A demonstrator at an Aug. 22 rally regarding the slated downsizing of the Adult Residential Facility posits a salient question to the city. Photo by Abraham Rodriguez

Nostalgic readers of a certain age may find themselves grinning at the mention of a long-ago recurring bit in Sesame Street in which a baker triumphantly announced the tally of messy desserts precariously balanced on his trays — five fancy fruitcakes!” before, invariably, taking a noisy, painful spill down the stairs, sending frosting and cakes everywhere. 

And thaaaaaat’s the story of five!” 

What a mess. What a predictable mess. 

Which brings us to Mayor London Breed and her health department’s recently announced move to repurpose 41 beds at the Adult Residential Facility on the San Francisco General Hospital campus. They now serve as permanent housing for severely mentally ill people, but Breed wants to turn them into temporary, Navigation Center-like shelter.

The rollout of this plan has been handled with all the acumen of that baker undertaking a jaunt down the stairs. But while transporting cakes from Point A to Point B is good and necessary, it becomes very difficult to explain why it’s good and necessary policy to reduce capacity for permanent housing earmarked for some of the city’s sickest and most vulnerable mentally ill people — some of whom have lived here for 15 years — and instead use the space as temporary shelter for people getting inside for, perhaps, a couple of weeks before whatever comes next. 

The city’s official rationale for why this is a good and intuitive move is, in fact, bad and counterintuitive. In a nutshell, shifting permanent housing for mentally ill people prone to homelessness into temporary shelter is being explained as the right thing to do because that permanent housing was sitting, unused. To repeat: In the midst of a homeless crisis, dozens of permanent beds created to meet the needs of the most hard-up mentally ill people were sitting, unused. 

Nobody, in fact, has been admitted into the Adult Residential Facility at SFGH since September 2018. 

And this, the Department of Public Health says, is because it struggled to hire the requisite number of workers to staff this housing. 

Now, granted, for the public sector to hire good and qualified people to work with the severely mentally ill is not a quick and easy process. This is not something to be accomplished by leaving a want ad tacked to a laundromat bulletin board. But it ain’t exactly a mission to Mars, either. If hiring difficulties were the issue here, and if our homeless situation qualifies as a crisis — which it does — you’d think there’d be more urgency on display. You’d think more effort would’ve been applied to solving this problem and getting those beds filled. 

Because it’s a hell of a thing for the social workers, who determine whether to conserve a mentally ill person and abridge his or her rights, to learn — only now — that this city had the capacity to house its vulnerable, mentally ill population that it neglected to use. 

It’s a hell of a thing for the doctors treating patients locked in jail-like inpatient psychiatric units who really ought to be in a less severe setting to learn — only now — that there are empty beds more suitable for their clients. But those beds were kept empty and are now slated to be eliminated. 

And it’s a hell of a thing for our elected legislators to learn — only now — about this long-planned move, despite engaging in frequent meetings with Health Department staff about how to extend aid to exactly the mentally ill population that should’ve been using the beds that the city wasn’t using, and is now moving to do away with. 

“We’ve been asking the Department of Public Health how many beds do we have? What are the vacancies? Where can we expand to meet need? Where can we add money?” says Supervisor Hillary Ronen. “Never, in any of our conversations, did this come up. Not once.”  

YouTube video

Jennifer Esteen’s voice crackles on the cell phone as she motors over the Altamont Pass, past the gyrating turbines, and into the vast agricultural landscape. Esteen is a DPH psychiatric nurse who is now on the city’s “transitions placement team.” It’s her job to monitor “board and care” facilities housing this city’s mentally ill residents who are too unwell to take their medications on their own, let alone cook, clean, or otherwise look after themselves. 

The city could probably use many more board and care facilities. But that’s not what’s happening. The city in 2013 contracted with 999 board and care beds, Esteen says. That number is now down to 601, and facilities are melting away in this city like polar ice. 

That’s why she’s on her way to check on her board and care clients in Modesto, where they now reside. It’s more financially viable for aging couples to sell their San Francisco houses and become millionaires than it is for them to care for the mentally ill homeless in these in-house facilities (which is not the easiest nor most lucrative way to earn a living). 

Like the precarious state of our polar ice caps, the diminishing number of board and care facilities in San Francisco is something every knowledgeable person in government knows about. In 2018, Mayor London Breed put out a release lamenting that, in the previous five years, the number of facilities contracting with the city had dipped from 70 to 37. She announced an additional $1 million to help secure 350 vulnerable people in their homes. 

