Los Angeles SYTF at Barry J Nidorf Facility SYTF Targeted Insp (2023-2024 inspection cycle)

September 20, 2023 Guillermo Viera Rosa, Interim Chief Probation Officer C/O Sheila Williams, Deputy Director Los Angeles County Probation Department 9150 E. Imperial Hwy. Downey, CA 90242 RE: 2023 TARGETED INSPECTION OF BARRY J. NIDORF SYTF - (WELF. & INST. CODE, § 209) Dear Interim Chief Viera Rosa: The Targeted Inspection of the Los Angeles County Probation Department’s Secure Youth Treatment Facility (SYTF) at Barry J. Nidorf Facility has been completed. We appreciate all the hard work and time spent by your staff preparing for, organizing, and making themselves available during the onsite visit. The Board of State and Community Corrections (BSCC) Targeted Inspection report is enclosed and consists of the following: This transmittal letter and a Targeted Title 15 Procedures Checklist, outlining applicable the minimum standards we targeted during this inspection. Please refer to the Title 15 Procedures Checklist for a summary of all relevant minimum standards, indicators of compliance or noncompliance, and information that was used to determine compliance. Scope of the Inspection For the targeted inspection, we focused on the following Title 15 minimum standards: 1321 Staffing 1360 Searches 1322 Youth Supervision Staff Orientation & 1361 Grievance Procedure Training 1370 Education Program 1324 Policy and Procedures Manual 1371 Programs, Recreation, And Exercise. 1325 Fire Safety Plan 1374 Visiting 1327 Emergency Procedures 1390 Discipline 1328 Safety Checks 1433 Requests for Health Care Services 1353 Orientation 1480 Standard Facility Clothing Issue 1354.5 Room Confinement 1482 Clothing Exchange 1357 Use of Force 1485 Issue of Personal Care Items 1358 Use of Physical Restraints 1487 Shaving 1358.5 Use of Restraint Devices for Movement 1488 Hair Care Services and Transportation Within the Facility Guillermo Viera Rosa, Interim Chief Probation Officer C/O Sheila Williams, Deputy Director Page 2 The inspection consisted of a review of the relevant policy and procedures1, a review of applicable documentation to ensure that practice and policies are aligned and consistent with Title 15, an on-site visit to review operations and physical plant, and interviews with administration, facility staff, youth, and collaborative partners. BSCC INSPECTION RESULTS Title 15, CCR Minimum Standards As indicated in the Initial Inspection Report (IIR) provided on August 11, 2023, we found the following items of noncompliance at the facility; please refer to the Procedures Checklist for detailed information regarding each section. 1. § 1321. Staffing. 2. § 1322. Youth Supervision Staff Orientation and Training. 3. § 1324. Policy and Procedures Manual. 4. § 1328. Safety Checks. 5. § 1353. Orientation. 6. § 1357. Use of Force. 7. § 1360. Searches. 8. § 1370. Education Program. 9. § 1371. Programs, Recreation, and Exercise. 10. § 1390. Discipline. Corrective Action Required As indicated in your IIR, an approved Corrective Action Plan (CAP) must be submitted to the BSCC no later than October 10, 2023 (Welfare and Institutions Code section 209 (d)). The CAP must clearly outline how the agency plans to correct each area of noncompliance, within a reasonable timeframe, not to exceed 90 days from the submittal of the CAP. BSCC staff is available for technical assistance as needed; you may submit a draft CAP at any time before the October 10 due date for preliminary review. Should you have questions, please email me at lisa.southwell@bscc.ca.gov or call me at (916) 838-9132. Sincerely, LISA SOUTHWELL Field Representative Facilities Standards and Operations Division 1 BSCC reviews only those policies and procedures required by, and applicable to, Title 15, CCR. BSCC staff do not “approve” policies and procedures. Agencies should seek review through their legal advisor, risk manager, and other persons deemed appropriate. 7205 Los Angeles SYTF @ BJN SYTF LTR 23-24 Guillermo Viera Rosa, Interim Chief Probation Officer C/O Sheila Williams, Deputy Director Page 3 Enclosures Cc: Presiding Judge, Juvenile Court, Los Angeles County* Chair, Juvenile Justice Commission, Los Angeles County* Chair, Board of Supervisors, Los Angeles County* County Administrator, Los Angeles County* *Copies of the full inspection are available online at www.bscc.ca.gov. 7205 Los Angeles SYTF@BJN LTR 23-24 JUVENILE HALLS, SPECIAL-PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections TARGETED INSPECTION PROCEDURES CHECKLIST1 BSCC Code: 7205 FACILITY NAME: FACILITY TYPE: Secure Youth Treatment Facility (SYTF) @ Barry J Nidorf Secure Youth Treatment Facility PERSON(S) INTERVIEWED: Tracy Novak, Marlon Barbarin, Curtis Miller and Scott Sanders. Various youth and staff throughout the facility. FIELD REPRESENTATIVE: DATE: Lisa Southwell August 7-11, 2023 TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1321 STAFFING DSB Manual Section 206: Staffing Requirement and Ratios Each juvenile facility shall: (a) have an adequate number of personnel Facility shift staffing forms were provided for sufficient to carry out the overall facility operation the week of July 20-July 27, 2023. and its programming, to provide for safety and security of youth and staff, and meet established Some shifts were minimally staffed. Staff standards and regulations; report they are routinely held over with no notice to cover shifts and report they are exhausted as a result. Most staff believe the unscheduled, mandatory holdovers negatively impact attendance. We noted instances in which youth were in dayrooms alone because the assigned unit ☐ ☒ ☐ staff were busy with other operational requirements (in and out of the office or down the hallway) or needed to use the restroom. Youth also report not feeling safe due to the lack of staff. Those youth we spoke to spoke highly of most staff but noted “we need more staff.” It was also reported by some youths that they are urinating in receptacles in their rooms due to a lack of staff and having to wait for long periods of time late at night. Staffing is an ongoing issue of noncompliance. (b) ensure that no required services shall be denied DSB Manual Section 206: Staffing because of insufficient numbers of staff on duty Requirement and Ratios absent exigent circumstances; There were periods noted where youth were not participating in required activities due to a ☐ ☒ ☐ lack of staff. We spoke with youth who confirmed that there has been some positive progress in youth going to school, high school graduates attending college classes, and youth getting outside for exercise 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. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 1 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (c) have a sufficient number of supervisory level DSB Manual Section 206: Staffing staff to ensure adequate supervision of all staff Requirement and Ratios members; At the time of inspection, the facility population average was 61 youth and staffing was minimal. The facility has recently undergone a management change, including senior management, directors, and some supervisors. During the time period reviewed, and per the documentation reviewed, we did not note any operational issues or concerns related to or due to lack of supervision and do not find the facility to be noncompliant in this area. Most ☒ ☐ ☐ shifts had a Supervisor (OD) and a Back-Up (BU) Supervisor on shift except for the 10 PM- 6 AM shifts, during which a few had only a Supervisor (OD) on duty. There were four additional shifts of the 21 reviewed, where other supervisors were noted to be on shift; however, there was no consistency as to how many supervisors were on which shift. Technical Assistance was provided, and it was suggested to management to review the facility supervisor and director roles and schedules to always ensure consistent supervisory coverage. (d) have a clearly identified person on duty at all DSB Manual Section 206: Staffing times who is responsible for operations and Requirement and Ratios activities and has completed the Juvenile ☒ ☐ ☐ Corrections Officer Core Course and PC 832 training; (e) have at least one staff member present on each DSB Manual Section 206: Staffing living unit whenever there are youth in the living unit; Requirement and Ratios ☒ ☐ ☐ (f) have sufficient food service personnel relative to DSB Manual Section 206: Staffing the number and security of living units, including Requirement and Ratios staff qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen supervision; direct food preparation and servings; ☒ ☐ ☐ conduct related training programs for culinary staff; and maintain necessary records; or, a facility may serve food that meets nutritional standards prepared