We invited some producers and vendors to speak on a panel. So we had several people, a collective of people who promote selfsufficiency and zero waste, and people really got into it. You could also get a certificate of doing the training from environmental department. In terms of turnout, i mentioned we had 60 people, just a sample of people that came from different organizations, sunday streets, undiscovered night market, st. Patricks day, comfort and joy. And whats exciting, too, is we had several brick and mortar venue. Environmental department was really pleased with the collaboration. They said that this event had exposed their work and their mission to a broader audience of entertainment people than previously. So they were really, really pleased. They want to continue collaborating with us. We did survey the group, and some of the highlights from those survey results, we had 70 response rate. Majority of people said they heard about us from facebook or email blast. 76 said this was their first time attending the event. 86 said that they learned something new they could apply to their business, and they said that they would likely recommend the event to another person in the industry, so that was a really nice response. Talking to director weiland before the hearing, and she wanted to give a Bigger Picture in terms of increasing audience. We currently have 21 2,171 subscribers for mailchimp, and we really want to increase that. I think that mailchimp and the facebook hosts are our most popular and most used platforms right now for getting the word out, so we hope to continue that. That is all i have. If you have any questions, let me know. President bleiman i do. Any discussion on the water bottle . Now are street fairs considered water bottle banned because its on the street or is it only on City Property . So yeah, any City Property, so that would include a street or sidewalk as well as a city building, you are not allowed to distribute any plastic water bottle, not even to volunteers or to staff with the exception of athletic events. President bleiman so did anybody at the meetidid so did anyone think of ways that they could do that . They could actually promote bring your own cup to the audiences, and they do their Due Diligence for compliance, they would fulfill that law. Theres different ways you can use it to your advantage. Wthey do that for the beer, but theres always supposed to be water available. Yeah. Theres always supposed to be water available. They can do it through a vendor or utilize it through sfpucs Potable Water fire hydrants. If they can make a case that its very cost prohibitive for them to bring in the water for various reasons, they can have the department bring in the water. So theres stores along the sidewalk, and the Grocery Stores sell plastic bottles, and theyre Walking Around with plastic bottles at the street fair. Thats legal because the point of sale is happening outside the venue. So as long as the vendors isnt involved in selling or distributing bottle waters . Yeah. Its the plastic bottle thats the problem. I see. Thank you. Sure. Whens the next one . We dont know yet. Keep you posted. Were up for suggestions always. Thank you. Thank you. President bleiman before i do Public Comment, i just wanted to say thank you for your work on thursday night. You did a stellar job organizing that bar crawl. I like to see it as you stressed out so we dont have to. Is there any Public Comment on Senior Analysts report . Seeing none, Public Comment is closed. [gavel]. President bleiman the next agenda item is our regular agenda under item number 6, hearing and possible action regarding the applications for permits under the jurisdiction of the entertainment commissioner. And before i ask Deputy Director azevedo, i just wanted to poll the crowd. Can you raise your hand if youre in support of the agenda item, the rite spot. Okay. Does anybody here have concerns for the agenda item . Okay. Nobody appears to be in opposition of the item. You can speak to the item. Its your right, but you can also judge who your leaders are, and we can judge by the out pouring of the crowd. This is your First Amendment right, and we encourage you to do so, but also, you dont have to if you dont feel like it. So now, id like to introduce or have Deputy Director azevedo introduce the applications for the evening. Before i introduce the application, im going to pass around a stack of about 120 letters. They did also receive that in advance. Absolutely, yes. These were all submitted in advance, including up until today, so thats reflective of everything that we received. Okay. The only permit on the regular agenda is for place of Entertainment Permit at the rite spot, located at 2099 folsom street. The rite spot has been providing venues for 30 years, and want to apply for a permit. There was an outpouring of support for this venue. Included are three tenants living above this spot. Additionally, the applicants distributed the letter included in your file to six of their neighbors businesses. There was no neighboring businesses. There was no opposition for this permit, and mission station approved this with no additional conditions. They completed all their inspections, and this is the last thing they need. Here to tell you more is manager, christina. Okay. Hi. Hi. President bleiman hello. So just state your name and tell us about the project. My name is christina hu. I manage the rite spot cafe, and yeah, were looking to get our place of Entertainment Permit so we can continue serving the community and having live entertainment. President bleiman can you just tell us a little bit about what type of entertainment youre going to be having there . Yeah. We host pretty intimate shows of music with, id say genres like blues, americana, folk, jazz, blues, r b. We do tributes once a month. We have comedy, opera every third sunday, so its pretty diverse, the type of entertainment we have, but definitely focused on an intimate space, and so we are a really small bar, yeah. What else should i say . Sorry. President bleiman oh, yeah, and can you tell us the length of time that you have been operating and doing events. Okay. Yeah. So the music usually goes president bleiman for how many years, and then also, wed like to know okay. So my family has owned the bar since 1990, and theyve had music since then, but before they purchased the bar, to my knowledge, they had been operating with music for maybe 15 years prior to that, so i think the mid70s or im just kind of basing this off of stories that people tell me, that theyve come to the rite spot and had music there. So i think that since the mid70s or something. It seems really popular in the 80s, as well, and then, we came to own it in the 90s, so yeah, weve had music for, yeah, pretty much that whole time without the permit. And we just didnt know that we needed one, to be honest, yeah. We also never received complaints. President bleiman got it. Questions . Hello. Thanks for coming in. Thank you. First of all, thank you for bringing such a great number of neighbors to this event. Its a testament to the Community Support for your venue. I have a couple of questions. Next one, do you have any it looks like we have some letters from residents directly above you . Yeah. Do you have any special soundproofing that keeps the sound contained in your venue . I dont believe we have sound proofing because the building is really old. The building itself is i think probably almost 100 years old, so i dont believe that there is. Okay. [inaudible] your neighbors upstairs were in support of you. Yeah. Theyre all fine with it. Most of them have lived there between five to longer. Five to i think one of thems lived there for over ten years, so yeah, theyve never complained, and theyve been happy to live above the bar, and acknowledge the sound, and theyre okay with it. And so have you had any complaints from any neighbors about sound . Yeah no, weve never had any complaints. We share the block with mostly comcast and then businesses, so the area isnt very residential at all. Okay. Thats great. So lets just say in the future if somebody has a complaint about the loud noise or music, what is your policy or procedure to address those in realtime . Definitely, kind of turn it down a bit, and maybe have our windows and doors closed. You have a manager on staff who can pick up the phone when somebody calls or stops by, and they have the ability yeah. We have a p. A. System, and we can control that ourselves. Okay. And the musicians, theyre pretty good, if its loud for us in the bar, we ask them to turn it down, and they do so. A lot of people find your bar such a benefit, and theyre here to support you. So what can you tell us is the secret to your success . So being a benefit to the community and giving a space for them to feel safe to express themselves. Awesome. Thank you so much for coming. Congratulations. Thank you. Real quick on the industry side. How long have you been managing . You took over from your parents . I help manage. They still own the place. Ive been doing this since probably late 2016. So four years. Yeah, i guess almost yeah. Are you there almost every night . Actually, i bar tend i am actually the bartender behind the bar two nights, depending mostly two nights a week, yeah. I come in when needed, but the bar is pretty small, so we usually have the man the bartender working that night. They have the you know, the ability to make decisions. So theyre the onstaff manager, the bartender is the yeah. Onstaff manager . Yeah, i would say so. Okay. And the groups youve had have been often rotating for the past 25 years or whatever . Yeah. I think our longest residency is over 25 years. Do you ever rent out your venue to a buyout situation . We do parties, mostly office parties. Sometimes weddings. And no complaints . No, yeah. So it sounds like, you know, its a great bar, and i guess during Public Comment, i would love to hear from the neighbors exactly, you know, what is your secret because we have very similar places that are were not getting the same kind of response. So i mean, i think its just the people that come. Its just they they together collectively love the space so much, so i think that helps. And i think its a family business, and your family has been there a long time. It does make a difference, im sure. I mean, some of the people have been coming well before my family has owned it, so their loyalty is really to the rite spot, the bar itself. Okay. Thank you. Thank you. I dont have any questions, but i just want to encourage, if we do vote in favor of this, just to see us as partners as well as the best relationships we have with places like yours that have been operating a long time, if there is a situation in the future, if you see our offices as a helpful partner in promoting night life and not the principal in a school thats coming to get you. Yeah. We have things work out really well. I just want to plant that seed in your mind. We regulate the night life and the sound, the other thing is we actually promote it. So were looking for cultural venues and places that offer cultural experiences for the city, and we want to make sure that we continue on both those joint missions. [please stand by] ive been going to the rite spot forever it seems. I used to go to the rite spot and people would ask you what kind of art do you do. Its right near project arteu, a lot of artists, im not an artist, but its a great place to hear music. People complain about what music costs these days, rite spot you go and make a donation to the musicians and its a place where people of all ages can afford to hear music. They have great food. Its just a great spot, the rite spot. They have art shows every month. So its a very welcoming place. I love going there, i love the music, i love the people, and these owners have done a great job in the last 20 years, is it . 