Mark Chambers v. City and County of San Francisco

Laguna Honda Hospital (LHH) residents challenge segregation in huge San Francisco institution

Mark Chambers v. City and County of San Francisco

ADAPT protesters at Laguna Honda in 2001 holding sign "Build Community Not Laguna Honda"

On September 18, 2008, Judge William H. Alsup granted final approval of the settlement agreement in Chambers et al. v. the City and County of San Francisco. This action was originally filed October 11, 2006, by six residents of Laguna Honda Hospital and the Independent Living Resource Center (ILRCSF) in San Francisco, alleging discrimination in the form of unnecessary institutionalization under the Americans with Disabilities Act. These residents prefer, and have been determined to be capable of, living in their own homes and in the community. The purpose of the Settlement Agreement is to enhance community-based living options, through the provision of services and housing, to class members.

The class - all Medi-Cal recipients who reside at LHH, are on the waitlist for LHH, are within two years post discharge from LHH, or are patients at SFGH and are eligible for discharge to LHH - was certified by the Court in July, 2007. Big crowd assembled in front of Laguna Honda facility.

Case Name: Chambers et al. v. the City and County of San Francisco

Judge: Hon. Judge William H. Alsup

Co-Counsel: The case was brought by Disability Rights California as lead counsel, with co-counsel from Disability Rights Education and Defense Fund (DREDF), AARP Foundation Litigation, the Bazelon Center for Mental Health Law, and the law firm of Howrey LLP (pro-bono).

Significant Court Documents

Summary of Settlement

Media Coverage

Press releases

Press Coverage

Additional Information

Overview of Laguna Honda Lawsuit


On October 11, 2006, six residents of Laguna Honda Hospital, joined by the Independent Living Resource Center (ILRCSF) in San Francisco, filed a lawsuit to challenge San Francisco’s discriminatory actions resulting in their unnecessary institutionalization at Laguna Honda. These residents prefer and have been determined to be capable of living in their own homes and in the community. San Francisco’s actions violate the Americans with Disabilities Act (ADA), which requires that individuals with disabilities be provided with services in the “most integrated setting appropriate” to their needs.

This lawsuit seeks relief from San Francisco that will enable Plaintiffs and the class of current and potential residents they represent to leave Laguna Honda, or avoid placement there, with affordable, accessible housing and services that will support full, independent, and productive lives.

The case is brought by Disability Rights California as lead counsel, with co-counsel from Disability Rights Education and Defense Fund (DREDF), AARP Foundation Litigation, the Bazelon Center for Mental Health Law, and the law firm of Howrey LLP (pro-bono). The case is before Judge William H. Alsup in federal district court, Northern District of California.


Laguna Honda Hospital and Rehabilitation Center was founded in 1866 as a Poor House. The main building houses almost 1,000 residents while Clarendon Hall houses approximately 140 residents. Most residents of the main building live in large, open wards with as many as 37 residents sleeping in close quarters, separated only by hospital curtains.

Laguna Honda is licensed for 1,214 skilled-nursing facility beds and 243 acute care beds. The census has been gradually lowered to a maximum of 1,065 residents as part of a negotiated settlement with the federal Centers for Medicare and Medicaid Services (“CMS”), which have repeatedly cited Laguna Honda for standard of care deficiencies and threatened to withdraw federal funding. In February 2006, the State Department of Health Services issued a 274-page statement of deficiencies against Laguna Honda Hospital, finding that the facility is providing substandard care.

State, federal and local funds pay for services at Laguna Honda. Medi-Cal is the only health insurance for approximately 95 percent of Laguna Honda residents. Laguna Honda is a “distinct part” skilled-nursing facility, meaning that it must either have some acute care beds or operate under the license of an acute care facility. As a distinct part skilled-nursing facility, Laguna Honda receives a daily rate of at least $310 per person per day from State and federal Medi-Cal funds, as well as additional federal subsidies. In addition, San Francisco pays approximately $120 per person per day out of its General Fund, making the total cost of care at Laguna Honda more than $180 million per year — almost $500 per day per resident. San Francisco’s General Fund subsidy to Laguna Honda has skyrocketed in recent years, from approximately $30 million in 2004-05 to approximately $48.7 million in 2006-07.

