To: County of Sonoma Board of Supervisors
Department or Agency Name(s): Department of Health Services, Human Services Department
Staff Name and Phone Number: Nolan Sullivan, 707-565-4774; Jan Cobaleda-Kegler, 707-565-5157; Paul Dunaway, 707-565-3673
Vote Requirement: Informational Only
Supervisorial District(s): Countywide
Title:
Title
Senate Bill 43 Implementation Update
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Recommended Action:
Recommended action
Receive an informational update on Senate Bill 43 Implementation
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Executive Summary:
On October 10, 2023, Governor Newsom signed Senate Bill 43 <https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202320240SB43> (Chapter 637, Statutes of 2023) making significant changes to the state’s involuntary detention and Lanterman-Petris-Short conservatorship laws. Key changes include a new definition of gravely disabled, requirements to explore alternatives to conservatorship, placing conserved people in the least restrictive level of care, and increased data reporting requirements.
Counties have until January 1, 2026, to implement Senate Bill 43 (SB 43). Six counties are currently implementing SB 43; however, limited data is publicly available. Preliminary data from a similar size county reflects a 25% increase in conservatorships from January 2024 - August 2025. Sonoma County has 200 people on conservatorship; a 25% increase would see the conservatee population grow to 250.
Over the last five years, the county’s Lanterman-Petris-Short conservatee caseload has ranged from 186-207 clients. To address the existing deficits and anticipated increases, the Human Services Department will require two Full Time Equivalent allocations. Similarly, the Department of Health Services will require two Full Time Equivalent allocations.
To prepare for SB 43, the county has taken several actions. A series of informational meetings are planned through 2025 with community, public, and private stakeholders, an SB 43 training will be held in November 2025, and a limited number of substance use disorder beds have been identified for conservatees meeting certain withdrawal management criteria. In Spring 2025, the county secured a $67.8 million Bond Behavioral Health Continuum Infrastructure Program award from the California Department of Health Care Services. Long-term, this will allow the county to add more treatment beds for substance use disorder and conservatee clients. No additional funding has been provided to counties to implement SB 43.
Discussion:
Senate Bill 43 (SB 43) made significant changes to the state’s involuntary detention and conservatorship laws under the Lanterman-Petris-Short (LPS) Act. These changes included amending and adding new definitions to the Welfare & Institutions (W&I) Code.
The amended definition of gravely disabled is shown in bold text below:
Gravely disabled now means a condition in which a person, as a result of a mental health disorder, severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder, is unable to provide for their basic personal needs for food, clothing, shelter, personal safety, or necessary medical care.
The bill expands the definition of “basic needs” to include not just food, shelter, and clothing, but also access to necessary medical care and personal safety.
This new definition applies to the three primary LPS Act processes:
• Crisis Intervention: Assessment, evaluation and crisis intervention or placement in an LPS-designated facility for evaluation and treatment for up to 72 hours (W&I Code § 5150 <https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=5150.&nodeTreePath=11.1.2.1&lawCode=WIC>).
• Intensive Treatment: Up to fourteen (14) days (W&I Code § 5250 <https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=5250&lawCode=WIC>); if necessary and appropriately authorized, the intensive treatment period for grave disability may be extended for up to two periods of thirty (30) days each (W&I Code 5350 <https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=5270.15&lawCode=WIC>, W&I Code § 5270.70 <https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=5270.70.&nodeTreePath=11.1.2.7&lawCode=WIC>).
• Conservatorship: Up to one year, and renewable, for ongoing behavioral health treatment and support (W&I Code § 5350 <https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=5350&lawCode=WIC>).
New definitions added to the W&I Code include, but are not limited, to:
• Severe substance use disorder - a diagnosed substance-related disorder that meets the diagnostic criteria of ‘severe’ as defined in the most current version of the Diagnostic and Statistical Manual of Mental Disorders.
• Personal safety - the ability of one to survive safely in the community without involuntary detention or treatment pursuant to the LPS Act.
• Necessary medical care - care that a licensed health care practitioner, while operating within the scope of their practice, determines to be necessary to prevent serious deterioration of an existing physical medical condition which, if left untreated, is likely to result in serious bodily injury as defined in W&I Code § 15610.67 <https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=15610.67&lawCode=WIC>.
Other SB 43 changes include the use of diagnostic criteria to determine if a severe substance use disorder (SUD) is present, requirements to investigate alternatives to conservatorship, placing conservatees in the least restrictive level of care, expanding the type of testimony that can be considered at LPS hearings, and expanded data collection and reporting requirements. Additional SB 43 information is available at California Department of Health Care Services, Behavioral Health Information Notice No: 24-011.pdf <https://www.dhcs.ca.gov/provgovpart/Documents/BHIN-24-011.pdf>.
