San Bernardino Probation (2023-2024 inspection cycle)

December 3, 2024 Tracy Reece, Chief Probation Officer San Bernardino Probation Department 175 W. 5th Street San Bernardino, CA 92401 2023-2024 UNANNOUNCED INSPECTION, WELFARE & INSTITUTIONS CODE SECTIONS 209 & 885, SAN BERNARDINO COUNTY PROBATION DEPARTMENT DETENTION FACILITIES Dear Chief Reece: An Unannounced Inspection of the San Bernardino County Probation Department was completed for the following facilities on Thursday, November 21, 2024: FACILITY NAME BSCC # FACILITY TYPE Central Valley Juvenile Detention 7483 JH Assessment Center- CVJDAC High Desert Juvenile Detention Assessment 7480 SYTF Center- ARISE 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. INSPECTION RESULTS The focus of the Unannounced Inspection was to evaluate four (4) Title 15 regulations. To ensure compliance with Title 15, we reviewed documentation for the following Title 15 regulations: • 1329 Suicide Prevention Plan • 1354 Separation • 1354.5 Room Confinement • 1361 Grievance Procedure We identified no items of noncompliance with Title 15 Minimum Standards. Refer to the attached Title 15 Modified Procedures Checklist for detailed information. An Exit Briefing with your staff was held on Thursday, November 21, 2024; BSCC staff presented an inspection overview and discussed technical assistance and best practice recommendations. Tracy Reece Chief Probation Officer Page 2 * * * Please email me at craigus.thompson@bscc.ca.gov or call (916) 597-4610 if you have any questions. Sincerely, CRAIGUS THOMPSON SR. Field Representative Facilities Standards and Operations Division Enclosures Cc: Presiding Judge, San Bernardino County Juvenile Court* Chair, Juvenile Justice Commission, San Bernardino County* Chair, Board of Supervisors, San Bernardino County* County Administrator, San Bernardino County* Teneka Haynes, Deputy Chief Probation Officer, San Bernardino County Kimberlee Drury, Deputy Chief Probation Officer, San Bernardino County *Copies of the inspection are available upon request or online at www.bscc.ca.gov. 7483+ San Bernardino Probation Unannounced Inspection JH SYTF LTR 23-24 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 2 BSCC Code: 7480 FACILITY NAME: San Bernardino Secure Youth Treatment Facility (ARISE) FACILITY TYPE: SYTF PERSON(S) INTERVIEWED: Khara Garnett-Todd, Division Director II-Superintendent; Aliena Darling, Division Director I; Bobby Wheeler, Probation Corrections Supervisor II (PCS II); Itzel Zepeda, Probation Corrections Officer-Inspections Officer; Ana Acosta, Probation Officer II- Safety Officer; Danielle Gibson, Probation Officer II-Safety Officer Corrections Officer-Inspection Officer FIELD REPRESENTATIVE: Craigus Thompson Sr. DATE: 11/21/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN Section 1329 Suicide Prevention Program The facility administrator, in collaboration with the Reviewed ten (10) youth suicide packets from healthcare and behavioral/mental health administrators, HDJDAC ARISE. Review of documentation shall plan and implement written policies and provided and policy and procedure manuals procedures which delineate a Suicide Prevention Plan. revealed compliance with this regulation. The plan shall consider the needs of youth experiencing past or current trauma. Suicide prevention responses It should be noted any Probation Correction shall be respectful and in the least invasive manner ☒ ☐ ☐ Officer (PCO) could initiate Suicide consistent with the level of suicide risk. The plan shall Observation Status (SOS) for a youth deemed include the following elements: a potential suicide risk. However, once placed on any level of SOS, only a member of Forensic Adolescent Services Team (FAST) could downgrade and/or remove the youth from SOS. (a) Suicide prevention training as required in Section Suicide Prevention Program: Guidelines >L 1322, Youth Supervision Staff Orientation, and Training ☒ ☐ ☐ and the Juvenile Corrections Officer Core Course. (b) Screening, Identification Assessment and Suicide Prevention Program: Purpose> Precautionary Protocols (1) All youth shall be screened for risk of suicide at All ARISE youth complete the Massachusetts ☒ ☐ ☐ intake and as needed during detention. Youth Screening Instrument (MAYSI) during the intake process. (2) All youth supervision staff who perform intake Guidelines >L >1 processes shall be trained in screening youth for risk ☒ ☐ ☐ of suicide. 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 Juvenile Facilities, Division 1, Chapter 1, Subchapter 5 for the complete list and text of regulations. 