20 years. But i went there before that. I met my friends there after the earthquake in 89. Its just a Great Community place to go. So thank you for your support. Thank you. Hi. Im ginger murray, and im one of the bartenders there. So i work at the place. But what i wanted to say about that is its not a place that generates a huge amount of money for anybody concerned. Certainly the band doesnt get paid a lot. However, myself included, and many of the musicians who are really great musicians and get paid well in other places, love to come there, because it is this very special we feel like we can be who we are. We feel we can care for each other, we feel like we can be alive in the space. Wonderful unique and fun way, and thats part of the secret sauce is that everybody feels cared for and respected and welcomed there. And the people who come in there just really love it. And sometimes they keep it a secret from other friends of theirs they dont like so much, because they dont want it to be ruined. But thats the thing is i think its so profound and powerful and has been for so many years that it cant really be ruined because the people who care for it really care for it as do i. And i love working there. Thank you. All right. Seeing no more Public Comment, Public Comment is closed. We can entertain a motion. I move to approve. Ill second. With the staff recommendation . Yes, with the staff recommendation the motion is to approve with staff recommendations. [roll call vote] congratulations, its been approved. [applause] its my understanding that because you took care of all your inspections and everything that you are okay to have entertainment tonight, so if you want to have a celebration, go for it. Try not to be the first night you get that complaint. [laughter] and please follow up with Deputy Director at your earliest convenience. Thank you for coming and congratulations. If you want to take a photo, our Senior Analyst can help with that. I dont know if i had anything extra in there. I think they should take a photo. The final agenda item is number 7, commissioners comments and questions. Commissioners . Comments . Questions . Thanks for the happy hour. That was great. Commissioner. Yeah, it was wonderful. I just want to make a comment about this last agenda item. I think its really powerful to see how a small mom and pop business has been able to turn out over a hundred letters of support and just understand just the process. So kudos to this little photo shoot happening over here. [laughter] i think we are very popular this tuesday night. So, yeah, i just want to say thank you everybody for coming out and for any of our viewers, come to our hearing. [laughter] let us know whats going on. I want to reiterate that. As hard as it is right now for a Small Business to get by in San Francisco, its groups like this that remind us why its so important we cherish them and do everything we can to protect them in the city. I want to reiterate that. Are there any Public Comments on commissioners comments and questions . Seeing none, Public Comment is closed, and ill adjourn this meeting at 6 07 p. M. [please stand by] [please stand by] better. San Francisco Department of environment is a place where climate hits the street. We know that we dont have all the answers. We need to support our local champions, our local community to find Creative Solutions and innovations that help us get to zero waste. Zero waste is sending nothing to landfill or incineration, using reuse and recovery and prevention as ways to achieve zero waste. The Grant Program is a Grant Program specifically for nonprofits in San Francisco to divert material from landfill. Its important to find the San Francisco Produce Market because theres a lot of edible food that can be diverted and they need positions to capture that food and focus on food recovery. San francisco Produce Market is a resource that connects farmers and their produce with businesses in the bay area. I think its a basic human right to have access to healthy foods, and all of this food here is available. Its a matter of creating the infrastructure, creating jobs, and the system whereby none of this goes to waste. Since the beginning of our program in july 2016 to date, weve donated over 1 Million Pounds of produce to our community partners, and thats resulted in over 900,000 meals to people in our community, which were very proud of. Carolyn at the San Francisco Produce Market texts with old produce thats available. The produce is always excellent. We get things like broccoli, brussels sprouts, bell peppers. Everything that we use is nice and fresh, so when our clients get it, they really enjoy it, and its important to me to feel good about what i do, and working in programs such as this really provides that for me. Its helping people. Thats what its really about, and i really enjoy that. The work at the Produce Market for me representing the intersection between environment and community, and when we are working at that intersection, when we are using our resources and our passion and our energy to heal the planet and feed the people, nothing gets better than citybe. The hon. London breed well, welcome, everybody. My names london breed, and i am the mayor. Werent we here just last year, celebrating the victory . First of all, i was at turkey day, and i didnt necessarily sit on lincolns side to pick sides, i sat on lincolns side somehow. I dont know how that ended up happening, but i think that i was your good luck charm oh, i was with you. Many of you know i mean to galileo high school, and i am a big fan of our high schools and a big supporter and a fan of making sure we continue to uplift young people when theyre doing something great not just as athletes, but we know you also have to keep your grade point up in order to play football in the first place. So to balance that at turkey day, and emerge for the second year in a row as state champions is absolutely an incredible accomplishment. When you came here last year, i was really excited, but this year, im even more excited because ive got a special surprise for all of you. Usually, when you win the super bowl, what do you get when you win the super bowl . Exactly. Were going to make sure that each and every player gets a Championship Ring this year. [applause] the hon. London breed so you get to design them yourself and figure out what you want on them. Its going to take a few weeks for them to get ordered and set up, but we are committed to supporting your Championship Ring so you can wear your rings with pride. And im really excited that you all are here today because we want to make sure that we honor you. And coach, come on up. [applause] the hon. London breed come on up. Thank you. The hon. London breed i just feel like i was your good luck charm because i did the coin toss and all that. It was a great day, and it was so fun. I would like to say, kerry bader, he said no mayor has been out to flip the turkey coin. So i hope we can make it a tradition and youll be out when you get the chance. The hon. London breed but i think its really important. Its important that we support young people that are staying focused and positive, and the fact that this team has come together as a team and accomplished something so amazing under your leadership is really its a testament to what you do. Because i know they hear from you every day, they hear from their parents, telling them the same stuff every year, to focus and to put on your gear. You know, i was like a lot of young people here, and i would tune it out and tune it out. But today is a great opportunity to let you know that your city supports you, that your city stands behind you, and we wanted to do something really special to make it clear we are proud of each and every one of you for putting in the hard work and getting to this point. And so today is about all of the young mustangs that really put San Francisco on the map in a whole nother way. So thank you for this, coach, for this incredible opportunity, and we are looking forward to you designating whoever you want to coordinate the ordering of the rings and how you pick out what you buy. So you can have your school and your year. You know what we do. Well do that. The hon. London breed congratulations. Thats awesome. [applause] thank you so much. Its a great gift. Its totally unbelievable, and i really appreciate that. But we have something for you. The hon. London breed for me . So basically, you know you went to galileo, so we have to make sure youre representing us when you walkthrough the city. The hon. London breed oh, you guys are so lucky. We didnt have this kind of stuff growing up. Just a couple couple things just about this here. It shows the legacy of what we have here. The hon. London breed oh, wow. This is called dedication, discipline, and desire, and weve been running the program for 19 years since ive been here. You have the dedication to run something every day, you have t the dedication to run a program, the discipline to run it every day, and the desire to be a champion. The hon. London breed wow. Thats a lot of years. And so many travels that you go through, this was unreal. Just kind of a Different Team than the year before. I tell everybody last years team was a ferrari. You could do anything with it. This years team was a buick. We had to run it out. Its amazing we did this, and its amazing for them because they bought into what we were selling. The best thing is when we went up to mariposa, its the championship. None of on us kids have been none of our kids have been out of San Francisco. Whats that smell . Well, thats cow smell. We rented a room to sit in before the game. And we went to this game. And here we are, asian, African American, white. Different group against a predominantly white culture. And everyone was thinking we would be the ones who broke down, we would be the ones who pointed fingers at each other. We would be the ones who screwed it up. And you would be proud of us, mayor. We didnt screw it up. Unbelievable. People there, unbelievable. What we did just awe stirring for me. Its just amazing to see the guys pull together and be like that and represent your city so well. So that was amazing, and for that, were going to give you the state championship hat because the norcal championship, we had to win that to get this. The hon. London breed thank you. When youre Walking Around, make sure you represent that. The hon. London breed whats that on your finger . Thats last years. Thats last years. The hon. London breed look at that. Undefeated. Well, this year, im getting the ring. Hold on. Right on. Well get that. The hon. London breed thank you. And the last thing i want to say is, you know, soak up this mome moment. Enjoy every single minute. Youre going to look back at this time and realize this was one of the best moments of your life. I know theres some folks from lincoln, so raise your hand if youre a lincoln alumni. They wish they were the age you are right now, in their seats right now. Coach, you want to introduce your players . Im here to enjoy. Thank you. We have one young man to speak for us. Its an interesting story. Simani came to us from another school his junior year, reardon. He went through a lot of stuff to get on the field. It was unreal, and his parents are great people. So timani, its your turn. I was just trying to say thank you to all the parents and all the alumni and all the coaches and, you know, making this year great, and helping us restate again and helping us and having our back this whole year. Most importantly, my teammates because we did it again, especially the last year, all the seniors this year. We had all the odds against us. We werent projected to win like we were supposed to, and we had a lot of people, you know, going against us and saying that we wouldnt make it, and we proved them wrong. So at this time, for our first group of eight players, brian pinto. [applause] jonas francovich. Luis quinteros. Tyree cross. [applause] eduardo garcia. [applause] xavier abrams. [applause] jack lau. [applause] and at this time, ill take a photo. Our next group of players is john tursano. Thank you. [applaus [applause] diego ramirez. [applause] jeffrey franco. [applause] andres montano. [applause] tony crossland. [applause] all right. Take our next group of photos right now. Next group of students, dean batar. [applause] nicholas walker. [applause] darren erfrey. [applause] michael leon. [applause] tamani morris. [applause] alex mchugh. Alex . [applause] our final group of student athletes, philip acuna. [applause] alexis velasquez. [applause] jonathan chow. [applause] sicoti manunua. [applause] leonardo gallegos. Mikha. [applause] mikhail hicks. [applause] and james wish. [applause] so were going to present certificates to the managers and coaches, and once we do the presentation of certificates, well take one big group photo here. I think well do it near the steps. All right. Here we go. To the managers, cassandra matana. [applause] crystal pimentel. [applause] sharina gutierrez. [applause] and elise hammond. [applause] and reilly zuleta wong. [applause] thank you, managers. And last but not least, our coaches. Coach pereno, of course. [applause] coach andre walker thomas. [applause] coach greg wood. [applause] coach edison zau. [applause] sheri bader. [applause] and coach mark walker. [applause] and again, id like to invite principal sherry bellisi to come up for a photo. The hon. London breed again, thank you to all the players, the coaches, the managers, the principal, the teachers, the alumni, the parents, the friends, the family. Congratulations again, and i think what were going to do at this time, since that concludes our program, were