Cotati City Council
June 27, 2023

Sonoma County
5 Year Strategic Plan
to Prevent and End
Homelessness
2023 – 2027
Adopted by the Sonoma County CoC Board on December 14, 2022 Prepared by Homebase
2 EXECUTIVE SUMMARY
No one in Sonoma County should be homeless. But on any given night, 2,900 individuals lack a home they can call their own. That sobering figure drives this strategic plan from a group known as the Sonoma County Continuum of Care.

Most people will not have heard of a Continuum of Care. Every region has one. We have a federal and state role – that being to coordinate and make sense of the homeless system in Sonoma County. We are individuals with lived experience of homelessness; local officials and homeless service providers who volunteered to work on this vital issue; members of the health care, housing, and behavioral health fields; and residents and business owners in Sonoma County. We would not be here, nor would we issue this plan, if we did not think that significant progress can (and must) be made to reach functional zero in homelessness.

The plan takes stock of the work that is already happening across the county, including the efforts of the dozens of organizations and hundreds of people who are working hard every day to prevent and end homelessness. It asks, how can we do better? What can we do to make the hard work of so many people even more effective? What are the gaps in service and needs in the community that we’re not currently filling? What should change in our current system of care so that it better meets the needs of people at risk of or in the midst of a crisis of homelessness? In short, what can we do to put us on a path to move from 2,900 people experiencing homelessness to functional zero?
We looked to many sources to answer those questions. System performance data helped us identify who is being served, who isn’t, and where the gaps and needs in the system lie.

It showed a troubling increase in
the percent of people
experiencing homelessness who
are living unsheltered.

It also showed the difficulty the
homeless system of care has
faced in reducing chronic
homelessness in Sonoma
County. This points to a need
to expand supportive housing
options in the county.
3 Racial disparities also emerged
from our analysis. Black
individuals make up three times
the share of the homeless
population as they do the
general population and Native
people make up four times
the share.

Hispanic/Latino households
spend more time homeless
than the overall average.

Equally concerning, nearly
two-thirds of households
experiencing homelessness
have a family member with
a disabling condition.

A wide range of stakeholders also informed the plan. Frontline workers told us about the chronic challenges they face due to having too few resources to meet their clients’ complex housing, economic and health needs. Program managers worried openly about burn-out and high turnover among their over-worked and under-paid staff. Equity advocates highlighted the structural factors that leave many people of color and members of the LGBTQIA+ community overrepresented in the homeless system of care. People with lived experience of homelessness spoke with deep appreciation for the support they received, but also highlighted times they felt overlooked or mistreated. Business leaders sought opportunities to partner in support of initiatives to address homelessness. Service providers and government leaders from throughout the County spoke of a need for greater coordination and collaboration across the system of care.

Community and stakeholder input led to the development of three overarching goals, which will guide the direction of the homeless system of care in Sonoma County for the next five years:

1. Invest in more housing and prevention. It is imperative to reduce the inflow of people into homelessness and create more pathways to long-term housing stability. Doing so will require investments in both homelessness prevention and housing solutions.

2. Strengthen supportive services. The current system of care strains to meet the complex and diverse supportive services needs of people in the community who are experiencing the crisis of homelessness. That strain is felt not only by people experiencing homelessness, but also by homeless service providers, who are overtaxed and under-resourced. Building supportive services capacity is critical to ease this strain and better meet the needs of those in a housing crisis.

3. Operate as one coordinated system. Sonoma is a large county with many local governments and a broad array of service providers and other stakeholders whose work directly or indirectly impacts homelessness. To achieve functional zero, partners across 4 the county must work to develop shared priorities, aligned investments, seamless coordination, and equitable solutions to the crisis of homelessness.

The strategic plan outlines community-identified strategies, supported by evidence-based best practices, to advance the three goals. It includes detailed ‘Early Action Steps” intended to help the CoC move from plan to action. Sonoma County should see concrete gains from implementing the plan, including:
● Creating more than 500 interim and non-congregate shelter beds over the next two years.
● Creating more than 1,000 permanent housing units or beds over the next five years, with 200 beds added per year.
● Establishing a sub-regionalized approach to street outreach, so that no one is left behind and all outreach teams meet baseline performance standards. ● Implementing more effective approaches to coordinated entry that allow the system to target specific solutions to meet an individual’s specific needs. ● Building systems to better coordinate with institutional actors, such as jails or hospitals, to ensure that people exiting those settings do not immediately become homeless. ● Improving compensation, benefits, and caseload ratios for frontline homeless services workers to avoid burn-out, limit turnover, and provide better care for clients; and ● Providing the public and decision-makers with specific data to evaluate how the system is functioning and improve accountability and system performance on an ongoing basis.

STRATEGIC PLAN VISION
The system of care in Sonoma County strives to be a leader in preventing homelessness, and in ensuring that people experiencing homelessness are supported in achieving housing stability, mental and physical wellness, and economic welfare through a collaborative, client-driven system of care that quickly and effectively delivers accessible, dignified treatment and services.

STRATEGIC PLAN GOALS

MORE HOUSING &

PREVENTION
Create comprehensive housing
interventions, from prevention to permanent
housing, to reduce inflow into homelessness
and increase pathways to housing stability
1 STRONGER SUPPORTIVE

SERVICES
Build supportive services capacity to meet
the complex and diverse needs of people
experiencing homelessness in the Sonoma
County region

OPERATE AS ONE

COORDINATED SYSTEM
Work across the Sonoma County region to
develop shared priorities, aligned investments,
seamless coordination, and equitable solutions
to address homelessness
Strategy 1.1: Preserve housing for those
at risk of homelessness by investing in
prevention and problem-solving
interventions
Strategy 1.2: Enhance and invest in noncongregate interim housing options Strategy 1.3: Develop sustainable
permanent housing solutions
Strategy 1.4: Support efforts to increase
the region’s supply of affordable housing
Strategy 2.1: Standardize minimum
compensation and training and provide
model wellness practices for housing and
supportive service providers
Strategy 2.2: Significantly expand mental
and physical healthcare services for
individuals experiencing homelessness,
including those living in supportive
housing
Strategy 2.3: Improve services dedicated
to the unique needs of specific populations
Strategy 2.4: Coordinate cross-sectors of
healthcare, behavioral health, and
homeless response
Strategy 2.5: Develop, expand, and
coordinate interventions to support those
living on the street, in encampments
Strategy 2.6: Create meaningful pathways
to economic self-sufficiency
Strategy 3.1: Develop a countywide coordinated
funding process to use available resources efficiently
and effectively to drive local priorities and ensure
accountability
Strategy 3.2: Prioritize funding to entities that align with local priorities to promote equity, center the
voices of people with lived experience, and utilize
evidence-based practices
Strategy 3.3: Ensure the voices of individuals with
lived experience of homelessness are consistently
incorporated into planning & evaluating the homeless
system of care
Strategy 3.4: Improve systemwide and project level
data collection, performance, and reporting
Strategy 3.5: Engage the community in the effort to
end homelessness in Sonoma County
Strategy 3.6: Improve transparency and effectiveness
of the Coordinated Entry System (entry points of the
homeless system of care)
Strategy 3.7: Eliminate disparities in access, service
provision, and outcomes in underserved and
overrepresented subpopulations in the homeless
system of care
Strategy 3.8: Monitor and report back as to progress
on the Strategic Plan’s action steps, and adjust
activities as conditions and new information warrants
3 9
2 TABLE OF CONTENTS
EXECUTIVE SUMMARY.............................................................................................................2 STRATEGIC PLAN VISION..........................................................................................................4 STRATEGIC PLAN GOALS ..........................................................................................................5 TABLE OF CONTENTS ...............................................................................................................6 INTRODUCTION .......................................................................................................................9 CURRENT SYSTEM OF CARE AND RELATED CHALLENGES ........................................................10 Overview........................................................................................................................................10 Leadership and Coordination..........................................................................................................11 Current System....................................................................................................................................................11 Challenges ...........................................................................................................................................................12 Homelessness Prevention and Diversion.........................................................................................13 Current System....................................................................................................................................................13 Challenges ...........................................................................................................................................................13 Coordinated Entry System ..............................................................................................................14 Current System....................................................................................................................................................14 Challenges ...........................................................................................................................................................14 Safe Parking....................................................................................................................................15 Current System....................................................................................................................................................15 Challenges ...........................................................................................................................................................15 Street Outreach...............................................................................................................................16 Current System....................................................................................................................................................16 Challenges ...........................................................................................................................................................17 Housing Solutions...........................................................................................................................17 Current System....................................................................................................................................................19 Average Length of Time Homeless by Housing Project Type ..............................................................................20 VI-SPDAT Scores by Housing Project Type...........................................................................................................20 Challenges ...........................................................................................................................................................22 Supportive Services.........................................................................................................................23 Current System....................................................................................................................................................24 Challenges ...........................................................................................................................................................24 A ROADMAP FOR SONOMA COUNTY: GOALS, STRATEGIES, AND ACTION STEPS ....................26 Sonoma County High Priorities ......................................................................................................26 Goal 1: More Housing and Prevention............................................................................................27 7 Strategy 1.1: Preserve Housing for Those at Risk of Homelessness by Investing in Prevention and ProblemSolving Interventions...........................................................................................................................................27 Strategy 1.2: Enhance and Invest in Non-Congregate Interim Housing Options.................................................29 Strategy 1.3: Develop Sustainable Permanent & Permanent Supportive Housing Solutions .............................31 Strategy 1.4: Support Efforts to Increase the Region’s Supply of Affordable Housing........................................32 Goal 2: Stronger Supportive Services...............................................................................................32 Strategy 2.1: Standardize Minimum Compensation, Training, and Wellness Practices for Housing and Supportive Service Providers...............................................................................................................................32 Strategy 2.2: Significantly Expand Mental and Physical Healthcare Services for Individuals Experiencing Homelessness, Including Those Living in Supportive Housing ............................................................................34 Strategy 2.3 Improve Services Dedicated to the Unique Needs of Specific Populations ....................................34 Strategy 2.4 Coordinate Cross Sectors of Healthcare, Behavioral Health, and Homeless Response ..................35 Strategy 2.5: Develop, Expand, and Coordinate Interventions to Support Those Living on the Street, in Encampments......................................................................................................................................................35 Strategy 2.6 Create Meaningful Pathways to Economic Self-Sufficiency ............................................................36 Goal 3: Operate as One Coordinated System...................................................................................36 Strategy 3.1: Develop a Countywide Coordinated Funding Process to Use Available Resources Efficiently and Effectively to Drive Local Priorities and Ensure Accountability ...........................................................................36 Strategy 3.2: Prioritize Funding to Entities that Align with Local Priorities to Promote Equity, Center the Voices of People with Lived Experience, and Utilize Evidence-Based Practices .............................................................37 Strategy 3.3: Ensure the Voices of Individuals with Lived Experience of Homelessness are Consistently Incorporated into Planning and Evaluating the Homeless System of Care .........................................................37 Strategy 3.4: Improve Systemwide and Project Level Data Collection, Performance, Reporting, and Transparency .......................................................................................................................................................38 Strategy 3.5: Engage the Community in the Effort to End Homelessness in Sonoma County ............................39 Strategy 3.6: Improve Transparency, Safety, and Effectiveness of the Coordinated Entry System ....................40 Strategy 3.7: Eliminate Disparities in Access, Service Provision, and Outcomes in the Homeless System of Care .............................................................................................................................................................................40 Strategy 3.8: Monitor and Report Back as to Progress on the Strategic Plan’s Action Steps, and Adjust Activities as Conditions and New Information Warrants ....................................................................................41 APPENDIX A: EARLY ACTION STEPS ........................................................................................42 Lead Agency Initial 2023 Efforts...............................................................................................42 Countywide Early Implementation Efforts ..............................................................................43 APPENDIX B: STRATEGIC PLANNING PROCESS........................................................................55 APPENDIX C: ACKNOWLEDGEMENTS .....................................................................................56 APPENDIX D: QUANTITATIVE DATA SOURCES ........................................................................58 APPENDIX E: HOMELESSNESS IN SONOMA COUNTY BY THE NUMBERS ..................................60 Homeless Population Overview................................................................................................60 Chronic Homelessness.........................................................................................................................................61 System Engagement ............................................................................................................................................63 8 Racial and Ethnic Disparities in Homelessness ....................................................................64 Homeless Population Across County Geography.................................................................67 Where People Are ...............................................................................................................................................67 Where People Are Served ...................................................................................................................................68 Households With and Without Children..................................................................................69 Homelessness by Household Type ......................................................................................................................69 Exits from Homelessness.....................................................................................................................................71 Vulnerable Populations..............................................................................................................73 Transitional Age Youth ..............................................................................................................74 Sheltered vs Unsheltered Transitional Age Youth Homelessness .......................................................................75 Veterans........................................................................................................................................77 Homeless Veteran Population.............................................................................................................................77 Comparing Homeless Veteran Population to Total Veteran Population.............................................................78 Comparing Veteran Households to Nonveteran Households..............................................................................79 APPENDIX F: ECONOMIC AND HOUSING LANDSCAPE OF SONOMA COUNTY ..........................80 Income and Poverty....................................................................................................................80 High-Cost Burden .......................................................................................................................81 Barriers for Special Populations ..............................................................................................82 Affordable Housing Stock .........................................................................................................83 APPENDIX G: CROSSWALK OF SUBREGIONAL STRATEGIC PLANS ............................................84 APPENDIX H: GLOSSARY OF KEY TERMS AND ENTITITES.........................................................88 9 INTRODUCTION
It would be hard to point to a problem in Sonoma County that needs more attention than homelessness. Climate change’s drought and wildfire ranks right up there too, but the public expects us to have more control over homelessness. Being unhoused, or seeing our unhoused neighbors suffer through cold and heat, often with physical or mental health-related disabilities, is heartbreaking and life-altering. We know that we can and must do better as a system of care.

We’re all part of that system. Whether we’re elected or appointed leaders, agency staff members, volunteers at community-based organizations, persons experiencing homelessness, residential property owners, employers, or Sonoma County neighbors going about their day-today activities; we all have a role to play in making homelessness brief, one-time, and rare.

This plan was prepared at the direction of the Sonoma County Continuum of Care (CoC), a body of representatives from County government, cities, service providers, persons with lived experience in homelessness, the faith community, and others. The CoC’s meetings are monthly and open to the public. The Plan has three goals:

1. More Housing and Homelessness Prevention. We need hundreds of more housing units of multiple types, beds, and more programs to stop homelessness before it happens.

2. Stronger Supportive Services. We all get the concept of housing, but housing for many must be paired with strong, individualized support, including behavioral and physical health care, recovery services, and budgeting financial management skills. Those looking for work need training; those who have a disability need support maintaining benefits.

3. Operate as One Coordinated System. It won’t shock Sonoma County readers to know that the homeless system of care could be more streamlined, effective, and equitable; easier to understand; and supportive of all individuals seeking help rather than perpetuating a system that says, “we don’t do that - they do.”
We believe that the goals, strategies, and action steps in the Plan, which include significant expenditures to modify and build a system that works, are the right ones. The steps outlined represent proven practices, community and expert consensus, and the realities of homelessness in Sonoma County. The goals of the plan are not easy nor cheap, but this is how we start moving the needle back to zero homelessness. We’re excited to implement this plan and to re-home our unhoused neighbors.

Sincerely,
Rebekah Sammet, Member, CoC Board Strategic Planning Committee and Lived Experience and Planning Board
Tom Schwedhelm, Co-chair, CoC Board Strategic Planning Committee Stephen Sotomayor, Co-chair, CoC Board Strategic Planning Committee 10 CURRENT SYSTEM OF CARE AND RELATED CHALLENGES
This section of the Strategic Plan reviews the current homeless system of care in Sonoma County. It also highlights many of the challenges surfaced through our conversations with stakeholders in that system of care and our analysis of related quantitative data. A more detailed look at that quantitative data may be found in Appendices D, E and F.

Overview
An effective homeless crisis response system quickly identifies and connects people who are experiencing or are at risk of homelessness to shelter, rehousing assistance, and other services. It works because it aligns a community, its programs, and services around one common goal — to make homelessness rare, brief, and nonrecurring. The figure below illustrates how the Sonoma system is organized, with the aim of preventing homelessness and helping people exit the system quickly when homelessness does occur.

Figure A: Sonoma County Homeless System of Care
11 Leadership and Coordination
An effective response to
homelessness requires a
community-wide effort that engages
stakeholders from a wide range of
jurisdictions, agencies, and sectors
in a shared strategy. The Sonoma
County Continuum of Care (CoC) is
the principal body that leads and
coordinates the county-wide
response to homelessness. The
CoC receives significant staff
support from the Sonoma County
Community Development
Commission (CDC or the
Commission). The CDC is the
designated Administrative
Entity/Lead Agency (Collaborative
Applicant) for the CoC, and is the
HMIS Lead that administers the
CoC’s Homeless Management
Information System (HMIS). As of April 1, 2022, the nonprofit, HomeFirst, became the operator of Coordinated Entry (CE), assuming the role of coordinator for Sonoma County’s front door to supportive housing and services.

Current System
The Sonoma County Continuum of Care is membership-based. Any person or entity committed to preventing and ending homelessness in Sonoma County may join the CoC as a participating member. To join as a Voting Member, an individual or entity must submit an application that the CoC Board may approve in its discretion. The Board reviews applications to ensure that voting members are located in Sonoma County and have made material contributions or commitments to supporting the vision of the CoC.

The CoC Board leads the Sonoma County Continuum of Care. It serves as the governing body that determines CoC policy and acts as the CoC's decision-making group. Mandated by the HUD’s Continuum of Care Program, the Board is responsible for oversight of funds designated to the CoC and regional planning/policy development for addressing homelessness.

The Board consists of 17 voting members, including local elected officials, nonprofit representatives, subject matter experts, and individuals with lived experience of homelessness.

