Responses to the Audit
Use the links below to skip to the specific response you wish to view:
- California Department of Corrections and Rehabilitation
- California State Auditor's Comments on the Response From California Department of Corrections and Rehabilitation
- Los Angeles County Sheriff’s Department
- California State Auditor's Comments on the Response From the Los Angeles County Sheriff’s Department
- Alameda County Sheriff’s Office
California Department of Corrections and Rehabilitation
August 28, 2018
Ms. Elaine M. Howle, State Auditor
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, CA 95814
Dear Ms. Howle:
The California Department of Corrections and Rehabilitation (CDCR) submits this letter in response to the California State Auditor’s (CSA) audit titled “Correctional Officer Health and Safety: Some State and County Correctional Facilities Could Better Protect Their Officers from the Health Risks of Certain Inmate Attacks.”
CDCR takes the health and wellness of all its employees seriously, and recognizes the responsibility to protect staff from the health risks associated with gassing incidents. To further ensure the safety of its staff, CDCR continues to create a culture of focused improvement, oversight, and accountability. Consistent with that commitment, all CDCR institutions, including the California Institution for Men (CIM), review each gassing incident carefully and continue to refine their communicable disease prevention programs. Additionally, CIM is committed to continuously evaluating and improving the performance of its gassing prevention and response practices.
CIM has already made progress improving its gassing incident prevention and response practices, and acknowledges there is further progress to be made. Among the improvements already implemented, CIM created a package for employees who are victims of gassing attacks. The package includes all relevant documents and instructions to ensure the employees are aware of their access to additional resources and are notified of their rights to have the inmate that gassed them tested for a communicable disease. Additionally, CIM continues to provide its staff with immediate access to medical care, evaluation, and follow-up by the appropriate healthcare providers. CIM also thoroughly reviews all incidents of staff assault to ensure protocols were followed and reviews were updated to include verification that the gassing package was provided to employees who are victims of gassing attacks. CDCR will consider the report’s recommendations and continue to improve its practices to ensure the wellbeing of all institution staff.
CDCR would like to thank CSA for their work on this report and will address the specific recommendations in a corrective action plan within the timelines outlined in the report. If you have further questions, please contact me at (916) 323-6001.
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
To provide clarity and perspective, we are commenting on the response from CDCR regarding our review of CIM. The number below corresponds to the number we have placed in the margin of its response.
We look forward to receiving CDCR’s 60‑day response to this report and identifying its progress and plans for implementing our recommendations.
August 28, 2018
Ms. Elaine M. Howle
California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, California 95814
Dear Ms. Howle:
RESPONSE TO MEN’S CENTRAL JAIL GASSING AUDIT
Please allow this letter to serve as a response to your audit report entitled “Correctional Officer Health and Safety: Some State and County Correctional Facilities Could Better Protect Their Officers from the Health Risks of Certain Inmate Attacks,” dated August 22, 2018. The Los Angeles County Sheriff’s Department (Department) is greatly appreciative of your work and desire to improve the working conditions of our personnel. While many of the protocols you recommend have long been in place, your audit has afforded us the opportunity to review our policies and ensure our procedures are adequately documented. Our responses to your specific recommendations are below:
o Medical services and workers’ compensation benefits available to them.
o The right to request the inmates be tested for communicable diseases.
o Counseling services available to staff.
Our current policies require Custody Services Division supervisors to treat gassing incidents as work related injuries if the bodily fluids or other substances make contact with the skin or membranes of an employee and complete a Workers’ Compensation Claim form. We encourage our employees to seek a medical evaluation and treatment. As part of the investigation, we advise victims of their right to request the inmate be tested for communicable diseases and the right to complete the Communicable Disease Exposure and Request for HIV Testing forms. The Supervisor’s Gassing Checklist is currently required to be completed in its entirety shortly after the gassing attack, ensuring supervisors complete all the required forms and notifications.
