of the protocol . Byway i did check with staff. And then the out reach component that that could be, could be in the order twice that amount. Ipg what we show the information of what we did you can see how that process worked . Thank you. And i do, i want to say that we have always approached this thinking that say town hall has been used after police shooteding, there is a town hall. This is one pod he will. So i appreciate your efforts to meet some of the goals within existing framework of the mt a orders. I do think that would be significant information as well as so interested in how pilot went as well as with the cost. Chair if we can open up for Public Comment or if either of you had any questions. Before we go to Public Comment. I just wanted thank the departments dph for working together and really collaborating on and then also, for engaging with us aon how we can strengthen the protocols and response after a traffic fatality. I know that the tragic incident that happened in january, there are a lot of Unanswered Questions at the immediate family and community had. And what was going to prevent future and i dont think the question have been really answered adequately but, for the community now almost half a year later. Whether that is a town hall or proactive out reach that, that has, i guess director referenced in the letter. That is really important to get their questions answered and to be able to really engage with the departments, about you know, about the incident and how to prevent it in the future. So members of the public wish to provide comment on this, line up to speak now. Those joining us please call 4154450001. Seek no one here in the chamber, looking to see if there are any callers on the phone line. Can you please call the first caller forward. My name is richard and i live in the Outer Richmond district and i think there should be town hall meeting and recently there has been four pedestrian accidents hit by cars and mta has done zero about them. In the last two, the one on 38 and gary, mta would not put a stop line to slow traffic down on gary there. Its a speedway there, and talked to staff and i think they need to change instead of being transit only, they need to be pedestrian and transit. So they shouldnt be adverse to putting stop signs on bus routes. There is a Senior Citizen was hit in the crosswalk by the Senior Center i think in may and ssmt a has done absolutely nothing to slow traffic down or to fix the problem at the intersection. I just found out it only activates. They a rule that i dont know. They should have the town meeting and they need to be held more accountable. One time a Senior Citizen got sent to the er and the rapid Response Team said were not going to do anything because the person didnt die. What kind of answer that . Can we have the next caller please. Speaker yes i want to support this resolution and i want to urge you to improve the vision zero responses. My friends and i have launched at vision zero locations all over the city. In bay view, marina, sunset richmond, yeah, everywhere we go, neighbors thank us for being here and ask what can be done. And so many tell us that theyve been asking for Safety Improvement but have no hope of change. You can do so much more and as for maybed engagement you can go to do things that youre doing. May we have the next caller, please . I think everyone can agree that traffic violence is out of control. We have to do something. And experience to do what we need to do streets safe and help San Francisco reach vision zero. The way we value it is more than ability to be safe. Thank you so much for your comments. Do we have any other callers in the queue. Madam clerk, there are no further callers in the queue. Thank you. Mr. Chair. Public comment is closed. Supervisor preston. Thank you, chair marand i should have at the offset thank you for scheduling this. Were in this crunch period right before our resoes where we dont have hearings for a month and we really appreciate you getting it on the agenda before we break. I think we made some progress in work withing mta on this. And it really have the time to negotiate just the details of what is in the new report that gets created and presented to the public. And what out reach component is in terms of getting the word out to neighbors and others in the immediate area of the fatality. So what i would like to do is to move this and hopefully make more progress before it comes back to committee and moves forward. Thank you, supervisor preston that sounds good to me. I move to continue this continue. Member preston. Aye. Preston aye. Clerk member mandelman. Aye. Chair mar. Aye. Clerk there are three ayes. Thank you, this will be continued. Madam clerk, do we have any further business. Clerk that concludes our business for today. Okay, we are adjourned. Whats going on everybody. Im nona at holiday plaza. Just got off the bart and getting ready for the parade inaudible [horns and cheering brash did you say you came off a flight to be here . I live in jacksonville florida. How long have you been a warriors fan . My firs game was inaudible inaudible the stands. The energy you get. That is one thing i miss about living in the bay. It is hard to explain till you see it. And we are not done. We still got inaudible im really really looking forward coming back next year. Well see you back again next year. Have so much fun. Have a great day darling. [cheers] we are at a point where we have this dynasty and will be here every single year. Thats right. One more lets go [cheers] how old are you . 