Data
As of September 2025, Sacramento, San Bernardino, San Diego, San Francisco, San Luis Obispo, and Stanislaus County are implementing SB 43. Approximately 52 counties opted to begin implementation on January 1, 2026. Data on the impact of SB 43 will be available in 2026 as counties comply with data reporting requirements. In the interim, limited data is publicly available. Initial estimates indicate the number of conservatees in San Luis Obispo County increased 25% and 29% in San Francisco County. Similar increases in Sonoma County would see the number of conservatees increase from 200 to 250 - 258. Over the last five years, the county’s LPS conservatees caseload has ranged from 186-207 clients as illustrated on page 10 of Attachment 3 - Presentation.
Placement and Treatment Considerations
In FY 2024/2025, the Department of Health Services (DHS) spent approximately $11.7 million placing 197 conserved individuals. Placement is determined by the individual’s least restrictive placement order and includes locked settings such as Institutions for Mental Disease, skilled nursing facilities, and mental health rehabilitation centers. It also includes unlocked settings like residential care facilities or other transitional or supportive housing settings. DHS contracts with a number of providers both locally and regionally in an effort to ensure individuals are not being held unnecessarily in locked settings such as psychiatric hospitals, emergency departments, or Sonoma County Jail.
DHS places strong emphasis on utilizing local placements so individuals have the ability to be near their primary support networks. Costs for each facility varies by its type and level of care needs the individual presents with upon admission. The average cost for placing an LPS conservatee is $60K annually. Alternatively, the annual cost to place a murphy conservatee is approximately $150K to $300K depending on type of placement and acuity level of the individual being placed.
Sonoma County currently has 65% of clients placed out of county to receive mental health treatment. Many facilities are over 100 miles away from Sonoma County. This can create obstacles with arranging for in-person court appearances, for county staff to complete periodic visits, and for families to see their loved ones. Being placed out of county can also create challenges when the client no longer meets criteria for LPS conservatorship and needs to be reintegrated back into the Sonoma County Mental Health services system. In the short term, the county has identified up to ten (10) SUD withdrawal management beds that are available for conservatees meeting certain criteria. This temporary option is intended to provide some relief while longer-term measures are being developed (e.g. Bond Behavioral Health Continuum Infrastructure Program construction).
In anticipation of future placement needs for individuals conserved under the enhanced grave disability SB 43 criteria, it is estimated that DHS will need an additional $1.4 - $2.9 million in new placement costs. Costs are subject to type of facility, length of stay, and treatment needs of the conserved individual.
Staffing
The LPS conservatee population has grown by 7% over the last five (5) years without a corresponding staffing increase. To address the existing 2025 deficits, the Human Services Department (HSD) will require two Full Time Equivalent allocations (FTE) and DHS will require two FTEs. To address the 2026 deficits as a result of SB 43 implementation, DHS will require two FTEs. A total of six FTEs (2025 needs and 2026 SB 43 implementation needs) are needed to provide services to conservatees for both HSD and DHS.
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HSD |
DHS |
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2.0 FTE Public Conservator Deputies |
2.0 FTE Senior Client Support Specialist |
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1.0 FTE Licensed Behavioral Health Clinician |
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1.0 FTE Behavioral Health Clinical Specialist |
Additional staffing would allow DHS to reduce staff caseload from 65 clients per FTE to 35 clients per FTE. As a result of fewer staff and larger individual caseloads of 65+, the DHS team has been unable to meet its obligations to provide adequate client care and make quarterly client visits as specified in its Memorandum of Understanding with the Conservator’s Office.
Increased staffing for HSD would result in a reduction of approximately 100 clients per deputy to 50 per FTE with room to grow to 62 clients. As indicated in the California State Association of Public Administrators, Public Guardians and Public Conservators report dated December 2021, the average caseload for medium sized counties is 45 per staff person across California (Attachment 2). With SB 43 implementation, caseload ratios are expected to increase. Two additional FTE allocations will allow the HSD team to better meet its obligations and provide adequate case management services.
DHS and HSD will continue evaluating staff capacity as implementation begins and will return to the Board with a request for general fund support for staffing during the FY 26-27 budget process.
Community Engagement and Training
The county has been preparing for SB 43 through community engagement meetings, training opportunities, and resource identification. Summer 2025 saw the kickoff of community meetings to share information about SB 43 and to gather feedback from stakeholders. Meeting invitations were extended to community providers, community organizations, public health and safety groups, private hospitals, federally qualified health centers, and others. During these meetings stakeholders sought clarity on the changes in law and impact on local systems. Additional stakeholder meetings are planned throughout 2025.
