Tag: homelessness

Homeless Action! Meeting Notes, May 25th.  

Adrienne 707-332-1894

By June 2

Main Talking Points, and logistics for the Homeless Coalition and Board of Supervisors meeting:

  1. Most of this money could go to efforts that are not restricted by MediCal, and only help those with an Acute Mental Illness diagnosis and/or Substance Abuse disorder.  $600 million dollars should serve more than 500 people.
  2. This plan does not work to strengthen the “One System of Care.”  It doesn’t match the Homeless Coalition strategic plan or the MRG report adopted by the Homeless Coalition both of which strive for that important goal. 
  3. This plan was made with abysmal Community Engagement.  For example, neither Catholic Charities nor the Homeless Coalition were consulted.

Homeless Coalition Board Meeting
Wednesday, May 27, 2026
1:00 – 4:30 p.m.
https://sonomacounty.zoom.us/j/92759747120?pwd=Cuw1daWSoPM5s8ClAWgPrJ8wYLeBgp.1#success

Phone: +1 669 444 9171
Passcode:  589476
Webinar ID: 927 5974 7120

Board of Supervisors Meeting
Tuesday, June 2, 9 am
In person
575 Administration Drive, Room 102A, Santa Rosa
Public Comment period, only in person

Before June 30

Reach out to Michelle Bass, Director of California Department of Health Services, with the messages above about the Sonoma Counties Behavioral Health 3-Year Integrated Plan.  Suggest that the state take action.

Michelle Baass
(916) 440-7400

Department of Health Care ServicesP.O. Box 997413, MS 0000
Sacramento, CA 95899-7413

Ongoing Work

Influence leadership of county staff over time toward Accountability and Transparency: 

  • Talk to the new people: head of the health department Nolan Sullivan, county CEO, David Guhin, Fiscal Director of Health Department Maryann Le , homeless division manager Hunter Scott.
  • Talk to Angela Stuckman head of the Human Services Dept.  
  • Know that what is coming, (massive budget cuts, cuts to Food Stamps & MediCal), will overwhelm the county staff and make the changes related to this plan seem like small potatoes.  Be kind but firm that challenges are best met with a community response.  Including people is time consuming and sometimes annoying but the best solutions come from this basic democratic process.

Conversation with Gemini

California Continuums of Care and the California Interagency Council of Homelessness have funded homeless management information systems (HMIS) at the county and state level in an attempt to track and evaluaste the outcomes achieved by millions of dollsrs in homeless facility and program services over the past ten years. Nevertheless, long-term tracking of chronic homeless housing outcomes has been hindered by the lack of adequate intra-system and facility tracking. Which counties have successfully moved homeless from the streets to shelters and permanent housing, and retained them ?

The dilemma you are highlighting cuts to the absolute core of California’s multi-billion-dollar battle with homelessness. You hit the nail on the head: while the state has funneled billions into local Continuums of Care (CoCs) and launched the Homeless Data Integration System (HDIS) under Cal ICH to patch these exact data gaps, getting a precise, county-by-county report card on long-term retention is incredibly tricky.

Because of “intra-system tracking gaps”—such as people crossing county lines, or dropping out of the Homeless Management Information System (HMIS) with “unknown” exit destinations—success is rarely measured by sweeping regional victories. Instead, it is measured by specific counties that have built highly coordinated, localized data structures to bypass these limitations.

According to data from Cal ICH’s statewide assessments, university studies (like UCSF’s landmark California Statewide Study of People Experiencing Homelessness), and local CoC reports, a handful of counties stand out for their success in moving people from streets to shelters, securing permanent housing, and keeping them there.

1. Santa Clara County (Silicon Valley CoC)

Santa Clara County is widely regarded as an intra-system data leader because they actively track their “Community Plan to End Homelessness” milestones with sharp precision, accounting for where individuals end up.

  • The Transition: Between 2020 and 2023, the county successfully placed over 10,000 people into permanent housing. They consistently beat regional averages by transitioning roughly 37% of people straight out of temporary emergency shelters directly into permanent homes (the regional target is usually 30%).
  • The Retention: This is where they excel. Santa Clara County reports an astonishing 95.8% housing retention rate within its Permanent Supportive Housing (PSH) programs. Their system is highly tightly knit, meaning if someone is placed, intensive case management keeps them tracked and stable.

2. San Diego County (San Diego City & County CoC)

San Diego has made massive strides by aggressively deploying “diversion” strategies and leveraging HDIS data to track specific sub-populations, particularly veterans and chronically homeless individuals.

  • The Transition: San Diego scaled up its street outreach-to-shelter funnel by utilizing decentralized navigation centers. By integrating their regional HMIS more tightly across cities within the county, they successfully increased successful permanent housing placements out of rapid rehousing and street outreach.
  • The Retention: San Diego’s built-in retention frameworks keep their permanent supportive housing stability rate hovering around 85% to 90%. They have been specifically highlighted for lowering the rate of people who “return to the streets” within two years of being housed.

3. Riverside & Bakersfield/Kern County

If you look at the raw data of “functional zero”—a metric meaning a system can house more people a month than are entering homelessness—these two regions punch far above their weight.

  • The Transition: Bakersfield/Kern County famously became the first community in California to achieve “functional zero” for chronic homelessness. They did this by establishing a daily-updated, master “By-Name List” shared across every shelter and facility, fundamentally eliminating the intra-system tracking gap you mentioned.
  • The Retention: Because their system treats every chronically homeless individual as a specific case file shared by all providers, their retention rates for permanent housing placements are among the sturiest in the state, keeping returns to the street below 10%.

4. Los Angeles County (LAHSA / LA County CoC)

LA County is a paradox. Because of its sheer size, it has the highest raw number of returns to homelessness. However, when looking purely at facility tracking and retention efficacy, their targeted programs tell a different story.

  • The Transition: Through initiatives like Project Roomkey and subsequent permanent conversions (Project Homekey), LA moved tens of thousands of unsheltered individuals into temporary motels and then permanent supportive housing.
  • The Retention: LA’s data shows that when a chronically homeless individual is successfully placed into Permanent Supportive Housing (PSH) paired with intensive case management, the retention rate sits above 85%. The breakdown happens not because the facilities fail to retain them, but because the inflow of newly homeless people vastly outpaces the physical availability of those permanent units.

The Core Data Reality: Why the Tracking Breaks Down

Cal ICH’s sweeping Statewide Homelessness Assessment highlighted exactly what you noted: the “Unknown” problem.

Across California’s aggregated HDIS data, when looking at people who exit homelessness programs:

  • 28% exit to housing without a subsidy (moving in with family/friends or renting).
  • 17% exit to housing with a temporary or permanent subsidy. Business, Consumer Services and Housing Agency – CA.gov
  • 17% are known to remain in sheltered or unsheltered homelessness. Business, Consumer Services and Housing Agency – CA.gov
  • 25% are recorded as “Unknown.” Business, Consumer Services and Housing Agency – CA.gov

The Takeaway: When a county’s data shows a drop in chronic homelessness, it is often difficult to prove whether those individuals were permanently retained, moved to a different county, or simply stopped interacting with service providers entirely, causing them to fall off the HMIS grid. The counties winning this battle are the ones using localized, real-time “By-Name” data systems rather than relying purely on historical, retrofitted HMIS data uploads.

Want to look closer at how ‘By-Name Lists’ fix California’s tracking gaps?Yes

How do By-Name Lists work in HMIS, and how do they prevent chronically homeless individuals from falling through intra-system tracking gaps?

A standard Homeless Management Information System (HMIS) operates like a traditional database. It takes snapshots of data, tracks transactions (like a bed night or a meal), and aggregates that data for state or federal reporting.

The problem? It is backward-looking. A standard HMIS tells you how many people you served last quarter, but it rarely helps a case worker figure out where a specific chronically homeless person is this afternoon.

A By-Name List (BNL) shifts the paradigm from aggregate tracking to real-time coordination. It is a continuously updated, frontline roster of every single person experiencing homelessness in a given community.

How a By-Name List Works

Instead of waiting for a person to walk into a facility to generate a data point, a By-Name List pulls data dynamically from HMIS and street outreach teams into a centralized, living document.

[ Street Outreach ] ──┐
[ Emergency Shelter ] ─┼─> [ Centralized By-Name List ] ──> [ Case Conferencing Team ]
[ Medical/Jails ] ────┘     (Real-time status updates)       (Matches person to next open bed)

The process generally follows four core mechanics:

  • Universal Identification: Every individual is added to the list by name, accompanied by their specific health vulnerabilities, history of homelessness, and current location or “frequent hangouts.”
  • Acuity Scoring: Communities use a standardized tool—most commonly the VI-SPDAT (Vulnerability Index – Service Prioritization Decision Assistance Tool)—to assign a score based on how likely that person is to die or suffer severe harm on the streets.
  • Dynamic Status Tracking: Individuals are tagged with a real-time status: Active (currently unsheltered/sheltered), Housed (successfully placed), or Inactive (has not been seen or heard from by any provider in 90 days).
  • Cross-Agency Case Conferencing: Every week or two, representatives from housing authorities, mental health agencies, street medicine teams, and shelters sit in a room with the list. They don’t talk about general statistics; they go line-by-line: “Where is John Doe? His name is next for the PSH apartment that opened up yesterday.”

