Was voluntary and not all of the hospitals would cooperate. This would support the mission of really identifying the gap and filling it. I think Hillary Ronen is willing to carry the legislation. She is preoccupied with Mental Health sf, which is a lot of work. I see the february 6, 2020 discussion of supporting the legislation. The legislation on collecting data for outofcounty discharge should be included in this list of legislation. I talked to the Health Commission about this. I emailed Clara Lindsey to send copies to you all. I have copies. We need to go forward on this. Thank you. Any other Public Comment on this item . With that Public Comment is closed. Commissioner koppel. Question for staff. I heard you mention that we are at zone capacity. I dont know that we have a zone capacity. Is that enough to get us where we want to be . If we think we need 4. 3 do 4. 7 we have zone capacity to make that. We dont need additional zone capacity to get there. Do we need that much. What is the strategy for people on Treasure Island . What are their options . We have plenty of parcels with healthcare and hospital facilities in the city. What do you do if you live on Treasure Island . Right now there arent any Health Facilities there. I can do more research to find out if they plan to be part of future development. Thanks. On that point as you recall the plan for Treasure Island calls for Ferry Service when there are a number of certain units on the island. They are looking to move that up so it happens sooner. They realize they need access for the early tenants not just five or six or eight years downn the road. Commissioner fung. Question for staff. You made an interesting point of the metric related to amount of medical facilities available to the population of the city. A couple of things occurred to me on that. Any idea how long it takes to develop a hospital . How long it takes to develop a hospital . We can look at that specifically but i imagine a long time. A long time. So the need for that type of facility, i think the department is saying that it is pretty well filled by existing facilities. The hospital specifically . In terms of beds and everything else. Skilled nursing. It is best to frame in terms of populations that are lacking access to care. That is my point. When you showed the slide on at risk vulnerable communities in the city. Can you summarize what i asked the question i asked you via email as to what obstructions are in the zoning . What specific obstructions are in the zoning . Yes. That would affect those at risk areas . We dont see a lot there are marginal things to do around the edges to make the process of healthcare approved. Overall the issues to providing more healthcare are economic, not related to land use. It is tied to work force, tied to the combination of public and private insurance that we have and the decisions to provide healthcare are made on a Large National scale. That is not what we talked about. That is all right. I will summarize what i thought we talked about. In quite a few of our districts, the obstruction is the can use process and the prohibition of medical facilities. I think it is incumbent upon the commission to revisit that, especially when you look at the areas at risk. They are the areas that dont have the hospitals. What is likely to go on that is probably Outpatient Facilities primarily and if there is preventative components, that is great. So would you send me back with which districts have prohibitions and which districts have it as conditional use, which takes forever in our city. There arent many. I have a table. I can pull it up if you would like. So there are few districts, i think there are seven where conditional use is required on the first floor and a handful more on the second floor. One thing that is easy is to make healthcare permanent on the second floor. There are access issues for a lot of facilities, they cant get the wheelchair up to the second floor. There are four commercial districts that prohibit. I have a table. I cant remember them off the top of my head. We are going to pull it up for you. That is another thing to do is decrease limitations in the neighborhood commercial areas. I would look at them as they are principally permitted. We talked about that, sheila and i talked about the fact we would do that when we come back to you in the spring with those kinds of recommendations. We agree it makes sense. I think hospitals are permitted anywhere in the city as conditional use. What we are talking about are the smaller Healthcare Facilities for some reason are banned in four districts in the city. So here is the table on the first floor where medical uses are either not permitted or condition and then on the second floor. It is not a huge number. This is a relatively minor tweak that could make it easier to get services into some of the neighborhoods. It is a differentiation nonprofit versus for profit medical providers. We can look at that. It is how we enforce and understand that. Most are nonprofit. Maybe not all of them. Many are nonprofit like kaiser. It is not necessarily. Perhaps you can tell me more about the distinction you want to make between nonprofit versus profit. Some of the prohibitions that occurred was in response to the for profit taking up store fronts. Commissioner diamond. My understanding is if number of facilities that can accommodate older adults decreased and the cost of care increased that we have a large number of older adults staying in their houses. I wonder