Well, that was then. On Aug. 19 of this year, 19 residents in the city-run board and care Adult Residential Facility at SFGH received letters informing them they’d have to relocate within 60 days. “The Mayor of San Francisco, London Breed, declared a state of emergency in September 2018 due to the increasing problem of homelessness,” reads the letter hand-delivered to the bewildered, mentally ill residents of the Adult Residential Facility. “In order to meet the needs of the city, our facility … has been asked to support response efforts. Accordingly, the majority of the beds at the ARF will be placed in suspension.” 

Everyone, it seems, must do their part to increase this city’s shelter bed count. 

Nurse Jennifer Esteen, helming the Aug. 22 rally she co-organized. Photo by Abraham Rodriguez.

The Adult Residential Facility, with its (erstwhile) capacity of 55 beds, sits on the ground floor of a building called the Behavioral Health Center at 887 Potrero Ave., a stone’s throw from the main General Hospital campus. A facility for elderly mentally ill patients with 59 beds is on the second floor and a locked facility for up to 47 mentally ill people who, to put it gently, may pose a security risk sits on the third floor. 

The first floor residents who received “Request to Relocate” notices have been asked to consider simply moving upstairs. That sounds easy but — and we’re being as sensitive as we can here — this is not an easy population. Some are scared to the point of having panic attacks and confused and simply don’t want to go. And, separate and apart from the individuals who live here, the city’s overall capacity for long-term housing of the mentally ill people — something San Francisco doesn’t have nearly enough of — stands to be reduced by 41 beds. 

While it’s great that the city is easing homeless people’s burdens through additional Navigation Center beds, Navigation Centers have long since ceased doing much navigation. As we’ve written in the past, the city needs to both build more Navigation Centers and stop monomaniacally focusing on Navigation Centers. 

Doing away with housing to increase Navigation Center shelter capacity is a move bordering on self-parody. 

And yet, from a realpolitik point of view, it does have some logic. Only 58 percent of the beds at the Adult Residential Facility are currently occupied. One floor up, at the elderly care center, only 63 percent of the beds are filled. Consolidation, at this moment in time, makes some sense. 

What doesn’t make sense is how this situation was allowed to occur in the first place. And fester. Both Supervisors Rafael Mandelman and Hillary Ronen told me that they wish the Board of Supervisors had been roped into this situation long, long ago. 

“My staffer asked [DPH] ‘what have you done to try to increase hiring?’” says Ronen. “‘Have you recruited in different ways? Have you increased wages?’ No. ‘Have you come to the Board of Supervisors and asked for an emergency declaration so we can streamline the process and make it easier?’ No.” 

Does anybody really think it’d be difficult to get Ronen et al. to approve funds to direct toward her political allies, the SEIU 1021 union, to hire nurses to care for this city’s most needy homeless population — instead of the far costlier and more inhumane scenario of relegating people onto the street? 

How many wins are in that win-win-win scenario? 

Supervisor Hillary Ronen told Mission Local that ‘dumbfounded’ doesn’t even begin to address her disbelief at the city’s move. She has suggested she’ll scrutinize this maneuver during a public hearing. Photo by Abraham Rodriguez.

Department of Public Health officials have made assurances that none of the Adult Residential Facility residents will be put outside. They have also intimated that the state license to run permanent housing here doesn’t expire for another two years, and the hiring holdups may be resolved by then. Maybe this housing would come back. 

But this rollout was so ill-handled that any pledges to just wait and see what happens by 2021 are not welcome. “It’s bullshit,” says Esteen. “It’s a bait and switch.” 

Blaming staffing shortages for all this, meanwhile, rang hollow to both the unionized workers and members of the Board of Supervisors. Staffing shortages are endemic across the city — and especially within DPH. As Mission Local reported earlier this year, that department regularly busts its budget, to the tune of scores of millions of dollars a year, on temporary nursing staff rather than hiring more full-time workers. 

Documents obtained by Mission Local reveal the city, citing staffing challenges, requested the state licensing body to decertify the 41 residential beds and transfer them into shelter purposes — all the way back in May. Nurses working on site say they weren’t told until July — and were also specifically ordered to keep quiet about this to the residents. “I felt like I was cheating them,” said longtime medication nurse W.D. Flient. 

(Of note, both the Adult Residential Facility and second floor Residential Care for the Elderly program were on “corrective action plans” following a bevy of citations from the state).

Last Thursday, Esteen and several labor unions organized a rally to “Save the ARF.” You didn’t have to be a San Francisco political whisperer to understand the message being directed at the mayor and DPH. The city’s largest unions, along with housing and homeless groups, are drawing a line in the sand — and the presence of Rudy Gonzalez, the executive director of the Labor Council, indicates that any attempts to transfer resources away from this residential facility and into a shelter will be fought by organized labor writ large. 

