Decline of assisted living facilities impacts S.F.’s aging homeless population

‘We need a much more aggressive strategy to provide beds for people’

For San Franciscans looking for assisted living in their hometown, options are dismal and the result can be life-threatening.

Over the past decade, the number of residential care facilities has plummeted across San Francisco. Between 2012-2018, The City lost 186 beds in residential care facilities for the elderly that serve under 15 people, according to city reports. More than two dozen of these small facilities shut down during that time, while just 74 beds were added at larger facilities.

“The impact is dramatic. These are the folks who built this city and now the options given to them are homelessness,” said Laura Slade Chiera, San Francisco’s executive director of legal assistance to the elderly.

Small changes have started to slow down the alarming trend, but only to an extent. Between 2018 and 2021, nearly 460 beds at assisted living facilities for the elderly were added. But these beds were almost entirely within large facilities that serve more than 100 people, including the San Francisco Campus for Jewish Living and Portola Gardens.

Smaller assisted living facilities that offer a more home-like setting, meanwhile, are falling out of the fabric of The City’s health care and housing networks, creating a gap in the care continuum as the population ages.

Those seeking assisted living often face long waitlists, are moved out of county or end up on the streets. As of January 2019, 103 individuals were waiting to be placed into an assisted living facility, according to a 2019 report by San Francisco’s Human Services Agency.

“We have lost a lot of board and care facilities, and this has contributed to the homelessness crises,” said Jennifer Friedenbach, director of the Coalition on Homelessness. Previously, “people could use their disability check and got a place to stay and food and support. Then over time, board and care was lost and the disability check wasn’t enough to cover rent and health care alone.”

New policies can help

City leaders are now exploring potential policy changes to help curb the trend. This month, the Board of Supervisors passed an ordinance that would require approval for the change of use of any existing residential care facility to discourage additional losses.

The rule also makes it easier to open new residential care facilities by removing permit requirements for facilities of seven or more beds in all residential zoning districts.

The ordinance will become effective on Oct. 31, but it’s already been put to the test through a pilot version of the policy that went into place in 2019 and was set to expire in October.

The interim policy helped slow down the conversion of one 33-bed facility on Broderick Street run by the nonprofit Richmond Area Multi-Services. The building’s owner sought not to renew the lease and sell the building, which was leased by the Department of Public Health. And supporters say the rule provided leverage in negotiating with the owner, who agreed to renew the lease for three more years.

“These residents we serve are very stable right now, but historically they had been homeless, hospitalized, and that’s why they stay with us so they can continue to live in the community,” said Christina Shea, director of clinical services at Richmond Area Multi-Services.

The owner of the building occupied by the Broderick Adult Residential Care Facility was considering selling the structure before a recently passed ordinance helped give the Department of Public Health valuable time to renegotiate its lease on the 33-bed facility. (Kevin N. Hume/The Examiner)

The owner of the building occupied by the Broderick Adult Residential Care Facility was considering selling the structure before a recently passed ordinance helped give the Department of Public Health valuable time to renegotiate its lease on the 33-bed facility. (Kevin N. Hume/The Examiner)

But even those who support the policy change worry it’s only a Band-Aid.

“My legislation is not the solution to this problem. It is a very small effort to slow the bleeding and open the door to new operators if they are trying to come into the space,” said San Francisco Supervisor Rafael Mandelman, who sponsored the legislation. “But as a city, we need a much more aggressive effort and strategy to provide beds for people who need a higher level of care than you can get in a permanent housing unit.”

In particular, housing and health care advocates say that increased funding for subsidies to cover bed costs is necessary to make these facilities financially sustainable for both residents and caregivers.

The monthly break-even rate for assisted living beds is over $2,000 for small facilities, according to the 2019 report, which is more than two times the Supplemental Security Income for assisted living residents in California. That has made it near impossible for some centers to stay financially feasible while catering to low-income residents without outside funding.

“There have been moves in recent budgets but not nearly at the scale we need,” said Mandelman, referring to the Department of Public Health’s goal of adding 400 overnight treatment beds. Just 73 of those beds are slotted for residential care, and there’s not yet a date on when those might become available.

A different kind of care

San Francisco was once home to a much wider network of home-based assisted living centers. Much like small day-care centers operating as in-home businesses, these facilities were run by families in homes throughout The City.

“Back to the 1970s, we had a flourishing mental health system in San Francisco and a big part of that was all of these Victorian homes that families could buy for cheap and convert into board and care,” said Friedenbach.

But over time, San Francisco’s exorbitant housing prices have pushed out these small businesses, and it has become more economical to invest in beds at facilities that are already financially stable. At the same time, the minimum wage has increased by 46% while the Supplemental Security Income rate for assisted living residents has only increased by 8%, making it harder and harder to keep staff and businesses afloat.

In some cases, centers were sold for condos, or the children of families who ran them lost interest in continuing the business.

“At the end of the day, it just doesn’t pencil out for many places,” said Susie Smith, deputy director or policy and planning at San Francisco Human Services Agency. “We have a growing older adult population and we need to provide different levels of care.”

Keeping these kinds of facilities open is also an obligation under Gov. Gavin Newsom’s Master Plan on Aging, which directs health systems to avoid unnecessary institutionalization and isolation.

Chiera, of Legal Assistance to the Elderly, hopes the recently codified policy can begin to chip away at a harmful pattern she’s seen again and again. “Anything that will increase the number of beds for residential care in San Francisco is great. We focus a lot on supportive housing and individual housing, which is needed, but it’s important we view this issue all the way through as folks age. It’s really a hardship to move so far away.”

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