going to go probably take a go down to the rotunda at the beginning of the stairs and take a picture. In the meantime, stay focused on your grades. Make sure you dont give your teachers and parents a hart time this year. Walk around like champions because you are champions, and make sure that Everybody Knows it when you step in the room. Thank you, and congratulations. Sfgovtv sfg. The San Francisco Health Commission is called to order. I will call roll. [roll call] clerk the second item on the agenda is the approval of the february 4, 2020 minutes. Commissioners, after review, does anyone have a motion to approve . Motion to approve. Second. All those in favor . Okay. Clerk thank you. There are no Public Comment requests for that item. Item 3 is the directors report. Good afternoon, commissioners. Gra grant colfax, director of health. You have the report in front of you. Just a couple of things. One is we are continuing our covid19 preparations and actions. Ive asked dr. Aragon to provide more details after my report, so he will be doing that in just a minute. We are continuing with our ongoing daily work, and that includes Behavioral Health options for people in the city as part of our Behavioral Health reform as part of health s. F. We are currently establishing a health center, to be established at 180 jones, with a particular focus on methamphetamine users. This will have a 15bed capacity, take care of many more than that over a 24hour period. This is really the beginning of a larger expansion if this initial phase is successful at providing more lowbarrier opportunities for people to have a place that is safe, that provides Harm Reduction approaches and also not only helps them but also mitigates the effects of Behavioral Health issues in the surrounding community. Im proud to announce an expansion of our hummingbird work. This is a pilot model that weve launched in the recent past, and were now looking at 36 valencia with 25 beds. A key issue in the city has been the issue around boarding care, and supporting boarding care. Weve had a number of boarding cares close in the city in the last few years, and we have a number of boarding cares going forward. So just a lot going on in terms of that, creating more beds, and more infrastructure. I also want to say that tonight is black history month, and a key focus across the department has been black African American patients in the community. We have a number of articles that you can read at your leisure. The Lunar New Year parade was particularly relevant this year because of concerns of covid19, and we know that with misunderstandings with regard to how covid19 is transmitted and the people that are at risk, theres an element of stigma and discrimination with this epidemic, and were concerned that were doing everything we can to mitigation that mitigate that, including having a very robust presence at this event. Another event was the hearts in San Francisco event, which is really celebrating the work thats being done at zuckerberg San Francisco general hospital. There was a discussion around Behavioral Health work and strengthening our behavioral work. A number of key faculty were highlighted and honored, including, im proud to say, the social medicine team, and the staff there. As you know, dr. Deb bourne and some of her team launching that across the department. So there are lots of news reports. The d. P. H. Was in the news quite a bit, particularly with regard to covid19 and the expansion of our health work. And i will just ask dr. Aragon to give a brief update on the everchanging dynamic situation with regard to covid19. Good afternoon. Thank you. The first thing i want to point out is the number of confirmed cases globally is over 75,000. Currently, there have been over 2,000 deaths. In the United States, we have a total of 29 cases. I want to explain what i mean by 29 cases. 15 cases the 15 cases i reported last week were people that were infected in wuhan, china. 13 of those, two were spouses. And then, 14 were infected near china. These were the Cruise Ship Passengers that just returned, so the total is 29, but there has not been any documented Community Transmission in the United States at this time. California continues to have six cases plus two of what are on military bases. San francisco continues to have zero cases. I want to point out that the virus has been named sars ii but its been officially named covid19. The virus that causes covid19 is sars cov ii. I also mentioned the repatriation of 14 passengers from the cruise ship in japan. We realize were not able to contact everybody, but were doing the best we can. And the other thing i want to mention is weve been doing site visits to hospitals, making sure theyre prepared there there be any transmission. In San Francisco, were preparing for the time when we would have Community Transmission in place. Were focusing on transmission, containment, and then, community education. If theres ongoing transmission, what would we do in that scenario . Thats what were doing. The last thing i want to mention is because there are no cases in San Francisco and because there has not been documented Community Transmission in the United States, we continue to have the same advice that we had before, so its business at usual. So thats the last thing thats it, unless theres any questions. Before we move on, i just want to take the opportunity to acknowledge you three. Because of your expertise and your preparedness. A lot has been asked of San Francisco by the c. D. C. And others. I know folks have been putting in very long hours, whether its doing outreach or addressing xenophobia in the community. You all deserve acknowledgement for this Additional Task that youve been doing in addition to everything else. So thank you to everyone in the department and for really helping to keep the public and the community informed and feeling safe, so thank you for that. Commissioner girado . I want to echo that. I have one question, and i need some words for you, okay . Sure. If i may. At our Child Development center where we do treat medically fragile kids who are on m. G. S or g. 2s, etc. , weve had a number of families cancel because they do not want to come in to a place where there are a lot of people in that area. And they specifically state flu or coronavirus. Do you have something we can state to families on the phone, in your best way versus mine, to be able to give one versus the other . Yeah. We dont have any confirmed cases, and thats really important. Were about one week away from being able to do diagnostic testing. Itll be another week before the state starts testing, and then, our own lab is going to be doing testing. Testing is really critical because well be able to test folks and to provide reassurance and then also to monitor the situation. So i think having a lot of negative tests as we Start Testing people is going to provide that reassurance that things are okay, so thatll be a real game changer when we have a diagnostic test. So at this point, i should state these two facts that you gave me. Yeah, state the fact. Its important it is important to do that because i know that people do worry, and its natural to worry, so we just keep emphasizing the facts, and tell them to work on sthings th sthi things that they can do, like the vaccine and education. Okay. Thank you. Commissioner chavez . Yes, thank you. I also wanted to add and thank president bernal for his comments, and commissioner b gerardo. As an emergency, and i would say that the press here seems to have been more responsible, also, probably at the fact that you were able to communicate with the press adequately and be able to have a level of credence with them that they were able to give that message out that in our community in chinatown to have the department of Public Health to have dr. Colfax, to have dr. Aragon, to have dr. Faba, be spokespersons. And it looks not only at the medical issues that might arise from this, but also the social issues that were involved, and that the city took a very positive position that was important to have all of us continue. But the other thing was to continue good sanitation at this point in time, and if anything was needed later, i think the credibility of this department is such that theyre going to follow this and listen. But i did want to thank the Department Also for the very swift outreach and meeting the community. I think its very different from where 13, 14 years ago, when we had the sars. We werent as well prepared, and there was a lot more concern and hysteria partly from ignorance. That still extends through much of the world, and particularly, of course, in the areas that are greatly affected, by i noted, but i was very pleased to see how San Francisco is handling the issue. I want to acknowledge victor lim at the department of emergency management. Hes been partnering with rachel kagan and her assistant, veroni veronica vane, and they have been instrumental in bringing us to gordon lau to speak to the students and bringing us to the parents. Can i just i just also want to acknowledge the department of emergency management, interagency, interdepartment response, so i want to acknowledge that. And i also think with regard to many people in the department who have been mobilized for this effort, you know, theres many people who are working literally 24 hours a day, in some cases, on this. And i think acknowledging Susan Phillips who were here just a couple of weeks ago, presenting on Communicable Diseases, as is dr. Julie schulte, who are a Communicable Disease specialist. Theyve been doing outreach at the federal level and also community level, as well. And finally, dr. Pak, who is our director of the Chinatown Health Clinic has just been a really key part of our Community Response as well as our medical response. Thank you, director colfax. Commissioners, other questions . Thank you. I will note for the record that there were no Public Comments. Item 4 is general Public Comment. Just for you all to know in case you dont know how we work here, i toldhold a timer. When the timer buzzes, your time is up. Great. Fix request is from first request is from ron weidel. Good afternoon, commissioners and president. My name is ron weidel. I complained to you on february 4. I stated that that article would render my ability to be ever employed, and if employed, it would reduce my ability to earn what i earned here. While my resume has impressed recruiters and employers, i still have no job offers. As one recruiter explained it to me last week, he was able to show the recruiter and the employer my impressive background and how im an impressive fit for the position. However, the employer had read the article prior to the interview and said it came across me looking at sketchy. I have a career that includes 12 years of military service, 18 years of service with city and county government. Every employer who has hired me has found me to be a valuable and valued memory mer of management. I have no reviews less than exceeds or meets expectations. I have no discipline actions. I also have no negative perceptions with the exception of that examiner article of october 7, 2019. While i have some ideas why the department would orchestrate such an article, i have no proof. But it is keeping me from being employed and putting the welfare of me and my family in jeopardy. When they asked Senior Management why the article was created, they were told it was a mistake. In closing, im asking that you pass a resolution requesting that the examiner have the article unpublished, which would have the effect of getting it offline. Im going to leave a copy of my remarks with mr. Moore, should you desire. Thank you. Thank you, mr. Weidel. And i think someone from the audience looked like he was going to good afternoon, commissioners. My name is barry pearl. Im a San Francisco homeowner, a resident of the ingleside and district 11. Im not sure if this issue has been raised with you, but we received a letter from recology dated january 17 of this year. The subject is adequate service requirements. I called recology in response to this letter which indicates that basically the property was not maintaining the Garbage Service properly, that the cans were overflowing. And when i contacted one of the Customer Service people at recology, i was told that they were completely unaware that this letter was going out, that it was sent to all residents of district 11. Its very accuseatory, without any basis in fact. It should never have gone out to district 11, and id like to know why this district was chosen essentially as this Pilot Project. So i think your relationship with recology needs to be reevaluated, and you need to look into this particular issue. Thank you. Okay. Those are the two Public Comment requests for