SAN FRANCISCO — The San Francisco Board of Supervisors on Tuesday expressed concern and frustration over potential patient discharges happening once again at the Laguna Honda Hospital and Rehabilitation Center in light of an agreed-upon grace period coming to a close on Friday.

At Tuesday’s board meeting, Laguna Honda interim CEO Roland Pickens laid out the hospital’s progress in reaching federal and state recertification, two days before the hospital may have to begin discharging its patients once again.

The discussion comes after federal and state regulators cited safety concerns at Laguna Honda last April, stripped it of its Medicare and Medicaid provider agreements and required the hospital to move all 700 patients out of the facility by September. Among the concerns were drug paraphernalia in the facility, a lack of infection prevention and control, and missed doses of medication.

Thanks to a settlement agreement initiated by City Attorney David Chiu in the summerthe US Department of Health and Human Services allowed the hospital to postpone patient discharges until February, and the federal Centers for Medicare and Medicaid Services (CMS) agreed to keep funding Laguna Honda, so long as they worked to find solutions to the cited issues .

Days before the no-eviction window closes, city supervisors and health leaders are once again concerned about the dangers of quickly discharging and transferring patients, many of whom have complex medical conditions.

The hospital alleges that of the 57 residents who were transferred into other facilities last summer, at least 12 died within three months.

In response, CMS has issued a dozen citations against Laguna Honda for the deaths, though Pickens alleges that the regulators were partially responsible because of their pressurizing, expedited timeline and lack of guidance.

“We maintain to this day that the best place for those residents [who died] was Laguna, and the best place for the residents at Laguna now is Laguna, which is why we are doing everything we can to ensure that we do not have to resume transfers,” said Pickens.

The organization California Advocates for Nursing Home Reform alleges that Laguna Honda evicted extremely sick patients “known to be at high risk for transfer trauma” to nursing homes outside of the city with “poor track records,” some even being sent to homeless shelters.

CANHR said the series of $3,000 fines were “a mere slap on the wrist for repeated and lethal acts of elder abuse.” They added that federal and state regulators played a “lead role” in the deaths by forcing Laguna Honda to evict patients quickly, without safety in mind.

Patricia McGinnis, CANHR’s executive director, called on the Legislature to investigate the leadership of the California Department of Public Health.

“CDPH must not be allowed to whitewash the deaths of these vulnerable residents and its own role in them,” McGinnis said.

dr Grant Colfax, head of the San Francisco Department of Public Health, said the department has issued a letter to CMS seeking out another pause in transfers, and CMS promised to respond before Friday. Concurrently, Laguna Honda is continuing to make improvements to become recertified, Colfax said.

“While we’ve made great progress over the last six months, and while there is more work ahead, I am confident in our direction,” said Colfax. “As we go through this process, we are again unwavering in our dedication to our residents and their families. The health, safety and well-being of our residents remains our top priority.”

Pickens said the hospital has worked closely with quality improvement experts to identify eight key issues that led to Laguna Honda’s decertification based on regulatory surveys from the past 18 months and developed an action plan to address all the concerns.

Some of the actions Laguna Honda plans to make to achieve the 300-plus milestones needed to reach recertification include creating better individualized care plans for its residents, especially those with mental health and substance abuse issues, creating better infrastructure to prevent residents from bringing illicit materials into the facility, and switching to in-person emergency preparedness drills rather than training their staff via online modules.

Laguna Honda has until May 13 to demonstrate progress toward meeting regulatory requirements before it resubmits its certification application.

“We are hopeful that when CMS comes back for their second monitoring survey, that they will see improvements and that the results will be better than they were for the first survey,” Pickens said.

Supervisor Dean Preston said he felt CMS was acting in bad faith for not responding to a request for an extension on the transfer pause.

“I cannot believe after a dozen people are dead as a result of how this has gone down to date, that CMS is not being more responsive and working with us around an extension,” said Preston at Tuesday’s meeting.

Supervisor Rafael Mandelman said he was “struck” by how much harm the oversight agencies have allegedly caused, and called their leadership “unaccountable” and “disconnected.”

“I’m sure they think they’re just following the rules they’re supposed to follow, but the real-life, on-the-ground impacts of the way in which they are proceeding is causing huge distress and stress, and in 12 cases, deaths,” Mandelman said.

Supervisor Hillary Ronen said CMS’s requests are “truly cruel and unbelievable.” She thanked Laguna Honda staff for “trying to accomplish the impossible” in meeting the regulators’ guidelines without much help.

“They don’t seem to take that into account on how much Laguna has bent over backwards to try to be helpful in resolving the crisis on our streets and with mental illness, that certainly the state and the feds don’t seem to provide any funding nor help,” Ronen said. “This whole thing is just mind-boggling.”

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Last week, federal regulators agreed to pause the transfers after several patients died within days or weeks of being moved from the hospital and rehabilitation center but the deadline to shut down the hospital remains.

Speaking at the press conference, Renne urged CMS to “come to your senses.”

“How much longer are we going to keep this up before more deaths occur?” Renne said.

CMS terminated its payments to Laguna Honda in April after two patients had nonfatal overdoses at the facility in 2021, and inspectors with the California Department of Public Health declared it to be “in a state of substandard care.”

The federal agency, which pays for care for the majority of the nursing home’s 700 patients, also ordered the facility to start discharging or transferring its patients ahead of a mid-September mandated closure.

Founded in 1866, the sprawling facility serves people who need long-term care but who can’t afford private nursing homes. Many of the patients have dementia, drug addiction and other complex medical needs.

City officials say patients and their families are the ones suffering the most because of the forced closure. Debra Bauer spoke Thursday about how the facility has helped her son, who has a traumatic brain injury, and has been a resident at the hospital for about 20 years.

“My son feels safe there, I don’t want that taken away from him,” she said. “I don’t want it taken away from him or any of the other residents that I see and we wave to in the hallways.”

The post San Francisco Sues Feds Over Compelled Closure of Laguna Honda Hospital appeared first on Los Gatos News And Events.

SAN FRANCISCO (CBS SF) — The city of San Francisco announced Thursday that it’s suing the federal government over its decision to cut off funding to Laguna Honda Hospital and the order forcing the nursing home to transfer all patients out of the facility by Sept. 13.

The lawsuit was filed Wednesday against the US Department of Health and Human Services (HHS) and Secretary Xavier Becerra. It alleges that the Centers for Medicare & Medicaid Services (CMS), which operates under HHS, forced the City to implement an unworkable closure and patient transfer plan that put them at risk and denies the City due process.