2 This is a modified version of the Procedures Checklist and is only intended for the 2024 Unannounced Inspection of the San Bernardino ARISE SYTF. 7480 San Bernardino ARISE Unannounced PRO 23-24 Page 1 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (3) All youth who have been identified during the Suicide Prevention Program: III > D > 2 intake screening process to be at risk of suicide shall be referred to behavioral/mental health staff for a Youth identified as at risk of suicide are ☒ ☐ ☐ suicide risk assessment. referred to the Forensic Adolescent Services Team (FAST). (4) Precautionary protocols shall be developed to I >Safety Plan ensure the youth’s safety pending the ☒ ☐ ☐ behavioral/mental health assessment. (c) Referral process to behavioral/mental health staff for I >Safety Plan assessment and/or services. ☒ ☐ ☐ (d) Procedures for monitoring of youth identified at risk I >Safety Plan for suicide. Youth identified as at risk for suicide are placed on Suicide Observation Status (SOS) I, II, or III. SOS I youth are monitored every ten ☒ ☐ ☐ minutes while in room. SOS II youth are monitored every five minutes while in room. SOS III youth are under direct supervision by staff at all times. (e) Safety Interventions I >Safety Plan (1) Procedures to address intervention protocols for youth identified at risk for suicide which may ☒ ☐ ☐ include, but are not limited to: (A) Housing consideration (B) Treatment strategies including trauma- I >Safety Plan informed approaches ☒ ☐ ☐ (2) Procedures to instruct youth supervision staff how I >Safety Plan to respond to youth who exhibit suicidal behaviors. ☒ ☐ ☐ (f) Communication Suicide Prevention Program: III >A (1) The intake process shall include communication with the arresting officer and family guardians ☒ ☐ ☐ regarding the youth’s past or present suicidal ideations, behaviors or attempts. (2) Procedures for clear and current information I >Safety Plan sharing about youth at risk for suicide with youth supervision, healthcare, and behavioral/mental ☒ ☐ ☐ health staff. (g) Debriefing of Critical Incidents Related to Suicides or Suicide Prevention Program VI >M Attempts (1) Process for administrative review of the ☒ ☐ ☐ circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected staff. Suicide Prevention Program V >K ☒ ☐ ☐ (3) Process for a debriefing event with affected youth. Suicide Prevention Program V >L ☒ ☐ ☐ 7480 San Bernardino ARISE Unannounced PRO 23-24 Page 2 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Documentation Suicide Prevention Program V >H (1) Documentation processes shall be developed to ☒ ☐ ☐ ensure compliance with this regulation Youth identified at risk for suicide shall not be denied the Suicide Prevention Program: Guidelines >J opportunity to participate in facility programs, services and activities which are available to other non-suicidal youth, unless deemed necessary for the safety of the youth or security of the facility. Any deprivation of ☒ ☐ ☐ programs, services or activities for youth at risk of suicide shall be documented and approved by the facility manager. 1354 SEPARATION Section 1354 Administrative Separation The facility administrator shall develop and implement At the time of the inspection, only one ARISE written policies and procedures that address: youth had been placed on Administrative Separation. Review of that youth’s Administrative Separation Request and Program forms revealed compliance with this regulation. Technical assistance was provided during the previous comprehensive inspection with regards to Administrative-separated youth being periodically placed in his room for meals and school. We also discussed including the ☒ ☐ ☐ actual times youth are completing exercise, free time, and programming on the Administrative Separation form. It should be noted documentation of the youth’s exercise, free time, and programming are documented each shift on the Administrative Separation form. Documentation of youth eating all meals outside of his room is also documented on the form. (a) separation of youth for reasons that include, but are Administrative Separation: Purpose not be limited to, medical and mental health conditions, assaultive behavior, disciplinary consequences and Documentation of youth assaultive behaviors ☒ ☐ ☐ protective custody. since entering the ARISE program noted on the Administrative Separation form. (b) consideration of positive youth development and Administrative Separation: Requirements >B trauma-informed care. ☒ ☐ ☐ (c) separated youth shall not be denied normal privileges Administrative Separation: Requirements >A available at the facility, except when necessary to accomplish the objective of separation. ☒ ☐ ☐ While on Administrative Separation, the youth received all Title 