item 4. Item 5 is a report back from the community and Public Health committee today. The community and Public Health committee met today, just before this meeting. We discussed sb 5 and sb 40, and the local efforts to implement the conservatorship program. We discussed the Eligibility Criteria and also what we might expect based on data from previous years. The goal is to provide conservatorship for somewhere between 50 and 100 individuals in San Francisco based on the criteria with an effort to directing them towards permanent and stable housing as well as addressing some of their Behavioral Health and Substance Abuse issues. After that, we received an update on the Methamphetamine Task force. The recommendations of the task force included the meth sobering center, which was addressed by director colfax in his report. The recommendations were grouped into four themes. I believe there were 17 recommendations and those included investing in models to improve health and wellness, to build capacity and training for staff and service providers, and to strengthen coordination among City Services and systems. All right. We can move onto item 6, which is an action item, commissioners. This is a d. P. H. Report, the budget for fiscal year 2021 and 2122. As usual, were having two budget hearings in the month of february. This is the second, however, our format is different than in previous years thanks to a ordinance passed by board of supervisors across all departments on how hearings on the budget should occur. So last year, we did an overview on the instructions and our target, the mayors fiveyear budget forecast, and some goals and themes for the budget submission, and today, were bringing you a package of budget initiatives that show specifically how we intend to propose to the commission that we meet those goals and targets. So you have a set of initiatives in front of you that were seeking your approval for today to submit to the Controllers Office at the end of this week and then to the Mayors Office following technical amendments or technical analysis. So this week, we are seeking that approval. The budget process, of course, doesnt end today. Once we submit our proposed budget from the departments to the Controllers Office and Mayors Office, the Mayors Office has really a space of about three months to deliberate what weve submitted, to have discussions with us and other policy makers in the city about what the mayor and the Mayors Office would like their budget submission to look like, and then, the mayor submits a budget to the board in june, and then the departments submit their budgets. Weve got a lot to do until june, and in previous years, we were going to use that time in collaboration with the Mayors Office and other interested stakeholders. The biggest piece, as we discussed last week, was the Mental Health s. F. Program, which, as you know, was legislated in 2019 with the active involvement of the defendan department. It was an ordinance passed by mayor breed and the board of supervisors, and it was a robust ambition that we could tackle budgets in San Francisco. Were not proposing exactly what that would look like. What were proposing to do is use that remaining three to four months to work with the Mayors Office and other stakeholders to come back then with a proposal for what that first twoyear budget cycle of Mental Health s. F. Would look like. The scope of the the real vision for that program is going to take time to really roll out, and its going to take money to roll out, and those are both things that are still under discussion is whats the sequencing of how we approach this, and what are the Funding Sources there . The funding measures could include budget measures or other sources of revenue. We want to build the infrastructure and start to launch on this as soon as possible. So in the Budget Proposal before you, we are meeting the instructions from the Mayors Office, so that means were covering the revenue projected in the fiveyear plan, we are meeting our target for reducing the rate of our general fund growth that was given to us in the mayors budget instructions. And in addition to that, were attempting to leave some balance over and above our target that would be a starting point for kind of a down payment to begin building out some details of how that Mental Health s. F. Program will look like over the next several months. So that theme, a little bit of a different approach, we have used in some past budget budget cycles before the commission, but i think its an acknowledgement of theres still work to do and thinking and decision make to do about Mental Health s. F. As we go through the rest of the budget cycle. So ill turn it over to jennie, and were happy to take questions. afternoon, directors. Im jennie tam. The first two items were around revenues at zuckerberg San Francisco general. The first item is our baseline revenues, which youve seen in years past, and so im pleased to say that we project to continue continue to project Revenue Growth at the hospital, and one thing youll note is that in the second year, our projection does drop by 15 million. This is due to the current the expiration of the current medical waiver thats due to expire at the end of this calendar year, december 2020, and the state and federal government are in the process of negotiating a new waiver. However, the devils in the details on that, but our team is definitely monitoring all the changes that are happening at the state given the close contact. But given the fact that they dont expect the actual specific details until the end of this year, it makes it hard for us to predict which programs will continue, in what format theyll continue, in what forms theyll be implemented, how do the other counties actually factor in, because its not just San Francisco that are interested in these waivers. So with that uncertainty, were projecting a lower amount of revenue, but this is something well definitely revisit in the following year. The second is around s. F. G. Revenues. Basically, were projecting 69. 5 million of onetime settlements, and this is related to the waiver, as well. As part of the negotiation, the federal government says if california is interested in any kind of new waiver, it must close out all the old reports from prior waivers before the end of this year. Currently, for San Francisco, we have eight years open, starting from 0708 to 1415. Assuming there are no significant changes in our cost reporting, we do expect we will be able to release the reserve against those reports, recognizing that revenue to help us balance. The third item is laguna honda baseline revenues, and this is our annual baseline projections for laguna honda, and this does report a release date. Item 4, im excited about this. Commissioners who have been here for several years, youll note that for several years, 1617, weve been loggislogg away for Electronic Health records. Its an integrated system thats both clinical and billing. There were multiple systems, multiple incident faces that will all be replaced, and im pleased to say that for wave one, were expecting 11 million worth of savings for that. This is partially catching up on the cost of doing business, so were requesting a 5 adjustment on our base contracts just for i. T. , but that still leaves 9 million and 8. 6 million ongoing to reach our general Fund Reduction target for the department. 85, the next item, is related to back funding, population for federal Funding Health grants. Population health is pretty specific about receiving grants from the federal and state governments, but there were some grants that expired, and pilots that were expected, and then, there were some grants that supported our core functions. So theyve requested to backfill 1. 5 million related to grants that are expiring and not expected to be renewed. The last Revenue Initiative is actually one thats revenue neutral, and its around the San Francisco health net work creating its own Specialty Pharmacy. This is a new program that would actually allow for the network to create a Specialty Pharmacy for patients with complex needs. This isnt just penicillin, but h. I. V. , oncology, antipsychotic drugs. Its a real hightouch population, and its a need that we see in the community. Based on our projections, we believe that we could cover recover and still provide the services for the community. It will take about two years to fully implement. The next cost is 3 million, analyzing the 8 million, but recognize many of these costs are having to do with contracts with smaller pharmacies to fill these requirements. We are centralizing our Quality Management program at the two hospitals, at laguna honda hospital and San Francisco general. This is being driven by three reasons. The first, as you know, drrp deficiencies found at laguna honda hospital with the discovery of patient abuse and diversion of nonpharmaceutical drugs. Secondly, with the implementation of epic, we found that the work flow has changed significantly, and to ensure that we are sort of maintaining best practices, we need to augment staff. And then third, in the last several years, the center for medicare and medicaid studies have been increasing its regulatory reporting requirements. These three events have caused us to think and rethink our Quality Management, and so we are centralizing, and so it is all under the health net work as opposed to having the central the hospitals having their own individual programs, and both the programs would report to a single q. M. Director, and this allows for a standard report and also allows for assigned separation of the g. M. Versus q. M. Versus the operations at the hospitals. In addition, to support our own requirements on compliance and privacy affairs, were going to be adding two positions to that program, just to make sure that we are maintaining and keeping up with all the regulatory requirements there. Next, we have three new Maternal Child Health equity initiatives. These initiatives are really focused around around birth and young families and pregnant young women, particularly from communities of color. Whats interesting about these programs is they really touch on three narratives. The first one is perinatal, and it provides basically Community Support and engagement for for expecting and new mothers. The second is a Doula Program that, again, supports women that have been identified by a Maternal Child Health program that would be interested in additional care and support during their pregnancy and shortly thereafter. And last is the abundant birth program. Its a financial Payment Program for women who are expecting. And so and women of lowincome that are expecting, and it actually is an income supplement program. And so when youre looking for these three initiatives, were looking at creating a community with the Financial Support and with the care, and that is sort of this multipronged approach that were looking at in terms of health equity. Because if we can intervene early on, thats where were going to get the most bang for our buck. These are interesting pilots and well be interested to see the impacts of them in the future. Next, we have operation and the census at San Francisco general. As you know, since weve opened up the new San Francisco several years ago, our census has been about budget, and so weve been running at a high census. And we recognized this in 1718. We created what was called the census project, which was sort of a pot of funds which would allow for the s. F. G. To tap into should it be going over census. But what it didnt provide was actually permanent positions, and so we now fast forward three years into the new zuckerberg San Francisco general, what were seeing is that our census projection isnt really dropping. What we hear is we want to operationalize the census that we have, add permanent positions, and were supporting the operations in three ways. The first is were going to be opening up a new med surge unit. Theyll be funding to flex up to 15 beds annually on average for im sorry, up to 15 beds per hospital policy, but it has permanent nursing positions to staff that adequately. We need to support our ancillary services, so we need to support Food Services and environmental services, including porters just to sort of maintain the hospital operations. And lastly, well be budgeting permanent licensed psychiatric technicians to support the e. D. To make sure that were meeting the hospital requirements around observation of clients with some acute Behavioral Health issues and be able to intervene as needed. Lastly, were our goal is really around workforce and supporting the work that we do, we have a lot of existing operations, and our goal with these with proposing 20 positions, supporting all aspects of h. R. Is really to better support our h. R. Operations. This is really just about getting supporting the operations, but what it does is it enables us to take on new initiatives, including Mental Health s. F. As well as meet the regulatory requirements at zuckerberg general and laguna honda. So when we take everything into consideration, and when we look at some of the Revenue Growth that was already assumed as part of the deficit, we see what is proposed as a surplus of 7 million. What we would like to do with this surplus is to put it as a down payment for Mental Health San Francisco. Again, we dont have the specific details of how we would implement that. Were working on an implementation plan, working with the Mayors Office for her budget submission. But with your approval, this is what we would like to do. All right. So as mentioned before, well be requesting your approval, and well be requesting programming, which can include all of these items, Mental Health services, drug sobering, street outreach and infrastructure included in the legislation. A few commissioners have asked me about wage equity in our department, and its a reporting requirement as part of the minimum compensation ordinance, and im pleased to say that the department has been involved with the Planning Efforts around the minimum compensation ordinance. For the commissioners that arent aware, its an ordinance that increases the minimum wage for employees on city contracts. So what this does for the current year, it increases the minimum wage from 15. 