In April, CMS terminated Laguna Honda’s participation in its Medicare/Medicaid programs after the hospital was found out of compliance on multiple safety inspections, including finding contraband like drug paraphernalia on site, and failure to adhere to hand hygiene, documentation and infection prevention protocols.

Laguna Honda Hospital

CBS

As a result of being decertified, the hospital lost federal funding that financed more than two-thirds of its services for nearly 700 patients with complex medical needs and low incomes.

The federal government also directed the facility to wind down its patient population, and the hospital transferred several dozen patients over 10 weeks. At least four patients were reportedly dead within a few days after their relocation, including three that were sent to homeless shelters. A total of nine patients died within days or weeks after transfer or discharge, according to City Attorney David Chiu.

Last week, Laguna Honda maintained transfers for its remaining 600 patients following the deaths.

The complaint alleges the CMS imposed an arbitrary Sept. 13 deadline for patient transfers and required it to close before the city’s appeals could be decided, which might make the transfers unnecessary.

In a press release, Chiu said a second-class-action lawsuit against both the State of California and the federal government filed by former City Attorney Louise Renne alleges the closure and transfer process violates the Americans with Disabilities Act and denies patients and their families due process .

“The federal government has put Laguna Honda and our City in an impossible situation,” said Chiu in a prepared statement. “As the final safety net for many of our most vulnerable San Franciscans, Laguna Honda serves too critical a need to be closed due to an arbitrary, bureaucratic decision. The City has been forced into an unworkable closure and transfer plan that has done far more harm than good.”

The lawsuit seeks declaratory and injunctive relief to eliminate the Sept. 13 deadline and extend federal funding to Laguna Honda at least until the appeals can be decided and all patients can be safely transferred or discharged.

“We are working hard to address issues that have been raised at Laguna Honda, and that important work will continue,” said Mayor London Breed in a prepared statement. “But closing this facility and forcing residents and families to go through the trauma of transfers should not be part of that process. This facility provides care and support for some of the most vulnerable people in our city, and that support must continue to keep them healthy and safe.”

“For over 150 years, San Franciscans have relied on Laguna Honda to provide critical care to our most vulnerable,” Renne said in a prepared statement. “We simply cannot allow Laguna Honda to close. The actions of CMS and the California Department of Health are illegal, unnecessary, and cruel.

Theresa Rutherford, the President-Elect of the SEIU 1021 and a longtime certified nursing assistant at Laguna Honda Hospital, released the following statement in response to the announcement of the lawsuits:

“Laguna Honda Hospital is more than just a hospital, it is a long-term home for many. Keeping patients at Laguna Honda, where they are provided some of the most unique and comprehensive care available in this country, must be a priority for our community and for elected officials at all levels.We support patients and families who are advocating to help stop the closure because we know it will save lives.

We understand how stressful and scary the last few months have been for workers and patients alike. Transfer trauma is a real danger for the people we care for, which is why our union is doing everything we can to get Laguna Honda Hospital recertified. We encourage community members to join us by contacting their elected leaders at all levels and asking them to stand with us.”

In May, Sen. Dianne Feinstein wrote a letter to Becerra asking to reverse the CMS decision to terminate Laguna Honda’s participation in its programs and force the relocation of its vulnerable patients.

“If CMS does not reverse its decision, these patients would again be put at risk as they’re transferred to other facilities,” Feinstein said in a statement last month. “This is particularly concerning after some patients were reportedly sent to homeless shelters ill-equipped to provide the necessary medical services.”

The hospital remains open and licensed as it continues to work on rejoining the federal programs.

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A nursing home run by the city of San Francisco will stop discharging patients as part of a federally-mandated closure plan after at least four patients died within days or weeks of being moved from Laguna Honda Hospital, officials said.

In April, the federal Centers for Medicare and Medicaid Services terminated its payments to Laguna Honda after two patients had nonfatal overdoses at the facility in 2021, and inspectors with the California Department of Public Health declared it to be “in a state of substandard care. ”

The federal agency, which pays for care for the majority of the nursing home’s 700 patients, also ordered the facility to start discharging or transferring its patients ahead of a mid-September mandated closure.

On Thursday, regulators agreed to pause the transfers, San Francisco’s Department of Public Health said in a statement.

San Francisco Department of Public Health is working to get the nursing home recertified ahead of a Sept. 13 closure deadline but it is still required to transfer or discharge all patients, according to a closure plan.

The city, supported by San Francisco representatives in Washington, including Sen. Diane Feinstein, asked the federal Medicare and Medicaid agency to pause all transfers from Laguna Honda Hospital, saying it has been a challenge to find places that can care for the patients’ complex health care needs.

Until Thursday, Laguna Honda had transferred or discharged 57 patients, including a few to homeless shelters. At least four patients died within days or weeks of being moved from Laguna Honda, the San Francisco Chronicle reported.

The transfers and discharges will be paused “while an assessment occurs over the coming weeks,” US Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure told the newspaper, adding that the agency posted a representative there on Tuesday.

Founded in 1866, the sprawling facility serves people who need long-term care but can’t afford private nursing homes. Many of the patients have dementia, drug addiction and other complex medical needs.

“Laguna Honda has served San Francisco’s most vulnerable residents for 150 years and we plan to do so for another 150 years,” Roland Pickens, Laguna Honda’s interim CEO, said in a statement.

Sen. Diane Feinstein in May called on Health and Human Services Secretary Xavier Becerra to reverse the federal agency’s decision to terminate Laguna Honda Hospital’s participation in Medicare and Medicaid programs and force the relocation of its vulnerable patients.

Feinstein said Friday that the hospital provides services for many patients who have no other options and that she hopes the federal agency works with the city of San Francisco to make the necessary improvements at the hospital so it can rejoin the Medicare and Medicaid programs.

“If (Centers for Medicare and Medicaid Services) does not reverse its decision, these patients would again be put at risk as they’re transferred to other facilities,” she said in a statement sent to homeless shelters ill-equipped to provide the necessary medical services.”

Pickens wrote in a letter to patients and their families that it’s not clear how long the transferring and discharging of patients will be suspended.

“We know the uncertainty is challenging but we hope this pause provides our community with relief,” he wrote.

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San Francisco’s current and former city attorneys filed a pair of lawsuits late Wednesday that they hope will bring a screeching halt to the federal government’s effort to shutter Laguna Honda Hospital and Rehabilitation Center next month.