Nine of the seats on the Board are appointed by local governments, the County Administrator, and the largest homeless services provider in the County, with provisions made to ensure broad geographic representation across jurisdictions. Five of the remaining seats are filled by people Sonoma County Continuum
of Care (CoC) - A
collaboration of local stakeholders working
together to prevent and end
homelessness
COC BOARD - (appoints CES
lead, HMIS
Lead, Administrative
Entity, Collaborative Applicant) CoC Partners
(Education,
legal, faith- based, medical,
law
enforcement) CoC
Committees & Workgroups HMIS Lead
(Sonoma County) Coordinated
Entry
(administered
by HomeFirst) Grantees
(housing and
services) Cities
Community
Stakeholders
(Businesses, neighbors, etc.)
Sonoma County
(Administrative
Entity, HMIS
Lead, Collaborative Applicant)
Figure B: Sonoma County Continuum of Care
12 who represent a range of stakeholder groups, including homeless services providers, health care organizations, people with lived experience of homelessness (both adult and transitional age youth (age 18-24)), and homeless advocacy organizations. The remaining three seats are “at large” positions not designated to represent any particular stakeholder groups, although members are encouraged to consider factors such as geographic diversity, subject matter expertise, and representativeness of people served by the homeless system of care when casting their votes. The CoC Board typically meets once per month, with additional meetings held as necessary.

Much of the work of the CoC is conducted through committees and work groups. Committees and work groups generally consist of some CoC Board members, CoC voting and participating members, and other volunteers. The CoC’s current committees are described in the glossary found in Appendix H.

The CoC designated the Sonoma County Community Development Commission (“CDC” or “Commission”) as the HMIS Lead, Lead Agency, and Collaborative Applicant for the CoC. In this role, the CDC coordinates efforts related to data collection and analysis, grant applications and awards, and system and project monitoring. More information about the CDC’s CoC roles can be found in the glossary found in Appendix H.

Challenges
Stakeholders throughout the homeless system of care see a need for stronger leadership and coordination. Much of the concern around coordination relates to funding. For example, some stakeholders noted that when the Community Development Commission issues a call for proposals from the homeless system of care, it often receives few responses. They speculated that one reason for this is that it is hard for providers to know whether it is worthwhile to submit a proposal – either because another program may be seeking funding for a similar project, or because the commission has a particular project or need in mind for which it wants to award the funding. They called for stronger outreach by the Commission to help providers develop proposals that are likely to win funding approval.

Stakeholders also noted a problem with expiring funding. The County currently has no system in place to track when funding awards expire. This often leaves the County and providers scrambling to replace funding at the end of a grant term. Stakeholders called for stronger tracking systems to allow all parties more time to plan for the end of grant terms and to seek alternative funding streams when available to support the ongoing availability of needed services.

Several stakeholders noted that coordination across the county has been most effective when one person took charge of a particular initiative or effort. Clear leadership roles create accountability and a decision-making chain that make it more likely that proposals for change will be brought to fruition. To that end, several stakeholders called for the creation of a senior position within the County to lead and coordinate the region’s efforts to prevent and end homelessness. The County has recently created just such a position within the Department of Health Services.
13 Homelessness Prevention and Diversion
In the context of the homeless system of care, prevention and diversion are closely related concepts. “Prevention” refers to the provision of supports, services and problem-solving to avert or avoid homelessness for those at risk of losing housing. “Diversion” refers to efforts to connect households that present at an entry point to the homeless system of care to alternate housing arrangements or supports that help them immediately return to permanent housing. In practice, prevention and diversion efforts use similar strategies, which may include financial assistance (to pay rent, utility bills, security deposits, moving costs, etc.) or supportive services (such as housing advice, landlord or family mediation, benefits advocacy, etc.), or both.

Current System
A range of prevention and diversion services and support are available in Sonoma County. ● The County provided approximately $150,000 in funding for prevention efforts in FY21/22, as well as over $30 million in Emergency Rental Assistance Program (ERAP) funding.
● A Multidisciplinary Team of County Safety Net partners shares data in IBM’s Watson Care Manager to coordinate discharge planning with jails and health care clinics to prevent homelessness of individuals with chronic health issues. ● The CoC partners with McKinney-Vento Liaisons in school districts to rapidly connect families at risk of homelessness with the Coordinated Entry system. ● Legal Aid of Sonoma County helps low-income tenants with eviction defense, Section 8 issues, mobile home park issues, habitability problems and price gouging. ● Access Point staff engage new clients in a housing problem solving conversation, to help them self-resolve their housing issues and divert out of the homeless system of care.

Through these efforts, the CoC hopes to reduce first-time homeless by 3% by 2024.

Challenges
A challenge in increasing prevention and diversion efforts in Sonoma County lies in a lack of clarity about effective strategies. With limited funding for homelessness, stakeholders expressed concern about spending money to keep someone housed when it’s not always clear (1) that the individual or household would become homeless but for the funding provided, and (2) that provided funding will ultimately succeed in keeping an individual or household housed.

Stakeholders called for further exploration of evidence-based best practices and data collection strategies.
14 Coordinated Entry System
Current System
Sonoma County’s Coordinated Entry System (CES or CE) helps people access an array of housing interventions and services through a single, coordinated process. It is intended to offer a “no wrong door” approach, so that getting help is not a matter of being lucky enough to talk to the right agency or case manager at the right time. Any access point should be able to connect people to appropriate and available services and housing resources. CE makes referrals only to permanent housing (not shelters) and is designed to be dynamic. Rather than operating on a “first come, first served” basis, CE maintains a By Names List that adjusts based on the vulnerability and need of individuals, families, and transition-aged-youth (TAY) entering and exiting the system. Unfortunately, demand for assistance often outpaces the availability of housing and other resources.

HomeFirst has managed CES since April 2022. CE is made-up of four core elements: Access, Assessment, Prioritization, and Referral. More information about these elements can be found in the glossary under the term Coordinated Entry System in Appendix H.

Challenges
● Single By Names List – Agencies currently compile separate By Names Lists (BNL) on a local/regional basis, and then use cross-jurisdictional case conferencing to match clients with available resources. Stakeholders agreed that it would be more efficient to compile a single BNL for all individuals and households in Sonoma County who are seeking assistance. However, some jurisdictions have resources available only to local residents. Accordingly, it is important that any move to create a single BNL retain the capacity to identify resources by region and sort by jurisdiction. ● Prioritization concerns – Stakeholders raised two different sets of concerns regarding prioritization within the CE system.
o VI-SPDAT – Some stakeholders raised concerns about the CE system’s assessment tool – the VI-SPDAT. Concerns include the tool’s equity implications (i.e. that it may bias the prioritization of housing placement against people of color/BIPOC), its intrusiveness, the trauma it may recreate, its inflexibility, and the repetitiveness of the process.
o Fairness – Another set of concerns addressed the need to make sure that prioritization is fairly administered, and that there are agreed-upon, universal priority standards. There is a particular worry that when encampments in unincorporated areas are cleared, residents who are moved out “jump the line” in the CE system. ● Information sharing – Information sharing is a concern both between agencies within the homeless system of care as well as with adjacent agencies that interact frequently with the homeless system of care, such as jails and hospitals. Many cited the challenge of securing proper confidentiality releases to share information across providers. Another issue is addressing information documented in case notes. Providers observed that what 15 is shared in case notes may not be accurate and may prejudice others in their willingness to provide care or in the kind of care they provide. They also suggested that it may be enough to know who is working with a particular client, without disclosing other confidential information. This would allow providers to reach out to each other when necessary. Others noted the need for a mechanism through which adjacent agencies could notify agencies in the homeless system of care of the release of a client who is experiencing homelessness. It may be important to prioritize access to emergency shelter beds for released clients, followed by enrollment in Coordinated Entry.

Safe Parking
Current System
A variety of churches and other organizations in Sonoma County offer “safe parking” sites – places where individuals and families who are experiencing homelessness and using a car or RV as their primary residence can safely park their vehicles. Sites typically provide access to bathrooms and may also offer meals or other support. Outreach efforts help connect site users to the homeless system of care.

Challenges
Stakeholders raised two significant concerns regarding Sonoma County’s safe parking sites:
● Safe parking sites are not well-integrated into the homeless system of care – There is no centralized listing of safe parking sites, and Coordinated Entry no longer makes referrals to them. Accordingly, they can be difficult for people experiencing homelessness to find. A barrier to better integration is that some sites do not want to be formally connected to the homeless system of care, for fear that doing so would complicate administration and intake at the site.
● Many parts of the county are not served by safe parking – Gaps in availability seem to be particularly acute in north county areas.
16 Street Outreach
Current System
A variety of agencies in Sonoma County conduct street
outreach efforts to reach people experiencing
homelessness who are living unsheltered, whether they
are on the streets, in parks, in their cars, or in
encampments (see sidebar). Broadly, the goals of this
work are to build connections with people who might not otherwise seek assistance or come to the attention of the homelessness service system, to ensure that people’s
basic needs are met, and to support people on their paths toward housing stability. Strong outreach and support
efforts can ease the burden on police and help people
experiencing homelessness avoid criminal justice
entanglement. As one outreach team member commented,
“Some officers are good about recognizing mental health issues, so they call us often. Others are scared by mental health issues, so they call us, too.”
Many of the larger communities in Sonoma County support local outreach teams. Sonoma County also supports a
cohort of its Interdepartmental Multidisciplinary Team
(IMDT) group (the cohort is called the HEART team or
Homeless Encampment Access and Resources Team)
that conducts outreach to people living in encampments on land outside of incorporated jurisdictions. The HEART Team also assists in clearing encampments.

A wide variety of service providers also provide medical care, or “street medicine,” to unsheltered people experiencing homelessness in locations like encampments, parks, and under bridges.

Outreach Teams by
Jurisdiction
Petaluma
Downtown Street Teams
Safe Teams
Santa Rosa
InResponse
Homeless Outreach Services Team
Rohnert Park
Unsheltered Friends Outreach
Homeless Outreach Services Team
Sonoma County
Interdepartmental
Multidisciplinary Team (IMDT)
17 Challenges
Encampments – Stakeholders called for a more consistent and coordinated approach toward addressing encampments of homeless individuals. People with lived experience of homelessness were particularly concerned about efforts to remove people from land when there is nowhere else for them to go. And when they must relocate, they lose touch with outreach workers, access to community, and their sense of safety. They called for more supported, alternative housing options such as tiny home villages, safe parking, and sanctioned encampments.

Street Medicine – Coverage and access are uneven. A widespread challenge lies in transporting clients to medical appointments. Some providers have funding to transport seniors, but not clients experiencing homelessness in general. There is also a need for more veterinary care for clients with pets. Stakeholders praised the work of Ruthless Kindness, an organization that provides free veterinary care at some shelters and encampments (among other places), but they noted that even more assistance is needed.

Housing Solutions
Sonoma County, like its peers across the country, embraces a “Housing First” approach to homelessness. As the National Alliance to End Homelessness explains, the Housing First approach “prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness, and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly, or attending to substance use issues. Additionally, Housing First is based on the understanding that client choice is valuable in housing selection and supportive service participation, and that exercising that choice is likely to make a client more successful in remaining housed and improving their life.”1
1 https://endhomelessness.org/resource/housing-first/
18 Housing First is viewed by State and Federal funders as essential (and required) to receive State and Federal funding for homelessness solutions. Given the evidence supporting Housing First’s effectiveness,2 as well as the significant funding tied to it,3 this Plan embraces a Housing First approach for Sonoma County. While not every individual organization or project providing services can meet the individualized needs of every household, the Plan aims to ensure that anyone facing a housing crisis in Sonoma County has a path to both shortand long-term housing stability.

To advance this model, the Sonoma County region and its CoC have supported a wide range of housing options designed to meet the needs of people experiencing homelessness. These include housing options designed to meet people’s immediate, short-term needs (e.g. emergency shelters and transitional housing), as well as long-term options to help end homelessness permanently (e.g. Rapid Rehousing and Permanent Supportive Housing).

To project the amount of supportive housing needed in Sonoma County, the Housing Working Group (of the CoC Strategic Planning Committee) worked with Homebase and consultant Andrew Hening to identify the existing housing supply by first examining the Housing Inventory Count (HIC) for Sonoma’s Continuum of Care. Then they looked at existing HMIS data to estimate the number of persons who become homeless in any one year, or inflow (this is a number different from the Point-in-Time Count data, which is one day’s count). Finally, they reviewed known models, such as the All Home California 1-2-4 model, to identify the number of interim housing units, permanent housing units, and prevention interventions that would be needed locally to create enough housing to reach Functional Zero. The All Home California 1-2- 4 model assumes that a functioning system of care needs a ratio of 1 unit of interim housing, 2 units of permanent housing, and four prevention interventions. This was not the only model examined, but the recommendations within the Plan generally follow this model. See the upcoming section, “A Roadmap for Sonoma County: Goals, Strategies, and Action Steps” for specifics.
2 https://endhomelessness.org/resource/data-visualization-the-evidence-on-housing-first/ 3 The largest sources of funds to address homelessness countywide come via California’s Homeless Housing, Assistance and Prevention (HHAP) and US HUD’s Continuum of Care (CoC) Programs. CA state law requires programs that receive funding primarily for homeless assistance adhere to Housing First components https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=WIC&division=8.&title=&part=&chapte r=6.5.&article. HUD reduces the points available (in the CoC competition for funding) to CoCs and new CoC projects for failing to adhere to Housing First principles. See 2022 HUD CoC NOFO, https://www.hud.gov/sites/dfiles/SPM/documents/Continuum_of_Care_Competition_and_Noncompetitive_YHDP .pdf.
19 Current System
For more information on a housing type listed below in
the Current System, see the glossary in Appendix H.

Table 1: *This number includes two California Project Homekey sites that are slated to be converted to Permanent Supportive Housing in 2023.

Housing Type Number of Beds 2022
Emergency Shelter 886
Transitional Housing* 371
Rapid Rehousing (RRH) 402
Permanent Supportive
Housing (PSH) 1,051
Emergency Shelters
Guerneville
● West County Shelter
Petaluma
● COTS Mary Isaak Center
Santa Rosa
● Catholic Charities’ Sam Jones Hall
● Catholic Charities’ Family
Support Center
● Social Advocates for Youth (SAY)
Dream Center and Coffee House
Teen Shelter
● Nation’s Finest / Hearn House
● Community Action Partnership’s
Sloan House
● YWCA Domestic Violence Shelter
● Redwood Gospel Mission’s The
Rose Women’s Shelter & Men’s
Mission Shelter
20 Average Length of Time Homeless by Housing Project Type In 2019 and 2020, households who accessed RRH alone had dramatically lower average length of time homeless. Figure C shows the average length of time homeless according to the type of project(s) households accessed. This could be in part because those receiving RRH services are supported with housing-focused case management, a strategy that could be employed at shelters and other early intervention points.

Figure C: Average Length of Time Homeless Based on Project Type. Data source: 2019 and 2020 Stella.

Households that accessed RRH were much more likely to exit to permanent destinations (Figure E).

VI-SPDAT Scores by Housing Project Type
Analysis of VI-SPDAT scores (vulnerability assessment scores for individuals seeking supportive housing) revealed that accepted referrals to RRH tended to have lower scores than the overall population of accepted referrals, while those in Emergency Shelter (ES) and PSH have the highest scores (Figure D). This suggests that the RRH outcomes discussed above may also be a result of accepted RRH referrals having lower acuity/vulnerability than those referred to PSH. Some providers also require households to have identified a housing option to secure an RRH subsidy.
117 94 115
257
63 184 224
302
381
159
211
105
266
0 100
200
300
400
All Households
ES/SH Only
TH Only
ES/SH + TH
RRH Only
ES/SH + RRH
TH+ RRH
ES/SH + TH + RRH
PSH Only
ES/SH + PSH
ES/SH + RRH + PSH
RRH + PSH
All Other Pathways
Average Length of Time Homeless
Number of Days
21 Figure D: VI-SPDAT Scores of Accepted Referrals Based on Project Type. Data source: CE dashboard. Note that because the sample size for certain scores and project types were low, this is the aggregate data for 2018-2022.

Similarly, when looking at exits to permanent versus temporary destinations by project type, RRH interventions (alone or when grouped with others) have the highest rate of exits to permanent housing options (Figure E). And despite PSH being a permanent housing option with no time limit, there are a significant number of exits to temporary locations. Stakeholders have identified increasing supportive services capacity at housing sites as a high priority for the Plan. Investment into staffing and operations capacity at existing Emergency Shelters is also paramount given shelter exits are overwhelmingly to temporary destinations.

Figure E: Exits to Permanent Destinations Based on Project Type. Data source: 2019 and 2020 Stella.

10.05 10.42

12.55 7.57

8.68 0.00

2.00 4.00

6.00 8.00

10.00 12.00
Overall ES PSH RRH Services
Average VI-SPDAT Scores for Accepted Referrals
VISPDAT Score
0 20
40 60
80 100
All Households
ES/SH Only
TH Only
ES/SH + TH
RRH Only
ES/SH + RRH
TH+ RRH
ES/SH + TH + RRH
PSH Only
ES/SH + PSH
ES/SH + RRH + PSH
RRH + PSH
All Other Pathways
Percent of Exits to Permanent Destinations Percent of Exits to Temporary Destinations Percent of Exits to Unknown Destinations
Exits by Project Type
Percent of All Exits
22 Challenges
The “Housing First” approach to addressing homelessness was a frequent topic of conversation among CoC stakeholders during planning. All generally acknowledged that it is a mandatory approach for state- and federally-funded homeless programs, however, providers shared their challenges in serving the higher needs of those who
have experienced long periods of homelessness. And in
congregate shelter, there can be a higher likelihood that those who have experienced trauma, or struggled with
mental health or substance abuse challenges, will be
challenged by the close quarters. Providers called for
greater investment in physical improvements to existing shelters to maximize non-congregate space. This will
promote safety, recovery, autonomy, and housing
stability.

Moreover, for the Housing First approach to support
those residing in shelter, staff must be able to use “housing-focused case management” strategies, which are aimed at resolving barriers to housing before other challenges or goals.

Adequate staffing and training are critical, as housing has proven integral to supporting physical and mental health recovery. PSH providers echo the
need for increased supportive services capacity.