50 to 16. 50. The city participated in a process with the controller and nonprofits to sort of plan for the impacts of the minimum compensation ordinance. That is a citywide process that was represented also by the Human Services agency and the Controllers Office. As a result of that, that committee made recommendations on how to address both of direct and the indirect impacts. So when we say direct impacts, its literally that change in the base wage, from 15. 50 to 16. 50 an hour, if youre making 15. 50, and reporting to somebody who made 17, theres sort of a compression issue. The controllers went through a rigorous application process where we notified the pool all of the funds were available. Nonprofits actually submitted applications to the Controllers Office, and through their evaluation, they allocated the department 1. 2 million that will be ongoing in our budgets to address the facts of n. C. O. We are expecting a 2. 5 increase for the cost of doing business also for our city contracts. Weve been receiving 2. 5 to 3 for the last several years. C. P. O. S are free to allocate this as they feel is appropriate, so they could use it towards wages or rent or whatever they believe is most appropriate for the organizations. All right. So the next step is we submit on friday, but we are not done. Well work with the Mayors Office over the next several months. On june 1, the mayor will submit her balanced budget, and we will go through the board approvals in june and july. Thats all i have for you at this time, but im happy to answer any questions you may have. All right. Before we go into questions have commissioners, we do have four requests for Public Comment. The first, taken in order, is mary kate buckelew, and after that is anthony carrasco, wesley reagan, a. Hi. My name is mary kate buckelew. Im here to support hespas budget asks and our Behavioral Health bucket. There are three asks that were making this year. One is for an Overdose Prevention site. They basically let people use under clinical supervision and access counseling and referrals and cares. The second is Transition Youth Services for transitionaged youth or t. A. Y. The request is for a t. A. Y. Residential center. We dont have ongoing funding. So the Overdose Prevention site would be about 2 million, and the special treatment ongoing operational funding would be about 1. 4 million. And i also just want to put in im very grateful to the department for the budgeting around the m. C. O. And codb, as a member of the Human Services network, were always pushing to see the deficits that were seeing across the nonprofit organizations are properly funded. It would be great to see the investments in the codb as well as the increase of 4. 3 . Thank you very much. Thank you. Hi there. My name is anthony carrasco. I work with mary kate over at p compass, and for the city of berkeley, i serve on the city Homeless Panel of experts. Maybe something that you might not be aware of, if you engage in conversation with someone about the topic of family, studies have shown that theyre dramatically more likely to have a strong sense of connection with you, and its a very, very interesting phenomenon. I have a hard time talking about family. I dont come from a very good family. My family experienced homelessness for about ten years, and Substance Abuse took one of my brothers away from me. But got to go to u. C. Berkeley, and i get to have a nice job now, but i do want to advocate again for some of these Substance Abuse issues. Youre all here because you care. Youre all here because some of this impacted you, and i just hope that other folks can be able to engage in conversation about family like anybody else. So the last thing im going to say is the ask that hespa are putting forward are completely in line with the Mental Health s. F. Initiative, and i hope that youll consider supporting it. Thank you. Thank you. Thank you, commissioners. My name is wesley saber, and i am the project manager with glide, and im speaking in support, to, of the hespa budget requests. Significant gaps persist. These result in long waits for shelter and housing, unmet Mental Health needs among homeless people, and a lack of exit from the Emergency Shelter system. Young people, too, need safe places to sleep and places to meet their needs. We desperate we i want to focus in on the Homeless Youth population. Current estimates suggest there are 1,145 transition age youths on the streets and in transition shelters. Among the Homeless Youth population in San Francisco, 76 of unaccompanied youth under 18 and 8 3 of transitionaged youth need shelter. Homeless Youth Experience major psychiatric disorders at rates up to 4 times higher than their peers, and 31 identified areas of Substance Abuse as a homeless need. Addressing homelessness is widely viewed as a preventive strategy up to 50 of chronically homeless adults are estimate today have been homeless as youth. Homelessness now translated to homelessness later. We have fantastic youth providers in San Francisco such as the Homeless Youth alliance, and larkin youth street services. Thank you. Good afternoon. My name is marny reagan. Im the director of larkin youth street services. Im here to support the hespa budget ask. It would use a model that sbienz substan sbienz combines Substance Use treatment and counseling, capturing youth through early intervention, screening and referral and decrease or eliminating substance misuse while increasing wellness through clinical intervention. Currently there are no programs to serve the needs of transitional age youth. There is tremendous need for both residential need for transitional age Homeless Individuals suffering from severe Behavioral Health needs. The two are linked as one is not successful without the other. As individuals churn through the systems, through the hospital and back on the streets, this is a key intervention to halt that cycle. Thank you. Thank you. Commissioners, questions . Commissioner chaplin . Yes, thank you. Thank you for the very comprehensive explanation of the budget initiatives. Im struck by the fact that we are looking at a total budget of almost 2. 5 billion, and therefore, our target, there, as you have pointed out is somewhat less, of course. Its a 3. 5 , right, per year. Correct. Which is therefore and that will equal 141 million over the years. And so i think what we would what i would like to look at is the thought that has gone into the initiatives. Im assuming that we have carefully been evaluating the different programs that we already have, and i guess the first thing, though, if youd answer, when you brought up the wage equity initiatives, this is in addition to this or its already been incorporated into the total cost, and likewise, the cost of doing business. Are those additional amounts that we dont have to count for or that have come from the controller or is it in our budget . Thats correct. The 1. 2 million and the 6. 6 million were expecting for the cost of doing business are in addition to the proposal you see before you. As you know, theres a number of costs that the city looks at overall in addition to the cost of doing business, m. C. O. It is our staff wages, health benefits, fringe benefits, and what you havent seen it the impact is the impact to that because thats sort of centrally managed by the Mayors Office and Controllers Office i do think thats an advancement in our budget here because perhaps in the distant past, those had to be absorbed by our budget. So i thank the Mayors Office for such instructions, really. Okay. So if we can go and im sorry i wasnt here at your first presentation. Im sure it was excellent, so ill only look at the budget initiatives and ask several questions maybe you had already answered them in the previous meeting. And in particular, the first one is i the estimate of about 38. 5 million additional in general revenue seems very large; so could you put that into a perspective . What percentage is that increase . I know its in here, ive read it before, but i cant quite remember. I mean, thats a big piece here of our budget balance. Well, i dont have the exact figures with me, which i should have. But so of our 2. 4 2. 3 to 2. 4 billion budget, about threequarters of that is revenue based. So actually, in the grand scheme of things, if you take our revenues together, and were at 1. 6 billion or so, this 38 million is significant. Its big. Its a lot of money, but its not often that we see in terms of how its increasing or how it comes through the various state and federal programs. So a couple of things that you are seeing in these rates is that we have or in the revenues that are in front of you are we have continued for the last several years, and you see it in our financial statements, to outperformed our Service Budgets in our fifa revenues and our budget revenues. Those are kind of the core waiver programs. Were conservative in those estimates. A portion of this revenue increase is us shoring up our revenues to what were seeing in terms of our actuals in the prior years financial statements, in the second quarter, the previous years financial statements. Well have those to the commission shortly. As generally described jennie described, we are budgeting a back down, so its not a yearoveryear, but its less aggressive, and that is us trying to be conservative for the reason that jennie described. We have a lot of moving pieces in terms of the current medicaid waiver, which is about 150 million in revenue for us. We dont know exactly what thats going to look like. In prior waivers, weve done better or worse, depending on the waiver and depending on the subbucket of money within the waiver, so we are anticipating that well have pieces of our waiver funding continue, albeit in a different form, but were trying to leave ourselves both a little bit of room, both to be conservative if something goes wrong, and frankly, so that next year, when were back here, if things go right, well have a little bit of room to work with. Okay. So if i may ask several more of them and i agree. I did find also that youre putting in 13 million of new revenue from the graduate program, is that right . Yes. Well, your first year. Thats correct. And then, the second year, youve dropped back. Yeah. Thats a new funding source. Compared to the 1. 