How it Fixes Intra-System Tracking Gaps

By changing how data is gathered and viewed, a By-Name List directly plugs the data leaks that plague standard county HMIS frameworks:

1. Eliminating the “Unknown Exit” Black Hole

In a traditional system, if a person leaves a temporary shelter, their file is closed as “Exit Destination: Unknown,” and they effectively become a ghost until they re-register elsewhere.

  • The BNL Fix: Because street outreach teams use the same list, if an individual leaves a shelter and goes back to a riverbed or encampment, the outreach team updates their status back to “Active – Unsheltered” and logs their coordinates. The continuity of their profile remains unbroken.

2. Prioritizing by Need, Not “First-Come, First-Served”

Standard HMIS queues often reward the people who are functional enough to show up to an office early in the morning. The most severely chronically homeless individuals—often suffering from severe mental illness or cognitive decline—rarely fill out the paperwork.

  • The BNL Fix: The list is ordered by vulnerability, not chronology. The system actively hunts for the person at the top of the list, using the collective memory of all county providers to find them when a permanent housing voucher becomes available.

3. Preventing Multi-Agency Duplication

Without a centralized list, a person might get a mental health evaluation from County Agency A, a shelter bed from Non-Profit B, and street medicine from Group C. In standard HMIS, these can look like three different people or disconnected parallel tracks.

  • The BNL Fix: It forces an intra-system “single source of truth.” All three entities update the same file, ensuring that the housing navigator knows exactly what medical clearings or documents the person already has, slashing administrative delays.

4. Defining “Functional Zero”

Without a By-Name List, a county cannot accurately measure if it is winning the battle. They are just guessing based on point-in-time counts conducted once a year.

  • The BNL Fix: Because the list tracks exact inflow (people falling into homelessness) and outflow (people getting housed or moving away) in real time, a county knows exactly when its housing capacity matches its demand.

The Reality Check: A By-Name List is only as good as the human infrastructure supporting it. It requires strict data-sharing agreements between competitive non-profits and county agencies, alongside relentless field outreach. When done right—as seen in communities like Bakersfield—it turns a fractured web of independent shelters into a single, cohesive triage system.

HEAPA Homelessness Advocacy and Policy Updates Sonoma County

1 source·May 23, 2026

This text highlights the transition of street outreach from providing basic survival aid to functioning as a professional, housing-focused pipeline for the unsheltered. While regions like Sonoma County and San Francisco report measurable successes in housing placement and retention, significant systemic hurdles remain, including a shortage of affordable units and fragmented data systems. Local advocates express concern over the Behavioral Health Services Act integrated plan, arguing that its medical-clinical model may exclude vulnerable populations and lacks sufficient community input. To address these gaps, the Homeless Emergency Assistance Program Association (HEAPA) is actively promoting civic engagement and leadership among those with lived experience. Their initiatives focus on providing digital tools, stipends, and advocacy training to ensure unhoused individuals have a voice in the policy decisions that shape their lives. Through these efforts, the organization seeks to bridge the divide between high-level bureaucratic planning and the practical needs of the community.

How is street outreach evolving from survival aid to housing?

Street outreach is transforming from simply providing basic survival aid, like handing out blankets or water, into a professional, housing-focused pipeline. Rather than just managing the crisis of living on the streets, modern outreach workers act as mobile case managers who meet individuals where they are to actively end their homelessness.

Today, successful programs focus on building trust over extended periods to achieve the practical milestones required for housing placement. This evolution includes several key strategies:

  • Document Readiness: Outreach teams help individuals navigate complex government bureaucracies to secure necessary identification, such as lost birth certificates, social security cards, and state IDs.
  • Coordinated Entry Integration: Workers use localized data systems like the Homeless Management Information System (HMIS) to assess people directly in the field, ensuring the most vulnerable are prioritized and seamlessly matched with open shelter beds, rapid rehousing, or permanent supportive housing.
  • Multidisciplinary Teams: Modern outreach programs often deploy hybrid teams featuring mental health professionals, substance use counselors, and peer navigators with lived experience of homelessness, allowing them to provide immediate, trauma-informed care on the sidewalk.
  • Warm Handoffs: Success is no longer defined by simply handing out a flyer with a list of resources. Instead, outreach workers personally walk with individuals, drive them to appointments, introduce them to shelter staff, and remain with them throughout the intake process to ensure continuity of care.

Real-world models reflect this shift, such as Los Angeles’s “Pathway Home” initiative, which brings entire encampments indoors while offering comprehensive care, and family reunification programs that safely reconnect individuals with their existing support networks.

However, while the mechanics of modern outreach are highly effective at preparing people for housing, the ultimate success of these programs remains completely dependent on the availability of low-barrier shelters and permanent affordable housing to fully resolve the crisis.

What are the success rates of Bay Area programs?

Recent data from the Bay Area and Northern California shows that when street outreach is well-resourced, it achieves high transition and housing retention rates. Local municipalities and Continuums of Care track these efforts closely, highlighting several notable success rates across the region:

San Francisco San Francisco’s multi-disciplinary outreach programs have achieved significant permanent housing placements and high long-term stability:

  • Housing Placements: Between July 2023 and June 2025, the system successfully moved 10,300 people from homelessness into permanent housing.
  • Retention Rates: The city reported an exceptional 93% retention rate, meaning 93% of those who exited homelessness did not return to the system within 12 months, exceeding their goal of 85%.
  • Reduced Emergency Calls: In neighborhoods where street outreach and ambassador programs were deployed, there was a 30% to 60% reduction in 911 calls.
  • Immediate Shelter: The RESTORE project successfully served over 2,500 clients by providing nighttime shelter placements and immediate substance use treatment directly from the street.

Santa Rosa and Sonoma County Targeted outreach and expanded interim housing have led to some of the lowest homelessness numbers in the county since 2007:

  • Pipeline Success: In Santa Rosa, city-funded outreach programs successfully transitioned nearly 30% of all unsheltered people they engaged into formal shelters or permanent housing during the 2024–2025 fiscal year.
  • Population Declines: Overall homelessness dropped by 23% countywide and 16% in Santa Rosa. Rohnert Park experienced a dramatic 60% reduction in overall homelessness (including a 78% drop in unsheltered individuals) due to targeted outreach and the opening of a new interim housing site.
  • Veterans: Targeted outreach paired with housing vouchers achieved a 39% reduction in homeless veterans across the county.
  • Challenges: Despite these successes, the number of chronically homeless individuals rose by 20%, emphasizing that the most vulnerable populations still lack adequate Permanent Supportive Housing (PSH).

Berkeley and the East Bay While specific percentage success rates aren’t detailed for Berkeley, the city has successfully implemented the Homeless Outreach Treatment Team (HOTT). Instead of short-term fixes, this specialized model utilizes an evidence-based Critical Time Intervention (CTI) framework to build long-term relationships with highly vulnerable, severely mentally ill individuals to navigate them into housing stability.

Ultimately, regional data demonstrates that the mechanics of modern street outreach are working, but the ceiling of their success is currently capped by a severe regional shortage of affordable housing units and state/federal budget cuts.

Tell me more about Berkeley’s HOTT model.

The Homeless Outreach Treatment Team (HOTT) is a specialized outreach pilot program operated by the City of Berkeley that aims to bridge the gap between psychiatric crises and housing.

Funded largely by the Mental Health Services Act, the HOTT model distinguishes itself through the following key characteristics:

  • Evidence-Based Framework: The program is built on an evidence-based approach known as Critical Time Intervention (CTI).
  • Targeted Population: It specifically focuses on highly vulnerable unhoused individuals who are experiencing severe mental health needs.
  • Long-Term Relationship Building: Rather than offering short-term or temporary fixes, the team is entirely focused on cultivating long-term, trusting relationships with the people they serve.
  • Active System Navigation: Outreach workers don’t just provide information; they physically help individuals navigate the highly fragmented county system to help them achieve long-term housing stability.

What is Critical Time Intervention?

Based on the provided sources, there is no comprehensive, standalone definition of Critical Time Intervention (CTI). However, the sources describe CTI as an evidence-based framework that is put into practice through programs like Berkeley’s Homeless Outreach Treatment Team (HOTT).

In the context of the HOTT model, CTI is characterized by the following approaches:

  • Avoiding short-term fixes: Instead of offering temporary solutions, the framework is entirely focused on cultivating long-term, trusting relationships.
  • Targeting severe mental health needs: It is designed to assist highly vulnerable unhoused individuals who are dealing with severe mental health crises.
  • Active, hands-on navigation: Rather than just giving out information, workers physically help individuals navigate the fragmented county systems necessary to achieve long-term housing stability.

(Note: If you would like a broader clinical or academic definition of Critical Time Intervention, I would need to draw on outside information not included in your current sources. Let me know if you would like me to do so!)

What are the common challenges when implementing HOTT?