The California Mental Health Services Authority (CalMHSA) offers certification training to individuals that are authorized to write certain involuntary holds (i.e. 5150 Holds). The DHS has identified staff and contractors that meet these criteria and is on track to have impacted staff trained by December 2025. On a parallel path, DHS is working with the Patients’ Rights Advocates to develop training for non-certified Behavioral Health staff and community providers. This training will address how and why conservatorships came about, the law pre- and post-SB 43, sample group exercises, and more. This training will be recorded and offered in November 2025.
LPS Conservatees and CARE Courts
Under the LPS Act, there are two subsets of conservatees that are under the supervision and care of the Conservator’s office and the Department’s Behavioral Health division. They are commonly referred as to General conservatees and Murphy conservatees. General conservatees are those individuals who, as a result of a mental illness, meet the criteria for involuntary hold for grave disability. This is the largest subset of conserved individuals in Sonoma County. Alternatively, Murphy conservatorships are those individuals who have been charged with a felony violent offense, pose a risk of danger to others, are found to be unrestorable after a finding of incompetent to stand trial, and also meet the criteria for grave disability. In 2024, The California Court of Appeals established it is unlawful for Murphy conservatees who are awaiting placement to be confined in the county jail indefinitely - Case # D084051, Central California Appellate Program <https://capcentral.org/case_summaries/in-re-lerke/>. Case # D084051, Central California Appellate Program <https://capcentral.org/case_summaries/in-re-lerke/>. The court noted that some individuals on Murphy conservatorships are incarcerated in county jail for years waiting for room in the state hospital, which often results in a significant deterioration of their mental health.
The Community Assistance Recovery and Empowerment (CARE) Act established local CARE Courts in each county aimed at delivering substance use and mental health services to vulnerable individuals who are experiencing homelessness or incarceration without being able to access necessary treatment and housing services. Successfully implemented in Sonoma County in December 2024, CARE Court intersects with SB 43 as medical providers must consider CARE Court as a least restrictive option upon making petitions for conservatorship and at subsequent annual renewal.
Monetary Sanctions
Counties are required to provide the DHCS with quarterly SB 43 data. Failure to comply with the accurate and timely submission of data may result in a corrective action plan, assessment of civil penalties, or both - Senate Bill 43, Chapter 637 <https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240SB43>.
Strategic Plan:
N/A
Racial Equity:
Was this item identified as an opportunity to apply the Racial Equity Toolkit?
Yes
See Attachment 1 for details on the Racial Equity Analysis
Prior Board Actions:
December 12, 2023, the Board adopted a resolution deferring changes made by California Senate Bill 43 (Regular Session 2023-2024) to Welfare & Institutions Code Section 5008 for the County of Sonoma to the date of January 1, 2026.
January 4, 2022, the Board adopted a resolution designating Crestwood Sonoma County Healing Center, as an involuntary detention facility for the purpose of assessment, evaluation, and treatment of adults who are a danger to others, danger to themselves, or gravely disabled under the Lanterman-Petris-Short (LPS) Act.
December 7, 2021 the Board authorized the Director of Health Services, or designee, to execute an agreement and amendments with Crestwood Behavioral Health, Inc. for the operation of the Los Guilicos Psychiatric Health Facility with a term beginning in fiscal year 2021-2022 and ending no later than 36 months after the beginning date, for a not-to-exceed amount of up to $5,110,000 annually.
June 2020 and June 2021, the Board adopted resolution numbers 20-0189 and 21-0245 designating various professionals as persons with authority to detain individuals who they have probable cause to believe are a danger to self or others, or gravely disabled.
In 2013, the Board adopted resolution number 13-0151 designating the Aurora Behavioral Health Hospital facility an involuntary detention facility for minors and adults under the LPS Act.
Fiscal Summary
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FY25-26 Adopted |
FY26-27 Projected |
FY27-28 Projected |
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Narrative Explanation of Fiscal Impacts:
There is no fiscal impact associated with this item. Additional staffing will be part of the FY 26/27 budget considerations.
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Staffing Impacts: |
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Narrative Explanation of Staffing Impacts (If Required):
None
Attachments:
Attachment 1 - Racial Equity Analysis
Attachment 2 - California Association of Public Administrators, Public Guardians, and Public Conservators Funding Data Report
Attachment 3 - Presentation
Related Items “On File” with the Clerk of the Board:
None