6 billion thank you this is a smaller amount of money. It looks big it is big. It is. But i think at one time, when we started on this commission, we were under 1 billion as a total, and these numbers are just sort of shocking to me sometimes. And so when youre speaking oh, let me go onto actually the expenditures. On the expenditures, we show a considerable number of f. T. E. S that are being added to the budget, and i know that each one seems to have a logic. Im wondering, we currently have two Quality Management programs already, one in each of the hospitals. By combining them, what is the logic for them adding ten more f. T. E. S . The basic logic is the event the at laguna honda exposed some deficiencies in our q. M. Systems, and so as weve reacted to that, and the team is still learning and going to learn as we implement this about what our program is going to look like. Theres several things that have come up. First, its the fact that there were issues that we didnt identify and remediate. Weve got work plans that have come out of the regulatory reviews in addition to that. And in particular, weve identified some issues when issues are identified, they are delivered to the management in nursing to investigate, and thats not a best practice. The best practice would be that you have a team that is outside and doing that investigation both so that youre not pulling away from patient care time, but also so that youre having clear delineation between those that are investigating and those who are responsible for providing the care. And so thats a piece of it. I think that the q. M. Team is being pretty direct, that there is going to be learning to do as we get this up and running. Well have parallel structures at each of the opportunities, and i think this is one of the things that came from the laguna honda patient care issues. When that happened, the zuckerberg general q. M. Team flexed over. Its more productive to look at ourselves as a system, where we can support each hospital. If theres a problem at one hospital, the team can flex to support that hospital and vice versa. I think therell be some learning, and over time, as we ve develop this model, therell be opportunities where we can share learning, but thisll be a learning Program Building out programs at the two hospitals. Also included in the network are some pharmacy positions that are driven by the work flows in epic where the medication the pharmacy protocols associated with epic are more rigorous and labor intensive than they were under our previous system, and so were correcting for that belatedly. So if i may go on with the issue of the f. T. E. S and understanding, under b3, theres f. T. E. S and i assume you really are meaning medical surge as versus medical surgical. Theres two words. Theres a medsurg unit, and we have a medical surgical policy, which is related to census. So when we open that unit based on criteria of census. Right, and thats what youre referring to, med surgery wimed surge, with an e, as opposed to a medical surgical unit. Okay. Shes giving me a thumbs up. With regards to this, weve heard of staffing in the emergency room and all. I notice that youre talking about bringing in also technicians to work in the psych units, right . Yes. At psych emergency. Are both going to help resolve part of the problems that we have heard in public testimony with regards to the issue at general . Sk yeah. And maybe ill ask if susan would be willing to come up and give a little color commentary. [inaudible] so ill comment about both initiatives. The first one, the staffing medical surgical beds for when we have surge at the hospital, like now, h 58 is one of our medical surgical units. We have been using it almost continuously for the last several years, and as greg mentioned, weve been doing that using temporary or p103 staff. There have been several times over the last few years that weve been able to close it, during the summertime, but most of the time, it needs to be open to accommodate four to 15 patients. Today, for example, its open with 12, and its only open to 12 because we dont have the staff to initiate it to 15. What this would allow us is to have that staff of 15 so we can staff it more reliablely, particularly in the winter, when we need it. So thats h58. The l. P. T. S, when our joint Commission Survey which was exactly almost eight years ago, we have four Emergency Rooms in pod a. Those require constant monitoring, and we do that with two assistants who can do that with cameras and staffing in the rooms. Recently, weve been using l. P. T. S one l. P. T. , precisely, that weve been able to find through the registry to ha staff that function in part. And its been extremely valuable because they come with training that even nurses in the medical department dont have. So weve been trying to use them to help us manage those patients who come in with Behavioral Health issues, some of which we treat and release, and some of whom who get medically cleared and go to psych emergency. So is the answer partially yes towards what we have been hearing in terms of the stress in the units, especially in the emergency room . There are stresses in the Emergency Department, for sure, and weve acknowledged that, and we have multiple plans in place to address both the staffing issues, the just basic keeping the keeping our units staffed, but also the issues that come with the Behavioral Health issues we have. These l. P. T. S are just one of the many things that were doing in the Emergency Department to address some of the things that you heard about. I have questions, but not on that. Thank you. Im great satisfied with the explanation on b3, and im hopeful that it will improve our overall quality of care. Strengthening the h. R. Says youre adding more personnel again, and i know that several years ago, we had very few personnel, and that created a number of issues. How do we know that this is the right number, because youve been adding all this time . Number two is that part of the problem is not our own department, but the citys own system in the delays in hiring. So how does and what creates an anticipation that this will actually then help answer our problem of more swift swiftly being able to add personnel to our staff . Yeah. Good question that weve been talking about ourselves, and it is part science. Its try as we might, the staffing in the division doesnt lend itself to a clean model like you might see in other areas where you have similar class or type of worker thats performing a similar type of service repetitive. T the so far starters, the department has added a lot of f. T. E. S over the last few years or so, but so those have been f. T. E. S associated with the opening of the new zuckerberg hospital, expansion with our new initiatives, etc. Second issue, within these f. T. E. S, there are a number of these that we have added as Temp Staffing to try to close the gap and keep up, but weve never budgeted them permanently. If we dont budget them permanently, well actually go backwards on those positions, and thats a quarter how many of those positions are cad18s . Thats a piece of this that were trying to lose ground. The other piece of data that we have that is imperfect is a couple of years back, the budget and legislative analysts did a comparison of city departments to try to look at kind of very high level squint and take a look at your ratio of h. R. Staffing to f. T. E. S, and it wasnt perfect, and they acknowledged that it wasnt perfect, but we had fewer h. R. To f. T. E. Compared to some bigger departments, including the p. U. C. , airport, h. S. A. So this is moving us toward that direction and catching up. What this would get us to is if you would add all our positions, including the ones that arent filled, wed be a little over a 50 1 ratio, so that is one person doing all of those functions that i managed per 50 staff, which its a big number of h. R. , but its relatively lean in terms of what you see regarding benchmarks. So i wont make the i. D. That we have identified the perfect number, but we have a new Human Resource director who you know this has been with the department in the past, has had a citywide civil perch, and this is his recommendation kind of coming in and doing a review of some blatant gaps that need to be closed, 1and well continue to evaluate that as he gets a little bit more time and his team gets a little more time to get a confident level. But i think we all agree if we dont make a change, were going to continue to lose ground. Well, i think my next question well well, it is a question. Im glad were taking the position, and we should take the position that we cannot do this without resources. You have indicated that the twoyear total shows 7 million. However, only the first year shows a positive, and by the second year, we show a negative. Im not sure if we use this balance well, first of all, its a very small amount compared to what must be a big program. Im in favor of being able to maintain the balance or even a positive that allows us to have health programs. But seriously, how much do you really consider that Mental Health is going to cost all of us . Well, so your first point about it being lop sided between the two years, thats a concerning one. Its a little beyond our view how all the city pieces will fit together, but weve already kind of contemplated for the vision for Mental Health s. F. , but there are pieces that are going to need to be definitive ongoing programs, and there are other pieces that are building infrastructure. So for example, if were going to launch a new program, one of the first things that we might need to do, and in some cases, weve already identified, is renovate a space to increase capacity, and thats the perfect use for a onetime or year one pool of dollars. On your second question, in terms of the total scale, theres still a lot of decisions to be made, but as we ballparked what this looks like, i think theres consensus that full implementation of this vision would be 100 million or more, and that would of course happen over time, and that is dependent on a lot of decisions, including how you scale up each time of programs. Thats why were going to look at the building blocks, but to get that full vision is going to require a Revenue Source thats either comes from their discussion about potentially a ballot measure, about whether therell be state or federal funds that we could draw that would support this. It is building the infrastructure so that were prepared to scale up when the city identifies the funds to do so. Thank you very much. Commissioner guillermo. Thank you, and thank you for addressing the questions last time that i had about the waiver my cowaiver impact, but i had another medical question. As c. M. S. Has had a couple of new proposals about how the states are going to fund their portion of medical, and the oversight that theyre going to impose, has that been built into projections . Are you referring to the mfar proposal . Yeah. So we are not proposing a budget that assumes that that regulation goes forward. Its such a big change that its hard to comprehend. I am confident to say that that would really very significantly disrupt the medical and safety net delivery system, and the biggest piece of that would be, as you point out, restrictions on the way that states or local governments can fund that nonfederal share. In San Francisco, we are predominantly funding our nonfederal share with city and county general fund revenues, and so that, at least on the very surface of it, is an issue for San Francisco counties. There are other counties in that systems that are funding that with kind of patch work revenues that theyre able to put together. But regardless of which county, we know that our entire statewide financing system is built collectively around those tools for financing the nonfederal share. And the counties are tied together. Were in it together, because we have the statewide allocations of resources that are distributed across the counties. We have a collective effort for thats being built over many years for the counties and other entities fund that federal share, so if that goes through, its going to cause a significant rethinking of the safety net that goes on in california. I think were very actively worrying and watching that and working through our organizations to advocate on that, and i know we have support from our policy and elected officials in california. But we havent budgeted around that because it doesnt exist its not finalized, and if it does become finalized, theres going to be a lot of steps for the state to determine how we react to that. So that is a big risk and fear thats out there. Yeah, and itll affect across the board pretty much everything that we provide through medical, and so im just im glad that youre watching it and worrying about it and working with other constituents, medical constituency provides around that. But i think providers around that. But i think if thats not the proposal that goes through, theres going to be Something Like that just because thats the way its going with this particular administration at c. M. S. And so i think the beneficiaries of our Medicaid Services are going to have to be informed because it affected its going to affect it affects us on a budget basis, but affects them in terms of their lives and their wellbeing. Absolutely. So i think thats something we should get involved with. The other question i had was around laguna honda. There is almost a double or a 100 increase in projected revenues that is shown. I think jennie, you mentioned it was rate increases. I was wondering if those rate increases are related to the new regulations that c. M. S. Has put into place with regard to the i dont know what to call, the not paying for therapists or therapy