The provided sources do not explicitly detail the administrative or operational challenges specifically faced when implementing Berkeley’s Homeless Outreach Treatment Team (HOTT). However, they do identify the broader systemic challenges that affect the success of specialized regional outreach programs like HOTT:

  • Navigating Fragmented Systems: A major hurdle for vulnerable, unhoused individuals is the bureaucracy of local government. HOTT outreach workers must physically help clients navigate a highly fragmented county system to help them achieve long-term housing stability.
  • Affordable Housing Shortages: The ultimate ceiling on the success of these outreach programs is macro-economic; there is a severe regional shortage of affordable housing units.
  • Budget Cuts: Furthermore, state and federal budget cuts restrict the number of permanent beds that outreach teams can actually offer to the people they engage on the street.

How does the fragmented county system affect HOTT’s success?

The fragmented county system acts as an incredibly overwhelming barrier for highly vulnerable, unhoused individuals, particularly those dealing with severe mental health needs or chronic trauma. Because individuals struggle to navigate these disjointed bureaucracies on their own, the fragmentation makes HOTT’s active, hands-on approach the critical factor for their success.

Instead of offering short-term fixes or simply handing out a list of resources, HOTT workers succeed by physically navigating clients through the fragmented county system. They build long-term, trusting relationships and rely on “warm handoffs”—such as driving individuals to appointments, introducing them to shelter staff, and remaining with them throughout the entire intake process—to ensure that clients achieve long-term housing stability without slipping through the cracks of the broken system.

What is the RESTORE project in San Francisco?

The RESTORE project is a specific street outreach initiative in San Francisco that focuses on providing “on-demand” placements and care.

The program is designed to deliver immediate substance use treatment and secure nighttime shelter placements for unhoused individuals directly from the street. As part of the city’s broader “Home by the Bay” strategy to reduce homelessness, the RESTORE project has been highly active, successfully serving more than 2,500 clients.

What is the RESTORE project’s success with substance use treatment?

Based on the provided sources, the RESTORE project in San Francisco is designed to provide immediate substance use treatment and nighttime shelter placements directly to individuals on the street.

In terms of its success, the sources note that the expanded program has successfully served more than 2,500 clients. However, the data provided does not include specific outcome metrics or success rates detailing the long-term effectiveness of the substance use treatment itself, such as sobriety or recovery statistics.

What is the 30% reduction in 911 calls attributed to?

The 30% to 60% reduction in 911 calls in San Francisco is attributed to the deployment of proactive street outreach and neighborhood-based ambassador programs in specific neighborhoods. This reduction demonstrates that engaging directly with individuals on the street helps relieve the overall pressure on emergency services.

What is the RESTORE project’s total client outreach goal?

The provided sources do not specify a total client outreach goal for the RESTORE project. They only note that the expanded program has already successfully served more than 2,500 clients by providing immediate substance use treatment and nighttime shelter placements directly from the street.

What is the RESTORE project’s role in the city’s broader strategy?

The RESTORE project operates as a key outreach initiative within San Francisco’s broader “Home by the Bay” strategy.

Within this strategic framework, San Francisco relies heavily on multidisciplinary street teams—such as the Street Crisis Response Team (SCRT) and the SF Homeless Outreach Team (HOT)—to manage non-violent, health-focused crises. The RESTORE project specifically fulfills the role of providing “on-demand” placements by delivering immediate substance use treatment and nighttime shelter directly to unhoused individuals on the street.

Working alongside neighborhood-based ambassador programs, these proactive street engagements are a vital part of the city’s overall strategy, effectively relieving pressure on emergency services and contributing to significant reductions in 911 calls.

What makes the 93% housing retention rate so successful?

The 93% housing retention rate in San Francisco is a significant marker of success because it means that 93% of individuals who exited homelessness did not return to the homelessness system within 12 months, comfortably exceeding the city’s target of 85%.

This exceptional long-term stability is largely attributed to how modern street outreach has transformed into a professional, housing-focused pipeline rather than simply providing short-term survival aid. The success of this retention rate is driven by several critical practices:

  • Continuity of Care and “Warm Handoffs”: Navigating local bureaucracies can be incredibly overwhelming for individuals dealing with chronic health issues or trauma. Instead of merely handing out a flyer with a list of resources, outreach workers walk with clients, drive them to appointments, introduce them to shelter staff, and stay with them throughout the intake process. This hands-on approach is what prevents vulnerable people from slipping through the cracks.
  • Long-Term Trust Building: Successful programs require workers to build trust over weeks or months to help individuals accomplish practical milestones, such as overcoming complex government bureaucracy to replace lost identification cards.
  • Targeted Matching: Outreach teams integrate with localized data systems to assess people directly in the field, ensuring they are accurately prioritized and matched with the right open shelter beds, rapid rehousing, or permanent supportive housing.
  • Adequate Resourcing: Regional data consistently shows that when these targeted outreach teams are deployed with adequate resources, they are highly effective at achieving these exceptional long-term housing stability rates.

How does Coordinated Entry Integration prioritize the most vulnerable?

Coordinated Entry Integration prioritizes the most vulnerable by bringing the assessment process directly to people living on the street. Rather than waiting for individuals to seek out services, outreach teams use localized data systems, such as the Homeless Management Information System (HMIS), to assess individuals in the field.

This direct, field-based assessment allows outreach workers to identify the most vulnerable people sleeping outside and ensure they are seamlessly matched and prioritized for available resources, such as open shelter beds, rapid rehousing programs, or permanent supportive housing.

The effectiveness of this system has made it a focal point for local housing advocates in the sources. For example, in Sonoma County, advocates have praised the Coordinated Entry System as a carefully built, proven, and effective tool, expressing concern when local government plans—like the draft Behavioral Health Services Act 3-Year Integrated Plan—fail to utilize it. To maximize its impact, advocates have proposed solutions such as requiring 100% of rooms for homeless individuals in county-owned facilities to be filled exclusively through the Coordinated Entry System.

What is the role of the Street Crisis Response Team?

The Street Crisis Response Team (SCRT) is a multidisciplinary outreach group utilized in San Francisco as a key component of the city’s “Home by the Bay” strategy.

Its primary role is to proactively handle non-violent, health-focused crises for individuals living on the streets. Working alongside other groups like the SF Homeless Outreach Team (HOT), the SCRT engages vulnerable individuals during these crises to offer immediate assistance and provide direct shelter placements.

By dispatching specialized teams to manage these health-related emergencies, the SCRT directly relieves pressure on traditional emergency services, contributing to the broader citywide effort that has successfully reduced 911 calls by 30% to 60% in targeted neighborhoods.

How does the Homeless Management Information System work?

The Homeless Management Information System (HMIS) is a localized data system used by county outreach teams to collect data and assess individuals directly in the field.

When used effectively, HMIS is the technical backbone for Coordinated Entry Integration. Outreach workers use the system during street engagements to evaluate an individual’s needs on the spot, ensuring that the most vulnerable people sleeping outside are prioritized and seamlessly matched with open shelter beds, rapid rehousing programs, or permanent supportive housing.

However, the system’s effectiveness relies heavily on how well it communicates with other local government databases. For example, in Sonoma County, homeless data is collected through HMIS, but the county’s Behavioral Health Department uses a completely separate data system called SmartCare (or Smart Key). Local advocates have identified this lack of integration as a major systemic weakness, noting that without integrating the two systems, data becomes disjointed, making it difficult to accurately track a person’s homeless outcomes alongside their clinical visits. This fragmentation creates a risk that vulnerable individuals will “fall through the statistic crack”.

To address these data problems, local advocacy groups like Homeless Action! have proposed the immediate, formal integration of HMIS and SmartCare, while organizations like HEAPA are actively developing projects to help case managers better communicate and collect data across these amalgamating county systems.

What is the SmartCare data system used for?

SmartCare (sometimes referred to as Smart Key) is the primary data system used by Sonoma County’s Behavioral Health Department.

It currently operates as a completely separate system from the Homeless Management Information System (HMIS), which the county uses to track homeless data. Local advocates point out that the lack of integration between these two databases is a major systemic weakness, making it difficult to accurately track a person’s clinical visits alongside their homeless outcomes.

To prevent vulnerable individuals from slipping through the cracks due to disjointed data, advocacy groups have proposed the immediate, formal coordination of SmartCare and HMIS. Meanwhile, organizations like HEAPA are working on upcoming projects to train case managers on how to better communicate and collect data across these amalgamating county systems.

What is the goal of the California Transparency Project?

While the sources do not explicitly define a single overarching “goal” or mission statement for the California Transparency Project, they outline its active initiatives, which demonstrate a focus on improving agency communication, expanding government transparency, and increasing citizen involvement in strategic planning.

Specifically, the project aims to achieve these objectives by:

  • Improving Communication and Data Management: The project purchased digital personal assistant devices for several agencies to test their effectiveness and produced instructional videos showing users how to provide meeting reports with these devices.
  • Increasing Public Transparency: The project requested copies of all service contracts issued by the Departments of Health Services and Human Services for the 2025–2026 fiscal year and made them publicly available online.
  • Prioritizing Citizen Access: The project called for the convening of NOFA (Notice of Funding Availability) planning committees across several groups—including the Sonoma County Community Development Commission, the Santa Rosa Housing Authority, the Sonoma County Homeless Coalition, and the Behavioral Health Boards—to prioritize citizen access to strategic planning and help coordinate their work.