Prior Lawsuit (Davis v. CHHSA)

In July 2000, Plaintiffs sued the City and County of San Francisco and several State departments for their failure to inform class members about, assess for, or offer or provide home and community based services instead of services at Laguna Honda. The parties to this suit, Davis et. al v. CHHSA et al., reached a partial settlement with the State and San Francisco in March, 2004.

Among other provisions, the settlement with San Francisco set up the Targeted Case Management (TCM) Program to screen, assess, and develop individual service/discharge plans for class members, and provide ongoing case management to class members who are likely to be discharged within 180 days. The settlement with San Francisco did not decide the issue of whether or not San Francisco provided adequate community based services and whether or not residents who qualify for community services are getting them within a reasonable time frame. Plaintiffs reserved the right to re-file on these issues if necessary.

Continuation of unnecessary institutionalization

Based on assessments by San Francisco’s Targeted Case Management Program, Laguna Honda residents continue to be unnecessarily institutionalized in violation of the ADA. The TCM assessments show that approximately 80% of residents could be served in the community if services and housing were offered to them, and that at least half of residents would prefer to live in the community. Many residents remain at Laguna Honda because they are on the waitlist for the TCM program, and because of the lack of affordable, accessible housing, intensive case management, money management, meals on wheels, and other services.

Rebuilding an anachronism

From reports that it has drafted or commissioned, San Francisco has received clear recommendations for improving long-term care services in the City, and for providing community services to Laguna Honda residents. Contrary to these recommendations, San Francisco is rebuilding Laguna Honda, with at least 780 beds, and perhaps up to 1,200 beds. Across the country, these large institutions have been replaced by small community-based housing arrangements with individualized support services.

Plaintiffs believe that San Francisco’s failure to develop and implement a plan to prevent and eliminate unnecessary institutionalization at Laguna Honda, while committing up to $640 million to rebuild an outmoded institution, constitutes a violation of the ADA and other laws.

The plaintiffs

Individual Plaintiffs are individuals with disabilities, all of whom have resided at Laguna Honda for one to 26 years. They represent a class of people who are at risk of placement at, or reside at, Laguna Honda. Plaintiffs would all prefer to live in the community with an array of services to meet their health care and other needs. According to assessments by Laguna Honda and San Francisco's Targeted Case Management Program, residents require some of the following services in order to be discharged: affordable, accessible housing; case management; assistance with meals and money management; transportation; primary health care; substance abuse treatment; and mental health services. All of these services are or could be made available in San Francisco but have not been provided to Plaintiffs.

  • Plaintiff Mark Chambers is a 47-year-old man who has been at Laguna Honda for over six years. He was admitted in 1999 after a severe head injury, which resulted in traumatic brain injury (TBI). Mr. Chambers uses a wheelchair and a computerized communication device. Mr. Chambers has many interests, including photography and astronomy, and, while living at Laguna Honda, has had volunteer jobs at Glide Memorial Church and the San Francisco Public Library. Mr. Chambers' Laguna Honda treatment team recommended that he be discharged to the community with supportive services. Mr. Chambers is desperate to leave Laguna Honda and be part of the outside world. He continues to wait for appropriate services to help him do so.
  • Plaintiff Gerald Scott is a 53-year-old man who has lived at Laguna Honda for over 26 years. He was disabled by an assault, causing brain damage, quadriplegia, and a seizure disorder. He uses an electric wheelchair to assist with mobility, and he has limited use of the right side of his body. In the years that Mr. Scott has been at Laguna Honda, numerous assessments have shown him to be able to, and prefer to, live in the community with specified supports, including in-home supportive services and accessible housing. He continues to want to leave Laguna Honda and awaits appropriate services to do so.
  • The Independent Living Resource Center of San Francisco (ILRCSF) is a non-profit organization that advocates for the rights of people with disabilities and provides services to help them live as independently as possible in the community and in their homes.

Legal claims and arguments

This case involves claims under federal and state civil rights laws: the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act; and state law Government Code section 11135. All of these laws prohibit discrimination on the basis of disability and require that government entities such as San Francisco provide services to people with disabilities in the most integrated setting appropriate to their needs. The United States Supreme Court has ruled that institutionalizing people with disabilities when community services can meet their needs is a form of discrimination under the ADA. Olmstead v. L.C., 527 U.S. 581 (1999). The Olmstead decision requires that individuals with disabilities be provided services in community settings, instead of in institutions, when the individuals are determined to be capable of, and do not oppose, community-based treatment, and if community placement can be reasonably accommodated by the responsible public entity.