and other kind of things. Are those two things related at all . No. So the revenues that you see, you look at the numbers on a4 i totally see why it looks like 100 . That first 6 million incremental, thats over and above what we budgeted today. I think jennie knows what that percentage is it looks like shes looking. Off of a 200 and 300 million base, so its a few percent. And then, in the second year, that incremental portion doubles, but its all told, its a single digit increase to the rates. And whats represented here is simply taking our updated estimated medical per diem, multiplying it by our bed days, and then calculating our medical revenue. So its a this is a fairly straightforward, and there are there are a number of potential changes that could significantly affect revenue at Laguna Laguna revenue, including how nursing funding is financed entirely. But what were proposing here is just that very simple baseline revenue based on the medical daily rate. So again, just something that would, i guess, bear watching and informing both us at full commission and the j. C. C. In terms of those impacts. Absolutely. Thank you for that suggestion. Thank you. Is there other questions . All right, we can move onto a motion to approve the sfdph budget 2021 and 2122 budget. So moved. Second. All right. All those in favor . Commissioners, if i could, i just want to say a special thanks to jennie lui. I could standup here, but she really is here until 9 00 at night, pulling this stuff together, as well as the budget team for the department. We have a really Incredible Team who does a huge amount of work of pulling it together and then keeping it together for the rest of the year, so i just want to acknowledge all of that work by jennie and all the budget team. Thank you. Thank you, jennie and all of you, as well. All right, commissioners. Lets move onto item 7, which is Drug Overdoses and drug use, a presentation. And let me know if yall need me to help you. [inaudible] good afternoon, everyone. Good afternoon, commissioners. Thank you so much for providing us the opportunity to come speak this afternoon. Dr. Kaufman and i are going to speak to Drug Overdoses in the community and some of the ways to address those. So todays presentation todays presentation, were going to go through some data thats going to show overdose reversals and some of the work thats happening in the community. Were also going to discuss Treatment Options and some of the services that we have to address drug use in the community and overdoses, and then finally, well end with some of our immediate and longer term strategies to address the situation. Okay. So i want to start with the data, how we get the data initially. So when a Drug Overdose happens, the death is reported to the medical examiners office, and then, the toxicolo toxicologist collects all the data, and that data is important because a Drug Overdose is different from other deaths in that its a rule out death in most circumstances. For example, somebody passed away, and you have no idea why. You have to collect all this data. Maybe they have a high level of methadone in their system, but theyre a patient in a methadone clinic. It takes a while to collect all of that and come to a cause of death. The cause of death determination is what takes the most time and limits our ability to get realtime data. That data then goes to department of vital records, and they confirm, Fact Checking and make sure that everything is collect. California has the reporting system, which is a fantastic system, that reports on all deaths that occur, and that is the data that we get back that we use for our analyses. Overall, because of the time it takes to close a case, its about five to six months before we have complete data. For example, if i were today to pull the data for january, i would capture about 3 to 4 of the Overdose Deaths that happened, which means that i cant pull data until about six months have passed in terms of getting complete data for any period of time. We are not alone in that. Most all the cities that i know of that report mortality dat data, they generally have a sixmonth lag between the time it takes to report cases. The other question i have is the frequency of reporting. The data ill present today is were going the presenting every six months. We have anywhere from 7 to 31 deaths in a month, so if you look at it by monthly reporting, one month, it looks like were doing great, and the other month, it looks like were doing terrible. The numbers are small, and theyre unstable until we get to at least sixmonth time periods. In terms of the number of Overdose Deaths, this chart gives you the numbers per sixmonth period because we only have the First Six Months of 2019 as complete data. As you can see in the first as you can see, we really maintained a flat number of Overdose Deaths relatively until through the first half of 2018, which is pretty impressive. We had the prescription opioid crisis, we had the heroin crisis, we had an estimated tripling of the number of people who inject drugs in San Francisco, and the mortality level remained flat during that time. With the second half of 2018 and progressing into at least the first half of 2019, we are seeing escalating deaths, and well run through those numbers more, but theyre generally driven by fentanyl. I havent seen a community that didnt suffer an increase in the vast number of Overdose Deaths, including places like vancouver, British Columbia that doesnt have the restrictions on federal programming that we face. A little more detail on this data in terms of opioids. What you can see here in gray is the number of fentanyl deaths. Below that is heroin deaths, and below that is prescription deaths. Back in 2010, we were pretty much all prescription deaths. As prescribing reduced, the deaths kind of transitioned to heroin, and then fentanyl started to emerge. We saw the first whiffs in 2015, and then, in 2019, fentanyl deaths increased substantially, and all of our data from 2019 are partial. They may represent anywhere from 30 to 70 of what the total will be. So Harm Reduction is the philosophy of the Health Department, and thats recognizing that people make change in different ways. So while we have the syringe access and disposable program, we also have absent space programs, and theres all these entry points in between, and thats acknowledgitaking the s acknowledge that everyone is different, and everyones behavior to change is different. Harm reduction treats people with respect and dignity so that when theyre ready to make that change, were there as the Health Department to offer that array of services. Harm reduction principles often come directly from the community, and i say this because philip mentioned the increase in fentanyl use in the city, and were definitely seeing that. And amongst the community of people who use drugs, many people are seeking out fentanyl, and many of them have developed a mechanism to reduce their harm, and we sue thee th a Harm Reduction strategy, for example, smoking fentanyl opposed to injecting it. Many safe consumption sites are offering tinfoil now. Other reduction strategies include methadone, and buprenorphine, which also allows that flexibility and that low barrier to engage people into services. So this slide demonstrates the work of our funded provide, the dope project, drug Overdose Prevention education project. The blue bars show the number of refills, people are returning to, whether its our syringe sites or any of the Distribution Sites to get a refill on their naloxone, and that may mean that theyve reduced an overdose, or it may mean that their naloxone was taken, but you can see that number has significantly increased overtime, and that just demonstrates the great work in the community and the importance of the messaging of having narcan available, and being trained to be able to administer it. Other efforts that are happening in the community to address the overdose are in the jail, where if someone has a history of opiate use or mentions that they are an opiate user, then narcan or naloxone will be put in their property upon release, and thats key because we know that a lot of people leave the system or leave jail and go immediately to use, and so its another strategy. And then, the newest is project friend, and thats working with First Responders and their families to distribute naloxone. And i believe its federally funded, but its available through San Francisco general and also u. C. , and these are just strategies to address the current trends. So i mentioned the needs to be flexibility with people who use drugs, and with that comes the need of many different strategies. Often low barrier strategies to engage people into services, and these include going out with health fairs, going out to homeless homeless encampments, and really engaging people. Also, the Harm Reduction therapy van has been able to set up in communities where people are hangout and just engage people into services. In the earlier presentation, it was mentioned about the crisis outreach teams that will be part of Mental Health s. F. Again, thats another example of really just responding to the needs in the community and recognizing that one strategy does not work for everyone and the need to constantly be flexible and reinvent the services that we have so that we can engage people. And the low barrier medical services at the syringe sites is such a good example of that. I had the opportunity to be at one of those sites one night, and it was amazing to see five people waiting in a queue to talk to a medical provider because they heard that they could get started on buprenorphine to curb their opiate cravings. And i think that thats very telling because its a safe place where people are already accepted. There are multiple different strategies that we use at the Health Department when there is a spike in overdoses. Were really fortunate that we work so closely with our funded provider, the drug Overdose Prevention education program, or d. O. P. E. So when there is an indication of overdose is, they work very closely with their providers to get the message out to the community to people who use drugs. Additionally, the Health Department sends out a medical advisory, and we send out messaging to the navigation centers, to homeless shelters, to schools. We have a very exhaustive list to share that sort of messaging. Additionally, with the syringe access and disposal program, we have a monthly meeting thats called the syringe access collaborative, and thats an opportunity for us to discuss the trends that were seeing in the community and have an opportunity to say, well, how should we address that . Additionally, there is a project thats called acdc, and thats a project of the d. O. P. E. Project, and thats where theyre actually able to get a sample of a drug supply that may have been associated with an overdose and test it, and then get that messaging back to communities. I should also add that our syringe access and disposal programs all carry Fentanyl Test strips, and thats an opportunity to test your drugs to see if it is tainted with fentanyl, and if it is, to use a Harm Reduction mechanism to engage in your activity. So basically what this slide shows is what ive been saying, theres just there needs to be a comprehensive plan when addressing Substance Use disorder. And so we have multiple or the Behavioral Health system has multiple entry points to address Substance Use, and that ranging from low barrier, that may be at a syringe access site or maybe as telebupe being offered as an option all along that continuum. And i think thats really important to note, and i often sound like a broken report saying that because no ones path getting into the system is different or some people may want to manage their use, and low barrier is what works for them. Other people may need more comprehensive services, and we have that capability with our system of Behavioral Health care. So just a little more on the Behavioral Health side. Generally, theyre providing buprenorphine and methadone, and this is in the context of Substance Use Disorder Treatment programs, which dont account for all the Substance Use disorder that goes on, has that treatment has definitely expanded within primary care settings, and jail health, as well, provides this therapy. There are 491 residential beds that are going to do Residential Management and treatment that goes up to 90 days as well as the residential step down programs. The Residential Program which eileen has referred to include the medical Street Program that dr. Zephen runs, and thats been impressive. I think one of the most innovative things that San Francisco has done is by going out to where people who are experiencing homeless live and providing buprenorphine in