by an outside source; (g) have sufficient administrative, clerical, DSB Manual Section 206: Staffing recreational, medical, dental, mental health, Requirement and Ratios building maintenance, transportation, control room, facility security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted ☒ ☐ ☐ from supervising youth; and, 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 2 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (h) assign sufficient youth supervision staff to DSB Manual Section 206: Staffing provide continuous wide awake supervision of Requirement and Ratios youth, subject to temporary variations in staff assignments to meet special program needs. The documentation reviewed provided staffing ☒ ☐ ☐ Staffing shall be in compliance with a minimum numbers that met the ratio. The SYTF @ the youth-staff ratio for the following facility types: BJN is compliant by ratio. (1) Juvenile Halls DSB Manual Section 206: Staffing (A) during the hours that youth are awake, Requirement and Ratios one wide-awake youth supervision staff member on duty for each 10 youth in LA County Probation requires by policy, a ☒ ☐ ☐ detention; PREA Staffing standard of 1-8 which exceeds Title 15 regulation. Both 1-10 and 1-8 have been met. (B) during the hours that youth are confined DSB Manual Section 206: Staffing to their room for the purpose of sleeping, one Requirement and Ratios wide-awake youth supervision staff member on duty for each 30 youth in detention; LA County Probation requires by policy, a ☒ ☐ ☐ PREA Staffing standard of 1-16 which exceeds Title 15 regulation. The facility does not meet its own policy but does meet the Title 15 ratio of 1-30. (C) at least two wide-awake youth DSB Manual Section 206: Staffing supervision staff members on duty at all Requirement and Ratios 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 DSB Manual Section 206: Staffing member on duty who is the same gender as Requirement and Ratios ☒ ☐ ☐ youth housed in the facility. (E) personnel with primary responsibility for DSB Manual Section 206: Staffing other duties such as administration, Requirement and Ratios supervision of personnel, academic or trade instruction, clerical, kitchen or maintenance ☒ ☐ ☐ shall not be classified as youth supervision staff positions. 2(a-e), Special Purpose JH and Removed as does not apply. 3(a-e), Camps 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 3 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1322 YOUTH SUPERVISION STAFF DSB Manual Section 205: Youth Supervision ORIENTATION AND TRAINING Staff Orientation and Training (a) Prior to assuming any responsibilities each Staff assigned to the facility to conduct youth youth supervision staff member shall be properly supervision duties consist of regularly oriented to their duties, including: assigned facility staff, deployed staff from the (1) youth supervision duties; field, and staff who may have been (2) scope of decisions they shall make; reassigned back into the facility. (3) the identity of their supervisor; (4) the identity of persons who are responsible There has been a significant movement of to them; staff to cover shifts and to staff the facility. It (5) persons to contact for decisions that are appears staff have been oriented, and those beyond their responsibility; and we spoke with were aware of the items (6) ethical responsibilities. identified in the regulation; however, we found no formalized process to ensure consistency in how the orientation was conducted. Technical assistance was provided, suggesting the development of a formalized orientation process to include a sign-off line that could be documented for the 40-hour ☒ ☐ ☐ training. This would ensure all staff coming into the facility receive a consistent orientation. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 4 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (b) Prior to assuming any responsibility for the DSB Manual Section 205: Youth Supervision supervision of youth, each youth supervision staff Staff Orientation and Training member shall receive a minimum of 40 hours of facility-specific orientation, including: The facility has had a significant movement of (1) individual and group supervision techniques; staff (as noted in 1322(a) above) in and out of (2) regulations and policies relating to discipline the facility and regularly uses a significant and rights of youth pursuant to law and the number of deployed and reassigned staff to provisions of this chapter; cover the staffing shortages in addition to the (3) basic health, sanitation and safety regularly assigned staff. measures; (4) suicide prevention and response to suicide We are unable to verify the 40 hours of attempts required facility-specific training as training (5) policies regarding use of force, de- records have not been provided. ☐ ☒ ☐ escalation techniques, chemical agents, mechanical and physical restraints; (6) review of policies and procedures referencing trauma and trauma-informed approaches; (7) procedures to follow in the event of emergencies; (8) routine security measures, including facility perimeter and grounds; (9) crisis intervention and mental health referrals to mental health services; (10) documentation; and (11) fire/life safety training (c) Prior to assuming sole supervision of youth, No training records were provided. each youth supervision staff member shall successfully complete the requirements of the ☐ ☒ ☐ Juvenile Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer No training records were provided. youth supervision staff shall successfully complete training pursuant to Section 830 et seq. of the Penal ☐ ☒ ☐ Code. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 5 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1324 POLICY AND PROCEDURES MANUAL The Detention Services Bureau manual was last updated in 2022. The policy has not been All facility administrators shall develop, publish, and updated to reflect policy or procedure changes implement a manual of written policies and specific to the Secure Youth Treatment Facility procedures that address, at a minimum, all (SYTF) population now that the Juvenile Hall regulations that are applicable to the facility. Such a has been closed. A policy manual specific to manual shall be made available to all employees, SYTF @ BJN has been drafted; however, the reviewed by all employees, and shall be policy and procedures specific to SYTF are not administratively reviewed at a minimum every two final or available to staff working at the facility. years, and updated, as necessary. Those records relating to the standards and requirements set forth We have been advised that the manual is in these regulations shall be accessible to the Board pending additional updates as upper on request. management and labor representatives still The manual shall include: need to review, approve, and finalize. SYTF staff do not have access to the draft manual and continue to use the Detention Services Bureau (DSB) manual; all policy cited in this report is from this manual. Multiple directives and full DSB policy sections have been approved and released to facility staff as recently as July 25, 2023; however, there is no consistency between these documents and actual practice, nor are staff required to sign off when a new policy update ☒ ☐ ☐ or directive is released to be sure it has been received, read and understood by facility staff, or that they have been trained on the new policy or directive. We suggest that all documents that are policy or procedure-based are reviewed to ensure that clear, consistent, and specific directions are provided to staff. We will continue to provide Technical Assistance as requested and assist with reviewing the individual sections as they become available upon request. This item will remain out of compliance until a final policy and procedure manual is available to all employees and the manual consistently addresses each of the required items for the facility. *Includes Regulation 1327: Emergency Procedures The remainder of the checkboxes in this regulation are left blank. (a) table of organization, including channels of communications and a description of job ☐ ☐ ☐ classifications; (b) responsibility of the probation department, purpose of programs, relationship to the juvenile court, the Juvenile Justice/Delinquency Prevention Commission or Probation Committee, probation ☐ ☐ ☐ staff, school personnel and other agencies that are involved in juvenile facility programs; (c) responsibilities of all employees; ☐ ☐ ☐ 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 6 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (d) initial orientation and training program for employees; ☐ ☐ ☐ (e) initial orientation, including safety and