15 minimum standards. (d) when the objective of the separation is discipline, Administrative Separation: Purpose Title 15 Section 1390 shall apply. ☒ ☐ ☐ (e) when separation results in room confinement, the Administrative Separation: Guidelines: E. separation shall occur in accordance with Welfare and Institutions Code Section 208.3 and Section 1354.5 of ☒ ☐ ☐ these regulations. (f) policies and procedures shall ensure a daily review of Administrative Separation: VII >B separated youth to determine if separation remains necessary. Reviews of youth on Administrative Separation ☒ ☐ ☐ are completed every twenty-four hours by the Division Director I/II. 7480 San Bernardino ARISE Unannounced PRO 23-24 Page 3 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT Section 1354.5 Room Confinement (a) The facility administrator shall develop and We reviewed twelve (12) youth Room implement written policies and procedures addressing Confinement Contract forms from ARISE. the confinement of youth in their room that are consistent Review of policy and procedure manual and with Welfare and Institutions Code Section 208.3. The documentation provided revealed compliance placement of a youth in room confinement shall be with this regulation. Each room confinement accomplished in accordance with the following contract reviewed provided excellent guidelines: ☒ ☐ ☐ documentation of why the youth was placed on room confinement and the efforts made by staff to reintegrate the youth back in the regular programming. It should be noted at the time of the inspection ARISE had not held a youth on room confinement exceeding four (4) hours. (1) Room confinement shall not be used before other, Room Confinement: Guidelines > C. less restrictive, options have been attempted and exhausted, unless attempting those options poses a Review of documentation revealed all youth threat to the safety or security of any youth or staff. ☒ ☐ ☐ placed on room confinement were appropriate as youth’s actions were posing a threat to the safety and security of the facility. (2) Room confinement shall not be used for the Room Confinement: Guidelines > H. purposes of punishment, coercion, convenience, or ☒ ☐ ☐ retaliation by staff. (3) Room confinement shall not be used to the extent Room Confinement: Guidelines > F. that it compromises the mental and physical health of ☒ ☐ ☐ the youth. (b) A youth may be held up to four hours in room Room Confinement: II >F 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. Room Confinement: II >H ☒ ☐ ☐ (2) Consult with mental health or medical staff. Room Confinement: II >H ☒ ☐ ☐ (3) Develop an individualized plan that includes the Room Confinement: II >B >1 goals and objectives to be met in order to reintegrate ☒ ☐ ☐ the youth to general population. (4) If room confinement must be extended beyond Room Confinement: III > B four hours, staff shall do each of the following: (A) Document the reasons for room confinement Room Confinement: I >A >2 and I >F and the basis for the extension, the date and time ☒ ☐ ☐ the youth was first placed in room confinement, It should be noted at the time of the inspection and when he or she is eventually released from ARISE had not held a youth on room room confinement. confinement exceeding four (4) hours. (B) Develop an individualized plan that includes Room Confinement: I >B > 1 the goals and objectives to be met in order to ☒ ☐ ☐ integrate the youth to general population. (C) Obtain documented authorization by the Room Confinement: VI >A facility superintendent or his or her designee ☒ ☐ ☐ every four hours thereafter. (5) This section is not intended to limit the use of Room Confinement: Definitions and single-person rooms or cells for the housing of youth Guidelines >A in juvenile facilities and does not apply to normal ☒ ☐ ☐ sleeping hours. 7480 San Bernardino ARISE Unannounced PRO 23-24 Page 4 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (6) This section does not apply to youth or wards in Room Confinement: Definitions and court holding facilities or adult facilities. ☒ ☐ ☐ Guidelines >M (7) Nothing in this section shall be construed to Room Confinement: Definitions and conflict with any law providing greater or additional Guidelines >N ☒ ☐ ☐ protections to youth. (8) This section does not apply during an Room Confinement: Definitions and extraordinary emergency circumstance that requires Guidelines >O 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 Room Confinement: Definitions and placed in a locked cell or sleeping room to treat and Guidelines >P 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. 