Tuolumne Probation (2023-2024 inspection cycle)

November 20, 2023 Dan Hawks, Chief Probation Officer Tuolumne County Probation Department 465 South Washington Street Sonora, CA 95370 2023-2024 COMPREHENSIVE INSPECTION, WELFARE & INSTITUTIONS CODE SECTIONS 209 & 885, TUOLUMNE COUNTY PROBATION DEPARTMENT DETENTION FACILITIES Dear Chief Hawks: The 2023-2024 Comprehensive Inspection of the Tuolumne County Probation Department has been completed. A pre-inspection briefing was held on Tuesday, March 14, 2023, and the following facilities were inspected between Tuesday, November 7, 2023 and Wednesday, November 8, 2023: FACILITY NAME BSCC # FACILITY TYPE Tuolumne MLRJDF JH 7716 JH Tuolumne Steps to Success 7718 CAMP Tuolumne Summit Program 7717 SYTF These inspections were conducted pursuant to Welfare and Institutions Code Sections 209 and 885 to determine compliance with the Minimum Standards for Juvenile Detention Facilities as outlined in Titles 15 and 24, California Code of Regulations. In addition, Board of State and Community Corrections (BSCC) staff conducted compliance monitoring pursuant to Welfare and Institutions Code Sections 209(f) and the federal Juvenile Justice and Delinquency Prevention Act (JJDPA) requirements for separation between juveniles and adults. In addition to inspection(s), Title 15, Section 1313, and its authorizing statute require annual inspections conducted by a local Health Officer, fire authority having jurisdiction, county building inspection by an agency designated by the County Board of Supervisors, County Superintendent of Schools, Juvenile Court, and Juvenile Justice Commission. The results of those inspections are considered a part of this report. INSPECTION RESULTS We identified no items of noncompliance with Title 15 Minimum Standards. Rather, we found the agency exceeds minimum standards for holding youth. Refer to the attached Title 15 Procedures Checklist for detailed information. Dan Hawks, Chief Probation Officer Page 2 No items of noncompliance were identified with Title 24 Minimum Standards. Refer to the Physical Plant Evaluation (PHY) and Living Area Space Evaluation (LASE) attachments for information related to Rated Capacity. Juvenile Justice and Delinquency Prevention Act Compliance Monitoring No violations of the JJDPA have been identified and no areas of noncompliance were noted. An Exit Briefing with your staff was held on Wednesday, November 8, 2023; BSCC staff presented an inspection overview and discussed technical assistance and best practice recommendations. * * * Please email me at elizabeth.gong@bscc.ca.gov or call (916) 704-2503 if you have any questions. Sincerely, ELIZABETH GONG Field Representative Facilities Standards and Operations Division Enclosures Cc: Presiding Judge, Tuolumne County Juvenile Court* Chair, Juvenile Justice Commission, Tuolumne County* Chair, Board of Supervisors, Tuolumne County* County Administrator, Tuolumne County* Kevin Parr, Interim Superintendent, Tuolumne County Probation Department *Copies of the inspection are available upon request or online at www.bscc.ca.gov. 7716 7718 7717 Tuolumne Probation JH Camp SYTF LTR 23-24 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7716 FACILITY NAME: Tuolumne County MLRJDF FACILITY TYPE: JH Mother Lode Regional Juvenile Corrections Detention Facility PERSON(S) INTERVIEWED: Dan Hawks, Chief Probation Officer; Annie Hockett, Assistant Chief Probation Officer; Christine Schultze, Supervising Probation Officer; Will Nielsen, Supervising Probation Officer; Ashley Champeaux, Teacher - Gold Ridge School; Kayla Rolfe, Transition Specialist, TCSOS; Cheyne Turberville, RN Wellpath Health Services - Juvenile Facility; Will Horton, Juvenile Corrections Officer II; Youth: Jacob Z, age 17; Zach D, age 17; Blanca, age 17. FIELD REPRESENTATIVE: Elizabeth Gong DATE: November 7-8, 2023 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1313 COUNTY INSPECTION AND EVALUATION OF BUILDING AND GROUNDS September 6, 2022 On an annual basis, or as otherwise required by law, July 21, 2023 each juvenile facility administrator shall obtain a ☐ ☒ ☐ documented inspection and evaluation from the following: (a) county building inspector or person designated by the Board of Supervisors to approve building safety; (b) fire authority having jurisdiction, including a fire clearance as required by Health and Safety Code ☒ ☐ ☐ September 2, 2022 Section 13146.1(a) and (b); July 31, 2023 (c) local health officer, inspection in accordance with Health and Safety Code Section 101045; 2022: Environmental Health: October 21, 2022 Medical/Mental Health: October 24, 2022 Nutritional Health: November 22, 2022 ☒ ☐ ☐ 2023: Environmental Health: October 24, 2023 Medical/Mental Health: November 2, 2023 Nutritional Health: October 23, 2023 (d) county superintendent of schools on the adequacy of educational services and facilities as required in Section ☒ ☐ ☐ July 28, 2022 1370; July 27, 2023 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. 7716 Tuolumne MLRJDF PRO 23-24 1 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) juvenile court as required by Section 209 of the Welfare and Institutions Code; and, ☒ ☐ ☐ May 27, 2021 December 8, 2022 (f) the Juvenile Justice Commission as required by Section 229 of the Welfare and Institutions Code or ☒ ☐ ☐ February 25, 2022 Probation Commission as required by Section 240 of the February 3, 2023 Welfare and Institutions Code. 1320 APPOINTMENT AND QUALIFICATIONS Section III, Number 1, Procedure I-A BSCC Note: Compliance with this section is determined by receipt of the Chief Probation Officer’s The elements of this regulation are certification letter confirming that all elements of addressed in a memorandum completed on regulation are met. March 3, 2023, by Chief Probation Officer Dan Hawks. ☒ ☐ ☐ (a) Appointment In each juvenile facility there shall be a superintendent, director or facility manager in charge of its program and employees. Such superintendent, director, facility manager and other employees of the facility shall be appointed by the facility administrator pursuant to applicable provisions of law. (b) Employee Qualifications Each facility shall: Section III, Number 1, Procedure II (1) recruit and hire employees who possess knowledge, ☒ ☐ ☐ Section III, Number 1, Procedure II-1 skills and abilities appropriate to their job classification and duties in accordance with applicable civil service or merit system rules; (2) require a medical evaluation and physical examination including tuberculosis screening test and ☒ ☐ ☐ Section III, Number 1, Procedure II-2 evaluation for immunity to contagious illnesses of childhood (i.e., diphtheria, rubeola, rubella, and mumps); (3) adhere to the minimum standards for the selection and training requirements adopted by the Board ☒ ☐ ☐ Section III, Number 1, Procedure II-3 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ Section III, Number 1, Procedure II-4 accordance with Section 1031 of the Government Code. (c) Contract personnel, volunteers, and other non- employees of the facility, who may be present at the Section III, Number 1, Procedure II-5 facility, shall have such clearance and qualifications as ☒ ☐ ☐ may be required by law, and their presence at the facility shall be subject to the approval and control of the facility manager. 7716 Tuolumne MLRJDF PRO 23-24 2 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1321 STAFFING Each juvenile facility shall: Section III, Number 2 (a) have an adequate number of personnel sufficient to Section III, Number 2, Procedure I-A carry out the overall facility operation and its programming, to provide for safety and security of youth and staff, and meet established standards and The facility has self-capped their population regulations; at 20 youth, applying a staffing ratio of 1:8. ☒ ☐ ☐ The facility currently has 2 Supervising Juvenile Corrections Officers (JCO). There are 4 Senior JCO’s plus one relief Senior (Extra Help), and 8-line JCO staff, with two other staff in background to fill the vacancies. A Field Probation Officer is assigned to the facility to assist with the Steps 2 Success Camp Program and Summit SYTF Program. (b) ensure that no required services shall be denied because of insufficient numbers of staff on duty absent ☒ ☐ ☐ Section III, Number 2, Procedure I-A exigent circumstances; (c) have a sufficient number of supervisory level staff to ensure adequate supervision of all staff members; ☒ ☐ ☐ Section III, Number 2, Procedure I-B (d) have a clearly identified person on duty at all times who is responsible for operations and activities and has Section III, Number 2, Procedure I-C completed the Juvenile Corrections Officer Core Course and PC 832 training; ☒ ☐ ☐ There is a Supervisor, Senior JCO, or designated lead staff on duty and in charge of the facility when the Superintendent is not on duty. (e) have at least one staff member present on each living unit whenever there are youth in the living unit; ☒ ☐ ☐ Section III, Number 2, Procedure I-D 7716 Tuolumne MLRJDF PRO 23-24 3 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) have sufficient food service personnel relative to the number and security of living units, including staff Section III, Number 2, Procedure I-E 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 ☒ ☐ ☐ Meals are provided by Summit Foods maintain necessary records; or, a facility may serve food through the Tuolumne County Jail and that meets nutritional standards prepared by an outside served by serve-safe certified JCO staff source; and/or youth. (g) have sufficient administrative, clerical, recreational, medical, dental, mental health, building maintenance, Section III, Number 2, Procedure I-F 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, Support staff and ancillary personnel are not part of youth supervision staff. (h) assign sufficient youth supervision staff to provide continuous wide awake supervision of youth, subject to Section III, Number 2, Procedure I-G temporary variations in staff assignments to meet special program needs. Staffing shall be in compliance with a minimum youth-staff ratio for the following facility ☒ ☐ ☐ types: The facility has made the decision to staff at a 1:8 ratio. (1) Juvenile Halls (A) during the hours that youth are awake, one wide- Section III, Number 2, Procedure I-H awake youth supervision staff member on duty for each 10 youth in detention; ☒ ☐ ☐ The facility staffs the facility at 1:8 during waking hours. (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake youth Section III, Number 2, Procedure I-I supervision staff member on duty for each 30 youth in detention; ☒ ☐ ☐ The facility staffs the facility at a 1:16 ratio during sleeping hours. (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number Section III, Number 2, Procedure I-J of youth in detention, unless an arrangement has been ☒ ☐ ☐ made for backup support services which allow for immediate response to emergencies; and, 7716 Tuolumne MLRJDF PRO 23-24 4 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (D) at least one youth supervision staff member on duty who is the same gender as youth housed in the facility. ☒ ☐ ☐ Section III, Number 2, Procedure I-K (E) personnel with primary responsibility for other duties such as administration, supervision of personnel, Section III, Number 2, Procedure I-F academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. ☒ ☐ ☐ Only JCO staff assigned to the living units supervise youth in detention. (2) Special Purpose Juvenile Halls (A) during hours that youth are awake, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake youth ☐ ☐ ☒ supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number of youth in detention, unless an arrangement has been ☐ ☐ ☒ made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other duties such as administration, supervision of personnel, academic or trade instruction, clerical, kitchen or ☐ ☐ ☒ maintenance shall not be classified as youth supervision staff positions. (3) Camps (A) during the hours that youth are awake, one wide- ☐ ☐ ☒ awake youth supervision staff member on duty for each 15 youth in the camp population; (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake youth ☐ ☐ ☒ supervision staff member on duty for each 30 youth present in the facility; (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number of youth in residence, unless arrangements have been ☐ ☐ ☒ made for backup support services which allow for immediate response to emergencies; 7716 Tuolumne MLRJDF PRO 23-24 5 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (D) at least one youth supervision staff member on duty ☐ ☐ ☒ who is the same gender as youth housed in the facility; (E) in addition to the minimum staff to youth ratio required in (h)(3)(A)-(B), consideration shall be given to the size, design, and location of the camp; types of youth ☐ ☐ ☒ committed to the camp; and the function of the camp in determining the level of supervision necessary to maintain the safety and welfare of youth and staff; (F) personnel with primary responsibility for other duties such as administration, supervision of personnel, academic or trade instruction, clerical, farm, forestry, ☐ ☐ ☒ kitchen or maintenance shall not be classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF ORIENTATION AND TRAINING Section III, Number 4, Procedure I-A (a) Prior to assuming any responsibilities each youth supervision staff member shall be properly oriented to Section III, Number 4, Procedure I-B their duties, including: Section III, Number 4, Procedure I-B, 1 (1) youth supervision duties; Section III, Number 4, Procedure I-C Section III, Number 4, Procedure I-D The agency spends three weeks to train to specific facility responsibilities and to ensure ☒ ☐ ☐ they are ready for all youth supervision duties. A Training Checklist Sign-Off is completed by the staff and trainer. The facility administration has implemented a curriculum ensuring staff and ancillary personnel working with and/or supervising youth are aware of their role and responsibilities. We reviewed the training checklists for the 3 newly hired JCO’s and found the curriculum within regulatory standards. (2) scope of decisions they shall make; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 2 (3) the identity of their supervisor; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 3 7716 Tuolumne MLRJDF PRO 23-24 6 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) the identity of persons who are responsible to them; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 4 (5) persons to contact for decisions that are beyond their responsibility; and ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 5 (6) ethical responsibilities. ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 6 (b) Prior to assuming any responsibility for the supervision of youth, each youth supervision staff Section III, Number 4, Procedure I-A member shall receive a minimum of 40 hours of facility- specific orientation, including: The facility has a detailed staff orientation which includes internal training by a ‘Field ☒ ☐ ☐ Training Officer’, mentoring and training new staff in facility operations. The trainer and staff initial a checklist after each component, including many areas which exceed T15 requirements. (1) individual and group supervision techniques; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 2 (2) regulations and policies relating to discipline and rights of youth pursuant to law and the provisions of ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 3 this chapter; (3) basic health, sanitation and safety measures; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 8 (4) suicide prevention and response to suicide attempts ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 9 (5) policies regarding use of force, de-escalation techniques, chemical agents, mechanical and physical ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 4 restraints; 7716 Tuolumne MLRJDF PRO 23-24 7 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (6) review of policies and procedures referencing ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 5 trauma and trauma-informed approaches; Section III, Number 4, Procedure I-C, 6 (7) procedures to follow in the event of emergencies; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 7 (8) routine security measures, including facility ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 13 perimeter and grounds; Section III, Number 4, Procedure I-C, 9 Section III, Number 4, Procedure I-C, 10 (9) crisis intervention and mental health referrals to There is a TCBH Case Manager assigned to ☒ ☐ ☐ mental health services; the facility who designates county BH Clinicians to complete groups and individual counseling for in-custody youth. The facility Superintendent is a Licensed Clinician and provides Crisis Counseling if BH staff are not on site. (10) documentation; and ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 11 (11) fire/life safety training ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 12 7716 Tuolumne MLRJDF PRO 23-24 8 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Prior to assuming sole supervision of youth, each youth supervision staff member shall successfully Section III, Number 4, Procedure I-B complete the requirements of the Juvenile Corrections Officer Core Course pursuant to Penal Code Section 6035. Of the current Senior and line JCO’s responsible for youth supervision, all 10 are ☒ ☐ ☐ core-trained. The agency has two vacancies with both positions in background. There are two extra-help line staff, one extra help senior, and a DPO that assist in covering necessary shifts. (d) Prior to exercising the powers of a peace officer youth supervision staff shall successfully complete Section III, Number 4, Procedure I-C training pursuant to Section 830 et seq. of the Penal Code. ☒ ☐ ☐ All 10 youth supervision staff and both Supervisors have completed PC 830. 1323 FIRE AND LIFE SAFETY Whenever there is a youth in a juvenile facility, there Section III, Number 22, Procedure I-A shall be at least one wide awake person on duty at all times who meets the training standards established by the Board for general fire and life safety which relate ☒ ☐ ☐ All cored youth supervision staff and specifically to the facility. Supervisors received Fire and Life Safety training in JCO Core. 1324 POLICY AND PROCEDURES MANUAL All facility administrators shall develop, publish, and Section III, Number 23, Procedure I implement a manual of written policies and procedures that address, at a minimum, all regulations that are applicable to the facility. Such a manual shall be made The facility Policy and Procedure Manual available to all employees, reviewed by all employees, ☒ ☐ ☐ was last reviewed on July 30, 2023. Facility and shall be administratively reviewed at a minimum staff are required to read the manual each every two years, and updated, as necessary. Those year, signing a document kept in their records relating to the standards and requirements set personnel file to verify compliance for this forth in these regulations shall be accessible to the policy requirement. Board on request. The manual shall include: (a) table of organization, including channels of communications and a description of job classifications; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 1 7716 Tuolumne MLRJDF PRO 23-24 9 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) responsibility of the probation department, purpose of programs, relationship to the juvenile court, the Juvenile Section III, Number 23, Procedure II-B, 2 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; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 3 (d) initial orientation and training program for employees; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 4 (e) initial orientation, including safety and security issues and anti-discrimination policies, for support staff, ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 5 contract employees, school, mental/behavioral health and medical staff, program providers and volunteers; (f) maintenance of record-keeping, statistics and communication system to ensure: ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6 (1) efficient operation of the juvenile facility; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-a (2) legal and proper care of youth; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-b (3) maintenance of individual youth's records; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-c (4) supply of information to the juvenile court and those ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-d authorized by the court or by the law; and, (5) release of information regarding youth. ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-e 7716 Tuolumne MLRJDF PRO 23-24 10 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) ethical responsibilities; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-f (h) trauma-informed approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 7 (i) culturally responsive approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 8 (j) gender responsive approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 9 (k) a non-discrimination provision that provides that all youth within the facility shall have fair and equal access Section III, Number 23, Procedure II-B, 10 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, ☒ ☐ ☐ The Non-Discrimination Policy is in the Youth national origin, immigration status, color, religion, Handbook and in the procedures of gender, sexual orientation, gender identity, gender admission, classification, and due process. It expression, mental or physical disability, or HIV status, is also posted in the living unit. 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 Section III, Number 23, Procedure II-B, 11 and ammunition, where applicable; ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 8 (m) establishment of procedures for collection of Medi-Cal eligibility information and enrollment of eligible ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 12 youth; and, 7716 Tuolumne MLRJDF PRO 23-24 11 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (n) establishment of a policy that prohibits all forms of sexual abuse, sexual assault and sexual harassment. Section III, Number 23, Procedure II-B, 13 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 ☒ ☐ ☐ The facility has a comprehensive PREA third party. policy, including staffing the facility at 1:8 and 1:16 based on a self-imposed cap of population. 