The Department of Health Services - Correctional Health Services (CHS), is in the process of revising their gassing policies related to employee exposures to communicable diseases. CHS will notify employees who have been directly exposed to bodily fluids of inmates, who have tested positive for HIV, or been diagnosed with a communicable disease such as AIDs, tuberculosis, or Hepatitis B or C. In addition, to the extent a gassing victim requests the inmate be tested, CHS policy will continue to require the victim be notified of the results of tests administered in response to the request. Employees will also be offered and provided with medical counseling both at the time of their initial report/request for testing, and at the time the test results are provided to them.
To ensure that it properly investigates gassing attacks and refers cases for prosecution, Men’s Central Jail should do the following:
o Implement procedures to ensure that it collects sufficient physical evidence.
o Develop goals for how long investigations should take and take steps to ensure its officers adhere to these guidelines.
Our Department has had a number of policies related to the collection and retention of evidence related to gassings which have been in place since May 16, 2017. Custody Division Manual §4-01/020.10 Battery by Gassing – identifies the specific evidence to be collected, including, at minimum, soiled uniforms, substance samples, and the container used to propel the bodily fluid.
According to our Department’s Manual of Policy and Procedures §5-04/080.30 Transfer of Property/Evidence to Central Property, attached hereto as Exhibit C, all such evidence shall be maintained at decentralized facilities. Custody Investigative Services (CIS), routinely transports evidence to Central Property to be held until the crime lab is able to conduct testing. Custody investigators continuously follow-up with crime lab personnel to ensure evidence items are being tested and processed as quickly as possible.
Our Manual of Policy and Procedures §4-01/005.25, Responsibility of the Investigating Detective, attached hereto as Exhibit D, clearly sets forth a goal for our jail detectives of closing all cases within 30 days of assignment. Each case, however, is unique and delays in receiving the results of crime lab testing can sometimes affect the amount of time it takes to properly complete a gassing attack investigation.
Our Field Operations Directive 11-01, requires detectives to complete a journal which “shall concisely indicate each investigative step taken by the investigator and shall capably provide another investigator or supervisor with enough information to ascertain the status of an investigation. Details of the investigation shall be documented in supplemental reports.” The Field Operations Directive, attached hereto as Exhibit E, also requires detective supervisors to ensure proper investigative diligence and approve the justifications supporting a request by a detective to keep a case open in excess of 60 days. Detectives are also required to submit a supplemental report to their supervisor providing a status update and justification should they need to keep a case open more than 90 days after assignment. Detective supervisors brief the detective unit commander every 30 days on cases open longer than 90 days.
Custody Services Division is currently in the process of revising policy to require a five business day period for data entry into the Los Angeles Regional Crime Information System (LARCIS). This will assist in the accountability and effectiveness of managing high volume case incidents. The revised policy shall incorporate other existing policies currently found under the Custody Division Manual, §4-01/000.00, Crime Reporting Procedures, attached hereto as Exhibit F, which states the statistical data shall include information contained in the Custody Services Division Crime Analysis Supplemental Form (SH-R-49C).
The revised policy will additionally require crime reports to be scanned and forwarded to the Jail Investigations Unit, immediately following data entry. These policy revisions will dictate evidence be properly processed and made available for the CIS evidence custodian to pick up within the same time period of five business days to further ensure gassing incidents are completed in a timely manner.
To ensure the safety of its staff, Men’s Central Jail should provide annual training that is specific to preventing and responding to gassing attacks.
While training specific to gassing incidents have been in place since 2013, the Department had been working on the development of a gassing awareness training video since January 2018. The video was recently completed by the Custody Training and Standards Bureau (CTSB), in collaboration with Psychological Services Bureau, and the Department of Health Services. This educational video provides personnel with useful information regarding preventative measures, response, documentation requirements, and available medical care/psychological aftercare services.
On August 22, 2018, the Department began distributing the training video. All employees can now access the video utilizing the Department’s intranet website Custody Division instructional bulletins portal. CTSB continues to formalize this training by developing specific curriculum. CTSB will document the presentation of this training to our staff using the Custody Training system format developed for the annual audit by the Board of State and Community Corrections, Standards of Training for Corrections.
Should you have questions, please contact Chief Joanne Sharp, Custody Services Division General Population, at (213) 893-5017.