security issues and anti-discrimination policies, for support staff, contract employees, school, ☐ ☐ ☐ mental/behavioral health and medical staff, program providers and volunteers; (f) maintenance of record-keeping, statistics and communication system to ensure: ☐ ☐ ☐ (1) efficient operation of the juvenile facility; ☐ ☐ ☐ (2) legal and proper care of youth; ☐ ☐ ☐ (3) maintenance of individual youth's records; ☐ ☐ ☐ (4) supply of information to the juvenile court and those authorized by the court or by the law; ☐ ☐ ☐ and, (5) release of information regarding youth. ☐ ☐ ☐ (g) ethical responsibilities; ☐ ☐ ☐ (h) trauma-informed approaches; ☐ ☐ ☐ (i) culturally responsive approaches; ☐ ☐ ☐ (j) gender responsive approaches; ☐ ☐ ☐ (k) a non-discrimination provision that provides that all youth within the facility shall have fair and equal access to all available services, placement, care, treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group identification, ancestry, national ☐ ☐ ☐ origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any chemical agents related security devices, and ☐ ☐ ☐ weapons and ammunition, where applicable; (m) establishment of procedures for collection of Medi-Cal eligibility information and enrollment of ☐ ☐ ☐ eligible youth; and, (n) establishment of a policy that prohibits all forms of sexual abuse, sexual assault and sexual harassment. The policy shall include an approach to preventing, detecting and responding to such ☐ ☐ ☐ conduct and any retaliation for reporting such conduct, as well as a provision for reporting such conduct by youth, staff or a third party. 1325 FIRE SAFETY PLAN The Fire Suppression Plan was completed and signed off by Brian Whalen on February 9, The facility administrator shall consult with the local 2023. fire department having jurisdiction over the facility, or with the State Fire Marshal, in developing a plan ☒ ☐ ☐ for fire safety which shall include, but not be limited to: (a) a fire prevention plan to be included as part of the manual of policy and procedures; 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 7 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (b) monthly fire and life safety inspections by facility DSB Manual Section 911: Fire Prevention and staff with two-year retention of the inspection Suppression record; ☒ ☐ ☐ Completed. (c) fire prevention inspections as required by DSB Manual Section 911: Fire Prevention and Health and Safety Code Section 13146.1(a) and Suppression (b); ☒ ☐ ☐ The facility has a current fire clearance. (d) an evacuation plan; DSB Manual Section 920: Emergency Evacuation and County of Los Angeles Building Emergency Plan of County Buildings ☒ ☐ ☐ Evacuation maps are in the units. Technical assistance was provided while in some of the units to reprint those that were marked up with graffiti. (e) documented fire drills not less than quarterly; DSB Manual Section 911: Fire Prevention and Suppression Fire drills have been completed monthly up until June 2023. Four units T, V, Y1, or Y2 did ☒ ☐ ☐ not participate in the monthly fire drill in July. Title 15 requires fire drills to be completed quarterly. (f) a written plan for the emergency housing of DSB Manual Section 921: Operation FLEE youth in the case of fire; and, and County of Los Angeles Building Emergency Plan of County Buildings If a full evacuation and emergency housing were necessary, the youth would be housed at ☒ ☐ ☐ Campus Kilpatrick per facility administration. Attempts were made to receive the updated policy and to date, we have not received a written plan. The agency is working on this process; this will need to be addressed in corrective action. (g) development of a fire suppression pre-plan in DSB Manual Section 911: Fire Prevention and cooperation with the local fire department. Suppression ☒ ☐ ☐ The fire suppression pre-plan was completed with Brian Whelan in February 2023. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 8 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1327 EMERGENCY PROCEDURES DSB Manual Section 900: Emergency Procedures to include: The facility administrator shall develop facility- DSB Manual Section 906: Escapes (Code specific policies and procedures for emergencies Green) that shall include, but not be limited to: DSB Manual Section 908: Major Disturbances (Code Red) DSB Manual Section 916: Hostages DSB Manual Section 907: Outside Intruder (Code Yellow) DSB Manual Section 917: Active Shooter DSB Manual Section 918: Terrorist Attack DSB Manual Section 919: Civil Disturbance ☒ ☐ ☐ DSB Manual Section 911: Fire Prevention and Suppression DSB Manual Section 913: Power Failure DSB Manual Section 915: Earthquakes DSB Manual Section 910: Testing of Emergency Equipment DSB Manual Section 920: Emergency Evacuation Emergency procedures are pending updates; the SYTF continues to use DSB Emergency Procedures in the interim. (a) escape, disturbances, and the taking of See above. ☒ hostages; ☐ ☐ (b) civil disturbance, active shooter and terrorist ☒ attack; ☐ ☐ (c) fire and natural disasters; ☒ ☐ ☐ (d) periodic testing of emergency equipment; ☒ ☐ ☐ (e) emergency evacuation of the facility; and ☒ ☐ ☐ (f) a program to provide all youth supervision DSB Manual Section 920: Emergency staff with an annual review of emergency Evacuation procedures. Annual Emergency Procedure Reviews are compliant. ☒ ☐ ☐ 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 9 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1328 SAFETY CHECKS DSB Manual Section 209: Duty Statement- Senior Detention Services Officer The facility administrator shall develop and DSB Manual Section 210: Duty Statement- implement policy and procedures that provide for Detention Services Officer direct visual observation of youth at a minimum of DSB Manual Section 211: Group Supervisor every 15 minutes, at random or varied intervals Nights during hours when youth are asleep or when DSB Manual Section 630: Safety Checks youth are in their rooms, confined in holding cells or confined to their bed in a dormitory. Safety checks were reviewed for July 20, 2023 Supervision is not replaced, but may be -July 27, 2023, for Units N, O, Z1, Z2, Y1, Y2, supplemented by, an audio/visual electronic T, and V for all shifts. This review consisted of surveillance system designed to detect overt, reviewing electronic records of the Guard 1 aggressive or assaultive behavior and to summon ☐ ☒ ☐ System. aid in emergencies. All safety checks shall be documented with the actual time the check is The review of the Guard 1 system report completed. indicated that safety checks exceed 15 minutes. We conducted a review of a random sample of video, which indicates inconsistencies with the Guard 1 report. We also noted that staff are not recording late checks in the system, as required by policy, nor are there any audits or reviews being completed by seniors or supervisors as required by Directive 1490. 1353 ORIENTATION DSB Manual Section 416: Orientation Process for Detained Youth The facility administrator shall develop and implement written policies and procedures to The documentation provided did not include orient a youth prior to placement in a living area. any information specific to the SYTF Both written and verbal information shall be population. provided and supplemented with video orientation if feasible. Provision shall be made to provide ☒ Technical Assistance provided that a accessible orientation information to all detained ☐ ☐ handbook and documentation will need to be youth including those with disabilities, limited implemented specific to the population and literacy, or English language learners. Orientation facility that includes the specific items required shall include information that addresses: by regulation for compliance. The remainder of the checkboxes in this regulation are left blank. (a) facility rules including contraband and searches and disciplinary procedures; ☐ ☐ ☐ (b) facility’s system of positive behavior interventions and supports, including behavior expectations, incentives that youth will receive for complying with facility rules, and consequences ☐ ☐ ☐ that may result when youth violate the rules of the facility; (c) age appropriate information that explains the facility’s policy prohibiting sexual abuse and sexual harassment and how to report incidents or ☐ ☐ ☐ suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; ☐ ☐ ☐ (e) the existence of the grievance procedure, the steps that must be taken to use it, the youth’s right to be free of retaliation for reporting a grievance, ☐ ☐ ☐ and the name of the person or position designated to resolve the issue; (f) access to legal services and information on the court process; ☐ ☐ ☐ 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 10 