1325 FIRE SAFETY PLAN The facility administrator shall consult with the local fire Section III, Chapter 22 department having jurisdiction over the facility, or with the State Fire Marshal, in developing a plan for fire ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 1 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; (b) monthly fire and life safety inspections by facility staff with two-year retention of the inspection record; Section III, Number 22, Procedure IV-A, 2 The facility has an assigned safety officer that conducts these inspections monthly. We ☒ ☐ ☐ reviewed all the monthly inspections from October 2022 to October 2023. The form and inspection process for recording deficiencies or need for repair are well documented and addressed by maintenance if necessary. (c) fire prevention inspections as required by Health and Safety Code Section 13146.1(a) and (b); ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 3 (d) an evacuation plan; ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 4 7716 Tuolumne MLRJDF PRO 23-24 12 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) documented fire drills not less than quarterly; Section III, Number 22, Procedure IV-A, 5 ☒ ☐ ☐ We reviewed fire drills from October 2022 to October 2023. The agency completes drills more frequently than required in regulation. (f) a written plan for the emergency housing of youth in the case of fire; and, Section III, Number 22, Procedure IV-A, 6 Section III, Number 22, Procedure IX-C, 1-c ☒ ☐ ☐ The facility has an agreement in effect for Stanislaus County Probation to accept all youth detained in the event of an emergency evacuation. (g) development of a fire suppression pre-plan in cooperation with the local fire department. ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 7 7716 Tuolumne MLRJDF PRO 23-24 13 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1326 SECURITY REVIEW Each facility administrator shall develop policies and Section III, Number 24 procedures to annually review, evaluate, and document security of the facility. The review and evaluation shall Section III, Number 33 Security Procedures include internal and external security, including, but not Section III, Number 34 Key Control limited to, key control, equipment, and staff training. Section III, Number 22, Procedure III-E Annual Review A Security Review memo was completed by Supervisor William Neilsen on March 20, ☒ ☐ ☐ 2023, outlining the security practices and needs for the facility. The memo identified the most current issues, the need to better secure the stairwell leading outside from the upper tier, and updating cameras, with the SB 823 Infrastructure Grant dollars. County Contractors were on- site during our inspection and have a timeline to complete the SB 823 projects by year-end. 1327 EMERGENCY PROCEDURES The facility administrator shall develop facility-specific Section III, Number 22 policies and procedures for emergencies that shall include, but not be limited to: ☒ ☐ ☐ An emergency procedure memo was completed by Assistant Chief Probation Officer/Facility Superintendent Annie Hockett on March 1, 2023. Section III, Number 25 Hostages Section III, Number 26 Escapes (a) escape, disturbances, and the taking of hostages; ☒ ☐ ☐ Section III, Number 32 Firearms in the Facility 7716 Tuolumne MLRJDF PRO 23-24 14 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section III, Number 22, X Civil Disturbance, Active Shooter, Terrorist Attack (b) civil disturbance, active shooter and terrorist ☒ ☐ ☐ attack; Section III, Number 28 Bomb Threat Section III, Number 30 Riot Control Section III, Number 22 Section III, Number 27 Hazard Mat Response (c) fire and natural disasters; ☒ ☐ ☐ Section III, Number 22, Procedure VIII Earthquake Section III, Number 22, Procedure IX Flood (d) periodic testing of emergency equipment; ☒ ☐ ☐ Section III, Number 29 Power Failure Section III, Number 22, Procedure IV-A, 4 (e) emergency evacuation of the facility; and ☒ ☐ ☐ Section III, Number 22, Procedure XI Evacuation Section III, Number 22, Procedure IV-C Initial Orientation (f) a program to provide all youth supervision staff ☒ ☐ ☐ with an annual review of emergency procedures. Facility staff are required to read the facility policy manual each year, which outline all Emergency Procedures in all situations. 7716 Tuolumne MLRJDF PRO 23-24 15 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1328 SAFETY CHECKS The facility administrator shall develop and implement Section III, Number 31 Safety Checks policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, at random or varied intervals during hours when youth The facility has implemented a better are asleep or when youth are in their rooms, confined electronic safety check system and in holding cells or confined to their bed in a dormitory. completes regular audits to ensure the Supervision is not replaced, but may be supplemented checks are random and varied. Audits are by, an audio/visual electronic surveillance system done weekly with a randomizer program and designed to detect overt, aggressive or assaultive video review to capture why the check was behavior and to summon aid in emergencies. All safety late. checks shall be documented with the actual time the check is completed. The system allows for deactivation when ☒ ☐ ☐ youth are “all out” and no check is needed. If there is a late check, facility administration is notified and staff are required to make an entry in the unit log the reason for the late check. We reviewed safety check audits for the months of October 2022 and January and July 2023. We found very few late checks in over the 10,000 checks required in the 3- month period. The audit process in place is effective and any consistent patterns are handled administratively, per policy. 7716 Tuolumne MLRJDF PRO 23-24 16 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN The facility administrator, in collaboration with the Section III, Number 36 healthcare and behavioral/mental health administrators, shall plan and implement written policies and procedures which delineate a Suicide The Suicide Prevention Plan and policy are a Prevention Plan. The plan shall consider the needs of collaboration with WellPath Medical and youth experiencing past or current trauma. Suicide Tuolumne County Behavioral Health, which prevention responses shall be respectful and in the includes very specific roles and least invasive manner consistent with the level of responsibilities for medical, behavior health, suicide risk. The plan shall include the following and probation facility staff. elements: The facility policy and annual training in suicide prevention is comprehensive and inclusive of all elements in regulation. The agency has an on-site Behavior Health Case Manager and multiple Clinicians with the ☒ ☐ ☐ agency to address and see youth as necessary. ACPO Annie Hockett continues to provide crisis counseling when necessary. There have not been any suicide attempts this cycle, however, there have been five incidents to place a youth on safety watch status due to ideation or suicidal gestures, three involving one youth. We reviewed two incident reports and found the agency compliant. Behavior Health is more involved in individual and follow-up for these behaviors but the facility Superintendent, who is a licensed Clinician, provides most of the immediate crisis intervention to diffuse and address these behaviors. (a) Suicide prevention training as required in Section 1322, Youth Supervision Staff Orientation, and ☒ ☐ ☐ Section III, Number 36, Procedure I-B Training and the Juvenile Corrections Officer Core Course. 7716 Tuolumne MLRJDF PRO 23-24 17 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Screening, Identification Assessment and Precautionary Protocols Section III, Number 36, Procedure I-C (1) All youth shall be screened for risk of suicide at intake and as needed during detention. Section III, Number 36, Procedure I-D The facility uses the MAYSI prior to housing youth at intake, which assesses the youth’s likeliness to have suicidal behaviors or ideations while in detention. The tool provides a caution or warning status which places a youth, per policy, on a special watch pending review and being seen by Behavior ☒ ☐ ☐ Health. The agency also has adapted the SAFE-T Assessment to identify certain suicide behaviors, which is implemented by Behavior Health. Behavior Health has a Case Manager and assigned clinicians to see youth on-site, a positive change from last cycle. Superintendent Annie Hockett continues to provide crisis interventions when TCBH is not on-site or available to respond immediately. (2) All youth supervision staff who perform intake processes shall be trained in screening youth for risk of Section III, Number 36, Procedure I-B suicide. ☒ ☐ ☐ The agency provides eight hours of initial training and an annual 2-hour refresher training for all youth supervision staff. (3) All youth who have been identified during the intake screening process to be at risk of suicide shall be ☒ ☐ ☐ Section III, Number 36, Procedure I-D referred to behavioral/mental health staff for a suicide risk assessment. 7716 Tuolumne MLRJDF PRO 23-24 18 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) Precautionary protocols shall be developed to ensure the youth’s safety pending the Section III, Number 36, Procedure II behavioral/mental health assessment. ☒ ☐ ☐ Youth are placed on a Safety Watch pending review or being seen by a BH or MH personnel. (c) Referral process to behavioral/mental health staff for assessment and/or services. Section III, Number 36, Procedure II-A ☒ ☐ ☐ Section III, Number 36, Procedure II-B (d) Procedures for monitoring of youth identified at risk for suicide. Section III, Number 36, Procedure II ☒ ☐ ☐ The facility proactively provides direct visual supervision of all youth who are identified as at risk of actively attempting or verbally discussing suicide. (e) Safety Interventions (1) Procedures to address intervention protocols for ☒ ☐ ☐ youth identified at risk for suicide which may include, Section III, Number 36, Procedure II-C but are not limited to: (A) Housing consideration Section III, Number 36, Procedure II-C, 1-3 ☒ ☐ ☐ The facility has a comprehensive suicide risk/needs assessment as well as the MAYSI Screening tool utilized for each intake. 7716 Tuolumne MLRJDF PRO 23-24 19 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (B) Treatment strategies including trauma-informed approaches Section III, Number 36, Procedure III-G The facility provides treatment strategies ☒ ☐ ☐ based on a training curriculum and policy, which references how staff address and supervise youth at risk, defined by the assessment. (2) Procedures to instruct youth supervision staff how to respond to youth who exhibit suicidal behaviors. Section III, Number 36, Procedure II-D Each of the incidents we reviewed revealed compliance with regulation and policy, as well as a vested interest in helping the youth. ☒ ☐ ☐ The forms, process, and administrative involvement/review are debriefed and used as training tools for staff. Facility staff are very aware of the risks and responses of suicidal behavior based on extensive training. (f) Communication (1) The intake process shall include communication Section III, Number 36, Procedure I-C with the arresting officer and family guardians regarding the youth’s past or present suicidal ideations, Section III, Number 36, Procedure I-E behaviors or attempts. ☒ ☐ ☐ The admission forms include several referenced areas that include communication with the officer and family. (2) Procedures for clear and current information sharing about youth at risk for suicide with youth ☒ ☐ ☐ Section III, Number 36, Procedure I-E supervision, healthcare, and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Suicides or Attempts Section III, Number 26, Procedure III-H (1) Process for administrative review of the ☒ ☐ ☐ circumstances and responses proceeding, during and after the critical incident. 