City Attorney David Chiu is asking a US District Court judge to stop the federal government from cutting off funds to Laguna Honda as of Sept. 13, a deadline the city calls arbitrary and which would force the nursing home to shut down and displace 600 vulnerable residents .

Former City Attorney Louise Renne filed a separate, class-action lawsuit against state and federal officials on behalf of those residents. Most patients at the skilled nursing facility—one of the largest in the US—are medically fragile and often very poor. Some have lived there for decades.

The pending closure has caused an uproar among supporters of the city-run nursing home, especially after the US Centers for Medicare and Medicaid forced Laguna Honda to begin transferring its frail patients in May in preparation for the closure. Of the 57 patients transferred or discharged, eight died within days or weeks of their moves.

An empty hallway at Laguna Honda hospital in San Francisco on July 20, 2022. The facility is required by the US Centers for Medicare and Medicaid to transfer or discharge all patients by mid-September after the federal agency decertified it in April.

Bronte Wittpenn/The Chronicle

Because 14% of the relocated people have died, possibly as a result of the phenomenon known as “transfer trauma,” federal officials agreed last month to pause the transfers.

“Pausing is not enough,” Renne told The Chronicle. “We’re asking them to end the discharge. Period. Families are worried sick. The mere threat of a discharge is wrong.”

In the city’s lawsuit, Chiu argues that the federal agency known as CMS chose a random date — Sept. 13 — to halt funding of more than $200 million a year in the form of Medicaid and Medicare reimbursements. The suit says shutting down the nursing home so quickly is illegal because San Francisco is appealing the agency’s decision to decertify Laguna Honda in the first place — and that appeal won’t be heard until at least October.

“We’re asking the federal government to exert compassion and common sense,” Chiu said. “Between the huge shortage of skilled nursing facility beds, we see potentially very negative consequences” if the facility is forced to shut down next month. “Individuals will become homeless. These people have nowhere to go.”

Renne put it more bluntly: “We’ve had eight deaths. Who knows if there would be more? (CMS) knows that as well as we do. How do they live with themselves?”

Chiu’s lawsuit notes that three patients discharged from Laguna Honda wound up in homeless shelters. And last month, when Laguna Honda officials called 1,400 nursing homes in a single week to try to comply with the transfer order, not one of them had a vacant bed eligible for Medicare or Medicaid reimbursement and with appropriate services for Laguna Honda’s patients, according to the suit.

“CMS’s unreasonable requirements are not only harmful to patients and impossible to achieve, they are also unlawful,” says the city’s lawsuit. Chiu argues that the agency shouldn’t be allowed to shut down Laguna Honda before the city can make its case that CMS was wrong to crack down so hard on the facility, and that closing it before the appeal is heard denies San Francisco due process.

CMS officials could not immediately be reached for comment after the suits were filed. In an interview on July 26, however, a CMS official speaking on condition of anonymity told The Chronicle that the agency could extend its deadline.

“The timing is something we can revisit,” the official said.

CMS decertified Laguna Honda in April, six months after state inspectors declared it to be “in a state of substandard care.” CMS set Sept. 13 as the date it would stop paying to care for the facility’s hundreds of residents. Laguna Honda depends on Medicare and Medicaid reimbursements of nearly $18 million a month, or more than two-thirds of its $26 million monthly budget.

The city’s lawsuit acknowledges that Laguna Honda must fix deficiencies and prevent them from recurring. But it also says the California Public Health Department — which recommended that CMS withdraw the Medicare and Medicaid funding — overstated the severity of the deficiences its inspectors found at Laguna Honda between October and March, and that it never should have made that recommendation.

Renne’s class-action suit, which seeks a trial by jury, makes the same argument. It’s also the basis of Chiu’s appeal.

San Francisco City Attorney David Chiu speaks at a press conference about abortion rights at City Hall on June 1, 2022.

Constanza Hevia H./Special to The Chronicle

Laguna Honda’s current troubles began in July 2021, after the facility reported that two patients had overdosed on illegal drugs and recovered. That report triggered the state visit in October, after which inspectors found the facility out of compliance.

The city’s lawsuit says the state’s finding was based on a “failure to eliminate all illicit drugs and contraband (such as cigarette lighters),” which in turn led to the recommendation that CMS terminate its contract with Laguna Honda on April 14 if the nursing home was still out of compliance.

Chiu argues that instead of allowing CMS to hastily shut down a vital institution, especially when there are virtually no adequate alternatives for most residents, the courts should give San Francisco time to make its case that decertifying Laguna Honda was done in error.

Laguna Honda is also correcting its deficiencies and should be allowed to complete that process, the lawsuit says. The nursing home “is confident that it will submit an application allowing it to be recertified as a Medicare and Medicaid provider by the end of the year.”

But if it has to shut down, Laguna Honda will need until Nov. 2023 to do so safely, the suit says.

In all, Chiu’s lawsuit paints a picture of a Catch-22 — an “impossible situation” — that CMS has forced on Laguna Honda, the city and the patients who depend on it. “Laguna Honda cannot stay open and it cannot close,” the suit says.

The city attorney said that “the federal government has left us with no choice” but to sue. “We’re hoping that CMS will come to the table and work with us to preserve this critical safety net.”

Nanette Asimov is a San Francisco Chronicle staff writer. Email: nasimov@sfchronicle.com Twitter: @NanetteAsimov

The post San Francisco sues federal authorities over Laguna Honda closure appeared first on Los Gatos News And Events.

Laguna Honda is in crisis, and it’s one that extends far beyond the hospital itself.

A full review of federal inspection reports from Laguna Honda Hospital and Rehabilitation Center reveals a tipping point for many aspects of San Francisco’s public health system.

As the availability of affordable health services and housing has declined, a growing population of older adults with complex health needs has few options besides the hospital—California’s largest public skilled nursing facility—one that is now threatened with closure.

Nearly 700 extremely low-income, medically fragile patients face displacement if Laguna Honda is not successful in its efforts to regain its lost certification.

In April, federal regulators said they would cut Laguna Honda off from government-subsidized health care such as Medicaid and Medi-Cal, which covers the costs of the majority of patients at the facility. The decision came after regulators reported dozens of safety code infractions from inspections launched after two nonfatal overdoses on site in 2021. Full reports from federal inspections can be found here.

The most recent safety survey in April found staff members failing to follow protocols around personal protective equipment. Previous findings were even more serious. In October 2021, 13 out of 37 sampled residents tested positive for non-prescribed substances. The reports say that two of these residents experienced “life-threatening emergencies” and hospitalization, and two others were reported to have fallen.

