At Scale, At Risk - Full ReportThis report details the Jury's research, investigation, findings, and recommendations.PublishedJune 23, 2026

– HSH Data Analytics. .............................................................................................. 38

– HOC Review of Contracts. ..................................................................................... 39

– HOC Statutory Authority. ...................................................................................... 39

– HSH Monitoring of Shelters and Housing. ........................................................... Required and Requested Responses .................................................................................... Methodology ....................................................................................................................... Glossary and Abbreviations ................................................................................................. Works Cited ......................................................................................................................... Appendix A: Timeline of this report’s events ......................................................................... Appendix B: Data reporting from other jurisdictions .............................................................. Appendix C: Oversight and Advisory bodies for HSH ............................................................. 62 2 About the San Francisco Civil Grand Jury The San Francisco Civil Grand Jury (the “Jury”) is a government oversight panel of nineteen San Francisco citizens who volunteer for one year. Each Jury determines which local government entities within San Francisco it will investigate. The Jury cannot investigate disputes between private parties, criminal activity, or activities outside its jurisdiction, which is the government of the City and County of San Francisco (“City”) and any other local governments within San Francisco city limits. The Jury publishes public reports with findings and recommendations based on its investigations. Read more about the San Francisco Civil Grand Jury here: https://www.sf.gov/departments-- civil-grand-jury 2025–2026 Civil Grand Jurors Brian Adam Maryann Hrichak Allyson Eddy Bravmann Gary Hsueh Rick Carell Joanna Karlinsky Robert J. Chansler Margaret Keane Ed Cooper Julia Molla Foreperson Robert Page Niket Desai Dustin Palmer Stan Feinsod William L. Pierog Foreperson Pro Tempore Barbara Savitz Joe Ferrero Tracy Wymer Mira Foster About the cover The images on the left and right are sites funded by the Department of Homelessness and Supportive Housing that are case studies contained in this report. On the left is the Jazzie Collins Apartments, a 96-unit permanent supportive housing site. On the right is 711 Post Street, a 280-bed semi-congregate shelter which is planned for closure in March 2027. Executive Summary San Francisco spends roughly $700 million annually on homelessness, and its Department of Homelessness and Supportive Housing (“HSH”) administers nearly $500 million on nonprofit contracts to deliver services each year, yet this system has gaps that jeopardize safety, accountability, and results. HSH was created in 2016 to bring unity and simplified accountability to the City’s homelessness programs, and it now serves roughly 27,000 people per year1 with a nearly 100% outsourced model through a network of nonprofit service providers. In response to HSH’s growth and the escalating homeless crisis, voters approved Proposition C in 2022, creating the Homelessness Oversight Commission (“HOC”) to bring accountability to a system that was insufficiently transparent or accountable relative to its scale and budget. This report finds that while HOC exists to bring independent governing oversight to HSH, its functional oversight is weak, its statutory authority is largely unutilized, and as a result, serious failures have escaped its detection and scrutiny. This finding aligns with the staff discussion of the Commission Streamlining Task Force (“CSTF”) on homelessness, which noted, “there have been several recent high-profile cases Citywide where a nonprofit either misused funds or mismanaged service delivery. In each case, City oversight mechanisms (such as regular contract and nonprofit monitoring and the Controller’s Office’s audits) caught and corrected these issues, not the departments’ commissions [i.e. HOC].”2 Oversight of HSH and its nonprofits exists but is not working as intended, or as needed for an entity that spends hundreds of millions annually to outsource its core services. Historically, the City’s oversight mechanisms emphasized fiscal compliance and fell short on programmatic measures. In part, this was a function of how program outcomes were defined in contracts. Performance is often measured by simple counts measuring actions or functions, not real outcomes. For instance, this includes how many people participated in intake orientation, or what percent of the people who completed exit surveys viewed a program favorably. Contracts did not include program standards set for client safety, exit success criteria, or real performance outcomes. 