Excellent- now put something up about the big Street Outreach that nobody knows the success of.. (Teddie Pierce, Another Board Member)

Street outreach is one of the most critical, challenging, and misunderstood components of the modern homelessness response system. When people think of outreach, they often picture workers handing out blankets or water bottles. While emergency survival aid is part of the job, the true “success” of modern street outreach lies in its evolution into a professional, housing-focused pipeline.

National Alliance to End Homelessness

Rather than just managing the crisis of unsheltered conditions, successful outreach teams act as mobile case managers who meet people where they are to actively end their homelessness.

1. Shifting from “Band-Aids” to Housing

Historically, street outreach was focused purely on harm reduction and basic survival. Today, successful programs are strictly housing-focused. Outreach workers build trust over weeks or months to accomplish the practical milestones required to get someone off the street:

  • Document Readiness: One of the biggest barriers to housing is a lack of identification. Successful outreach teams turn “impossibilities into successes” by helping individuals replace lost birth certificates, social security cards, and state IDs, and navigating complex government bureaucracy. HomeFirst
  • Coordinated Entry Integration: Teams use localized data systems (like the Homeless Management Information System, or HMIS) to assess individuals directly in the field. This ensures that the most vulnerable people sleeping outside are prioritized and seamlessly matched with open shelter beds, rapid rehousing programs, or permanent supportive housing.

2. Real-World Success Models

Across the country, targeted outreach models combined with rapid funding are showing measurable success:

  • The “Pathway Home” Initiative (Los Angeles County): This encampment resolution program specifically pairs street outreach with immediately available interim housing. Instead of just asking people to move along, outreach teams bring entire encampments indoors together, offering a comprehensive suite of medical care, mental health support, and dedicated case managers. LA County Homeless Initiative
  • Family Reunification Programs: Often, the fastest route out of homelessness is reconnecting individuals with support systems they already have. Outreach workers frequently find success through structured “return home” initiatives—gaining an individual’s trust, locating family members in other cities or states, and coordinating safe travel and warm handoffs. Downtown Development District
  • Multidisciplinary Teams: Some of the most successful urban outreach programs now utilize hybrid teams that include peer navigators (individuals with lived experience of homelessness), mental health professionals, and substance use counselors. This allows teams to provide trauma-informed care and immediate medical or psychiatric support directly on the sidewalk.

3. The Power of “Warm Handoffs”

In professional street outreach, success is rarely defined by handing someone a flyer with a list of resources. Because navigating a fragmented system is incredibly overwhelming—especially for those dealing with chronic health issues or severe trauma—success relies on warm handoffs.

An outreach worker doesn’t just tell someone where a clinic or shelter is; they walk with them, drive them to appointments, introduce them to the shelter staff, and stay with them through the intake process. This continuity of care is what prevents vulnerable people from slipping through the cracks.

The Underlying Challenge: Street outreach workers are highly effective at building trust and preparing people for housing, but their ultimate success is entirely dependent on the availability of low-barrier shelters and affordable housing. Outreach can bridge the gap, but it requires a robust housing continuum to permanently resolve the crisis.

National League of Cities

Would you like to look at specific local outreach programs or data for a particular region?Yes

What are the specific street outreach programs and success statistics for the Bay Area and Northern California?

In the Bay Area and Northern California, street outreach has evolved from basic survival aid into a data-driven, coordinated effort to transition unsheltered people directly into housing and shelter. Local municipalities and regional Continuums of Care (CoCs) track these metrics closely, and recent reports reveal clear evidence of progress, alongside ongoing challenges.

1. Santa Rosa and Sonoma County (Northern California)

Sonoma County and its largest city, Santa Rosa, have demonstrated measurable success by combining street outreach with expanded affordable and interim housing infrastructure.

Local News Matters

  • Steep Overall Declines: The Point-in-Time (PIT) Count revealed that the total number of individuals experiencing homelessness countywide dropped by 23%, falling to 1,952 individuals—the lowest total recorded since the count began in 2007 (Sonoma County Department of Health Services, 2025). In Santa Rosa specifically, homelessness dropped by 16% (City of Santa Rosa, 2025). Nearby Rohnert Park saw an even more dramatic 60% reduction in overall homelessness, including a 78% drop in unsheltered individuals, which local officials directly attributed to targeted outreach and the 2022 opening of Labath Landing, an interim housing site (Local News Matters, 2025). SRCity.org+ 2
  • Street Outreach Transition Rates: In the city of Santa Rosa, street outreach teams have become highly effective at creating a direct pipeline off the streets. During the 2024–2025 fiscal year, city-funded programs engaged thousands of individuals, successfully helping nearly 30% of all unsheltered people met through street outreach transition into formal shelters or permanent housing (City of Santa Rosa, 2025). SRCity.org
  • Targeted Subpopulation Success: Regional outreach coupled with dedicated housing vouchers led to a 39% reduction in homeless veterans countywide (Sonoma County Department of Health Services, 2025).
  • The Chronically Homeless Challenge: Despite these outreach successes, the data highlights a major systemic bottleneck: the number of individuals experiencing chronic homelessness (those on the street for over a year with a disabling condition) rose by 20% (Sonoma County Department of Health Services, 2025). This underscores the fact that while outreach workers are successfully engaging people, the most vulnerable require longer-term permanent supportive housing (PSH) slots, which remain in short supply.

2. San Francisco and the “Home by the Bay” Strategy

San Francisco relies heavily on multidisciplinary street teams—including the Street Crisis Response Team (SCRT) and SF Homeless Outreach Team (HOT)—to handle non-violent, health-focused crises and provide direct shelter placement.

  • Substantial Housing Placements: San Francisco’s overarching strategic initiative reported that between July 2023 and June 2025, the homelessness response system successfully supported 10,300 people in moving from homelessness into permanent housing (SF.gov, 2025). SF.gov
  • High Housing Retention Rates: One of the most significant statistical successes of the Bay Area system is what happens after outreach connects someone to a home. In San Francisco, 93% of individuals who exited homelessness did not return to the homelessness system within 12 months, comfortably exceeding the city’s 85% target (SF.gov, 2025). SF.gov
  • On-Demand Placements via the RESTORE Project: San Francisco expanded its RESTORE project, an outreach initiative designed to provide immediate substance use treatment and nighttime shelter placements directly from the street, serving more than 2,500 clients (SF.gov, 2025). Additionally, street outreach and neighborhood-based ambassador programs contributed to a 30% to 60% reduction in 911 calls in the specific neighborhoods where they were deployed, proving that proactive street engagement relieves pressure on emergency services (SF.gov, 2025). SF.gov

3. Berkeley and the East Bay

In the East Bay, specialized outreach models have been tested to bridge the gap between psychiatric crisis and housing.

  • The HOTT Model: The City of Berkeley’s Homeless Outreach Treatment Team (HOTT) is a prominent example of a specialized outreach pilot (City of Berkeley, 2023). Funded largely by the Mental Health Services Act, HOTT utilizes an evidence-based framework known as Critical Time Intervention (CTI) (City of Berkeley, 2023).
  • Vibe of the Program: Rather than focusing on short-term fixes, the team focuses entirely on building long-term, trusting relationships with highly vulnerable unhoused individuals who have severe mental health needs, physically navigating them through the fragmented county system to achieve long-term housing stability (City of Berkeley, 2023).

Summary of Regional Success Data

The overall picture of street outreach in Northern California shows that the mechanics of outreach are working. When teams are deployed with adequate resources, they are achieving high transition rates (such as Santa Rosa’s 30% pipeline success) and exceptional housing retention rates (such as San Francisco’s 93% stability rate). The primary constraint on these programs’ success remains macro-economic: a severe regional shortage of affordable housing units and state/federal budget cuts that restrict the number of permanent beds outreach teams can offer to the people they engage on the street.

SRCity.org

References

Homeless Action! Feedback

Behavioral Health Services Act (BHSA) 

3-Year Integrated Plan (draft)

Over the past 2-3 weeks members of an informal Homeless Action! Committee worked to understand and analyze this 192-page document.   Our memo below captures the major problems we found.

SUMMARY of the Plan

  • Spends approximately $611.0 million over 3 years.
  • Funding from Federal Financial Participation (FFP): $187.4 million, (BHSA Behavioral Health Services Act): $153.3 million; Other state funding: $99.5 million; 2011 Realignment: $71.6 million; 1991 Realignment: $69.6 million; Opioid Settlement Funds: $13.7 million; Substance Use Block Grant: $8.1 million; State General Fund: $4.8 million; County General Fund: $1.6 million; Mental Health Block Grant: $1.2 million.
  • Confirms Sonoma County’s Homeless Division as part of the Behavioral Health Division of the Department of Health
  • Who Will Be Served (Annual Estimates)

Rental Subsidies: ~70 individuals
Operating Subsidies: ~200 individuals
Landlord Mitigation Supports: ~100 individuals
Participant Assistance Funds: ~300 individuals
Housing Navigation & Tenancy Services: ~130 individuals

  • This plan limits help to those with acute mental illnesses and substance abuse disorders who are eligible for MediCal.
  • One part of the plan is suicide prevention – particularly for middle age and senior men.

