Proposition D – Laguna Honda Hospital, Zoning for Health Care Facilities

Voter Guide

Laguna Honda Hospital is San Francisco’s largest skilled nursing facility. Proposition D is an initiative ordinance that would codify the admissions policies for Laguna Hondain the City’s Planning Code. It would place the following restrictions on admissions:

  • Prohibit admitting people whose primary diagnosis is psychiatric or behavioral
  • Prohibit admitting those who pose a threat to themselves or others
  • Prohibit admitting those who need short-term skilled nursing services (fewer than six months in duration).
  • Give San Francisco residents priority in admissions

Proposition D would create these restrictionsby zoning the Laguna Honda area as a “special use district.”

In addition, Proposition D would change the uses permitted on publicly owned land throughout the city—not just at Laguna Honda—to allow for construction of new assisted-living facilities by either public agencies or—this is the new part—private developers.

Proposition D is an initiative placed on the ballot by San Franciscans for Laguna Honda, a group that gathered voters’ signatures. This measure requires a simple majority—50 percent, plus one additional vote—to pass.




In recent years, Laguna Honda has primarily housed aged people with medical conditions requiring long-term care. During the past several years, the Department of Public Health (DPH) began transferring some patients to Laguna Honda from San Francisco General Hospital. The change in the admissions policy was made partially in responseto a management audit of the Health Department. The audit found that some General Hospital patients were being cared for in acute-care beds at a cost of $1,300 per day, but those patients only required less-expensive skilled nursing care that could be provided at Laguna Honda. Because these patients did not require acute care, Medicare did not cover their payments, and the difference in cost was being subsidized by the Health Department. The Department of Public Health corrected this mismanagement, which was costing the City millions of dollars per year, by transferring patients who did not require acute care to Laguna Honda.

Proposition D’s proponents say that the transferred patients are younger and often exhibit aggressive behavior that puts the more traditional patients, and staff, at risk. As evidence, they cite incidents including an arson and readmissions of patients who had previously been discharged for violent acts. While Laguna Honda’s admissions policy has been modified several times since the new policy was instituted in 2004, Proposition D’s proponents believe that there aren’t enough safeguards to keep dangerous patients out of Laguna Honda,and gathered signatures to place Proposition D onthe ballot to permanently keep such patients out. Historically, decisions on where to place patients have been made by doctors andhealth administrators, guided by state and federal legislation. The Department of Public Health acknowledges that there have been problems with combining different patient populations, but says adjustments to admissions policies and other administrative changes can reduce risk of future incidents.


Hospital Admissions Issues

The measure contains a broad prohibition against admitting people whose diagnosis is “primarily psychiatric” and those who “pose a danger to themselves or to others,” and a requirement to immediately discharge current patients who fall into these categories. Because they are so broadly written, these prohibitions could be legally interpreted as prohibiting patients the proponents of the measure do not intend. For example, a DPH memo says Proposition D could force the discharge of more than 300 patients from Laguna Honda, including those with advanced Alzheimer’s disease (who often exhibit aggressive behavior in the late stages of the disease), those with AIDS and dementia, and those with brain injuries asa result of trauma—all of whom may be considered to have a “primarily psychiatric” diagnosis.

Advocacy groups opposing Proposition D have questioned its legality. Protection and Advocacy, Inc., an organization that advocates for people with disabilities, argues that Proposition D’s prohibitions “impermissibly discriminate on the basis of disability, . . . severity of disability, and impermissibly deny non-residents of San Francisco access to services” and violate state and federal laws. “Additionally, California law specifically prohibits discrimination against individuals with psychiatric disabilities in the zoning of health facilities, and mandates that psychiatric treatment facilities must be allowed in any area zoned for hospitals or nursing facilities.”

Proponents of Proposition D counter that the group is ideologically opposed to residential care facilities.