The surveys also found multiple examples of drug paraphernalia and illicit substances on-site, including fentanyl and methamphetamine. One report said a guest coming into the facility was suspected of bringing in drugs on multiple occasions.

“The failed practices place all residents to unsafe (sic) living environment and negative health outcomes,” a report from October 14 reads.

Other inspections between October and April highlight disputes among residents, as well as preventable accidents, such as a woman who was not properly buckled into her wheelchair after a dialysis appointment and fell in a transportation van, resulting in bone fractures.

The Centers for Medicare and Medicaid Services, which overseas government health care programs, will return to Laguna Honda for follow-up inspections in September and again in December. At the same time, the hospital must implement a closure plan that involves moving people out in order to sustain federal funding during the recertification process.

The facility is still licensed for the time being, but losing federal funding would be devastating to operations.

Tipping point

The crisis unfolding at Laguna Honda in part represents the culmination of a years-long decline in public health resources for low-income elders and people with disabilities including those with substance use challenges.

The total number of assisted living facilities in San Francisco decreased by 22% from 2012 to 2018, according to a 2019 city report, creating a gap in board-and-care options specifically for adults under age 60. That same population has filtered through San Francisco General Hospital at Laguna Honda in recent decades.

“San Francisco is being punished for addressing a need while everyone else has abandoned the field,” Supervisor Rafael Mandelman said at a Board of Supervisors meeting on June 14. “This is some kafkaesque nonsense.”

Many experts in nursing home regulations are baffled by regulators’ decision to decertify Laguna Honda, which is the largest skilled nursing facility in the state. Some say the challenges found at the facility pale in comparison to some of the horrific circumstances and abuse that have been identified in other nursing homes that received the same level of punishment from federal regulators.

“This should be addressed absolutely. But typically, what we see are just horrific, almost nightmarish conditions that terminate care for Medicare and Medicaid funding. In this case, it seems like lacked supervision or culture of drug use that needs to be remedied,” said Anthony Chicotel, an attorney with the California Advocates for Nursing Home Reform.

Yet others, including former staff at San Francisco’s largest skilled nursing facility, feel The City has downplayed the recent infractions and other issues reported internally for years.

“The City and county have minimized the infractions to the public but in fact, they are quite serious,” said Teresa Palmer, a geriatrician who worked at Laguna Honda from 1989 to 2005. “By not admitting the real problem, by minimizing it, that doesn’t make for a good prognosis.”

Either way, nearly all of these problems are fixable in some form or another, asserts Roland Pickens, interim CEO of Laguna Honda, whether through enhanced training or new programming specific for individuals with substance use disorder.

For instance, one citation involved a nurse who reported seeing a lighter, burned aluminum foil and plastic brown straws in a resident’s room indicating possible fentanyl use, but the nurse left the items where they were. In documents provided by federal regulators, the nurse said he had not been advised on how to handle such situations and stated “we need training” on how to deal with illicit drugs or supplies.

Exactly how many patients at Laguna Honda struggled with substance use issues is unclear. Hypertension, dysphagia, epilepsy, pulmonary disease, major depressive disorders and other diseases are listed among the top 10 most common resident diagnoses, according to the hospital’s 2019-20 annual report. But treatment or other services for substance use disorder are not included on the list.

Hospital officials said they are exploring changes to where residents with substance use disorders, mental disabilities and other health needs are located within the facility.

“It may very well be that as we emerge from this recertification process, we will establish a unit that may cohort particular patients who now may be dispersed among the units,” Pickens said to the Board of Supervisors on June 14.

However, the growing gap in public health services beyond Laguna Honda’s walls for The City’s aging low-income and unhoused populations will be much harder to solve.

A place to go

Laguna Honda makes up a significant portion of San Francisco’s entire stock of skilled nursing beds, and the city is a key funder of assisted living services.

At the same time, patient flow into Laguna Honda has evolved greatly in the last 20 years so a growing number of residents now come directly from San Francisco General Hospital. Laguna Honda has become a key destination for the population that has suffered most from the decline in assisted living facilities that take Medi-Cal or Medicaid patients.

The change in patient flow over the years has resulted in an increasingly younger and male-skewing population with health challenges far more complex than a typical nursing home. How to appropriately care for elderly residents as well as younger patients with complex mental disabilities and drug use challenges has become a sticking point.

San Francisco is currently working towards a goal of adding nearly 400 mental health care beds across the city. For the 2022-24 budget years, Breed is allocating $57.5 million for the operation of new-acquired behavioral health facilities with 360 beds altogether.

In the meantime, local options for patient transfers are exhausted. Just six individuals have already been discharged from Laguna Honda, according to the most recent numbers shared by hospital officials. Transferring the remaining 670 medically-fragile residents will be nearly impossible by September, the earliest possible date of closure, according to a notice sent to patients in May.

“The numbers state that we probably aren’t going to meet that goal (to discharge all patients before any possible closure) but we are going to do everything we can,” Pickens told the Board of Supervisors on June 14.

Those familiar with the changes at Laguna Honda over the years stress the urgency of funding alternative care options in San Francisco.

“We don’t have disability-friendly substance use treatment for even unhoused elders,” said Palmer. “There is a lack of services. Once you’re an unhoused elder, you’re, excuse my language, shit out of luck.”

The post Laguna Honda disaster displays San Francisco’s fragile well being system | Information appeared first on Los Gatos News And Events.

Laguna Honda is in crisis, and it’s one that extends far beyond the hospital itself.

A full review of federal inspection reports from Laguna Honda Hospital and Rehabilitation Center reveals a tipping point for many aspects of San Francisco’s public health system.

As the availability of affordable health services and housing has declined, a growing population of older adults with complex health needs has few options besides the hospital—California’s largest public skilled nursing facility—one that is now threatened with closure.

Nearly 700 extremely low-income, medically fragile patients face displacement if Laguna Honda is not successful in its efforts to regain its lost certification.

In April, federal regulators said they would cut Laguna Honda off from government-subsidized health care such as Medicaid and Medi-Cal, which covers the costs of the majority of patients at the facility. The decision came after regulators reported dozens of safety code infractions from inspections launched after two nonfatal overdoses on site in 2021. Full reports from federal inspections can be found here.

The most recent safety survey in April found staff members failing to follow protocols around personal protective equipment. Previous findings were even more serious. In October 2021, 13 out of 37 sampled residents tested positive for non-prescribed substances. The reports say that two of these residents experienced “life-threatening emergencies” and hospitalization, and two others were reported to have fallen.