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE LOS ANGELES COUNTY SHERIFF'S DEPARTMENT
To provide clarity and perspective, we are commenting on the response to the audit from the LASD regarding our review of its Men’s Central Jail. The numbers below correspond to the numbers we have placed in the margin of its response.
During Men’s Central review of the draft audit report, it provided evidence to demonstrate that it offered all victims medical care for the 15 cases we reviewed. Therefore, we removed this specific recommendation for Men’s Central. However, we were not able to do so until late in the audit process as it did not provide documentation until August 2018. During our audit fieldwork, Men’s Central stated that, in some cases, documentation of the medical care did not exist. However, upon receiving our draft audit report, the Los Angeles County Office of County Counsel, which supports the LASD, provided the necessary documentation. Men’s Central’s practice of using County Counsel to filter our requests likely resulted in this delay and similar delays during the audit process. For example, beginning in March 2018 we made repeated attempts during our audit fieldwork to obtain complete evidence from Men’s Central regarding its efforts to provide counseling services for victims of gassing attacks. However, Men’s Central refused to provide access to the necessary documentation, first through the Los Angeles County Counsel’s Office, then through outside private counsel at an unknown additional cost to the county. Men’s Central did not provide counseling records until July 2018, which created a substantial delay in our ability to answer the audit questions.
The exhibits that Men’s Central references throughout its response are available for inspection upon request during business hours at the California State Auditor’s office.
The response by Men’s Central fails to address the concerns we identified with its evidence collection practices. As shown in Table 3, Men’s Central only collected physical evidence of the crime in nine of the 15 gassing attacks we reviewed, indicating the need for it to implement procedures to ensure that officers follow its policies for collecting sufficient physical evidence of the gassing attacks that inmates committed.
Contrary to its statement, Men’s Central’s current policy does not require completion of investigations within 30 days. Instead, the policy it refers to only states that it will classify an investigation as inactive and closed when detectives make no progress after 30 days. Moreover, its investigators took 70 days on average to complete investigations for the 15 gassing attacks we reviewed, as we display in Figure 4. As Men’s Central’s investigations far exceeded 30 days on average, it should follow our recommendation by adopting goals and ensuring officers adhere to those goals.
For clarification, the training that Men’s Central refers to is part of its new employee training and therefore is provided only once to each employee. Moreover, we only became aware of its new training video as part of its response to our audit. Thus, it is unclear if the training video will ensure that officers are better prepared to prevent and respond to a gassing attack. We look forward to learning more about Men’s Central’s implementation of this recommendation in its 60‑day response to this report.
August 28, 2018
Elaine M. Howle, CPA, State Auditor California State Auditor
621 Capitol Mall, Suite 1200
Sacramento, California 95814
SUBJECT: RESPONSE TO THE DRAFT STATE AUDIT REPORT 2018- 106
Dear Ms. Howle:
Thank you for the DRAFT State Audit Report 2018-106. Kindly note the Alameda County Sheriff’s Office offers the following response:
Please convey our sincere appreciation to your audit team for their hard work and professionalism in preparing the State Audit Report 2018-106. With regards to the recommendations that were made by your audit team, you will note the Alameda County Sheriff’s Office partially agrees and disagrees with suggested recommendations.
Again, thank you for the opportunity of reviewing the DRAFT State Audit Report. Please feel free to contact me should you have any questions at (510) 272-6878.
Gregory J. Ahern
Alameda County Sheriffs Office's ("ACSO") Response to the California State Audit report entitled
Correctional Officer Health and Safety: Some State and County Correctional Facilities Could Better
Protect Their Officers From the Health Risks of Certain Inmate Attacks 2018-106
ACSO thanks the California State Auditor for the opportunity to respond and for the hard work performed in preparing this report. ACSO respectfully submits its responses to certain key findings and recommendations below.
Santa Rita Jail ("SRJ") does not have adequate procedures to ensure that victims of gassing attacks are notified of aftercare medical and counseling services, and of the right to request that inmates be tested for communicable disease
SRJ should revise its policies and procedures to require documentation that its supervisors are notifying victims of gassing attacks in a timely manner of available medical and counseling services, workers' compensation benefits, and the right to request inmate testing.