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (g) access to routine and emergency health and mental health care; ☐ ☐ ☐ (h) access to education, religious services, and recreational activities; ☐ ☐ ☐ (i) housing assignments; ☐ ☐ ☐ (j) opportunity for personal hygiene and daily showers including the availability of personal care ☐ ☐ ☐ items (k) rules and access to correspondence, visits and telephone use; ☐ ☐ ☐ (l) availability of reading materials, programming, and other activities; ☐ ☐ ☐ (m) facility policies on the use of force, use of restraints, chemical agents and room confinement; ☐ ☐ ☐ (n) immigration legal services; ☐ ☐ ☐ (o) emergencies including evacuation procedures; ☐ ☐ ☐ (p) non-discrimination policy and the right to be free from physical, verbal or sexual abuse and ☐ ☐ ☐ harassment by other youth and staff; (q) availability of services and programs in a language other than English if appropriate; ☐ ☐ ☐ (r) the process for requesting different housing, education, programming and work assignments; ☐ ☐ ☐ (s) a process for which parents/guardians receive information regarding the youth’s stay in the facility that at a minimum includes answers to frequently asked questions and provides contact information ☐ ☐ ☐ for the facility, medical, school and mental health; and, (t) a process by which youth may request access to Title 15 Minimum Standards for Juvenile ☐ ☐ ☐ Facilities. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 11 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT DSB Manual Section 1303: Room Confinement. (a) The facility administrator shall develop and implement written policies and procedures As noted in DSB Manual Section 1324, addressing the confinement of youth in their room additional policy documentation was provided that are consistent with Welfare and Institutions including Policy Section 600, which includes Code Section 208.3. The placement of a youth in 607: Modified Program. There are conflicts room confinement shall be accomplished in between the policies and directives that need accordance with the following guidelines: clarification. We requested documentation for July 20-27, 2023. We were told that there was no room confinement between those times and were eventually provided with three (3) room confinement packets dating back to May 2023. One of the packets lacked a director’s four-hour review. Youth reported they may be placed in their room for time outs to calm down until they can be counseled after an incident, or after an incident for various reasons. Staff report some of the same; however, no egregious lengths of time were reported. Based upon these conversations, it appears staff are either not aware of what constitutes ☐ ☐ ☐ room confinement or do not have adequate resources to place youth in room confinement safely. The policy lacks clarity; in parts, the policy directs staff to seclude youth from the rest of the group utilizing the youth’s room for a cool-down period where officers provide continued direct observation. The policy is not specific to whether the door remains open or is closed. If the door is closed, this becomes room confinement. Since the policy is not specific, we are unsure what the actual procedure is. The policy should be updated, and all staff should be retrained to recognize room confinement to maintain compliance. Any use of room confinement must be documented to ensure compliance with both statute and regulation. Without documentation, we are unable to determine when and how room confinement is occurring. We will be conducting follow-up inspections to determine compliance. The remainder of the checkboxes in this regulation are left blank. (1) Room confinement shall not be used before other, less restrictive, options have been attempted and exhausted, unless attempting ☐ ☐ ☐ those options poses a threat to the safety or security of any youth or staff. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 12 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (2) Room confinement shall not be used for the purposes of punishment, coercion, ☐ ☐ ☐ convenience, or retaliation by staff. (3) Room confinement shall not be used to the extent that it compromises the mental and ☐ ☐ ☐ physical health of the youth. (b) A youth may be held up to four hours in room confinement. After the youth has been held in room confinement for a period of four hours, staff ☐ ☐ ☐ shall do one or more of the following: (1) Return the youth to general population. ☐ ☐ ☐ (2) Consult with mental health or medical staff. ☐ ☐ ☐ (3) Develop an individualized plan that includes the goals and objectives to be met in order to ☐ ☐ ☐ reintegrate the youth to general population. (4) If room confinement must be extended beyond four hours, staff shall do each of the ☐ ☐ ☐ following: (A) Document the reasons for room confinement and the basis for the extension, the date and time the youth was first placed ☐ ☐ ☐ in room confinement, and when he or she is eventually released from room confinement. (B) Develop an individualized plan that includes the goals and objectives to be met in order to integrate the youth to general ☐ ☐ ☐ population. (C) Obtain documented authorization by the facility superintendent or his or her designee ☐ ☐ ☐ every four hours thereafter. (5) This section is not intended to limit the use of single-person rooms or cells for the housing of youth in juvenile facilities and does not apply ☐ ☐ ☐ to normal sleeping hours. (6) This section does not apply to youth or wards in court holding facilities or adult ☐ ☐ ☐ facilities. (7) Nothing in this section shall be construed to conflict with any law providing greater or ☐ ☐ ☐ additional protections to youth. (8) This section does not apply during an extraordinary emergency circumstance that requires 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. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 13 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (9) This section does not apply when a youth is placed in a locked cell or sleeping room to treat and 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. 1357 USE OF FORCE Directive 1477: Detention and Residential Treatment Services Bureaus Manual-Physical The facility administrator, in cooperation with the Intervention Policy (DSB Manual Section responsible physician, shall develop and DSB-1000/RTSB-1700) Issued 06/22/2022. implement written policies and procedures for the Policy 1000 was issued on July 25, 2023, and use of force, which may include chemical agents. approved by DSB Bureau Chief Kevin Woods. Force shall never be applied as punishment, Policy Section 1000 was reapproved from discipline, retaliation or treatment. previous Directive 1477. (a) At a minimum, each facility shall develop policies and procedures which: All staff, including those deployed or reassigned to the facility, have not been trained as required in the Use of Force, including the use of OC, despite the original directive being approved in June 2022. Training requires initial training and an annual refresher. We understand that training has been developed and scheduling is in progress. During our review of incident documentation, there were a few packets missing the incident ☒ ☐ debriefs or parent contact as required. There ☐ have been changes in personnel lately; while this does not appear to be an ongoing issue, it is being addressed through a training memo to the supervisors responsible for the tasks. The policy also notes the availability of resource teams comprised of mental health, nursing, and probation staff to respond to situations to defuse and de-escalate crises. There were no such teams at the facility at the time of inspection. We noted that for most of the incidents reviewed, a debrief was not completed; the First Team reports not receiving reports timely. Aside from specific items of noncompliance, the remainder of the checkboxes in this regulation are left blank. (1) restricts the use of force to that which is deemed reasonable and necessary, as defined in Section 1302 to ensure the safety and security ☐ ☐ ☐ of youth, staff, others and the facility. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 14 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (2) outline the force options available to staff including both physical and non-physical options and define when those force options are ☐ ☐ ☐ appropriate. (3) describe force options or techniques that are expressly prohibited by the facility. ☐ ☐ ☐ (4) describe the requirements of staff to report any inappropriate use of force, and to take ☐ ☐ ☐ affirmative action to immediately stop it. (5) define a standardized reporting format that includes time period and procedure for documenting and reporting the use of force, including reporting requirements of management and line staff and procedures for reviewing and tracking use of force incidents by supervisory and or management staff, which ☐ ☐ ☐ include procedures for debriefing a particular incident with staff and/or youth for the purposes of training as well as mitigating the effects of trauma that may have been experienced by staff and /or the youth involved. (6) Include an administrative review and a system for investigating unreasonable use of ☐ ☐ ☐ force. (7) define the role, notification, and follow-up Parent contact was not consistently procedures required after use of force incidents documented. ☒ for medical, mental health staff and parents or ☐ ☐ legal guardians. (8) describe the limitations of use of force on pregnant youth in accordance with Penal Code Section 6030(f) and Welfare and Institutions ☐ ☐ ☐ Code Section 222. (b) Facilities that authorize chemical agents as a Only one use of OC was provided for review in force option shall include policies and procedures eight (8) incidents reviewed; documentation that: indicates it was deployed consistent with (1) identify who is approved to carry and/or policy and procedure. ☐ ☐ ☐ utilize chemical agents in the facility and the type, size and the approved method of deployment for those chemical agents. (2) mandate that chemical agents only be used 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 reasonably possible. (3) outline the facility’s approved methods and timelines for decontamination from chemical agents. This shall include that youth who have been exposed to chemical agents shall not be ☐ ☐ ☐ left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. (4) define the role, notification, and follow-up No parent was notified in this instance. procedures required after use of force incidents ☒ involving chemical agents for medical, mental ☐ ☐ health staff and parents or legal guardians. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 15 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (5) provide for the documentation of each incident of use of chemical agents, including the reasons for which it was used, efforts to de- escalate prior to use, youth and staff involved, the date, time and location of use, ☐ ☐ ☐ decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure The facility has not completed training as which require that agencies provide initial and required by policy. ☒ regular training in use of force and chemical agents ☐ ☐ when appropriate that address: (1) known medical and behavioral health conditions that would contraindicate certain ☒ ☐ ☐ types of force; (2) acceptable chemical agents and the ☒ methods of application. ☐ ☐ (3) signs or symptoms that should result in immediate referral to medical or behavioral ☒ ☐ ☐ health. (4) instruction on the Constitutional Limitations ☒ of Use of Force. ☐ ☐ (5) physical training force options that may ☒ require the use of perishable skills. ☐ ☐ (6) timelines the facility uses to define regular ☒ training. ☐ ☐ 1358 USE OF PHYSICAL RESTRAINTS Directive 1477: Detention and Residential Treatment Services Bureaus Manual-Physical The facility administrator, in cooperation with the Intervention Policy (DSB Manual Section responsible physician and mental health director, DSB-1000/RTSB-1700) Issued on June 22, shall develop and implement written policies and 2022. procedures for the use of restraint devices. Restraint devices include any devices which ☒ Policy 1000 was issued on July 25, 2023, and immobilize a youth's extremities and/or prevent the ☐ ☐ approved by DSB Bureau Chief Kevin Woods. youth from being ambulatory. Restraints are not generally used. Of the incidents reviewed for the time period requested, only one incident included the use of restraints. Physical restraints may be used only for those youth who present an immediate danger to themselves or others, who exhibit behavior which results in the destruction of property, or reveals the ☒ intent to cause self-inflicted physical harm. ☐ ☐ Physical restraints should be utilized only when it appears less restrictive alternatives would be ineffective in controlling the youth’s behavior. In no case shall restraints be used as punishment or discipline, or as a substitute for treatment. The use of restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through affixing of hands and feet together behind ☒ ☐ ☐ the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 16 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS The provisions of this section do not apply to the use of handcuffs, shackles or other restraint devices when used to restrain youth for movement or transportation within the facility. Movement within ☒ ☐ ☐ the facility shall be governed by Section 1358.5, Use of Restraint Devices for Movement Within the Facility. Youth shall be placed in restraints only with the approval of the facility manager or designee. The facility manager may delegate authority to place a ☒ youth in restraints to a physician. Reasons for ☐ ☐ continued retention in restraints shall be reviewed and documented at a minimum of every hour. A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no later than two hours from the time of placement. ☒ ☐ ☐ The youth shall be medically cleared for continued retention at least every three hours thereafter. A mental health consultation shall be secured as The Physical Interventions Policy was not soon as possible, but in no case longer than four clear regarding the four (4) hour requirement hours from the time of placement, to assess the for MH assessment for treatment if an incident need for mental health treatment. occurs after hours. Facility management has ☒ ☐ ☐ drafted a training memo that has been sent to facility supervisors to clarify the procedure to resolve the issue until the policy can be updated. Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and to ensure the safety and well-being of the youth. Observations of the youth's behavior ☒ ☐ ☐ and any staff interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. In addition to the requirements above, policies and procedures shall address: ☒ ☐ ☐ (a) documentation of the circumstances leading to an application of restraints. (b) known medical conditions that would contraindicate certain restraint devices and/or ☒ ☐ ☐ techniques. (c) acceptable restraint devices. ☒ ☐ ☐ (d) signs or symptoms which should result in ☒ ☐ ☐ immediate medical/mental health referral. (e) availability of cardiopulmonary resuscitation ☒ ☐ ☐ equipment. (f) protective housing of restrained youth. While in restraint devices, all youth shall be housed alone or in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. ☒ ☐ ☐ (h) exercising of extremities. ☒ ☐ ☐ (a) identification of acceptable restraint devices, staff approved to utilize restraint devices and the ☒ ☐ ☐ required training. (b) the circumstances leading to the application of restraints must be documented. ☒ ☐ ☐ 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 17 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1358.5 USE OF RESTRAINT DEVICES FOR DSB Manual Section 809: The Use of MOVEMENT AND TRANSPORTATION Mechanical Restraints for Movement and WITHIN THE FACILITY. Transport Within the Facility The Facility Administrator, in cooperation with the responsible physician and behavioral/mental ☒ ☐ ☐ health director, shall develop and implement written policies and procedures for the use of restraint devices when the purpose is for movement or transportation within the facility that shall include the following: (a) identification of acceptable restraint devices, staff approved to utilize restraint devices and the ☒ ☐ ☐ required training. (b) the circumstances leading to the application of restraints must be documented. ☒ ☐ ☐ (c) an individual assessment of the need to apply Eight (8) incidents/Safe Crisis Management restraints for movement or transportation that (SCM) reports were provided for our review. includes consideration of less restrictive Other documentation reviewed consisted of alternatives, consideration of a youth’s known Room Confinement and Special Incident medical or mental health conditions, trauma Reviews. informed approaches, and a process for ☒ ☐ ☐ documentation and supervisor review and It is rare that the facility staff use handcuffs to approval. control the movement of youth post-incident. We found only one of eight (8) use-of-force incidents in which handcuffs were utilized and the assessment was not completed. (d) consideration of safety and security of the facility, with a clearly defined expectation that restraint devices shall not be used for the ☒ ☐ ☐ purposes of discipline or retaliation. (e) the use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section ☒ ☐ ☐ 222. 