The surveys also found multiple examples of drug paraphernalia and illicit substances on-site, including fentanyl and methamphetamine. One report said a guest coming into the facility was suspected of bringing in drugs on multiple occasions.

“The failed practices place all residents to unsafe (sic) living environment and negative health outcomes,” a report from October 14 reads.

Other inspections between October and April highlight disputes among residents, as well as preventable accidents, such as a woman who was not properly buckled into her wheelchair after a dialysis appointment and fell in a transportation van, resulting in bone fractures.

The Centers for Medicare and Medicaid Services, which overseas government health care programs, will return to Laguna Honda for follow-up inspections in September and again in December. At the same time, the hospital must implement a closure plan that involves moving people out in order to sustain federal funding during the recertification process.

The facility is still licensed for the time being, but losing federal funding would be devastating to operations.

Tipping point

The crisis unfolding at Laguna Honda in part represents the culmination of a years-long decline in public health resources for low-income elders and people with disabilities including those with substance use challenges.

The total number of assisted living facilities in San Francisco decreased by 22% from 2012 to 2018, according to a 2019 city report, creating a gap in board-and-care options specifically for adults under age 60. That same population has filtered through San Francisco General Hospital at Laguna Honda in recent decades.

“San Francisco is being punished for addressing a need while everyone else has abandoned the field,” Supervisor Rafael Mandelman said at a Board of Supervisors meeting on June 14. “This is some kafkaesque nonsense.”

Many experts in nursing home regulations are baffled by regulators’ decision to decertify Laguna Honda, which is the largest skilled nursing facility in the state. Some say the challenges found at the facility pale in comparison to some of the horrific circumstances and abuse that have been identified in other nursing homes that received the same level of punishment from federal regulators.

“This should be addressed absolutely. But typically, what we see are just horrific, almost nightmarish conditions that terminate care for Medicare and Medicaid funding. In this case, it seems like lacked supervision or culture of drug use that needs to be remedied,” said Anthony Chicotel, an attorney with the California Advocates for Nursing Home Reform.

Yet others, including former staff at San Francisco’s largest skilled nursing facility, feel The City has downplayed the recent infractions and other issues reported internally for years.

“The City and county have minimized the infractions to the public but in fact, they are quite serious,” said Teresa Palmer, a geriatrician who worked at Laguna Honda from 1989 to 2005. “By not admitting the real problem, by minimizing it, that doesn’t make for a good prognosis.”

Either way, nearly all of these problems are fixable in some form or another, asserts Roland Pickens, interim CEO of Laguna Honda, whether through enhanced training or new programming specific for individuals with substance use disorder.

For instance, one citation involved a nurse who reported seeing a lighter, burned aluminum foil and plastic brown straws in a resident’s room indicating possible fentanyl use, but the nurse left the items where they were. In documents provided by federal regulators, the nurse said he had not been advised on how to handle such situations and stated “we need training” on how to deal with illicit drugs or supplies.

Exactly how many patients at Laguna Honda struggled with substance use issues is unclear. Hypertension, dysphagia, epilepsy, pulmonary disease, major depressive disorders and other diseases are listed among the top 10 most common resident diagnoses, according to the hospital’s 2019-20 annual report. But treatment or other services for substance use disorder are not included on the list.

Hospital officials said they are exploring changes to where residents with substance use disorders, mental disabilities and other health needs are located within the facility.

“It may very well be that as we emerge from this recertification process, we will establish a unit that may cohort particular patients who now may be dispersed among the units,” Pickens said to the Board of Supervisors on June 14.

However, the growing gap in public health services beyond Laguna Honda’s walls for The City’s aging low-income and unhoused populations will be much harder to solve.

A place to go

Laguna Honda makes up a significant portion of San Francisco’s entire stock of skilled nursing beds, and the city is a key funder of assisted living services.

At the same time, patient flow into Laguna Honda has evolved greatly in the last 20 years so a growing number of residents now come directly from San Francisco General Hospital. Laguna Honda has become a key destination for the population that has suffered most from the decline in assisted living facilities that take Medi-Cal or Medicaid patients.

The change in patient flow over the years has resulted in an increasingly younger and male-skewing population with health challenges far more complex than a typical nursing home. How to appropriately care for elderly residents as well as younger patients with complex mental disabilities and drug use challenges has become a sticking point.

San Francisco is currently working towards a goal of adding nearly 400 mental health care beds across the city. For the 2022-24 budget years, Breed is allocating $57.5 million for the operation of new-acquired behavioral health facilities with 360 beds altogether.

In the meantime, local options for patient transfers are exhausted. Just six individuals have already been discharged from Laguna Honda, according to the most recent numbers shared by hospital officials. Transferring the remaining 670 medically-fragile residents will be nearly impossible by September, the earliest possible date of closure, according to a notice sent to patients in May.

“The numbers state that we probably aren’t going to meet that goal (to discharge all patients before any possible closure) but we are going to do everything we can,” Pickens told the Board of Supervisors on June 14.

Those familiar with the changes at Laguna Honda over the years stress the urgency of funding alternative care options in San Francisco.

“We don’t have disability-friendly substance use treatment for even unhoused elders,” said Palmer. “There is a lack of services. Once you’re an unhoused elder, you’re, excuse my language, shit out of luck.”

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Laguna Honda Hospital is a facility with a rich history of scandal and mismanagement. For it to now be facing an existential crisis over a series of comparatively minor violations feels a bit like Al Capone going to prison over tax evasion.

But Capone did indeed go to the slammer — you can buy the commemorative t-shirt at Pier 39. And, as mind-boggling as it may be, the 700-odd vulnerable patients here may be out on their ears before year’s end if the hospital fails to meet the latest terms imposed by the federal government. If Laguna Honda comes up short in a top-to-bottom recertification process, it could lose Medicare and Medi-Cal funding in four to six months’ time.

This would blow a roughly $20 million a month hole in the city’s budget and open up the real possibility of patients being transferred hundreds if not thousands of miles away — or, tragically, to the curb and immediate homelessness. A high percentage of Laguna Honda’s patients exhibit behaviors that would’ve led to them being screened out of almost any other nursing facility, and it’s unrealistic to expect beds to be found for them.

“They would probably have to soak up a bed at General Hospital until they ended up in jail, or a bed comes up in a locked facility for people who are criminally insane,” sums up Dr. Teresa Palmer, a geriatrician who worked at Laguna Honda from 1989 to 2004.