1361 GRIEVANCE PROCEDURE Section 1361Grievance and Appeals The facility administrator shall develop and implement We reviewed grievances from the months of written policies and procedures whereby any youth may July, August, and September 2024. In all, we appeal and have resolved grievances relating to any reviewed twenty-five (25) grievances from condition of confinement, including but not limited to ARISE. Also we reviewed ten (10) Grievance health care services, classification decisions, program ☒ ☐ ☐ and Appeals Procedure Acknowledgement participation, telephone, mail or visiting procedures, forms from ARISE that are signed by youth food, clothing, bedding, mistreatment, harassment or during the intake process. Review of policy violations of the nondiscrimination policy. There shall be and procedure and review of documentation no time limit on filing grievances. Policies and provided revealed compliance with this procedures shall include provisions whereby the facility regulation. manager ensures: (a) a grievance form and instructions for registering a Grievance and Appeals: I >A >1 and I >B >1 grievance, which includes provisions for the youth to have free access to the form; Walkthrough of the facility revealed youth have ☒ ☐ ☐ free access to grievance forms which are in the dayroom of each living unit. (b) the youth shall have the option to confidentially file Grievance and Appeals: I >B >1 >a, b, c the grievance or to deliver the form to any youth supervision staff working in the facility; ☒ ☐ ☐ There is a confidential lock box located within each housing unit of the facility. (c) resolution of the grievance at the lowest appropriate Grievance and Appeals: V >A >1 >a staff level; ☒ ☐ ☐ (d) provision for a prompt review and initial response to Grievance and Appeals: Guidelines > B. grievances within three (3) business days, grievances that relate to health and safety issues must be All grievances reviewed had an initial ☒ ☐ ☐ addressed immediately; response completed prior to three business days. 7480 San Bernardino ARISE Unannounced PRO 23-24 Page 5 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (1) The youth may elect to be present to explain Grievance and Appeals: V > 2 >a his/her version of the grievance to a person not directly involved in the circumstances which led to the ☒ ☐ ☐ grievance. (2) Provision for a staff representative approved by Grievance and Appeals: I > C >2 the facility administrator to assist the youth. ☒ ☐ ☐ (e) provision for a written response to the grievance Grievance and Appeals: V >2 >b which includes the reasons for the decisions; ☒ ☐ ☐ (f) a system which provides that any appeal of a Grievance and Appeals: VI 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 (10) Grievance and Appeals: Guidelines: B. business days unless circumstances dictate a longer time frame. The youth shall be notified of any delay; and, All grievances reviewed were completed and ☒ ☐ ☐ resolved prior to ten (10) business days of submission. (h) the policy shall provide multiple internal and external Grievance and Appeals: Purpose methods to report sexual abuse and sexual harassment. ☒ ☐ ☐ Whether or not associated with a grievance, concerns of Grievance and Appeals: Guidelines: H. parents, guardians, staff or other parties shall be addressed and documented in accordance with written ☒ ☐ ☐ policies and procedures within a specified timeframe. 7480 San Bernardino ARISE Unannounced PRO 23-24 Page 6 of 6 A453 JUV PRO eff. 07.01.24 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 2 BSCC Code: 7483 FACILITY NAME: Central Valley Juvenile Detention Assessment Center FACILITY TYPE: JH (CVJDAC) PERSON(S) INTERVIEWED: Bernadette Galicia, Acting Division Director II-Superintendent; Veronica Love, Division Director I; Shaunie Bostick, Probation Corrections Supervisor I (PCS I)/Inspection Officer; Anthony Moore, PCS II; Ramon Velasco, PCS I; Ydren Jones, PCS I; Kacie Klaus, PCS I; Ashley Walker, Probation Corrections Officer (PCO); Alexandria Lespron, PCS I; Monica Moreno, PCS II; Jina Esparza, PCS I; Miisha Jones, PCS I; Angelica Moreno Heath, PCS I; Daryl Drake, PCS II; Sofia Jimenez, PCS I FIELD REPRESENTATIVE: Craigus Thompson Sr. DATE: 11/21/2024 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN Section 1329 Suicide Prevention Program The facility administrator, in collaboration with the Reviewed ten (10) youth suicide packets from healthcare and behavioral/mental health administrators, CVJDAC. Review of documentation provided shall plan and implement written policies and and policy and procedure manuals revealed procedures which delineate a Suicide Prevention Plan. compliance with this regulation. The plan shall consider the needs of youth experiencing past or