ACSO partially agrees with this recommendation. ACSO's current General Orders (GO) and Detentions and Corrections Policies and Procedures (P&P), including No. 3.15 and GO Nos. 3.16 and 3.18, which are provided to alt ACSO personnel, require that ACSO personnel who come into contact with bodily fluids must immediately report the exposure to their supervisor. The policies also set forth in detail a victims' rights to medical services, workman's compensation, counseling, and the right to request that an inmate or detainee be tested for HIV antibodies or infectious diseases. Such requests must be made in accordance with Cal. Penal Code § 7510 which sets forth a detailed scheme for providing inmates with due process before conducting medical testing. ACSO's Safety Manual setting forth its Illness, Injury & Prevention Program ( U IIPP") also includes a detailed attachment (Attachment 3) and training presentation on the risks associated with exposure to bodily fluids and associated personnel reporting requirements. The IIPP must be carefully reviewed and signed by each ACSO employee.
ACSO also notes that state law provides that local correctional facilities may only implement a general process of testing all inmates in custody for communicable diseases upon authorization by the local governing body, and that only known infections can be communicated to victims. (See Penal Code § 7505.) Alameda County has not passed a resolution authorizing such testing and thus ACSO most often has no knowledge of an inmate's medical status that can be provided to a gassing victim. ACSO will work with its medical provider to ensure that where infection is or becomes known, that information is communicated immediately as required.
ACSO thanks CSA for this recommendation and will add a feature to its internal systems to require that supervisors responding to gassing reports confirm in writing that the required notifications have been given to the victim,
SRJ does not consistently investigate gassing attacks in a thorough and timely manner.
SRJ should implement procedures to ensure that it collects sufficient physical evidence and submits the gassing substance for laboratory testing; develop practices to ensure that it submits all cases for prosecution when probable cause exists; and expedite its review of the four cases CSA identified to determine if submission to the district attorney for prosecution is required.
ACSO partially agrees with these recommendations. ACSO notes that the findings do not appear to take into consideration the fact that approximately half of the individually listed cases at SRJ in 2017 were committed by one inmate, and ACSO's collaboration and responsiveness to district attorney requests with respect to the evidence needed for prosecution in Alameda County.
ACSO works cooperatively with the district attorney to thoroughly investigate and gather evidence as required in response to all gassing attacks. While, as noted in the report, Alameda County has limited resources for testing gassing substances, ACSO will make every effort to test gassing substances dependent on the crime lab's capabilities and ability to gather adequate samples going forward. ACSO is also reviewing the four cases noted by the report to determine whether probable cause and the required elements of a crime are present.
SRJ has not established adequate internal processes to prevent and respond to gassing attacks.
SRJ should follow its policy and pursue appropriate internal disciplinary actions, taking mental health and competency into account. SRJ should also develop a written policy regarding the placement of "gasser" tags on inmate cells, and specifically track all gassing attacks and use the tracking data as a tool to prevent future attacks. Finally, SRJ should provide annual training that is specific to preventing and responding to gassing attacks.
ACSO does not agree with these recommendations. It is ACSO's experience that the efficacy and propriety of inmate discipline is a highly complex and evolving issue, and one that requires an individualized consideration of the inmate's medical and mental health as well as criminal history. Inmate due process rights must also be respected. Inmate discipline by regulation cannot be immediate. Inmates are afforded their right to due process thus ensuring the discipline is not punitive and retaliatory in nature. ACSO's first priority is to maintain the safety and security of its correctional facility for all inmates and ACSO personnel. Many inmates engaged in gassing behavior suffer from mental health challenges which require ACSO to consult with its behavioral health partners at the Alameda County Health Care Services Agency when contemplating internal discipline. Many are also indigent or have already lost all privileges other than time credits. ACSO does not agree that keeping such inmates incarcerated longer is likely to result in fewer gassing attacks or positively impact the safety or security of SRJ. ACSO also does not agree that memorializing its practice of using "gasser" tags in yet another written policy would provide any additional benefit. There is no indication that the practice developed at SRJ is inconsistently applied.