Without adequate services, providers believe “Housing
First” becomes “Housing Only.” It’s the stability that
housing someone rapidly offers that supports someone
engaging in services, however, Sonoma County lacks
sufficient case management and licensed behavioral
health staff to meet the needs of many high-acuity
individuals. Accordingly, stakeholders called for greater investment in social, health, and behavioral services
across all interventions to support the principles on
which “Housing First” is based.

Not surprisingly, one of the key challenges identified by all stakeholders engaged in the strategic planning
process, is the need for more affordable housing
countywide. Data reviewed shows that many people
spend half their income or more on housing, and too
many cannot find housing they can afford at all.

Stakeholders broadly agreed that if housing were more
affordable, fewer people would be homeless.
“Housing is really hard for everyone –
even people with full time jobs can't
afford to live here.”
-Homeless Advocate
“Because services aren't mandatory, it’s
important to give people grace while
they are actively using [substances]. We
know there are some we won't be able to
reach, but if they stay safe and don't
harm others, we hope we can hold on to
them and hope eventually they do start
using our [support] services.”
-Shelter Staff Member
“I hear from nonprofits, ‘Yes, we're doing
Housing First, but we need the support to
do that well.’ Support means resources
for staffing, training, etc. Staff must be
better prepared to offer case
management for a wide variety of
situations. That's implicit in Housing First,
because not everyone is housing ready.”
-CDC Staff
23 Supportive Services
Nonprofits, community groups, and county agencies provide a variety of services that can help people to exit homelessness and stay housed long-term. Programs such as mental health treatment, employment and job training, health care, substance use recovery, and transportation can meaningfully help people attain greater stability.

The Housing-Focused Case Management model is a crucial support for people experiencing, exiting, and at risk of homelessness. Case managers work to identify an individual or household’s barriers to obtaining, and their strengths in maintaining, permanent housing. As many people experiencing homelessness are often facing complex or challenging circumstances, they report being more well-position to address them once housed.

Short-term and ongoing services that help individuals manage physical, mental, and emotional health; disability; aging; and substance abuse are critical for implementing successful Housing First programs. Housing without adequate services will be insufficient for many.

Housing-Focused Case Management
Housing First requires a concentrated focus on assessing barriers to housing and achieving housing stability. For individuals not currently housed, the primary goal is to develop a strategy to assist them in securing housing. Once housed, the goal is to ensure that adequate supports are in place, such as connections to public and community resources, to support permanent housing stability.

Everyone is ready for a housing-focused plan, whether they are on the street, or in their car, a shelter, or a supportive housing unit. But housing must come with a plan for support, services, community, crises, and achieving individual goals.

Creating a Housing-Focused Plan

1. Assess household barriers to housing and strengths for maintain housing

2. Set goals and action steps, recognizing individual choice, and building in flexibility

3. Support long-term housing stability

4. Monitoring progress and follow-up (prevent homelessness) Example: An individual lacks shelter and seeks housing. When they have been employed in the past, they have been able to find housing and stability. When unemployed, they drink alcohol more frequently. A Housing-Focused approach would ask:
● Will working towards gaining employment reduce the drinking and help secure housing, or ● Will quitting drinking lead to employment and stable housing? 24 Current System
Many adults experiencing homelessness in Sonoma County have a disability or significant impairment, including chronic physical impairments, mental illness, substance use disorder, or combinations of multiple conditions. While many were disabled prior to losing their housing, others acquired their disability as a result of living on the streets or being without stable housing – an experience that is extremely dangerous and traumatic.4 To return to housing successfully and remain stably housed, people experiencing homelessness often require ongoing treatment and support – both before and after they are housed.

Currently, service providers throughout Sonoma County work to provide wraparound services for clients or connect them to other resources in the community. However, the availability of services is insufficient to meet demand, and access to services varies by provider and across geographies.

Challenges
A concern raised repeatedly by stakeholders across
the homeless system of care was the need to provide
more compensation and support for front-line workers.

Recruiting and retaining qualified staff is a challenge throughout the system. Stakeholders cited high turnover from burn-out and non-competitive salaries as a significant barrier to building rapport with clients and maintaining a skilled, experienced staff that is ready to help those with complex needs.
4 See, e.g., Lilanthi Balsuriya, MD, MMS, Eliza Buelt, MD, Jack Tsai, PhD, “The Never-Ending Loop: Homelessness, Psychiatric Disorder and Mortality,” Psychiatric Times, Vol. 37, Issues 5 (May 29, 2020):
https://www.psychiatrictimes.com/view/never-ending-loop-homelessness-psychiatric-disorder-and-mortality “Our entry-level people are exposed
to the most challenging client and
case situations, but they're paid the
least. We need to do a better job of
getting people who can do that
effectively, without burning them
out.”
-Service Provider
25 “We need to make this work for people who
are on the front lines sustainable. This is the
lowest paying job, but it puts people at high
risk. We need to be able to make people who
are doing this work feel like they can have a
career and aren't themselves at risk of
homelessness.”
-Service Provider
“Turnover becomes a challenge. Even at the
shelters the turnover is high. It is a very taxing
job. A lot of people come into a job like this
thinking they want to do something good, but
it is tough work and not everyone is cut out
for it. That is where we see a lot of turnover.”
-Service Provider
26 A ROADMAP FOR SONOMA COUNTY: GOALS, STRATEGIES, AND ACTION STEPS
Sonoma County High Priorities
I. Prioritize and fund interventions that are most likely to reduce chronic homelessness, including evidenced-based Housing First projects, such as Permanent Supportive Housing.

II. Fund new permanent and temporary housing solutions in a long-term goal ratio of up to 75% permanent housing units and 25% interim housing units. This ratio may be different in the early years of the Plan – with more funds going to interim housing that can later be transitioned to permanent housing.

III. Expand existing temporary housing programming to provide more non-congregate settings, housing-focused case management, and supportive services.

IV. Ensure direct service providers are paid wages and benefits that allow them to live in Sonoma County, receive adequate training and support, and have caseloads that align with best practices for serving a target population.

V. Fund new and renewing programs that have demonstrated success in supporting people experiencing homelessness in achieving housing stability. The homeless system of care should strive for a funding ratio of up to 80% to existing, evidence-based, or proven programs and 20% to innovative or “promising practice” program concepts with evaluation plans.

VI. Develop a new vulnerability assessment, prioritization, and placement process that results in equitable housing placement. A year after use, examine (and revise if needed), to ensure that BIPOC individuals/families receive equitable placement.

VII. The system of care should allocate funds based on need and aspire to provide the same access to quality services no matter where an individual lives in Sonoma County. 27 Goal 1: More Housing and Prevention
Create comprehensive housing interventions, from prevention to permanent housing, to reduce inflow into homelessness and increase pathways to housing stability Strategy 1.1: Preserve Housing for Those at Risk of Homelessness by Investing in Prevention and Problem-Solving Interventions Action Steps

1.1a: Develop a needs-based assessment tool for rapid provision of financial assistance to prevent homelessness.

1.1b: Improve role of Sonoma County 211 to make quick connections for prevention information and prevention assistance, helping to quickly address time sensitive cases.

1.1c: Expand training of housing problem-solving techniques to help households identify choices and solutions to quickly end their housing crisis. Include open to the community “office hours” to help caregivers increase their knowledge of and techniques as to how to help an unhoused friend or family member navigate through systems.

1.1d: Review inventory of prevention services and determine the best assessment and services models for implementation.

1.1e: Co-locate prevention resources at existing entry points to the homeless system of care, including CE access points, shelters, and benefits offices.

1.1f: Consult with area property managers as well as Legal Aid of Sonoma County. Following consultation, consider funding legal assistance programs to provide eviction prevention services. A best practice is to fund enough eviction protection to cover the average number of Unlawful Detainers annually that lack legal aid support.

1.1g: Fund landlord and family mediation services to preserve existing housing or support reunification.

1.1h: Offer financial counseling/budgeting classes to support those who are at risk of homelessness or newly housed (attach to those receiving financial assistance). 28 Model Prevention Programs5
5 Additional resources for examining homeless prevention: https://nlihc.org/resource/homelessness-preventionprograms-improve-outcomes-and-save-money; https://www.samhsa.gov/homelessness-programs-resources/hprresources/housing-shelter.

Santa Clara County Homelessness Prevention
System (HPS) provides temporary financial
assistance, legal support, and case management
and other services.

Eligibility
● Resident of Santa Clara County (immigration
status not considered)
● Low-income (approx. $134,800 for a 4-
person household)
● Currently housed but at risk of losing
housing within 14 days
o Can’t pay upcoming rent
o Received eviction notice
o Unsafe to stay in housing
o Must leave for other reasons
● At high risk of homelessness based on a
short assessment questionnaire
Documentation requirements are flexible but
may include IDs, a lease, income documentation,
and recent bills.
https://preventhomelessness.org/
Keep Oakland Housed is a coordinated strategy
and partnership to help Oakland residents at risk
of losing their homes through legal
representation, financial assistance, and
supportive services.

Eligibility
● Oakland residents experiencing a housing
crisis
● Household income at or below 30% of Area
Median Income, with priority to extremely
low-income households
● Legal representation will be provided to
tenants with an active eviction lawsuit up to
50% AMI
Documentation required includes proof of
identity and income, eviction related notices,
landlord W-9 or new lease.
https://www.keepoaklandhoused.org/
29 Strategy 1.2: Enhance and Invest in Non-Congregate Interim Housing Options Action Steps

1.2a: Fund and develop 200 more non-congregate interim housing options (100 in FY 22-23 and 100 in 23-24)6 via:
● Fund remodeling and creation of additional space in existing congregate shelters to lessen shelter resistance (e.g., privacy barriers, smaller sleeping pods, sober sections, providing pet friendly accommodations), and
● Fund more non-congregate interim housing such as NCS shelters, tiny homes, mobile homes, RVs, Homekey sites. Work to place EHVs here where appropriate, with supportive services.

1.2b: Evaluate existing Safe Parking sites to determine the effectiveness of the intervention in supporting households to achieve housing stability. If appropriate, fund additional sites as a part of 1.2a.

1.2c: Require all renewing and newly contracted interim housing and shelter providers to adhere to Housing First principles and provide Housing-Focused Case Management.

1.2d: With opening of Caritas’ Center and its Nightingale beds, evaluate the current need for medical respite/recuperative care, develop lessons learned from past efforts, and secure funding to meet the outstanding need with the goal of reducing the strain on temporary housing capacity.

1.2e: Develop a recruitment model to increase involvement of people with lived experience in program design at interim housing sites.

1.2f: Secure appropriate interim housing for:
● Families with children and unaccompanied youth; and
● Persons exiting the justice system.
6 These amounts generally follow the All Home California “1-2-4” Model, as applied to Sonoma County, https://www.allhomeca.org/regionalactionplan/.
30 What is Safe Parking?
For many people who lose their homes, their vehicles become their primary shelters. However, it can be difficult to find a place to legally park vehicles overnight, and people experiencing homelessness can ill afford to pay the fines that come with parking citations. Even when legally parked, people living in their vehicles often face harassment from nearby residents or business operators, risk break-ins when they leave their vehicles unattended, and generally lack reliable access to toilets, showers, laundry, and garbage disposal, to support healthy hygiene and sanitation. It can also be difficult for outreach and support workers to connect with people living in their vehicles as the vehicle dwellers often must move their vehicles regularly to avoid citations and harassment.

Safe Parking sites seek to address these challenges. They are typically run by a nonprofit, social service or religious organization and offer sanctioned access to parking lots at least overnight, and sometimes throughout the day.

Programs usually provide on-site access to bathrooms (either in an adjacent building or a portable toilet) and waste disposal and include case management support or referral to homeless support services. Most also provide other supportive services, such as access to showers, meals, wi-fi and charging stations for electronic devices. A recent study found that over half of the safe parking sites studied also provided funds for repairing vehicles and paying for insurance and vehicle registration.1
Does Safe Parking Work?
Safe Parking programs are relatively new, making it difficult to assess their effectiveness, or to identify the factors that may make some approaches more effective than others. An important measure of success for any program is the percent of people who move from the program to stable housing. One early study suggests that on this measure, Safe Parking programs should be compared to street outreach efforts.2 It finds that Safe Parking programs generally achieved stronger outcomes than the street outreach programs in their communities.

FIVE practices that can enhance the effectiveness of Safe Parking programs:3 I. Intentional design – Ensuring that the design of the program is well-suited to the entity sponsoring it. Small organizations, for example, may have difficulty operating distributed-site models. Umbrella organizations such as governments or large nonprofits may need to partner with other entities to establish and support programs on smaller lots where a sense of community and connectedness can help maintain safety and ensure program success.

II. Strategic location. Many different factors define a good location. Sites should not conflict with local zoning, landscaping and other buffers can help minimize complaints from nearby property owners, and convenience relative to employment opportunities and social services can also be a bonus.

III. Building trust and community among parkers. Outreach and support that builds trust and a sense of community helps programs function better. They produce fewer noise complaints and security and sanitation concerns. Strong trust and community may also contribute to site users’ sense of stability, which could help them move on to permanent housing.

IV. Social Service Integration. Nearly all Safe Parking programs provide case management for parkers, whether doing so directly, through a contract with another agency, or by referral to social service providers.

V. Engaging stakeholders. Strong safe parking programs engage site users regularly about their expectations for usage. They also engage community stakeholders, including law enforcement, about the goals and operations of the sites.
1 Christopher Weare, Lindsay McElwain, Daniel Schiele, Laila Waheed, “Safe Parking: Insights from a Review of National Program.” Center for Homeless Inquiries (N.D.). https://static1.squarespace.com/static/5e40681539b77957555f10e0/t/609ef366f1f5035bc056db19/162102973 5677/Safe+Parking+Briefer+Final.pdf
2 Ibid.
3 Lindsay McElwain, Daniel Schiele, Laila Waheed, “Smart Practices for Safe Parking.” Center for Homeless Inquiries (April 2021). https://priceschool.usc.edu/wp-content/uploads/2021/06/Smart-Practices-for-SafeParking-USC-2021.pdf 31 Strategy 1.3: Develop Sustainable Permanent & Permanent Supportive Housing Solutions
Action Steps

1.3a: Fund and develop 1,000 more permanent and permanent supportive housing units and programs (200 per year for five years)7 – to include:
● Master leasing, purchasing, or otherwise securing new, existing, or renovated housing units.
● Pairing more units with Project-Based Vouchers (PBV). ● Increasing funding for capital development given it cannot carry debt in permanent supportive housing projects.
● Aligning housing authority policies and preferences for “Move On” placements that help free up other PSH, including the ability of tenants in PBV units to receive “Move On” TBVs after 1 year in PBV.
● Investing in and assigning housing navigators to households receiving vouchers. ● Encourage transition of interim housing to permanent housing if need for transitional has changed; and
● Improve housing location services to identify and support new landlord participants.

1.3b: Facilitate case conferencing around PSH referrals, prioritization, retention, service-right sizing, preservation of landlord relationships.

1.3c: Where property management companies are involved, supportive housing providers should align management with Housing First principles and use eviction as the tool of last resort.

1.3d: Work with local jurisdictions to obtain mainstream (or other) housing vouchers to replace current city-funded housing efforts to free up local dollars to fund additional homeless services.

1.3e: Dedicate approximately eight percent8 of CoC resources to fund recovery housing as described in HUD’s Recovery Housing Policy Brief.9

1.3f: Identify resources to support the Emergency Housing Voucher (EHV) program (e.g. fund supportive services for chronically homeless individuals with vouchers).

1.3g: Evaluate, and if effective, invest in the Community Housing Connectors developed to support individuals using Tenant-Based Rental Assistance in securing market rate housing through marketing, landlord incentives, and housing navigation and stabilization. 7 These amounts generally follow the All Home California “1-2-4” Model, as applied to Sonoma County, https://www.allhomeca.org/regionalactionplan/.
8 The Sonoma County Annual Homeless Census and Survey asks respondents if they desire “clean and sober housing.” The average percentage of affirmative responses from the last three Point-in-Time surveys is 8%. (2019:
8%, 2020: 10%, and 2022: 5%).”
9 HUD Recovery Housing Policy Brief, Recovery Housing is a housing model that uses substance use-specific services, peer support, and physical design features to support individuals and families on a particular path to recovery from addiction, typically emphasizing abstinence. Recovery Housing might not conflict with Housing First, so long as entry into the program is based on the choice of the program participant. https://www.hudexchange.info/resource/4852/recovery-housing-policy-brief/ 32 Strategy 1.4: Support Efforts to Increase the Region’s Supply of Affordable Housing

1.4a: Collaborate with local jurisdictions to achieve a Prohousing Designation10 from the California Housing and Community Development Department to increase the competitiveness of local grant applications to the State.

1.4b: Serve as a resource to willing local jurisdictions to help meet the Low, Very Low, and Extremely Low-Income unit requirements of their Regional Housing Needs Assessment (RHNA) allocations.

Goal 2: Stronger Supportive Services
Build supportive services capacity to meet the complex and diverse needs of people experiencing homelessness in the Sonoma County region
Strategy 2.1: Standardize Minimum Compensation, Training, and Wellness Practices for Housing and Supportive Service Providers
Action Steps

2.1a: Establish minimum compensation (wages and benefits) for supportive services staff as based on the recommendations from the Sonoma County Service Providers’ Roundtable.

2.1b: Set case management/staffing caseload ratios in line with HUD11 and SAMHSA.12 guidance, which considers the acuity of the population served, the intensity of case management provided, and the housing setting or project type (e.g., SAMHSA recommends an optimal PSH caseload as 12 to 15 people per staff member).

2.1c: The system of care should prioritize 2.1a and 2.1b over expanding services to other or new programming until such time as 2.1a and 2.1b are accomplished.