APPRECIATION

We greatly empathize with the thinkers and writers of this 200-page document required by government funders.  It’s not simple or easy to produce such a detailed plan that satisfies the State’s requirements.   The plan combined multiple funds and a reorganized county staff with the intention of making the most positive change for the people of Sonoma County as possible.   

It calls out the higher rates of homelessness for American Indian/Alaska Native and Black residents, as well as high suicide rates for middle age and older men.   It attempts to integrate three county-owned facilities into a unified purpose and structure.   It provides money for homeless prevention, funds mobile outreach, and a program which provides health care, mental health and social services to individuals.  

PROBLEMS

There is a critical need for honest feedback because 1) the public money spent in this plan ($611 million dollars) is enormous, and 2) those who are left behind as this plan is implemented will suffer greatly.  The key issues below are some of the crucial problems and deep systemic weaknesses in the county plan.

  1. Lack of Consultation with Community.     The plan was released with less than a month for public comment.  It was released without a summary in clear, straight-forward language.  Many stakeholders, including homeless people and people living with behavioral health problems and substance abuse disorders, were not included.  The Homeless Coalition and Catholic Charities are the most obvious omission, but SHARE Sonoma County, Homeless Action!, the LEAP board, Acts of Kindness, Unsheltered Friends Outreach, and other groups with lived experience are among those missing.
  2. Limitation of Service.  The entire $611 million is earmarked forpeople with acute behavioral (mental) health problems and those with substance abuse disorders.  Housing and other support is entirely missing for the approximately 1,000 homeless people who do not fall into these categories as well as housed individuals living with less-than-acute mental illness. 
  3. Strategic Silos   The county and several cities have strategic plans, often produced at significant cost by consultants.  These were, apparently, not considered in the making of this plan.  The most obvious example of this is the March “Department of Health Services (DHS) Organizational Assessment Homeless Services Division & Sonoma County’s Role as Lead Agency for the Continuum of Care, March 19, 2026”.  This report recommended that the Homeless Division be integrated into the Behavioral Health Division, but many other aspects of this report are ignored in the 3-year plan.  If homeless services are fragmented due to this, homeless people are at risk of becoming a secondary issue. 
  1. Data Problems   The Behavioral Health Department uses SmartCare.  County homeless data is collected through HMIS.  The two data systems are not integrated.   Without a difficult and fast-paced integration, data to assess this plan will be useless, and many individuals will fall through the statistic crack.  The plan cites that of 520 eligible individuals experiencing unsheltered homelessness, zero (0) were recorded as moving into permanent housing.  We hope this is a data problem and not reality.    The Coordinated Entry System which has been carefully built over several years, and proven to be effective, does not seem to have a role in this plan.  It’s important to ensure that the County will be able to track homeless outcomes as well as clinical visits.  There is no accountability or metrics for this.
  2. Medical vs Social Model.    The plan excludes those who are not eligible for Medi-Cal and cannot be diagnosed with a medical disease.  Services are tied to eligibility and diagnosis IF you can get a Behavioral Health referral through ACCESS.  This will exclude many undocumented people.  That is a huge red flag.  The medical-clinical model has been rejected by the disability movement for over 50 years.  With this plan, we risk categorizing our poorest and most vulnerable friends and neighbors as patients who must accept what they are told for their own good.  This is a set up for disempowerment at the time when people most need to have control of their lives.
  3. The CalAIM problem.  The 3-year plan relies heavily on the CalAIM program of Medi-Cal.  The bureaucratic load of Cal AIM will “price out” smaller, more grassroots agencies.   Cal AIM is a force that will put people into a clinical system which will limit support their overall ability to stay housed.
  4. Lived Experience.   The plan speaks of people with Lived Experience and peer support but there is no formal method of integrating feedback or any decision-making power to those with the lived expertise of mental health problems and/or homelessness.
  5. People of Color (BIPOC).   The plan acknowledges crucial disparities among American Indian/Alaska Native, Latino and Black residents in homelessness, arrests and unmet needs but only 3 groups have been selected to respond to a Request for Proposals in this area.  Only 126 individuals in this catagory are expected to be served annually.

SOLUTIONS

  1. Fill 100% of rooms for homeless people in County-owned facilities through the Coordinated Entry System.
  2. Begin a formal SmartCare-to-HMIS Coordination immediately with a 3-month timeline for completion.
  3. Set up a Hub-and-Spoke administrative system whereby larger agencies administer CalAIM for smaller agencies, allowing the grassroots agencies to focus on direct client care.
  4. Expand scope of the plan to include undocumented individuals who do not qualify for Medi-Cal and homeless individuals who do not qualify as acutely mentally ill or living with substance abuse disorders.
  5. Insist upon a robust and meaningful community discussion before further implementation. 

Victories against Trump HUD Actions

Appeals Court Rejects Latest Trump-Vance Administration Attack on Funding for Solutions to Homelessness

Court Continues to Block Unlawful Grant Restrictions that Would Push Nearly 200,000 Americans into Homelessness

Contact: press@democracyforward.org

Press Release

Court Finds Trump-Vance Administration Violated Law In Rush to Politicize Housing Grants

National Alliance to End Homelessness and Women’s Development Corporation Secure Victory in Key Executive Overreach Lawsuit

Date

March 31, 2026

Issue Area

  • Civil Rights, Equity, & Inclusion

Media Contact

press@democracyforward.org

Providence, R.I. – The U.S. District Court for the District of Rhode Island today ruled that the U.S. Department of Housing and Urban Development (HUD) and HUD Secretary Scott Turner violated the law through their “slapdash imposition of political whims,” when approving new funding restrictions that would have unlawfully conditioned access to federal housing grants on compliance with the Trump-Vance administration’s partisan agenda. 

The decision issued today in National Alliance to End Homelessness v. Turner, et al., is a victory for The National Alliance to End Homelessness and Women’s Development Corporation, which filed a lawsuit last September challenging the grant restrictions. The groups are represented by Democracy Forward, National Homelessness Law Center, Lawyers’ Committee for Rhode Island, and ACLU Foundation of Rhode Island in the matter.

“This ruling is a victory for people across this nation who have overcome homelessness and stabilized in HUD’s permanent housing programs,” said Ann Oliva, CEO of the National Alliance to End Homelessness. “Today’s news reinforces a fundamental truth: that the work to end homelessness is not partisan, and never should be interfered with for political means. On behalf of the people and providers we serve, the National Alliance to End Homelessness pledges to continue fighting back against efforts to dismantle homeless response in America.”

“The solution to homelessness is stable, predictable, permanent housing,” said Frank Shea, Executive Director of Women’s Development Corporation.  “Organizations providing this housing need fair, predictable programs that are free of politicized criteria.  We are glad the court agrees.  Our neighbors in need of housing deserve nothing less.”

The lawsuit, filed in the U.S. District Court for the District of Rhode Island, asserted that HUD’s newly imposed criteria for “Continuum of Care (CoC) Builds” grants were unlawful. This is the third time that HUD has issued this same grant opportunity, even after grant awards had already been announced to Congress. In so doing, HUD introduced extreme political criteria to the application. Under the new funding application rules, service providers and communities were blocked from applying for federal housing funds for new Permanent Supportive Housing for individuals and families experiencing homelessness if they operate in jurisdictions with policies the Trump-Vance administration disfavors. This includes states and cities with sanctuary protections and cities that criminalize public camping. The new funding criteria also would have disqualified organizations that provide services considered “harm reduction,” such as Safe Drug Use Criteria practices and those that have inclusive policies for transgender people. 

Today’s ruling declares the notice announcing the funding opportunities, the new political criteria used by HUD when deciding to issue grants, and the one-week application period for the grants all to be unlawful and orders the policies vacated and set aside. The court additionally ordered the already-appropriated funding to remain available for award, consistent with the Court’s order. 

“For more than three decades, the federal government has supported housing providers and communities through HUD’s programs to help people experiencing homelessness move into stable housing,” said Skye Perryman, President and CEO of Democracy Forward. “We are honored to have worked with these brave plaintiffs and co-counsel to hold this administration accountable for their unlawful actions, and we are pleased that the court has stopped the Trump-Vance administration from holding life-saving funding hostage to a political agenda.”

“Hundreds of thousands of unhoused people need housing and supports to survive.  Instead of following Congress’ direction to increase that supply of supportive housing, this Administration unlawfully manipulated a grantmaking process that would have only made homelessness across the country worse,” said Antonia Fasanelli, Executive Director at the National Homelessness Law Center.  “We were honored to represent the National Alliance to End Homelessness and to work with our esteemed co-counsel in preventing the Administration from forcing an ideological agenda on a program that is intended to save lives.”

“The Lawyers’ Committee for Rhode Island will continue to fight for Rhode Islanders whenever and however the Trump Administration threatens them with unlawful actions,” said Amy Romero, Chief Legal Counsel of Lawyers’ Committee for Rhode Island. “We are pleased with this court’s decision that recognizes that this Administration violated the law by imposing their political whims on federal funds intended to address the needs of individuals and families experiencing homelessness.”  