ACSO also already requires extensive training on officer safety and defensive techniques, as well as custodial criminal investigations, and is unaware of any gassing specific defensive tactics or investigation training programs. As noted earlier, ACSO personnel are also trained on responding to and mitigating the effects of exposures to bodily fluids. ACSO does not agree that it should create a gassing specific training curriculum.
Finally, ACSO includes gassing attacks in its tracking of all inmate related incidents/assaults. ACSO does not agree that it has the resources or ability to create a new internal tracking system exclusive to gassing attacks. ACSO also does not agree that it has the expertise or capability to analyze inmate characteristics, assess patterns, or come to conclusions about the factors that lead to inmate gassing attacks. While no separate tracking system for gassing attacks exists, ACSO's current internal systems are capable of extracting data related to gassing attacks, as is reflected by the data provided in this report.
CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM THE ALAMEDA COUNTY SHERIFF'S OFFICE
To provide clarity and perspective, we are commenting on the response from the Alameda County Sheriff’s Office regarding our review of Santa Rita. The numbers below correspond to the numbers we have placed in the margin of its response.
As noted here, we concluded that Santa Rita had policies in place to notify victims of the availability of aftercare services and the right to request that an inmate be tested for communicable diseases. However, as indicated in Table 2, we found that Santa Rita did not track whether it notified victims of these rights. As a result, we were unable to determine if Santa Rita complied with its aftercare policies and procedures.
Although Santa Rita indicated that it partially agrees with our recommendation, its response confuses the issue by focusing on a single inmate that committed repeated gassing attacks. State law requires correctional facilities to use every available means to investigate and refer all cases to the local district attorney for prosecution, regardless of whether the gassing attack is committed by the same inmate. However, as indicated in Table 3, Santa Rita did not consistently meet its responsibility to collect physical and evidence and did not test the evidence to confirm the presence of a bodily fluid. Therefore, we stand by our recommendation that Santa Rita should implement procedures to ensure that it collects sufficient physical evidence and submits the gassing substance for laboratory testing, as state law requires, and regardless of whether the gassing attack is committed by inmates who are repeat offenders.
Santa Rita’s disagreement with our recommendation to pursue appropriate internal disciplinary actions is contrary to its own policy. Specifically, as indicated here, the purpose of Santa Rita’s policy for imposing internal discipline on inmates is to maintain control and promote desirable changes in inmate attitude and behavior. However, as we note in Table 5, Santa Rita took disciplinary action for only one of the 15 gassing incidents we reviewed. Consequently, because the Alameda County district attorney obtained convictions for only 15 percent of the gassing attacks, as shown in Table 4, Santa Rita’s failure to follow its policy to impose internal discipline has resulted in many inmate perpetrators not receiving any consequences for those attacks. Moreover, as noted here, our recommendation for Santa Rita to pursue appropriate internal discipline action for an inmate who commits a gassing attack recognizes that it must take into consideration an inmate’s mental health and competency when making this decision.
We disagree with Santa Rita’s position that memorializing its practice of using “gasser” tags in a written policy would not provide any additional benefit. Developing a formal policy on the use of “gasser” tags would help ensure that all correctional staff, including newly trained officers, are aware of the requirement and implement it consistently.
We stand by our recommendation that Santa Rita should provide annual training that is specific to preventing and responding to gassing attacks. As we state here, training specific to gassing attacks could help officers be more prepared to prevent and respond to these incidents. Moreover, as we indicate in Table 5, two of the six victims at Santa Rita indicated that they had not received training to help protect themselves from a gassing attack—demonstrating that not all of its staff have received adequate training.
A correctional facility’s tracking of gassing attacks should result in information that is consistent and readily accessible, which is not currently the case at Santa Rita. Specifically, as we state here, Santa Rita currently must consult three separate databases to obtain information about gassing attacks at its facility. As a result, staff and management are unable to easily analyze the specific circumstances surrounding gassing attacks and to reassess their current procedures for responding to and preventing future attacks. Moreover, we are puzzled by Santa Rita’s statement that it does not have the expertise or capability to analyze gassing attack data because as a correctional facility, it is in the best position to understand and use this information.