2.1d: Provide quarterly no-cost training opportunities for service providers – include Trauma Informed Care, Housing-Focused Case Management, Motivational Interviewing, Psychosocial Rehabilitation, and Cultural Competence.
10 The California Department of Housing and Community Development’s Prohousing Designation Program provides incentives to cities and counties in the form of points or preference in the scoring of competitive housing, community development, and infrastructure programs. Preference may include priority processing or funding points when applying for funding including Affordable Housing & Sustainable Communities, Infill Infrastructure Grant, Transformative Climate Communities, and Transit and Intercity Rail Capital Program. More information can be found here https://www.hcd.ca.gov/planning-and-community-development/prohousing-designation-program. 11 HUD Homeless System Response: Case Management Ratios, https://files.hudexchange.info/resources/documents/COVID-19-Homeless-System-Response-Case-ManagementRatios.pdf 12 SAMHSA Evidence-Based Practices Kit, Evaluating Your Program: Permanent Supportive Housing, https://store.samhsa.gov/sites/default/files/d7/priv/evaluatingyourprogram-psh.pdf 33 2.1e: Create model policies and procedures for service providers that promote staff wellness at the organizational level and fund necessary supports including training, consultation, and time off.

2.1f: Ensure providers are equipped with safety plans and adequate security personnel to handle emergencies such as violence or medical crisis.

HUD GUIDANCE FOR HOMELESS SYSTEM RESPONSE CASE MANAGEMENT RATIOS Community-based (Non-housing based) Case Management
Population Intensive/ Therapeutic
Intervention
Targeted Navigation
to Housing
General support to increase
system engagement
Individuals 10-12 20-30 50
Families 8-12 20-25 50
Youth (TAY) 10-12 20-25 50
Housing-based Case Management
Population Scattered Site
Supportive Housing
Caseload
Single Site Supportive
Housing Caseload
Existing Stably Housed Tenants
Individuals 10-20 10-20 20-50
Families 10-12 10-12 12-40
Youth (TAY) 10-15 10-15 15-30
Housing-based Case Management (Critical Time Intervention, useful in RRH) Population Scattered Site Caseload Single Site Caseload Caseload of Mostly Stably Housed Tenants
Individuals 20 20 20
Families 12 12 12
Youth (TAY) 15 15 15
Housing-based Case Management (Intensive Caseloads/High-Acuity Tenants) Population Scattered Site
Caseload
Single Site
Caseload
Existing Stably Housed Tenants
Individuals 10 15 20
Families 10 15 15
Indiv. w/ Dual dx SUD/SMI 10 10 15
Indiv. w/ Intel. Dis./Dev. Dis. 10 10 10
Older Adults 10 15 15
Youth (TAY) 10 15 20
Table 2: HUD Guidance.
34 Strategy 2.2: Significantly Expand Mental and Physical Healthcare Services for Individuals Experiencing Homelessness, Including Those Living in Supportive Housing
Action Steps

2.2a: Triage outreach and housing care teams in this manner:
(1) Review/affirm baseline standards for supportive services by housing type and for street outreach teams. Fund these base teams accordingly. (2) Where clients have higher needs that exceed the qualifications of our base teams, establish and fund high-skilled crisis & housing placement teams (such as IMDT) that support the base teams across Sonoma County wherever the need is.

2.2b: Leverage CalAIM’s Enhanced Care Management and Community Supports programs to assist in funding intensive care coordination across multiple systems.

2.2c: Build a system that has the ability to refer individuals to:
● At least 1 position at all interim and permanent supportive housing sites (dedicated to people experiencing homelessness) that is trained to provide physical health support (e.g., nurse, paramedic).
● At least 1 position at all interim and permanent supportive housing sites (dedicated to people experiencing homelessness) that is trained to provide mental health and substance abuse support (e.g., LCSW, LMFT).

2.2d: Increase the availability of detox and substance abuse services, including on site AA and NA groups.

2.2e: Provide ongoing medication management services to residents of shelters and supportive housing sites.

2.2f: Review, affirm, and fund mental health supportive services for existing and any new No Place Like Home (NPLH) projects.

2.2g: Report back regularly as to program accountability with Measure O.

2.2h: Develop and report annually on how a needs-based funding allocation for the CoC did or did not reflect population alignment with the Point in Time Count.

Strategy 2.3 Improve Services Dedicated to the Unique Needs of Specific Populations
Action Steps

2.3a: Develop and ensure system connection (via systems mapping and named contacts) with services for:
● Households with criminal justice involvement, including discharge planning for persons exiting jail and prison.
● Transition-Aged Youth.
● Long-term learning and developmental disabilities.
● Persons leaving hospitalization or other health care; and ● Older adults who are aging/experiencing dementia.
35 Strategy 2.4 Coordinate Cross Sectors of Healthcare, Behavioral Health, and Homeless Response
Action Steps

2.4a: Create a system map that shows the current pathway through the system of care. Map would be for community members, elected leaders, and individuals experiencing homelessness. Regularly review and update the System Map to assist in streamlining the system.

2.4b: Secure a neutral facilitator to bring County and sector leaders together to align services, funding, and goals.

2.4c: Identify need for care facilities (inc. skilled nursing, board and care, memory care, inpatient psychiatric, crisis residential, crisis stabilization & social rehabilitation) based on current capacity.

Strategy 2.5: Develop, Expand, and Coordinate Interventions to Support Those Living on the Street, in Encampments
Action Steps

2.5a: Ensure that the homeless system of care reinforces the importance of our unhoused clients’ dignity and respect at all times (via Ombudsperson – Action Step 3.3c).

2.5b: Implement a subregional approach to street outreach to achieve the goals of Built for Zero.

2.5c: Evaluate existing service provider managed encampments to determine the effectiveness of the intervention in supporting households to achieve housing stability. If managed encampments are determined to be appropriate, consider funding following the setting of protocols and standards to ensure safety, provide supportive services, and maintain a housing-focus.

2.5d: Support approaches to outreach and encampment management that include offering services before any clearances, closely aligned partnerships with law enforcement so that outreach and behavioral health specialists are first in, and where outreach workers serve as liaisons who bridge understanding between law enforcement and individuals experiencing homelessness.

2.5e: Prepare for 2024 Care Courts Implementation in Sonoma County.

2.5f: Provide limited HMIS access to individuals seeking services for the purpose of maintaining current contact and location information.
36 Strategy 2.6 Create Meaningful Pathways to Economic Self-Sufficiency Action Steps

2.6a: Increase resource information for residents to increase income through 211 and other entry points to social and homeless services (linked to Action Step 1.1b).

2.6b: Assess Sonoma County-funded peer navigation program (peers support others in identifying relevant supportive services) for impact and reach; continue to fund or expand depending on gaps, needs, and outcomes.

2.6c: Establish a countywide SSI advocacy program, such as SOAR.

2.6d: Increase employment and training opportunities for homeless adults.

Goal 3: Operate as One Coordinated System
Work across the Sonoma County region to develop shared priorities, aligned investments, seamless coordination, and equitable solutions to address homelessness Strategy 3.1: Develop a Countywide Coordinated Funding Process to Use Available Resources Efficiently and Effectively to Drive Local Priorities and Ensure Accountability
Action Steps

3.1a: Task the CoC Funding and Evaluation Committee with monitoring ongoing, expiring, and new funding sources to make recommendations to the CoC Board.

3.1b: Adopt a long-term funding strategy that can align resources to support the Plan’s goals, strategies, and actions steps (see 1.2a; 1.3a; 2.1a; 3.2a; 3.8a for key funding related strategies).

3.1c: Develop a shared service vision and procurement process (consistent with established procurement rules) when funding opportunities within the county that can be received by and awarded to multiple jurisdictions (i.e. County, CoC, Housing Authority).

3.1d: Provide ongoing outreach, coordination, and technical assistance to prospective funding applicants to build confidence and capacity in providers.

3.1e: Create an annual calendar of funding opportunities and related processes to allow jurisdictions and providers to better plan and coordinate activities. 37 Strategy 3.2: Prioritize Funding to Entities that Align with Local Priorities to Promote Equity, Center the Voices of People with Lived Experience, and Utilize Evidence-Based Practices
Action Steps

3.2a: Fund new and renewing programs that have demonstrated success in supporting people experiencing homelessness in achieving housing stability. The homeless system of care should strive for a funding ratio of up to 80% for existing, evidence-based, or proven programs and 20% for innovative or “promising practice” program concepts.

3.2b: Incorporate equity goals into performance measures and invest in programs closing equity gaps, disaggregating data by age, race, ethnicity, and language.

3.2c: Monitor and provide technical assistance to providers related to incorporating input into program service design from people with lived experience.

3.2d: Identify agencies and partners who are led by people of color and/or who offer culturalspecific services. Examine the system to ensure those agencies and partners have the resources necessary to apply for, secure, and successfully administer homeless services funding.

3.2e: Incorporate peer support into housing programs and services whenever the literature on best practices indicates that it is appropriate.

Strategy 3.3: Ensure the Voices of Individuals with Lived Experience of Homelessness are Consistently Incorporated into Planning and Evaluating the Homeless System of Care
Action Steps

3.3a: Provide standing opportunities for input from the Sonoma County Lived Experience Advisory and Planning (LEAP) and (when established) Youth Action Boards at CoC Board (including the Strategic Planning Committee), City Council and Board of Supervisors meetings, and by invitation to other meetings regarding available funding awards and service delivery.

3.3b: Evaluate the potential to improve 211 as a centralized client-friendly platform to share upto-date information for people experiencing homelessness to learn about services (e.g., warming/cooling shelters, portable restrooms, showers, meals, vouchers, etc.), program requirements/timelines (e.g., documentation needed, deadlines). Include avenues for lived experience representatives to share input.

3.3c: Create an ombudsman appeals process where concerns about poor or discriminatory treatment by a provider in shelters or Interim Housing can be addressed.

3.3d: Pay people with lived experience who meet job requirements at rates that mirror the activities performed by existing paid staff.
38 Strategy 3.4: Improve Systemwide and Project Level Data Collection, Performance, Reporting, and Transparency
Action Steps

3.4a: CoC System and Program Performance Metrics. Affirm the below as the key metrics by which the Sonoma County System of Care and its programs will be measured:

1. Placements into permanent housing

2. Retention of permanent housing

3. Reducing the length of time homeless

4. Returns to homelessness

5. Increased client income (earned and non-earned)

3.4b: Establish an Open HMIS that allows for providers across the homeless system of care to view client level data to ensure continuity of care, while balancing privacy concerns.

3.4c: Review progress towards system level goals quarterly and project level goals annually

3.4d: Require HMIS participation by all interim and supportive housing providers who primarily serve people experiencing homelessness.

3.4e: Ensure adequate funding is made available to purchase HMIS licenses and train staff on a regular and ongoing basis.

3.4f: Centralize a system to track outcomes expected of grantees.

3.4g: Establish a working group to explore the expansion of the County’s Accessing Coordinated Care and Empowering Self Sufficiency (ACCESS) Sonoma13 initiative to include additional County departments, local jurisdictions, and nonprofit providers to improve system wide coordination of care (using Allegheny County, Pennsylvania Department of Human Services’ Data Warehouse as a model).14 13 ACCESS Sonoma is a county initiative that focuses on the critical needs of residents who are experiencing physical and mental health challenges, economic uncertainty, housing instability, substance use disorders, criminal justice engagement and social inequity. It employs a four-pronged approach; an Interdepartmental Multidisciplinary Team staffed by representatives from all the Safety Net Departments, an Integrated Data Hub/Watson Care Manager developed in partnership with IBM, a system of governance led by the County’s Safety Net Collaborative, and partnerships with community-based organizations and academic institutions. The result is coordinated care from across our Safety Net Departments for our most vulnerable residents. https://sonomacounty.ca.gov/administrative-support-and-fiscal-services/county-administratorsoffice/projects/access-sonoma 14 The Allegheny DHS Data Warehouse brings together and integrates person and service data from a wide variety of sources both internal and external to the county. It was created by consolidating publicly-funded human services data (e.g., behavioral health, child welfare, intellectual disability, homelessness and aging) and, over time, expanded to include data from other sources. The Data Warehouse was designed primarily to improve services to people, but also to improve the ability of workers to perform their jobs and to support management decisionmaking.https://www.alleghenycounty.us/human-services/news-events/accomplishments/dhs-datawarehouse.aspx 39 Strategy 3.5: Engage the Community in the Effort to End Homelessness in Sonoma County
Action Steps

3.5a: Communications Plan. Convene the County communications team, city information teams, and outside assistance to effectively and regularly inform the CoC Board, the County, cities, service providers, the media, the public, and persons experiencing homelessness as to current issues, funding, practices, and programs in the Sonoma County System of Care. Information should include:
• Social media posts and print media content.
• Regular opportunities for the public to speak with and ask questions of key officials within the System of Care, including members of the LEAP Board. • A dashboard of data and key metrics associated with the System of Care (as shown in

3.4a), including comparisons to State and National data, as well as trends over the previous 3-year period.
• Progress made on this Strategic Plan.
• Content relevant to persons experiencing homelessness; and • Content relevant to diverse audiences, using culturally competent methods and translations.

3.5b: Develop and regularly distribute materials that explain and educate about the local causes of homelessness.

3.5c: Develop materials to explain the use and success of evidence-based best practices.

3.5d: Organize regular and consistent opportunities for community support such as calls to action, funding needs, donation drives, job fairs, housing opportunities, shadowing opportunities for interested parties/the public with service providers, etc.

3.5e: Develop funding streams from the private sector, philanthropic organizations, and private donors to support individual providers.
40 Strategy 3.6: Improve Transparency, Safety, and Effectiveness of the Coordinated Entry System
Action Steps

3.6a: Use the By Names List (BNL) methodology to better account for all persons experiencing homelessness in the county and in alignment with Built for Zero (BFZ).15

3.6b: Coordinate encampment solutions and management based on agreed-upon regional priorities such as threats to public health and safety (fire, waterways), organization and size of encampment, and more.

3.6c: Facilitate case conferencing around PSH referrals, prioritization, retention, and service right-sizing. Develop a prioritization hierarchy for placement into supportive housing (linked to Action Step 1.3b).

3.6d: Incorporate existing local and countywide by names lists into HMIS.

3.6e: Ensure that the Coordinated Entry process maintains a person-centered approach that involves the respectful consideration of the following factors:
● Client Choice
● Client Needs
● Safety Considerations
● The Value of Reducing Barriers
● Provider Capacity, Expertise, and Competency
Strategy 3.7: Eliminate Disparities in Access, Service Provision, and Outcomes in the Homeless System of Care
Action Steps

3.7a: Develop a new vulnerability assessment, prioritization, and placement process to replace the VI-SPDAT that includes an analysis of individuals’ housing strengths and results in equitable housing placement. A year after use, examine (and revise if needed) to ensure that BIPOC individuals/families receive equitable placement (part of accomplishing 3.7c and 3.7d).

3.7b: Track access and outcomes data by age, race, ethnicity, gender, and sexual orientation.

3.7c: Ensure that Black, Indigenous, and Persons of Color (BIPOC) are provided equal services within the homeless system of care.

3.7d: Address racial and ethnic disparities access and outcomes of the homeless system of care.

3.7e: Ensure that the CoC Board’s and the system of care’s racial and ethnic representation reflects the population of Sonoma County’s homeless community. Consider updating the Charter to include designated seats for BIPOC members.

3.7f: Build up Equity-Centered Results-Based Accountability (RBA) framework.

3.7g: Accommodate multi-generational households; work to keep households intact. 15 Built for Zero methodology can be found here https://community.solutions/built-for-zero/methodology/. 41 3.7h: Support the LEAP Board in advancing the objectives developed with Bay Area Regional Health Inequities Initiative (BARHII) to address racial and ethnic disparities access and outcomes of the homeless system of care.

3.7i: Ensure that at least two persons with Lived Experience in homelessness serve on the CoC Board.

Strategy 3.8: Monitor and Report Back as to Progress on the Strategic Plan’s Action Steps, and Adjust Activities as Conditions and New Information Warrants
Action Steps

3.8a: Task the CoC Strategic Planning Committee to monitor and report on the progress of Plan implementation and advise the Board of Supervisors, local jurisdictions, and other bodies, including school districts, on how to adhere to the Plan and when to deviate from the Plan based on new information. Regular data review and report out of the three key data metrics quarterly to stakeholders.

3.8b: Track progress towards Early Action Steps (Appendix A), consider investing in project management software to assist.

3.8c: Build out implementation steps for remaining action steps (those not currently outlined in Appendix A: Early Action Steps). Build out shared ownership for these and remaining items between CoC and other partners.

3.8d: When noteworthy research is released, including but not limited to the expected UCSF Benioff Homelessness and Housing Initiative’s California Statewide Survey of Homelessness (CSHH), the CoC shall consider and adjust strategies and actions as needed.
42 APPENDIX A: EARLY ACTION STEPS
Lead Agency Initial 2023 Efforts
The Lead Agency (Sonoma County Community Development Commission) will begin 2023 with the following Early Implementation Efforts (listed in full in the section that follows):
• In alignment with Built for Zero, establish a single By Names List to better serve all individuals experiencing homelessness in Sonoma County (3.6a)
• Create a new vulnerability assessment, prioritization, and placement process to replace the VI-SPDAT that includes an analysis of individuals’ housing strengths and results in equitable housing placement (3.7a) • Develop a robust communication strategy to keep the public and individuals experiencing homelessness more informed of services, policy changes, challenges, and successes (3.5a) • Strengthen and prioritize the supportive services in the existing homeless response system (2.1a+b) • Build an effective and equitable subregional street outreach model (2.5b) • Adopt a long-term funding strategy for homeless services (3.1b) • Ensure the system of care and its individual programs are evaluated based on key performance metrics (3.4a) • Add 200 PSH and 100 non-congregate shelter beds (1.2a, 1.3a) • Ensure an effective transition to Department of Health Services (not listed in Strategic Plan) 43 Countywide Early Implementation Efforts
Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

1.1a
Develop a needs-based assessment tool for
rapid provision of financial assistance to
prevent homelessness. 2-1-1
County ARPA $$,
possible city
sources or
philanthropy
(Season of Sharing)

1.1b
Improve role of Sonoma County 211 to make
quick connections for prevention information
and prevention assistance, helping to quickly
address time sensitive cases. See also Action
Step 2.6a
SoCo HSD, 2-1-1 County ARPA $$ for
2-1-1

1.1c
Expand training on housing problem-solving
techniques to help households identify choices
and solutions to quickly end their housing
crisis. Include open to the community “office
hours” to help caregivers increase their
knowledge of and techniques as to how to
help an unhoused friend or family member
navigate through systems.