The suit claims that plaintiffs and the class have been forced to remain institutionalized at Laguna Honda due to San Francisco’s failure to provide alternative community based services in a timely way.

What plaintiffs want

Plaintiffs are seeking relief from the Court that will enable them to receive the home and community based services, including housing, that San Francisco has assessed them to need and prefer, in a timely way. Such relief includes:

  • Assurances that San Francisco will provide access to housing and service providers for the approximately 500 LHH residents who are eligible for the Nursing Facility A/B Waiver as of January 2007, and will commit to appropriate timelines and processes for doing so
  • Assurances that San Francisco will support the Community Living Trust Fund at an adequate level to enable class members to avoid, or leave, LHH placement;
  • Commitments, including timelines, process and funding, to ensure:
    • That LHH residents have access to the housing options that have been identified as barriers to discharge from LHH, including supportive housing, affordable and accessible low-income independent housing (particularly for non-seniors), and transitional housing;
    • Provision of the intensive case management and wraparound services that are needed by class members, including those with mental health needs;
    • Page 5 of 9;
    • Provision of adequate mental health services, substance abuse treatment, home delivered meals, transportation, representative payee services, and other needed services for which class members currently remain on waitlists for lengthy periods of time;
    • Provision of personal attendant care services for individuals who have complicated needs and/or behavior issues, and/or need “bridge” services to accommodate their need for 24-hour care; and
    • Implementation of a real-time housing inventory and one-stop application process to avoid missed opportunities, reduce inefficiency, and decrease wait-time for subsidized housing.

This relief is consistent with numerous reports and recommendations that have been issued or commissioned by San Francisco. Specifically:

Investigation by the United States Department of Justice

In April 2003, the United States Department of Justice (DOJ) issued a letter of findings against Defendant for violations of the ADA with respect to its administration of Laguna Honda. The letter concluded that “a significant number of Laguna Honda residents are unnecessarily isolated in the nursing home,” and that “the City continues to be in violation of the ADA and continues to fail to ensure that Laguna Honda residents are being served in the most integrated setting appropriate to meet their needs.”

The DOJ ordered Defendant to implement remedial measures, including: 1) expanding community-based services (specifically, residential services for individuals with mental health or substance abuse disorders, housing and housing supports, housing and residential programs for individuals who have physical as well as mental disabilities, assertive community treatment, vocational services and day treatment options); 2) conducting a needs assessment of Laguna Honda residents to “reconsider the need to rebuild 1,200 beds at Laguna Honda Hospital and review the City budget to determine how to allocate funds appropriately to ensure that Laguna Honda residents are not unnecessarily isolated;” and 3) creating and maintaining an inventory of housing options in San Francisco that will be utilized by Laguna Honda residents. To date, the required remedial measures have not been implemented.

The Living With Dignity Policy Committee

The Living with Dignity Policy Committee was established to provide guidance to the Department of Aging and Adult Services, as well as to DPH and the Department of Human Services, for planning and implementation of improvements in the long term care system for seniors and people with disabilities. The Committee conducted an extensive needs assessment resulting in a four-year plan in April 2004, entitled the Strategic Plan to Improve Community-Based Long Term Care and Supportive Services in San Francisco. The Plan described the current system as “fragmented,” characterized by limited coordination and access to services, as well as fragmentation and duplication of services. Consistent with other recommendations, the Committee urged better coordination of services, increased access to services, and expansion of the community system’s capacity.

San Francisco Controller’s Report

In May 2005, the San Francisco City Controller was asked, due to concerns about the enormous cost-overruns of the proposed 1,200-bed Laguna Honda rebuild, to make recommendations for successful completion of the rebuild. His report concluded that there are only two options worth considering. Option One would use “all reasonably available funds to complete a 1,200 bed skilled nursing facility at Laguna Honda,” and would cost an estimated $221 million over the approved $400 million, or approximately $500,000 per bed. Option Two would downsize the rebuild to 780 skilled nursing facility beds, build 235 assisted living units in lieu of the remaining skilled nursing facility beds, and use the cost savings to fund a variety of services in the community. The total estimated number of people served under Option Two would exceed 1,800.

The Controller’s Report found that for each $2 million not spent at Laguna Honda, 100 people could be served in the community, by providing a combination of payment supplements, or “patches” to residential care providers, supportive housing and services, and accessibility modifications to existing housing.