8. You are 8 and you have been awarrior fan 8 years so your whole life. Yep. How awesome is it to be at this parade today, are you excited . Im really excited. Is it your firs parade . Yeah. It is awesome and so much fun. Who are you excited to see . inaudible has he been your favorite player 8 years kblrks yeah. I love it. [cheers] how long have you been a warriors fan, sir. My goodness, 70. I was in 75 75. Actually i won a free throw contest at 10 years old and basketball signed by addles and thermman, a San Francisco war riors. inaudible how awesome is to see them acquire what they have and have this dynasty kblrks it is super cool to see this and see the players. It is fun. You feel that is where we will stay or get inaudible inaudible i think we have inaudible i do. I have no doubt. Have so much fun. Thank you so much. Have a great day. [cheers] we are going to head over to make our way to the main stage and check out all the action up close and personal. Lets go. How awesome is it to be part of this parade today . Are you guys stoked . So excited. Yes if you can only hear how load that was. All the way in the front in the vip section. The warriors players are up on the stage. Lelts polk hear what they have to say. The finals, stefen curry give it up for your 2022 World Champion Golden State Warriors [cheers] what does it mean to have the first parade in San Francisco . How much are you looking forward to this one . Let me tell you, im so excited the streets are lined up and blue and gold, we are going to give a homecoming like no other. Welcome home warriors we represent you guys. The life you give us, the inspuration and free males meals and Standing Ovations in had kitchen. All those things matter, because this is what it is all about is entertaining you guys, giving you something to cheer for and be passionate about. Giving us the tonight to do Amazing Things that havent been done in history and represent the entire bay area in the process, so it means a lot. We all been here the entire time and try to continue to build this. It means the world and now we back having a parade and San Francisco, so lets go do it. The Warriors Team was just introduced behind me on the stage. London breed just gave a heartfelt speech. A beautiful asunny day in San Francisco, a wonderful day for a parade, so lets get it going. [cheers] and that is it for the 2022 Golden State Warrior parade. Huge thanks to everybody involved and the city of San Francisco. The cleanup crew getting the city back to tip top shape. For more information about the great city departments,. My name is Angela Wilson and im an owner of the market i worked at a butcher for about 10 years and became a butcher you i was a restaurant cook started in sxos and went to uc; isnt that so and opened a cafe we have produce from small farms without small butcher shops hard for small farms to survive we have a been a butcher shop since 1901 in the heights floor and the case are about from 1955 and it is only been a butcher shot not a lot of businesses if San Francisco that have only been one thing. Im all for vegetarians if you eat meat eat meat for quality and if we care of were in a losing battle we need to support butcher shops eat less we sell the chickens with the head and feet open somebody has to make money when you pay 25 for a chicken i guarantee if you go to save way half of the chicken goes in the enlarge but we started Affordable Housing depends on it occurred to us this is a male field people said good job even for a girl the interesting thing it is a womens field in most of world just here in United States it is that pay a mans job im an encountered woman and raise a son and teach i am who respect woman i consider all womens who work here to be impoverished and strong in San Francisco labor is high our cost of good ideas we seal the best good ideas the profit margin that low but everything that is a laboring and thats a challenge in the town so many people chasing money and not i can guarantee everybody this is their passion. Im the ive been cooking mile whole life this is a really, really strong presence of women heading up kitchens in the bay area it is really why i moved out here i think that we are really strong in the destroy and really off the pages kind of thing i feel like women befrp helps us to get back up im definitely the only female here i fell in love i love setting up and love knowing were any food comes from i do the lamb and thats how i got here today Something Special to have a female here a male dominated field so i think that it is very special to have women and especially like it is going at it you know im a tiny girl but makes me feel good for sure. The sad thing the building is sold im renegotiating my lease the neighborhood wants us to be here with that said, this is a very difficult business it is a constant struggle to maintain freshness and deal with what we have to everyday it is a very high labor of business but something im proud of if you want to get a job at Affordable Housing done nasal you need a good attitude and the jobs on the bottom you take care of all the produce and the fish and computer Ferry Terminal and work your way up employing people with a passion for this and empowering them to learn. Good morning everyone. Welcome to the july 26 meeting of the San Francisco county transportation board. I am chair mandelman and supervisor peskin is our vice chair and today we have our new clerk and welcome and to angela for being the acting clerk the past several months and also i want to thank michael at sf govtv. Mr. Saunders could you please call the roll. Yes chair. Commissioner chan. Present. Chan present. Commissioner supervisor dorsey