those settings, i think thats some of the really impressive work. The Behavioral Health pharmacy has expanded services. Theyre able to provide buprenorphine and continue patients on buprenorphine in that setting. And the buprenorphine prescriptions having increased in San Francisco. We also have two programs that provide contingency management for methamphetamine use disorder, and thats really the most evidencebased intervention that we have at the time. And then, we have pharmacotherapy research, which is the work that i run, and that dr. Colfax initiated in his prior incarnation at this department. And weve had some success in particular with medication mirtazapine, a Research Pathway that we continue to explore. In terms of use Disorder Treatment, these are the numbers for 2014 through 2018. There has been some reduction in treatment numbers, particularly, you can note in hal and a little bit of a reduction, about 150 fewer people treated for heroin use disorder in 2018 compared to 2014. I actually think a major driver of the decline in some of these numbers is the transition to primary care for treatment of many of these use disorders. For example, expanded use of medications for alcohol use disorder and have really seen an up tick in recent years. As you can see in the graph on the right, buprenorphine treatments have increased substantially. So weve actually probably seen an increase in the number of people receiving treatment for use disorders, although a slight decrease in those accessing traditional Treatment Programs. So we gave some background on some of the stuff that were working on, and i just want today highlight some of the immediate actions. One of the biggest things is findtreatment. Org, and that was the site that was mentioned earlier at the Committee Meeting where it shows the availability of treat beds, and thats huge because its updated every day, and it will allow us at d. P. H. The opportunity to also have realtime feedback of, well, why are x beds at x Agency Always empty as compared to other beds that are full . So itll give us realtime feedback and data, and itll also provide the opportunity for Different Levels of staff to be able to just check in realtime what are the Treatment Options available as i work with my client. Also, the expansion of the Hummingbird Community model, which we know that the model at San Francisco general has been very successful, and now, the Health Department is looking at expanding that to a Community Location where programs such as the Syringe Programs will be able to refer people directly to anybody needing that sort of respite. Additionally, we are working on expanding the or opening the first meth sobering center, which is also something that we heard directly from the meth task force. It was a recommendation by the group, and were able to move forward on that. So theres a lot of Different Things that are very exciting, and to address the issues on the streets. And a little further on that note is the efforts on Overdose Prevention. So about a third of the Overdose Deaths in San Francisco occur in singleroom occupancy hotel units, and thats always been a particular challenge because people are oftentimes isolated, and so simply providing naloxone in the community may not be able to prevent some of these deaths. So we have some support from california partner of Public Health to initiate this as a Pilot Project working with some of these facilities to try to develop really tenant run Overdose Prevention projects. Project friend was already mentioned by eileen, and that is a situation where paramedics are able to give innaloxone takehome kits to community members. And then finally, just lowering barriers to treatment, and that includes expanding the hours at our cbhs clinic, and also expanding the opportunities for telebupe, and thinking how can that expand, how can we expand other areas for people to access treatment . So for future initiatives, back in december, the mayor and the board of supervisors unanimously passed Mental Health s. F. , and were really excited about that because in that, we will be able to think through other initiatives that well be able to address issues on the streets, and that includes the expansion of crisis outreach teams that will be out in the streets that will be able to work and address concerns and be able to engage people directly into services. That also means expansion 247 of the Behavioral Health pharmacy, Mental Health reform, and also thinking through, well, how does Substance Use and alcohol use fall into that, and just thinking of the opportunities for expansion within that . And just thinking of the Overdose Prevention sites and other dropin sites that are an opportunity to engage with people who are on the streets and need a safe place to be inside. And then finally, we are available for questions, but we also have our colleagues here from Behavioral Health who would be able to answer any of the questions on Behavioral Health services and Substance Use treatment. Thank you. Thank you for your presentation. Commissioners, questions . Commissioner chung . Hi. Thank you for the presentation. So this is the questions that i asked in our previous meeting, and hopefully, youll be able to help me out here. I see that theres actually an increase in meth overdose related deaths, and how do we well, since theres no real treatment, how do you prevent death . Like, what strategies are we using to prevent methrelated Overdose Deaths . Thats a great question, and a very difficult one to answer. The cause of death from acute methamphetamine poisoning is a difficult one. Its not like an opioid death that can be reversed with naloxone. Its generally thought to be a cardiac event or sesh certi cerebrovascular event, or a brain bleed. This is to encourage people to get into a Treatment Program or to modulate use, things like that, and those are those are also sometimes full of challenges, so i dont have a great answer for you. I wish i did because id love to see love to be able to directly address that the way we can directly address opioid overdose. Thank you. I dont have any other questions, and i appreciate that in addition to that because personally, i think that sometimes there might be a different cause of death and and sometimes like, you know, exceptional death, like falling out of buildings or something, but it might be caused by psychosis of stimulant use. How do we actually tell that story, you know, in these, like, death reports . So in those death reports, the data that i provide are deaths that were determined to be due to acute prisoning from the given drugs, when you look more broadly, you could, for example, look at all deaths that involved a positive toxicology report, and thats going to include a Motor Vehicle accident, a Motor Vehicle collision, or, you know, any cause of death. And so in order to look at more something more directly that we know can reasonably be attributed to the drug, we restrict it to acute prisoning. The other one acute poisoning. The other ones are going to be tricky. If somebody falls out of a window due to a drug, that may be, but its a tougher question to answer. Thank you. Director colfax, you had a comment . I just wanted to thank the team for their presentation, and i think the other key point, as dr. Kaufman has made, just the important of good data here, and ensuring that were using data to drive our decisions. I think one thing that bears mentioning is the s. T. D. Reports that you see that dr. Ph phil dr. Philip presented. And then, the work that eileen did with, the work for community partners, theyre not here as much today, but that were always reaching out and engaging in. To the commissioners discussion about methamphetamine use, and i think we have to be and the meth task reports emphasizes and says that an array of options need to be available. We dont have the buprenorphine that we need to see. We have a National Institute of Health Research program that is specifically looking at these pieces so you have a full spectrum of work being done across the departments, including the Harm Reduction approaches that were taking today. And then dr. Kaufmans team has done a number of randomized controlled studies. But i think there are tihings that we can do for methamphetamine users going forward. I also think from the Harm Reduction perspective, the morbidity piece, while the overdose death is the final common pathway, and the most tangible one, we know that drug use is affecting people. We need to know that the department is commit today that, and we dont lose sight of the use or primary use. Really make sure we take that Harm Reduction approach, not just focused on that drug at the moment but across the continuum of care. Thanks. I just had a quick question. With regard to first of all, the data is excellent. Thank you very much. Looking at the dramatic increase in deaths by fentanyl overdose, does your data differentiate whether the fentanyl is in a different substance or fentanyl on its own . No, in general, it doesnt do that. In general, we know the narratives from case reports of people who had died as well as the access of the d. O. P. E. Project and the syringe project and research of people who use drugs in San Francisco, most people who are using fentanyl choose to use fentanyl. Its a drug that can produce a more reliable effect than, for example, black tar heroin. It is less expensive, its easier to transport, so it has largely replaced the other opioids on the street because it is favorable it has those favorable elements to it. Unfortunately, its also much more likely to result in death. There are cases where there may have been contamination, and there are definitely cases where people who were using intended to use cocaine or methamphetamine but it happened to be fentanyl. I think in general, opioids in San Francisco historically were black tar heroin, easily distinguished from a white powder stimulant, and now were seeing white powder opioids that arent so easily distinguished, and theres been some tragic errors in consumption, as well. Commissioner green . Yes, thank you for this wonderful work. I had some questions about your point of entry because it seems, you know, that a lot of these require clients to come to a place or show up to a place, and im wondering if youre gathering data about a few things. One would be what time of day to people come . What point of entries are prominent . Are you giving out, you know, both Fentanyl Test strips and naloxone . And then, how are you going to kind of quantify that so we can understand where to focus the resources . We have a system and youre going to obviously expand it, and all the ideas that i think are forth coming are really excellent. I guess the other one is how much is this happening at night because thats one of the worries in terms of points of entry. So what date are you planning to gaer to gather on that component. I think i would call one of my colleagues from Behavioral Health as far as points of entry on the systems of care. I can say for the syringe access and disposal programs, we have Services Available seven days a week at different sites and hours vary to meet the need. Two of the sites specifically that offer low barrier medical care are in the evenings, and weve had to think creatively on how to, if someone needs a prescription for buprenorphine, how can that get filled in the evening hours so that we can stay engaged with people. But i think that people are staying engaged, people are coming back to the syringe site do sites, and for whatever reason, they werent seeing that same type of respect at a fourwall clinic. Were, again, recognizing that need because we had a meeting about a year ago with front line workers, with Behavioral Health, and we talked about a lot of the barriers that were seeing directly in the field, and that was one of them. Like, if someones ready at 9 00 at night, saying well come back at 8 00 a. M. Doesnt exactly work. Good evening, commissioners. Im the project manager. So we have about 65 programs that we are funding from outpatient methamphetamine services, residential. And what eileen was mentioning, we were expanding the service hours. We are working with healthright 360 to have an intake person that can go into homes in the evenings and provide the medication. Because in healthright 360, we have two intake sites that will be open from 5 00 p. M. To 9 00 p. M. , and also we are working to expand the pharmacy 247. Those are the improvements that we are making into the point of entry that youre requesting. So do you think youd be able at some point to give us some data about points of entry, which are more successful, whether expanding hours makes a difference, you know, in terms of zip codes and things like that . Also, the other thing i think wed