CE Operator, key
service providers
HHAP, Cal-AIM and
Cal-AIM capacity
building grants

1.1d
Review inventory of prevention services and
determine the best assessment and services
models for implementation
More Housing and Prevention
Lead Agency Staff TBD

1.2a
Fund and develop 200 more non-congregate
interim housing options (100 in FY 22-23 and
100 in 23-24) via:
- Fund remodeling and creation of additional
space in existing congregate shelters to
lessen shelter resistance (e.g., privacy
CoC Board w/Lead
Agency Staff

HHAP, HHIP,
Homekey, Measure
O, MHSA, EHVs,
more
44 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding
barriers, smaller sleeping pods, sober
sections, providing pet friendly
accommodations), and
- Fund more non-congregate interim
housing such as NCS shelters, tiny
homes, mobile homes, RVs, Homekey
sites. Work to place EHVs here where
appropriate, with supportive services.

1.2b
Evaluate existing Safe Parking sites to
determine the effectiveness of the intervention
in supporting households to achieve housing
stability. If appropriate, fund additional sites as
a part of 1.2a.

City of Santa Rosa,
Lead Agency Staff TBD

1.2c
Require all renewing and newly contracted
interim housing and shelter providers to
adhere to Housing First principles and provide
Housing-Focused Case Management.

Lead Agency Staff N/A

1.3a
Fund and develop 1,000 more permanent and
permanent supportive housing units and
programs (200 per year for five years) – to
include:
- Master leasing, purchasing, or otherwise
securing new, existing, or renovated
housing units.
- Pairing more units with Project-Based
Vouchers.
- Increasing funding for capital development
given it cannot carry debt in permanent
supportive housing projects.

CoC Board, County,
Cities w/Lead Agency
Staff

HHAP, HHIP,
Homekey, Measure
O, MHSA, Housing
Authorities' PBVs,
more
More Housing and Prevention
45 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding
- Aligning housing authority policies and
preferences for “Move On” placements
that help free up other PSH, including the
ability of tenants in PBV units to receive
“Move On” TBVs after 1 year in PBV.
- Investing in and assigning housing
navigators to households receiving
vouchers.
- Encourage transition of Interim Housing to
Permanent Housing if need for interim
housing has changed; and
- Improve housing location services to
identify and support new landlord
participants.

1.3b
Facilitate case conferencing around PSH
referrals, prioritization, retention, service-right
sizing, preservation of landlord relationships
(linked to Action Step 3.6a).

CE Operator, PSH
managers/developers
Existing Case
Conferencing
Processes

2.1a
Establish minimum compensation (wages and
benefits) for supportive services staff as based
on the recommendations from the Sonoma
County Service Providers’ Roundtable.

Service Providers
Roundtable

HHAP, HHIP,
Measure O, more
Stronger Supportive
Services

2.1b
Set case management/staffing caseload ratios
in line with HUD and SAMHSA guidance,
which considers the acuity of the population
served, the intensity of case management
provided, and the housing setting or project
type (e.g., SAMHSA recommends an optimal
PSH caseload as 12 to 15 people per staff
member).

Service Providers
Roundtable

HHAP, HHIP,
Measure O, more
46 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

2.1c
The system of care should prioritize 2.1a and

2.1b over expanding services to other or new
programming until such time as 2.1a and 2.1b
are accomplished.

CoC Board N/A

2.1d Provide quarterly no-cost training opportunities
for service providers – include Trauma
Informed Care, Housing-Focused Case
Management, Motivational Interviewing,
Psychosocial Rehabilitation, and Cultural
Competence.

Lead Agency Staff in
collaboration with CE
Operator, various
trainers
TBD

2.2a
Triage outreach and housing care teams in
this manner:
1) Review/affirm baseline standards for
supportive services by housing type and
for street outreach teams. Fund these
base teams accordingly.
2) Where clients have higher needs that
exceed the qualifications of our base
teams, establish and fund high-skilled
crisis & housing placement teams (such as
IMDT) that support the base teams across
Sonoma County wherever the need is.

SoCo DHS, Service
Providers, Lead
Agency Staff

HHAP, HHIP,
Measure O, more

2.2b
Leverage CalAIM’s Enhanced Care
Management and Community Supports
programs to assist in funding intensive care
coordination across multiple systems.

SoCo DHS, ID Key
Service Provider Lead Cal-AIM
Stronger Supportive Services
47 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

2.3a:

Develop and ensure system connection (via
systems mapping and named contacts) with
services for:
- Households with criminal justice
involvement, including discharge planning
for persons exiting jail and prison.
- Transition-Aged Youth.
- Long-term learning and developmental
disabilities.
- Persons leaving hospitalization or other
health care; and
- Older adults who are aging/experiencing
dementia.

Lead Agency Staff /
Consultant
County ARPA
Funds for
Implementation of
Front-End
Assessment

2.4a
Create a System Map that shows the current
pathway through the System of Care. Map
would be for community members, elected
leaders, and individuals experiencing
homelessness. Regularly review and update
the System Map to assist in streamlining the
system.

Lead Agency Staff /
Consultant HHAP Admin

2.5a
Ensure that our system reinforces the
importance of our unhoused clients’ dignity
and respect at all times (via Ombudsperson –
Action Step 3.3c).

CoC Board and Lead
Agency Staff
(Ombudsperson)
HHAP Admin

2.5b
Implement a subregional approach to street
outreach to achieve the goals of Built for Zero.

So Co DHS, Service
Providers, Lead
Agency Staff
Realigned Existing
Funding
Stronger Supportive Services
48 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

2.5c
Evaluate existing service provider managed
encampments to determine the effectiveness
of the intervention in supporting households to
achieve housing stability. If managed
encampments are determined to be
appropriate, consider funding following the
setting of protocols and standards to ensure
safety, provide supportive services, and
maintain a housing-focus.

TBD
County and city
discretionary funds,

HHAP, HHIP

2.6a
Increase resource information for residents to
increase income through 211 and other entry
points to social and homeless services (linked
to Action Step 1.1b).
211
County ARPA
Funds for 2-1-1
Enhancement

2.6b
Assess Sonoma County-funded peer
navigation program (peers support others in
identifying relevant supportive services) for
impact and reach; continue to fund or expand
depending on gaps, needs, and outcomes.

WCCS is 2022 Lead County ARPA
Funds

2.6c Establish a countywide SSI advocacy
program, such as SOAR.

Lead Agency Staff
Service Providers
SoCo Strategic Plan
funding

3.1a
Task the CoC Funding and Evaluation
Committee with monitoring ongoing, expiring,
and new funding sources to make
recommendations to the CoC Board.

CoC F&E Committee,
Lead Agency Staff Existing sources
Operate as One
Coordinated System

3.1b
Adopt a long-term funding strategy that can
align resources to support the Plan’s goals,
strategies, and actions steps (see 1.2a; 1.3a;
Lead Agency Staff,
Consultant, CoC F&E
Committee
County ARPA
Funds for
Implementation of
Front-End
Assessment
Stronger Supportive Services
49 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

2.1a; 3.2a; 3.8a for key funding related
strategies).

3.2a
Fund new and renewing programs that have
demonstrated success in supporting people
experiencing homelessness in achieving
housing stability. The homeless system of
care should strive for a funding ratio of up to
80% for existing, evidence-based, or proven
programs and 20% for innovative or
“promising practice” program concepts.

Coc Board, Lead
Agency Staff
Existing resources,
consider more
flexible funding for
sober placements
(such as Measure
O)

3.2b Incorporate equity goals into performance
measures and invest in programs closing
equity gaps, disaggregating data by age, race,
ethnicity, and language
CoC F&E Committee,
Lead Agency Staff Existing resources

3.2c
Monitor and provide technical assistance to
providers related to incorporating input into
program service design from people with lived
experience
LEAP Board, Lead
Agency Staff TBD

3.2d
Identify agencies and partners who are led by
people of color and/or who offer culturalspecific services. Examine the system to ensure those agencies and partners have the
resources necessary to apply for, secure, and
successfully administer homeless services
funding.

Lead Agency Staff HHAP, HHIP Admin

3.3a
Provide standing opportunities for input from
the Sonoma County Lived Experience
Advisory and Planning (LEAP) and (when
LEAP Board, YAB HHAP, HHIP Admin
Operate as One Coordinated System
50 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding
established) Youth Action Boards at CoC
Board (including the Strategic Planning
Committee), City Council and Board of
Supervisors meetings, and by invitation to
other meetings regarding available funding
awards and service delivery.

3.3b
Create a centralized client-friendly platform to
share up-to-date information for people
experiencing homelessness to learn about
services (e.g., warming/cooling shelters,
portable restrooms, showers, meals,
vouchers, etc.), program
requirements/timelines (e.g., documentation
needed, deadlines). Include avenues to share
input.

LEAP Board, Lead
Agency Staff, 2-1-1 HHAP, HHIP Admin

3.3c
Create an ombudsman appeals process
where concerns about poor or discriminatory
treatment by a provider in shelters or Interim
Housing can be addressed.

LEAP Board, Lead
Agency Staff HHAP, HHIP Admin

3.4a
CoC System and Program Performance
Metrics. Affirm the below as the key metrics by
which the Sonoma County System of Care
and its programs will be measured:
1) Placements into permanent housing
2) Retention of permanent housing
3) Reducing the length of time homeless
4) Returns to homelessness
5) Increased client income (earned and nonearned)
CoC Board, Lead
Agency HMIS Staff,
and CoC F&E
Committee
Operate as One Coordinated System
HHAP, HHIP Admin
51 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

3.4b
Establish an Open HMIS that allows for
providers across the homeless response
system to view client level data to ensure
continuity of care, while balancing privacy
concerns.

HMIS Committee,
Coordinated System
of Care Committee to
CoC Board
TBD

3.4g
Establish a working group to explore the
expansion of the County’s Accessing
Coordinated Care and Empowering Self
Sufficiency (ACCESS) Sonoma initiative to
include additional County departments, local
jurisdictions, and nonprofit providers in order
to improve system wide coordination of care.

HMIS Committee,
Coordinated System
of Care Committee to
CoC Board
TBD

3.5a
Convene the County communications team,
city information teams, and outside assistance
to effectively and regularly inform the CoC
Board, the County, cities, service providers,
the media, the public, and persons
experiencing homelessness as to current
issues, funding, practices, and programs in the
Sonoma County System of Care. Information
should include:
• Social media posts and print media
content.
• Regular opportunities for the public to
speak with and ask questions of key
officials within the System of Care,
including members of the LEAP Board.

Lead Agency Staff
w/County and City
PIOs
County
discretionary funds,
Operate as One Coordinated System
others TBD
52 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding
• A dashboard of data and key metrics
associated with the System of Care (as
shown in 3.4a), including comparisons to
State and National data, as well as trends
over the previous 3-year period.
• Progress made on this Strategic Plan;
• Content relevant to persons experiencing
homelessness; and
• Content relevant to diverse audiences,
using culturally-competent methods and
translations.

3.5b
Develop and regularly distribute materials that
explain and educate about the local causes of
homelessness.

Lead Agency staff TBD

3.6a
Use the By Names List (BNL) methodology to
better account for all persons experiencing
homelessness in the county and in alignment
with Built for Zero.

CE Operator, City and
County subregional
liaisons, service
providers
HHAP, HHIP, City
and County
discretionary funds,
some existing
sources

3.6b
Coordinate encampment solutions and
management based on agreed-upon regional
priorities such as threats to public health and
safety (fire, waterways), organization and size
of encampment, and more.

SoCo DHS, City and
County subregional
liaisons, service
providers, other City
and County reps
HHAP, HHIP, City
and County
discretionary funds,
some existing
sources

3.6c
Facilitate case conferencing around PSH
referrals, prioritization, retention, and service
right-sizing. Develop a prioritization hierarchy
for placement into supportive housing (linked
to Action Step 1.3b).

CE Operator, PSH
managers/developers,
HCD TA Provider
Existing Case
Conferencing
Processes
Operate as One Coordinated System
53 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding

3.7a
Develop a new vulnerability assessment,
prioritization, and placement process to
replace the VI-SPDAT that includes an
analysis of individuals’ housing strengths and
results in equitable housing placement. A year
after use, examine (and revise if needed) to
ensure that BIPOC individuals/families receive
equitable placement (part of accomplishing

3.7c and 3.7d).

HCD TA, Lead Agency
Staff, CE Operator
Existing sources +
no-cost HCD TA

3.7b
Track access and outcomes data by age,
race, ethnicity, gender, language, and sexual
orientation.

Lead Agency Staff HHAP, HHIP, etc.

3.7c
Ensure that BIPOC residents are provided
equal services within the homeless response
system (see 3. 7a).

Lead Agency Staff TBD

3.7d
Address racial and ethnic disparities access
and outcomes of the homeless response
system (see 3.7a).

Lead Agency Staff TBD

3.7e
Ensure that the CoC Board’s and the System
of Care’s race/ethnic representation reflects
the population of Sonoma County’s homeless
community. Consider updating the Charter to
include designated seats for BIPOC members.

CoC Board N/A

3.8a
Task the CoC Strategic Planning Committee
to monitor and report on the progress of Plan
implementation and advise the Board of
Supervisors, local jurisdictions, and other
bodies, including school districts, on how to
adhere to the Plan and when to deviate from
CoC's SP Committee,
Lead Agency Staff HHAP, HHIP
Operate as One Coordinated System
54 Goals and Action
Steps
Description of the Priority Action Step Possible
Organization Lead(s) Possible Funding
the Plan based on new information. Regular
data review and report out of the three key
data metrics quarterly to stakeholders.

3.8b
Track progress towards Early Action Steps,
consider investing in project management
software to assist.

CoC's SP Committee,
Lead Agency Staff HHAP, HHIP

3.8c
Build out implementation steps for remaining
action steps (those not currently outlined in
Early Action Steps). Build out shared
ownership for these and remaining items
between CoC and other partners.

CoC's SP Committee,
Lead Agency Staff HHAP, HHIP

3.8d
When noteworthy research is released,
including but not limited to the expected UCSF
Benioff Homelessness and Housing Initiative's
California Statewide Survey of Homelessness
(CSHH), the CoC shall consider and adjust
strategies and actions as needed.

CoC's SP Committee,
Lead Agency Staff TBD
Operate as One Coordinated System
55 APPENDIX B: STRATEGIC PLANNING PROCESS
The Sonoma County strategic planning process was highly informed by stakeholder feedback throughout 2022. Extensive outreach was made to solicit input from a diverse group and including many sectors including business leaders, service providers, people with lived experience of homelessness, City and County staff and representatives, physical and mental health experts, law enforcement, private and public funders, and community leaders serving overrepresented and underserved populations. Planning activities included the following:
● In-depth review of Sonoma County’s past efforts to
assess and address homelessness through an
examination of existing reports, plans, and data to
understand the local economic landscape, demographics
of who is homeless, and strategies already being
employed.
● 14 Stakeholder Focus Groups centered around the
following themes and groups:
o Promoting Racial Equity
o Leadership and Coordination
o Crisis Response
o Funding
o Housing First
o Coordination of the System
o Encampments
o Housing Solutions
o Reducing Barriers to Access and Housing
o Business Leaders
o Permanent Supportive Housing Providers
o Permanent Supportive Housing Supportive Services Providers o People with Lived Experience of Homelessness Residing in Emergency Shelter o People with Lived Experience of Homelessness Residing in Permanent Supportive Housing
● Coordination with Lived Experience Advisory and Advocacy Groups o Homeless Action Sonoma (HAS)
o Lived Experience Advisory and Planning (LEAP) Board
● 8 convenings of the Front-End Improvements Working Group focused on enhancing the point of entry to homeless services and Coordinated Entry. ● Planning Meetings with County Ending Homelessness Unit twice a month. ● Monthly CoC Strategic Planning Committee (SPC) meetings to steer the planning process. Committee included representatives from nonprofit and faith-based organizations, City and County agencies and government, and people with lived experience of homelessness. The following SPC subcommittees were also leveraged: Housing, Increasing Income, and Coordinated System of Care.
● Monthly meetings of a newly formed CoC Logistics Working Group to guide stakeholder outreach.
✓ In-Depth Review
of Past Efforts
✓ 14 Focus Groups
✓ Lived Experience
Advisory & Groups
✓ 8 Front-End Focus
Groups
✓ Several Planning
and CoC Meetings
56 APPENDIX C: ACKNOWLEDGEMENTS
The Sonoma County Continuum of Care and Homebase wish to thank everyone who gave their time, thoughts, experiences, and well-argued beliefs in the development of this Plan.

Participation was broad, kind, respectful, candid, direct and collaborative. It modeled the “One Coordinated System” called for in the strategic plan’s overarching goals.