if you are looking at what as the Planning Department and Building Department we are doing to help those older adults modify houses to stay there as long as they need to. People moving bedrooms down stairs, Kitchen Facilities down stairs, changing banisters, changing the bathrooms, all of the physical changes necessary for older adults to stay in their houses. It wasnt part of this plan to look at modifying residences. I would have to do research to the existing. They would be subject to existing regulations. We have to see if the existing regulations are barriers to staying in their homes. Given they have to stay in homes there is no other solution. It would be interesting to know if there are barriers we could remove. That should be part of it. Commissioner koppel. I recommend addressing the supervisors in those districts if it is permitted. We heard from supervisor mandelman or his aid here. They were saying they are seeing too many care facilities line upper market street. It is formula retail. Iit is unfair competition for te local ground floor businesses trying to stay afloat. Commissioner moore. I want to remind everybody this master plan has only been around for a relatively short time. It was written in reaction to the process of working on c. P. M. C. I am not sure if you remember how many years it took, probably 12 or more. It was very long. That is the timeframe it takes. I think it is an important tool to bring forward all issues and creates a clear overview how we look at every aspect of healthcare planning that did not exist before. If you participated in the c. P. M. C. You would understand what tool it is. I want to acknowledge the tremendous work you have done and the clarity with which you are presenting. It forces us to take every decision under the microscope. These things are not isolated. The location decisions but they manifest in the plan. I am appreciative this tool exists. I am appreciative of the plan and your tremendous work. It b umbs me out. Healthcare is profit driven. We live in the segregated city. Racially segregated. Even though we have zone capacity. The truth is if you live in the bayview or silver avenue or, you know, the valley or Treasure Island, you dont have access to healthcare. When we did the c. P. M. C. Project, part was rebuilding st. Lukes. That was a hard fight. That had not had happened without a lot of organizing. It bumbs me out. I wish we had tools to build Healthcare Facilities, obgyn, in those neighborhoods where the disparity in Health Outcomes because of socioeconomic and environmental factors make it that people need more healthcare. That would make sense in an ideal world. That is not the world we live in. I wish as a Planning Department we would consider that in terms of recommendations to the supervisors to have incentives. I was curious in your presentation you mentioned about now there being new subsidies for longterm care facilities. I would be interested in hearing that. As commissioner diamond suggestion suggesting, the numbers dropped. The population is getting older. Proportion to children to seniors in the city. I think it is a legitimate Public Policy issue. I would be interested in knowing what that looks like by race and income. I know that people are struggling. If you are my age where you have kids at home and also parents aging, it can become an intense economic and social pressure for families in San Francisco. Looking to housing people i am curious what the subsidies are for longterm care. It is not capital subsidies, it is operational . I want to verify. I should definitely verify that first. That is interesting. We have lost so many. To me, you know, increasing the, you know, subsidy is important to stabilize. Any barriers, i have heard about all kinds of smart things. I am worried about this aspect. I want to echo and thank you for bringing that up. The plan also does help us with trends assessment. It brings up those factors outside of city control that we can push for, we can make recommendations at a higher level to help garner more support at another level for these types of care facilities. Thank you for bringing that up. Commissioner moore. Could you perhaps answer the question on capacity for Mental Health . I saw a report just yesterday in the paper which pointed out there are quite a fuelty underutilized beds that is . Contradiction to what we encounter where people through homelessness or other results of poverty seem to show more and more signs of needing Mental Healthcare which seem to be not quite available to them. Would you comment on that . It tells us where in the system for whether or not somebody has a Behavioral Health concern there is an open bed so a provider who sees somebody in crisis is able to get them where they need to go. Our city is making those improvements. I acknowledge what you just asked about. Commissioner diamond. My understanding one of the biggest costs issues is the availability of labor pool where the cnas are coming from. I dont know if the master plan looks at that. I know everything seems to tie back to lack of Affordable Housing for workers and people commuting two hours in each direction. Is the scope of the work encompassing the problems the institutions face in finding labor supply . Yes in terms of acknowledging that challenge, the salaries for providers and the cost of living here that our professionals are having to live very far out of county, especially nursing staff. That is all assessed and covered in the Healthcare Services