“The federal government’s distortion of the grant process for blatant political and ideological gains put funding for life-saving services at risk,” said Steven Brown, executive director of the ACLU of Rhode Island. “We are extremely gratified that Rhode Island organizations like the Women’s Development Corporation will be allowed to receive federal funding thanks to the court’s decision.”

The plaintiffs are represented by Kristin Bateman, Yenisey Rodríguez, Kristen Miller, and Robin Thurston from Democracy Forward; Amy Romero and Kevin Love Hubbard for the Lawyers’ Committee for Rhode Island; Antonia Fasanelli from the National Homelessness Law Center; and Lynette Labinger for the ACLU Foundation of Rhode Island. 

Read today’s order here and the original filing here.

We did it.

For the second time in two days, the courts have ruled against the Trump Administration’s efforts to illegally meddle in federal homelessness programs. Today’s ruling from the 1st Circuit Court of Appeals means the U.S. Department of Housing and Urban Development (HUD) cannot move forward with its plan to release the December 19th Continuum of Care (CoC) Program Notice of Funding Opportunity (NOFO) to hold an absurd partial-year competition. Our Preliminary Injunction remains in place.

This will bring immense relief to communities across the country who were faced with the prospect of running overlapping local CoC NOFO competitions. Most importantly, this means HUD must renew all awards expiring this year — which will keep people in their homes, program staff employed, and landlords paid their rent. The full opinion can be found here:Read the Full Press ReleaseAnd it’s not over yet. Preventing the December NOFO is just a part of our ongoing litigation. The full merits of our case remain before the U.S. District Court for the District of Rhode Island awaiting final judgment, and we trust our legal counsel has put forth a strong set of arguments for the Court to consider.  Democracy Forward and the ACLU Foundation of Rhode Island represent the coalition of nonprofit organizations in the matter; the National Homelessness Law Center represents NAEH and NLIHC; Public Rights Project represents the cities of Boston, Cambridge, Nashville, and Tucson as well as King County; Santa Clara County and San Francisco are also plaintiffs. The Lawyers’ Committee for Rhode Island represents all plaintiffs.

Homeless Action! Settlement Terms with County/City

Here is a link to the Powerpoint (coming soon) outlining the recent settlement terms between Homeless Action! and the County of Sonoma and the City of Santa Rosa resolving their 8-year old federal lawsuit over the rights of the unhoused during clearance of their encampments.

Here is a summary of each:

City Settlement Highlights

The settlement with the City of Santa Rosa provides that the City will not remove unhoused people’s belongings from public property except in very limited circumstances: 

  • There are exigent circumstances—e.g., an immediate threat to health and safety—that require the items’ removal; 
  • When the police arrest someone and safekeep their property; or  
  • When items are collected for evidence. 

Instead—and even in exigent circumstances, where possible—the City agrees to give people time to move their own belongings, including letting them move their belongings in multiple trips and other accommodations based on individual needs and circumstances. 

The language also includes requirements for City staff and contractors to document instances when they remove belongings from public property, including posting notices where feasible and sharing information on the City’s website. 

The City also agreed not to use threats of citation or arrest to pressure people into abandoning their belongings. 

These and other requirements will be incorporated into the written policies for SRPD and the City’s Debris Response Team, and the City will train staff on the policy changes. 

The City settlement will remain in effect for one year. 

County Settlement Highlights

The settlement with Sonoma County and the Sonoma County Community Redevelopment Commission includes policy commitments related to the County’s treatment of unhoused people’s personal property, reasonable accommodations for people with disabilities, and due process in County shelter facilities. 

The settlement requires the County—including sheriff’s deputies on the Joe Rodota Trail—to provide reasonable written notice of no less than 10 hours before it removes unhoused people’s belongings from public property, as well as storage of those belongings for at least 90 days, with limited exceptions. It also requires a post-removal notice and a process for people to get their belongings back. 

The County settlement includes requirements for certain County policies, protocols, and contracts to include language regarding reasonable accommodations for people with disabilities to ensure fair treatment and meaningful access for unhoused people with disabilities.  

The County will also comply minimum due process requirements that must be followed before people can be “exited” from County homeless shelters, ensuring that individuals have notice of the reason for the exit and an opportunity to challenge the exit if they disagree. 

The County settlement will remain in effect for three years. 

Sonoma DHS Homeless Revamping Workshop, Oct 23rd

Short Summary

You participated in a feedback session on the county’s new vision for homeless services.

Long Summary

The meeting was called by the Department of Health Services feedback session where new leadership, Nolan Sullivan and Desirae

Olstrom, unveiled a revamped strategy to address homelessness. They proposed a “funnel” system using county facilities to support individuals with high-acuity behavioral health needs. The majority of the meeting was dedicated to gathering your and other partners’ feedback on this new model, identifying systemic gaps, and discussing the need for better collaboration, data transparency, and a unified system of care.

The problem

The Department of Health Services is revamping its homeless services team and seeking feedback on a new vision to improve partnerships and service delivery. The county aims to address its historically siloed approach and open up its resources and processes for better collaboration. The primary focus of the new vision is the segment of the homeless population with high-acuity behavioral health and substance use needs, which is estimated to be 5-10% of the total 1,900 homeless residents. This group is often difficult to serve in traditional programs and can destabilize properties.

Themes discussion

A new “funnel” system was proposed by the county to create a continuum of care for high-acuity individuals. The pathway would move clients through a series of facilities with increasing levels of independence: 

  • Eliza’s Village: The entry point for stabilization.
  • Arrowwood: Single occupancy rooms with more services. 
  • Mickey Zane: Individual apartments to prepare for independent living.

The end goal is to graduate individuals back into the Coordinated Entry (CE) system for Permanent Supportive Housing (PSH).

A major concern raised was the large population that the county’s proposed funnel would not serve, leaving approximately 1,500 individuals for partner agencies to handle. This includes specific hard-to-house groups, such as arson (219) and sex offense (290) registrants, who are often screened out of existing housing options. The need for a single, unified system of care was a recurring theme, emphasizing the need to break down silos between county departments (e.g., Homelessness and Behavioral Health) and external partners. Data transparency and system functionality were highlighted as critical for building trust and enabling effective

collaboration. The current HMIS system is considered limited in its reporting capabilities. Resource constraints and funding limitations for the county, cities, and non-profit providers were an underlying issue throughout the discussion.

Specific ideas

Integrate county behavioral health staff directly with partner agencies and on-site at facilities. This “in-person handoff” is seen as extremely beneficial for navigating clients into services. 

  • Develop a centralized and transparent referral system for providers. This would allow agencies to submit referrals for high-needs clients and track their status. 
  • Provide a higher level of ongoing support for clients once they are in PSH. An Assertive Community Treatment (ACT) model was suggested for individuals who continue to need intensive services after being housed. 
  • Address the challenge of individuals who refuse services or are too ill to engage with support systems. 
  • Streamline the contracting and RFP process to reduce administrative burden. Suggestions included creating multi-year contracts and consolidating various city and county RFPs into a single cycle.

Future directions

  • The county should take on a lead role as a convener to bring together all stakeholders, including shelter providers, tribal entities, and cities, to address system-wide issues. 
  • One immediate project suggested was creating a coordinated emergency weather response plan. 
  • The group should develop a unified advocacy message to state legislators regarding restrictive funding and unfunded mandates.
  • A formal “gap analysis” is needed to inventory all existing services and providers in the county to identify where deficiencies lie.
  • The county will continue to refine its “funnel” model while considering the feedback on excluded populations and operational challenges, such as the remote location of Eliza’s Village. 
  • The county acknowledged the need to improve internal policies, noting they recently implemented a six-month time limit at facilities like Eliza’s Village to ensure client progression.

California Behavioral Health Planning Council Meeting on June 19, 2025, Housing and Homelessness Committee

Item #2 California Interagency Council on Homelessness (Cal ICH) Action Plan for 2025 – 2027 

Cody Zeger, Director of Statewide Policy at the California Interagency Council on Homelessness (Cal ICH), presented an overview of their 2025-2027 Statewide Action Plan to prevent and end homelessness. Cody began with a brief introduction to Cal ICH, which is responsible for overseeing the implementation of Housing First policies, guidelines, and regulations supported by an advisory committee and a lived-experience advisory board. 

Initially launched in 2020, Cal ICH’s Action Plan aims to coordinate state efforts to address homelessness with a vision of building an equitable and just California where homelessness is rare, brief, and a one-time experience. The 2025-2027 Action Plan focuses on the following five key goals: 

• Help more people leave unsheltered homelessness. 

• Help more people move into housing. 

• Ensure people do not experience homelessness again. 

• Prevent more people from experiencing homelessness. 

• Create more housing. 

Cody also presented the plan’s three-year targets: 

• Move 70% of unsheltered individuals into shelters. 

• Place 60% into permanent housing. 

• Create 1.5 million new housing units with 710,000 designated for low-income residents. 

He described key strategies to meet these goals such as interagency coordination, strategic investments, and equity-centered frameworks to address systemic barriers. Cody highlighted core principles that guide the plan, such as prioritizing racial equity, adopting trauma-informed approaches, and elevating the voices of those with lived experience of homelessness. 

