Butte County Probation (2023-2024 inspection cycle)

May 29, 2024 Melissa Romero, Chief of Probation Butte Probation Department 42 Country Center Drive Oroville, CA 95965 2023-2024 TARGETED INSPECTION, WELFARE & INSTITUTIONS CODE SECTIONS 209 & 885, YUBA COUNTY PROBATION DEPARTMENT DETENTION FACILITIES Dear Chief Romero: The 2023-2024 Targeted Inspection of the Butte County Probation Department County Probation Department has been completed. A pre- inspection briefing was held on Tuesday, February 20, 2024, and the following facility facilities were inspected between Tuesday, March 26, 2024 and Tuesday, April 2, 2024 : FACILITY NAME BSCC # FACILITY TYPE Butte Juvenile Hall 7027 JH Butte County Probation Camp 7029 CAMP Program Butte Secure Youth Treatment 7030 SYTF Facility These inspections were conducted pursuant to Welfare and Institutions Code Sections 209 and 885 to determine compliance with the Minimum Standards for Juvenile Detention Facilities as outlined in Titles 15 and 24, California Code of Regulations. In addition, Board of State and Community Corrections (BSCC) staff conducted compliance monitoring pursuant to Welfare and Institutions Code Sections 209(f) and the federal Juvenile Justice and Delinquency Prevention Act (JJDPA) requirements for separation between juveniles and adults. In addition to the annual inspection, Title 15, Section 1313, and its authorizing statute require annual inspections conducted by a local Health Officer, fire authority having jurisdiction, county building inspection by an agency designated by the County Board of Supervisors, County Superintendent of Schools, Juvenile Court, and Juvenile Justice Commission. The results of those inspections are considered a part of this report. INSPECTION RESULTS We identified the following item of noncompliance with Title 15 Minimum Standards: Melissa Romero, Chief of Probation Page 2 Juvenile Hall Title 15 Regulation, § 1328, Safety Checks: During a video surveillance recording review, BSCC observed the Juvenile Detention Officer and graveyard staff skipping multiple required safety checks. Refer to the attached Procedures Checklist for detailed information. Juvenile Justice and Delinquency Prevention Act Compliance Monitoring No violations of the JJDPA have been identified, and no areas of noncompliance were noted. CORRECTIVE ACTION PLAN (CAP) An Exit Briefing with your staff was held on Wednesday, April 3, 2024; BSCC staff presented an overview of the inspection and discussed technical assistance and best practice recommendations. BSCC staff reviewed and provided an Initial Inspection Report for noncompliance items found during the inspection. Your agency provided BSCC staff with a CAP addressing these issues on Wednesday, May 22, 2024, we responded to the CAP under a separate cover letter. * * * Please email me at forrest.coleman@bscc.ca.gov or call (916) 508-7559 if you have any questions. Sincerely, FORREST COLEMAN Field Representative Facilities Standards and Operations Division Enclosures Cc: Presiding Judge, Butte County Juvenile Court* Chair, Juvenile Justice Commission, Butte County* Chair, Board of Supervisors, Butte County* County Administrator, Butte County* Superintendent of Institutions, Mariah Ruddy, Butte County Probation Dept *Copies of the inspection are available upon request or online at www.bscc.ca.gov. 7027+ Butte County Probation Camp JH SYTF LTR 23-24 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7027 FACILITY NAME: Butte County Juvenile Hall FACILITY TYPE: Juvenile Hall PERSON(S) INTERVIEWED: Mariah Ruddy, Superintendent; Lorrain Bass, Assistant Superintendent; Tim Bowers, Food Services Supervisor; Nicole Calcutta, Site Director (Boys and Girls Club); Marla Oates, Associate Clinical Social Worker (Youth for Change); Karen Ely, RN; Ayana Venable, Supervising JDO; 2 male youth; 1 female youth; Random youth during the tour. FIELD REPRESENTATIVE: Forrest Coleman DATE: March 26, 2024, through April 2, 2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1321 STAFFING Policy 217, Staffing Plan Policy 201, Supervision of Youth Each juvenile facility shall: (a) have an adequate number of personnel sufficient to BSCC staff reviewed the above policies and carry out the overall facility operation and its procedures, as well as the agency’s programming, to provide for safety and security of youth Organization Chart, random weekly staff and staff, and meet established standards and schedule, and daily unit schedule covering regulations; the first week of January, February, and March of 2024. In addition, we made personal observations. ☒ ☐ ☐ The above policy identifies all expectations and responsibilities of the Title 15 Regulation minimum standards. The facility’s Superintendent ensures that each shift is staffed with enough youth supervision staff to ensure the overall facility operation and its programming including, but not limited to providing safety and security to youth and to staff while maintaining Title 15 standards. 1 This document is intended for use as a tool during the inspection process; this worksheet may not contain each Title 15 regulation that is required. Additionally, many regulations on this worksheet are SUMMARIES of the regulation; the text on this worksheet may not contain the entire text of the actual regulation. Please refer to the complete California Code of Regulations, Title 15, Minimum Standards for Local Facilities, Division 1, Chapter 1, Subchapter 5 for the complete list and text of regulations. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 1 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) ensure that no required services shall be denied Policy 217, Staffing Plan 4B because of insufficient numbers of staff on duty absent exigent circumstances; As of March 30, 2024, the Butte County Juvenile Detention Officer (JDO) classification will be re-classified to Deputy Probation Officer (DPO). The JDO position will be eliminated. According to the facility Superintendent, the JDO staff will participate in an STC-certified “Transitional DPO CORE” training. This training will provide the elements of DPO CORE that are not included in Counselor CORE training. Also, DPO staff who have an interest in working in the BCJH, as youth supervision staff, will have the ☒ ☐ ☐ opportunity to attend a “Transitional Counselor CORE” training. For the purposes of this report, youth supervision detention staff will be referred to as Juvenile Detention Officers. At the time of the inspection, the Butte County Juvenile Hall has the below youth supervision staffing assigned to its facility: • 17 Juvenile Detention Officers • 5 Extra Help Juvenile Detention Officers (c) have a sufficient number of supervisory level staff to Policy 217, Staffing Plan 5B ensure adequate supervision of all staff members; Through our review of the above policy, visual observations, work schedules, and interviews with JDO staff and youth housed at the facility, BSCC staff determined that BCJH regularly ensures that there is always a Supervising Juvenile Detention Officer (SJDO) present at the facility on each shift. When the SJDO is absent from the shift, a JDO is assigned to work in the Supervisor’s ☒ ☐ ☐ role, as the “Lead Officer”. At the time of the inspection, the Butte County Juvenile Hall supervisory level staffing consisted of: • 6 Supervising Juvenile Detention Officers (1 Camp) • 1 Assistant Superintendent • 1 Superintendent 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 2 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) have a clearly identified person on duty at all times Policy 217, Staffing Plan 6B who is responsible for operations and activities and has completed the Juvenile Corrections Officer Core Course The elements of this regulation are confirmed and PC 832 training; in the Chief Probation Officer (CPO) Appointment and Qualifications Letter, written by CPO Melissa Romero, and dated January 2, 2024. Monday through Friday during standard ☒ ☐ ☐ business hours the facility Superintendent and in her absence, the Assistant Superintendent is responsible for ensuring the daily overall operations of the facility are adequately maintained. In review of the sign-in to work shift scheduler, a supervisor is always clearly identified and on duty each shift. (e)have at least one staff member present on each living Policy 217, Staffing Plan 7B unit whenever there are youth in the living unit; BSCC staff reviewed surveillance video recordings, made personal observations, as well as, conducted interviews with staff and youth housed at the facility, BCJH regularly ensures that there is always a staff present in the unit or where a youth is present. Youth are never left unsupervised. BSCC staff provided technical assistance in providing clarity that to maintain compliance, the graveyard staff should be stationed on the ☒ ☐ ☐ unit and not in the adjacent JDO office during their shift. Title 15 Regulations, in part, defines a Living Unit as “A living unit that shall not be divided in a way that hinders direct access, supervision, immediate intervention or other action if needed”. Based on this definition an adjoined staff office is not a part of the living unit. Staff can go check in, document filing, answer the phone, use the restroom, etc., but cannot remain stationed in the office for extended periods consistently throughout the shift. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 3 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) have sufficient food service personnel relative to the Policy 200 Financial Practices, Section 200. 8B number and security of living units, including staff qualified Policy 217, Staffing Plan and available to: plan menus meeting nutritional requirements of youth; provide kitchen supervision; direct BSCC staff interviewed Food Services staff. food preparation and servings; conduct related training The Food Service Supervisor also performs programs for culinary staff; and maintain necessary as a Cook. The Food Services personnel is records; or, a facility may serve food that meets nutritional as follows: standards prepared by an outside source; • 1 Food Service Supervisor (Cook) • 1 Full-time Cook • 3 Extra Help Cooks BSCC staff observed that the kitchen staffing is at a minimum level, in terms of extra help staff available to work. According to the BCJH Superintendent, there are currently two cook ☒ ☐ ☐ applicants in the hiring background process. BSCC staff also observed that there is no Registered Dietician to review menus annually or periodically and provide guidance, including but not limited to reviewing the kitchen policy manual. The facility is currently in negotiation with contracting with a qualified Registered Dietician. Without the availability of a Registered Dietician and the limited experience of the Supervising Cook. BSCC was informed that a Registered Dietitian will be available by April 21, 2024, to annually review the meal menus. BSCC also discussed the importance of ensuring that a kitchen policy manual is available. (g) have sufficient administrative, clerical, recreational, Policy 201, Supervision of Youth medical, dental, mental health, building maintenance, Policy 217, Staffing Plan transportation, control room, facility security and other support staff for the efficient management of the facility, BSCC staff interviewed medical services and to ensure that youth supervision staff shall not be personnel, contracted behavioral health staff, diverted from supervising youth; and, and detention staff. We also made personal observations over the course of the inspection week. BCJH has one full-time Nurse that works Monday through Friday from 0630 to 1500. ☒ ☐ ☐ There are 2 Licensed Vocational Nurses who cover weekend shifts and as-needed coverage. The facility has contracted with a local community-based organization, identified as “Youth for Change”. The Youth for Change (YFC) provides behavioral health services for youth. The YFC staffing primarily consists of an Associate Clinical Social Worker and a Licensed Clinical Social Worker (Supervisor). 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 4 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h)assign sufficient youth supervision staff to provide Policy 201, Supervision of Youth continuous wide awake supervision of youth, subject Policy 217, Staffing Plan to temporary variations in staff assignments to meet special program needs. Staffing shall be in compliance Butte County Camp Condor is a detention with a minimum youth-staff ratio for the following camp within the BCJH complex, located on a facility types: housing unit. As well the Butte SYTF, also identified as the Commitment to Success Program (CSP) is a facility with the BCJH ☒ ☐ ☐ complex. The Camp, the SYTF/CSP, and the Juvenile Hall are cross-training to provide supplemental staff coverage to each facility on an as needed basis. Further, all three facilities abide by the same BCJH policies and procedures that align with Title 15 regulations. (1)Juvenile Halls Policy 201, Supervision of Youth (A) during the hours that youth are awake, one wide- Policy 217, Staffing Plan awake youth supervision staff member on duty for each 10 youth in detention; In a review of housing unit video surveillance recordings, housing unit logs, and the daily staff schedule, as well as, through personal observation, the BCJH ensures that “One wide-awake” JDO staff is present and that staffing ratios are consistently in compliance ☒ ☐ ☐ with Title 15 minimum standards for this regulation. At the time of the inspection, there were eight youth (one female) housed at the Butte County Juvenile Hall facility, not including youth housed at the Camp and SYTF facilities. (B) during the hours that youth are confined to their Policy 201, Supervision of Youth room for the purpose of sleeping, one wide-awake Policy 217, Staffing Plan youth supervision staff member on duty for each 30 ☒ ☐ ☐ youth in detention; (C) at least two wide-awake youth supervision staff Policy 201, Supervision of Youth members on duty at all times, regardless of the Policy 217, Staffing Plan number of youth in detention, unless an arrangement has been made for backup support services which Through a review of housing unit logs and the allow for immediate response to emergencies; and, ☒ ☐ ☐ daily staff schedule, personal observations, as well as, through interviews with detention staff, BCJH regularly ensures that the minimum youth-to-staff ratio is met. (D) at least one youth supervision staff member on duty Policy 201, Supervision of Youth who is the same gender as youth housed in the facility. Through documentation review, personal observations, as well as, through interviews with youth and detention staff, BCJH regularly ensures that there are always male and ☒ ☐ ☐ female staff on duty. At the time of this inspection, there was one female youth detained at the BCJH. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 5 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (E) personnel with primary responsibility for other duties Policy 201, Supervision of Youth such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or The above policy clearly identifies roles and maintenance shall not be classified as youth supervision responsibilities of staff who are not deemed ☒ ☐ ☐ staff positions. youth supervision staff. Only youth supervision staff provide supervision of the youth. (2)Special Purpose Juvenile Halls The Butte County Juvenile Hall is not a (A) during hours that youth are awake, one wide-awake Special Purpose Juvenile Hall. Therefore, the ☐ youth supervision staff member on duty for each 10 youth ☐ ☒ below section A through E is not applicable to in detention; this facility. (B)during the hours that youth are confined to their room N/A for the purpose of sleeping, one wide-awake youth supervision staff member on duty for each 30 youth in ☐ ☐ ☒ detention; (C) at least two wide-awake youth supervision staff N/A members on duty at all times, regardless of the number of youth in detention, unless an arrangement has been ☐ ☐ ☒ made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty N/A who is the same gender as youth housed in the facility. ☐ ☐ ☒ (E) personnel with primary responsibility for other duties N/A such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or ☐ ☐ ☒ maintenance shall not be classified as youth supervision staff positions. (3)Camps Although Butte County Camp Condor facility (A) during the hours that youth are awake, one wide- is located on a housing unit within the juvenile awake youth supervision staff member on duty for each hall complex, cross-trains staff, and abides by 15 youth in the camp population; the same policies and procedures as the BCJH, it is independently identified as a ☐ ☐ ☒ Camp facility and not a juvenile hall facility. Therefore, the below camp sections A through F is not applicable to this facility inspection report. (B)during the hours that youth are confined to their room N/A for the purpose of sleeping, one wide-awake youth supervision staff member on duty for each 30 youth ☐ ☐ ☒ present in the facility; (C)at least two wide-awake youth supervision staff N/A members on duty at all times, regardless of the number of youth in residence, unless arrangements have been made for backup support ☐ ☐ ☒ services which allow for immediate response to emergencies; (D)at least one youth supervision staff member on N/A duty who is the same gender as youth housed in ☐ ☐ ☒ the facility; (E) in addition to the minimum staff to youth ratio N/A required in (h)(3)(A)-(B), consideration shall be given to the size, design, and location of the camp; types of youth committed to the camp; and the ☐ ☐ ☒ function of the camp in determining the level of supervision necessary to maintain the safety and welfare of youth and staff; 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 6 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (F) personnel with primary responsibility for other N/A duties such as administration, supervision of personnel, academic or trade instruction, clerical, ☐ ☐ ☒ farm, forestry, kitchen or maintenance shall not be classified as youth supervision staff positions. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 7 of 21 A453 JUV Targeted PRO eff. 1/2024 1328 SAFETY CHECKS Policy 506 Youth Safety Checks 0B The facility administrator shall develop and The facility maintains safety check implement policy and procedures that provide for documentation within the unit logbook. direct visual observation of youth at a minimum of BSCC staff reviewed the unit logbook for the every 15 minutes, at random or varied intervals months of January through March of 2024. during hours when youth are asleep or when We also reviewed random video surveillance youth are in their rooms, confined in holding cells of detention staff conducting safety checks. or confined to their bed in a dormitory. Supervision is not replaced, but may be supplemented by, an In a review of video surveillance recordings audio/visual electronic surveillance system showing staff conducting in-room safety designed to detect overt, aggressive or assaultive checks of youth during the graveyard shift, behavior and to summon aid in emergencies. All BSCC staff observed noncompliance. It was safety checks shall be documented with the actual observed, on several occasions, that Juvenile time the check is completed. Detention Officer and graveyard staff skipped required safety check time intervals and as a result, conducted safety checks up to twenty minutes beyond the 15-minute Title 15 requirement. Further, in review of the unit logbook, BSCC staff observed non-compliance with the Juvenile Detention Officer, and graveyard staff not accurately documenting the actual time safety checks were conducted. The previously indicated late safety checks were not accurately reflected in the unit logbook. Regarding noncompliance, BSCC staff provided technical assistance including, but not limited to, requiring supervisors to ☐ ☒ ☐ conduct daily reviews of safety check entries in the unit logbook and requiring supervisors to routinely conduct random video surveillance audits of safety checks being conducted. Additionally, ensure audit reviews through oversight by the facility Administration. The agency provided a Corrective Action Plan (CAP) and is actively working toward resolving the noncompliance by, no later than, July 1, 2024. Lastly, due to the co-mingling of the documentation for safety checks, youth movements, activity programming, and the shift summary on the same logbook pages, there were inconsistencies with the standard safety check documentation requirements. BSCC staff also found it challenging to identify youth who were in and out of their respective rooms. BSCC staff discussed and provided best outcome recommendations that primarily focused on having the ability to clearly review and track safety checks. At a minimum, we suggest that safety checks are recorded on a separate page of the logbook independent of other day-to-day noted information. We noted that the facility has paid for and is in the final stages of implementing the use of the safety check and tracking software, Guardian RFID. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 8 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN Procedure 707 Suicide Prevention and 1B Intervention The facility administrator, in collaboration with the healthcare and behavioral/mental health Within the last year, the facility has contracted administrators, shall plan and implement written with a community-based organization policies and procedures which delineate a Suicide identified as Youth for Change (YFC). Youth Prevention Plan. The plan shall consider the for Change provides behavioral health needs of youth experiencing past or current services and counseling for the you housed trauma. Suicide prevention responses shall be at the facility. The facility is currently respectful and in the least invasive manner incorporating Youth for Change into the consistent with the level of suicide risk. The plan Suicide Prevention Plan. shall include the following elements: Historically, health services through WellPath have aided the facility with suicide behavior assessments and prevention. Their role will not change. BSCC staff observed that, in terms of methods of suicide prevention, and the use of the least invasive manner consistent with the ☒ ☐ ☐ level of suicide risk, WellPath policy (HCD- 211_B-05 Suicide Prevention and Intervention program 3.4 provides a blanket method of suicide prevention for all youth. In part, it states, “All personal property and clothing shall be removed from the patient”. However, the BCJH Suicide Prevention Plan states “Staff may elect to have outer clothing removed and wear suicide smock, if the Supervisor, in conjunction with if the mental health professional, feels it is appropriate. BSCC staff discussed the importance of ensuring that both agencies collaborate to ensure corresponding policies and procedures are in alignment with actual practices. The medical staff acknowledged that practices are site-specific and in line with Title 15 regulations. (a) Suicide prevention training as required in Policy 300 Member Orientation Section 1322, Youth Supervision Staff Policy 707 Suicide Prevention and Orientation, and Training and the Juvenile Intervention Corrections Officer Core Course. The elements of this regulation are confirmed in the Chief Probation Officer (CPO) Appointment and Qualifications Letter, written ☒ ☐ ☐ by CPO Melissa Romero, and dated January 2, 2024. An annual refresher training is included in the BCJH Suicide Prevention Plan. In addition, staff receive suicide prevention training during Counselor CORE training. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 9 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Screening, Identification Assessment and Policy 400 Emergency Procedures Precautionary Protocols (1)All youth shall be screened for risk of suicide The booking officer communicates with the at intake and as needed during detention. arresting officer, facility staff, family members, and medical and mental health personnel as part of the screening process for suicide risk. Screening and assessment forms completed ☒ ☐ ☐ at intake include: Detention Risk Assessment and the Intake Screening Questionnaire. Intake staff also communicate with the arresting officer and communicate with the youth’s parent/guardian. (2)All youth supervision staff who perform intake Policy 700 Health Authorities processes shall be trained in screening youth for risk of suicide. The elements of this regulation are confirmed in the CPO appointment and qualifications ☒ ☐ ☐ letter dated January 2, 2024. An annual refresher training is included in the BCJH Suicide Prevention Plan. (3)All youth who have been identified during the Policy 400 Emergency Procedures intake screening process to be at risk of suicide shall be referred to behavioral/mental health staff Youths identified during the intake screening for a suicide risk assessment. process to be at risk of suicide shall be seen ☒ ☐ ☐ by a WellPath Behavioral Health therapist within 96 hours of admission. WellPath will refer the youth to behavioral health services, Youth for Change for further assessment. (4)Precautionary protocols shall be developed to Policy 707 Suicide Prevention and ensure the youth’s safety pending the Intervention behavioral/mental health assessment. Per the above policy, youth found to be at risk for suicide are placed on “Suicide Watch” status and remains under direct observation pending behavioral health assessment. Precautionary protocols include, but are not limited to the following: ☒ ☐ ☐ • Maintain constant visual observation. • 5-8 minute watch • Counseling • Contact medical or mental health staff. • Remove only the items decided upon by medical or mental health staff and the supervisor. • Move youth to a downstairs room. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 10 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Referral process to behavioral/mental health Policy 400 Emergency Procedures staff for assessment and/or services. Procedure 707 Suicide Prevention and Intervention BSCC staff reviewed suicide attempts and/or suicide ideations from the prior March 2023 inspection to the current inspection. We also interviewed Behavioral Health and Medical staff. Per the facility policy, if there is an immediate ☒ ☐ ☐ safety concern, detention staff may determine that the youth’s clothing shall be removed. Otherwise, detention staff will contact behavioral health and maintain direct observation of the youth pending a behavioral health assessment to remove the youth’s clothing. Further, WellPath medical services are onsite 7 days per week, from 6:45 AM to 7:15 PM. Behavioral Services are onsite up to 3 days per week. (d) Procedures for monitoring of youth identified Policy 707 Suicide Prevention and at risk for suicide. Intervention To monitor youth at risk for suicide, the facility utilizes the following: ☒ ☐ ☐ • Suicide Watch- Direct visual observation. • 5-8 minute Watch • Special Observation- Housing and room items allowed precautions. (e)Safety Interventions Procedure 707 Suicide Prevention and (1)Procedures to address intervention protocols for Intervention youth identified at risk for suicide which may include, but are not limited to: Safety interventions may include but are not ☒ ☐ ☐ (A)Housing consideration limited to, Special Observation- Housing and room items allowed precautions, housed in a downstairs room, and counseling. (B) Treatment strategies including trauma- Procedure 707 Suicide Prevention and informed approaches Intervention The elements of this regulation are confirmed in the CPO appointment and qualifications letter dated January 2, 2024. ☒ ☐ ☐ Youth for Change conducts trauma-focused counseling and provides Child and Family Team meetings (CFT). (2) Procedures to instruct youth supervision staff Policy 707 Suicide Prevention and how to respond to youth who exhibit suicidal Intervention behaviors. ☒ ☐ ☐ An annual refresher training that includes trauma informed approaches is included in the BCJH Suicide Prevention Plan. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 11 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f)Communication Policy 501 Youth Intake The intake process shall include communication with the arresting officer and family guardians regarding The booking officer communicates with the the youth’s past or present suicidal ideations, ☒ ☐ ☐ arresting officer, facility staff, family members, behaviors or attempts. and medical and mental health personnel about suicide risk. Procedures for clear and current information sharing Procedure 707 Suicide Prevention and about youth at risk for suicide with youth Intervention supervision, healthcare, and behavioral/mental health staff. Butte County Juvenile Hall ensures the following as part of the documentation and notification process: • Documentation in the logbook and in a Serious Incident Report (SIR) • Communicate with medical/mental ☒ ☐ ☐ health staff to determine their programming needs. • Document on the Suicide watch check-off sheet. • Start a folder with suicide observation forms to document room checks and any special information. • Notify their parents or legal guardian and probation officer. (g)Debriefing of Critical Incidents Related to Suicides or Procedure 707 Suicide Prevention and Attempts Intervention (1)Process for administrative review of the ☒ ☐ ☐ circumstances and responses proceeding, during and after the critical incident. Procedure 707 Suicide Prevention and (2)Process for a debriefing event with affected staff. ☒ ☐ ☐ Intervention (3)Process for a debriefing event with affected youth. Procedure 707 Suicide Prevention and ☒ ☐ ☐ Intervention (h)Documentation Procedure 707 Suicide Prevention and (1) Documentation processes shall be developed to Intervention ensure compliance with this regulation Reporting and monitoring documentation is as follows: ☒ ☐ ☐ • Incident Report • Medical Notification • Mental Health Suicide Watch • Observation Sheet Youth identified at risk for suicide shall not be denied Procedure 707 Suicide Prevention and the opportunity to participate in facility programs, Intervention services and activities which are available to other non-suicidal youth, unless deemed necessary for the BSCC staff reviewed incident reports, and safety of the youth or security of the facility. Any interviewed detention staff and youth housed ☒ ☐ ☐ deprivation of programs, services or activities for at the facility. We also interviewed behavioral youth at risk of suicide shall be documented and health and medical services staff. BSCC approved by the facility manager. determined compliance with this section of the regulation. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 12 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT Policy 601 Safety Removal (Room 2B Confinement) (a)The facility administrator shall develop and implement written policies and procedures addressing BSCC staff reviewed the 15 most recent the confinement of youth in their room that are examples of room confinement-related consistent with Welfare and Institutions Code Section ☒ ☐ ☐ incident reports, reviewed room confinement 208.3. The placement of a youth in room confinement logs, and interviewed youth detained at the shall be accomplished in accordance with the following facility as well as detention staff. We also guidelines: interviewed medical and behavioral health staff to gain further insight. (1)Room confinement shall not be used before Policy 601 Safety Removals (Room other, less restrictive, options have been attempted Confinement) and exhausted, unless attempting those options ☒ ☐ ☐ poses a threat to the safety or security of any youth BCJH meets Title 15 minimum standards for or staff. the elements of this regulation. (2)Room confinement shall not be used for the Policy 601 Safety Removals (Room purposes of punishment, coercion, convenience, or Confinement) retaliation by staff. ☒ ☐ ☐ Documentation supports compliance with this regulation. Room confinement is always used appropriately. (3)Room confinement shall not be used to the Policy 601 Safety Removals (Room extent that it compromises the mental and physical Confinement) ☒ ☐ ☐ health of the youth. (b)A youth may be held up to four hours in room Policy 601 Safety Removals (Room confinement. After the youth has been held in room Confinement) confinement for a period of four hours, staff shall do one or more of the following: Since the prior inspection, documentation shows that no youth has been held in room confinement beyond the four-hour threshold. The facility uses the following documentation tools to help track and log room confinement include, but are not limited to: ☒ ☐ ☐ • Administration Separation Monitoring Log • Pod Logbook • Safety and Security Behavioral Removal log • Administrative Separation Check-Off Log Policy 601 Safety Removals (Room (1)Return the youth to general population. ☒ ☐ ☐ Confinement) Policy 601 Safety Removals (Room Confinement) (2)Consult with mental health or medical staff. Per policy, if after one hour the youth’s ☒ ☐ ☐ behavior continues to be a threat to facility, safety and security, the facility LMFT may be contacted to assess and counsel the youth. (3)Develop an individualized plan that includes the Policy 601 Safety Removals (Room goals and objectives to be met in order to Confinement) reintegrate the youth to general population. ☒ ☐ ☐ Individualized plans are identified as Behavior Modification Plans. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 13 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) If room confinement must be extended beyond Policy 601 Safety Removals (Room four hours, staff shall do each of the following: Confinement) (A)Document the reasons for room confinement and the basis for the extension, Since the prior inspection, documentation ☒ ☐ ☐ the date and time the youth was first placed in shows that no youth has been held in room room confinement, and when he or she is confinement beyond the four-hour threshold. eventually released from room confinement. (B)Develop an individualized plan that includes Policy 601 Safety Removals (Room the goals and objectives to be met in order to Confinement) integrate the youth to general population. ☒ ☐ ☐ The facility utilizes an Administrative Separation Form that complies with the elements of this regulation. (C) Obtain documented authorization by the Policy 601 Safety Removals (Room facility superintendent or his or her designee Confinement) ☒ ☐ ☐ every four hours thereafter. (5) This section is not intended to limit the use of Policy 601 Safety Removals (Room single-person rooms or cells for the housing of youth Confinement) in juvenile facilities and does not apply to normal ☒ ☐ ☐ sleeping hours. (6)This section does not apply to youth or wards in Policy 601 Safety Removals (Room court holding facilities or adult facilities. ☒ ☐ ☐ Confinement) (7) Nothing in this section shall be construed to Policy 601 Safety Removals (Room conflict with any law providing greater or additional Confinement) ☒ ☐ ☐ protections to youth. (8) This section does not apply during an Policy 601 Safety Removals (Room extraordinary emergency circumstance that requires Confinement) a significant departure from normal institutional operations, including a natural disaster or facility- wide threat that poses an imminent and substantial ☒ ☐ ☐ risk of harm to multiple staff or youth. This exception shall apply for the shortest amount of time needed to address this imminent and substantial risk of harm. (9) This section does not apply when a youth is Policy 601 Safety Removals (Room placed in a locked cell or sleeping room to treat and Confinement) protect against the spread of a communicable disease for the shortest amount of time required to reduce the risk of infection, with the written approval of a licensed physician or nurse practitioner, when the youth is not required to be in an infirmary for an ☒ ☐ ☐ illness. Additionally, this section does not apply when a youth is placed in a locked cell or sleeping room for required extended care after medical treatment with the written approval of a licensed physician or nurse practitioner, when the youth is not required to be in an infirmary for illness. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 14 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1357 USE OF FORCE Policy 305 Chemical Agents Training Procedure 514.1 The facility administrator, in cooperation with the Policy 514 Use of Force responsible physician, shall develop and implement Procedure 514 Force Options written policies and procedures for the use of force, Policy 515 Restraints which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or BSCC staff reviewed 15 of the most recent treatment. Use of Force (UOF) Incident reports covering (a) At a minimum, each facility shall develop policies and ☒ ☐ ☐ the time from the prior March 2023 procedures which: comprehensive inspection to the current inspection. This includes 4 incident reports involving the use of OC pepper spray. We also interviewed youth housed at the facility and detention staff. We also interviewed collaborative partners to gain further insight to confirm compliance with this regulation. (1)restricts the use of force to that which is deemed Policy 514 Use of Force reasonable and necessary, as defined in Section Procedure 514 Force Options 1302 to ensure the safety and security of youth, staff, Procedure 514.1 Chemical Agents others and the facility. Decontamination Procedure ☒ ☐ ☐ In review, or reports and interviews with youth, SYTF JDO staff utilized use force that is deemed reasonable and necessary. (2)outline the force options available to staff including Policy 514 Use of Force both physical and non-physical options and define Procedure 514 Force Options when those force options are appropriate. BCJH detention staff receive an initial 4-hour weaponless defensive training and policy ☒ ☐ ☐ review outlining both physical and non- physical de-escalation options. An additional 4 hours of refresher training occur annually. (3) describe force options or techniques that are Policy 514 Use of Force expressly prohibited by the facility. Procedure 514 Force Options BCJH Use of Force Options includes the below: • Verbal Commands • OC Spray ☒ ☐ ☐ • Soft Hands/ Physical Escort • Hard hands/Full Restraint • Strikes/Kicks • Convex Shield • Mechanical Restraints (4)describe the requirements of staff to report any Policy 514 Use of Force inappropriate use of force, and to take affirmative Procedure 514 Force Options ☒ ☐ ☐ action to immediately stop it. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 15 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5)define a standardized reporting format that Policy 514 Use of Force includes time period and procedure for documenting Procedure 514 Force Options and reporting the use of force, including reporting requirements of management and line staff and procedures for reviewing and tracking use of force Detention staff must complete use-of-force incidents by supervisory and or management staff, Incident Reports prior to ending his/her shift. ☒ ☐ ☐ which include procedures for debriefing a particular Supervisory reviews are conducted prior to incident with staff and/or youth for the purposes of the end of the shift that the incident occurred. training as well as mitigating the effects of trauma Reviews and debriefings were clearly that may have been experienced by staff and /or the documented in Incident Reports. youth involved. (6)Include an administrative review and a system for Policy 514 Use of Force investigating unreasonable use of force. Procedure 514 Force Options Through a review of the Use of Force incident reports, we observe that the supervisor ☒ ☐ ☐ provides a final analysis and debrief of the incident. Also, the Superintendent reviews the use of force incident reports to ensure the use of force was in accordance with facility policy. (7)define the role, notification, and follow-up Policy 514 Use of Force procedures required after use of force incidents for Procedure 514 Force Options medical, mental health staff and parents or legal guardians. BSCC staff interviewed supervisory, ☒ ☐ ☐ detention, and medical staff to help determine compliance with the elements of this regulation. (8)describe the limitations of use of force on Policy 307 Health Care Orientation and pregnant youth in accordance with Penal Code Training Section 6030(f) and Welfare and Institutions Code ☒ ☐ ☐ Section 222. Policy 514 Use of Force Policy 515 Restraints (b) Facilities that authorize chemical agents as a force Policy 305 Chemical Agents Training option shall include policies and procedures that: Policy 514 Use of Force (1)identify who is approved to carry and/or utilize Procedure 514.1 Chemical Agents chemical agents in the facility and the type, size Decontamination Procedure and the approved method of deployment for those chemical agents. Four incidents involving the use of chemical ☒ ☐ ☐ agents (OC spray) were reported. BCJH staff observed that detention staff satisfactorily completed the department's eight-hour, STC-approved Chemical Agents course before being approved to carry OC spray. (2)mandate that chemical agents only be used Policy 514 Use of Force when there is an imminent threat to the youth’s safety or the safety of others and only when de- escalation efforts have been unsuccessful or are In a review of the Incident Reports, in most ☒ ☐ ☐ not reasonably possible. cases, chemical agents were used to de- escalate youth-on-youth mutual physical combat. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 16 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (3)outline the facility’s approved methods and Policy 514 Use of Force timelines for decontamination from chemical Procedure 514.1 Chemical Agents agents. This shall include that youth who have Decontamination Procedure been exposed to chemical agents shall not be left ☒ ☐ ☐ unattended until that youth is fully decontaminated BSCC staff interviewed medical personnel, or is no longer suffering the effects of the chemical youth housed at the facility, JDO staff, and agent. supervisors. Compliance was confirmed. (4) define the role, notification, and follow-up Policy 514 Use of Force procedures required after use of force incidents involving chemical agents for medical, mental health ☒ ☐ ☐ staff and parents or legal guardians. (5)provide for the documentation of each incident of Policy 514 Use of Force use of chemical agents, including the reasons for Procedure 514.1 Chemical Agents which it was used, efforts to de-escalate prior to use, Decontamination Procedure youth and staff involved, the date, time and location ☒ ☐ ☐ of use, decontamination procedures applied and Incident Reports reviewed meet the Title 15 identification of any injuries sustained as a result of minimum standards for this regulation. such use. (c)Facilities shall develop policies and procedure which Policy 305 Chemical Agents Training require that agencies provide initial and regular training Procedure 514 Force Options in use of force and chemical agents when appropriate that address: The elements of this regulation are identified (1)known medical and behavioral health conditions in Phase One of the training procedure and that would contraindicate certain types of force; confirmed in the CPO Melissa Romero’s Appointment and Qualifications Letter dated January 2, 2024. The referenced policy and curriculum for ☒ ☐ ☐ weaponless defense and verbal de- escalation techniques include knowing of any pre-existing medical and/or behavioral health conditions that would limit or restrict certain UF techniques. Use of Force training is included in the Counselor Core Training and annual updates for the use of force. (2) acceptable chemical agents and the methods of Procedure 514 Force Options application. BCJH detention staff and supervisors are trained and have available to them, the ☒ ☐ ☐ following types of chemical agent(s): OC (Oleoresin Capsicum) spray canisters (3) signs or symptoms that should result in Procedure 514 Force Options immediate referral to medical or behavioral health. Procedure 514.1 Chemical Agents Decontamination Procedure The Training Manager ensures that all ☒ ☐ ☐ personnel who are authorized in the use of chemical agents have also been trained in the proper medical treatment of person or persons affected by chemical agents. (4)instruction on the Constitutional Limitations of Procedure 514 Force Options Use of Force. ☒ ☐ ☐ 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 17 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5)physical training force options that may require Procedure 514 Force Options the use of perishable skills. The elements of this regulation are identified in Phase One of the training procedure and ☒ ☐ ☐ confirmed in the CPO Melissa Romero’s Appointment and Qualifications Letter dated January 2, 2024. (6)timelines the facility uses to define regular Procedure 514 Force Options training. Youth supervision staff trained and approved ☒ ☐ ☐ to carry OC spray are required to take annual refresher training. 1361 GRIEVANCE PROCEDURE Policy 609 Youth Grievances The facility administrator shall develop and implement BSCC staff reviewed youth grievance written policies and procedures whereby any youth may grievances and due process documentation appeal and have resolved grievances relating to any examples for December 2023 through March condition of confinement, including but not limited to 2024 and reviewed grievance logs from health care services, classification decisions, program October 2023 to the present. ☒ ☐ ☐ participation, telephone, mail or visiting procedures, food, clothing, bedding, mistreatment, harassment or violations of the nondiscrimination policy. There shall be no time limit on filing grievances. Policies and procedures shall include provisions whereby the facility manager ensures: (a) a grievance form and instructions for registering a Policy 609 Youth Grievances grievance, which includes provisions for the youth to have free access to the form; During our physical inspection, we observed that grievance forms were readily available to youth. In addition, grievance lock boxes were in the housing pods to allow youth to ☒ ☐ ☐ confidentially submit a grievance if needed. There is an acknowledgment form signed by staff and the youth acknowledging that the grievance and appeals procedures have been thoroughly explained to the youth. (b) the youth shall have the option to confidentially file Policy 609 Youth Grievances the grievance or to deliver the form to any youth supervision staff working in the facility; The youth were aware of the grievance ☒ ☐ ☐ procedures the location of the grievances and the grievance lockbox to confidentially file a grievance if needed. (c) resolution of the grievance at the lowest appropriate Policy 609 Youth Grievances staff level; The unit supervisor checks the grievance box ☒ ☐ ☐ daily and provides detention staff with a response to the grievance for a resolution. (d) provision for a prompt review and initial response to Policy 609 Youth Grievances grievances within three (3) business days, grievances that relate to health and safety issues must be ☒ ☐ ☐ addressed immediately; (1)The youth may elect to be present to explain his/her Policy 609 Youth Grievances version of the grievance to a person not directly involved in the circumstances which led to the The youth interviewed indicated that during ☒ ☐ ☐ grievance. the intake and orientation process, the grievance procedure was clearly explained. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 18 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2)Provision for a staff representative approved by the Policy 609 Youth Grievances facility administrator to assist the youth. ☒ ☐ ☐ (e)provision for a written response to the grievance Policy 609 Youth Grievances which includes the reasons for the decisions; The documentation as well as interviews ☒ ☐ ☐ show that detention staff respond professionally. (f)a system which provides that any appeal of a Policy 609 Youth Grievances grievance shall be heard by a person not directly involved in the circumstances which led to the ☒ ☐ ☐ grievance; (g)resolution of the grievance must occur within ten The unit supervisor checks the grievance box (10)business days unless circumstances dictate a daily. BSCC staff observed that the facility longer time frame. The youth shall be notified of any sets a standard to respond to grievances delay; and, within 24 hours. However, BSCC staff observed a time when a series of grievances were responded to outside of Title 15 time. The facility cited personnel issues that may ☒ ☐ ☐ have contributed to the mishandling/ misplacement of grievances. BSCC staff provided technical assistance that supervisory staff ensure the proper handling of grievances. We also reminded the facility that the youth shall be notified of any delay. (h)the policy shall provide multiple internal and external Policy 609 Youth Grievances methods to report sexual abuse and sexual harassment. ☒ ☐ ☐ Whether or not associated with a grievance, concerns of Policy 609 Youth Grievances parents, guardians, staff or other parties shall be addressed and documented in accordance with written ☒ ☐ ☐ policies and procedures within a specified timeframe. 1371 PROGRAMS, RECREATION, AND EXERCISE. Policy 1000 Youth Programs and Services 3B Policy 1002 Programs Exercise and The facility administrator shall develop and implement Recreation written policies and procedures for programs, recreation, Procedure 1002 Daily Schedules and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. For the months of January, February, and March of 2024, BSCC staff reviewed the programs provided and their schedules. ☒ ☐ ☐ BSCC staff reviewed the program's daily calendar available to youth. We commend the BCJH for the array of pro-social programming offered to youth detained at the facility. The facility’s policy and procedure are applicable to the elements of this regulation, as required. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 19 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Juvenile facilities shall provide the opportunity for Policy 1002 Programs Exercise and programs, recreation, and exercise a minimum of Recreation three hours a day during the week and five hours a Procedure 1002 Daily Schedules day each Saturday, Sunday or other non-school days, of which one hour shall be an outdoor activity, The program schedules show the programs weather permitting. provided. Technical assistance was provided in suggesting to the agency that to ensure ☒ ☐ ☐ ongoing compliance, individual youth participation and non-participation should be clearly documented on a consistent basis. In addition, clearly indicate the start and end times of programs that were provided during wake hours. A youth’s participation in programs, recreation, and Policy 1002 Programs Exercise and exercise may be suspended only upon a written Recreation finding by the administrator/manager or designee Procedure 1002 Daily Schedules that a youth represents a threat to the safety and security of the facility. ☒ ☐ ☐ There was no documentation provided to indicate a youth’s participation in any program was suspended. Such program, recreation, and exercise schedule Policy 1002 Programs Exercise and shall be posted in the living units. Recreation Procedure 1002 Daily Schedules ☒ ☐ ☐ During the physical facility inspection, we observed program and recreation schedule calendars posted in the living units. There will be a written annual review of the programs, Policy 102 Annual Review and Performance- recreation, and exercise by the responsible agency Based Goals and Objectives to ensure content offered is current, consistent, and Policy 1002 Programs Exercise and relevant to the population. Recreation Procedure 1002 Daily Schedules ☒ ☐ ☐ A memorandum written by Superintendent, Mariah Ruddy, and dated March 6, 2024, confirms an annual review of the programs, recreation, and exercise was reviewed to meet the elements of this regulation. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 20 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Programs. All youth shall be provided with the Policy 1002 Programs Exercise and opportunity for at least one hour of daily programming to Recreation include, but not be limited to, trauma focused, cognitive, Procedure 1002 Daily Schedules evidence-based, best practice interventions that are culturally relevant and linguistically appropriate, or pro- BSCC staff reviewed random Programs social interventions and activities designed to reduce Exercise and Recreation logs, and pertinent recidivism. These programs should be based on the documentation for the months of January, youth’s individual needs as required by Sections 1355 February, and March 2024. We also and 1356. Such programs may be provided under the interviewed youth housed at the facility, direction of the Chief Probation Officer or the County detention staff, behavioral health staff, and Office of Education and can be administered by county education service staff. partners such as mental health agencies, community based organizations, faith-based organizations or The facility provides meaningful programming Probation staff. for youth. In particular, the facility is one of Programs may include but are not limited to: only a few detention facilities to have a Boys (1) Cognitive Behavior Interventions; and Girls Club component that is onsite (2) Management of Stress and Trauma; weekly providing programming services and (3) Anger Management; ☒ ☐ ☐ counseling. The Boys and Girls Club (4) Conflict Resolution; programming includes but is not limited to, (5) Juvenile Justice System; Arts, Character Leadership, Sports and (6) Trauma-related interventions; Recreation, Health Wellness, and College (7) Victim Awareness; Career guidance. The facility also has a (8) Self-Improvement; gardening program, substance abuse (9) Parenting Skills and support; counseling, and programming provided in (10)Tolerance and Diversity; conjunction with education services. (11)Healing Informed Approaches; (12)Interventions by Credible Messengers; Technical assistance was provided in (13)Gender Specific Programming; suggesting to the agency that to ensure (14)Art, creative writing, or self-expression; ongoing compliance, individual youth (15)CPR and First Aid training; participation and non-participation should be (16)Restorative Justice or Civic Engagement; clearly documented on a consistent basis. (17)Career and leadership opportunities; and, BSCC staff provided best practice methods of (18)Other topics suitable to the youth population. daily documentation for the required elements of this regulation. (b)Recreation. All youth shall be provided the opportunity Policy 1002 Programs Exercise and for at least one hour of daily access to unscheduled Recreation activities such as leisure reading, letter writing, and Procedure 1002 Daily Schedules ☒ ☐ ☐ entertainment. Activities shall be supervised and include orientation and may include coaching of youth. (c)Exercise. All youth shall be provided with the Policy 1002 Programs Exercise and opportunity for at least one hour of large muscle Recreation activity each day. Procedure 1002 Daily Schedules After a review of program activity logs, and ☒ ☐ ☐ interviews with youth housed at the facility and detention staff, Butte County JH meets compliance with the Title 15 minimum standards for this regulation The administrator/manager may suspend, for a Policy 1002 Programs Exercise and period not to exceed 24 hours, access to recreation Recreation and programs. The administrator/manager shall ☒ ☐ ☐ document the reasons why suspension of recreation and programs occurs. 7027 Butte Juvenile Detention JH Targeted Inspection PRO 23-24 Page 21 of 21 A453 JUV Targeted PRO eff. 1/2024 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7029 FACILITY NAME: Butte County Probation’s Camp Program also referred to in this FACILITY TYPE: Camp inspection report as the Butte County Camp Condor (BCCC) PERSON(S) INTERVIEWED: Mariah Ruddy, Superintendent; Lorrain Bass, Assistant Superintendent; Tim Bowers, Food Services Supervisor; Nicole Calcutta, Site Director (Boys and Girls Club); Marla Oates, Associate Clinical Social Worker (Youth for Change); Karen Ely, RN; Ayana Venable, Supervising JDO; 1 male youth; Random youth during the tour. FIELD REPRESENTATIVE: Forrest Coleman DATE: March 26, 2024, through April 2, 2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1321 STAFFING Policy 217, Staffing Plan Policy 201, Supervision of Youth Each juvenile facility shall: (a) have an adequate number of personnel sufficient to Butte County Camp Condor is a facility within carry out the overall facility operation and its programming, the Butte County Juvenile Hall (BCJH) to provide for safety and security of youth and staff, and complex and is physically located on a housing meet established standards and regulations; unit within the complex. The facility shares a housing unit with the Butte Secure Treatment Facility also referred to as Commitment to Success Program (CSP) The Butte County Camp Condor and the Juvenile Hall conduct staff training together. Cross-training the staff provides an opportunity to utilize staff from either facility if needed. Further, Butte Camp Condor abides by the same BCJH policies and procedures, as well ☒ ☐ ☐ as the Title 15 regulations including, but not limited to, staffing. BSCC staff reviewed the above policies and procedures, as well as the agency’s Organization Chart, random weekly staff schedule, and daily unit schedule covering the first week of January, February, and March of 2024. In addition, we made personal observations. The above policy identifies all expectations and responsibilities of the Title 15 Regulation minimum standards. The facility’s Superintendent ensures that each shift is staffed with enough youth supervision 1 This document is intended for use as a tool during the inspection process; this worksheet may not contain each Title 15 regulation that is required. Additionally, many regulations on this worksheet are SUMMARIES of the regulation; the text on this worksheet may not contain the entire text of the actual regulation. Please refer to the complete California Code of Regulations, Title 15, Minimum Standards for Local Facilities, Division 1, Chapter 1, Subchapter 5 for the complete list and text of regulations. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 1 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS staff to ensure the overall facility operation and its programming including, but not limited to providing safety and security to youth and to staff while maintaining Title 15 standards. (b) ensure that no required services shall be denied Policy 217, Staffing Plan 4B because of insufficient numbers of staff on duty absent exigent circumstances; As of March 30, 2024, the Butte County Camp Condor Juvenile Detention Officer (JDO) classification will be re-classified to Deputy Probation Officer (DPO). The JDO position will be eliminated. According to the facility Superintendent, the JDO staff will participate in an STC-certified “Transitional DPO CORE” training. This training will provide the elements of DPO CORE that are not included in Counselor CORE training. Also, DPO staff who have an interest to work in the Camp, SYTF and or the BCJH, as youth supervision staff, will have the opportunity to attend a ☒ ☐ ☐ “Transitional Counselor CORE” training. For the purposes of this report, youth supervision staff will be referred to as Juvenile Detention Officers (JDO). At the time of the inspection the Butte County Camp Condor, in conjunction with the Juvenile Hall, has assigned to its facility, the below youth supervision staffing: • 5 Juvenile Detention Officers • 5 Extra Help Juvenile Detention Officers (c) have a sufficient number of supervisory level staff to Policy 217, Staffing Plan 5B ensure adequate supervision of all staff members; Through our review of the above policy, visual observations, work schedules, and interviews with JDO staff and youth housed at the facility, BSCC staff determined that Butte County Camp Condor regularly ensures that there is always a Supervising Juvenile Detention Officer (SJDO) present at the facility on each shift. When the SJDO is absent from the shift, a JDO is assigned to work in the Supervisor’s ☒ ☐ ☐ role, as the “Lead Officer”. At the time of the inspection, in conjunction with the Juvenile Hall, the Butte County Camp Condor supervisory level staffing consisted of: • 1 Supervising Juvenile Detention Officer (5 JH) • 1 Assistant Superintendent • 1 Superintendent 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 2 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d)have a clearly identified person on duty at all times who Policy 217, Staffing Plan 6B is responsible for operations and activities and has completed the Juvenile Corrections Officer Core Course The elements of this regulation are confirmed and PC 832 training; in the Chief Probation Officer (CPO) Appointment and Qualifications Letter, written by CPO Melissa Romero, and dated January 2, 2024. Monday through Friday during standard ☒ ☐ ☐ business hours the facility Superintendent and in her absence, the Assistant Superintendent is responsible for ensuring the daily overall operations of the facility are adequately maintained. In a review of the sign-in to work shift scheduler, a supervisor is clearly always identified and on duty each shift. (e) have at least one staff member present on each living Policy 217, Staffing Plan 7B unit whenever there are youth in the living unit; BSCC staff provided technical assistance in providing clarity that to maintain compliance, the graveyard staff should be stationed on the unit and not in the adjacent JDO office during their shift. Title 15 Regulations, in part, defines a Living Unit as “A living unit that shall not be divided in a way that hinders direct access, ☒ ☐ ☐ supervision, immediate intervention or other action if needed”. Based on this definition an adjoined staff office is not a part of the living unit. Staff can go check in, document filing, answer the phone, use the restroom, etc., but cannot remain stationed in the office for extended periods of time consistently throughout the shift. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 3 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) have sufficient food service personnel relative to the Policy 200 Financial Practices, Section 200. 8B number and security of living units, including staff qualified Policy 217, Staffing Plan and available to: plan menus meeting nutritional requirements of youth; provide kitchen supervision; direct BSCC staff interviewed Food Services staff. food preparation and servings; conduct related training The Food Service Supervisor also performs as programs for culinary staff; and maintain necessary a Cook. The Food Services personnel is as records; or, a facility may serve food that meets nutritional follows: standards prepared by an outside source; • 1 Food Service Supervisor (Cook) • 1 Full-time Cook • 3 Extra Help Cooks BSCC staff observed that the kitchen staffing is at a minimum level, in terms of extra help staff available to work. According to the Camp Superintendent, there are currently two cook applicants in the hiring background process. ☒ ☐ ☐ BSCC staff also observed that there is no Registered Dietician to review menus annually or periodically and provide guidance with, including but not limited to reviewing the kitchen policy manual. The facility is currently in negotiation with contracting with a qualified Registered Dietician. Without the availability of a Registered Dietician and the limited experience of the Supervising Cook, oversight is needed with updating the kitchen Manual. BSCC was informed that a Registered Dietitian will be available by April 21, 2024, to annually review the meal menus. BSCC also discussed the importance of ensuring that a kitchen policy manual is available. (g) have sufficient administrative, clerical, recreational, Policy 201, Supervision of Youth medical, dental, mental health, building maintenance, Policy 217, Staffing Plan transportation, control room, facility security and other support staff for the efficient management of the facility, and BSCC staff interviewed medical services to ensure that youth supervision staff shall not be diverted personnel and contacted behavioral health from supervising youth; and, staff and Camp staff. We also made personal observations over the course of the inspection week. BCCC has one full-time Nurse that works Monday through Friday from 0630 to 1500. ☒ ☐ ☐ There are 2 Licensed Vocational Nurses who cover weekend shifts and as-needed coverage. The facility has contracted with a local community-based organization, identified as “Youth for Change”. The Youth for Change (YFC) provides behavioral health services for youth. The YFC staffing primarily consists of an Associate Clinical Social Worker and a Licensed Clinical Social Worker (Supervisor). 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 4 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) assign sufficient youth supervision staff to provide Policy 201, Supervision of Youth continuous wide awake supervision of youth, subject to Policy 217, Staffing Plan temporary variations in staff assignments to meet special program needs. Staffing shall be in compliance Butte County Camp Condor is a facility within with a minimum youth-staff ratio for the following facility the BCJH complex, located on a housing unit types: within the complex. The Camp shares a housing unit with the Butte SYTF, also identified as the Commitment to Success ☒ ☐ ☐ Program (CSP). Juvenile Detention Officers for all facilities within the Juvenile Hall complex are cross-trained to provide supplemental staff coverage to each facility on an as-needed basis. Further, all the facilities abide by the same BCJH policies and procedures that align with Title 15 regulations. (1)Juvenile Halls Although Butte County Camp Condor is (A) during the hours that youth are awake, one wide- located on a housing unit within the juvenile awake youth supervision staff member on duty for each hall complex, is cross trains with JH staff, and 10 youth in detention; abides by the same policies and procedures as the BCJH, it is independently identified as a ☒ ☐ ☐ Camp type of facility and not a Juvenile Hall facility. Therefore, this Juvenile Hall sub- section (A through E) is not applicable to this facility inspection report. (B) during the hours that youth are confined to their N/A room for the purpose of sleeping, one wide-awake youth supervision staff member on duty for each 30 ☒ ☐ ☐ youth in detention; (C) at least two wide-awake youth supervision staff N/A members on duty at all times, regardless of the number of youth in detention, unless an arrangement has been ☒ ☐ ☐ made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty N/A who is the same gender as youth housed in the facility. ☒ ☐ ☐ (E) personnel with primary responsibility for other duties N/A such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or maintenance shall ☒ ☐ ☐ not be classified as youth supervision staff positions. (2)Special Purpose Juvenile Halls The Butte County Camp Condor is not a (A) during hours that youth are awake, one wide-awake Special Purpose Juvenile Hall. Therefore, the youth supervision staff member on duty for each 10 youth ☐ ☐ ☒ below sub-section (A through E) is not in detention; applicable to this facility. (B) during the hours that youth are confined to their room N/A for the purpose of sleeping, one wide-awake youth supervision staff member on duty for each 30 youth in ☐ ☐ ☒ detention; (C) at least two wide-awake youth supervision staff N/A members on duty at all times, regardless of the number of youth in detention, unless an arrangement has been made ☐ ☐ ☒ for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty N/A who is the same gender as youth housed in the facility. ☐ ☐ ☒ 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 5 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (E) personnel with primary responsibility for other duties N/A such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or maintenance shall ☐ ☐ ☒ not be classified as youth supervision staff positions. (3)Camps Policy 201, Supervision of Youth (A)during the hours that youth are awake, one wide-awake Policy 217, Staffing Plan youth supervision staff member on duty for each 15 youth in the camp population; The Butte County Camp Condor (BCCC) is a facility that exists within the juvenile hall complex. The BCCC shares and cross-trains staff and abides by the same policies and procedures as the BCJH. Therefore, the Butte Camp Condor operates under the same staffing ratios as the BCJH. In a review of housing unit video surveillance recordings, housing unit logs, the daily staff schedule, as well as, through personal ☒ ☐ ☐ observation, the BCCC ensures that “One wide-awake” JDO staff is present and that staffing ratios are consistently in compliance with Title 15 minimum standards for this regulation. Effective March 30, 2024, Butte Camp Condor Juvenile Detention Officers will be reclassified as Deputy Probation Officers. At the time of the inspection, there was 1 Butte County Camp Condor youth who was housed at the facility. (B) during the hours that youth are confined to their room Policy 201, Supervision of Youth for the purpose of sleeping, one wide-awake youth Policy 217, Staffing Plan supervision staff member on duty for each 30 youth present in the facility; Through a review of housing unit logs, the ☒ ☐ ☐ daily staff schedule, personal observations, as well as, through interviews with BCCC staff, the facility regularly ensures that the minimum youth-to-staff ratio is met. (C) at least two wide-awake youth supervision staff Policy 201, Supervision of Youth members on duty at all times, regardless of the Policy 217, Staffing Plan number of youth in residence, unless arrangements ☒ ☐ ☐ have been made for backup support services which allow for immediate response to emergencies; (D) at least one youth supervision staff member on Policy 201, Supervision of Youth duty who is the same gender as youth housed in the facility; Through documentation review, personal observations, as well as, through interviews with youth and BCCC staff, the facility ☒ ☐ ☐ regularly ensures that there are always male and female staff on duty. At the time of this inspection, there were no female youth housed at the Butte County CC. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 6 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (E) in addition to the minimum staff to youth ratio Policy 201, Supervision of Youth required in (h)(3)(A)-(B), consideration shall be given to the size, design, and location of the camp; Only youth supervision staff provide types of youth committed to the camp; and the supervision of the youth. ☒ ☐ ☐ function of the camp in determining the level of supervision necessary to maintain the safety and welfare of youth and staff; (F) personnel with primary responsibility for other Policy 201, Supervision of Youth duties such as administration, supervision of Policy 217, Staffing Plan personnel, academic or trade instruction, clerical, farm, forestry, kitchen or maintenance shall not be The above policy clearly identifies the roles classified as youth supervision staff positions. and responsibilities of staff who are not deemed youth supervision staff. Only youth ☒ ☐ ☐ supervision staff provide supervision of the youth. With the presence of a Core Trained youth supervision staff, youth may assist the Cook in the kitchen with meal prepping. 1328 SAFETY CHECKS Policy 506 Youth Safety Checks 0B The facility administrator shall develop and The facility maintains safety check implement policy and procedures that provide for documentation within the unit logbook. BSCC direct visual observation of youth at a minimum of staff reviewed the unit logbook for the months every 15 minutes, at random or varied intervals of January through March of 2024. We also during hours when youth are asleep or when youth reviewed random video surveillance of Camp are in their rooms, confined in holding cells or Condor staff conducting safety checks. confined to their bed in a dormitory. Supervision is not replaced, but may be supplemented by, an In a review of video surveillance recordings, audio/visual electronic surveillance system showing staff conducting in-room safety designed to detect overt, aggressive or assaultive checks of youth during the graveyard shift, behavior and to summon aid in emergencies. All BSCC staff observed compliance with safety safety checks shall be documented with the actual checks. time the check is completed. However, due to the co-mingling of the documentation for safety checks, youth movements, activity programming, and the ☒ ☐ ☐ shift summary on the same logbook pages, there were inconsistencies with standard safety check documentation requirements. BSCC staff also found it challenging to identify youth who were in and out of their respective rooms. BSCC staff discussed and provided best outcome recommendations that primarily focused on having the ability to clearly review and track safety checks. At a minimum, we suggest that safety checks are recorded on a separate page of the logbook independent of other day-to-day noted information. We noted that the facility has paid for and is in the final stages of implementing the use of the safety check and tracking software, Guardian FRID. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 7 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN Procedure 707 Suicide Prevention and 1B Intervention The facility administrator, in collaboration with the healthcare and behavioral/mental health Within the last year, the facility has contracted administrators, shall plan and implement written with a community-based organization identified policies and procedures which delineate a Suicide as Youth for Change (YFC). Youth for Change Prevention Plan. The plan shall consider the needs provides behavioral health services and of youth experiencing past or current trauma. counselling for the you housed at the facility. Suicide prevention responses shall be respectful The facility is currently incorporating Youth for and in the least invasive manner consistent with the Change into the Suicide Prevention Plan. level of suicide risk. The plan shall include the following elements: Historically, health services through WellPath have aided the facility with suicide behavior assessments and prevention. Their role will not change. BSCC staff observed that, in terms of methods of suicide prevention, and the use of the least invasive manner consistent with the level of ☒ ☐ ☐ suicide risk, WellPath policy (HCD-211_B-05 Suicide Prevention and Intervention program 3.4) provides a blanket method of suicide prevention for all youth. In part, it states, “All personal property and clothing shall be removed from the patient”. However, the BCJH Suicide Prevention Plan states “Staff may elect to have outer clothing removed and wear suicide smock, if the Supervisor, in conjunction with if the mental health professional, feels it is appropriate. BSCC staff discussed the importance of ensuring that both agencies collaborate to ensure corresponding policies and procedures are in alignment with actual practices. The medical staff acknowledged that practices are site-specific and in line with Title 15 regulations. (a) Suicide prevention training as required in Policy 300 Member Orientation Section 1322, Youth Supervision Staff Orientation, Policy 707 Suicide Prevention and Intervention and Training and the Juvenile Corrections Officer Core Course. The elements of this regulation are confirmed in the Chief Probation Officer (CPO) Appointment and Qualifications Letter, written by CPO Melissa Romero, and dated January 2, 2024. ☒ ☐ ☐ In conjunction with the Butte County Juvenile Hall Suicide Prevention Plan, an annual refresher training is included in the BCCC annual training. In addition, staff receive suicide prevention training during Counselor CORE training. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 8 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Screening, Identification Assessment and Policy 400 Emergency Procedures Precautionary Protocols (1)All youth shall be screened for risk of suicide at BCCC youth are initially booked through the intake and as needed during detention. Butte County Juvenile Hall intake and admissions unit. The booking officer communicates with the arresting officer, facility staff, family members, and medical and mental health personnel as part of the screening process for suicide risk. ☒ ☐ ☐ Screening and assessment forms completed at intake include: Detention Risk Assessment and the Intake Screening Questionnaire. Intake staff also communicate with the arresting officer and communicate with the youth’s parent/guardian. (2) All youth supervision staff who perform intake Policy 700 Health Authorities processes shall be trained in screening youth for risk of suicide. The elements of this regulation are confirmed in the CPO appointment and qualifications ☒ ☐ ☐ letter dated January 2, 2024. An annual refresher training is included in the facility's Suicide Prevention Plan. (3) All youth who have been identified during the Policy 400 Emergency Procedures intake screening process to be at risk of suicide shall be referred to behavioral/mental health staff Youths identified during the intake screening for a suicide risk assessment. process to be at risk of suicide shall be seen ☒ ☐ ☐ by a WellPath Behavioral Health therapist within 96 hours of admission. WellPath will refer the youth to behavioral health services, Youth for Change for further assessment. (4) Precautionary protocols shall be developed to Policy 707 Suicide Prevention and Intervention ensure the youth’s safety pending the behavioral/mental health assessment. Per the above policy, youth found to be at risk for suicide are placed on “Suicide Watch” status and remains under direct observation pending behavioral health assessment. Precautionary protocols include, but are not limited to the following: ☒ ☐ ☐ • Maintain constant visual observation. • 5-8 minute watch • Counseling • Contact medical or mental health staff. • Remove only the items decided upon by medical or mental health staff and the supervisor. • Move the youth to a downstairs room. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 9 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Referral process to behavioral/mental health Policy 400 Emergency Procedures staff for assessment and/or services. Procedure 707 Suicide Prevention and Intervention BSCC staff reviewed suicide attempts and/or suicide ideations from the prior March 2023 inspection to the current inspection. We also interviewed Behavioral Health and Medical staff. Per the facility policy, if there is an immediate safety concern, BCCC staff may determine that the youth’s clothing shall be removed. Otherwise, BCCC staff will contact behavioral health and maintain direct observation of the youth pending a behavioral health assessment to remove the youth’s clothing. Further, WellPath medical services are onsite 7 days per week, from 6:45 AM to 7:15 PM. ☒ ☐ ☐ Behavioral Services are onsite up to 3 days per week. (d)Procedures for monitoring of youth identified at Policy 707 Suicide Prevention and Intervention risk for suicide. To monitor youth at risk for suicide, the facility utilizes the following: • Suicide Watch- Direct visual ☒ ☐ ☐ observation. • 5-8 minute Watch • Special Observation- Housing and room items allowed precautions. (e)Safety Interventions Procedure 707 Suicide Prevention and (1)Procedures to address intervention protocols for Intervention youth identified at risk for suicide which may include, but are not limited to: Safety interventions may include but are not ☒ ☐ ☐ (A)Housing consideration limited to, Special Observation- Housing and room items allowed precautions, housed in a downstairs room, and counseling. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 10 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (B)Treatment strategies including trauma-informed Procedure 707 Suicide Prevention and approaches Intervention The elements of this regulation are confirmed in the CPO appointment and qualifications letter dated January 2, 2024. ☒ ☐ ☐ Youth for Change conducts trauma-focused counselling and provides Child and Family Team meetings (CFT). (2) Procedures to instruct youth supervision staff Policy 707 Suicide Prevention and Intervention how to respond to youth who exhibit suicidal behaviors. An annual refresher training that includes trauma-informed approaches is included in the ☒ ☐ ☐ Suicide Prevention Plan. Also, following the prior 2023 comprehensive inspection, staff participated in suicide prevention refresher training. (f)Communication Policy 501 Youth Intake The intake process shall include communication with the arresting officer and family guardians regarding the The booking officer communicates with the youth’s past or present suicidal ideations, behaviors or ☒ ☐ ☐ arresting officer, facility staff, family members, attempts. and medical and mental health personnel in relation to suicide risk. Procedures for clear and current information sharing Procedure 707 Suicide Prevention and about youth at risk for suicide with youth supervision, Intervention healthcare, and behavioral/mental health staff. Butt County Camp Condor ensures the following as part of the documentation and notification process: • Documentation in the logbook and in a Serious Incident Report (SIR) • Communicate with medical/mental ☒ ☐ ☐ health staff to determine their programming needs. • Document on the Suicide watch check-off sheet. • Start a folder with suicide observation forms to document room checks and any special information. • Notify their parents or legal guardian and probation officer. (g) Debriefing of Critical Incidents Related to Suicides or Procedure 707 Suicide Prevention and Attempts Intervention (1)Process for administrative review of the ☒ ☐ ☐ circumstances and responses proceeding, during and after the critical incident. Procedure 707 Suicide Prevention and (2)Process for a debriefing event with affected staff. ☒ ☐ ☐ Intervention (3)Process for a debriefing event with affected youth. Procedure 707 Suicide Prevention and ☒ ☐ ☐ Intervention 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 11 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h)Documentation Procedure 707 Suicide Prevention and (1) Documentation processes shall be developed to Intervention ensure compliance with this regulation Reporting and monitoring documentation is as follows: ☒ ☐ ☐ • Incident Report • Medical Notification • Mental Health Suicide Watch • Observation Sheet Youth identified at risk for suicide shall not be denied Procedure 707 Suicide Prevention and the opportunity to participate in facility programs, Intervention services and activities which are available to other non-suicidal youth, unless deemed necessary for the BSCC staff reviewed incident reports and safety of the youth or security of the facility. Any interviewed BCCC staff and youth housed at ☒ ☐ ☐ deprivation of programs, services or activities for youth the facility. We also interviewed behavioral at risk of suicide shall be documented and approved health and medical services staff. BSCC by the facility manager. determined compliance with this section of the regulation. 1354.5 ROOM CONFINEMENT Policy 601 Safety Removal (Room 2B Confinement) (a)The facility administrator shall develop and implement written policies and procedures addressing BSCC staff requested to review the 15 most the confinement of youth in their room that are consistent recent examples of room confinement-related with Welfare and Institutions Code Section 208.3. The incident reports. However, there was only one placement of a youth in room confinement shall be youth committed to the BCCC and the two accomplished in accordance with the following ☒ ☐ ☐ incidents were from the same youth sole. guidelines: BSCC staff reviewed room confinement logs and interviewed the youth detained at the facility as well as BCCC staff. We also interviewed medical and behavioral health staff to gain further insight. (1)Room confinement shall not be used before other, Policy 601 Safety Removals (Room less restrictive, options have been attempted and Confinement) exhausted, unless attempting those options poses a ☒ ☐ ☐ threat to the safety or security of any youth or staff. BCCC meets Title 15 minimum standards for the elements of this regulation. (2)Room confinement shall not be used for the Policy 601 Safety Removals (Room purposes of punishment, coercion, convenience, or Confinement) retaliation by staff. ☒ ☐ ☐ Documentation supports compliance with this regulation. Room confinement is always used appropriately. (3)Room confinement shall not be used to the extent Policy 601 Safety Removals (Room that it compromises the mental and physical health of Confinement) ☒ ☐ ☐ the youth. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 12 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b)A youth may be held up to four hours in room Policy 601 Safety Removals (Room confinement. After the youth has been held in room Confinement) confinement for a period of four hours, staff shall do one or more of the following: Since the prior inspection, documentation shows that no youth has been held in room confinement beyond the four-hour threshold. The facility uses the following documentation tools to help track and log room confinement include, but are not limited to: ☒ ☐ ☐ • Administration Separation Monitoring Log • Pod Logbook • Safety and Security Behavioral Removal log Administrative Separation Check-Off Log. Policy 601 Safety Removals (Room (1)Return the youth to general population. Confinement) ☒ ☐ ☐ Policy 601 Safety Removals (Room Confinement) (2)Consult with mental health or medical staff. Per policy, if after one hour the youth’s ☒ ☐ ☐ behavior continues to be a threat to facility safety and security, the facility LMFT may be contacted to assess and counsel the youth. (3)Develop an individualized plan that includes the Policy 601 Safety Removals (Room goals and objectives to be met in order to reintegrate Confinement) the youth to general population. ☒ ☐ ☐ Individualized plans are identified as Behavior Modification Plans. (4)If room confinement must be extended beyond four Policy 601 Safety Removals (Room hours, staff shall do each of the following: Confinement) (A)Document the reasons for room confinement and the basis for the extension, the date and ☒ ☐ ☐ Since the prior inspection, documentation time the youth was first placed in room shows that no youth has been held in room confinement, and when he or she is eventually confinement beyond the four-hour threshold. released from room confinement. (B)Develop an individualized plan that includes Policy 601 Safety Removals (Room the goals and objectives to be met in order to Confinement) integrate the youth to general population. ☒ ☐ ☐ The facility utilizes an Administrative Separation Form that complies with the elements of this regulation. (C) Obtain documented authorization by the Policy 601 Safety Removals (Room facility superintendent or his or her designee Confinement) ☒ ☐ ☐ every four hours thereafter. (5) This section is not intended to limit the use of Policy 601 Safety Removals (Room single-person rooms or cells for the housing of youth Confinement) in juvenile facilities and does not apply to normal ☒ ☐ ☐ sleeping hours. (6) This section does not apply to youth or wards in Policy 601 Safety Removals (Room court holding facilities or adult facilities. ☒ ☐ ☐ Confinement) 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 13 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (7) Nothing in this section shall be construed to Policy 601 Safety Removals (Room conflict with any law providing greater or additional Confinement) ☒ ☐ ☐ protections to youth. (8) This section does not apply during an Policy 601 Safety Removals (Room extraordinary emergency circumstance that requires Confinement) a significant departure from normal institutional operations, including a natural disaster or facility-wide threat that poses an imminent and substantial risk of ☒ ☐ ☐ harm to multiple staff or youth. This exception shall apply for the shortest amount of time needed to address this imminent and substantial risk of harm. (9)This section does not apply when a youth is placed Policy 601 Safety Removals (Room in a locked cell or sleeping room to treat and protect Confinement) against the spread of a communicable disease for the shortest amount of time required to reduce the risk of infection, with the written approval of a licensed physician or nurse practitioner, when the youth is not required to be in an infirmary for an illness. ☒ ☐ ☐ Additionally, this section does not apply when a youth is placed in a locked cell or sleeping room for required extended care after medical treatment with the written approval of a licensed physician or nurse practitioner, when the youth is not required to be in an infirmary for illness. 1357 USE OF FORCE Policy 305 Chemical Agents Training Procedure 514.1 The facility administrator, in cooperation with the Policy 514 Use of Force responsible physician, shall develop and implement Procedure 514 Force Options written policies and procedures for the use of force, which Policy 515 Restraints may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. BSCC Staff observed that only two reports (a)At a minimum, each facility shall develop policies and resulting in the use of force were reported to procedures which: ☒ ☐ ☐ have occurred in the prior six months. This includes the three incident reports involving the use of OC pepper spray. We also interviewed youth housed at the facility and Camp staff. We also interviewed collaborative partners to gain further insight to confirm compliance with this regulation. (1) restricts the use of force to that which is deemed Policy 514 Use of Force reasonable and necessary, as defined in Section 1302 Procedure 514 Force Options to ensure the safety and security of youth, staff, others Procedure 514.1 Chemical Agents and the facility. Decontamination Procedure ☒ ☐ ☐ In review, or reports and interviews with youth, BCCC JDO staff utilized use force that was deemed reasonable and necessary. (2)outline the force options available to staff including Policy 514 Use of Force both physical and non-physical options and define Procedure 514 Force Options when those force options are appropriate. BCCC staff receive an initial 4-hour weaponless defensive training and policy ☒ ☐ ☐ review outlining both physical and non- physical de-escalation options. An additional 4 hours of refresher training occur annually. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 14 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (3) describe force options or techniques that are Policy 514 Use of Force expressly prohibited by the facility. Procedure 514 Force Options BCCC’s Use of Force Options includes the following: • Verbal Commands • OC Spray ☒ ☐ ☐ • Soft Hands/ Physical Escort • Hard hands/Full Restraint • Strikes/Kicks • Convex Shield • Mechanical Restraints (4)describe the requirements of staff to report any Policy 514 Use of Force inappropriate use of force, and to take affirmative Procedure 514 Force Options ☒ ☐ ☐ action to immediately stop it. (5)define a standardized reporting format that includes Policy 514 Use of Force time period and procedure for documenting and Procedure 514 Force Options reporting the use of force, including reporting requirements of management and line staff and procedures for reviewing and tracking use of force BCCC staff must complete use-of-force incidents by supervisory and or management staff, Incident Reports prior to ending his/her shift. ☒ ☐ ☐ which include procedures for debriefing a particular Supervisory reviews are conducted prior to the incident with staff and/or youth for the purposes of end of the shift that the incident occurred. training as well as mitigating the effects of trauma that Reviews and debriefings were clearly may have been experienced by staff and /or the youth documented in Incident Reports. involved. (6)Include an administrative review and a system for Policy 514 Use of Force investigating unreasonable use of force. Procedure 514 Force Options Through a review of the Use of Force incident reports, we observe that the supervisor ☒ ☐ ☐ provides a final analysis and debrief of the incident. Also, the Superintendent reviews the use of force incident reports to ensure the use of force was in accordance with facility policy. (7)define the role, notification, and follow-up Policy 514 Use of Force procedures required after use of force incidents for Procedure 514 Force Options medical, mental health staff and parents or legal guardians. BSCC staff interviewed supervisory, detention, ☒ ☐ ☐ and medical staff to help determine compliance with the elements of this regulation. (8)describe the limitations of use of force on pregnant Policy 307 Health Care Orientation and youth in accordance with Penal Code Section 6030(f) Training and Welfare and Institutions Code Section 222. ☒ ☐ ☐ Policy 514 Use of Force Policy 515 Restraints 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 15 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Facilities that authorize chemical agents as a force Policy 305 Chemical Agents Training option shall include policies and procedures that: Policy 514 Use of Force (1)identify who is approved to carry and/or utilize Procedure 514.1 Chemical Agents chemical agents in the facility and the type, size and Decontamination Procedure the approved method of deployment for those chemical agents. Three incidents involving the use of chemical agents (OC spray) were reported. All three ☒ ☐ ☐ use-of-force reports involved the same youth. BSCC staff observed that BCCC staff satisfactorily completed the department's eight-hour, STC-approved Chemical Agents course prior to being approved to carry OC spray. (2)mandate that chemical agents only be used Policy 514 Use of Force when there is an imminent threat to the youth’s safety or the safety of others and only when de- escalation efforts have been unsuccessful or are not In a review of the Incident Reports, in most ☒ ☐ ☐ reasonably possible. cases, chemical agents were used to de- escalate youth-on-youth mutual physical combat. (3)outline the facility’s approved methods and Policy 514 Use of Force timelines for decontamination from chemical agents. Procedure 514.1 Chemical Agents This shall include that youth who have been Decontamination Procedure exposed to chemical agents shall not be left ☒ ☐ ☐ unattended until that youth is fully decontaminated or BSCC staff interviewed medical personnel, is no longer suffering the effects of the chemical youth housed at the facility, JDO staff, and agent. supervisors. Compliance was confirmed. (4) define the role, notification, and follow-up Policy 514 Use of Force procedures required after use of force incidents involving chemical agents for medical, mental health ☒ ☐ ☐ staff and parents or legal guardians. (5) provide for the documentation of each incident of Policy 514 Use of Force use of chemical agents, including the reasons for Procedure 514.1 Chemical Agents which it was used, efforts to de-escalate prior to use, Decontamination Procedure youth and staff involved, the date, time and location ☒ ☐ ☐ of use, decontamination procedures applied and Incident Reports reviewed meet the Title 15 identification of any injuries sustained as a result of minimum standards for this regulation. such use. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 16 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Facilities shall develop policies and procedure which Policy 305 Chemical Agents Training require that agencies provide initial and regular training in Procedure 514 Force Options use of force and chemical agents when appropriate that address: The elements of this regulation are identified in (1) known medical and behavioral health conditions Phase One of the training procedure and that would contraindicate certain types of force; confirmed in the CPO Melissa Romero’s Appointment and Qualifications Letter dated January 2, 2024. The referenced policy and curriculum for ☒ ☐ ☐ weaponless defense and verbal de-escalation techniques include knowing of any pre-existing medical and/or behavioral health conditions that would limit or restrict certain UF techniques. Use of Force training is included in the Counselor Core Training and annual updates for the use of force. (2) acceptable chemical agents and the methods of Procedure 514 Force Option application. BCCC staff and supervisors are trained and have available to them, the following types of ☒ ☐ ☐ chemical agent(s): OC (Oleoresin Capsicum) spray canisters (3)signs or symptoms that should result in immediate Procedure 514 Force Options referral to medical or behavioral health. Procedure 514.1 Chemical Agents Decontamination Procedure The Training Manager ensures that all ☒ ☐ ☐ personnel who are authorized in the use of chemical agents have also been trained in the proper medical treatment of persons or persons affected by chemical agents. (4)instruction on the Constitutional Limitations of Procedure 514 Force Options Use of Force. ☒ ☐ ☐ (5)physical training force options that may require Procedure 514 Force Options the use of perishable skills. The elements of this regulation are identified in Phase One of the training procedure and ☒ ☐ ☐ confirmed in the CPO Melissa Romero’s Appointment and Qualifications Letter dated January 2, 2024. (6)timelines the facility uses to define regular Procedure 514 Force Options training. Youth supervision staff trained and approved ☒ ☐ ☐ to carry OC spray are required to take annual refresher training. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 17 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1361 GRIEVANCE PROCEDURE Policy 609 Youth Grievances The facility administrator shall develop and implement BSCC staff reviewed youth grievance written policies and procedures whereby any youth may grievances and due process documentation appeal and have resolved grievances relating to any examples for December 2023 through March condition of confinement, including but not limited to 2024 and reviewed grievance logs from health care services, classification decisions, program October 2023 to the present. ☒ ☐ ☐ participation, telephone, mail or visiting procedures, food, clothing, bedding, mistreatment, harassment or violations of the nondiscrimination policy. There shall be no time limit on filing grievances. Policies and procedures shall include provisions whereby the facility manager ensures: (a) a grievance form and instructions for registering a Policy 609 Youth Grievances grievance, which includes provisions for the youth to have free access to the form; During our physical inspection, we observed that grievance forms were readily available to youth. In addition, grievance lock boxes were in the housing pods to allow youth to ☒ ☐ ☐ confidentially submit a grievance if needed. There is an acknowledgment form signed by staff and the youth acknowledging that the grievance and appeals procedures have been thoroughly explained to the youth. (b)the youth shall have the option to confidentially file the Policy 609 Youth Grievances grievance or to deliver the form to any youth supervision staff working in the facility; The youth were aware of the grievance ☒ ☐ ☐ procedures the location of the grievances and the grievance lockbox to confidentially file a grievance if needed. (c) resolution of the grievance at the lowest appropriate Policy 609 Youth Grievances staff level; The unit supervisor checks the grievance box ☒ ☐ ☐ daily and provides detention staff with a response to the grievance for a resolution. (d) provision for a prompt review and initial response to Policy 609 Youth Grievances grievances within three (3) business days, grievances that relate to health and safety issues must be addressed ☒ ☐ ☐ immediately; (1)The youth may elect to be present to explain his/her Policy 609 Youth Grievances version of the grievance to a person not directly involved in the circumstances which led to the grievance. The youth interviewed indicated that during the ☒ ☐ ☐ intake and orientation process, the grievance procedure was clearly explained. (2)Provision for a staff representative approved by the Policy 609 Youth Grievances facility administrator to assist the youth. ☒ ☐ ☐ (e)provision for a written response to the grievance Policy 609 Youth Grievances which includes the reasons for the decisions; ☒ ☐ ☐ The documentation as well as interviews show that detention staff respond professionally. (f)a system which provides that any appeal of a Policy 609 Youth Grievances grievance shall be heard by a person not directly ☒ ☐ ☐ involved in the circumstances which led to the grievance; 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 18 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g)resolution of the grievance must occur within ten (10) Policy 609 Youth Grievances business days unless circumstances dictate a longer time frame. The youth shall be notified of any delay; The unit supervisor checks the grievance box and, daily. BSCC staff observed that the facility sets a standard to respond to grievances within 24 hours. However, BSCC staff observed a time when a series of grievances were responded ☒ ☐ ☐ to outside of Title 15 time. The facility cited personnel issues that may have contributed to the mishandling/ misplacement of grievances. BSCC staff provided technical assistance that supervisory staff ensure the proper handling of grievances. We also reminded the facility that the youth shall be notified of any delay. (h) the policy shall provide multiple internal and external Policy 609 Youth Grievances methods to report sexual abuse and sexual harassment. ☒ ☐ ☐ Whether or not associated with a grievance, concerns of Policy 609 Youth Grievances parents, guardians, staff or other parties shall be addressed and documented in accordance with written ☒ ☐ ☐ policies and procedures within a specified timeframe. 