This assessment is as harsh as it sounds. The fate of both this city and its most vulnerable populations are not in a solid place right now.

Laguna Honda, seen in 1926. Photo courtesy of OpenSFHistory.org

You may have missed the existential crisis unfolding at this 156-year-old institution. It’s easy to. Laguna Honda shelters the people society is most eager to overlook: The frail elderly and — increasingly — mentally ill and/or drug-addicted younger patients. This is a combustible and counterintuitive mix, and plays no small role in the fix Laguna Honda now finds itself in.

“There are a huge number of men here between ages 50 and 70,” says Palmer. At most nursing homes, she continues, you’d be more likely to find “a majority of ladies in their 80s.”

Between 1999 and 2021, the percentage of women at Laguna Honda dropped from 56 percent to 37 percent.

The problems at Laguna Honda, like Hemingway’s description of bankruptcy, have come gradually then suddenly. As would bankruptcy, so to speak, if federal funding is yanked.

Laguna Honda was founded in 1866 as an almshouse for geriatric Gold Rush forty-niners. We could start this story then. Or we could start it in 1999, when voters approved a $299 million bond to “save” the hospital. Or in 2006, when a licensing survey noted that the younger, more ambulatory patients flowing into Laguna Honda were toting drugs, alcohol, loaded firearms, and abusing the elders — staff even futilely erected signs reading “no hitting.”

Or we could start in 2019, when Laguna Honda staff took demeaning, nude photos of incapacitated patients and doped them up with non-prescribed medication (the first of several lawsuits settled last year for $800,000).

Nursing Director: “Our team have exhausted most options in helping eliminate or minimize the contraband and illicit substances into the unit.” … (Resident 2) voluntarily handed the burnt aluminum foil, plastic pen body case burned on one end and a cigarette lighter that he’s holding. … Resident even stated “they know I’m doing this.”

California Department of Public Health Survey of Laguna Honda Hospital, March 28, 2022

But, instead, we’ll start in July 2021, when two of the younger, more ambulatory patients here purportedly wandered off campus, wandered back on with methamphetamine and fentanyl, and suffered non-fatal overdoses.

The hospital reported the overdoses to regulators — to not do so would be unthinkable following the 2019 scandals that led to $780,000 in fines and a slew of lawsuits. And this triggered a concatenation of regulatory procedures that led to where we are today and put the hospital at the brink.

Laguna Honda, on multiple subsequent occasions, did not meet inspectors’ expectations on its “termination revisit survey.” In April, inspectors found 27 different violations. Some of these were not insignificant — incomplete patient assessments or staff wearing improper or inadequate PPE around patients. Other assessments seemed to be more of the ticky-tack variety: medicated shampoo without a prescription, medicated creams and lotions in patient rooms, “three open plastic bags were hanging (unattended) in a dirty hamper.”

These are the infractions that triggered the feds to last month broach the possibility of yanking funding. Laguna Honda announced this month that it now must go through the rigmarole of working to demonstrate that it could relocate all of its residents as a condition to continue receiving government funding. It will receive that funding while it works to recertify and avoid relocating anyone. It’s a Kafkaesque turn of events. Laguna Honda has so much to answer for going back through the years — but it’s the medicated shampoo et al. that was noted on this most recent report.

Adding to the surreal nature of these proceedings, the federal agency currently calling the shots, the Centers for Medicare & Medicaid Services (CMS), is responsible for overseeing all the truly horrific, for-profit, deathtrap nursing homes you saw on 60 minutes. There is no universe in which Laguna Honda compares to these charnel houses, and the overseers’ Inspector Javert-like focus on this public hospital is hard to explain. As is any “solution” that might result in the dispersal of its residents.

Laguna Honda Hospital. Photo by Christopher Michel.

“I don’t know why they are being so harsh,” says Dr. Derek Kerr, a 21-year physician at Laguna Honda who has since turned into a whistleblower and critic of the facility. “Laguna Honda is always judged harshly. If you have one violation in a 700-bed unit that is as bad as one violation in a 15-bed nursing home. They don’t take into account the denominator.”

And while 27 violations sounds like a lot, says Charlene Harrington, a professor emeritus at UC San Francisco, Laguna Honda is seven times the size of an average nursing home facility. And, she continues, the average number of violations recorded on such an inspection is eight — meaning Laguna Honda had about half what you’d expect, per capita.

“California has had extremely poor enforcement of nursing homes, and has some of the worst nursing homes in the country. And that has gone on for years,” says Harrington. “Laguna Honda had some deficiencies, and I am not excusing the deficiencies. But the [overseers’] behavior in this case is inexplicable. They have let other facilities go for years … awful, for-profit facilities where really terrible things are going on.”

Multiple emails to CMS officials have not yet been returned.

Harrington has studied nursing homes and regulation for 40 years. And she is at a loss to explain what is going on here: “I can’t think of any case like this before.”

Laguna Honda in 1875. Photo courtesy of OpenSFHistory.org

There is nothing like a threat from outside to cement allegiances inside. So, at noon on Wednesday, Mayor London Breed and the SEIU 1021 — who maintain a Ralph Wolf-and-Sam Sheepdog relationship — will both appear at a rally to save this hospital.

Government officials across San Francisco described CMS as rigid and intractable. Former California Attorney General Xavier Becerra is now the head of the Department of Health and Human Services, which runs CMS. But, city officials say, he may be trying extra hard not to be seen as playing favorites.

CMS, city officials say, intransigently insists that its procedures are proscribed and must be done by the book, come what may. And you know the mayor’s office has been bending their ears, as has the office of Rep. Nancy Pelosi — and, if need be, every California politician there is will join the queue.

What a predicament: At last San Francisco has run into a situation in which it can’t just have his political mommy and daddy make some calls and get it out of his longstanding ineptitude. The process, at least thus far, seems to be politically impenetrable. How unfortunate, then, that this appears to be a process devoid of common sense or empathy in which, ostensibly for the patients’ own safety, hundreds of them may be jettisoned to parts unknown or pushed to the street.

That’s just plain stupid.

Maybe that will come up at the rally tomorrow. It’s doubtful, however, the city officials will examine their own role in this fine mess. But we can. So let’s go back to that bond measure in 1999.

“Laguna Honda had some deficiencies, and I am not excusing the deficiencies. But the [overseers’] behavior in this case is inexplicable. They have let other facilities go for years … awful, for-profit facilities where really terrible things are going on.”