Of course, there is a terrifying possibility looming. The city, citing hiring issues, failed to utilize precious long-term housing beds in the midst of a homeless crisis. But, in an effort to preserve those housing beds — and still burdened by this city’s sclerotic hiring process — the worst-case scenario may arise. The move to augment shelter space may be thwarted but, at the same time, the residential beds may stay unfilled. 

Thursday’s rally came on a flawless sunny day. But this dark thought persisted.

What a mess. What a predictable mess. 


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Managing Editor/Columnist. Joe was born in San Francisco, raised in the Bay Area, and attended U.C. Berkeley. He never left.

“Your humble narrator” was a writer and columnist for SF Weekly from 2007 to 2015, and a senior editor at San Francisco Magazine from 2015 to 2017. You may also have read his work in the Guardian (U.S. and U.K.); San Francisco Public Press; San Francisco Chronicle; San Francisco Examiner; Dallas Morning News; and elsewhere.

He resides in the Excelsior with his wife and three (!) kids, 4.3 miles from his birthplace and 5,474 from hers.

The Northern California branch of the Society of Professional Journalists named Eskenazi the 2019 Journalist of the Year.

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  1. First off, I do not agree that “the must vulnerable” are the people who are stabilized in this housing.

    “The most vulnerable” are the people living on the streets in psych crisis.

    Stabilized people can be moved to another facility to make room for beds to stabilize those in crisis and remain stable themselves.

    I find it difficult to believe that the homeless advocates, service providers and SEIU members, some who have been doing this work for decades, were unaware of these unused beds.

    San Franciscans are demanding that the people living in an open air mental facility become patients who can get the treatment and support that they need to be stabilized.

    If all we get are the various interests squabbling amongst themselves whenever the Mayor proposes anything, while failing to execute on articulating a viable agenda and moving that, then seriously, a pox on all of their houses.

    This is all about parochial interests and preserving the status quo, not about rearranging funding at the DPH to get crisis mental health stabilization online and scaled.

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    1. In reply to Marcos,
      You are correct, the most vulnerable are those with mental health issues on the streets. That being said, this facility houses those most vulnerable people, after months or years of effort tostkbilize them, often requiring costly hospitalizations and time in very costly other levels of care for rehabilitation and stabilization, including locked facilities. They are then placed in facilities like this, which are decreasing in numbers every day within the City of SF. There are no other places to move these people to in order to use those beds for crisis beds.
      And the number of people languishing in inappropriate and much more expensive levels of care because of the lack of this level of care, is growing every day( remember the number of resources and time energy and cost to stabilize). One of the issues here is why these beds were not utilized for all this time, when there is a crisis of need for this level of care.
      Yes we need more crisis stabilization resources in this city, but once clients get through crisis there needs to be somewhere to go besides the street or they are in crisis again.
      The people who need these beds as board and care beds are people who are not able to be in the community independently. These board and care beds provide supervision medications, meals and management of personal and environmental hygiene.
      Taking these beds away from this segment of the population to provide a temporary shelter is wrong. Open more shelters and save this very needed resource for this vulnerable population.
      To answer the question of the providers in this city being aware of these unfilled beds, yes providers at every level have been aware of these beds and have asked weekly or more frequently, when can we place clients? The City and management have not made them available to utilize at all for almost a year. The question of why, when the demand has been so urgent, is one that hopefully will be revealed.

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  2. “And this, the Department of Public Health says, is because it struggled to hire the requisite number of workers to staff this housing. “

    That is a big lie. I work here and we have plenty of staff.

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  3. San Fiasco.
    Yes – you’re on your own in this town. Assume no help from any city services.

    Great reporting and insight from Mr. Eskenazi.
    Thank you.

    We are constantly bombarded with stories of the inane incompetence of city administration.
    Coupled with horror stories of things some of our unlucky citizens are subject to.
    Add to that – with a 12 bil (and climbing) budget we are rated as one of the worst run cities in the nation.

    On the flip side – what city administered services do work?

    How about a story on that. You know – just to give some balance. Reading about the latest fiasco is depressing.

    The only thing I can think of that’s been a smash up success is the million needle giveaway program. That being judged by the amount of needles littering the streets, sidewalks and scattered within our transit system.

    Maybe the pit stop thing too.

    Anything else?

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    1. It’s the out of control people who are not cutting it. The 5th rule of Karma is tragically disregarded in this failing city. You are responsible for your own life. Nothing the city can ever do or spend, will ever compensate ignoring this primal rule.

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