7716 Tuolumne MLRJDF PRO 23-24 20 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) Process for a debriefing event with affected staff. ☒ ☐ ☐ Section III, Number 36, Procedure III-G (3) Process for a debriefing event with affected youth. ☒ ☐ ☐ Section III, Number 36, Procedure III-G (h) Documentation (1) Documentation processes shall be developed to ☒ ☐ ☐ Section III, Number 36, Procedure III-F ensure compliance with this regulation Youth identified at risk for suicide shall not be denied the opportunity to participate in facility programs, Section III, Number 36, Procedure II-G services and activities which are available to other non- suicidal youth, unless deemed necessary for the safety Section III, Number 36, Procedure II-I 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 The facility staff work within policy to identify facility manager. the youth’s specific housing needs, programming elements, and engagement with other youth. 1340 REPORTING OF LEGAL ACTIONS Each facility shall submit to the Board a letter of Section IV, Number 1 notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities responsible for juvenile facility operation. ☒ ☐ ☐ There are no pending legal actions against the Tuolumne County Motherlode Regional Juvenile Detention Facility. 1341 DEATH AND SERIOUS ILLNESS OR INJURY OF A YOUTH WHILE DETAINED Section IV, Number 3, I-F (1) Death of a Youth. (a) The facility administrator, in cooperation with the Section IV, Number 3, I-A health administrator and the behavioral/mental health director, shall develop written policies and procedures ☒ ☐ ☐ in the event of the death of a youth while detained, which include notifications to necessary parties, which may include the Juvenile Court, the parent, guardian or person standing in loco parentis and the youth’s attorney of record. 7716 Tuolumne MLRJDF PRO 23-24 21 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The health administrator, in cooperation with the facility administrator, shall develop written policies and Section IV, Number 3, I-B procedures to assure there is a medical and operational review of every in-custody death of a youth. ☒ ☐ ☐ Section IV, Number 3, I-C The review team shall include the facility administrator and/or facility manager, the health administrator, the responsible physician and other health care and supervision staff who are relevant to the incident. (c) The administrator of the facility shall provide to the Board a copy of the report submitted to the Attorney Section IV, Number 3, I-D General under Government Code Section 12525. A ☒ ☐ ☐ copy of the report shall be submitted to the Board within 10 calendar days after the death. (d) Upon receipt of a report of the death of a youth from the administrator, the Board may within 30 calendar Section IV, Number 3, I-E days inspect and evaluate the juvenile facility, jail, lockup or court holding facility pursuant to the ☒ ☐ ☐ provisions of this subchapter. Any inquiry made by the Board shall be limited to the standards and requirements set forth in these regulations. (2) Serious Illness or Injury of Youth. (a) The facility administrator, in cooperation with the Section IV, Number 3, I-H health administrator, shall develop written policies and procedures for the notification to necessary parties, ☒ ☐ ☐ which may include the Juvenile Court, the parent, guardian or person standing in loco parentis and the youth’s attorney of record in the case of a serious illness or injury of a youth. 1342 POPULATION ACCOUNTING Each juvenile facility shall submit required population ☒ ☐ ☐ Section IV, Number 4 and profile survey reports to the Board within 10 working days after the end of each reporting period, in a format to be provided by the Board. 1343 JUVENILE FACILITY CAPACITY (EXCERPT) When the number of youth detained in a living unit of a Section IV, Number 5 juvenile facility exceeds its rated capacity for more than ☒ ☐ ☐ fifteen (15) calendar days in a month, the facility administrator shall provide a crowding report to the Board in a format provided by the Board. 7716 Tuolumne MLRJDF PRO 23-24 22 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1350 ADMITTANCE PROCEDURES The facility administrator shall develop and implement Section V, Number 1 Purpose written policies and procedures for admittance of youth that emphasize respectful and humane engagement Section V, Number 1-C with youth, and reflect that the admission process may be traumatic to youth who may have already experienced trauma. Policies shall be trauma- The agency has a comprehensive intake informed, culturally relevant, and responsive to the process for youth and includes an “Intake language and literacy needs of youth. In addition to the Checklist” to ensure all procedural elements requirements of Sections 1324 and 1430 of these are met. The facility only accepts youth regulations: identified with risks to community safety or themselves, as screened from the Detention Risk Assessment Instrument (DRAI), the MAYSI, and an internal risk/needs screening tool. ☒ ☐ ☐ We reviewed 10 comprehensive intake packets that included the checklist; the Intake Health Screening; Property Inventory; the Youth Strengthening Admissions Assessment (Trauma, emotional, risks and needs); PREA Acknowledgement; Language and Gender Preference Forms; Admission Report; Consent for Medical Treatment; Dental Permission Slip; and MAYSI/DRAI Assessments. The process is inclusive of information to assist staff and agency partners for youth care while in custody. (a) the admittance process shall include: (1) Access to two free phone calls within one hour of ☒ ☐ ☐ Section V, Number 1, Procedure I-S admittance in accordance with the provisions of Welfare and Institution Code Section 627; (2) Offer of a shower; ☒ ☐ ☐ Section V, Number 1, Procedure I-M Section V, Number 1, Procedure I-L (3) Documented secure storage of personal ☒ ☐ ☐ belongings; Section V, Number IV 7716 Tuolumne MLRJDF PRO 23-24 23 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) Offer of food upon arrival; ☒ ☐ ☐ Section V, Number 1, Procedure I-M (5) Screening for physical and behavioral health and safety issues, intellectual or developmental ☒ ☐ ☐ Section V, Number 1, Procedure I-F disabilities; (6) Screening for physical and developmental disabilities in accordance with Sections 1329, 1413, ☒ ☐ ☐ Section V, Number 1, Procedure I-C and 1430 of these regulations; (7) Contact with Regional Center for the Developmentally Disabled for youth that are ☒ ☐ ☐ Section V, Number 1, Procedure I-D suspected of or identified as having a developmental disability, pursuant to Section 1413; and, (8) Procedures consistent with Section 1352.5. ☒ ☐ ☐ Section V, Number 6 (b) juvenile hall administrators shall establish written criteria for detention that considers the least restrictive Section V, Number 1, Procedure I-III environment. ☒ ☐ ☐ The facility has specific criteria for detention, which allows for an override if justified. (c) juvenile camps and post-dispositional programs in juvenile halls shall develop policies and procedures Section V, Number I-N that advise the youth of the estimated length of stay, ☒ ☐ ☐ inform them of program guidelines and provide written screening criteria for inclusion and exclusion from the program. (d) juvenile halls shall develop policies and procedures that advise any committed youth of the estimated ☒ ☐ ☐ Section V, Number I-N length of his/her stay. 7716 Tuolumne MLRJDF PRO 23-24 24 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1350.5 SCREENING FOR THE RISK OF SEXUAL ABUSE Section V, Number 6 The facility administrator shall develop and implement written policies and procedures to reduce the risk of sexual abuse by or upon youth. The policy shall require The facility developed a tool, the Youth facility staff to assess each youth within 72 hours of ☒ ☐ ☐ Strengthening Admissions Assessment, admission based on the following information: within their classification screening instrument to address youth who are potential perpetrators or victims of sexual assault or abuse. (a) Prior sexual victimization or abusiveness; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (b) Gender nonconforming appearance or manner; or identification as lesbian, gay or bisexual, transgender, ☒ ☐ ☐ Section V, Number 6, Procedure I-B queer or intersex, and whether the youth may, therefore, be vulnerable to sexual abuse; (c) Current charges and offense history; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (d) Age; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (e) Level of emotional and cognitive development; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (f) Physical size and stature; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (g) Mental illness or mental disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (h) Intellectual or developmental disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B 7716 Tuolumne MLRJDF PRO 23-24 25 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (i) Physical disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (j) The youth’s perception of vulnerability; and, ☒ ☐ ☐ Section V, Number 6, Procedure I-B (k) Any other specific information about the individual youth that may indicate heightened needs for The Classification/Youth Housing Screening supervision, additional safety precautions, or tool and the Youth Strengthening Admissions separation from certain other youth. Assessment were developed in coordination ☒ ☐ ☐ with BH to establish and identify information which could or would assist in all safety elements. Staff shall ascertain this information through conversations with the youth during the admittance Section V, Number 6, Procedure I-A process, medical and behavioral health screenings; during classification assessments; and by reviewing court records, case files, facility behavioral records, ☒ ☐ ☐ and other relevant documentation from the youth’s The admission risk/needs assessment is files. used to assist in classification of all admitted youth. The facility administrator shall implement appropriate controls on the dissemination of information within the Section V, Number 6, Policy I-B facility relative to responses received pursuant to this ☒ ☐ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other youth. 7716 Tuolumne MLRJDF PRO 23-24 26 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1351 RELEASE PROCEDURES The facility administrator shall develop and implement Section V, Number 7 written policies and procedures for release of youth from custody which provide for: The agency conducts weekly Multi- Disciplinary Team meetings with the Behavior Health Case Manager, Wellpath Medical staff, and the on-site teaching staff prior to release and during the youth’s stay. ☒ ☐ ☐ Transition planning and ongoing services in the community are addressed. The meetings continue to occur weekly for detention and commitment youth. We reviewed numerous release documents indicating compliance of all elements related to the release process. (a) verification of identity/release papers; ☒ ☐ ☐ Section V, Number 7, Procedure I-A (b) return of personal clothing and valuables; ☒ ☐ ☐ Section V, Number 7, Procedure I-F (c) notification to the youth's parents or guardian; ☒ ☐ ☐ Section V, Number 7, Procedure I-D (d) notification to the facility health care provider in accordance with Sections 1408 and 1437 of these ☒ ☐ ☐ Section V, Number 7, Procedure I-C regulations, for coordination with outside agencies; and, (e) notification of school staff; ☒ ☐ ☐ Section V, Number 7, Procedure I-H (f) notification of facility mental health personnel. ☒ ☐ ☐ Section V, Number 7, Procedure I-G 7716 Tuolumne MLRJDF PRO 23-24 27 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS The facility administrator shall develop and implement policies and procedures for post-disposition youth to Section V, Number 7, Procedure I-A coordinate the provision of transitional and reentry ☒ ☐ ☐ services including, but not limited to, medical and behavioral health, education, probation supervision and community-based services. The facility administrator shall develop and implement written policies and procedures for the furlough of The facility does not furlough youth from youth from custody. ☒ ☐ ☐ custody. 