Los Guilicos Village

Intensive Care Team

En Español

Through the ACCESS Initiative, the Department of Health Services (DHS) has been successful in getting individuals experiencing homelessness into housing into housing. The Intensive Care Team addresses the behavioral health, medical, and social service needs of this population through managed care.

The Intensive Care Team has a comprehensive plan for outreach, engagement and housing placement for individuals experiencing, which includes identifying those occupants with reasonable accommodation needs and finding the appropriate housing placement and necessary services immediately.

The Intensive Care Team will work to assess homeless individuals to help ensure successful housing placement and linkages to services and support.

Outreach, Assessment and Placement for Individuals Experiencing Homelessness

The Intensive Care Team conducts outreach and engagement on the Trail using the two key forms that gather information about:

  • Services and benefits that individuals currently have/need.
  • Housing preferences and options, including any accommodation requirements as we consider housing options.


The Intensive Care Team screens for health services and benefits needs using a tracking sheet and entering notes into Watson Care Manager.

  • Benefits: Individuals are asked if they receive Medi-Cal, Cal Fresh, General Assistance, or Social Security. If they do not receive these benefits, the Intensive Care Team outreach staff and individuals will discuss whether the benefit is needed or appropriate. If yes, an individual is connected to the an. Eligibility Specialist assigned to the Intensive Care Team who helps the person to apply for the benefit. When it is appropriate, a person’s case may expedited based on need or emergency.
  • Health Services: Individuals are asked if they have a medical provider, are receiving mental health services or receiving substance use disorder (SUD) services. If they have no medical provider, the Intensive Care Team member will work with the individual to enroll with the appropriate community health center to establish primary care. If the individual is not receiving mental health or SUD services, the Intensive Care Team outreach staff and occupant will discuss whether the assessment and services in this area are recommended. If the  individual is receptive, they will be referred for an ANSA (MH Adult Needs Assessment) or ASAM (Am. Society of Addiction Medicine) assessment to determine the appropriate services needed.
  • Disease Control: Every Tuesday and Thursday from 1:00 p.m. – 3:00 p.m. the Intensive Care Team and the Disease Control unit of the Health Department will conduct testing for certain conditions and provide vaccines. Testing will be performed for HIV, Syphilis, Hep-C and TB. Vaccinations will be offered for Flu and Hep-A.


The Intensive Care Team outreach staff uses a two-page form to assess housing needs and determine if the individual has a disability that needs to be considered when placing an  individual in shelter or housing. Prioritization is established by:

  • Subject Matter Expert Prioritization: Staff from the Intensive Care Team and partner organizations understand the various vulnerabilities of the population. Together, they will determine vulnerability on a 1 through 5 scale and prioritize an individual for shelter and housing.
  • Individual Preference: Individuals are asked preference during the screening and this is being considered during the prioritization process.
  • Disability: All individuals are being asked about disability accommodations and those who have needs are being screened for reasonable accommodations as housing options are considered.
  • Partners/groupings: Intensive Care Team staff are asking about partners to find opportunities for shared rooms where possible. Social groupings are also being considered as they have natural support structures and are likely to be more successful together.
  • A Good Fit: Prioritization for housing versus shelter will consider the individual needs of the inhabitants including the ability to live in a communal space; no known violence; not a registered sex offender; and other related considerations.

Contact Information

575 Administration Drive
Suite 104A
Santa Rosa, CA 95403
38.464665, -122.725235

Responding to Homelessness

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The County has a strong commitment to provide a path to permanent stable housing for all people experiencing homelessness. The Sonoma County Community Development Commission is the lead agency charged with preventing and ending homelessness.