Supervisors push departments for clearer SB 43 outcomes as implementation yields modest conservatorship gains

San Francisco supervisors pressed city health and disability agencies on Thursday about the implementation of California Senate Bill 43, with elected officials and officials from the Department of Public Health and the Department of Disability and Aging Services agreeing that legal change alone has not produced broadly improved outcomes for people with severe mental illness or co-occurring substance use disorders.

President Rafael Mandelmann of the Board of Supervisors convened the hearing at his request and said SB 43 “was not my first ride on the merry-go-round” of conservatorship reform. Mandelmann told the committee, “SB 43 implementation in San Francisco has not been a success in my view,” and said he expected a candid assessment of what has worked and what has not.

Daniel Tsai, director of the Department of Public Health, and Kelly Dearman, executive director of the Department of Disability and Aging Services and public conservator, described a coordinated interagency rollout after San Francisco adopted SB 43 on Jan. 1, 2024. The definition of grave disability was expanded under SB 43 to include severe substance use disorder and inability to provide for personal safety or necessary medical care, in addition to inability to meet basic needs for food, clothing or shelter.

Dearman summarized the conservatorship process under the Lanterman-Petris-Short Act (LPS): only the public conservator may file for conservatorship, which typically begins with a 30-day temporary conservatorship that can proceed to a permanent conservatorship if the court so orders. She said the public conservator accepts and petitions the court for about 94% of the justification-and-recommendation (JNR) forms received from clinicians and that nearly all temporary conservatorship petitions are granted; since 2023 the office had one denial from the court.

The departments reported that, from January 2024 through May 2025, the city had 186 temporary conservatorships granted after SB 43 implementation, including 50 granted since the start of 2025. Of those, 163 used the expanded grave-disability criteria to strengthen petitions; the departments said there have been no conservatorships granted solely on the new SB 43 criteria (severe substance use disorder alone). Departments also reported that 46 of the expanded-criteria cases were filed since January 2025.

At the same time, officials said placement capacity limits have constrained their ability to expand conservatorship use. Tsai and Dearman told the committee the city suffers a shortage of locked subacute beds and residential placements that can manage dually diagnosed clients who need both psychiatric and substance-use treatment. Tsai estimated San Francisco’s shortage of locked subacute beds at roughly 100 to 140 beds and said the city currently purchases or leases approximately 48 out-of-county beds for some clients.

To reduce reliance on out-of-county placements, the departments described a pilot that began in the prior month in which teams hold a shelter bed and layered clinical supports for specific cases when locked subacute beds are unavailable; Tsai said the pilot had identified five clients at the time of the hearing where a shelter bed plus intensive wraparound supports was being held as a placement plan.

Committee members pressed departments on other operational questions. President Mandelmann and Supervisor Connie Chan asked whether the city has an estimate of how many people in San Francisco meet clinical standards for conservatorship; officials said the need exceeds current capacity but declined to supply a single fixed number, noting that demand can grow when outreach and identification improve. Department data showed the monthly average caseload in 2025 rose 3% compared with 2023 but fell 1% versus 2024 — the departments said some of that decline reflects terminations when individuals stabilize and move to less restrictive interventions.

Concerns about short 5150 (72-hour) holds also emerged. Department officials said many people admitted on 5150 due to intoxication no longer meet hold criteria after a short period and are legally required to be released; hospital clinicians, they said, often must decide within hours whether someone continues to meet criteria. Officials said the departments have trained more than 1,700 staff in SB 43-related procedures and have created a centralized LPS review list for individuals who might be eligible; at the time of the hearing DAS reported 26 active people on that review list.

Jill Nielsen, deputy director at the Department of Disability and Aging Services and the city’s public conservator, said the city was seeing on average 90-day temporary conservatorship assessments and that the majority of temporary conservatorships involved unique individuals rather than repeated short-term re-referrals. Later in the hearing a staff member told the committee the observed reoccurrence (recidivism) rate for conservatorship re-referrals was approximately 5%.

Officials and advocates urged stronger state involvement. Departments and the Controller’s work group said SB 43 lacked state funding, technical assistance and an oversight body; speakers called for state-level coordination, regulation of placement denials and new financing. Clinicians also suggested possible legislative avenues such as assisted outpatient-treatment-like options that could permit community-administered long-acting antipsychotic medication under court supervision.

Public commenters at the hearing urged fuller and faster use of SB 43 and stronger coordination among street outreach, hospitals and the public conservator. Justin Saa, a San Francisco resident, told supervisors: “We have the law. We have the legal clarity to use it. What we need now is coordination, accountability, and your leadership.” Several commenters described people visible on public streets who they said met the expanded SB 43 criteria.

President Mandelmann asked that the committee revisit implementation progress in six months. Chair Matt Dorsey moved to continue the item to the call of the chair to allow follow-up work; the committee approved the motion by roll call (Member Sauter, aye; Vice Chair Mahmood, aye; Chair Dorsey, aye).