current trauma. Suicide prevention responses It should be noted any Probation Correction shall be respectful and in the least invasive manner ☒ ☐ ☐ Officer (PCO) could initiate Suicide consistent with the level of suicide risk. The plan shall Observation Status (SOS) for a youth deemed include the following elements: a potential suicide risk. However, once placed on any level of SOS, only a member of Forensic Adolescent Services Team (FAST) could downgrade and/or remove the youth from SOS. (a) Suicide prevention training as required in Section Suicide Prevention Program: Guidelines >L 1322, Youth Supervision Staff Orientation, and Training ☒ ☐ ☐ and the Juvenile Corrections Officer Core Course. (b) Screening, Identification Assessment and Suicide Prevention Program: Purpose> Precautionary Protocols (1) All youth shall be screened for risk of suicide at All CVJDAC youth complete the ☒ ☐ ☐ intake and as needed during detention. Massachusetts Youth Screening Instrument (MAYSI) during the intake process. (2) All youth supervision staff who perform intake Guidelines >L >1 processes shall be trained in screening youth for risk ☒ ☐ ☐ of suicide. 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 Juvenile Facilities, Division 1, Chapter 1, Subchapter 5 for the complete list and text of regulations. 2 This is a modified version of the Procedures Checklist and is only intended for the 2024 Unannounced Inspection of the San Bernardino Central Valley Juv Det & Assessment Center Juvenile Hall. 7483 San Bernardino CVJDAC Unannounced PRO 23-24 Page 1 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (3) All youth who have been identified during the Suicide Prevention Program: III > D > 2 intake screening process to be at risk of suicide shall be referred to behavioral/mental health staff for a Youth identified as at risk of suicide are ☒ ☐ ☐ suicide risk assessment. referred to the Forensic Adolescent Services Team (FAST). (4) Precautionary protocols shall be developed to I >Safety Plan ensure the youth’s safety pending the ☒ ☐ ☐ behavioral/mental health assessment. (c) Referral process to behavioral/mental health staff for I >Safety Plan assessment and/or services. ☒ ☐ ☐ (d) Procedures for monitoring of youth identified at risk I >Safety Plan for suicide. Youth identified as at risk for suicide are placed on Suicide Observation Status (SOS) I, II, or III. SOS I youth are monitored every ten ☒ ☐ ☐ minutes while in room. SOS II youth are monitored every five minutes while in room. SOS III youth are under direct supervision by staff at all times. (e) Safety Interventions I >Safety Plan (1) Procedures to address intervention protocols for youth identified at risk for suicide which may ☒ ☐ ☐ include, but are not limited to: (A) Housing consideration (B) Treatment strategies including trauma- I >Safety Plan informed approaches ☒ ☐ ☐ (2) Procedures to instruct youth supervision staff how I >Safety Plan to respond to youth who exhibit suicidal behaviors. ☒ ☐ ☐ (f) Communication Suicide Prevention Program: III >A (1) The intake process shall include communication with the arresting officer and family guardians ☒ ☐ ☐ regarding the youth’s past or present suicidal ideations, behaviors or attempts. (2) Procedures for clear and current information I >Safety Plan sharing about youth at risk for suicide with youth supervision, healthcare, and behavioral/mental ☒ ☐ ☐ health staff. (g) Debriefing of Critical Incidents Related to Suicides or Suicide Prevention Program VI >M Attempts (1) Process for administrative review of the ☒ ☐ ☐ circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected staff. Suicide Prevention Program V >K ☒ ☐ ☐ (3) Process for a debriefing event with affected youth. Suicide Prevention Program V >L ☒ ☐ ☐ 7483 San Bernardino CVJDAC Unannounced PRO 23-24 Page 2 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Documentation Suicide Prevention Program V >H (1) Documentation processes shall be developed to ☒ ☐ ☐ ensure compliance with this regulation Youth identified at risk for suicide shall not be denied the Suicide Prevention Program: Guidelines >J opportunity to participate in facility programs, services and activities which are available to other non-suicidal youth, unless deemed necessary for the safety of the youth or security of the facility. Any deprivation of ☒ ☐ ☐ programs, services or activities for youth at risk of suicide shall be documented and approved by the facility manager. 