1360 SEARCHES DSB Manual Section 700: Searches The facility administrator shall develop and implement written policies and procedures ☒ ☐ ☐ governing the search of youth, the facility, and visitors. Policies and procedures shall provide that: (a) Searches shall be conducted to ensure the DSB Manual Section 701: Introduction safety and security of the facility, public, visitors, youth, and staff. According to policy, room and unit area searches are required daily, and two thorough contraband searches are required weekly. A July Search Log was provided for review. ☐ ☒ ☐ Room and facility searches were not completed as required; only unit searches were completed. It is unknown if any individual rooms were searched during the month as no other documentation was received. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 18 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (b) Searches shall be conducted in a manner that We have provided technical assistance on preserves the privacy and dignity of the person several occasions regarding the searches and being searched and shall not be conducted for how they are conducted. We will continue to harassment or as a form of discipline or follow up with facility managers and seek to be punishment. ☐ ☐ ☐ present during unit searches. The section is left blank as we did not view a search in progress. (c) Strip searches and visual or physical body DSB Manual Section 701: Introduction cavity searches shall comply with Penal Code ☒ ☐ ☐ Section 4030. (d) Physical body cavity searches shall only be Policy DSB Manual Sections: conducted by a medical professional. 702: Types of Searches and Definitions 711: Admissions Procedures - Strip Search and/or Visual Body Cavity Search ☒ ☐ ☐ We are unaware of any physical body cavity searches completed. (e) Any youth held after a detention hearing shall DSB Manual Section 703: Searches of Youth only be strip searched with prior approval of a Housed in Juvenile Facilities - General supervisor when there is reasonable suspicion Information based on specific and articulable facts to believe ☒ ☐ ☐ that youth is concealing contraband. The Documentation was provided for our review reasonable suspicion shall be documented. and was found to be compliant. (f) Searches of transgender and intersex youth DSB Manual Section 706: Transgender Youth shall comply with Section 1352.5. Searches ☒ ☐ ☐ We are unaware of any transgender or intersex youth being searched. (g) Cross-gender pat-down searches and strip DSB Manual Section 705: Cross-Gender searches are prohibited except in exigent Searches circumstances or when conducted by a medical ☒ ☐ ☐ professional. Such searches must be justified and We are unaware of any cross-gender pat- documented in writing. down searches being completed. 1361 GRIEVANCE PROCEDURE Policy DSB Manual Section 1715: Youth Grievance Procedures The facility administrator shall develop and implement written policies and procedures whereby any youth may appeal and have resolved grievances relating to any condition of confinement, including but not limited to health care services, classification decisions, program ☒ ☐ ☐ 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 Policy DSB Manual Section 1715: Youth a grievance, which includes provisions for the Grievance Procedures youth to have free access to the form; (b) the youth shall have the option to confidentially ☒ ☐ ☐ Youths can submit a grievance either by paper file the grievance or to deliver the form to any youth or by computer while in school. supervision staff working in the facility; 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 19 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (c) resolution of the grievance at the lowest Policy DSB Manual Section 1715: Youth appropriate staff level; Grievance Procedures Grievances are addressed by the grievance officer and or supervisors. Issues that can be ☒ ☐ ☐ addressed informally by unit staff are not considered grievances. Youth report they can turn their grievances into any staff member or into the confidential box for pick up by the grievance officers. (d) provision for a prompt review and initial Policy DSB Manual Section 1715: Youth response to grievances within three (3) business Grievance Procedures days, grievances that relate to health and safety issues must be addressed immediately; We found the practice for submitting a grievance electronically was not working in the manner prescribed by regulation and there are limitations as to the number of characters that could be used. This was discussed with agency subject matter experts who are actively working with their developers to address this issue. Technical assistance was provided and it was agreed that in the interim, the agency will be notifying and educating all current youth of this malfunction and have designated a workaround. Future youth will be noticed ☒ ☐ ☐ through orientation until the issue is addressed. The agency will provide documentation of all youth noticed by September 15, 2023. Also noted was “immediate response” was not shown to be made available for emergent issues as required for electronic submissions due to IT issues. This too is being addressed. All youth will be notified that for assistance with any health and safety issues, they should seek assistance from a staff member immediately regardless of grievance status or type of grievance submitted. This issue will continue to be under review at future visits to ensure compliance. (1) The youth may elect to be present to explain Policy DSB Manual Section 1715: Youth his/her version of the grievance to a person not Grievance Procedures ☒ ☐ ☐ directly involved in the circumstances which led to the grievance. (2) Provision for a staff representative approved ☒ ☐ ☐ by the facility administrator to assist the youth. (e) provision for a written response to the grievance which includes the reasons for the ☒ ☐ ☐ decisions; (f) a system which provides that any appeal of a grievance shall be heard by a person not directly ☒ ☐ ☐ involved in the circumstances which led to the grievance; 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 20 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (g) resolution of the grievance must occur within ten (10) business days unless circumstances ☒ ☐ ☐ dictate a longer time frame. The youth shall be notified of any delay; and, (h) the policy shall provide multiple internal and external methods to report sexual abuse and ☒ ☐ ☐ sexual harassment. Whether or not associated with a grievance, concerns of parents, guardians, staff or other parties shall be addressed and documented in ☒ ☐ ☐ accordance with written policies and procedures within a specified timeframe. 1370 EDUCATION PROGRAM This section was reviewed for attendance only. All other sections in 1370 have been deleted as they were not reviewed during this targeted b(6) The minimum school day shall be inspection. consistent with State Education Code Requirements for juvenile court schools. The Daily attendance reports have been received facility administrator, in conjunction with directly from LACOE. While attendance has education staff, must ensure that operational improved since past inspections, and youth procedures do not interfere with the time are attending class in the classrooms, these afforded for the minimum instructional day. ☐ ☒ ☐ reports continue to indicate that youth are Absences, time out of class or educational arriving late to school. Probation must focus instruction, both excused and unexcused, shall on getting youths to school on time. be documented. Youths enrolled in college courses are also reporting having daily access to their courses. Documentation of sign-in sheets were provided for review along with a schedule of courses. 1371 PROGRAMS, RECREATION, AND DSB Manual Section 622: Programs EXERCISE. DSB Manual Section 623: Recreation and Exercise The facility administrator shall develop and implement written policies and procedures for ☐ ☒ ☐ programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. Juvenile facilities shall provide the opportunity for DSB Manual Section 622: Programs programs, recreation, and exercise a minimum of DSB Manual Section 623: Recreation and three hours a day during the week and five hours Exercise a day each Saturday, Sunday or other non-school days, of which one hour shall be an outdoor Based upon on review of documentation and ☐ ☒ ☐ activity, weather permitting. conversations with youth, it is apparent that youth do not receive their full complement of Title 15 requirements for programs and recreation consistently. A youth’s participation in programs, recreation, and DSB Manual Section 622: Programs exercise may be suspended only upon a written DSB Manual Section 623: Recreation and finding by the administrator/manager or designee Exercise that a youth represents a threat to the safety and ☒ ☐ security of the facility. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 21 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS Such program, recreation, and exercise schedule DSB Manual Section 622: Programs shall be posted in the living units. DSB Manual Section 623: Recreation and Exercise We found schedules to be posted for the most part; however, schedules do not always match ☒ ☐ ☐ what is being provided operationally. We recommend unit staff be sure that these schedules are reviewed periodically. Many times, the documents are illegible, and staff are not aware of the actual program schedule. There will be a written annual review of the DSB Manual Section 622: Programs programs, recreation, and exercise by the DSB Manual Section 623: Recreation and responsible agency to ensure content offered is Exercise current, consistent, and relevant to the population. ☐ ☐ ☐ This section is left blank as we did not inspect this section. (a) Programs. All youth shall be provided with the DSB Manual Section 622: Programs opportunity for at least one hour of daily DSB Manual Section 623: Recreation and programming to include, but not be limited to, Exercise trauma focused, cognitive, evidence-based, best practice interventions that are culturally relevant The documentation we reviewed indicates and linguistically appropriate, or pro-social that programs are not consistently being interventions and activities designed to reduce provided. In some cases, the program recidivism. These programs should be based on provider keeps sign-in sheets of youth the youth’s individual needs as required by Sections attendance, but facility documentation does 1355 and 1356. Such programs may be provided not consistently match sign-ins. We suggest under the direction of the Chief Probation Officer or that staff be retrained in how the BSCC the County Office of Education and can be Section 1371 activity form should be administered by county partners such as mental completed to ensure compliance going health agencies, community-based organizations, forward. faith-based organizations or Probation staff. Programs may include but are not limited to: We suggest that staff be retrained in how the (1) Cognitive Behavior Interventions; form should be completed to ensure (2) Management of Stress and Trauma; compliance going forward. ☐ ☒ ☐ (3) Anger Management; (4) Conflict Resolution; (5) Juvenile Justice System; (6) Trauma-related interventions; (7) Victim Awareness; (8) Self-Improvement; (9) Parenting Skills and support; (10) Tolerance and Diversity; (11) Healing Informed Approaches; (12) Interventions by Credible Messengers; (13) Gender Specific Programming; (14) Art, creative writing, or self-expression; (15) CPR and First Aid training; (16) Restorative Justice or Civic Engagement; (17) Career and leadership opportunities; and, (18) Other topics suitable to the youth population. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 22 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (b) Recreation. All youth shall be provided the DSB Manual Section 623: Recreation and opportunity for at least one hour of daily access Exercise to unscheduled activities such as leisure reading, letter writing, and entertainment. Youth are not provided with age-appropriate, Activities shall be supervised and include stimulating recreational activities to engage in orientation and may include coaching of youth. during their recreational period. Youth do not have access to other entertaining or recreational activities such as television with sports and age-appropriate programs. Staff provide youth with game consoles in some units as they are not provided by the agency. It has been repeatedly noted that “they (the youth) break them or take them ☐ ☒ ☐ apart”, which is why they are not provided by the agency. This is a supervision issue. It was also noted there is no consistency between units in what items are offered. We understand there are different units and different phases to the facility; however, recreation and related activities should be provided to all youth consistently. Moreover, Probation Managers should have access to replacement items. Youth must have age- appropriate, suitable, engaging recreation and recreational activities. (c) Exercise. All youth shall be provided with the DSB Manual Section 623: Recreation and opportunity for at least one hour of large muscle Exercise activity each day. Documentation reviewed and interviews with youth and staff indicated that youth are ☒ ☐ ☐ receiving outdoor exercise except for during inclement weather (too hot) or if a youth or a group of youth refuse to participate. If a youth refuses to exercise, it is documented and captured by the youth’s signature. The administrator/manager may suspend, for a DSB Manual Section 622: Programs period not to exceed 24 hours, access to recreation DSB Manual Section 623: Recreation and and programs. The administrator/manager shall Exercise ☒ ☐ ☐ document the reasons why suspension of recreation and programs occurs. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 23 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1374 VISITING DSB Manual Section 304: Visiting Documentation was provided for the period of The facility administrator shall develop and July 12, 2023, to July 27, 2023. implement written policies and procedures for visiting, that include provisions for special visits. Youth were questioned as to the visiting Youth shall be allowed to receive visits by parents, process and if they had children, were they guardians or persons standing in loco parentis, and allowed to visit with them. Those youths who children of youth. Other family members, such as have children but did not visit with them grandparents and siblings, and supportive adults, indicated that the youth were either not listed may be allowed to visit with the approval of the ☒ ☐ ☐ on the child’s birth certificate or they were in facility administrator or designee, and in conjunction the process of being approved and with the youth’s case plan or in the best interest of transportation of the child being arranged. the youth. The youth noted that they were given their full two (2) hours with their parents and had additional time on a different date with their child. All visits shall occur at reasonable times, subject DSB Manual Section 304: Visiting only to the limitations necessary to maintain order and security. Visitation shall not be denied solely Formal Visitation occurs on the weekends. based on the visitor’s criminal history. The staff shall Parents can make special arrangements as determine in each case, whether the visitor’s necessary and if needed if they cannot make ☒ ☐ ☐ criminal history represents a risk to the safety of the weekend visits. youth or staff in the facility. Any denial of visitation or limitation on visitations shall be communicated to the youth, person denied and facility administrator. Opportunity for visitation shall be a minimum of two DSB Manual Section 304: Visiting hours per week. Visits may be supervised, but conversations shall not be monitored unless there is Documentation was provided noting that a security or safety need. visitation was being offered during the ☒ ☐ ☐ appropriate times as required. The youth we spoke to confirmed that regular visitation is occurring. Provisions for special visits, in addition to the two- DSB Manual Section 304: Visiting hour minimum and/or outside of the regular visiting hours, shall be accommodated as necessary and Youth stated special visits had been provided within the discretion of the facility administrator or more freely in the recent past; however, due to designee. Family therapy and professional visits contraband and other facility operational shall be accommodated outside the provisions of issues (staffing), these visits have been this regulation. Facilities may provide visitation limited. ☒ ☐ ☐ opportunities outside of normal visiting hours to accommodate special visits. Youth stated special visits had been provided more freely previously; however, due to contraband and other facility operational issues (staffing), these visits have been limited in the last 3 to 4 months. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 24 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS The facility may provide access to technology as an DSB Manual Section 304: Visiting alternative, but not as a replacement, to in-person DSB Manual Section 306: Virtual visiting. Communication The facility is not currently utilizing technology as a resource for visits or communications. Assigned facility cell phones had been used previously but are not currently being used due to inadequate supervision resources and oversight of the calls. We noted in speaking with several youths that ☒ ☐ ☐ their family members are unable to visit due to distance, lack of transportation, or other reasons. We encouraged the reintegration of technology to provide youth with the opportunity to have face-to-face communication with their families, especially for those youth who do not receive visits. We noted that some youths have not had contact with their family in quite some time. Using technology such as FaceTime or Duo would mitigate this issue. 