April 15, 2019– Mary Greeley News – This summer, Tom Gray will lose his home.
A slim man with hunched shoulders and a halting voice, Gray, 72, has schizophrenia. Before he landed in Carmen Palarca’s board-and-care home 11 years ago, he spent 20 years living on the streets, many of them huddled in a doorway across from a San Francisco Whole Foods.
“I feel kind of sad and worried a little bit,” Gray said quietly, sitting in the Sunset District home’s small kitchen on a recent afternoon.
He hadn’t yet received official notice from Palarca of her plans to close, but knew it was likely. She had, in fact, sent a letter to the city a few days earlier outlining her intent to shutter the home.
The planned closure of yet another board-and-care home reflects a broader trend affecting thousands of low-income Californians with serious mental illness. While housing values soar and minimum-wage increases drive up staffing costs, state reimbursement rates to board-and-cares have remained stagnant. The result: More facilities are shutting their doors.
There are no reliable statewide data on the decrease of homes serving this population. But since 2012, San Francisco has lost more than a third of licensed residential facilities that serve people younger than 60, and more than a quarter of those serving older clients. Much of the decline has been in small, homelike facilities like Palarca’s, which provide food, laundry and medication help — and are more likely to accept low-income people with mental illness.
Los Angeles, which has a large portion of the state’s board-and-cares, has lost more than 200 beds for low-income people with serious mental illness in the past year.
Advocates say the state needs to collect better data and significantly increase reimbursement rates if it hopes to save the remaining facilities.
“If legislators don’t get onto this, we’re in big trouble,” said Lisa Kodmur, a health care consultant working with Los Angeles County on the issue. “We will see more homelessness, more incarceration, more institutionalization, more people living on the streets.”
The housing crisis has placed those concerned about board-and-care in a strange predicament: Many now find themselves advocating for facilities they consider to be of poor quality and outmoded. That’s because the alternatives they see — homelessness, incarceration, long-term placement in nursing homes or locked facilities — are worse.
“Our inventory is so dire that we are now trying to save an industry that is not a darling,” said Adriana Ruelas, legislative affairs director of the Steinberg Institute, which advocates for better mental health policies.
Solutions lawmakers are considering
Last week, the Steinberg Institute convened advocates and policymakers in Sacramento to address the disappearing board-and-cares. Among potential solutions being considered:
Increasing the state’s supplement to federal Supplemental Security Income rates to increase reimbursement rates to board-and-cares. Currently, the federal government pays $771 and the state pays $423 for SSI; residents keep a small amount for personal needs and the rest goes to the board-and-cares.
Expanding the state’s assisted-living waiver program, which uses Medi-Cal funds to allow vulnerable people to stay in board-and-cares instead of nursing homes. The program is currently authorized to serve fewer than 6,000 people. AB50, carried by Assemblyman Ash Kalra, D-San Jose, would broaden the program to serve more than 18,000.
Requiring the state to maintain data on board-and-care residents to better understand their needs; AB1766 is carried by Assemblyman Richard Bloom, D-Santa Monica.
Using funds from the Mental Health Services Act or No Place Like Home funds to help maintain board-and-cares.
Sacramento Mayor Darrell Steinberg is a former state Senate leader who co-founded the institute and was recently appointed by Gov. Gavin Newsom to lead a new commission on homelessness and supportive housing. He calls the closures “catastrophic.”
“They are not the perfect solution for everybody,” he said. “But, perspective here: It’s real shelter with care. The losses here are only making an already horrendous problem worse.”
At the root of the problem is money. Many facilities are closing because owners are selling the properties, or because operators are aging and their children don’t want to take on a business that is not financially sound.
Licensed board-and-cares, also known as adult residential facilities, receive a government-set monthly rent of $1,058 — just less than $35 a day — from tenants to pay for housing, 24-hour care and three daily meals. The tenants cover that cost with their monthly Supplemental Security Income checks, a combination of federal and state funds for people with serious mental illness.
A report published in January by San Francisco’s Long-Term Care Coordinating Council noted the city’s minimum wage has increased by 46% since 2012, while the SSI rate for assisted living residents has increased by just 8%. The report estimated the monthly break-even rate for board-and-cares at more than $2,000 per bed, about double what low-income residents currently pay.
Some counties, including San Francisco and Los Angeles, pay a “patch” using local and state funds to boost this rate to about $1,700 a month. Operators say that’s still not enough.
Dr. Jonathan Sherin, director of the Los Angeles Department of Mental Health, said he’s been “ranting and raving” for years about the “alarming rate” of disappearance of board-and-cares in his city.
“It’s a broken business model,” he said. When homes close, his county scrambles to place the residents elsewhere. But that worsens the backlog for people in jails, hospitals or locked psychiatric facilities waiting for housing in the community.
And once homes are sold, NIMBYism—the “Not in My Backyard” attitude — can make it difficult to open new facilities in the same locations.
Ideally, Palarca said she would like to sell the home where Gray lives to someone willing to maintain it as a board-and-care. But so far, she said, no potential buyer has seen a way to make the numbers work.
Larry Mateo, 59, once operated five board-and-care homes in San Francisco. By the end of last year, he’d closed them all. Now one is for sale, and two others are being rented to young people who can pay the high rates commanded in the city.
“That’s an easy no-brainer decision,” Mateo said. “I don’t have payroll, I don’t have to go buy groceries, I don’t have to deal with clientele.”