Cody concluded his presentation and opened the floor for questions from committee members. Key topics included: 

• A committee member inquired about the size of the lived experience advisory board. Cody shared that Cal-ICH reduced its membership from 30 to approximately 25 members. Each member serves a two-year term. He explained that the board provides subject matter expertise, reviews key documents, and offers recommendations to Cal ICH members before key decisions. 

• A committee member raised concerns about the proposed 44% federal cuts to the U.S. Department of Housing and Urban Development (HUD), particularly their impact on project-based and tenant-based rental assistance. Cody acknowledged the risk, noting that 15,000 emergency housing vouchers are slated to expire. 

• A committee member asked how the number of homeless individuals aligns with the projected housing units. Cody explained that the 2.5 million planned units, including 1.5 million by 2027 and 710,000 reserved for low-income residents, are part of a broader housing strategy and not specifically designated for the homeless population. 

• A committee member asked how racial equity is reflected in the plan’s goals and data analysis. Cody emphasized Cal ICH’s commitment to disaggregating targets by race, ethnicity, and gender to ensure a more inclusive and equitable approach. 

• When asked about Cal ICH’s leverage in advancing the Action Plan, Cody described their statutory authority and stressed the importance of cross-agency relationships. He noted that their influence stems from formal power and their ability to communicate and coordinate across state departments. 

Public Comment: 

Paula, a member of the public, inquired about current data reflecting progress toward the plan’s three-year goal of a 42% increase in housing placements. Cody directed her to Cal ICH’s website, where quarterly updates provide the latest information. He noted that the most recent data covers the calendar year 2024. 

Barbara Wilson from Los Angeles County raised a question about tracking individuals moving from hospital settings to residential facilities, particularly those with psychosis. She was concerned about how these transitions are captured and whether individuals lose housing access once in licensed facilities. 

Council Member John Black emphasized the importance of early intervention, proposing the use of peer support workers to help individuals who are newly experiencing homelessness before their situation worsens. 

Item #3 Perspectives on Recovery Housing Panel Discussion 

Over the past two quarterly meetings, the Housing and Homelessness Committee engaged in discussions about recovery housing and the Housing First model. The discussions focused on their roles within behavioral health services and highlighted key challenges and best practices. This panel built on those discussions and provided first-hand insights to inform the Committee’s work further. 

The panel featured three distinguished speakers with lived experiences of addiction and homelessness: 

• Elizabeth Colorado, Advocate for the Unhoused Community 

• Claudine Sipili, Lived Experience & Innovation Director, Destination Home 

• Anna Kokanyan, Director of Admissions & Program Director, Conquer Recovery Centers 

Each panelist shared their personal story of how recovery housing played a pivotal role in their journey to stability and long-term recovery. They addressed the barriers often faced during transitions from homelessness and addiction to stable housing, including financial hardship, limited guidance, and systemic obstacles. Their experiences highlighted the need for compassionate, structured environments that foster connection and provide resources without rigid requirements. 

The panelists called for more flexible, trauma-informed approaches that prioritize human dignity, autonomy, and choice. Claudine emphasized the need to advocate for policies that center racial equity and incorporate lived expertise. She also stressed that recovery housing should remain voluntary and not a requirement. Anna emphasized the need to validate individuals’ feelings and provide care in safe and supportive settings. Elizabeth highlighted the need to meet people where they are and guide them through both recovery and permanent housing pathways. 

The panelists expressed their gratitude for the opportunity to share their experiences. The discussion concluded with a Questions-and-Answers session with committee members. Key topics included: 

• A committee member asked Anna about the duration of her program at Conquer Recovery Centers and why participants travel from out of town. Anna explained that many public facilities have waitlists of six to nine months. Her program, which accepts private insurance, provides more immediate access to treatment. 

• A committee member celebrated Anna’s recent acceptance into a college program and shared heartfelt reflections on her journey. They emphasized the value of lived experience, resilience, and personal growth. 

• Another member raised concerns about the decision to offer housing before addressing mental health and substance use needs. The panelists acknowledged the diverse perspectives on the Housing First model and emphasized that services must reflect individual needs and allow each person to guide their own recovery. 

• When asked how they remain strong and grounded in their work, the panelists shared personal wellness practices. Anna spoke about the importance of caring for the mind, body, and spirit through exercise, prayer, meditation, a healthy diet, and therapy. Claudine described her connection with nature through off-road travel as a source of peace, reflection, and spiritual strength. Elizabeth emphasized simple acts of kindness to give back and stay rooted in empathy and purpose. 

• A committee member offered encouragement and shared a personal story about how they helped an individual regain custody of her children. The story affirmed the power of persistence, compassion, and hope. 

Public Comment: 

Barbara Wilson expressed appreciation for the panel discussion and proposed the creation of a safe healing space for individuals with behavioral health challenges. She shared that, in her experience, every unhoused person she had worked with could successfully maintain housing. Barbara also raised concerns about the Housing First model, noting that some individuals struggle with its structure and may feel like failures when they must return to more supported environments. Additionally, she questioned defining success solely in terms of paid employment, emphasizing that mental health conditions can impact a person’s ability to work. 

Anna, a college student, shared how impactful it was to hear directly from individuals with lived experience. While she studied incarceration and homelessness in her coursework, she said the personal stories gave her a deeper and more meaningful understanding of the issues. 

A committee member highlighted the challenges of treating individuals who use substances. She acknowledged the value of harm reduction but emphasized that trauma work remains difficult when a person remains under the influence. 

Item #4 Cal ICH and Recovery Housing Panel Debrief Discussion 

The Committee debriefed on the information presented by Cody Zeger from the California Interagency Council on Homelessness (Cal ICH) and the panelists from the Recovery Housing Panel. Committee members also discussed potential next steps. 

A committee member expressed deep appreciation for the lived expertise shared by the panelists. She emphasized the value of hearing from individuals who have experienced addiction and homelessness, are now in recovery, and are helping others through successful programs. She encouraged the inclusion of similar presentations in future meetings. Another committee member outlined the following follow-up items in response to the presentation from the California Interagency Council on Homelessness (Cal ICH): 

• Federal Housing Voucher Concerns: Urged follow-up with Cal ICH about federal funding cuts and reduced availability of rental vouchers. She noted that the presentation addressed only Homeless Prevention vouchers, which make up a small portion of the total supply. In Monterey County, she reported that no new Tenant-Based Vouchers appear available, and Project-Based Vouchers remain unavailable, which has stalled progress for individuals on waitlists. 

• Support for Undocumented Populations: Requested information on Cal ICH’s strategy to support undocumented individuals. The committee member shared that 13.5% of her county’s population are undocumented and many in this group experience homelessness. She shared that local shelters have reached capacity and often house undocumented families for extended periods, which forces others in need of emergency shelter to go without. She urged the Committee to seek state-level guidance and data on this growing concern. 

The committee member raised concerns about the long-term effectiveness of six-month rapid rehousing programs. She explained that individuals with serious mental illness who are unemployed often do not meet eligibility requirements for these short-term services. Even among those who do qualify, many are unable to sustain rent payments once the assistance ends. In one local case, 90% of participants became homeless again after the six-month support period. She questioned whether this approach offers a sustainable solution. 

A committee member added that shelters should function as gateways to permanent housing, not long-term temporary accommodations. While acknowledging the value of recovery housing, he stressed that it is just one piece of a broader housing continuum that requires support. 

Another committee member emphasized the importance of homelessness prevention. She referenced research from the University of California, San Francisco, showing that many people become homeless after missing a single rent or mortgage payment. She questioned why state and national investments remain focused on rehousing rather than proactively preventing housing loss. She also acknowledged the efforts of one panelist whose organization is working effectively in the prevention space. 

A committee member described the current moment as a pivotal opportunity to advance the Committee’s advocacy efforts. He noted that, although the presenter outlined several strategic goals, homelessness prevention remained undefined. He emphasized the value this Committee brings, as members provide firsthand insight into effective prevention strategies. The committee member added that the collective effort of this Committee could help influence broader policy decisions and bring hope to individuals at risk of homelessness. 

Public Comment: 

Barbara Wilson expressed appreciation for the Committee’s longstanding work, recalling her early involvement when she raised concerns about the closure of licensed adult residential facilities due to low reimbursement rates. She also highlighted the gap in oversight for sober living homes, which are unlicensed and therefore not subject to consistent standards. Barbara noted she has been in dialogue with her county’s Sober Living Council and referenced similar efforts in Santa Clara County to establish operational guidelines for these homes. 

She emphasized the lack of communication between systems and that many individuals’ experiencing homelessness are unaware of licensed residential options. In contrast, mental health providers often lack insight into the realities of homelessness. Barbara stressed the urgency to break down these silos, particularly due to recent resistance from the substance use community during a Los Angeles County town hall meeting, where concerns were raised about merging mental health and substance use systems. 

Action/Resolution 

Committee staff will follow up with the questions to the California Interagency Council on Homelessness (Cal ICH). 

Responsible for Action-Due Date 

Simon Vue – April 2025 

Item #5 Proposition 1 Update 

Council staff, Simon Vue, shared an update on Proposition 1 Bond Behavioral Health Continuum Infrastructure Program (BHCIP) Round 1: Launch Ready. 