1354 SEPARATION Section 1354 Administrative Separation The facility administrator shall develop and implement At the time of the inspection, only one written policies and procedures that address: CVJDAC youth had been placed on Administrative Separation. Review of policy and procedure and Administrative Separation Request and Program forms revealed compliance with this regulation. ☒ ☐ ☐ We suggested the actual times youth are completing exercise, free time, and programming be documented on the form. We also suggested documenting youth refusals of Title 15 requirements, Medical services, and Behavioral Health services. (a) separation of youth for reasons that include, but are Administrative Separation: Purpose not be limited to, medical and mental health conditions, assaultive behavior, disciplinary consequences and Documentation of youth assaultive behaviors ☒ ☐ ☐ protective custody. since entering the CVJDAC program noted on the Administrative Separation form. (b) consideration of positive youth development and Administrative Separation: Requirements >B trauma-informed care. ☒ ☐ ☐ (c) separated youth shall not be denied normal privileges Administrative Separation: Requirements available at the facility, except when necessary to >A accomplish the objective of separation. ☒ ☐ ☐ While on Administrative Separation, the youth received all Title 15 minimum standards. (d) when the objective of the separation is discipline, Administrative Separation: Purpose Title 15 Section 1390 shall apply. ☒ ☐ ☐ (e) when separation results in room confinement, the Administrative Separation: Requirements >E separation shall occur in accordance with Welfare and Institutions Code Section 208.3 and Section 1354.5 of ☒ ☐ ☐ these regulations. (f) policies and procedures shall ensure a daily review of Administrative Separation: VII >B separated youth to determine if separation remains necessary. Reviews of youth on Administrative Separation ☒ ☐ ☐ are completed every twenty-four hours by the Division Director I/II. 7483 San Bernardino CVJDAC Unannounced PRO 23-24 Page 3 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT Section 1354.5 Room Confinement (a) The facility administrator shall develop and We reviewed ten (10) youth Room implement written policies and procedures addressing Confinement Contract forms from CVJDAC. the confinement of youth in their room that are consistent Review of policy and procedure manual and with Welfare and Institutions Code Section 208.3. The documentation provided revealed compliance placement of a youth in room confinement shall be with this regulation. Each room confinement accomplished in accordance with the following contract reviewed provided excellent guidelines: documentation of why the youth was placed ☒ ☐ ☐ on room confinement and the efforts made by staff to reintegrate the youth back in the regular programming. It should be noted at the time of the inspection CVJDAC had not held a youth on room confinement exceeding four (4) hours since the previous targeted inspection conducted in July 2024. (1) Room confinement shall not be used before other, Room Confinement: Guidelines > C. less restrictive, options have been attempted and exhausted, unless attempting those options poses a Review of documentation revealed all youth threat to the safety or security of any youth or staff. ☒ ☐ ☐ placed on room confinement were appropriate as youth’s actions were posing a threat to the safety and security of the facility. (2) Room confinement shall not be used for the Room Confinement: Guidelines > H. purposes of punishment, coercion, convenience, or ☒ ☐ ☐ retaliation by staff. (3) Room confinement shall not be used to the extent Room Confinement: Guidelines > F. that it compromises the mental and physical health of ☒ ☐ ☐ the youth. (b) A youth may be held up to four hours in room Room Confinement: II >F 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. Room Confinement: II >H ☒ ☐ ☐ (2) Consult with mental health or medical staff. Room Confinement: II >H ☒ ☐ ☐ (3) Develop an individualized plan that includes the Room Confinement: II >B >1 goals and objectives to be met in order to reintegrate ☒ ☐ ☐ the youth to general population. (4) If room confinement must be extended beyond Room Confinement: III > B four hours, staff shall do each of the following: (A) Document the reasons for room confinement Room Confinement: I >A >2 and I >F and the basis for the extension, the date and time the youth was first placed in room confinement, It should be noted at the time of the inspection ☒ ☐ ☐ and when he or she is eventually released from CVJDAC had not held a youth on room room confinement. confinement exceeding four (4) hours since the previous targeted inspection conducted in July 2024. (B) Develop an individualized plan that includes Room Confinement: I >B > 1 the goals and objectives to be met in order to ☒ ☐ ☐ integrate the youth to general population. (C) Obtain documented authorization by the Room Confinement: VI >A facility superintendent or his or her designee ☒ ☐ ☐ every four hours thereafter. 