1352 CLASSIFICATION The facility administrator shall develop and implement Section V, Number 9 written policies and procedures on classification of ☒ ☐ ☐ youth for the purpose of determining housing placement in the facility. Such procedures shall: (a) provide for the safety of the youth, other youth, facility staff, and the public by placing youth in the Section V, Number 9, Procedure I-A appropriate, least restrictive housing and program ☒ ☐ ☐ settings. Housing assignments shall consider the need for single, double or dormitory assignment or location within the dormitory; (b) consider facility populations and physical design of the facility; ☒ ☐ ☐ Section V, Number 9, Procedure I-A (c) provide that a youth shall be classified upon admittance to the facility; classification factors shall Section V, Number 9, Procedure I-B include, but not be limited to: age, maturity, sophistication, emotional stability, program needs, Section V, Number 9, Procedure C-1 to 12 legal status, public safety considerations, medical/mental health considerations, gender and gender identity of the youth; The Classification/Youth Housing Screening Tool and the Youth Strengthening Admissions Assessment continue to be used ☒ ☐ ☐ to evaluate a youth’s classification needs. The facility has one unit with 30 beds, so determining appropriate housing is important to ensure staff contact and observation needs can be easily met. The screening tools were developed in coordination with BH to establish and identify all safety elements to address youth needs and behaviors. 7716 Tuolumne MLRJDF PRO 23-24 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) provide for periodic classification reviews, including provisions that consider the level of supervision and the Section V, Number 9, Procedure I-E youth's behavior while in custody; and, ☒ ☐ ☐ The reviews occur weekly. (e) provide that facility staff shall not separate youth from the general population or assign youth to a single Section V, Number 9, Procedure I-F occupancy room based solely on the youth's actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, gender expression, mental ☒ ☐ ☐ Staff have the ability to override or determine or physical disability, or HIV status. This section does particular housing needs based on the not prohibit staff from placing youth in a single overall circumstances from the numerous occupancy room at the youth's specific request or in admission and classification screening tools. accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, bisexual, transgender, questioning or intersex identification or ☒ ☐ ☐ Section V, Number 9, Procedure I-G status as an indicator of likelihood of being sexually abusive. 7716 Tuolumne MLRJDF PRO 23-24 29 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1352.5 TRANSGENDER AND INTERSEX YOUTH. The facility administrator shall develop written policies Section V, Number 10 and procedures ensuring respectful and equitable treatment of transgender and intersex youth. The policies shall provide that: The facility developed a gender preference form which includes staff having a conversation with youth at admission and a signature from the youth after the gender preferences are identified to ensure responsiveness to their requested preferences as it relates to search, housing, and clothing. This is also communicated to ancillary staff to have consistent gender references. ☒ ☐ ☐ While on-site, we identified 2 youth who have identified as Transgender Females. The agency does a good job in addressing the youth’s needs. One youth is from Tuolumne County and is currently involved with Wellpath Medical assistance. The other youth is from Mariposa County and is being seen by Mariposa Medical and Behavior Health staff. Our interviews with these youth revealed staff and facility partners are providing good and caring services. (a) Facility staff shall respect every youth’s gender identity and shall refer to the youth by the youth’s Section V, Number 10, Procedure I-A preferred name and gender pronoun, regardless of the youth’s legal name. Facilities may prohibit the use of ☒ ☐ ☐ gang or slang names or names that otherwise compromise facility operations as determined by the facility manager or designee, and shall document any decision made on this basis. (b) Facility staff shall permit youth to dress and present themselves in a manner consistent with their gender ☒ ☐ ☐ Section V, Number 10, Procedure I-B identity and shall provide youth with the institution’s clothing and undergarments consistent with their gender identity. 7716 Tuolumne MLRJDF PRO 23-24 30 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Facility staff shall house youth in the unit or room that best meets their individual needs and promotes Section V, Number 10, Procedure I-C their safety and well-being. Staff may not automatically house youth according to their external anatomy and ☒ ☐ ☐ shall document the reasons for any decision to house youth in a unit that does not match their gender identity. In making a housing decision, staff shall consider the youth’s preferences, as well as any recommendations from the youth’s health or behavioral health provider. (d) Facility administrators shall ensure that transgender and intersex youth have access to medical and ☒ ☐ ☐ Section V, Number 10, Procedure I-D behavioral health providers qualified to provide care and treatment to transgender and intersex youth. (e) Consistent with the facility’s reasonable and necessary security considerations and physical plant, Section V, Number 10, Procedure I-E facility staff shall make every effort to ensure the safety ☒ ☐ ☐ and privacy of transgender and intersex youth when the youth are using the bathroom or shower, or dressing or undressing. Facility staff shall not conduct physical searches of any youth for the purpose of determining the youth’s Section V, Number 10, Procedure I-F anatomical sex. Whenever feasible, the facility shall ☒ ☐ ☐ respect the youth’s preference regarding the gender of Section V, Number 10, Procedure I-G the staff member who conducts any search of the youth. 7716 Tuolumne MLRJDF PRO 23-24 31 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1353 ORIENTATION The facility administrator shall develop and implement Section V, Number 11, I-a, D and E written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Section V, Number 10, Procedure I-D, 1 and information shall be provided and supplemented with 2 video orientation if feasible. Provision shall be made to provide accessible orientation information to all detained youth including those with disabilities, limited Youth are provided with a Handbook at literacy, or English language learners. Orientation shall admission containing all elements of this include information that addresses: regulation as well as a PREA Pamphlet. We reviewed the handbook and found the explanation of all elements was easy for youth to understand. It provides an ☒ ☐ ☐ operational understanding for youth expectations, rights, and how to address any identified needs that may arise during their stay. We also reviewed the Orientation Sign- Off document youth sign when admitted and oriented to the facility, acknowledging their understanding of the facility guidelines, expectations, and processes. We interviewed 3 of the 11 youth in custody and they acknowledged they understood the handbook and their ability to ask staff questions regarding their stay. (a) facility rules including contraband and searches and disciplinary procedures; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 1 (b) facility’s system of positive behavior interventions and supports, including behavior expectations, Section V, Number 10, Procedure I-B, 2 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 ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 3 harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 4 7716 Tuolumne MLRJDF PRO 23-24 32 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) the existence of the grievance procedure, the steps that must be taken to use it, the youth’s right to be free ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 5 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 ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 6 court process; (g) access to routine and emergency health and ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 7 mental health care; (h) access to education, religious services, and ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 8 recreational activities; (i) housing assignments; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 9 (j) opportunity for personal hygiene and daily showers including the availability of personal care items ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 10 (k) rules and access to correspondence, visits and telephone use; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 11 (l) availability of reading materials, programming, and other activities; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 12 (m) facility policies on the use of force, use of restraints, chemical agents and room confinement; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 13 (n) immigration legal services; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 14 7716 Tuolumne MLRJDF PRO 23-24 33 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (o) emergencies including evacuation procedures; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 15 (p) non-discrimination policy and the right to be free from physical, verbal or sexual abuse and harassment ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 21 by other youth and staff; (q) availability of services and programs in a language other than English if appropriate; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 16 (r) the process for requesting different housing, education, programming and work assignments; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 18 (s) a process for which parents/guardians receive information regarding the youth’s stay in the facility that Section V, Number 10, Procedure I-B, 17 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. ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 19 7716 Tuolumne MLRJDF PRO 23-24 34 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354 SEPARATION The facility administrator shall develop and implement Section V, Number 13 written policies and procedures that address: We reviewed 15 incidents of Separation from October 2022 to October 2023, two of which were Voluntary Separation. In total, the agency had 91 Separation incidents, 5 Voluntary Separations. The agency documents behavior separation in an Activity Report or Incident Report, prompting staff to document the reason for and efforts to return the youth to programming. Youth go to the library (second classroom not in use and in the unit), to reflect on the behavior resulting in the separation. ☒ ☐ ☐ The agency uses the CICO (Check in, Check out) Daily Point Sheet to document incidents that result in behavior separation but are not a violation of a major rule. The form allows for points (0-2) based on the Positive Behavior and Supports (PBIS) model for respectful, responsible, and safe behaviors. This form is completed for each youth daily and allows for the recording of incidents that do not represent the PBIS model. This is tracked to have the information recorded for case planning and counseling services while the youth is in custody. (a) separation of youth for reasons that include, but are not be limited to, medical and mental health conditions, ☒ ☐ ☐ Section V, Number 13, I-A, 1-6 assaultive behavior, disciplinary consequences and protective custody. (b) consideration of positive youth development and trauma-informed care. ☒ ☐ ☐ Section V, Number 13, I-C (c) separated youth shall not be denied normal privileges available at the facility, except when ☒ ☐ ☐ Section V, Number 13, I-B and E necessary to accomplish the objective of separation. 