Our sincere thanks go to:
● The Strategic Planning Committee of the Sonoma County Continuum of Care, and the chairs and other members of its three working groups (Increasing Income, Housing, and Coordinating the System of Care).
● The 17 members of the Continuum of Care Governing Board. ● Our community-based partners, such as Catholic Charities of Santa Rosa, Reach for Home, COTS, West County Community Services, Homeless Action Sonoma, Sonoma Applied Village Services, Redwood Gospel Mission, Interfaith Shelter Network, Nation’s Finest, SHARE Sonoma County, DEMA, Burbank Housing, and others. ● The Sonoma County Board of Supervisors.
● Our city partners in Healdsburg, Petaluma, Rohnert Park, and Santa Rosa who were willing and able to assign their knowledgeable and busy on-staff housing and homelessness specialists to this effort.
● Our team members with lived experience of homelessness, especially those who serve on our Lived Experience Advisory and Planning (LEAP) Board. ● County of Sonoma Team members, including the Community Development Commission’s Ending Homelessness Division and Sonoma County Housing Authority, leadership at the Department of Health Services (DHS) and DHS’ Interdepartmental Multi-Disciplinary Team cohort known as HEART (Homeless Encampment Access and Resource Team), and representatives of the departments of Human Services, Parks, Probation, and of the County Administrative Office.
● Our colleagues at the Santa Rosa Housing Authority.
● Members of equity-based communities who participated in forums and conversations. ● Our Coordinated Entry provider, HomeFirst.
● Our Health Care partners like Partnership Health Plan, Santa Rosa Community Health, West County Health Center, and others.
● Our colleagues at the US Department of Veterans Affairs. ● Our colleagues at the California Department of Housing and Community Development. ● Members of the public, the business and tourism industry, and all who participated in our Zoom sessions.
57 Special thanks to:

Strategic Planning Committee, SPC, Chairs
Tom Schwedhelm and Stephen Sotomayor
Chairs of the Three SPC Working Groups
Karen Fies, Tom Bieri, and Tom Schwedhelm
County DHS, as our SPC Meeting and Logistics Lead
Alea Tantarelli
Lead Lived Experience Representative on the SPC
Ludmilla Bade
DHS Experience, Advice, and Counsel
Tina Rivera
DHS Practical Field Ideas
Will Gayowski
The County CDC EH Team - for multiple inputs at multiple times Dave Kiff, Michael Gause, Thai Hilton, Karissa White, Araceli Rivera, Chuck Mottern, Daniel Overbury-Howland, and Adam Siegenthaler
SC Housing Authority for Voucher Counsel and Advice
Martha Cheever
For Additional Expertise
Andrew Hening of Andrew Hening Consulting LLC
Chair of the Lived Experience Advisory and Planning Board Rebkah Sammet,
The Homebase Team Members
Aram Hauslaib, Amanda Wehrman, Emma Beers, Lauren Larin, Matt Weber, Mihir Vorha, and Tania Morales
58 APPENDIX D: QUANTITATIVE DATA SOURCES
Given the dynamic nature of homelessness, data concerning people experiencing homelessness is often incomplete. Sonoma County and the CoC are consistently working to improve data collection through the annual Point-In-Time count and the Homeless Management Information System (HMIS). This plan relies on several sources of data using the best information available to understand the demographics and needs of the Sonoma County homeless population. The following data sources were used for this plan: Point-In-Time counts, Housing Inventory Counts, System Performance Measures, Homeless Management Information System, and U.S. Census data.

Data Source What is Measured Limitations
Point-In-Time (PIT)
Count
A count of individuals experiencing
homelessness at a given point in time in a
community.

Estimate that is generally considered low
as it misses hard-to-reach populations,
such as unsheltered populations and
people sleeping in vehicles and
abandoned buildings.

Homeless Inventory
Count (HIC)
A count of all the available beds intended
for individuals in a community
experiencing or who have experienced
homelessness.

Projects are not broken out by county
and thus the locations of service sites are
limited.

Longitudinal
Systems Analysis
(LSA) Data (also
called Stella)
Household-level Homeless Management
Information System (HMIS) analysis that
is processed through HUD’s Homelessness
Data Exchange (HDX) 2.0 Stella system to
measure and track system functionality.

Stella analyzes data from Emergency
Shelter, Safe Haven, Transitional
Housing, Rapid Rehousing, and
Permanent Supportive Housing projects.

While Stella and LSA offer a wealth of
automated data analysis with
visualization, this tool cannot be used to
measure the intersections between
subpopulations, projects, regions, and
household types. For CA-504 we only
have access to Stella data for 2019 and
2020. In this document when Stella data
is shown without a date specified it
reflects 2020 data.

System Performance
Measures (SPMs)
Aggregated Individual-level HMIS Data
used to help CoCs set baselines and
benchmarks. It aggregates the following
project type information: Street outreach,
Emergency Shelter, Safe Haven,
Transitional Housing, Rapid Rehousing,
Permanent Supportive Housing, and
Other Permanent housing.

These measures are better for comparing
different CoCs. Data within a CoC cannot
be analyzed by individual project types,
regions, or subpopulations.

Sonoma County
Coordinated Entry
Dashboard
Publicly available data and visualizations
of information about clients accessing
coordinated entry from FY2018-FY2022.

This dashboard contains client data by
household type, VI-SPDAT score, and
housing project type but no information
on subpopulations or racial demographics.
59 2020 Census Decennial count of people in Sonoma
County.

This is high-level data with limited
ability to assess intersections between
demographics.
2019 American
Community Survey
The largest household survey
administered by the US Census Bureau.

The survey is sent to about 3.5 million
addresses chosen at random every year.

This is a survey, not a census, so the
people who are randomly chosen to
respond may not be exactly
representative of the entire county.
2021 United Way
California Real Cost
Measure study
United Way of California conducted a
study to measure county-specific cost of
living. It uses costs of housing, health
care, childcare, transportation and other
basic needs to calculate a Real Cost
Measure (RCM), a more comprehensive
measure of cost of living in a county than
state or federal poverty measures.

Not all costs that make up the RCM will
be relevant to all families. By its nature,
RCM will be higher than federal and state
poverty measures and this may obscure
some information about people who earn
the least.
2021 California
Housing Partnership
Affordable Housing
Needs Report
The 2021 Affordable Housing Needs
Report offers specific recommendations
to policymakers to remedy California’s
housing challenges and highlights key
indicators of housing affordability for
low-income families in Sonoma County,
including: market conditions, federal and
state funding, local wages and rent, and
LIHTC production/preservation
Report uses similar sources as other
reports here so face similar limitations
around having high-level data and using
limited sample sizes.
2020 + 2022 Sonoma
County Homeless
Census
Sonoma County and social research firm
ASR conducted this survey alongside the
2020 PIT count to get more in-depth
information about the homeless
population in the county.

Most of this data has a sample size of
about 400 people, which is roughly 15%
of the homeless population. Furthermore,
because of challenges in contacting and
interviewing the population, those
included in the survey may differ
systematically from the total homeless
population in ways that make results not
representative of the population.
60 APPENDIX E: HOMELESSNESS IN SONOMA COUNTY BY THE NUMBERS Homeless Population Overview
Sonoma County conducts a Point-in-Time (PIT) Count of individuals experiencing homelessness biannually.16 PIT data from 2017 to 2022 (Figure F) provides an overview for the state of homelessness in Sonoma County. Total homelessness slightly increased from 2017 to 2018 as changes in methodology utilizing peer involvement resulted in more comprehensive counts in rural areas of the county. From there, total homelessness steadily decreased for several years. However, in 2022, unsheltered homelessness increased drastically despite sheltered homelessness dropping to the lowest count since 2008. Like in 2018, changes in methodology due to the COVID-19 pandemic meant a more comprehensive unsheltered count was conducted. Even with changes in methodology contributing to a more comprehensive count, it’s likely that other factors similarly contributed to the increase such as hardships due to the pandemic and decreased capacity at congregate shelter sites due to social distancing.

Figure F: Sonoma Homeless Population. Data source: PIT. 16 Due to the COVID-19 pandemic, Sonoma County was not able to conduct a count in 2021 but proceeded to do so in 2022.
2835
2996 2951
2745
2893
988 1067 994 1043
805
1847 1929 1957
1702
2088
0 500
1000
1500
2000
2500
3000
3500
2017 2018 2019 2020 2022
Total Homeless Sheltered Homeless Unsheltered Homeless
Sonoma Homeless Population
61 According to the 2022 Sonoma
County Homeless Census, an indepth survey conducted by Sonoma County and social research firm ASR
alongside the 2022 PIT with a sample
size of 354 people, most people who
are homeless in Sonoma County
are also from Sonoma County
(Figure G).

Chronic Homelessness
Chronic homelessness has followed the overall total homeless trends from 2017-2022 (Figure H). Chronic homelessness accounts for about 25% of total homelessness.

Figure H: Total vs Chronic Homeless Population. Data source: 2017-2022 PIT.

As with the total homeless population, most of the chronic homeless population is unsheltered (Figure I).
2835 2996 2951 2745 2893
598 747 675 562 725
0 1000
2000
3000
4000
2017 2018 2019 2020 2022
Total Homeless Total Chronically Homeless
Total vs Chronically Homeless Population
88%
9% 3%
Sonoma County Other California County Out of State
Place of Residence at Time of Housing Loss
The 2022 increase in individuals experiencing unsheltered homelessness requires an effort to target strategies to address the unique needs of households living in places not meant for human habitation to ensure they can access supportive services as appropriate and move into housing as quickly and stably as possible.

Figure G: Place of Residence. Data source: 2022 Sonoma County Homeless Census.
62 Figure I: Chronic Homeless Population. Data source: 2017-2022 PIT. 0 100
200
300
400
500
600
700
800
2017 2018 2019 2020 2022
Total Chronically Homeless Sheltered Chronically Homeless Unsheltered Chronically Homeless
Chronically Homeless Population
The continued prevalence of households who are chronically homeless, despite efforts to prioritize those with an extended history of homelessness, points to a need to expand supportive housing options to house those currently experiencing chronic homelessness, and to prevent households experiencing homelessness from aging into chronicity. 63 System Engagement
From where are people entering
the homelessness system of
care? Stella P, a system
performance analysis tool from
the HUD’s Homeless Data
Exchange, provides more detail.

Unlike PIT data, Stella
demonstrates who is served over
time, as opposed to a snapshot
of system use. It is similarly
important to keep in mind that
PIT data measures individuals,
whereas Stella data measures
households. Stella data shows
that most households are first
time homeless in the system
but there are many who are
continuously homeless
(Figure J).

System Performance Measures
(SPMs), key performance metrics from the community’s Homeless Management Information System (HMIS), provide more detail on the first-time homeless population. It is important to keep in mind that like PIT data, this data measures total individuals from a system level, while Stella data measures total households from a system level. The number of people who are first time homeless has been stable since 2018 (Figure K). The first-time homeless population in Sonoma has consistently been above comparable national medians, whether compared to “Largely Suburban CoCs” as HUD had classified the Santa Rosa, Petaluma/Sonoma County CoC (from 2015-2019) or “Other Largely Urban CoC as it was re-classified in 2020.

The average length of time homeless has been relatively stable since 2015, and this has also been above national medians for comparable CoCs (Figure K). The average length of time homeless in 2020 was measured in SPMs as 134 days, though it was measured as 117 days in 2020 Stella data.
1406
1254
62 51
306 343
73 62
855 895
0 500
1000
1500
2019 2020
First Time Homeless in the System
Returning from a Permanent Destination
Re-engaging from a Temporary Destination
Re-engaging from an Unknown Destination
Continuously Homeless
System Engagement
Number of Households
Figure J: System Engagement. Data source: 2019 and 2020 Stella. 64 Figure K: First Time Homeless Population (left) and Average Length of Time Homeless (right). Data source: SPMs.

Racial and Ethnic Disparities in Homelessness
Black and Native individuals are overrepresented in the homeless population. While White individuals make up nearly the same share of the general population as they do the homeless population, Black individuals make up three times the share of the homeless population as they do the general population and Native people make up four times the share (Figure L). 0 500
1000
1500
2000
2500
3000
2015 2016 2017 2018 2019 2020
First Time Homeless
Number of People
0 20
40 60
80 100
120
140
160
180
200
2015 2016 2017 2018 2019 2020
Average Length of Time Homeless
Number of Days
This HMIS SPM data suggests that relative to comparable CoCs, Sonoma has an opportunity to make improvements to decrease the number of people entering homelessness for the first time by diverting them from the system and reducing the average length of time spent homeless.
65 Figure L: Racial and Ethnic Demographics of the County and homeless population. Data sources: 2020 census and 2020 PIT.

While Figure L shows the percentage that each racial or ethnic group makes up of the homeless population, another way of considering racial disparity is calculating the percent of each racial or ethnic group that is homeless. This is done by dividing the PIT count for a given group by the census count for that group. As shown in Figure M, this makes racial disparities clear: while about 0.57% of the White population is homeless, 2.04% of the Black population and 2.71% of the Native population is homeless. These racial disparities have been consistent since at least 2015 (data not shown).
63 2
5 2 0
14 15
58 29
64 6
1 9
1 19
75 25
0 10
20 30
40 50
60 70
80 White
Black
Asian
American Indian or Alaska Native
Native Hawaiian/Other PI
Multiple Races
Other
Not Hispanic/Latino
Hispanic/Latino
General Population (2020 Census) Homeless Population (2020 PIT) Sonoma Demographics
Population in Percentage (%)
66 Figure M: Percent of Racial and Ethnic Groups that are Homeless. Data Sources: 2020 Census and 2020 PIT.

Of the people that do engage with the system, there are several racial and ethnic disparities in how they move through it.

Hispanic/Latino households spend more time homeless than the overall average. Black, Native, and multiple race households spend less time homeless than average (Figure N). As for Asian and Native Hawaiian/other Pacific Islander (PI) populations, there were too few households identified in homeless data to interpret confidently.

0.57%

2.04%

0.15%

2.71%

2.23%

0.80% 0.72%

0.48%
0 0.5
1 1.5
2 2.5
3 White
Black
Asian
American Indian or Alaska Native
Native Hawaiian/Other PI
Multiple Races
Non-Hispanic/non-Latin...

Hispanic/Latino
Homelessness in Each Demographic
Percent of Total Population by Demographic
67 Figure N: Average Length of Time Homeless by Race and Ethnicity. Data source: 2019 and 2020 Stella.

Homeless Population Across County Geography
Where People Are
According to PIT counts, most people experiencing homelessness are in Santa Rosa (Figure O).

Figure O: Homelessness by Region. Data source: 2019-2022 PIT. 117 121
136
100
130
98 141
91 0
20 40
60 80
100
120
140
160
All
White,...

White, Hispanic/Latino
Black
Asian
American Indian or Alaska Native
Native Hawaiian/Other PI
Multiple Races
Average Length of Time Homeless
Number of Days
8 8 7
15 22
27 11 12
5 3 4 4
61 56 58
0 10
20 30
40 50
60 70
2019 2020 2022
North County South County West County Sonoma Valley Santa Rosa Percent of Total Homelessness by Region
Percent of Total
Homelessness
68 Across the county, cost of living is highest in Santa Rosa. In 2021 The United Way conducted surveys in many California counties to estimate county-specific thresholds for poverty. This Real Cost Measure (RCM) accounts for the cost of housing, health care, childcare, transportation, and other basic needs. In contrast, traditional poverty guidelines primarily account for the cost of food. A much higher percentage of Santa Rosa households have incomes below this RCM compared to households in other parts of the county. This difference would be overlooked if only measuring households against the federal poverty level. A higher percentage of households in Santa Rosa also pay 30% or more of their income on housing (Figure P), indicating high cost of living and potential for housing instability.

Figure P: Poverty Measures by County Region. Data source: United Way 2021 Real Cost Measure (RCM) study.

Where People Are Served
Regardless of the type of housing project households’ access, most of them are served in a city (Figure Q). Consistent with this data, the county CE dashboard’s map shows that most CE assessments happen in Santa Rosa (data not shown).
19 4
35 34
6 39
23 4
35 0
10 20
30 40
50 Below RCM Below federal poverty level Paying 30% or more on housing North County Santa Rosa South County
Poverty Measures
PErcent of Households
The high cost of living, especially in Santa Rosa, points to the need to increase opportunities for maximizing household income, and to identify or develop flexible funding sources that can support in maintaining housing stability. 69 Figure Q: Households Served in Each Geographic Area. Data Source: 2019 and 2020 Stella Households With and Without Children
Whether or not households that are homeless have children is an important distinction to consider because it can have significant effects on their experience, access, service needs, and housing requirements.

Homelessness by Household Type
86% of households that are homeless do not have children (Figure R).

Figure R: Number of households of each household type. Data source: 2019 and 2020 Stella. 1310
483
0 0
662
165
0 0
237
60 0 0
0 200
400
600
800
1000
1200
1400
City
Served in Shelters and TH
Suburb
Rural
Unknown
City
Served in RRH
Suburb
Rural
Unknown
City
Served in PSH
Suburb
Rural
Unknown
Households Served in Each Type of Area
Number of Households
2424
2094
288
24 0
500
1000
1500
2000
2500
3000
All Households Adult Only Adult and Children Children Only Types of Households that are Homeless
Number of Households
70 Interestingly, of these Adult Only households, 97% of them are households of one person (data not shown). This means households made up of individual people make up most of the county’s homeless population.

Stella data is consistent with the data in the County’s Coordinated Entry dashboard: from FY2018-FY2021, single adults made up about 75% of CE clients (Table 3).

Client’s Household Type FY2018 FY2019 FY2020 FY2021
Single Adults 1090 1187 1048 1123
Families 215 264 242 208
Youth 97 117 109 121
Table 3: Clients served in CE organized by their household type. Data source: County CE dashboard.

The County has been increasing the number of RRH and PSH beds for households without children for several years (Figure S). Continuing these trends may help decrease the homeless population.

Figure S: RRH (left) and PSH (right) Beds by Household Type. Data source: HIC.

Overall, households spend an average of 117 days homeless according to 2020 Stella data (Figure T). Although households with children make up a small share of homeless households, these households do spend a longer time homeless, suggesting that these households could face barriers to housing.
0 100
200
300
400
500
600
700
201320142015201620172018201920202021
RRH Beds by Household Type
Number of Beds
0 200
400
600
800
1,000
1,200
200720082009201020112012201320142015201620172018201920202021 PSH Beds by Household Type
Number of Beds
71 Figure T: Average Length of Time Homeless by Household Type. Data source: 2019 and 2020 Stella.

Exits from Homelessness
When different household types get housed, where are they exiting homelessness to? A majority of Adult Only households exit to temporary destinations while a majority of Adult and Child households exit to permanent destinations (Figure U). Considering that most of the temporary destinations that households exit to are places not meant for human habitation (data not shown), there is a clear need to improve outcomes for Adult Only households.

