Access in Sonoma County

I received this question about Sonoma Access in the context of the buying of local hotels for the most frail individuals who are homeless (see below). The article says that the Azura homeless residents will have access to something called “ACCESS”.   This post explains the terms and programs.

Before I go into that I want to point out that this proposal allows the County to have housing units at just 36% of the cost of what “regular” Affordable Housing costs us now.

“The $8 million acquisition of the 44-room Hotel Azura was made through the state’s Project Homekey program, established in June in response to the COVID-19 health emergency.  Officials said the hotel on Healdsburg Avenue would be converted into interim housing for up to 66 individuals when escrow is closed, possibly by next week.”

$8,000,000.00 for 44 units  is $181,818.18 per unit.  Affordable Housing developers like EAH, Burbank, etc. are building full size apartments for approximately $500,000.00 per unit.  So, although less in size, the cost comes in at just 36.36% of more expensive affordable housing.


Here’s some information to help you understand the “Access” programs. 

Sonoma County has three (3) distinct activities which are referred to as “Access”.

There is the high level management group which tries to integrate County Safety Net programs at the County Administrator’s Office (CAO office).

There is the Behavioral Health Access Team which is the more historic and traditional “Access Team” (Health Services Behavioral Health division)

There is a transit related Access project for seniors and folks with disabilities. (Area Agency on Aging) Sonoma Access (senior transit)


I am going to talk here about ACCESS as it relates to the Behavioral Health Access Team but you can read about Management Leadership here:


The Behavioral Health Access team – 565-6900 or 800-870-8786 is the screening process then service delivery for people with behavioral health challenges.

“Our multidisciplinary teams provide these services:


The Behavioral Health Department is also the umbrella for an effort of departmental collaboration called the IMDT:

The Interdepartmental Multi-Disciplinary Team (“IMDT”) model overcomes the issues of program silos by allowing County Departments, Agencies and Community Service Providers to share information about shared clients. The IMDT consists of frontline staff: clinicians, social workers, Adult Protective Service workers, probation officers, housing specialist and eligibility workers who work to collaboratively coordinate care and goals to address the holistic needs of the vulnerable residents they serve.”

The difference between the Behavioral Health Access Team and the IMDT is related to where in the process the person being served is. The Access team as described above works with people with chronic and persistent behavioral health issues that need to be served over the long term.  The IMDT team as described is related to screening and introducing individuals to the right level of service.  The web site explains each “cohort”.

IMDT has six cohorts, teams that work with specific groups of people.  They are Emergency Rapid Response, High Needs Homeless, Emergency Department High Utilizers, Mental Health Diversion, Homeless Encampment Access & Resource Team (HEART), and COVID-19-Vulnerable.

In gradients of increasing support and services:  The HEART team (Homeless Encampment Access & Resource Team) works with people who have no home or residence. They work closely with community nonprofits as well as the HOST team (HOST is Homeless Outreach Services Team, which is most closely associated with the City of Santa Rosa and Catholic Charities) HOST is sponsored by the City of Santa Rosa and the Water Agency as well as the Community Development Commission (CDC).

Another stage is what we used to call Whole Person Care (WPC) and which is now referred to as the High Needs Homeless (HNH) program.  People in that genre have specific qualifications designated by the funding source. The Whole Person Care program is a state funded program in multiple counties throughout California.  The criteria for that are: first of all, the person is on Medi-Cal, second they are homeless, and, third, they have a chronic and persistent behavioral health issues and meet one of several other criteria. These criteria include frequent use of health care resources, substance use disorders, or criminal justice involvement.

High Needs Homeless staff persons do outreach and engagement to qualify people and then passes people forward to Intensive Case Management (ICM). ICM lasts for a period of time until the issues are resolved – for example the person is set up with therapy or healthcare or housing or SSI.  In many instances they are passed along to the regular Behavioral Health Access team for ongoing care and case management. Each of these programs has various arrangements with community providers.

A critical aspect of the whole person care project (now “High Needs Homeless”) was it developed the interdepartmental multidisciplinary team (IMDT) with a very specialized release of information (ROI).

I have been a social worker since 1983 and what has been done with the IMDT in Sonoma County (as well as in other communities) is truly an innovation and a resource which is very valuable to the individuals they serve.

Through the County’s IMDT team program they are able to have cohorts of individuals that they are following and who can be discussed with the rest of the community providers on the Team.  Notably, all participants are asked to sign the ROI mentioned because everyone must respect the person’s confidentiality.

The HEART group has a weekly meeting on Tuesday; and the HNH (High Needs Homeless) group has a weekly meeting every Wednesday in which people from multiple agencies can talk about specific individuals and plan for their care.

It’s hard to understand the inner workings of most social service agencies but I can best describe it by talking about some of what happens in the meetings.  Usually there are staff people from the health care clinics (such as West County, Petaluma Valley, Santa Rosa community health).  There are also people from the nonprofit organizations who are part of the release of information and there are people from the public defenders or the human services department or the probation department; all of whom are concerned with the same group of people. The discharge planners from the jail are also regular and very important participants. 

In this way if someone has been in and out of jail multiple times and has not been connected with services all of these folks can talk about what to do next. Another practical thing that happens is that the healthcare providers are able to tell the other service providers when the individual has their next healthcare appointment and then the HNH or HEART staff or others who are working with that person can help them get to their healthcare appointments.

This is all within the confidentiality “bubble” and with great respect for the individual’s rights and expectations. If you have done any work in mental health or human services in California you know that confidentiality is by far one of the most important things we are concerned about.  The only thing that’s more important is the well-being of the individual and their right to decide what they do.

The IMDT process as developed under Whole Person Care phase and the leadership of the County has developed a very practical way to serve the highest needs users. This is important because the highest needs users are also the most fragile people in the community and they are the most expensive users of multiple resources.