7716 Tuolumne MLRJDF PRO 23-24 35 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) when the objective of the separation is discipline, Title 15 Section 1390 shall apply. Section V, Number 13, I Disciplinary Separation The facility makes good use of the space in the single unit facility for separation, using the not-occupied classroom, which allows a full ☒ ☐ ☐ visual of the youth while in the separated location. This space allows youth a cool- down period to reflect on the behaviors that necessitated a separation but not to the level of room confinement. The process is working and accomplishing the goal in regulation, despite their physical plant. (e) when separation results in room confinement, the separation shall occur in accordance with Welfare and ☒ ☐ ☐ Section V, Number 13, Procedure I-E Institutions Code Section 208.3 and Section 1354.5 of these regulations. (f) policies and procedures shall ensure a daily review of separated youth to determine if separation remains The facility only separates youth for short necessary. periods of time to re-focus behavior. Our review of all incidents revealed most were poor decisions that are not aligned with the PBIS Model of behavior with others. The agency only uses this tool when they have exhausted every verbal counseling attempt. The youth are evaluated regularly ☒ ☐ ☐ and returned to normal programming in most cases, less than an hour after separation began. We note the agency completes a Reintegration Plan in each incident to allow for conversations about the behavior leading to the separation and discussion of how the youth’s actions could be different. The agency also allows for Due Process when a youth is separated for discipline, including minor rule violations. 7716 Tuolumne MLRJDF PRO 23-24 36 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT (a) The facility administrator shall develop and Section V, Number 14 implement written policies and procedures addressing the confinement of youth in their room that are consistent with Welfare and Institutions Code Section The facility has had 35 incidents of RC from 208.3. The placement of a youth in room confinement October 2022 through October 2023, with shall be accomplished in accordance with the following four involving one youth for self-harm-related guidelines: behavior. The agency has a process to ensure staff document all efforts to reintegrate and follow the RC form prompts. Incident report documentation for the reason of room ☒ ☐ ☐ confinement was clear in each incident we reviewed. No youth were on RC for more than 3 hours and 30 minutes (1), 2-3 hours (7), 1-2 hours (17), and 12 youth under 30 minutes. Each youth participated in a Reintegration Plan, allowing staff to communicate and have a conversation about the incident, what could have been done differently, and a review of the Due Process process for the behavior leading to the RC. (1) Room confinement shall not be used before other, less restrictive, options have been attempted and ☒ ☐ ☐ Section V, Number 14, I-A exhausted, unless attempting those options poses a threat to the safety or security of any youth or staff. Section V, Number 14, Procedure II-A (2) Room confinement shall not be used for the purposes of punishment, coercion, convenience, or ☒ ☐ ☐ Section V, Number 14, I-B retaliation by staff. (3) Room confinement shall not be used to the extent that it compromises the mental and physical health of Section V, Number 14, I-C the youth. ☒ ☐ ☐ Section V, Number 14, Procedure II-B (b) A youth may be held up to four hours in room confinement. After the youth has been held in room ☒ ☐ ☐ Section V, Number 14, Procedure II-C confinement for a period of four hours, staff shall do one or more of the following: 7716 Tuolumne MLRJDF PRO 23-24 37 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section V, Number 14, I-E, 1 (1) Return the youth to general population. ☒ ☐ ☐ Section V, Number 14, Procedure II-D, 1 Section V, Number 14, I-E, 3 (2) Consult with mental health or medical staff. ☒ ☐ ☐ Section V, Number 14, Procedure II-D, 2 (3) Develop an individualized plan that includes the goals and objectives to be met in order to reintegrate Section V, Number 14, I-E, 6 the youth to general population. Section V, Number 14, Procedure II-D, 3 ☒ ☐ ☐ As soon as a youth is placed on RC, an individual plan form is developed with the youth and attempts to follow through are made. (4) If room confinement must be extended beyond four hours, staff shall do each of the following: Section V, Number 14, Procedure II-D, 4 ☒ ☐ ☐ Each component is addressed in policy and documentation review included the elements required to extend. (A) Document the reasons for room confinement and the basis for the extension, the date and time the youth ☒ ☐ ☐ Section V, Number 14, I-E, 2 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 ☒ ☐ ☐ Section V, Number 14, I-E, 6 youth to general population. (C) Obtain documented authorization by the facility superintendent or his or her designee every four hours ☒ ☐ ☐ Section V, Number 14, I-E, 5 thereafter. (5) This section is not intended to limit the use of single- person rooms or cells for the housing of youth in ☒ ☐ ☐ Section V, Number 14, I-I juvenile facilities and does not apply to normal sleeping hours. 7716 Tuolumne MLRJDF PRO 23-24 38 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (6) This section does not apply to youth or wards in court holding facilities or adult facilities. ☒ ☐ ☐ Section V, Number 14, I-J (7) Nothing in this section shall be construed to conflict with any law providing greater or additional protections ☒ ☐ ☐ Section V, Number 14 Policy Statement to youth. (8) This section does not apply during an extraordinary emergency circumstance that requires a significant Section V, Number 14, I-K departure from normal institutional operations, including a natural disaster or facility-wide threat that ☒ ☐ ☐ poses an imminent and substantial risk of harm to multiple staff or youth. This exception shall apply for the shortest amount of time needed to address this imminent and substantial risk of harm. (9) This section does not apply when a youth is placed in a locked cell or sleeping room to treat and protect Section V, Number 14, I-L 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. 1355 INSTITUTIONAL ASSESSMENT AND PLAN The facility administrator shall develop and implement ☒ ☐ ☐ Section V, Number 16 written policies and procedures for assessment and case planning. 7716 Tuolumne MLRJDF PRO 23-24 39 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Assessment: The assessment is based on information collected Section V, Number 16, Policy I-A during the admission process with periodic review, which includes the youth's risk factors, needs and strengths including, but not limited to, identification of substance abuse history, educational, vocational, We reviewed a sampling of IAP’s for youth counseling, behavioral health, consideration of known including an initial, updated, 3-month, 6- history of trauma, and family strengths and needs. month, Change in Treatment, and Transition Plans, each focusing on the identified needs and service approach while in or transitioning out of custody. The plans focus on a Youth Strength and Needs Assessment, which incorporates information from the following areas: Emotional/Behavioral Health; Cognitive Development and Functioning; Social Development and Functioning; Physical Health/Disabilities; Education; Trauma/ ☒ ☐ ☐ Resiliency; Family Relationships; Alcohol/ Drugs; Prior/Current Offense; Adult Relationships; and any other information which impacts a youth’s strengths or needs. A Treatment Plan is developed based on responses to the Assessment, which is scored, to identify the top three needs and strengths. We found each assessment to be detailed and informative, as well as individualized to each youth. The process is inclusive of required elements and documentation of timelines, which are more than required in policy and regulation. Staff work within the plan to provide reachable and attainable goals, both for in-custody treatment and upon release into the community. (b) Institutional Case Plan: (1) A case plan shall be developed for each youth held Section V, Number 16, Policy I-B for at least 30 days or more and created within 40 days of admission. ☒ ☐ ☐ IAP’s are completed at 14 days or sooner, with follow-up assessments at the 3-month, 6-month, 9-month, 12-month, and transition planning timelines. 7716 Tuolumne MLRJDF PRO 23-24 40 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) The institutional plan shall include, but not be limited ☒ ☐ ☐ to, written documentation that provides: (A) objectives and time frame for the resolution of problems identified in the assessment; ☒ ☐ ☐ Section V, Number 16, Procedure II-A (B) a plan for meeting the objectives that includes a description of program resources needed and ☒ ☐ ☐ Section V, Number 16, Procedure II-B, 1-3 individuals responsible for assuring that the plan is implemented; (3) periodic evaluation of progress towards meeting the objectives, including periodic review and discussion of ☒ ☐ ☐ Section V, Number 16, Procedure II-C the plan with the youth; (4) a transition plan, the contents of which shall be subject to existing resources, shall be developed for ☒ ☐ ☐ Section V, Number 16, Procedure II-D post dispositional youth in accordance with Section 1351; and, (5) in as much as possible and if appropriate, the plan, including the transition plan, shall be developed with ☒ ☐ ☐ Section V, Number 16, Procedure II-E input from the family, supportive adults, youth, and Regional Center for the Developmentally Disabled. 1356 COUNSELING AND CASEWORK SERVICES The facility administrator shall develop and implement Section V, Number 16, Procedure V-A written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall Facility staff document behavior, both ensure: positive and negative, in the youth’s ‘Check in, Check out’ (CICO) Daily Point sheets. This identifies their behavior each shift, as ☒ ☐ ☐ well as their participation in all T15 requirements. We reviewed daily/weekly summaries and phone call status for each youth in custody recorded on the CICO sheets. This daily documentation reveals the positive and negative activities as it relates to all areas of a youth’s program. (a) youth will receive assistance with needs or concerns that may arise; ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 1 (b) youth will receive assistance in requesting contact with parents, other supportive adults, attorney, clergy, ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 2 probation officer, or other public official; and, 7716 Tuolumne MLRJDF PRO 23-24 41 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) youth will be provided access to available resources to meet the youth’s needs. ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 3 1357 USE OF FORCE The facility administrator, in cooperation with the Section V, Number 17 (UF) responsible physician, shall develop and implement written policies and procedures for the use of force, Section V, Number 17, Procedure II-B, 5 which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. We reviewed 10 of the 11 incidents involving the use of force from October 2022 through (a) At a minimum, each facility shall develop policies October 2023. The reports provided clear and procedures which: and relevant information based on the narrative in the report and accompanied by additional documentation if the incident involved Room Confinement (if appropriate), Separation, Use of Restraints, Due Process, or a response from agency partners. Most involved unit disturbances or assaultive ☒ ☐ ☐ behavior from youth. Two of the incidents involved the use of OC Spray and 8 youth were restrained following a UF incident for movement to their room or intake holding. Senior and supervisory staff review and debrief incidents along with involved staff and the superintendent. Documentation and forms were complete and articulate in terms of all necessary requirements. (1) restricts the use of force to that which is deemed reasonable and necessary, as defined in Section 1302 ☒ ☐ ☐ Section V, Number 17, Procedure I-B to ensure the safety and security of youth, staff, others and the facility. (2) outline the force options available to staff including both physical and non-physical options and define when ☒ ☐ ☐ Section V, Number 17, Procedure V-A, 1-6 those force options are appropriate. (3) describe force options or techniques that are expressly prohibited by the facility. ☒ ☐ ☐ Section V, Number 17, Procedure V-B, 1-8 7716 Tuolumne MLRJDF PRO 23-24 42 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) describe the requirements of staff to report any inappropriate use of force, and to take affirmative action ☒ ☐ ☐ Section V, Number 17, Procedure II-B, 7 to immediately stop it. (5) define a standardized reporting format that includes time period and procedure for documenting and Section V, Number 17, Procedure V 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. ☒ ☐ ☐ Section V, Number 17, Procedure V-C (7) define the role, notification, and follow-up procedures required after use of force incidents for medical, mental ☒ ☐ ☐ Section V, Number 17, Procedure VI-A, B health staff and parents or legal guardians. and C (8) describe the limitations of use of force on pregnant youth in accordance with Penal Code Section 6030(f) ☒ ☐ ☐ Section V, Number 17, Procedure III and Welfare and Institutions Code Section 222. (b) Facilities that authorize chemical agents as a force option shall include policies and procedures that: Section V, Number 18 (1) identify who is approved to carry and/or utilize chemical agents in the facility and the type, size and the Section V, Number 18, Procedure I-A approved method of deployment for those chemical agents. ☒ ☐ ☐ Only senior staff are permitted to carry OC spray in the facility. It is important to note there have been two chemical spray incidents since October of 2022, involving one youth. (2) mandate that chemical agents only be used when there is an imminent threat to the youth’s safety or the ☒ ☐ ☐ Section V, Number 18, Procedure I-B 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 Section V, Number 18, Use I-F include that youth who have been exposed to chemical ☒ ☐ ☐ agents shall not be left unattended until that youth is fully Section V, Number 18, Use I-H, 5 and 6 decontaminated or is no longer suffering the effects of the chemical agent. Section V, Number 18, Use I-I, 1 through 8 7716 Tuolumne MLRJDF PRO 23-24 43 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) define the role, notification, and follow-up procedures required after use of force incidents involving chemical Section V, Number 18, Use I-E (CFMG) agents for medical, mental health staff and parents or legal guardians. ☒ ☐ ☐ Section V, Number 18, Use I-F (BH and parent/legal guardian) (5) provide for the documentation of each incident of use of chemical agents, including the reasons for which Section V, Number 18, Use I-G, 1-5 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 which require that agencies provide initial and regular Section V, Number 17, Procedure IV training in use of force and chemical agents when appropriate that address: ☒ ☐ ☐ Senior staff are only authorized to carry OC Spray. Staff are trained annually by certified STC Instructor. (1) known medical and behavioral health conditions that would contraindicate certain types of force; ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 6 (2) acceptable chemical agents and the methods of application. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 2 (3) signs or symptoms that should result in immediate referral to medical or behavioral health. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 7 (4) instruction on the Constitutional Limitations of Use of Force. Section V, Number 18, Procedure I-B ☒ ☐ ☐ This is part of the training curriculum for Use of Force. (5) physical training force options that may require the use of perishable skills. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B 7716 Tuolumne MLRJDF PRO 23-24 44 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (6) timelines the facility uses to define regular training. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B 1358 USE OF PHYSICAL RESTRAINTS The facility administrator, in cooperation with the Section V, Number 19 and 20 responsible physician and mental health director, shall develop and implement written policies and procedures for the use of restraint devices. Restraint devices The facility has the WRAP as a restraint with include any devices which immobilize a youth's ☒ ☐ ☐ very specific limitations on its use. extremities and/or prevent the youth from being ambulatory. There has been no use of the WRAP since July 2022. Physical restraints may be used only for those youth who present an immediate danger to themselves or Section V, Number 19, Policy I-B 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 Section V, Number 19, Policy I-F restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through Section V, Number 19, Policy I-Q affixing of hands and feet together behind the back ☒ ☐ ☐ (hogtying) is prohibited. The use of restraints on Section V, Number 19, Policy I-R pregnant youth is limited in accordance with Penal Code Section V, Number 19, Policy I-S Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of handcuffs, shackles or other restraint devices when Section V, Number 19, Policy I-C 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. 7716 Tuolumne MLRJDF PRO 23-24 45 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Youth shall be placed in restraints only with the approval of the facility manager or designee. The facility manager Section V, Number 19, Policy I-B may delegate authority to place a youth in restraints to a physician. Reasons for continued retention in restraints Section V, Number 19, Policy I-V shall be reviewed and documented at a minimum of every hour. Section V, Number 19, Policy I-W ☒ ☐ ☐ Senior JCO’s are designated to approve placement of restraints in the absence of the facility Superintendent. The WRAP must have Superintendent approval. A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no Section V, Number 19, Policy I-J 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 soon as possible, but in no case longer than four hours from ☒ ☐ ☐ Section V, Number 19, Policy I-K the time of placement, to assess the need for mental health treatment. Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and Section V, Number 19, Policy I-N to ensure the safety and well-being of the youth. ☒ ☐ ☐ Observations of the youth's behavior and any staff Section V, Number 19, Procedure I-B interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. Section V, Number 19, Procedure I-J In addition to the requirements above, policies and procedures shall address: ☒ ☐ ☐ Section V, Number 19, Procedure I-M (a) documentation of the circumstances leading to an application of restraints. (b) known medical conditions that would contraindicate certain restraint devices and/or techniques. ☒ ☐ ☐ Section V, Number 19, Policy I-M (c) acceptable restraint devices. ☒ ☐ ☐ Section V, Number 19, Policy I-B (d) signs or symptoms which should result in immediate medical/mental health referral. ☒ ☐ ☐ Section V, Number 19, Procedure I-J 7716 Tuolumne MLRJDF PRO 23-24 46 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) availability of cardiopulmonary resuscitation equipment. ☒ ☐ ☐ Section V, Number 19, Procedure I-D (f) protective housing of restrained youth. While in restraint devices, all youth shall be housed alone or in ☒ ☐ ☐ Section V, Number 19, Policy I-H a specified housing area for restrained youth which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. ☒ ☐ ☐ Section V, Number 19, Policy I-H (h) exercising of extremities. ☒ ☐ ☐ Section V, Number 19, Policy I-H 1358.5 USE OF RESTRAINT DEVICES FOR MOVEMENT AND TRANSPORTATION WITHIN THE Section V, Number 21 FACILITY. The Facility Administrator, in cooperation with the responsible physician and behavioral/mental health Staff are trained to use control holds at escort director, shall develop and implement written policies and must get authorization to use other force and procedures for the use of restraint devices when ☒ ☐ ☐ for movement. There were 8 incidents the purpose is for movement or transportation within involving the use of restraints for movement the facility that shall include the following: of a youth to their room. All were 2-3 minutes, except for one incident where a youth was in restraints for 7 minutes as he remained combative. (a) identification of acceptable restraint devices, staff approved to utilize restraint devices and the required Section V, Number 19, Policy I-B training. ☒ ☐ ☐ Staff are trained annually by certified STC Instructor. (b) the circumstances leading to the application of restraints must be documented. ☒ ☐ ☐ Section V, Number 21, Procedure A 7716 Tuolumne MLRJDF PRO 23-24 47 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) an individual assessment of the need to apply restraints for movement or transportation that includes Section V, Number 21, Procedure B consideration of less restrictive alternatives, consideration of a youth’s known medical or mental ☒ ☐ ☐ health conditions, trauma informed approaches, and a process for documentation and supervisor review and approval. (d) consideration of safety and security of the facility, with a clearly defined expectation that restraint ☒ ☐ ☐ Section V, Number 21 Procedure C 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 ☒ ☐ ☐ Section V, Number 21 Procedure D Welfare and Institutions Code Section 222. 