Figure U: Exits by Household Type. Data source: 2019 and 2020 Stella. 117 116
133
11 0
20 40
60 80
100
120
140
All Adult Only Adult and Children Children Only
Average Days Homeless
Number of Days
32 71 71
54 27 25
14 2 4
0 20
40 60
80 Adult Only Adult and Children Children Only
Permanent Destinations Temporary Destinations Unknown Destinations Exits
Percent of Exiting
Households
Significant progress could be made in decreasing the homeless population by addressing homelessness among Adult Only households as they make up most homeless households.

While the County has been steadily increasing the number of PH beds available, there is also a need to increase staffing and provide additional resources to support staff in housing individuals experiencing homelessness.
72 Overall, most households that are homeless are Adult Only households, and these households are less likely to have successful exits from homelessness. In contrast, households with children have more permanent exits, but they spend a longer time homeless. This indicates a need to improve the homeless system of care for both types of households.

Racial and ethnic disparities persist when households exit homelessness. (See Figure V).

Black, Native, and multiple race households exit to temporary destinations more frequently than average. As these populations all have shorter length of time homeless (see Figure N), but do not have better outcomes, this may mean there are factors within the homeless system of care that cause people of color to stop engaging with the system.

Figure V: Exits by Race and Ethnicity. Data source: 2019 and 2020 Stella.

In contrast, Hispanic/Latino households exit to permanent destinations more frequently than average. During focus groups with providers representing the Hispanic/Latino population, it was suggested that households in this community who are homeless may rely more heavily on family or community ties than non- Hispanic/Latino households and that this may explain the higher rate of exits to permanent destinations by Hispanic/Latino households. However, available data (see Figure P) shows that Hispanic/Latino households exit the homeless system of care to family and friends at rates similar to non- Hispanic/Latino households. While this does not rule out cultural or social factors as playing a role in homelessness or exits from homelessness between ethnic groups, it does indicate that exits to family and friends are not accounting for the overall higher rates of exits to permanent destinations for Hispanic/Latino households.
37% 37%
48%
42%
36%
28%
50% 50%
43%
54% 57% 56%
13% 13% 10%
5% 8%
15%
0%
10%
20%
30%
40%
50%
60%
All
White,...

White, Hispanic/Latino
Black
American Indian or Alaska Native
Multiple Races
Permanent Destinations Temporary Destinations Unknown Destinations Exits by Race and Ethnicity
Percent of All Exits
73 Figure W: Percent of Exits to Friends and Family by Ethnicity. Data source: 2019 and 2020 Stella.

Vulnerable Populations
The County also has a sizeable number of households that are homeless with added vulnerabilities (Figure X, left). About 65% of homeless households have a disabled member and 29% have adults over the age of 55. These vulnerable households spend much longer homeless (Figure X, right), so consideration of these households’ specific housing needs and barriers is warranted.

Figure X: Vulnerable Household Types (left) and Their Length of Time Homeless (right). Data source: 2019 and 2020 Stella.
5%
4%
6%
2%
0%
1%
2%
3%
4%
5%
6%
7%
Permanent Destinations Temporary Destinations
Non-Hispanic/Non-Latino Hispanic/Latino
Percent of Permanent and Temporary Exits to Friends+Family Percent of Exits
2424
691
18 72
1590
0 500
1000
1500
2000
2500
3000
All
Adult Only 55+
Adult(s) parenting 18-24
Adult(s) with 3+ children
Have a Disabled Member
Vulnerable Household Types
Number of Households
117
147
125
139 136
0 40
80 120
160
All
Adult Only 55+
Adult(s) parenting 18-24
Adult(s) with 3+ children
Have a Disabled Member
Average days homeless
Number of Days
74 Transitional Age Youth
Transitional age youth (TAY) is a subpopulation of people ages 18-24 which is defined because of this age group’s unique vulnerabilities and service needs. The Sonoma PIT count began tracking TAY in 2013. As shown in Figure Y, TAY has consistently made up 15-20% of the homeless population from 2013-2022, except for 2020, when they made up 11%.

Figure Y: Sonoma TAY Homeless Population. Data source: PIT. 4280 4266
3097
2906 2835
2996 2951
2745
2893
537 445
263 305 297 226 277 201
23 873 873
647 582
431 490 554
305
498
2870 2948
2187
2019 2107
2280
2120 2239 2372
0 500
1000
1500
2000
2500
3000
3500
4000
4500
2013 2014 2015 2016 2017 2018 2019 2020 2022
Total Homeless under 18 18-24 (TAY) over 24
Sonoma Homeless Population: TAY
The high percentage of households experiencing homelessness who have a disabled family member points to the need to increase the availability of mobile and on-site mental health services, substance abuse services, and physical healthcare services.

It would be worthwhile to assess what strategies were being used in 2020 to serve this population to successfully decrease their homelessness or identify if this was just due to changes in data collection.
75 Sheltered vs Unsheltered Transitional Age Youth Homelessness PIT data also shows that TAY who are homeless may be facing barriers to housing, as they make up a disproportionately large share of the unsheltered homeless population (Figure Z).

Figure Z: TAY Sheltered Homeless Population. Data source: PIT.

Correspondingly, TAY make up a disproportionately small share of the sheltered homeless population at about 5% (Figure AA).
3309 3309
2060
1906 1847 1929 1957
1702
297 297
61 108 119 38 125
64 810 810
593 503
371 423 512
246
2202 2202
1406 1295 1357 1468
1320 1392
0 500
1000
1500
2000
2500
3000
3500
2013 2014 2015 2016 2017 2018 2019 2020
Total Homeless under 18 18-24 (TAY) over 24
TAY Unsheltered Homeless Population
Number of People
76 Figure AA: TAY Sheltered Homeless Population. Data source: 2013-2020 PIT.

This disparity in TAY homelessness
could be a result of TAY not receiving
the services they need to access
housing. It could also mean that TAY
are not being prioritized for housing
due to biases in the prioritization tool
that favor older adults. Using the
County’s CE dashboard, it is
apparent that youth receive on
average slightly lower VI-SPDAT
scores (Figure BB). The VI-SPDAT is
Vulnerability Index & Service
Prioritization Decision Assistance
Tool used by many communities to
determine a household’s vulnerability
and need for supportive housing.
971 957
1037 1000 988
1067
994 1043
240
148
202 197 178 188 152 137
63 63 54 79 60 67 42 59
668
746 781
724 750
812 800 847
0 200
400
600
800
1000
1200
2013 2014 2015 2016 2017 2018 2019 2020
Total Homeless under 18 18-24 (TAY) over 24
TAY Sheltered Homeless Population
Number of Peoppe

9.06 9.40

8.27 7.96

0.00 2.00

4.00 6.00

8.00 10.00

12.00 Overall single adult family youth
Average VISPDAT Scores for
Accepted Referrals
VISPDAT Score
Figure BB: Figure BB. VI-SPDAT Scores of Accepted Referrals Based on Household Type. Data source: CE dashboard. Note that because the sample size for certain scores and
household types were low, this is the aggregate data for 2018-2022.
77 Veterans
Homeless Veteran Population
As with the total homeless population (see Figure F), unsheltered homelessness among veterans incrementally decreased between 2017-2020 with a drastic increase in 2022, while sheltered counts remained relatively unchanged (Figure CC).

Figure CC: Veteran Homeless Population. Data source: 2017-2020 PIT.

Veteran households make up about 10% of homeless households (Figure DD).

Figure DD: Veteran Status of Homeless Households. Data source: 2019 and 2020 Stella. 211 207 210
139
191
66 63 68
47 45
145 144 142
92 146
0 50
100
150
200
250
2017 2018 2019 2020 2022
Total Homeless Sheltered Homeless Unsheltered Homeless
Sonoma Homeless Veteran Population
Number of People
2124
254
1698
2094
219
1705
0 500
1000
1500
2000
2500
Total Households Veteran Households Nonveteran Households 2019 2020
Veteran Status of Homeless Households
Number of Households
78 The vast majority of veterandedicated beds are PSH
(Figure EE). Because veteran
homelessness has been
decreasing, but dedicated
veteran beds have not, in 2020
there were 3.5 times as many
veteran PSH beds as there
were veterans who were
homeless in the PIT count.

This could point to data quality
issues, or the need to
reallocate resources.

Comparing Homeless Veteran Population to Total Veteran Population Across many factors, the homeless veteran population in the County is very similar to the total veteran population in the County. One stark difference is that homeless veterans are younger:
while most of the veteran population is over the age of 65, about two-thirds of the homeless veteran population is younger than 65 (Figure FF).

Figure FF: Total Veteran Population Compared to Homeless Veteran Population. Data sources: 2019 ACS and 2019 and 2020 Stella.
93 33 36
88 0 0 1 0 2
83 9
91 36
77 83
5 3 0 0
9 78
5 0
20 40
60 80
100
Male
Has Disabling Condition
Age <65
White
Black
American Indian
Asian
Native Hawaiian
Multiple Races
Non-Hispanic/Non-Latin...

Hispanic/Latino
All Veterans (2019 ACS) Homeless Veterans (2020 Stella) Total Veterans vs Homeless Veterans
Percent
0 100
200
300
400
500
2017 2018 2019 2020

ES TH RRH PSH
Dedicated Veteran Beds
Number of Beds
Figure EE: Figure 22. Dedicated Veteran Beds. Data source: 2017- 2020 HIC.
79 Comparing Veteran Households to Nonveteran Households Overall, homeless veteran households are similar to homeless nonveteran households in chronic homelessness, first time homelessness, and length of time homeless.

One difference among veteran
households is that they have a
much higher percentage of exits
to permanent destinations than
total households and nonveteran
households (Figure GG).

Providers serving veteran
households may have suggestions
that can be applied throughout the
system to improve outcomes.
32 49
30 0
10 20
30 40
50 60
Total
Households
Veteran
Households
Nonveteran
Households
Exits by Veteran Status
Percent of Exits to Permanent
Destinations
The availability of veteran beds implies that the primary barrier to housing for veterans experiencing homelessness is not subsidies, but access and supportive services. Several factors are likely causing barriers, but the best way to determine what gaps exist in the system are to solicit feedback from households accessing the system.

Figure GG: Exits from Homelessness by Veteran Status. Data source: 2019 and 2020 Stella.
80 APPENDIX F: ECONOMIC AND HOUSING LANDSCAPE OF SONOMA COUNTY
Income and Poverty

6.4% of the total population are living in poverty. Black, Native, and Hispanic/Latino populations have higher poverty rates than the White population. This means they fall below the federal poverty line at rates higher than White people. This fact is important to consider when trying to determine who may be at risk of homelessness, or is in fact facing homeless, but have not been counted formally through the PIT count.

Figure HH: Poverty by Race (left) and Ethnicity (right). Data source: 2019 ACS. Error bars reflect ACS’ calculated margin of error.

7.9 17.7

11.9 9

14.8 14.8

10.3 0
5 10
15 20
25 White
Black or African American
American Indian and Alaska
Native
Asian
Native Hawaiian and Other
Pacific Islander
Some other race
Two or more races
Poverty by Race
Percent Below Poverty Line

7.7 12.1
0 2
4 6
8 10
12 14
White alone, not
Hispanic or Latino
Hispanic or Latino
origin (of any race)
Poverty by Ethnicity
Percent Below Poverty Line
The PIT count did not show significant disparities based on Hispanic/Latino ethnicity; however, Hispanic/Latino people have higher poverty rates than White people, suggesting that perhaps there are homeless Hispanic/Latino people who do not engage with the system, or who are at-risk of homelessness (see Figure HH). This could be a sign that there are ethnic disparities in homelessness in the County that need to be addressed. 81 The median per capita annual earnings in Sonoma County are $40,183. Black, Native, and Hispanic/Latino populations have lower incomes than the White population. This data is similar to poverty rates examined above and may suggest that more Hispanic/Latino people are homeless than estimated by the PIT count.

Figure II: Mean Per Capita Income by Race (left) and Ethnicity (right). Data source: 2019 ACS. Error bars reflect ACS’ calculated margin of error.

High-Cost Burden
According to a 2021 study, over half of renters in Sonoma County spend more than 30% of their income on rent, with an average rent cost of $1710/month. Disparities are present most visibly for Black renters, as shown in Figure JJ.

Figure JJ: Percent Facing High Housing Burden. Data source: California Housing Partnership. 2021 Sonoma County Affordable Needs Housing Report.
0 10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
White
Black or African American
American Indian and Alaska
Native
Asian
Native Hawaiian and Other
Pacific Islander Some other race
Two or more races
Mean Per Capita Income by Race
Dollars
0 10,000
20,000
30,000
40,000
50,000
60,000
70,000
White alone, not
Hispanic or Latino
Hispanic or Latino
origin (of any race)
Mean Per Capita Income by
Ethnicity
Dollars
0%
20%
40%
60%
80%
White, Non-Hispanic / NonLatinoWhite, Hispanic / Latino Black or African-American Asian Percent Facing High Housing Burden
82 From 2016-2021, home prices increased by 40%. Racial disparities are also apparent in terms of homeownership; two in three Asian and white households in Sonoma County own their own homes, double the rate of Black households at 34%, and well above the share of Hispanic/Latino households at 39%.

Barriers for Special Populations
An estimated 9097 people experience homelessness in Sonoma County each year. Of that number, 40% have a disabling condition, 24% are over the age of 55, and 13% are unaccompanied children or transition age youth (TAY).

By contrast, 12% of the general population in Sonoma County report having a disability, with

7.5% of the population under the age of 65 reporting a disabling condition. Overall, 21% of individuals in the County are over the age of 65.

Special populations like the aging population and individuals with disabilities require additional considerations to ensure that supports offered are responsive to their unique needs. Some needs are in respect to accommodations around mobility or other physical supports, but there are also ever-changing needs around income, and supports to help households maintain housing stability.

Planning for appropriate services and staffing to meet the needs of vulnerable populations should emphasize client choice and empowerment. Progress could be made by developing a menu of resources available to vulnerable populations, consisting of options such as housing stability support, tenancy training, substance abuse treatment, and family reunification.
83 Affordable Housing Stock
As of July 2021, there were roughly 205,903
total housing units across the County. Of
those units, 8.3% were vacant. 12,715 lowincome renter households lack access to affordable housing.

Figure KK: Availability of Affordable Housing. Data Source: California Housing Partnership. 2021 Sonoma County Affordable Needs Housing Report.

Creating opportunities for the development and restoration of affordable housing stock will begin to bridge the gap between the need for affordable housing units, and the number of people experiencing homelessness in need of a housing unit. 84 APPENDIX G: CROSSWALK OF SUBREGIONAL STRATEGIC PLANS The Sonoma County strategic planning effort took place in the context of many other planning efforts addressing homelessness in Sonoma County and the State of California. These include:
● City of Cloverdale Homelessness Strategic Plan, adopted August 2022. ● City of Petaluma Strategic Plan to End Homelessness, adopted June 2022 ● City of Santa Rosa Homelessness Solutions Strategic Plan, adopted November 2022 ● City of Sonoma / Sonoma Valley Homelessness Strategic Assessment, adopted June 2022
● Northern Sonoma County Strategic Plan to End Homelessness, adopted May 2021 ● Sonoma County Five Year Strategic Plan 2021-2026, adopted March 2021 ● State of California Action Plan for Preventing and Ending Homelessness in California, adopted March 2021, updated and adopted September 2022
Not surprisingly, these plans share many ideas and strategies in common. Among other things, they call for improving regional collaboration, increasing local government management capacity, expanding and improving both interim and permanent housing options, strengthening street outreach and support, investing in prevention and diversion efforts, strengthening supportive services, increasing the involvement of people with lived experience of homelessness, advancing efforts to implement the “Housing First” approach, boosting efforts to educate and engage the public, increasing the availability and use of housing vouchers, and increasing pathways for economic self-sufficiency. The chart on the following page highlights the provisions from each of the above plans that touch on these shared themes. 85 Common Themes/Actions in Homeless Strategic Plans - Sonoma County and Cities Jurisdiction Improve
Regional
Collaboration
Increase Local
Gov’t Mgmt.

Capacity
Increase/I
mprove
Interim
Housing
Improve
Street
Support
Increase
Prevention/
Emergency
Funding
More
Perm.

Housing
Stronger
Support
Services
Voices of
People With
Lived
Experience
Housing
First
Metrics Ensure
Equity
Better
Public
Engagement
More
Affordable
Housing;
Vouchers
Access to
Jobs
Cloverdale Goals 7d, 6c, 6d Goal 7b Goal 1c Goals 4a,
2d, 2f, 4f,
4b, 4d
Goals 2b, 1b,
3b, 5f
Goals 3c,
3e, 1a, 6a
Goals 4e,
6b, 6c
Goals 2g, 4h Goal 7c Goals 5a,
5c, 5d, 5e,
7a
Goals 1a, 3c,
3e, 6a
Goal 4i
North County "coordinated
approach" and a
"quick response
system", "shared
data systems",
Tactics 4.A.i,

4.A.ii
Tactics

2.A.i,

2.A.ii,

2.A.iii,

2.A.iv,

2.A.vi
Tactics

3.A.ii,

3.A.v
Tactics 5,

5.A.i, 5.A.iv
More
RRH,
Tactics

6.A.i,

6.A.ii
Tactic

3.A.v
Tactic

2.A.i
Referre
d to
Tactics 1,

1.A.ii,

1.A.iii,

1.A.iv,

1.A.v
Tactic 5.A.iii Tactic

1.A.vii
Petaluma Strategy 8 Strategy 5 Strategy 3 Strategy
1, 4
Strategy 4, 6,
others
Strategy 2 Strategy
2, 4
Strategy
7 Strategy 7 Strategy 2 Referred
to
Santa Rosa Theme 1,
Theme 3,
Recs 1a, 1b
Recs 1.3,
1h
Theme 2,
Recs 1.2,
2d, 2b,

2.1, 2.2,
2e, 2.3,

2.4 Theme 2,
Recs 1.1, 1.7
Recs 1.4,
3d
Recs 1e,

3.3, 3e
Recs 3.4, 3g Rec 1.5 Rec 1.7 Recs 3.5,
3h
Recs 1.8,
3b, 3c,

3.1, 3a
Recs 1.4, 3.2,
3d
86 Sonoma
Valley
Findings 4, 5, 6 Finding 2 Finding 7 Findings
4, 5, 6
Referred to Finding 7 Findings
5, 6, 8
Referred
to
Finding
3 Referred
to
Finding 1,
8 Sonoma
County
(Overall Strat
Plan)
Healthy and
Safe
Communities
(HSC) Pillar,
Obj 1.3, Goal 3,
Obj. 4.2, 4.5
HSC Goal
1, Obj.