Charlene Harrington, UCSF professor emeritus

Voters, you may recall, agreed to go into $299 million in bonded debt to build a new, 1,200-bed facility. They were promised that this would house the city’s frail elders.

But that didn’t happen. The price tag ballooned by hundreds of millions of dollars and the capacity of the hospital was reduced by hundreds of beds. And, top it off, the city began transferring younger, mentally ill and/or substance addicted patients into the hospital.

So yes, we paid more, got less, and the hospital is not exclusively serving the elderly population that voters were enticed to pony up and help.

As noted earlier, this situation is longstanding. By 2004, Palmer left Laguna Honda, in large part because she felt the influx of “out-of-control” mentally ill and/or substance abuse addicts was unsafe. “They are deforming the hospital to accommodate an antisocial minority,” says Kerr, who was forced out in 2010.

There is no scenario in which crippling and defunding Laguna Honda and ejecting its patients is in anybody’s best interests — and, Palmer still describes it as “a better nursing home than most” and a place where she would’ve put her own mother.

The city must do all it can to fend off this doomsday scenario, and a consulting firm with an expertise in re-certification has already been hired.

But the city must also address the untenable situation of commingling the frail elderly and ambulatory mentally ill and/or addicts. In 1999, you’ll recall, 56 percent of Laguna Honda’s residents were female — and the average age was 76. By 2021, only 37 percent of the residents were women. And while patients’ average age wasn’t disclosed in ’21, it had dropped to 64 by 2013.

A state Department of Public Health survey from March, 2022 obtained by Kerr and shared with Mission Local notes staff observing residents overtly smoking drugs off aluminum foil and seeing little they could do to prevent this.

“Our team have exhausted most options in helping eliminate or minimize the contraband and illicit substances,” a nursing director is quoted as saying. The patient in question surrendered his burnt aluminum foil, plastic pen and lighter. “They know I’m doing this,” he said.

This city has chosen to serve populations nobody else would. But it has chosen to do so in a manner that has proven to be unworkable and led to the current crisis.

San Francisco owes it to itself and Laguna Honda’s residents to solve this crisis. But also to ponder its own role in it. And make things right. Gradually then suddenly.

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Federal regulators have threatened to pull critical funding from San Francisco’s Laguna Honda Hospital after two patients overdosed at the facility last year, a dramatic measure that could force the hospital to shut down.

Officials with San Francisco’s health department, which runs Laguna Honda, said Wednesday that the hospital had fallen out of regulatory compliance, putting its funding from Medicare and Medicaid in jeopardy. Laguna Honda, one of the largest skilled nursing facilities in the country, is run by the city and cares for more than 700 patients, including people with dementia, drug addiction and other complex medical needs, who live on the hospital’s campus.

The hospital has until April 14 to remedy a number of issues identified by state health officials — including the presence of contraband found on Laguna Honda’s campus — in order to stave off a potential financial calamity that could displace hundreds of medically fragile patients.

State officials said they were working with Laguna Honda to bring the hospital into compliance and avoid closure.

“There’s a commitment from (Department of Public Health) and the city to keep Laguna Honda open,” Roland Pickens, director of the San Francisco Health Network, told The Chronicle. “But it would be very difficult financially to remain open without the reimbursement” payments from the Centers for Medicare and Medicaid Services.

Laguna Honda began a correction plan with the California Department of Public Health in October, after state officials found the hospital “in a state of substandard quality of care,” according to a statement from the San Francisco Department of Public Health.

The finding came after staff at Laguna Honda reported two overdoses at the hospital in July, neither of them fatal. Hospital officials disclosed these incidents to the state, adhering to a self-reporting requirement that Laguna Honda implemented in 2019, after a state investigation turned up evidence of patient abuse.

By documenting the overdoses, Laguna Honda triggered an extended survey by the state, which led to the state’s conclusion in October that the hospital had fallen out of compliance. With the correction plan in place, hospital staff had six months to fix deficiencies and enhance safety measures, including steps to eliminate drug paraphernalia or illicit substances from the campus.

Although Pickens and Laguna Honda CEO Michael Phillips said in an interview that the hospital worked diligently to retrain its staff and remind workers to be on the lookout for banned items, state regulators witnessed violations when they inspected the site. In January, state regulators concluded that one hospital worker was not following protocols. This month, inspectors discovered a patient was smoking in a communal bathroom, while another patient on oxygen had a lighter.

On March 22, the state put Laguna Honda in immediate jeopardy for noncompliance with federal regulations and standards, a severe designation that officials lifted five days later after the hospital quickly responded with restrictions on visitors bringing in items and increased safety searches, among other reforms. Laguna Honda officials are contemplating new security infrastructure, such as scanning machines at entrances to screen visitor packages for prohibited materials.

Still, the six-month window is closing for the hospital to substantially finish its corrective plan, while also resolving the problems uncovered at the subsequent site visits.

The looming deadline puts strain on an institution that managed to avert a deadly coronavirus surge in 2020, but is still grappling with the abuse scandal of 2019, which Pickens and Phillips said had no bearing on the current remedial plan. Last year the city agreed to pay $800,000 to settle one of three lawsuits filed by patients alleging they were abused by staff. One of the cases is a class action, involving multiple plaintiffs.

Phillips, the CEO, pointed to the challenges that plague Laguna Honda.

“We care for some of the most vulnerable residents in the city of San Francisco,” he said, many of whom have histories of substance abuse, which may persist as they undergo treatment. Since the hospital is not a locked facility, people can come and go as they please, opening the possibility that they may procure drugs outside and then return to campus, Phillips said.

“Despite our best efforts, illicit substances will eventually find their way onto our campus,” Phillips said. “We’re continuously looking for ways to improve our protocols so that we can find more innovative ways to identify these substances and keep them away from our residents.”

Staff at the hospital struggle to balance patients’ privacy and freedom of movement with the need to sustain a safe environment and take a hard line on illicit substances or materials. Phillips and Pickens said their discussions with regulators have been amicable and collaborative, but that the state is still obliged to follow a process that puts the hospital at risk of shutting down.

“It’s a perfunctory process that was triggered by the October incident,” Pickens said, suggesting that if the state had been quicker to validate all of the hospital’s reforms, “perhaps we wouldn’t be so close to the April 14 deadline.”

Laguna Honda relies on payments from Medi-Cal and Medicaid to fund most of its services, since most patients are low- or extremely-low-income and burdened with complicated medical needs. It was unclear where patients would go if the hospital is unable to stay afloat.