Some residents, however, initially refused to leave.
“Some said, ‘I have no place to go. I love this place,’” Mateo said. “We had to call the sheriff to move them out because they just didn’t want to move. I’m not sure if it was part of their mental illness, but they didn’t want to adapt to change. They said, ‘This is my home. Why are you moving me out?’”
About a third, or some 35,000, of the state’s homeless individuals have serious mental illness, according to estimates from the Treatment Advocacy Center, a nonprofit that advocates for expanded psychiatric services.
As tent encampments proliferate, efforts to house homeless people with mental illness have gained traction.
Last fall, voters passed the No Place Like Home Act, allowing the state to borrow $2 billion to increase the supply of permanent supportive housing, which pairs affordable housing with mental health services.
But not everyone with a serious mental illness is independent enough to thrive in that setting. Some still need help with meals and laundry and medications. The disappearance of board-and-cares leaves these vulnerable people without an option, said Ruelas of the Steinberg Institute.
After landing in hospitals because of psychosis, paranoia and hallucinations in his early 20s, Tristan Scremin was discharged to board-and-care homes. Without this option, Scremin, now 45, speculates he might have ended up on the streets. Instead, he was able to stabilize and now works as a community liaison for Painted Brain, an arts-based mental health agency in Los Angeles.
“I see a lot of seriously mentally ill people on the street who are obviously having difficulty figuring out basic things,” he said. “If I had lost my chance to be in a board-and-care home, if I’d become homeless, I think it would have been very difficult.”
“We’re just really failing this population,” said Molly Davies, Los Angeles County’s long-term care ombudsman. She worries that funding gaps are not only forcing closures, but worsening conditions at board-and-cares that can be inhumane.
She’s seen bedbug and rat infestations, and a typhus outbreak.
Regulators are sometimes lenient, she said, because they don’t want to lose more beds. They know that as licensed homes close, unlicensed ones proliferate with no oversight whatsoever.
Residents of Palarca’s board-and-care now face the possibility of being relocated to Central Valley communities they’ve never visited.
“I’m settled here. I’m used to it here,” said Setsuko Letchford, 70, who said she hears voices that constantly badger her. “I don’t have any place to go. They should find me someplace to go.”
Palarca, 77, and her husband, Domingo, 87, bought the seven-bedroom home for $96,000 in 1976, after they moved to San Francisco from the Philippines. Carmen was working as a benefits eligibility worker for the city of San Francisco; Domingo was a mechanic for United Airlines. They wanted additional income to pay for their children’s college educations.
Now, they want to relax and travel. Still, Palarca worries for Letchford and Gray and the home’s seven other residents. Clients in the home she closed in 2016 were farmed out to other facilities, some outside of the city.
“They didn’t have a choice,” she said.
Kelly Hiramoto, director of transitions for the San Francisco Health Network, said the city is aware closures can be stressful for residents, although she wouldn’t label it a crisis because she said the city is generally able to find alternative placements.
The city subsidizes board-and-care beds for about 500 individuals, she said, starting at an additional $22 a day on top of the SSI rate, with half of those located outside of the county.
Benson Nadell, San Francisco’s long-term care ombudsman, said he expects the city’s remaining board-and-care homes to disappear in 15 years, if not sooner, given the current funding model. But he said he’d like to see new models, ones that prioritize programming and independence for the residents.
The Steinberg Institute’s Ruelas also would like to see a dynamic system that provides life skills and activities, not just medication, laundry and food. She said Progress Foundation, which offers residential treatment options in San Francisco, Napa and Sonoma, is one model to consider.
Steve Fields, the nonprofit’s executive director, said board-and-care homes should be saved — and transformed into something better. Otherwise, he said, “counties without any imagination go back and reinvent the thing we don’t need anymore.”
Across the city from Palarca’s closing home, Aurora Concepción is trying to keep hers open.
She’s closed two homes in recent years because of staffing costs but still has three others.
Brightly lit, with immaculate blond wood floors and big windows that look out on the Financial District, the homes, perched on a hill in the Portola district, are much nicer than most board-and-cares, Nadell said.
Concepción, 70, lives among her clients and said she feels driven by a mission.
“What I have is what they have; what I eat is what they eat,” she said. “I always tell them, ‘We are a family here.’”
Arriving from the Philippines in 1972, she took a bank job doing data entry and later stayed home to care for her daughter. She opened her first board-and-care in 1978, then another, then another. At her peak, she cared for 30 people. With the closures, she’s down to 16.
To stay open, she has reduced paid staff from four to one. She and her ex-husband and children handle shopping, cooking and medications. She washes the laundry at night when utility rates are cheaper, buys food in bulk, and said she hasn’t taken a real vacation in 40 years.
“We’re pinching pennies,” she said. “I make a joke all the time: We’re the cheapest hotel in town.”
On a recent morning, residents gathered to eat the lunch Concepción had prepared: salami-and-cheese sandwiches, chicken tomato soup and chocolate sandwich cookies.
After lunch, Concepción offered a tour of one of the homes she’s closed. The brightly lit upstairs looks out onto a city panorama. It will doubtless command a fortune in rent on the private market. But Concepción laments that she couldn’t keep it open for residents with mental illness.
“They deserve a second chance,” she said. “They deserve a home.”
credit: In part with https://www.sfchronicle.com/bayarea/article/SF-board-and-care-homes-for-seriously-mentally-13766754.php#photo-17218909