4.1, 4.4
HSC
Goal 1,
Obj. 1.2,

4.3 HSC Obj 5.5 HSC Obj.

3.2, 4.4
HSC Obj

4.3 HSC Obj 4.1 HSC
Goal 2
HSC
Obj. 2.3,
Racial
Equity
and
Social
Justice
Obj 4.1
Organizational
Excellenc
e Pillar -
Goal 2
HSC Obj.

3.2, 3.3
HSC Obj.

4.1 Sonoma
County
Homeless
Strategic Plan
Operate As One
Coordinated
System (Goal
3), Strategies

3.1, 3.6a-f
Stronger
Supportive
Services
(Goal 2),
Strategy 2.5;
Operate as
One Coord.

System (Goal
3), Strategy

3.6a-d
More
Housing
and
Prevent.
(Goal 1),
Strategy

1.2 Stronger
Supporti
ve
Services
(Goal 2),
Strategy

2.5 More
Housing and
Prevention
(Goal 1),
Strategy 1.1
More
Housing
and
Preven.
(Goal 1),
Strategy

1.3 Stronger
Support
Services
(Goal 2),
Strategies

2.1 - 2.6
More
Housing and
Prevention
(Goal 1),
Strategy

1.2e; Operate
as One
Coord.

System (Goal
3), Strategies

3.2 & 3.7i
More
Housing
and
Prevent.
(Goal 1),
Strat.

1.2c,1.3;
Operate
as One
Coord.

System
(Goal 3),
Strategy

3.2a
Operate
as One
Coord.

System
(Goal
3),
Strat.

3.4 Operate
as One
Coord.

System
(Goal 3),
Strat.

3.2b &

3.7a-g
Operate
as One
Coord.

System
(Goal 3),
Strategy

3.5 More
Housing and
Prevention
(Goal 1),
Strategies

1.3a, 1.3d
Stronger
Support
Services
(Goal 2),
Strat. 2.6b
& 2.6d
87 State of
California
Action Plan
Action Area 1,
Objective 3
Action Area
1, Objectives
3 & 5
Action
Area 3,
Objective
9 Action
Area 2,
Object. 7
& 8
Action Area
5, Objective
15 Action
Area 4,
Object. 12
& 13
Action
Area 2,
Objective
8; Action
Area 3,
Objective
10 Action Area
1, Objective
2 Action
Area 1,
Objective
6; Action
Area 4,
Objective
11 HHAP,
Proc.,
Output
&
Outcom
es
Action
Area 1,
Objectiv
e 1; Area
4,
Object.
11 & 12
Action
Area 1,
Objective
6 Action Area
4, Objective
12 Action
Area 1,
Object. 4;
Action
Area 5,
Object. 14
88 APPENDIX H: GLOSSARY OF KEY TERMS AND ENTITITES
At risk of homelessness is a status given to individuals and their families who have unstable housing and inadequate income and resources.17
Behavioral Health describes the connection between a person's behaviors and the health and wellbeing of the body and mind.18 Case management includes assessment, planning, facilitation, care coordination, evaluation and advocacy with people experiencing homelessness. Staff work with individuals and families to address their comprehensive needs to help them exit homelessness and stay housed.

Chronically Homeless is when a person has been homeless for at least a year, either 12 months consecutively or over the course of at least 4 separate occasions in the past 3 years. To be chronically homeless, the individual or head of household must also have a disability.

By Names List would be a complete and inclusive list of every person experiencing homelessness in the Sonoma County. It would include information collected and shared with the individual’s consent like their name, history, health considerations, and housing needs.

Continuum of Care (CoC) is the group organized to carry out the responsibilities prescribed in the CoC Program Interim Rule19 for a defined geographic area. A CoC is composed of representatives of organizations including nonprofit homeless providers, victim service providers, faith-based organizations, governments, businesses, advocates, public housing agencies, school districts, social service providers, mental health agencies, hospitals, universities, affordable housing developers, law enforcement, organizations that serve homeless and formerly homeless Veterans, and homeless and formerly homeless persons. Responsibilities of a CoC include operating the CoC, designating and operating an HMIS, planning for the CoC (including coordinating the implementation of a housing and service system within its geographic area that meets the needs of the individuals and families who experience homelessness there), and designing and implementing the process associated with applying for CoC Program funds.

CoC Board is the governing body that determines policy and acts as the CoC's decision-making group.

Mandated by HUD's Continuum of Care Program, the board is responsible for oversight of funds designated to the CoC and regional planning/policy development for addressing homelessness. In 17 See 24 C.F.R. § 576.2 for complete definition of “at risk of homelessness” under the Emergency Solutions Grant Program.
18 CDC, The Critical Need for a Population Health Approach: Addressing the Nation’s Behavioral Health During the COVID-19 Pandemic and Beyond. Available at: https://www.cdc.gov/pcd/issues/2020/20_0261.htm 19 CoC Interim Rule, https://www.hudexchange.info/resource/2033/hearth-coc-program-interim-rule/ 89 Sonoma County, the CoC Board consists of local elected officials, nonprofit representatives, subject matter experts, and individuals with lived homeless experience. The Sonoma County CoC Board has the following committees:

Coordinated Entry Advisory Committee ensures the CoC is compliant with federal and state requirements, and that a countywide Coordinated Entry System (CES) is in place that is effective and responsive to real-time community needs.

Funding and Evaluation Committee is responsible for the oversight of funding and evaluation of projects for the CoC. Its duties also include reviewing funding applications for new and renewal projects as part of the U.S. Department of Housing and Urban Development’s annual CoC funding competition.

Governance Charter Policy Review Committee is responsible for making recommendations to the CoC Board for any revisions or updates to the CoC’s Governance Charter, bylaws, and policies.

HMIS Data Committee (staffed by the HMIS Lead Agency) is responsible for advising the CoC Board on issues regarding Sonoma County’s web-based Homeless Management Information System (HMIS), developing and maintaining the dashboard of metrics to achieve the vision of functional zero homelessness, and alerting the CoC Board of providers whose data jeopardizes the overall system.

Strategic Planning Committee oversees the strategic planning activities of the CoC to ensure that the homeless system of care operates effectively and efficiently in achieving CoC system performance objectives.

CoC Program is designed to promote communitywide commitment to the goal of ending homelessness; provide funding for efforts by nonprofit providers, and state and local governments to quickly rehouse homeless individuals and families while minimizing the trauma and dislocation caused to homeless individuals, families, and communities by homelessness; promote access to and effect utilization of mainstream programs by homeless individuals and families; and optimize selfsufficiency among individuals and families experiencing homelessness.

CoC Program Interim Rule focuses on regulatory implementation of the CoC Program, including the CoC planning process. The CoC Program was created through the McKinney-Vento Homeless Assistance Act as amended by the HEARTH Act of 2009.20
20 Ibid.
90 Coordinated Entry System (CES) provides a centralized approach to connect the region’s most vulnerable homeless residents to housing through a single community-wide assessment tool and program matching system. CES is made-up of four core elements:

Access – Sixteen agencies around Sonoma County serve as entry-points for individuals and families in need of housing resources. People may seek help from these agencies in person or by phone. The County’s 211 information system also actively refers people at risk of homelessness or experiencing homelessness to these agencies for assistance.

Assessment – Agencies use a locally modified Vulnerability Index – Service Prioritization Decision Assistance Tool (VI-SPDAT) to assess clients’ housing, health, and social needs. It incorporates factors such as length of time homeless, medical vulnerability, the severity of presenting issues, and individuals’ or households’ ability to address their own housing instability.

Prioritization – People seeking assistance are placed on local “By Names Lists” that prioritize listed individuals and households based on the VI-SPDAT’s assessment of their vulnerability and need. Service providers throughout the County use these lists to prioritize access to available resources, eliminating the need for clients to seek assistance program-by-program.

Referral – Agencies use the By Names Lists to match each client with the best housing and service options available for their needs. Unfortunately, demand for assistance often outpaces the availability of housing and other resources. Eligible individuals and households who are the most vulnerable and the most in need – as ranked on the By Names List – will be connected to available supportive housing programs first.

Congregate Shelters are facilities with overnight sleeping accommodations, in shared quarters, the primary purpose of which is to provide temporary shelter for the homeless.

Cost burden is the ratio of housing costs to household income. For renters, housing cost is gross rent (contract rent plus utilities). For owners, housing cost is "select monthly owner costs,” which includes mortgage payment, utilities, association fees, insurance, and real estate taxes.

Diversion is a strategy that prevents homelessness for people seeking shelter by helping them identify immediate alternate housing arrangements and, if necessary, connecting them with services and financial assistance to help them return to permanent housing.

Emergency Shelter is any facility with overnight sleeping accommodations, the primary purpose of which is to provide temporary shelter for the homeless in general or for specific populations of the homeless. Shelter may include year-round emergency shelters, winter and warming shelters, navigation centers and transitional housing. These types of shelter have varying hours, lengths of stay, food service, and support services.
91 Emergency Solutions Grants (ESG) provides federal funds to assist people to quickly regain stability in permanent housing after experiencing a housing crisis and/or homelessness.

Encampment is a group of people living in public places outside.

Federal Poverty Guidelines are issued each year by the federal Department of Health and Human Services. The guidelines are a simplification of the federal poverty thresholds and are used to determine financial eligibility for certain federal programs.

Flexible Funds have increasingly been permitted and encouraged as an allowable expense by federal, state, and County funders. Flexible funds can be used for different purposes. They can pay for costs that will result in an immediate solution of a housing crisis. They can bridge the gap while permanent housing is secured. They can cover household needs that will help people keep their housing. Flexible funding can be used to purchase grocery cards, gas cards, certificates or licenses to work, car repair, furniture, pest extermination, storage, essential minor repairs to make living space more habitable, transportation vouchers/passes, costs for birth certificates or other documents, bus or train tickets, shipping belongings, housing application fees, credit checks, rental deposits, past due rent, onemonth rent on new units, utility deposit, and/or utility payments.

Functional Zero means that the number of people experiencing homelessness at any time does not exceed the community's ability to house that many people within a brief period of time. This requires systems to prevent homelessness, be able to quickly detect homelessness when it occurs, and permanently and promptly resolve it.

Homeless is defined by HUD in four categories:
(1) individuals and families who lack a fixed, regular, and adequate nighttime residence and includes a subset for an individual who resided in an emergency shelter, or a place not meant for human habitation and who is exiting an institution where he or she temporarily resided; (2) individuals and families who will imminently lose their primary nighttime residence; (3) unaccompanied youth and families with children and youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition; and (4) individuals and families who are fleeing, or are attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member.

Homeless Emergency Assistance and Rapid Transition to Housing Act (HEARTH Act) was signed into law in 2009. HEARTH reauthorized the McKinney-Vento Act. It also provided substantial changes to the law, updating the definition of homelessness and chronic homelessness, as well as 92 other changes including consolidating competitive grants, simplifying match requirements, and providing prevention resources.

Homeless Housing, Assistance and Prevention (HHAP) Program is a $650 million one-time block grant that provides local jurisdictions with funds to support regional coordination and expand or develop local capacity to address their immediate homelessness challenges.

Homeless Management Information System (HMIS) is a local information technology system used to collect client-level data and data on the provision of housing and services to homeless individuals and families and persons at risk of homelessness.

Housing and Urban Development (HUD), U.S. Department of, is the federal agency responsible for national policy and programs that address housing needs, improve and develop communities, and enforce fair housing laws.

Housing First is a well-accepted, national, evidenced-based best practice that eliminates barriers to housing, ensuring individuals and families can exit homelessness as quickly as possible. Housing First is an approach to connect households experiencing homelessness quickly and successfully to permanent housing without preconditions and barriers to entry, such as sobriety, treatment, or service participation requirements. Supportive services are offered on a voluntary basis to maximize housing stability and prevent returns to homelessness as opposed to addressing predetermined treatment goals prior to permanent housing entry.21
Low-barrier shelters are emergency shelters that have removed most requirements/obstacles for entry into the program so that households are more likely go indoors to connect to services rather than stay on the street. For example, unhoused residents are allowed to bring their pets and possessions, to live with their partners, and do not have to exit the shelter each morning. They are not expected to abstain from using alcohol or other drugs, so long as they do not engage in these activities in common areas of the shelter and are respectful of other residents and staff.

Mainstream Voucher is rental assistance voucher for non-elderly persons with disabilities.

McKinney-Vento Act is a federal statute that has a more expansive definition of homelessness than the HUD definition. The Act requires schools to track students experiencing homelessness. For public education programs up through high school, homelessness includes people experiencing homelessness under the HUD definition, but also includes youth who are couch surfing or doubled-up (e.g., with multiple families sharing the same space).
21 What Housing First Really Means, National Alliance to End Homelessness (NAEH), https://endhomelessness.org/what-housing-first-really-means/ 93 Motivational Interviewing is a client-centered, evidence-based approach used by direct service providers working with people experiencing homelessness. It focuses on allowing individuals to direct their own path toward the change they seek, rather than trying to convince them of what they need to do. The provider builds trust, listens, and then acts as a guide to help the client to identify their own personal next steps.

Non-congregate shelters provide overnight sleeping accommodations with individual quarters, such as hotels, motels, and dormitories.

People with lived experience is a term used to refer to people who have lived through the experience of homelessness and have first-hand knowledge of what it feels like to live unsheltered and/or to move through the homeless system of care.

Point-in-Time (PIT) Count is a biennial process required of CoCs by HUD to count the number of people experiencing homelessness on a single night in January. The PIT count provides a snapshot of data available on the size and characteristics of the homeless population in a CoC over time.

Permanent Supportive Housing (PSH) provides long-term housing with intensive supportive services to persons with disabilities. These programs typically target people with extensive experiences of homelessness and multiple vulnerabilities and needs who would not be able to retain housing without significant support.

Prevention is a strategy intended to target people who are at imminent risk of homelessness (whereas diversion usually targets people as they are initially trying to enter shelter).

Project-Based Voucher (PBV) is a rental assistance voucher that is attached to a particular unit, meaning if you live in a rental unit under the PBV Program and move, the assistance stays with the unit. The tenant enters into a Housing Assistance Payments contract with the property owner for a specified unit and for a specified term.

Rapid Rehousing (RRH) provides rental housing subsidies and tailored supportive services for up to 24-months, with the goal of helping people achieve permanent housing stability. RRH is considered a permanent housing solution by HUD.

Shared housing is a living arrangement between two or more unrelated people who choose to live together to take advantage of the mutual benefits it offers. Families, students, young adults, seniors, and Veterans have been using this arrangement for generations. It is now recognized as a viable option for people exiting homelessness.
94 Sonoma County Community Development Commission (CDC or the Commission) exists to open doors to permanent housing and opportunity through the following initiatives: Rental Assistance, Ending Homelessness, and Housing & Neighborhood Investments.

HMIS Lead is responsible for developing HMIS data quality, privacy, and security plans and monitoring compliance with HUD regulations. The CoC designated the CDC as the HMIS Lead.

Lead Agency (and Collaborative Applicant) is responsible for the financial management of funds received by the CoC, including applying for state and federal grants, running local competitions for funding, and administering grants to local service providers. The CoC has designated the CDC as the Lead Agency and Collaborative Applicant. The CDC drafts and submits grant applications on behalf of the CoC, receives grant awards, develops and administers agreements with subgrantees on behalf of the CoC, and conducts ongoing project and system monitoring and state reporting. The CDC provides staff support to the CoC, its Board, committees, and work groups.

Street outreach involves multi-disciplinary teams who work on the streets or in encampments to engage with people experiencing homelessness who may be disconnected or alienated from services and supports that are offered at an agency.

Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services (HHS) that leads public health efforts to advance the behavioral health of the nation and to improve the lives of individuals living with mental and substance use disorders, and their families. As stable housing is a critical component of recovery, SAMHSA’s homelessness programs and resources work to end homelessness by improving access to treatment and services that support health and wellness.

Supportive services include assistance applying for benefits, mental health and substance use services, outpatient health services, information and referral services, child care, education, life skills training, employment assistance and job training, housing search and counseling services, legal services, outreach services, transportation, food assistance, risk assessment and safety planning (particularly for individuals and families experiencing domestic violence), and case management services such as counseling, finding and coordinating services, and monitoring and evaluating progress in a program.

Tenant-based Rental Assistance (TBRA) is rental assistance that can be used in the private rental market and is not attached to a particular unit. The tenant enters into a lease with the owner.

Transition Age Youth (TAY) are persons between age 18 and 24 who are transitioning from childhood to adulthood.
95 Transitional Housing (TH) provides temporary housing accommodations and supportive services.

While many households benefit most from direct connections to permanent housing programs such as RRH or PSH (which are often more cost-effective over the long term), transitional housing can also be an effective support in the intermediary. Certain subpopulations, such as people fleeing domestic violence and transitional age youth, can meaningfully benefit from a transitional housing environment.

Trauma-informed care is a practice that focuses on understanding and compassion, especially in response to trauma. The practice utilizes tools that empower people to work toward stability. It recognizes a wide range of trauma that can impact people experiencing homelessness; physical, psychological, social, and emotional trauma. It emphasizes the safety of both clients and providers.

Vulnerability Index & Service Prioritization Decision Assistance Tool (VI-SPDAT) is a prescreening/triage tool designed to assess the vulnerability of an individual experiencing homelessness and prioritize them for housing based on their relative need as compared to others seeking supportive housing. The VI-SPDAT is used at Coordinated Entry access points.