1371 PROGRAMS, RECREATION, AND EXERCISE. Policy 1000 Youth Programs and Services 3B Policy 1002 Programs Exercise and The facility administrator shall develop and implement Recreation written policies and procedures for programs, recreation, Procedure 1002 Daily Schedules and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. For the months of January, February, and March of 2024, BSCC staff reviewed the programs provided and their schedules. BSCC staff reviewed the program's daily calendar ☒ ☐ ☐ available to youth. We commend the Butte County Camp Condor for the array of pro- social programming offered to youth detained at the facility. The facility’s policy and procedure are applicable to the elements of this regulation, as required. Juvenile facilities shall provide the opportunity for Policy 1002 Programs Exercise and programs, recreation, and exercise a minimum of Recreation three hours a day during the week and five hours a day Procedure 1002 Daily Schedules each Saturday, Sunday or other non-school days, of which one hour shall be an outdoor activity, weather The program schedules show the programs permitting. provided. Technical assistance was provided in suggesting to the agency that to ensure ☒ ☐ ☐ ongoing compliance, individual youth participation and non-participation should be clearly documented on a consistent basis. In addition, clearly indicate the start and end times of programs that were provided during wake hours. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 19 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS A youth’s participation in programs, recreation, and Policy 1002 Programs Exercise and exercise may be suspended only upon a written finding Recreation by the administrator/manager or designee that a youth Procedure 1002 Daily Schedules represents a threat to the safety and security of the facility. ☒ ☐ ☐ There was no documentation provided to indicate a youth’s participation in any program was suspended. Such program, recreation, and exercise schedule shall Policy 1002 Programs Exercise and be posted in the living units. Recreation Procedure 1002 Daily Schedules ☒ ☐ ☐ During the physical facility inspection, we observed program and recreation schedule calendars posted in the living units. There will be a written annual review of the programs, Policy 102 Annual Review and Performance- recreation, and exercise by the responsible agency to Based Goals and Objectives ensure content offered is current, consistent, and Policy 1002 Programs Exercise and relevant to the population. Recreation Procedure 1002 Daily Schedules ☒ ☐ ☐ A memorandum written by Superintendent, Mariah Ruddy, and dated March 6, 2024, confirms an annual review of the programs, recreation, and exercise was reviewed to meet the elements of this regulation. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 20 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Programs. All youth shall be provided with the Policy 1002 Programs Exercise and opportunity for at least one hour of daily programming to Recreation include, but not be limited to, trauma focused, cognitive, Procedure 1002 Daily Schedules evidence-based, best practice interventions that are culturally relevant and linguistically appropriate, or pro- BSCC staff reviewed random Programs social interventions and activities designed to reduce Exercise and Recreation logs, and pertinent recidivism. These programs should be based on the documentation for the months of January, youth’s individual needs as required by Sections 1355 and February, and March 2024. We also 1356. Such programs may be provided under the direction interviewed youth housed at the facility, of the Chief Probation Officer or the County Office of detention staff, behavioral health staff, and Education and can be administered by county partners education service staff. such as mental health agencies, community based organizations, faith-based organizations or Probation staff. The facility provides meaningful programming Programs may include but are not limited to: for youth. In particular, the facility is one of only (1) Cognitive Behavior Interventions; a few detention facilities to have a Boys and (2) Management of Stress and Trauma; Girls Club component at the facility that is (3) Anger Management; onsite weekly providing programming services (4) Conflict Resolution; ☒ ☐ ☐ and counseling. The Boys and Girls Club (5) Juvenile Justice System; programming includes but is not limited to, (6) Trauma-related interventions; Arts, Character Leadership, Sports and (7) Victim Awareness; Recreation, Health Wellness, and College (8) Self-Improvement; Career guidance. The facility also has a (9) Parenting Skills and support; gardening program, substance abuse (10)Tolerance and Diversity; counseling, and programming provided in (11)Healing Informed Approaches; conjunction with education services. (12)Interventions by Credible Messengers; (13)Gender Specific Programming; Technical assistance was provided in (14)Art, creative writing, or self-expression; suggesting to the agency that to ensure (15)CPR and First Aid training; ongoing compliance, individual youth (16)Restorative Justice or Civic Engagement; participation and non-participation should be (17)Career and leadership opportunities; and, clearly documented on a consistent basis. (18)Other topics suitable to the youth population. BSCC also staff provided best practice methods of daily documentation for the required elements of this regulation. (b) Recreation. All youth shall be provided the opportunity Policy 1002 Programs Exercise and for at least one hour of daily access to unscheduled Recreation activities such as leisure reading, letter writing, and Procedure 1002 Daily Schedules ☒ ☐ ☐ entertainment. Activities shall be supervised and include orientation and may include coaching of youth. (c)Exercise. All youth shall be provided with the Policy 1002 Programs Exercise and opportunity for at least one hour of large muscle Recreation activity each day. Procedure 1002 Daily Schedules After a review of program activity logs, and ☒ ☐ ☐ interviews with youth housed at the facility and detention staff, Butte County Camp Condor meets compliance with the Title 15 minimum standards for this regulation The administrator/manager may suspend, for a Policy 1002 Programs Exercise and period not to exceed 24 hours, access to recreation Recreation and programs. The administrator/manager shall ☒ ☐ ☐ document the reasons why suspension of recreation and programs occurs. 7029 Butte County Probation’s Camp Program CAMP PRO 23-24 Page 21 of 21 A453 JUV Targeted PRO eff. 1/2024 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7030 FACILITY NAME: Butte Secure Youth Treatment Facility/ Commitment to Success FACILITY TYPE: SYTF Program (CSP) PERSON(S) INTERVIEWED: Mariah Ruddy, Superintendent; Lorrain Bass, Assistant Superintendent; Tim Bowers, Food Services Supervisor; Nicole Calcutta, Site Director (Boys and Girls Club); Marla Oates, Associate Clinical Social Worker (Youth for Change); Karen Ely, RN; Ayana Venable, Supervising JDO; 1 male youth; Random youth during the tour. FIELD REPRESENTATIVE: Forrest Coleman DATE: March 26, 2024, through April 2, 2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1321 STAFFING Policy 217, Staffing Plan Policy 201, Supervision of Youth Each juvenile facility shall: (a) have an adequate number of personnel sufficient to Butte County Secure Youth Treatment Facility carry out the overall facility operation and its programming, is a facility within the Butte County Juvenile to provide for safety and security of youth and staff, and Hall (BCJH) complex and is physically located meet established standards and regulations; on a housing unit within the complex. The Secure Youth Treatment Facility and the Juvenile Hall conduct staff training together. Cross-training the staff provides an opportunity to utilize staff from either facility if needed. Further, Secure Youth Treatment Facility abides by the same BCJH policies and procedures, as well as the Title 15 regulations including, but not limited to, staffing. BSCC staff reviewed the above policies and ☒ ☐ ☐ procedures, as well as the agency’s Organization Chart, random weekly staff schedule, and daily unit schedule covering the first week of January, February, and March of 2024. In addition, we made personal observations. The above policy identifies all expectations and responsibilities of the Title 15 Regulation minimum standards. The facility’s Superintendent ensures that each shift is staffed with enough youth supervision staff to ensure the overall facility operation and its programming including, but not limited to providing safety and security to youth and to staff while maintaining Title 15 standards. 1 This document is intended for use as a tool during the inspection process; this worksheet may not contain each Title 15 regulation that is required. Additionally, many regulations on this worksheet are SUMMARIES of the regulation; the text on this worksheet may not contain the entire text of the actual regulation. Please refer to the complete California Code of Regulations, Title 15, Minimum Standards for Local Facilities, Division 1, Chapter 1, Subchapter 5 for the complete list and text of regulations. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 1 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) ensure that no required services shall be denied Policy 217, Staffing Plan 4B because of insufficient numbers of staff on duty absent exigent circumstances; As of March 30, 2024, the Butte County Juvenile Detention Officer (JDO) classification will be re-classified to Deputy Probation Officer (DPO). The JDO position will be eliminated. According to the facility Superintendent, the JDO staff will participate in an STC-certified “Transitional DPO CORE” training. This training will provide the elements of DPO CORE that are not included in Counselor CORE training. Also, DPO staff who have an interest to work in the SYTF and or the BCJH, as youth supervision staff, will have the ☒ ☐ ☐ opportunity to attend a “Transitional Counselor CORE” training. For the purposes of this report, youth supervision SYTF staff will be referred to as Juvenile Detention Officers (JDO). At the time of the inspection the Butte County Secure Youth Treatment Facility has assigned to its facility, the below youth supervision staffing: 5 Juvenile Detention Officers 5 Extra Help Juvenile Detention Officers (c) have a sufficient number of supervisory level staff to Policy 217, Staffing Plan 5B ensure adequate supervision of all staff members; Through our review of the above policy, visual observations, work schedules and interviews with JDO staff and youth housed at the facility, BSCC staff determined that Butte County SYTF regularly ensures that there is always a Supervising Juvenile Detention Officer (SJDO) present at the facility on each shift. When the SJDO is absent from the shift, a JDO is assigned to work in the Supervisor’s role, as ☒ ☐ ☐ the “Lead Officer”. At the time of the inspection, the Butte County Secure Youth Treatment Facility supervisory level staffing consisted of: • 1 Supervising Juvenile Detention Officer (5 JH) • 1 Assistant Superintendent • 1 Superintendent 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 2 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d)have a clearly identified person on duty at all times who Policy 217, Staffing Plan 6B is responsible for operations and activities and has completed the Juvenile Corrections Officer Core Course The elements of this regulation are confirmed and PC 832 training; in the Chief Probation Officer (CPO) Appointment and Qualifications Letter, written by CPO Melissa Romero, and dated January 2, 2024. Monday through Friday during standard ☒ ☐ ☐ business hours the facility Superintendent and in her absence, the Assistant Superintendent is responsible for ensuring the daily overall operations of the facility are adequately maintained. In a review of the sign-in to work shift scheduler, a supervisor is clearly always identified and on duty each shift. (e) have at least one staff member present on each living Policy 217, Staffing Plan 7B unit whenever there are youth in the living unit; BSCC staff provided technical assistance in providing clarity that to maintain compliance, the graveyard staff should be stationed on the unit and not in the adjacent JDO office during their shift. Title 15 Regulations, in part, defines a Living Unit as “A living unit that shall not be divided in a way that hinders direct access, ☒ ☐ ☐ supervision, immediate intervention or other action if needed”. Based on this definition an adjoined staff office is not a part of the living unit. Staff can go check in, document filing, answer the phone, use the restroom, etc., but cannot remain stationed in the office for extended periods of time consistently throughout the shift. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 3 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) have sufficient food service personnel relative to the Policy 200 Financial Practices, Section 200. 8B number and security of living units, including staff qualified Policy 217, Staffing Plan and available to: plan menus meeting nutritional requirements of youth; provide kitchen supervision; direct BSCC staff interviewed Food Services staff. food preparation and servings; conduct related training The Food Service Supervisor also performs as programs for culinary staff; and maintain necessary a Cook. The Food Services personnel is as records; or, a facility may serve food that meets nutritional follows: standards prepared by an outside source; • 1 Food Service Supervisor (Cook) • 1 Full-time Cook • 3 Extra Help Cooks BSCC staff observed that the kitchen staffing is at a minimum level, in terms of extra help staff available to work. According to the SYTF Superintendent, there are currently two cook ☒ ☐ ☐ applicants in the hiring background process. BSCC staff also observed that there is no Registered Dietician to review menus annually or periodically and provide guidance with, including but not limited to reviewing the kitchen policy manual. The facility is currently in negotiation with contracting with a qualified Registered Dietician. Without the availability of a Registered Dietician and the limited experience of the Supervising Cook, oversight is needed with updating the kitchen Manual. BSCC was informed that a Registered Dietitian will be available by April 21, 2024, to annually review the meal menus. BSCC also discussed the importance of ensuring that a kitchen policy manual is available. (g) have sufficient administrative, clerical, recreational, Policy 201, Supervision of Youth medical, dental, mental health, building maintenance, Policy 217, Staffing Plan transportation, control room, facility security and other support staff for the efficient management of the facility, and BSCC staff interviewed medical services to ensure that youth supervision staff shall not be diverted personnel, contracted behavioral health staff, from supervising youth; and, and SYTF staff. We also made personal observations over the inspection week. SYTF has one full-time Nurse that works Monday through Friday from 0630 to 1500. ☒ ☐ ☐ Two Licensed Vocational Nurses cover weekend shifts and as-needed coverage. The facility has contracted with a local community-based organization, identified as “Youth for Change”. The Youth for Change (YFC) provides behavioral health services for youth. The YFC staffing primarily consists of an Associate Clinical Social Worker and a Licensed Clinical Social Worker (Supervisor). 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 4 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) assign sufficient youth supervision staff to provide Policy 201, Supervision of Youth continuous wide awake supervision of youth, subject to Policy 217, Staffing Plan temporary variations in staff assignments to meet special program needs. Staffing shall be in compliance Butte County Secure Youth Treatment Facility with a minimum youth-staff ratio for the following facility is a detention facility within the BCJH complex, types: located on a housing unit within the complex. As well the Butte SYTF, also identified as the Commitment to Success Program (CSP) is a ☒ ☐ ☐ facility with the BCJH complex. The Camp, the SYTF/CSP, and the Juvenile Hall are cross- training to provide supplemental staff coverage to each facility on an as-needed basis. Further, all three facilities abide by the same BCJH policies and procedures that align with Title 15 regulations. (1)Juvenile Halls Although Butte County Secure Youth (A) during the hours that youth are awake, one wide- Treatment Facility is located in a housing unit awake youth supervision staff member on duty for each within the juvenile hall complex, cross-trains 10 youth in detention; with JH staff, and abides by the same policies and procedures as the BCJH, it is ☒ ☐ ☐ independently identified as a Secure Youth Treatment type of facility and not a Juvenile Hall facility. Therefore, this Juvenile Hall sub- section (A through E) is not applicable to this facility inspection report. (B) during the hours that youth are confined to their N/A room for the purpose of sleeping, one wide-awake youth supervision staff member on duty for each 30 ☒ ☐ ☐ youth in detention; (C) at least two wide-awake youth supervision staff N/A members on duty at all times, regardless of the number of youth in detention, unless an arrangement has been ☒ ☐ ☐ made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty N/A who is the same gender as youth housed in the facility. ☒ ☐ ☐ (E) personnel with primary responsibility for other duties N/A such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or maintenance shall ☒ ☐ ☐ not be classified as youth supervision staff positions. (2)Special Purpose Juvenile Halls The Butte County Secure Youth Treatment (A) during hours that youth are awake, one wide-awake Facility is not a Special Purpose Juvenile Hall. youth supervision staff member on duty for each 10 youth ☐ ☐ ☒ Therefore, the below section (A through E) is in detention; not applicable to this facility. (B) during the hours that youth are confined to their room N/A for the purpose of sleeping, one wide-awake youth supervision staff member on duty for each 30 youth in ☐ ☐ ☒ detention; (C) at least two wide-awake youth supervision staff N/A members on duty at all times, regardless of the number of youth in detention, unless an arrangement has been made ☐ ☐ ☒ for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty N/A who is the same gender as youth housed in the facility. ☐ ☐ ☒ 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 5 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (E) personnel with primary responsibility for other duties N/A such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or maintenance shall ☐ ☐ ☒ not be classified as youth supervision staff positions. (3)Camps Policy 201, Supervision of Youth (A)during the hours that youth are awake, one wide-awake Policy 217, Staffing Plan youth supervision staff member on duty for each 15 youth in the camp population; The Butte County Secure Youth Treatment Facility is a facility that exists within the juvenile hall complex. The SYTF shares and cross-trains staff and abides by the same policies and procedures as the BCJH. Therefore, the Secure Youth Treatment Facility operates under the same staffing ratios as the BCJH. In a review of housing unit video surveillance recordings, housing unit logs, and the daily staff schedule, as well as, through personal ☒ ☐ ☐ observation, the SYTF ensures that “One wide-awake” JDO staff is present and that staffing ratios are consistently in compliance with Title 15 minimum standards for this regulation. Effective March 30, 2024, Secure Youth Treatment Facility Juvenile Detention Officers will be reclassified as Deputy Probation Officers. At the time of the inspection, there were 6 SYTF/ Commitment to Success Program youth who were housed at the facility. (B) during the hours that youth are confined to their room Policy 201, Supervision of Youth for the purpose of sleeping, one wide-awake youth Policy 217, Staffing Plan supervision staff member on duty for each 30 youth present in the facility; Through a review of housing unit logs, the ☒ ☐ ☐ daily staff schedule, personal observations, as well as, through interviews with SYTF staff, the facility regularly ensures that the minimum youth-to-staff ratio is met. (C) at least two wide-awake youth supervision staff Policy 201, Supervision of Youth members on duty at all times, regardless of the Policy 217, Staffing Plan number of youth in residence, unless arrangements ☒ ☐ ☐ have been made for backup support services which allow for immediate response to emergencies; (D) at least one youth supervision staff member on Policy 201, Supervision of Youth duty who is the same gender as youth housed in the facility; Through documentation review, personal observations, as well as, through interviews with youth and SYTF staff, SYTF regularly ensures that there are always male and female ☒ ☐ ☐ staff on duty. At the time of this inspection, there were no female youth housed at the Butte County SYTF. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 6 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (E) in addition to the minimum staff to youth ratio Policy 201, Supervision of Youth required in (h)(3)(A)-(B), consideration shall be given to the size, design, and location of the camp; Only youth supervision staff provide types of youth committed to the camp; and the supervision of the youth. ☒ ☐ ☐ function of the camp in determining the level of supervision necessary to maintain the safety and welfare of youth and staff; (F) personnel with primary responsibility for other Policy 201, Supervision of Youth duties such as administration, supervision of Policy 217, Staffing Plan personnel, academic or trade instruction, clerical, farm, forestry, kitchen or maintenance shall not be The above policy clearly identifies the roles classified as youth supervision staff positions. and responsibilities of staff who are not deemed youth supervision staff. Only youth ☒ ☐ ☐ supervision staff provide supervision of the youth. With the presence of a Core Trained youth supervision staff, youth may assist the Cook in the kitchen with meal prepping. 1328 SAFETY CHECKS Policy 506 Youth Safety Checks 0B The facility administrator shall develop and The facility maintains safety check implement policy and procedures that provide for documentation within the unit logbook. BSCC direct visual observation of youth at a minimum of staff reviewed the unit logbook for the months every 15 minutes, at random or varied intervals of January through March of 2024. We also during hours when youth are asleep or when youth reviewed random video surveillance of SYTF are in their rooms, confined in holding cells or staff conducting safety checks. confined to their bed in a dormitory. Supervision is not replaced, but may be supplemented by, an In a review of video surveillance recordings, audio/visual electronic surveillance system showing staff conducting in-room safety designed to detect overt, aggressive or assaultive checks of youth during the graveyard shift, behavior and to summon aid in emergencies. All BSCC staff observed compliance with safety safety checks shall be documented with the actual checks. time the check is completed. However, due to the co-mingling of the documentation for safety checks, youth movements, activity programming, and the ☒ ☐ ☐ shift summary on the same logbook pages, there were inconsistencies with standard safety check documentation requirements. BSCC staff also found it challenging to identify youth who were in and out of their respective rooms. BSCC staff discussed and provided best outcome recommendations that primarily focused on having the ability to clearly review and track safety checks. At a minimum, we suggest that safety checks are recorded on a separate page of the logbook independent of other day-to-day noted information. We noted that the facility has paid for and is in the final stages of implementing the use of the safety check and tracking software, Guardian FRID. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 7 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN Procedure 707 Suicide Prevention and 1B Intervention The facility administrator, in collaboration with the healthcare and behavioral/mental health Within the last year, the facility has contracted administrators, shall plan and implement written with a community-based organization identified policies and procedures which delineate a Suicide as Youth for Change (YFC). Youth for Change Prevention Plan. The plan shall consider the needs provides behavioral health services and of youth experiencing past or current trauma. counseling for the you housed at the facility. Suicide prevention responses shall be respectful The facility is currently incorporating Youth for and in the least invasive manner consistent with the Change into the Suicide Prevention Plan. level of suicide risk. The plan shall include the following elements: Historically, health services through WellPath have aided the facility with suicide behavior assessments and prevention. Their role will not change. BSCC staff observed that, in terms of methods of suicide prevention, and the use of the least invasive manner consistent with the level of ☒ ☐ ☐ suicide risk, WellPath policy (HCD-211_B-05 Suicide prevention and Intervention program 3.4) provides a blanket method of suicide prevention for all youth. In part, it states, “All personal property and clothing shall be removed from the patient”. However, the BCJH Suicide Prevention Plan states “Staff may elect to have outer clothing removed and wear suicide smock, if the Supervisor, in conjunction with if the mental health professional, feels it is appropriate. BSCC staff discussed the importance of ensuring that both agencies collaborate to ensure corresponding policies and procedures are in alignment with actual practices. The medical staff acknowledged that practices are site-specific and in line with Title 15 regulations. (a) Suicide prevention training as required in Policy 300 Member Orientation Section 1322, Youth Supervision Staff Orientation, Policy 707 Suicide Prevention and Intervention and Training and the Juvenile Corrections Officer Core Course. The elements of this regulation are confirmed in the Chief Probation Officer (CPO) Appointment and Qualifications Letter, written by CPO Melissa Romero, and dated January 2, 2024. ☒ ☐ ☐ In conjunction with the Butte County Juvenile Hall Suicide Prevention Plan, an annual refresher training is included in the SYTF annual training. In addition, staff receive suicide prevention training during Counselor CORE training. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 8 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Screening, Identification Assessment and Policy 400 Emergency Procedures Precautionary Protocols (1)All youth shall be screened for risk of suicide at SYTF youth are initially booked through the intake and as needed during detention. Butte County Juvenile Hall intake and admissions unit. The booking officer communicates with the arresting officer, facility staff, family members, and medical and mental health personnel as part of the screening process for suicide risk. ☒ ☐ ☐ Screening and assessment forms completed at intake include: Detention Risk Assessment and the Intake Screening Questionnaire. Intake staff also communicate with the arresting officer and communicate with the youth’s parent/guardian. (2) All youth supervision staff who perform intake Policy 700 Health Authorities processes shall be trained in screening youth for risk of suicide. The elements of this regulation are confirmed in the CPO appointment and qualifications ☒ ☐ ☐ letter dated January 2, 2024. An annual refresher training is included in the facility's Suicide Prevention Plan. (3) All youth who have been identified during the Policy 400 Emergency Procedures intake screening process to be at risk of suicide shall be referred to behavioral/mental health staff Youths identified during the intake screening for a suicide risk assessment. process to be at risk of suicide shall be seen ☒ ☐ ☐ by a WellPath Behavioral Health therapist within 96 hours of admission. WellPath will refer the youth to behavioral health services, Youth for Change for further assessment. (4) Precautionary protocols shall be developed to Policy 707 Suicide Prevention and Intervention ensure the youth’s safety pending the behavioral/mental health assessment. Per the above policy, youth found to be at risk for suicide are placed on “Suicide Watch” status and remain under direct observation pending behavioral health assessment. Precautionary protocols include, but are not limited to the following: ☒ ☐ ☐ • Maintain constant visual observation. • 5-8 minute Watch • Counseling • Contact medical or mental health staff. • Remove only the items decided upon by medical or mental health staff and the supervisor. • Move the youth to a downstairs room. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 9 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Referral process to behavioral/mental health Policy 400 Emergency Procedures staff for assessment and/or services. Procedure 707 Suicide Prevention and Intervention BSCC staff reviewed suicide attempts and/or suicide ideations from the prior March 2023 inspection to the current inspection. We also interviewed Behavioral Health and Medical staff. Per the facility policy, if there is an immediate safety concern, SYTF staff may determine that the youth’s clothing shall be removed. Otherwise, SYTF staff will contact behavioral health and maintain direct observation of the youth pending a behavioral health assessment to remove the youth’s clothing. Further, ☒ ☐ ☐ WellPath medical services are onsite seven days per week, from 6:45 AM to 7:15 PM. Behavioral Services are onsite up to three days per week. (d)Procedures for monitoring of youth identified at Policy 707 Suicide Prevention and Intervention risk for suicide. To monitor youth at risk for suicide, the facility utilizes the following: • Suicide Watch- Direct visual ☒ ☐ ☐ observation. • 5-8 minute Watch • Special Observation- Housing and room items allowed precautions. (e)Safety Interventions Procedure 707 Suicide Prevention and (1)Procedures to address intervention protocols for Intervention youth identified at risk for suicide which may include, but are not limited to: Safety interventions may include but are not ☒ ☐ ☐ (A)Housing consideration limited to, Special Observation- Housing and room items allowed precautions, housed in a downstairs room, and counseling. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 10 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (B)Treatment strategies including trauma-informed Procedure 707 Suicide Prevention and approaches Intervention The elements of this regulation are confirmed in the CPO appointment and qualifications letter dated January 2, 2024. ☒ ☐ ☐ Youth for Change conducts trauma-focused counseling and provides Child and Family Team meetings (CFT). (2) Procedures to instruct youth supervision staff Policy 707 Suicide Prevention and Intervention how to respond to youth who exhibit suicidal behaviors. An annual refresher training that includes trauma-informed approaches is included in the ☒ ☐ ☐ BCJH Suicide Prevention Plan. Also, following the prior 2023 comprehensive inspection, staff participated in suicide prevention refresher training. (f)Communication Policy 501 Youth Intake The intake process shall include communication with the arresting officer and family guardians regarding the The booking officer communicates with the youth’s past or present suicidal ideations, behaviors or ☒ ☐ ☐ arresting officer, facility staff, family members, attempts. and medical and mental health personnel in relation to suicide risk. Procedures for clear and current information sharing Procedure 707 Suicide Prevention and about youth at risk for suicide with youth supervision, Intervention healthcare, and behavioral/mental health staff. Butt County Secure Youth Treatment Facility ensures the following as part of the documentation and notification process: • Documentation in the logbook and in a Serious Incident Report (SIR) • Communicate with medical/mental ☒ ☐ ☐ health staff to determine their programming needs. • Document on the Suicide watch check-off sheet. • Start a folder with suicide observation forms to document room checks and any special information. • Notify their parents or legal guardian and probation officer. (g) Debriefing of Critical Incidents Related to Suicides or Procedure 707 Suicide Prevention and Attempts Intervention (1)Process for administrative review of the ☒ ☐ ☐ circumstances and responses proceeding, during and after the critical incident. Procedure 707 Suicide Prevention and (2)Process for a debriefing event with affected staff. ☒ ☐ ☐ Intervention (3)Process for a debriefing event with affected youth. Procedure 707 Suicide Prevention and ☒ ☐ ☐ Intervention 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 11 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h)Documentation Procedure 707 Suicide Prevention and (1) Documentation processes shall be developed to Intervention ensure compliance with this regulation Reporting and monitoring documentation is as follows: ☒ ☐ ☐ • Incident Report • Medical Notification • Mental Health Suicide Watch • Observation Sheet Youth identified at risk for suicide shall not be denied Procedure 707 Suicide Prevention and the opportunity to participate in facility programs, Intervention services and activities which are available to other non-suicidal youth, unless deemed necessary for the BSCC staff reviewed incident reports, and safety of the youth or security of the facility. Any interviewed SYTF staff and youth housed at ☒ ☐ ☐ deprivation of programs, services or activities for youth the facility. We also interviewed behavioral at risk of suicide shall be documented and approved health and medical services staff. BSCC by the facility manager. determined compliance with this section of the regulation. 1354.5 ROOM CONFINEMENT Policy 601 Safety Removal (Room 2B Confinement) (a)The facility administrator shall develop and implement written policies and procedures addressing BSCC staff requested to review the 15 most the confinement of youth in their room that are consistent recent examples of room confinement-related with Welfare and Institutions Code Section 208.3. The incident reports. However, there were only six placement of a youth in room confinement shall be youth committed to the SYTF and there have accomplished in accordance with the following been no incidents resulting in room guidelines: ☒ ☐ ☐ confinement. BSCC staff reviewed room confinement logs and interviewed the youth detained at the facility as well as SYTF staff. We also interviewed medical and behavioral health staff to gain further insight. (1)Room confinement shall not be used before other, Policy 601 Safety Removals (Room less restrictive, options have been attempted and Confinement) exhausted, unless attempting those options poses a ☒ ☐ ☐ threat to the safety or security of any youth or staff. SYTF meets Title 15 minimum standards for the elements of this regulation. (2)Room confinement shall not be used for the Policy 601 Safety Removals (Room purposes of punishment, coercion, convenience, or Confinement) retaliation by staff. ☒ ☐ ☐ Documentation supports compliance with this regulation. Room confinement is always used appropriately. (3)Room confinement shall not be used to the extent Policy 601 Safety Removals (Room that it compromises the mental and physical health of Confinement) ☒ ☐ ☐ the youth. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 12 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b)A youth may be held up to four hours in room Policy 601 Safety Removals (Room confinement. After the youth has been held in room Confinement) confinement for a period of four hours, staff shall do one or more of the following: Since the prior inspection, documentation shows that no youth has been held in room confinement beyond the four-hour threshold. The facility uses the following documentation tools to help track and log room confinement include, but are not limited to: ☒ ☐ ☐ • Administration Separation Monitoring Log • Pod Logbook • Safety and Security Behavioral Removal log Administrative Separation Check-Off Log Policy 601 Safety Removals (Room (1)Return the youth to general population. ☒ ☐ ☐ Confinement) Policy 601 Safety Removals (Room Confinement) (2)Consult with mental health or medical staff. Per policy, if after one hour the youth’s ☒ ☐ ☐ behavior continues to be a threat to facility safety and security, the facility LMFT may be contacted to assess and counsel the youth. (3)Develop an individualized plan that includes the Policy 601 Safety Removals (Room goals and objectives to be met in order to reintegrate Confinement) the youth to general population. ☒ ☐ ☐ Individualized plans are identified as Behavior Modification Plans. (4)If room confinement must be extended beyond four Policy 601 Safety Removals (Room hours, staff shall do each of the following: Confinement) (A)Document the reasons for room confinement and the basis for the extension, the date and ☒ ☐ ☐ Since the prior inspection, documentation time the youth was first placed in room shows that no youth has been held in room confinement, and when he or she is eventually confinement beyond the four-hour threshold. released from room confinement. (B)Develop an individualized plan that includes Policy 601 Safety Removals (Room the goals and objectives to be met in order to Confinement) integrate the youth to general population. ☒ ☐ ☐ The facility utilizes an Administrative Separation Form that complies with the elements of this regulation. (C) Obtain documented authorization by the Policy 601 Safety Removals (Room facility superintendent or his or her designee Confinement) ☒ ☐ ☐ every four hours thereafter. (5) This section is not intended to limit the use of Policy 601 Safety Removals (Room single-person rooms or cells for the housing of youth Confinement) in juvenile facilities and does not apply to normal ☒ ☐ ☐ sleeping hours. (6) This section does not apply to youth or wards in Policy 601 Safety Removals (Room court holding facilities or adult facilities. ☒ ☐ ☐ Confinement) 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 13 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (7) Nothing in this section shall be construed to Policy 601 Safety Removals (Room conflict with any law providing greater or additional Confinement) ☒ ☐ ☐ protections to youth. (8) This section does not apply during an Policy 601 Safety Removals (Room extraordinary emergency circumstance that requires Confinement) a significant departure from normal institutional operations, including a natural disaster or facility-wide threat that poses an imminent and substantial risk of ☒ ☐ ☐ harm to multiple staff or youth. This exception shall apply for the shortest amount of time needed to address this imminent and substantial risk of harm. (9)This section does not apply when a youth is placed Policy 601 Safety Removals (Room in a locked cell or sleeping room to treat and protect Confinement) against the spread of a communicable disease for the shortest amount of time required to reduce the risk of infection, with the written approval of a licensed physician or nurse practitioner, when the youth is not required to be in an infirmary for an illness. ☒ ☐ ☐ Additionally, this section does not apply when a youth is placed in a locked cell or sleeping room for required extended care after medical treatment with the written approval of a licensed physician or nurse practitioner, when the youth is not required to be in an infirmary for illness. 