master plan. We have had discussions with Community Members and institutions themselves how in our guidelines and recommendations we can also be inclusive of providing housing and systems like that to make those challenges alleviate them as well. [please stand by] we provide care to our immigrant communities, so we are looking at what the impact of some of these threats are. It is briefly mentioned in the plan currently on what impact it may have on some of the populations in accessing services. Okay. Thank you very much. Do you have a question . That will place us on item 12 for the water supply informational presentation. Good afternoon, president melgar and commissioners, im chris, the purpose of this presentation is to provide an overview of how the Utilities Commission and Planning DepartmentWork Together to coordinate the citys water supply system. First, steve richie with the sfpc will address the urban Water Management plan, the water supply assessment process for large projects, recent amendments to the state plan and how the city plans for droughts. Then ill discuss how the Planning Department addresses water supply in our ceqa and federal review documents. And following the city staff presentation, peter will present on behalf of the river trust. So i would like to start by introducing sfpc assistant general manager steve richie. Good afternoon, commissioners. Steve richie, assistant general manager for water, the San Francisco public Utilities Commission. If i could have the slides please. Im going to review the legal requirements we need to follow for water supply planning in our actual practical approach based on our experience and where we see the future taking us a little bit. First, a background for a couple slides. Our water system is depicted here. This is a schematic that spans the width of california. We put it to fit on a slide. 85 percent comes from those reservoirs. The area outlined in gold is our service area for the entire system. This is our map of our wholesale customers and San Francisco. Based on the depth of the blue color it shows how much of a communitys water supply depends on the San FranciscoRegional Water system. The darkest blue on the east bay gets 100 percent of its supply from San Francisco from us and just below that the Alameda CountyWater District only gets 20 percent of its water supply from us. Most of the peninsula are dark blue colors, so a lot of people depend on our system from water supply. Onethird of the supply from the system is used in the city of San Francisco and about twothirds is used outside of the city of San Francisco. In terms of water supply planning, im going to talk about the urban Water Management planning act and development of urban Water Management plans and water supply assessments. Then im going to talk about our water supply planning approach we use for the system based on our experience. What is the urban Water Management planning act . It was enacted in 1986. Its referred to as the show me the water act, because at that time, there were a lot of developments proposed around california, and there was no relationship to water supply planning, and folks were concerned that we were not connecting these two vital decisionmaking processes. So the purpose of the act was to assure longterm supply reliability and efficient use of Water Supplies to meet existing and future demands. Requirements of the act is that plans need to be prepared by urban water suppliers that have more than 3,000 connections. Plans need to be updated every five years. Our last plan was developedd in 2015 and issued in 2016 so we are looking forward to a new urban Water Management plan in the next year, year and a half. The plan needs to cover a 20year planning horizon. We rely on San Francisco planning for population and job projections. The plans are submitted to the California Department of Water Resources for review and verification that we have met the legal requirements. So whats in the urban Water Management plan, a description of the system and service area, supplies and demands over the next 20 years, compliance with the Water Conservation act of 2009 which called for all urban areas to produce their demands by roughly 20 percent, and we already comply with that, so we have done a good job there. Our supply reliability, demand management or constant vacation plans demonstrate we are conservation plans demonstrate. Obviously in california, droughts are a great concern to us. On the front of the retail Water Conservation plan, its a document that summarizes our program and how we plan to achieve water savings over the next five years. We do this every five years as part of the urban Water Management plan. It describes specific measures to be implemented and how much water savings costs and effect ondemand from that and explains other factors that explain what measures are implement and criteria used to evaluate measures. One of the things we found is changing out the fixtures is the most effective way to achieve conservation savings, so weve invested in that to achieve savings that are going to be required by the code. What weve seen over time is a steady decline in the per capita water use to gallons per capita per day, and that we meet all state requirements. Weve done lots of Different Things in terms of evaluation, fixture replacements and other things. What you see is a graph showing the decrease in per person water use over time, the darker line there, the darker bars are the per capita water use on a gross basi