“As you can imagine, there’s a shortage of skilled nursing beds throughout the country,” Pickens said. “California and San Francisco are no exception. It would take quite a while, if it ever came to trying to find new placements for those 700 patients at Laguna.”

He hopes for what he says is a more likely scenario: All agencies collaborate to bring Laguna into compliance by April 14.

In a statement, California Department of Public Health officials said, “Resident and worker safety remains our highest priority, and we continue to coordinate closely with Laguna Honda Hospital and Rehabilitation Center, and our local and federal partners to help ensure the facility meets the regulatory requirements to provide safe and appropriate care to all residents and patients,” the statement read.

Phillips contended that, in spite of past missteps, Laguna Honda has done everything it can to earn the public’s trust.

“As you can imagine, there are thousands of interactions with caregivers and patients throughout any given day,” he said. “There are multiple opportunities for bad outcomes. And yet, in the vast majority of cases, there are no bad outcomes. There are just a small handful of these things that happen, and we report them, as we are required to do.”

Rachel Swan is a San Francisco Chronicle staff writer. Email: rswan@sfchronicle.com Twitter: @rachelswan

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Years ago, Dee Nguyen realized that the sun might set on his foodie career because he had to focus on caring for his son. So he had a brilliant idea: Break of Dawn.

The restaurant concept would only be breakfast-brunch. This way he would not work late at night as a top chef at the Ritz-Carlton Laguna Niguel, as he used to do before. He announced and accepted his new concept. After a year, it became a critic’s darling.

• Chef Dee Nguyen at his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen is closing his restaurant in late August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

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  Chef Dee Nguyen at his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen is closing his restaurant in late August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

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  Chef Dee Nguyen at his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen is closing his restaurant in late August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

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  Chef Dee Nguyen at his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen is closing his restaurant in late August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

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  Chef Dee Nguyen at his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen is closing his restaurant in late August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

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  Chef Dee Nguyen took advantage of seats in an old theater outside his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen closes his restaurant at the end of August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

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  Chef Dee Nguyen made tables out of old sewing machines at his Break of Dawn restaurant in Laguna Hills, California on Wednesday, July 21, 2021. Nguyen closes his restaurant at the end of August. He will convert the concept to BoD, a 70% plant-based menu with a fixed price steak option, and move the entire operation to Old Towne Orange. (Photo by Jeff Gritchen, Orange County Register / SCNG)

It’s bittersweet that he’s closing his restaurant in Laguna Hills at the end of August, but he’s embraced a second brilliant idea: moving operations to Old Towne Orange and starting a new concept: BoD. He will live on site, include dinner and still be able to properly take care of his son Berlin.

That is Nguyen’s top priority, because Berlin was born with kidney damage and complications arose. In April 2003, he was operated on at the age of 16 months. During the operation, his breathing tube became blocked and he was left without oxygen for at least 10 minutes. He was in a coma for a month, suffered brain damage, and was diagnosed with cerebral palsy.

Even now, Berlin still needs a lot of care and attention. Moving to Orange guarantees that his father will continue to be there for him.

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The new location will consist of two parts, an approximately 2,000 square meter area at 171 N. Cypress St., which is intended for the restaurant, and an adjacent 950 square meter house for Nguyen’s residence. The property is located in Old Towne, very close to the Hilbert Museum of California Art.

Nguyen is doing well in South County but is looking forward to the move.

“The reason we’ve been successful here for 14 years is because of loyalty because this is not a walk-up restaurant,” he said. “You have to know that we exist in order to come back here. Orange is right in the middle of Chapman University and tourism is constantly flowing through it. So you will always have customers. “

Po-Sun Chen and Mark Carlos of the BrightView Design Group have designed plans that include an owner’s room, culinary garden, fruit grove with communal table, shade structure with vines and a “promenade” garden with raised planters.

Nguyen will work with the city commissioned by architect Susan Secoy, owner of Orange’s historic Ice House, to design the restaurant. Construction is scheduled to start in early 2022. Nguyen calls his style a “modern farmhouse with Eichler influences”.

“I told her, Susan, my house is a hipped roof house from 1905, but I love Eichler houses. Can you integrate and manufacture this modern Eichler farmhouse for me? So she’s building a courtyard with a tree. ”This room, which is located in the driveway between the two houses, will be the entrance to the restaurant with 50 seats.

She will add an orange steel wall. “A blank space with the BoD logo on it,” said Ngyuen. “Perfect for Instagram. Children love this stuff. “

Nguyen has already started testing the steak portion of his fresh concept at pop-ups on Saturday night. “It’s a fixed point, the same setup,” he said. When it opens in orange, it goes one step further. “You get a four-course meal, but you have four or five options for the steak itself. You can choose different types of cuts at different prices. ”Along with the beef, he serves a 70 percent plant-based menu with seafood.

Nguyen’s menus have always been creative. Born in Vietnam and classically trained at the California Culinary Academy in San Francisco, he layers Asian flavors and preparations on many classics of fine cuisine. Parker House rolls are glossy glazed with a little sweetened condensed milk to give the tips the texture of a dim sum bun. Smoked salmon, served on hearty oat pancakes, contains pickled onions that are deliciously tucked away in a banh mi.

But this chef also knows how to keep prices reasonable and serve home-style cooking like a hearty pan of potatoes or wild desserts like white chocolate and Basque-style parmesan cheesecake. Some of the breakfast items will be temporarily available at the old location, which is becoming a Mexican restaurant operated by Break of Dawn employee Alejandro Cuellar.

In the new BoD, the fixed-price steak menu starts at $ 40, then prices vary depending on whether you choose a more unusual cut such as rib-eye or New York steak. The meal includes soup, salad, and a side dish like french fries. Starters and desserts are available at an additional cost.

The restaurant will only have about 50 seats, but Nguyen is completely satisfied with it. “If I pay my rent and at the end of the night have my $ 10 and eat my in-n-out hamburger, I’ll be fine,” said Nguyen. “I’m not here to make money. I am not here to get rich. I have never been. Since the accident in Berlin I’ve seen life differently. “

breaking Dawn

Find it: 24291 Avenida De La Carlota, Laguna Hills, 949-587-9418.

Open: Until August 29th with breakfast and brunch 8 am-1pm Wednesday-Sunday and Steak-Prix-Fix-Dinner Saturday, August 7th, 14th and 21st, from 5.30pm to 7.30pm takes place on August 28th for 100 USD per person instead, cash only. For more information, visit facebook.com/breakofdawnrestaurant.

What’s next: BoD comes to 171 N. Cypress St., Orange in 2022.

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