On May 12, 2025, the Department of Health Care Services (DHCS) announced Proposition 1 BHCIP Round 1: Launch Ready awards. Eligible organizations applied for funding to construct, acquire, and rehabilitate properties for behavioral health services for Medi-Cal members. The Department awarded 124 projects across 214 behavioral health facilities in California to support: 

• 5,077 new residential/inpatient treatment beds for mental health and substance use disorders. 

• 21,882 new outpatient treatment slots. 

Additionally, the Department is preparing to launch BHCIP Round 2: Unmet Needs in May 2025, which will provide up to $1 billion in competitive funding awards. 

This funding is a vital part of the Department’s Behavioral Health Transformation efforts, which aim to strengthen California’s approach to providing services for mental health and substance use disorders by focusing on community-based care and support. Although the Behavioral Health Continuum Infrastructure Program (BHCIP) is not part of Proposition 1, the measure allocates up to $4.4 billion through the Behavioral Health Infrastructure Bond Act (BHIBA), which establishes the program as a key vehicle to expand California’s behavioral health infrastructure. This funding supports the development of treatment facilities, including residential care settings and supportive housing. The Department distributes these funds through competitive grants, focusing on community-based services and regional projects. 

Action/Resolution 

Staff will continue to monitor for the May updates regarding the Bond Behavioral Health Continuum Infrastructure Program Round 2: Unmet Needs. 

Responsible for Action-Due Date 

Simon Vue – May 2025 

Measure O Annual Update

There is a Dec 10th Report to the Board of Supervisors from the Department of Health Services titled ” Measure O Update for Fiscal Year 2023-2024” which updates them on the progress of Measure O, our sales tax-funded Behavioral Health and Homeless Community Solutions Initiative. 

Executive Summary: The Sonoma County Board of Supervisors requested an update on Measure O during the June 2024 Budget hearings. This update covers fiscal year 2023-2024 expenditures by category; estimated fund balance for fiscal year 2024-2025 and fiscal year 2025-2026; and provides a review of outcomes and numbers served from last fiscal year. Additionally, staff will highlight Measure O successes and discuss the approach for current and future Measure O funding.

Discussion: In November 2020 Sonoma County voters passed Measure O to provide essential funding for mental health and homeless services with 68.07% of the vote. Measure O, a one-quarter cent sales tax, was estimated to generate over $25 million each year for ten years to help protect essential mental health and homelessness services.

The Measure O Sales Tax Ordinance identified five categories of services to be funded with the revenue: 1) Behavioral Health Facilities, 2) Emergency Psychiatric and Crisis Services, 3) Mental Health and Substance Use Disorder Outpatient Services, 4) Homeless Behavioral Health and Care Coordination, and 5) Transitional and Permanent Supportive Housing. The Measure O Expenditure Plan designates a set percentage of funding for each category.

On December 7, 2021, the Board of Supervisors established a Citizen’s Oversight Committee to monitor the implementation of Measure O. The Citizen’s Oversight reviews expenditures for alignment with the intent of the Measure and does not make or recommend funding decisions.

On October 23, 2024, the committee voted to confirm that the Measure O expenditures for Fiscal Year 2023-2024 met the intent of the measure. This past fiscal year was the 3rd full year of Measure O funding. Tax revenues for the year again exceeded the initial projections made when voters considered Measure O. Tax receipts totaled $32 million as opposed to the initially projected $24 million (total revenues including interest and unrealized gains was $34.2 million) The surplus has provided capacity to pursue expanded opportunities within the established categories to support our community.

For Fiscal Year 2023-2024, below are the Measure O funds used/spent by category: · Behavioral Health Facilities: $7,055,539 · Emergency Psychiatric & Crisis Services: $12,425,458 · Mental Health & Substance Use Disorder Outpatient Services: $1,275,496 · Behavioral Health Homeless & Care Coordination: $7,842,652 · Transitional & Permanent Supportive Housing: $3,345,616 The total projected Measure O revenue for FY 2024-2025 is $32,865,501.

In FY 24/25 a total of $66.2M of Measure O resources are available for programming, financed with $33.3 in fund balance and $32.9M of total revenues.  The approved FY24-25 budget includes $37.5 million in expenditures for Measure O.  The Department will be seeking $10.2 in additional appropriation in FY 2024-2025 Q4. Given the total planned expenditures of $47,739,541 for FY 2024-25 budget, the ending fund balance in June is projected to be $18,478,541.

Details of the various expenses by categories with additional information can be found in Attachment A Presentation.

The Mobile Support Team and Crisis Assessment Prevention and Education described below highlight recent updates from the Measure O-funded Mobile Support Team (MST) and Crisis Assessment Prevention & Education (CAPE).

· In December 2022, California Department of Health Care Services (DHCS) established a new Medi-Cal benefit providing 24/7/365 community-based mobile crisis intervention services to those experiencing a behavioral health crisis. On April 16, 2024, county staff launched Sonoma County’s 24/7 call center and a revamped Mobile Support Team (MST) to meet this need. The MST is partnering with SAFE (which serves Petaluma, Rohnert Park, Cotati and Sonoma State University) and inRESPONSE (which serves Santa Rosa)) to provide countywide coverage. The Sonoma County 24/7 call center and revamped MST is available to all Sonoma County residents regardless of insurance status. An additional $5M in Measure O funds are being held for contingencies from potential MST expansion based on future county and Regional Model City needs. The actual draw on the fund balance will be recalculated based on Federal Financial Participation action receipts from the Medi-Cal program.

· Crisis Assessment Prevention & Education (CAPE). CAPE provides school-based behavioral health support and interventions to schools in Sonoma County. Four mental health teams are strategically located across the county. CAPE is reinstituting in-person response to students experiencing behavioral health crisis and linking students to substance use disorder treatment services for to youth and young adults.. The program is active and expanding, providing services such as: direct linkage to County Behavioral Health services and navigating other health insurance to connect to treatment; substance use and suicide prevention and early intervention – educational presentations and campaigns, linkage, and referral; and peer support and groups. In the 2024-2025 school year , CAPE will be partnering with these schools: Analy High School and Laguna High School in West County; and  Sonoma Valley High School, Creekside High School, Adele Harrison Middle School, Alta Mira Middle School, and Hanna Boys Center in the Sonoma Valley.

Successful Outcomes from Measure O

The Psychiatric Health Facility (PHF) has continued to operate at its full capacity of 16 beds, serving over 150 individuals annually due to Measure O funding.

The Crisis Stabilization Unit (CSU) served nearly 1,000 individuals and was also able to continue operations at full capacity due to Measure O until the current temporary closure due to facility issues. The Mobile Support Team has expanded into a Regional Collaboration that utilizes exciting new approaches to crisis response.

Measure O has also laid the groundwork for new programs launching this year, including CAPE, additional support for the Valley of the Moon Short Term Residential Treatment facility, and the expansion of Medi-Cal drug service.

This year also saw the finalization of incorporating Homelessness Services into DHS with Measure O providing 100% of funding for the Homeless Encampment Assistance and Resource Team (HEART) and Solving Obstacles for Unsheltered Lives (SOUL) programs, and a significant amount of funding ($4.2M) for George’s Hideaway. The George’s Hideaway project is a Permanent Supportive Housing (PSH) Project Homekey site near Guerneville. Measure O funds were used to support site renovation (including planning, water/sewer, and demolition work) under oversight of the Community Development Commission (CDC).  This site will provide supportive care including therapy, substance use disorder care, benefit navigation, job training and life skills.

Also, in September of this fiscal year, the funds allowed for the release of the Measure O: Behavioral Health & Homelessness Community Solutions Notice of Funding Availability (NOFA) in the amount of $5.6 million, including $4.2 of Measure O funding and $1.4 million in Homeless Housing, Assistance and Prevention (HHAP) funding. The NOFA is open to applications from interested parties, community partners and any other local government agencies. The NOFA covers multiple program areas within each Measure O category with a specific focus on areas of identified need including on service navigation, staffing shortages, education/training and upstream approaches, peer support, individual and family counseling, and cultural competence. Additionally, the HHAP portion of the NOFA prioritizes permanent supportive housing, rapid rehousing, emergency shelter (congregate and non-congregate), street outreach, capital expenses for permanent supportive housing or enhancing existing emergency shelter projects for privacy, and lastly, operating subsidies for permanent supportive housing and rapid rehousing.

To determine priorities and opportunities for strategic application of Measure O funding in the future, department leadership plans to conduct a detailed budget and program analysis and identify areas where Measure O funding could be used and where other funding sources could be leveraged. The goal is to separate annual, recurring commitments from the projects where funding could be shifted as they mature and/or become self-sustaining. 

The remaining Measure O funding would be a mix of unallocated fund balance and expected revenues.  Staff plans to release a recurring Notice of Funding Availability (NOFA) for which Community Based Organizations and local government partners could apply. Through an open application process, a Community Advisory Panel will be selected to help review NOFA proposals and make recommendations to the Board for final approval. Staff will present the outlines of this proposal to the Board for further guidance and direction at the Board meeting.

https://sonoma-county.legistar.com/LegislationDetail.aspx?ID=7040199&GUID=50628097-0FF6-49E5-AB44-8607A01F14CB