1390 DISCIPLINE DSB Manual Section 1103: Discipline Guidelines The facility administrator shall develop and DSB Manual Section 1104: Corporal implement written policies and procedures for the Punishment discipline of youth that shall promote acceptable behavior; including the use of positive behavior The facility continues to operate with no interventions and supports. Discipline shall be contemporary behavior management process imposed at the least restrictive level which promotes or disciplinary process for negative behavior the desired behavior and shall not include corporal including assaultive behavior. punishment, group punishment, physical or psychological degradation. Deprivation of the The facility lacks a suitable discipline process. following is not permitted: There were eight (8) SCMs provided, of which, two (2) were missing the Sanctions and Appeals form, one (1) was a Mental Health Incident, and five (5) were not completed ☐ ☒ ☐ correctly. Of the five (5), three (3) did not have sanctions identified and in the other two (2), the form was not completed correctly. A suitable, age-appropriate incentive-based program to encourage positive and proactive behavior and include disciplinary actions as appropriate must be developed and implemented. This section also impacts 1391 and Due Process forms. We strongly suggest reviewing both for implementation purposes and to ensure consistency between the two policies. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 25 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS The facility administrator shall establish rules of DSB Manual Section 1103: Discipline conduct and disciplinary penalties to guide the Guidelines conduct of youth. Such rules and penalties shall DSB Manual Section 1106: Rules and include both major violations and minor violations, Regulations be stated simply and affirmatively, and be made available to all youth. Provision shall be made to Facility rules and penalties or sanctions must provide accessible information to youth with be established. As neither the policy nor the ☐ ☒ ☐ disabilities, limited English proficiency, or limited orientation manual have been completed, this literacy. section is also marked as noncompliant as a result. The remainder of this regulation has been deleted. 1433 REQUESTS FOR HEALTH CARE DSB Manual Section 1702: Access to SERVICES (EXCERPT) Care/Request for Services The health administrator, in cooperation with the The youth we spoke to are aware of the facility administrator, shall develop policy and process to access emergency and non- procedures to establish a daily routine for youth to ☒ ☐ ☐ emergency medical, dental, and convey requests for emergency and non- behavioral/mental health care services. emergency medical, dental and behavioral/mental Services were said to be provided in a timely health care services. manner. 1480 STANDARD FACILTY CLOTHING ISSUE DSB Manual Section 403: Procedures for Newly Admitted Youth The youth’s personal clothing, undergarments and footwear may be substituted for the institutional clothing and footwear specified in this regulation. ☒ ☐ ☐ The facility has the primary responsibility to provide clothing and footwear. Clothing provisions shall ensure that: Clothing is clean, reasonably fitted, durable, easily DSB Manual Section 403: Procedures for laundered, in good repair, and free of holes and Newly Admitted Youth tears. ☒ ☐ ☐ Clothes were noted to be clean and fit well. (a) The standard issue of climatically suitable DSB Manual Section 403: Procedures for clothing for youth shall consist of but not be limited Newly Admitted Youth ☒ ☐ ☐ to: DSB Manual Section 403: Procedures for Newly Admitted Youth (1) Socks and serviceable footwear; ☒ ☐ ☐ The youth had socks and shoes. Neither had holes nor were in disrepair. DSB Manual Section 403: Procedures for Newly Admitted Youth (2) Outer garments; ☒ ☐ ☐ Jackets are not currently necessary due to summer weather. (3) New non-disposable underwear which shall DSB Manual Section 403: Procedures for remain with the youth throughout their stay, Newly Admitted Youth and; ☒ ☐ ☐ Youth stated they believe they are provided with their own underwear. (4) Undergarments, that are freshly laundered DSB Manual Section 403: Procedures for and free of stains, including tee shirts and bras. Newly Admitted Youth ☒ ☐ ☐ Youth stated their undergarments are clean, and free from stains and returned clean to them. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 26 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS (b) Clothing is laundered at the temperature DSB Manual Section 403: Procedures for required by local ordinances for the commercial Newly Admitted Youth laundries and dried completely in a mechanical dryer or other laundry method approved by the ☒ ☐ ☐ local health officer. (c) Suitable clothing is issued to pregnant youth. The facility houses only males. ☐ ☐ ☒ 1482 CLOTHING EXCHANGE DSB Manual Section 505: Housekeeping The facility administrator shall develop and The facility has a practice in place for clothing implement written policies and site-specific exchange. procedures for the cleaning and scheduled exchange of clothing. Unless work, climatic The youth we spoke with noted receiving clean conditions, or illness necessitates more frequent clothing as required. ☒ ☐ ☐ exchange, outer garments, except for footwear, shall be exchanged at least once each week. Tee shirts, bras, and underwear shall be exchanged daily; youth shall receive their own underwear back at exchange. 1485 ISSUE OF PERSONAL CARE ITEMS DSB Manual Section 508: Housekeeping: Personal Hygiene Supplies There shall be written policies and site-specific procedures developed and implemented by the All youth we spoke with noted having access facility administrator for the availability of personal ☒ ☐ ☐ to all required items. hygiene items. Each female youth shall be provided with sanitary napkins, panty liners and tampons as requested. Each youth to be held over 24 hours shall be provided with the following personal care items; Toothbrush; DSB Manual Section 508: Housekeeping: (a) Toothpaste; Personal Hygiene Supplies (b) Soap; (c) Comb; All youth we spoke with noted having access (d) Shaving implements; to all required items. (e) Deodorant; DSB Manual Section 508: Housekeeping: (f) Lotion; Personal Hygiene Supplies (g) Shampoo; and, (h) Post-shower conditioning hair products. (i) Youth shall not be required to share any ☒ ☐ ☐ personal care items listed in items (a) through (d). Liquid soap provided through a common dispenser is permitted. Youth shall not share disposable razors. Double edged safety razors, electric razors, and other shaving instruments capable of breaking the skin, when shared among youth, shall be disinfected between individual uses by the method prescribed by the State Board of Barbering and Cosmetology in Sections 979 and 980, Chapter 9, Title 16, California Code of Regulations. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 27 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION Yes No NA P/P REFERENCE – COMMENTS 1487 SHAVING DSB Manual Section 510: Shaving and Haircut Procedures Youth shall have access to a razor daily, unless their appearance must be maintained for reasons Most youth we spoke to noted having access of identification in Court. All youth shall have equal ☒ ☐ ☐ to shaving upon request. There were a few opportunity to shave face and body hair. The youths who noted that their unit ran out of facility administrator may suspend this razors but they were able to shave after staff requirement in relation to youth who are retrieved more. considered to be a danger to themselves or others. 1488 HAIR CARE SERVICES (EXCERPT) DSB Manual Section 510: Shaving and Haircut Procedures Hair care services shall be available in all juvenile facilities. Youth shall receive hair care services All the youth presented as well-groomed. The monthly. Equipment shall be cleaned and ☒ ☐ ☐ youth I spoke with said the Barber does not disinfected after each haircut or procedure, by a come but staff are cutting those youth’s hair method approved by the State Board of Barbering who are requesting a haircut. and Cosmetology. 7205 Los Angeles SYTF at BJN SYTF PRO 23 24 Page 28 of 28 A453 JUV PRO eff. 1/2019 (23-24).dot