7483 San Bernardino CVJDAC Unannounced PRO 23-24 Page 4 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) This section is not intended to limit the use of Room Confinement: Definitions and single-person rooms or cells for the housing of youth Guidelines >A in juvenile facilities and does not apply to normal ☒ ☐ ☐ sleeping hours. (6) This section does not apply to youth or wards in Room Confinement: Definitions and court holding facilities or adult facilities. ☒ ☐ ☐ Guidelines >M (7) Nothing in this section shall be construed to Room Confinement: Definitions and conflict with any law providing greater or additional Guidelines >N ☒ ☐ ☐ protections to youth. (8) This section does not apply during an Room Confinement: Definitions and extraordinary emergency circumstance that requires Guidelines >O 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 Room Confinement: Definitions and placed in a locked cell or sleeping room to treat and Guidelines >P 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. 1361 GRIEVANCE PROCEDURE Section 1361Grievance and Appeals The facility administrator shall develop and implement We reviewed twenty (20) CVJDAC grievances written policies and procedures whereby any youth may from the months of August, September, and appeal and have resolved grievances relating to any October 2024. Also we reviewed ten (10) condition of confinement, including but not limited to Grievance and Appeals Procedure health care services, classification decisions, program ☒ ☐ ☐ Acknowledgement forms from CVJDAC that participation, telephone, mail or visiting procedures, are signed by youth during the intake process. food, clothing, bedding, mistreatment, harassment or Review of policy and procedure and review of violations of the nondiscrimination policy. There shall be documentation provided revealed compliance no time limit on filing grievances. Policies and with this regulation. procedures shall include provisions whereby the facility manager ensures: (a) a grievance form and instructions for registering a Grievance and Appeals: I >A >1 and I >B >1 grievance, which includes provisions for the youth to have free access to the form; Walkthrough of the facility revealed youth have ☒ ☐ ☐ free access to grievance forms which are in the dayroom of each living unit. (b) the youth shall have the option to confidentially file Grievance and Appeals: I >B >1 >a, b, c the grievance or to deliver the form to any youth supervision staff working in the facility; ☒ ☐ ☐ There is a confidential lock box located within each housing unit of the Facility. (c) resolution of the grievance at the lowest appropriate Grievance and Appeals: V >A >1 >a staff level; ☒ ☐ ☐ 7483 San Bernardino CVJDAC Unannounced PRO 23-24 Page 5 of 6 A453 JUV PRO eff. 07.01.24 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) provision for a prompt review and initial response to Grievance and Appeals: Guidelines > B. grievances within three (3) business days, grievances that relate to health and safety issues must be All grievances reviewed had an initial ☒ ☐ ☐ addressed immediately; response completed prior to three business days. (1) The youth may elect to be present to explain Grievance and Appeals: V > 2 >a his/her version of the grievance to a person not directly involved in the circumstances which led to the ☒ ☐ ☐ grievance. (2) Provision for a staff representative approved by Grievance and Appeals: I > C >2 the facility administrator to assist the youth. ☒ ☐ ☐ (e) provision for a written response to the grievance Grievance and Appeals: V >2 >b which includes the reasons for the decisions; ☒ ☐ ☐ (f) a system which provides that any appeal of a Grievance and Appeals: VI 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 (10) Grievance and Appeals: Guidelines: B. business days unless circumstances dictate a longer time frame. The youth shall be notified of any delay; and, All grievances reviewed were completed and ☒ ☐ ☐ resolved prior to ten (10) business days of submission. (h) the policy shall provide multiple internal and external Grievance and Appeals: Purpose methods to report sexual abuse and sexual harassment. ☒ ☐ ☐ Whether or not associated with a grievance, concerns of Grievance and Appeals: Guidelines: H. parents, guardians, staff or other parties shall be addressed and documented in accordance with written ☒ ☐ ☐ policies and procedures within a specified timeframe. 7483 San Bernardino CVJDAC Unannounced PRO 23-24 Page 6 of 6 A453 JUV PRO eff. 07.01.24