Officials describe limited use of San Francisco's housing conservatorship and pilot steps to broaden pathways

Supervisor Rafael Mandelmann, sponsor of the hearing, opened by recounting the board's decision to opt into the state SB 1045 conservatorship framework and said the city has moved slowly to implement it. Mandelmann said he convened the hearing to assess progress and lessons learned after nearly two years.

Jill Nielsen, Deputy Director of Programs for the Office of the Public Conservator, and Angelica Almeida, director of Forensic and Justice-Involved Behavioral Health Services at the Department of Public Health (DPH), described legal and practical hurdles that have limited the program's reach. Nielsen told the committee the local implementation had become more complex than original drafts because of added state and local requirements: the city must compile hospital documentation for each 5150 hold and meet strengthened voluntary-service-offer requirements derived from SB 40 and local ordinance amendments. She said those documentation thresholds make preparing a conservatorship case time-consuming and legally vulnerable if contested.

Almeida described a pilot that uses an outpatient referral pathway (a provision in the Welfare & Institutions Code) to identify candidates in the community and refer them directly to the public conservator without short-term hospital holds. Almeida said that, since the start of the calendar year, the city has used the outpatient pathway to conserve 10 individuals and is piloting an expansion modeled on Los Angeles County's program. Both officials said their priority remains serving people in the least-restrictive setting possible and that conservatorship is intended for a small subset of people who repeatedly decompensate and refuse voluntary treatment.

Officials gave several numeric updates: since June staff have identified 140 people who were offered less-restrictive interventions (case management, assisted outpatient treatment); 60 of those individuals have stepped off the pathway; as of a January status count there were 63 individuals with five or more 5150 holds in a 12-month period (the local trigger for outreach), 16 with eight or more 5150s (the local threshold for filing a petition), and seven who had received formal notices they were on the pathway. DPH said one person had been placed on a housing conservatorship to date and 10 were conserved through the outpatient pilot this year.

Committee members pressed for more granular data: Supervisor Matt Haney asked how many people with five or more 5150s are being offered housing, how many are homeless and how many 5150s are initiated by police versus hospitals or other providers. DPH staff said the department receives aggregate 5150 counts from hospitals and has more detailed records at San Francisco General and other cooperating hospitals; however, hospital privacy rules and fragmented record systems make citywide person-level matching and origin-tracking more difficult. Staff said they would follow up with detailed counts and placements.

Several supervisors raised concerns about capacity. Mandelmann and other members said the city lacks sufficient dual-diagnosis and locked subacute beds; even when funding was allocated the purchases had been delayed, and COVID-19 reduced intake capacity at residential programs. Supervisors urged both legislative and budgetary work to expand placements and consider whether local ordinance requirements (for example, the extra documented voluntary-offer requirements beyond state law) should be revisited to speed referrals.

Public commenters included family members and advocates who warned against overuse of involuntary measures and urged stronger upstream housing and voluntary services, particularly for Black and Latinx San Franciscans who are disproportionately affected. Departments emphasized that housing, intensive outreach, coordinated entry, the street crisis response team and Mental Health SF all play roles alongside conservatorship.

Chair Marr closed by voting to "file" the hearing for now, saying staff would return with additional updates, and the committee recorded a 3-0 vote to accept the hearing and ask for an update in about six months. Mandelmann signaled intent to pursue related state-level funding and legislative support for an expanded conservatorship capacity.