Health Management Associates’ Report

In July 2005, Health Management Associates (“HMA”), a consultant retained by San Francisco, issued a report on long-term care provided by DPH. HMA found that the City’s investment in health care services is “second to none” in the nation, approximately $400 per capita compared to a nationwide average of $64. Unfortunately, a tremendous portion of that money is used to fund institutional services, however, primarily at Laguna Honda.

HMA recognized that San Francisco over-relies on institutional care due to its lack of integrated planning and management, resulting in duplication of services and insufficient community-based services. HMA strongly criticized the proposed Laguna Honda rebuild, stating, “[w]hile it appears that 780 beds will be constructed at the Laguna Honda Hospital site, a [skilled nursing facility] of this size is contrary to all national trends.” HMA advised against investing resources in additional institutional services, stating that “the disparate interests of various parties should not be permitted to be used to justify business as usual in regards to the rebuild of LHH.” HMA stated that new nursing homes should have no more than 100-200 beds to allow for “reasonable quality control, patient safety, and good economics.”

HMA’s recommendations for improving San Francisco Department of Public Health’s delivery of long-term care services included: identifying appropriate long-term care options to enable individuals to be diverted or discharged from Laguna Honda; reducing the need for institutional care by expanding the availability of respite care, companion services, assistance with meals, adaptive equipment and environmental accessibility modifications, housing, transportation, adult day health care; completing an inventory of the current housing infrastructure to enable online monitoring of housing availability; and increasing its investment in case management in order to facilitate utilization of community-based long-term care resources.

San Francisco Long-Term Care Coordinating Council

In November 2004, San Francisco’s Mayor appointed the Long-Term Care Coordinating Council (“LTCCC”) as an advisory body to provide advice and policy guidance on all aspects of long-term care in San Francisco. The LTCCC drafted the Community Placement Plan, which recommends measures intended to “provide safe and healthful transitions” from Laguna Honda and other institutions, including ensuring that individuals have timely access to housing, discharge planning services, case management, and appropriate community-based services. The LTCCC has recommended that day health/housing be substituted for some of the nursing facility beds planned in the rebuilt Laguna Honda.

Critiques of Laguna Honda and San Francisco Long-Term Care

Health Management Associates - The San Francisco Department of Public Health: Its Effectiveness as an Integrated Health Care Delivery System and Provider of a Continuum of Long Term Care Services , September 2005
Ed Harrington, Controller - Cover Letter to San Francisco Mayor Gavin Newsom re: HMA Report , September 2005
Ed Harrington, Controller, City and County of San Francisco - Laguna Honda Replacement Program: Where do we go from here? , May 2005
U.S. Department of Justice, Civil Rights Division - Investigation of Laguna Honda Hospital and Rehabilitation Center , April 1, 2003
U.S. Department of Justice, Civil Rights Division - Investigation of Laguna Honda Hospital , May 6, 1998
Settlement Agreement between San Francisco and U.S. Department of Justice , June 13, 2008

Chambers Pleadings

Order Granting Final Approval of Settlement Agreement , September 18, 2008
Chambers Settlement Agreement
Order Granting Motion for Class Certification , July 12, 2007
First Amended Complaint for Declaratory and Injunctive Relief , October 12, 2006

Olmstead and Long-Term Care

Bazelon Center for Mental Health Law - Primer on Olmstead and Medicaid for Laguna Honda Residents
AARP California - Reimagining America - Creating a National System for Home and Community-Based Care

Davis v. CHHSA settlement documents

Summary of Settlement - Davis v. CHHSA, Laguna Honda Hospital , November 2004
Settlement Agreement Between Plaintiffs and Defendant City and County of San Francisco , December 12, 2003
Attachment 1 - Screening Questions
Attachment 2 - Minimum Data Set - Home Care (MDS-HC)*
Attachment 3 - MDS-HC Based Care Planning*
Attachment 4 - Community Based Services and Supports - Medi-Cal Services
Attachment 5 - Consumer Satisfaction Survey - Targeted Case Management (TCM) Program
Attachment 6 - interRAI Mental Health Supplement (Draft 1)*
Settlement Agreement Between Plaintiffs and State Defendants

*Not available via this web page; for more information call Disability Rights California's Bay Area office - 510.267.1200