1 2025 Homelessness Needs Assessment, Office of the Controller, City Performance, Dec 10, 2025, pg. 7. Final Report Supplemental Appendices, Commission Streamlining Task Force, Jan 28, 2026, pg. 371 4 These gaps have real consequences. Permanent supportive housing (“PSH”) represents the largest share of HSH’s housing portfolio. Yet it operates with limited external oversight, inconsistent monitoring, and insufficient accountability mechanisms. Data shows troubling outcomes at PSH sites. Roughly a quarter (26%)3 of all accidental drug overdose deaths in San Francisco occurred at PSH sites in 2024, and based on press reports, we estimate roughly a third (32%)4 of accidental drug overdose deaths for those with fixed addresses in San Francisco occurred at PSH sites.5 San Francisco collects thousands of “critical incident reports” (“CIRs”) each year, filed by its nonprofit service providers to document service issues. The most serious codes concern deaths, overdoses, overdose reversals, violence, and emergencies requiring police, fire or ambulance response. But these CIRs are not systematically analyzed in aggregate to identify troubling patterns or trends, compare and manage providers, identify systemic risks, or prevent future harm. The well-reported death of Eric McCain, whose body was allegedly undiscovered for 10-12 days6 in a PSH unit, the Jazzie Collins Apartments operated by HomeRise, raises concerns about client safety. Reported conditions at or around 711 Post Street, a large-scale shelter site operated by Urban Alchemy, also prompt concerns about issues not captured by the contractual metrics for performance and outcomes. HSH described Urban Alchemy’s 711 Post Street as a success based on its contractual service and outcome objectives. At the same time, community neighbors reported ongoing safety and quality of life issues were not considered or assessed by HSH. The Jury has concluded that such issues and concerns are not limited to these incidents; they reflect a system that often lacks the tools, oversight, and accountability to provide adequate services to a population with high levels of disease and disability, including serious mental illness, chronic physical disease, infectious disease, substance use disorders, physical disability, and functional impairment.7 3 "Behavioral Health Services Director's Update, Behavioral Health Commission," Hillary Kunins, Sep 18, 2025, p. 6. Estimated from the 875 overdose deaths from “"Housing first, morgue second," Susan Dyer Reynolds, The Voice of San Francisco, Aug 28, 2025, as numerator, and the total number of overdose deaths for those with fixed addresses (2,747) over the same period from the Office of the Chief Medical Examiner. BOS Public Safety and Neighborhood Services Committee, April 23, 2026, p.3. 6 “At a ‘model’ S.F. complex for the formerly homeless, a man lay dead for days unnoticed,” Matthias Gafni, Matthew Mitchell, Susie Neilson, SF Chronicle, Mar 20, 2026. UCSF Benioff Homelessness and Housing Initiative, Toward Thriving: Understanding Health & Homelessness, Nov 2025. At the same time, the City’s homelessness data systems remain scattered across departments; this fragmentation obscures a full view of client needs, and ultimately hinders successful client service outcomes. At the system level, it works against network optimization (ex. Mayor Lurie’s “right beds” strategy which focuses on service-rich, mental health, and recovery-oriented beds rather than raw numbers) and limits the ability to use data to generate triggers that can alert HSH to respond to early warning signs. New investments in data infrastructure are underway, but they have not yet translated into meaningful improvements in decision-making or oversight. This report identifies five areas that need addressing: ● CIRs provide vital insight into client safety, but HSH has not used this data effectively to identify patterns of concern or to improve safety at housing sites. ● HSH is lagging in presenting data that allows for benchmarking nonprofits by program or housing type, and in using data to trigger targeted program monitoring. ● HSH ceased the established practice of submitting certain contracts to HOC for review and consent, notifying HOC of all renewals and extensions as line items. ● HOC has yet to exercise the full extent of its statutory authority, and lacks the training and resources to meet the public’s expectations as set by the 2022 Prop C initiative. ● The Shelter Monitoring Committee is set to terminate, and HSH is insufficiently resourced to absorb SMC’s work, and oversee PSH sites effectively. The current approach is not enough. San Francisco has invested billions to address homelessness over the last decade, yet the crisis continues to deepen. The homeless count at the start of each year has grown at roughly a 30% compound annual rate since 2020, reaching an estimated 8,000 individuals at the start of 2025 (we estimate this based on HSH’s inflow and outflow data, i.e. 5,488 homeless at start of 2024 plus 17,859 inflow for 2024 minus 15,292 outflow for 2024 = 8,055)8 — and those entering the system arrive with increasingly complex medical, behavioral health, and substance use needs. Meanwhile, successful exits from homelessness to stable housing, represent only 30–40% of total outflow9 — meaning the majority of people leaving HSH's system are not exiting homelessness on stable terms. The number of successful exits has declined 14.3% year-over-year (on a calendar basis, -9.3% on a fiscal basis) in HSH’s most recent data. Homelessness is growing faster than it is being resolved. Homelessness Trends Dashboard: Inflow and Outflow Analysis, HSH; 1,899 actual “Homeless at Start” for 2020 and an estimated 8,000 for 2025, which represents a CAGR of 33% over 5 years. Exits from Homelessness, HSH; Successful exits to stable housing totaled 5,756 for 2024, and total outflow from HSH’s Inflow and Outflow Analysis was 15,292 for 2024. This is not a picture of success. Growth in spending hasn't solved the problem and now HSH faces a plateauing budget. This report’s recommendations call for restoring independent contract reviews, more robust exercise of chartered oversight authority, integrating safety metrics into contract management, and building data-driven intelligence into monitoring and auditing workflows. This report includes Findings and Recommendations; they identify timely steps needed to help HSH protect the vulnerable people it serves and deliver on its stated mission to “make homelessness in San Francisco rare, brief and one-time, through the provision of coordinated, compassionate and high-quality services.”10 10 HSH’s mission statement in the section “About Us,” on its sf.gov website 7 Charter Reform This report arrives at a moment of transition for oversight in San Francisco. On May 12, 2026, the Board of Supervisors (“BOS”) voted 6-4 to approve an Administrative Code ordinance on first reading (File No. 260217, the “Ordinance”), which adopts some of the CSTF’s