Land Use Issues

The mechanism used in Proposition D to createthe restrictions on admissions to Laguna Hondais to change the uses permitted on the land on which Laguna Honda is built. It creates a “special use district,” or an area of land in the city in which the controls apply. Because the measure is written this way, the legal controls over admissions to the hospital would be a matter of land use, not health policy, and as such would presumably be primarily under the jurisdiction of the Planning Department. Consequently, should a dispute arise over whether an individual can be admitted into Laguna Honda, the Planning Department would presumably have a role as arbiter.

Proposition D also makes significant changes to land-use laws that would apply citywide, not just in the area near Laguna Honda. Much of the land owned by the City is zoned “P.” P districts primarily allow public buildings and other public uses—for example, the land under the City-owned Candlestick Park is zoned P. There are numerous P districts throughout the city. Currently, publicly owned residential health care facilities are permitted in P districts, but privately owned and operated facilities are not. If Proposition D passes, the city attorney has opined that it would allow public and privately owned long-term skilled nursing facilities in such zoning, with the approval of the Planning Department.



  • It is unsafe to combine populations of patients with dramatically different care needs. This is especially true in a setting where seniors and those with disabilities, who are often vulnerable, are combined with those who present a risk to their safety. Laguna Honda is not equipped to accommodate both types of patients safely.
  • San Francisco, with an aging population, will need a long-term skilled nursing facility for years to come. Using Laguna Honda’s beds for overflow patients from San Francisco General Hospital will detract from the City’s ability to care for seniors.
  • Using a land-use approach to address this problem is practical since a change in zoning will stay in effect over the long term, whereas health administrators can change admissions policies for short-term goals that undermine the long-term interests of the city.
  • Much of the City-owned land in P districts is underutilized, and private developers should have the opportunity to build and operate residential health care facilities on these lands, subject to approval by the Planning Department.



  • Health care decisions should not be made using land-use policy. This measure would, in effect, make the City’s zoning administrator the arbiter of highly complex health care decisions that obviously belong in the hands of trained health care professionals.
  • Once this measure is approved, it can only be changed by a subsequent measure on the ballot. This means that if we approve this measure we would be locking in highly specific admissions controls in perpetuity. Health care as a field is constantly changing, and the city’s population and its medical needs are changing, too. It is irresponsible to hamstring future generations by creating a permanent solution to a short-term problem.
  • The legislation is overly broad, and as written it will have unintended consequences far beyond the proponents’ intent, potentially including dismissal of dozens or even hundreds patients who, most agree, should continue to be treated at Laguna Honda.
  • It is unfair to ask the voters to make a decision on an issue that requires years of study and professional knowledge to fully comprehend. The types of decisions at issue in this measure are extremely technical and require a high degree of case-by-case judgment by professionals. It is futile to attempt to codify these decisions in broad legal directives without sacrificing the quality of the decision-making, and without shifting the decisions away from medical professionals and toward the legal system.
  • This measure is a stealthy effort to open up new development opportunities. It is bizarre to combine the change in admissions policy with the blanket allowance of private long-term care facilities on public land. These two changes are entirely independent of one another and should not be combined into the same measure. Their combination, in fact, raises serious questions about the true intentions of this measure.



SPUR recommends a “no” vote on Proposition D.
Proposition D’s goal of patient safety is obviously shared by its proponents and opponents. We acknowledge that many of the measure’s proponents are genuinely attempting to make a change to benefit vulnerable populations in need of care. However, this measure is a classic example of how overly broad political and legal solutions to complex problems can have severe unintended consequences. The selection of physical planning and land-use administrators, from a department with no health expertise, to make what should be medical decisions is inappropriate, impractical and doomed to failure. Decisions about patient placement are professional, medical and managerial—they have no business in a ballot measure. Proposition D’s proponents want to lock in what they say are Laguna Honda's traditional admission policies, but Laguna Honda’s mission has changed over the years and will unquestionably change again in response to advances in technology and treatment. Should Proposition D pass, its provisions could only be changed by passage of another ballot measure.

Moreover, the measure will make some unsettling technical changes to the Planning Code that could apply citywide. While there may be a case for making these changes, the issue should be analyzed by planning professionals and addressed through a deliberative public process—not slipped quietly into a ballot measure with no public discussion or debate.