For our community, the value of group housing or intermediate housing as described in the hotels that are currently being bought serves individuals. Giving a person a pillow and door is a first step in actually helping them. For many years various advocates in the community have both accepted the Housing First concept that’s a national concept, and have complained about Housing First concept because of problems created by the lack of follow up services.  What we have now in our homeless services system is the opportunity to fully realize one of the aspirations of Housing First. The promise of Housing First was that once you got people housed, then you could work with them closely to resolve multiple problems that might have brought them to become homeless.

The holistic Continuum of Care board (CoC) is charged with coordinating all of these activities in a community. The CoC is a federally required decision making group because the federal Housing and Urban Development (HUD) Department is a primary funding source. It is in the interests of the people who have no homes and the people who serve them in the entire community to understand that we are at a very useful point.

There is an opportunity because of COVID-19 and the necessity to place people into special non-congregate shelters (NCS), as well as upgrade and modify of the congregate shelters such as Mary Isaac at COTS in Petaluma and Catholic Charities.  We have a very clear sense of who the highest needs users are and most importantly what those particular individuals think they need. I hope we can build on this opportunity.

Some important follow up questions:

Do community providers believe that their clients are being served by all this focus?  

Do the clients believe they are being helped by all this focus?

Can the County incorporate some numbers about the number of people who’ve experienced life changes due to the efforts to these teams?

And can we verify the answers to these questions?

Good questions, but we should start by giving credit where it is due… and learn from this new access we have.


Original article

Santa Rosa Hotel Acquired Through Project Homekey as Transitional Housing

Hotel Azura in Santa Rosa will be converted into interim housing for up to 66 individuals.

By Bay City News  Published November 11, 2020  Updated on November 11, 2020 at 9:02 am  Copyright BAYCN – Bay City News

The purchase of a Santa Rosa hotel to provide temporary housing for vulnerable people lacking shelter was approved Tuesday by the Sonoma County Board of Supervisors.

The $8 million acquisition of the 44-room Hotel Azura was made through the state’s Project Homekey program, established in June in response to the COVID-19 health emergency.

Officials said the hotel on Healdsburg Avenue would be converted into interim housing for up to 66 individuals when escrow is closed, possibly by next week.

“Adding Hotel Azura into our housing portfolio will give us the opportunity to bring more of our COVID-19 vulnerable individuals who are experiencing homelessness into supportive housing, with a path to permanent housing,” said Supervisor Susan Gorin. “I applaud the state for helping counties pursue housing that truly meets people’s needs, with supportive services and access to grocery stores, medical services and transportation.”

Priority access to the accommodations will go to those who are homeless and are most vulnerable to COVID-19. Those housed at the hotel will have also receive assistance from the county’s Accessing Coordinated Care to Empower Self Sufficiency Initiative (ACCESS) program that uses county and community programs to provide needed resources.

ACCESS services include primary health care, behavioral health services and support, economic and food assistance, and employment training.

Supervisors on Tuesday also approved the purchase of the Sebastopol Inn in Sebastopol, but that acquisition is pending state approval of funding.

4 Replies to “Access in Sonoma County”

  1. Terry Rowan

    Gerry, nice work compiling this data. The questions you ask about whether all these listed services and organizations actually are helping the targeted clients is apt. You ask us first to be thankful that we have access to information. I suggest if we are looking through a telescope from space, the hodgepodge of federal, state, and county functions claiming (in their titles) to be working to alleviate homelessness are sadly inadequate, and many may be the kind of bureaucratic organizations who really exist to perpetuate themselves, conduct studies, issue reports, and go home at night to a good meal and a warm bed while contemplating tomorrow’s committee work about “that gosh-darned problem out there that just won’t go away.”

  2. Anita

    Thank you Gerry,
    I am still harping on the issue brought up by Kennedy last year. If we are not certified/authorized for federal funding through the Medicare program then we are missing out on a huge block of monies. What is the problem with getting this certification? What is missing in the system of mental health that needs to be corrected. Human services/Access is not doing their part to fund the services. They are asking the county to fund this when they have access to another source, not to mention that the system of human services is broken, Can it be fixed?? This is the challenge to Barbie Robinson. And I wish she would do her job! Anita

  3. Alice Linn

    Thank you for this article related to the wonderful new purchase of Hotel Azura in Santa Rosa with state Project Homekey funds, and about the Behavioral Health Access team/s.

  4. Denise

    Hey Gerry, Here are some facts you might not be aware of:
    1) The Grand Jury 2020 Grand Jury report stated the County needed to start spreading homeless services around Sonoma County. The Hotel Azura purchase is a prime example of this. The St. Rose Neighborhood has two homeless facilities IN THE NEIGHBORHOOD along with two within a 1/4 mile and another one 1/2 mile away. We also have the mega Caritas Village homeless housing project in the process of being built IN OUR NEIGHBORHOOD. No other neighborhood in the ENTIRE county has this amount of services located in and around it.
    2) In the last 12 years, the County has started and discountinued 27 programs to address homelessness. Most with out documented goals or results based on metrics. Millions of $ spent and only 172 in “permanent housing”. This should concern everyone.
    3) The map of essential services near the Hotel Azura that the County provided with their application was completely false. They listed three 25,000 foot grocery stores and 9 medical offices that did NOT exist. Addresses turned out to be parking lots, massage parlors, liquor and cigarette stores, unrelated office buildings, etc.
    None of this makes us feel secure that the County can manage the Hotel Azura adequately. In the meantime, where are the YIMBYs* in this county? Everyone thinks these facilities are a grand idea when they’re not in their neighborhoods. *(Yes in my backyard.)


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