1357 USE OF FORCE Policy 305 Chemical Agents Training Procedure 514.1 The facility administrator, in cooperation with the Policy 514 Use of Force responsible physician, shall develop and implement Procedure 514 Force Options written policies and procedures for the use of force, which Policy 515 Restraints may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. BSCC Staff observed that there were six (a)At a minimum, each facility shall develop policies and ☒ ☐ ☐ reports resulting in the use of force reported to procedures which: have occurred in the prior six months. We also interviewed youth housed at the facility and SYTF staff. We also interviewed collaborative partners to gain further insight to confirm compliance with this regulation. (1) restricts the use of force to that which is deemed Policy 514 Use of Force reasonable and necessary, as defined in Section 1302 Procedure 514 Force Options to ensure the safety and security of youth, staff, others Procedure 514.1 Chemical Agents and the facility. Decontamination Procedure ☒ ☐ ☐ In review, or reports and interviews with youth, SYTF JDO staff utilized force that was deemed reasonable and necessary. (2)outline the force options available to staff including Policy 514 Use of Force both physical and non-physical options and define Procedure 514 Force Options when those force options are appropriate. SYTF staff receive an initial 4-hour weaponless defensive training and policy ☒ ☐ ☐ review outlining both physical and non- physical de-escalation options. An additional four hours of refresher training occur annually. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 14 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (3) describe force options or techniques that are Policy 514 Use of Force expressly prohibited by the facility. Procedure 514 Force Options SYTF Use of Force Options includes the below: • Verbal Commands ☒ ☐ ☐ • OC Spray • Soft Hands/ Physical Escort • Hard hands/Full Restraint • Strikes/Kicks • Convex Shield • Mechanical Restraints (4)describe the requirements of staff to report any Policy 514 Use of Force inappropriate use of force, and to take affirmative Procedure 514 Force Options ☒ ☐ ☐ action to immediately stop it. (5)define a standardized reporting format that includes Policy 514 Use of Force time period and procedure for documenting and Procedure 514 Force Options reporting the use of force, including reporting requirements of management and line staff and procedures for reviewing and tracking use of force SYTF staff must complete use-of-force incidents by supervisory and or management staff, Incident Reports prior to ending his/her shift. ☒ ☐ ☐ which include procedures for debriefing a particular Supervisory reviews are conducted prior to the incident with staff and/or youth for the purposes of end of the shift that the incident occurred. training as well as mitigating the effects of trauma that Reviews and debriefings were clearly may have been experienced by staff and /or the youth documented in Incident Reports. involved. (6)Include an administrative review and a system for Policy 514 Use of Force investigating unreasonable use of force. Procedure 514 Force Options Through a review of the Use of Force incident reports, we observe that the supervisor ☒ ☐ ☐ provides a final analysis and debrief of the incident. Also, the Superintendent reviews the use of force incident reports to ensure the use of force was in accordance with facility policy. (7)define the role, notification, and follow-up Policy 514 Use of Force procedures required after use of force incidents for Procedure 514 Force Options medical, mental health staff and parents or legal guardians. BSCC staff interviewed supervisory, detention, ☒ ☐ ☐ and medical staff to help determine compliance with the elements of this regulation. (8)describe the limitations of use of force on pregnant Policy 307 Health Care Orientation and youth in accordance with Penal Code Section 6030(f) Training and Welfare and Institutions Code Section 222. ☒ ☐ ☐ Policy 514 Use of Force Policy 515 Restraints 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 15 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Facilities that authorize chemical agents as a force Policy 305 Chemical Agents Training option shall include policies and procedures that: Policy 514 Use of Force (1)identify who is approved to carry and/or utilize Procedure 514.1 Chemical Agents chemical agents in the facility and the type, size and Decontamination Procedure the approved method of deployment for those chemical agents. Three incidents involving the use of chemical agents (OC spray) were reported. All three ☒ ☐ ☐ use-of-force reports involved the same youth. BSCC staff observed that SYTF staff satisfactorily completed the department's eight-hour, STC-approved Chemical Agents course prior to being approved to carry OC spray. (2)mandate that chemical agents only be used Policy 514 Use of Force when there is an imminent threat to the youth’s safety or the safety of others and only when de- escalation efforts have been unsuccessful or are not In a review of the Incident Reports, in most ☒ ☐ ☐ reasonably possible. cases, chemical agents were used to de- escalate youth-on-youth mutual physical combat. (3)outline the facility’s approved methods and Policy 514 Use of Force timelines for decontamination from chemical agents. Procedure 514.1 Chemical Agents This shall include that youth who have been Decontamination Procedure exposed to chemical agents shall not be left ☒ ☐ ☐ unattended until that youth is fully decontaminated or BSCC staff interviewed medical personnel, is no longer suffering the effects of the chemical youth housed at the facility, JDO staff, and agent. supervisors. Compliance was confirmed. (4) define the role, notification, and follow-up Policy 514 Use of Force procedures required after use of force incidents involving chemical agents for medical, mental health ☒ ☐ ☐ staff and parents or legal guardians. (5) provide for the documentation of each incident of Policy 514 Use of Force use of chemical agents, including the reasons for Procedure 514.1 Chemical Agents which it was used, efforts to de-escalate prior to use, Decontamination Procedure youth and staff involved, the date, time and location ☒ ☐ ☐ of use, decontamination procedures applied and Incident Reports reviewed meet the Title 15 identification of any injuries sustained as a result of minimum standards for this regulation. such use. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 16 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Facilities shall develop policies and procedure which Policy 305 Chemical Agents Training require that agencies provide initial and regular training in Procedure 514 Force Options use of force and chemical agents when appropriate that address: The elements of this regulation are identified in (1) known medical and behavioral health conditions Phase One of the training procedure and that would contraindicate certain types of force; confirmed in the CPO Melissa Romero’s Appointment and Qualifications Letter dated January 2, 2024. The referenced policy and curriculum for ☒ ☐ ☐ weaponless defense and verbal de-escalation techniques include knowing of any pre-existing medical and/or behavioral health conditions that would limit or restrict certain UF techniques. Use of Force training is included in the Counselor Core Training and annual updates for the use of force. (2) acceptable chemical agents and the methods of Procedure 514 Force Option application. SYTF staff and supervisors are trained and have available to them, the following types of ☒ ☐ ☐ chemical agent(s): OC (Oleoresin Capsicum) spray canisters (3)signs or symptoms that should result in immediate Procedure 514 Force Options referral to medical or behavioral health. Procedure 514.1 Chemical Agents Decontamination Procedure The Training Manager ensures that all ☒ ☐ ☐ personnel who are authorized in the use of chemical agents have also been trained in the proper medical treatment of person or persons affected by chemical agents. (4)instruction on the Constitutional Limitations of Procedure 514 Force Options Use of Force. ☒ ☐ ☐ (5)physical training force options that may require Procedure 514 Force Options the use of perishable skills. The elements of this regulation are identified in Phase One of the training procedure and ☒ ☐ ☐ confirmed in the CPO Melissa Romero’s Appointment and Qualifications Letter dated January 2, 2024. (6)timelines the facility uses to define regular Procedure 514 Force Options training. Youth supervision staff trained and approved ☒ ☐ ☐ to carry OC spray are required to take annual refresher training. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 17 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1361 GRIEVANCE PROCEDURE Policy 609 Youth Grievances The facility administrator shall develop and implement BSCC staff reviewed youth grievance written policies and procedures whereby any youth may grievances and due process documentation appeal and have resolved grievances relating to any examples for December 2023 through March condition of confinement, including but not limited to 2024 and reviewed grievance logs from health care services, classification decisions, program October 2023 to the present. ☒ ☐ ☐ participation, telephone, mail or visiting procedures, food, clothing, bedding, mistreatment, harassment or violations of the nondiscrimination policy. There shall be no time limit on filing grievances. Policies and procedures shall include provisions whereby the facility manager ensures: (a) a grievance form and instructions for registering a Policy 609 Youth Grievances grievance, which includes provisions for the youth to have free access to the form; During our physical inspection, we observed that grievance forms were readily available to youth. In addition, grievance lock boxes were in the housing pods to allow youth to ☒ ☐ ☐ confidentially submit a grievance if needed. There is an acknowledgment form signed by staff and the youth acknowledging that the grievance and appeals procedures have been thoroughly explained to the youth. (b)the youth shall have the option to confidentially file the Policy 609 Youth Grievances grievance or to deliver the form to any youth supervision staff working in the facility; The youth were aware of the grievance ☒ ☐ ☐ procedures the location of the grievances and the grievance lockbox to confidentially file a grievance if needed. (c) resolution of the grievance at the lowest appropriate Policy 609 Youth Grievances staff level; The unit supervisor checks the grievance box ☒ ☐ ☐ daily and provides detention staff with a response to the grievance for a resolution. (d) provision for a prompt review and initial response to Policy 609 Youth Grievances grievances within three (3) business days, grievances that relate to health and safety issues must be addressed ☒ ☐ ☐ immediately; (1)The youth may elect to be present to explain his/her Policy 609 Youth Grievances version of the grievance to a person not directly involved in the circumstances which led to the grievance. The youth interviewed indicated that during the ☒ ☐ ☐ intake and orientation process, the grievance procedure was clearly explained. (2)Provision for a staff representative approved by the Policy 609 Youth Grievances facility administrator to assist the youth. ☒ ☐ ☐ (e)provision for a written response to the grievance Policy 609 Youth Grievances which includes the reasons for the decisions; ☒ ☐ ☐ The documentation as well as interviews show that detention staff respond professionally. (f)a system which provides that any appeal of a Policy 609 Youth Grievances grievance shall be heard by a person not directly ☒ ☐ ☐ involved in the circumstances which led to the grievance; 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 18 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g)resolution of the grievance must occur within ten (10) Policy 609 Youth Grievances business days unless circumstances dictate a longer time frame. The youth shall be notified of any delay; The unit supervisor checks the grievance box and, daily. BSCC staff observed that the facility sets a standard to respond to grievances within 24 hours. However, BSCC staff observed a time when a series of grievances were responded ☒ ☐ ☐ to outside of Title 15 time. The facility cited personnel issues that may have contributed to the mishandling/ misplacement of grievances. BSCC staff provided technical assistance that supervisory staff ensure the proper handling of grievances. We also reminded the facility that the youth shall be notified of any delay. (h) the policy shall provide multiple internal and external Policy 609 Youth Grievances methods to report sexual abuse and sexual harassment. ☒ ☐ ☐ Whether or not associated with a grievance, concerns of Policy 609 Youth Grievances parents, guardians, staff or other parties shall be addressed and documented in accordance with written ☒ ☐ ☐ policies and procedures within a specified timeframe. 1371 PROGRAMS, RECREATION, AND EXERCISE. Policy 1000 Youth Programs and Services 3B Policy 1002 Programs Exercise and The facility administrator shall develop and implement Recreation written policies and procedures for programs, recreation, Procedure 1002 Daily Schedules and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. For the months of January, February, and March of 2024, BSCC staff reviewed the programs provided and their schedules. BSCC staff reviewed the program's daily calendar ☒ ☐ ☐ available to youth. We commend the Butte County Secure Youth Treatment Facility for the array of pro-social programming offered to youth detained at the facility. The facility’s policy and procedure are applicable to the elements of this regulation, as required. Juvenile facilities shall provide the opportunity for Policy 1002 Programs Exercise and programs, recreation, and exercise a minimum of Recreation three hours a day during the week and five hours a day Procedure 1002 Daily Schedules each Saturday, Sunday or other non-school days, of which one hour shall be an outdoor activity, weather The program schedules show the programs permitting. provided. Technical assistance was provided in suggesting to the agency that to ensure ☒ ☐ ☐ ongoing compliance, individual youth participation and non-participation should be clearly documented on a consistent basis. In addition, clearly indicate the start and end times of programs that were provided during wake hours. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 19 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS A youth’s participation in programs, recreation, and Policy 1002 Programs Exercise and exercise may be suspended only upon a written finding Recreation by the administrator/manager or designee that a youth Procedure 1002 Daily Schedules represents a threat to the safety and security of the facility. ☒ ☐ ☐ There was no documentation provided to indicate a youth’s participation in any program was suspended. Such program, recreation, and exercise schedule shall Policy 1002 Programs Exercise and be posted in the living units. Recreation Procedure 1002 Daily Schedules ☒ ☐ ☐ During the physical facility inspection, we observed program and recreation schedule calendars posted in the living units. There will be a written annual review of the programs, Policy 102 Annual Review and Performance- recreation, and exercise by the responsible agency to Based Goals and Objectives ensure content offered is current, consistent, and Policy 1002 Programs Exercise and relevant to the population. Recreation Procedure 1002 Daily Schedules ☒ ☐ ☐ A memorandum written by Superintendent, Mariah Ruddy, and dated March 6, 2024, confirms an annual review of the programs, recreation, and exercise was reviewed to meet the elements of this regulation. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 20 of 21 A453 JUV Targeted PRO eff. 1/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Programs. All youth shall be provided with the Policy 1002 Programs Exercise and opportunity for at least one hour of daily programming to Recreation include, but not be limited to, trauma focused, cognitive, Procedure 1002 Daily Schedules evidence-based, best practice interventions that are culturally relevant and linguistically appropriate, or pro- BSCC staff reviewed random Programs social interventions and activities designed to reduce Exercise and Recreation logs, and pertinent recidivism. These programs should be based on the documentation for the months of January, youth’s individual needs as required by Sections 1355 and February, and March 2024. We also 1356. Such programs may be provided under the direction interviewed youth housed at the facility, of the Chief Probation Officer or the County Office of detention staff, behavioral health staff, and Education and can be administered by county partners education service staff. such as mental health agencies, community based organizations, faith-based organizations or Probation staff. The facility provides meaningful programming Programs may include but are not limited to: for youth. In particular, the facility is one of only (1) Cognitive Behavior Interventions; a few detention facilities to have an actual (2) Management of Stress and Trauma; Boys and Girls Club component at the facility (3) Anger Management; that is onsite weekly providing programming (4) Conflict Resolution; ☒ ☐ ☐ services and counseling. The Boys and Girls (5) Juvenile Justice System; Club programming includes but is not limited (6) Trauma-related interventions; to, Arts, Character Leadership, Sports and (7) Victim Awareness; Recreation, Health Wellness, and College (8) Self-Improvement; Career guidance. The facility also has a (9) Parenting Skills and support; gardening program, substance abuse (10)Tolerance and Diversity; counseling, and programming provided in (11)Healing Informed Approaches; conjunction with education services. (12)Interventions by Credible Messengers; (13)Gender Specific Programming; Technical assistance was provided in (14)Art, creative writing, or self-expression; suggesting to the agency that to ensure (15)CPR and First Aid training; ongoing compliance, individual youth (16)Restorative Justice or Civic Engagement; participation and non-participation should be (17)Career and leadership opportunities; and, clearly documented on a consistent basis. (18)Other topics suitable to the youth population. BSCC staff provided best practice methods of daily documentation for the required elements of this regulation. (b) Recreation. All youth shall be provided the opportunity Policy 1002 Programs Exercise and for at least one hour of daily access to unscheduled Recreation activities such as leisure reading, letter writing, and Procedure 1002 Daily Schedules ☒ ☐ ☐ entertainment. Activities shall be supervised and include orientation and may include coaching of youth. (c)Exercise. All youth shall be provided with the Policy 1002 Programs Exercise and opportunity for at least one hour of large muscle Recreation activity each day. Procedure 1002 Daily Schedules After a review of program activity logs, and ☒ ☐ ☐ interviews with youth housed at the facility and detention staff, Butte County SYTF meets compliance with the Title 15 minimum standards for this regulation The administrator/manager may suspend, for a Policy 1002 Programs Exercise and period not to exceed 24 hours, access to recreation Recreation and programs. The administrator/manager shall ☒ ☐ ☐ document the reasons why suspension of recreation and programs occurs. 7030 Butte Secure Youth Treatment Facility SYTF PRO 23-24 Page 21 of 21 A453 JUV Targeted PRO eff. 1/2024