1359 SAFETY ROOM PROCEDURES (a) The facility administrator, and where applicable, in The facility does not have a Safety Room. cooperation with the responsible physician, shall develop and implement written policies and procedures governing the use of safety rooms, as described in Title 24, Part 2, Section 1230.1.13. The room shall be used to hold only 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. A safety room shall not be used for punishment or discipline, or as a substitute for treatment. Policies and procedures shall: (1) include provisions for administration of necessary nutrition and fluids, access to a toilet, and suitable ☐ ☐ ☒ clothing to provide for privacy; (2) provide for approval of the facility manager, or ☐ ☐ ☒ designee, before a youth is placed into a safety room; (3) provide for continuous direct visual supervision and documentation of the youth's behavior and any staff ☐ ☐ ☒ interventions every 15 minutes, with actual time recorded; (4) provide that the youth shall be evaluated by the ☐ ☐ ☒ facility manager, or designee, every four hours; (5) provide for immediate medical assessment, where appropriate, or an assessment at the next daily sick ☐ ☐ ☒ call; and, (6) provide a process for documenting the reason for placement, including attempts to use less restrictive ☐ ☐ ☒ means of control, and decisions to continue and end placement. 7716 Tuolumne MLRJDF PRO 23-24 48 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The placement of a youth in the safety room shall be ☐ ☐ ☒ accomplished in accordance with the following: (1) safety room 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. (2) safety room shall not be used for the purposes of punishment, coercion, convenience, or retaliation by ☐ ☐ ☒ staff. (3) safety room shall not be used to the extent that it compromises the mental and physical health of the ☐ ☐ ☒ youth. (c) A youth may be held up to four hours in the safety room. After the youth has been held in the safety room ☐ ☐ ☒ 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. (d) If confinement in the safety room must be extended beyond four hours, staff shall develop an individualized plan that includes the requirements of Section 1354.5 ☐ ☐ ☒ and the goals and objectives to be met in order to integrate the youth to general population. 1360 SEARCHES , The facility administrator shall develop and implement Section V, Number 23 written policies and procedures governing the search of youth, the facility, and visitors. Policies and procedures ☒ ☐ ☐ Section V, Number 23, Procedure IX Room shall provide that: Section V, Number 23, Procedure X Facility Section V, Number 23, Procedure XI Visitor (a) Searches shall be conducted to ensure the safety and security of the facility, public, visitors, youth, and ☒ ☐ ☐ Section V, Number 23, Policy I-A and B staff. (b) Searches shall be conducted in a manner that preserves the privacy and dignity of the person being ☒ ☐ ☐ Section V, Number 23, Policy I-C searched and shall not be conducted for harassment or as a form of discipline or punishment. 7716 Tuolumne MLRJDF PRO 23-24 49 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Strip searches and visual or physical body cavity searches shall comply with Penal Code Section 4030. Section V, Number 23, Policy I-D ☒ ☐ ☐ There have been no strip searches at the facility from July 2022 to October 2023, only 3 since the facility opened in 2017. (d) Physical body cavity searches shall only be conducted by a medical professional. ☒ ☐ ☐ Section V, Number 23, Policy I-E (e) Any youth held after a detention hearing shall only be strip searched with prior approval of a supervisor Section V, Number 23, Procedure II, III, IV when there is reasonable suspicion based on specific ☒ ☐ ☐ and articulable facts to believe that youth is concealing contraband. The reasonable suspicion shall be documented. (f) Searches of transgender and intersex youth shall comply with Section 1352.5. ☒ ☐ ☐ Section V, Number 23, Procedure V-D (g) Cross-gender pat-down searches and strip searches are prohibited except in exigent Section V, Number 23, Policy I-J and K circumstances or when conducted by a medical ☒ ☐ ☐ professional. Such searches must be justified and documented in writing. 1361 GRIEVANCE PROCEDURE The facility administrator shall develop and implement Section V, Number 30 written policies and procedures whereby any youth may appeal and have resolved grievances relating to any condition of confinement, including but not limited The facility has had 34 grievances filed from to health care services, classification decisions, July 2022 to October 2023, most of which program participation, telephone, mail or visiting were resolved by staff with two being procedures, food, clothing, bedding, mistreatment, appealed to the Superintendent. harassment or violations of the nondiscrimination policy. There shall be no time limit on filing grievances. ☒ ☐ ☐ Policies and procedures shall include provisions Of the youth we interviewed, each whereby the facility manager ensures: understood the process and felt the resolution was fair. The forms are step-by-step based and compliant with policy and regulation. 7716 Tuolumne MLRJDF PRO 23-24 50 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) a grievance form and instructions for registering a grievance, which includes provisions for the youth to Section V, Number 30, Policy I-A have free access to the form; ☒ ☐ ☐ Section V, Number 30, Policy I-B (b) the youth shall have the option to confidentially file the grievance or to deliver the form to any youth ☒ ☐ ☐ Section V, Number 30, Policy I-D supervision staff working in the facility; (c) resolution of the grievance at the lowest appropriate staff level; ☒ ☐ ☐ Section V, Number 30, Policy I-F (d) provision for a prompt review and initial response to grievances within three (3) business days, grievances ☒ ☐ ☐ Section V, Number 30, Procedure I-C that relate to health and safety issues must be addressed immediately; (1) The youth may elect to be present to explain his/her version of the grievance to a person not directly ☒ ☐ ☐ Section V, Number 30, Procedure I-D involved in the circumstances which led to the grievance. (2) Provision for a staff representative approved by the facility administrator to assist the youth. ☒ ☐ ☐ Section V, Number 30, Policy I-C (e) provision for a written response to the grievance which includes the reasons for the decisions; ☒ ☐ ☐ Section V, Number 30, Policy I-F (f) a system which provides that any appeal of a grievance shall be heard by a person not directly ☒ ☐ ☐ Section V, Number 30, Procedure I-F involved in the circumstances which led to the grievance; Section V, Number 30, Procedure I-G (g) resolution of the grievance must occur within ten (10) business days unless circumstances dictate a ☒ ☐ ☐ Section V, Number 30, Procedure I-H longer time frame. The youth shall be notified of any delay; and, 7716 Tuolumne MLRJDF PRO 23-24 51 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) the policy shall provide multiple internal and external methods to report sexual abuse and sexual Section V, Number 30, Procedure I-G harassment. Section V, Number 30, Procedure I-H ☒ ☐ ☐ Section V, Number 30, Procedure I-I Section V, Number 30, Procedure I-J Whether or not associated with a grievance, concerns of parents, guardians, staff or other parties shall be ☒ ☐ ☐ Section V, Number 30, Procedure I-N addressed and documented in accordance with written policies and procedures within a specified timeframe. 1362 REPORTING OF INCIDENTS A written report of all incidents which result in physical Section V, Number 32 harm, use of force, serious threat of physical harm, or death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the We reviewed numerous incident reports staff and submitted to the facility manager by the end of involving UF, UR, RC, and Separation. the shift, unless additional time is necessary and authorized by the facility manager or designee. 1363 USE OF REASONABLE FORCE TO COLLECT DNA SPECIMENS, SAMPLES, IMPRESSIONS Section V, Number 33, Procedure III-A (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections personnel including peace officers, may employ reasonable force ☒ ☐ ☐ The facility has not had to use force to collect to collect blood specimens, saliva samples, and thumb DNA since 2017. or palm print impressions from individuals who are required to provide such samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request. (1) For the purpose of this section, the “use of reasonable force” shall be defined as the force that an Section V, Number 33, Procedure III-B objective, trained and competent correctional ☒ ☐ ☐ employee, faced with similar facts and circumstances, would consider necessary and reasonable to gain compliance with this section. (2) The use of reasonable force shall be preceded by efforts to secure voluntary compliance. Efforts to secure Section V, Number 33, Procedure III-B voluntary compliance shall be documented and include ☒ ☐ ☐ an advisement of the legal obligation to provide the requisite specimen, sample or impression and the consequences of refusal. 7716 Tuolumne MLRJDF PRO 23-24 52 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The force shall not be used without the prior written authorization of the supervising officer on duty. The Section V, Number 33, Procedure III-C authorization shall include information that reflects the fact that the offender was asked to provide the requisite specimen, sample, or impression and refused. ☒ ☐ ☐ The use of force for this regulation requires authorization from the Facility Superintendent. (1) If the use of reasonable force includes a cell extraction, the extraction shall be videotaped. Video Section V, Number 33, Procedure IV-A shall be directed at the cell extraction event. The videotape shall be retained by the agency for the length ☒ ☐ ☐ Section V, Number 33, Procedure IV-B of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7716 Tuolumne MLRJDF PRO 23-24 53 A453 JUV PRO eff. 1/2019 (23-24).dot 1370 EDUCATION PROGRAM (a) School Programs Section VI, Number 1, Policy II-A The County Board of Education shall provide for the administration and operation of juvenile court schools in conjunction with the Chief Probation Officer, or designee The Tuolumne County Superintendent of pursuant to applicable State laws. The school and facility Schools provides educational and vocational administrators shall develop and implement written opportunities via the Golden Ridge policy and procedures to ensure communication and Educational Center (GREC) onsite, online coordination between educators and probation staff. college through Columbia Community Culturally responsive and trauma-informed approaches College, and vocational opportunities should be applied when providing instruction. Education through the Motherlode Job Training for staff should collaborate with the facility administrator to Tuolumne County. A TCSOS Transition use technology to facilitate learning and ensure safe Specialist assists with youth exiting the technology practices. The facility administrator shall facility and returning to schools in the request an annual review of each required element of community as well as with enrollment and the program by the Superintendent of Schools, and a curriculum oversight, in Columbia College, a report or review checklist on compliance, deficiencies, community college nearby. It is noted youth and corrective action needed to achieve compliance eligible for Dual enrollment are attending with this section. Such a review, when conducted, online classes at the college as well. The cannot be delegated to the principal or any other staff of SOS last received WASC Accreditation in any juvenile court school site. The Superintendent of 2022. Schools shall conduct this review in conjunction with a qualified outside agency or individual. Upon receipt of the review, the facility administrator or designee shall PBIS was trained to all new staff initially but review each item with the Superintendent of Schools most have moved on since 2017. The and shall take whatever corrective action is necessary TCSOS plans to revitalize PBIS as a to address each deficiency and to fully protect the ☒ ☐ ☐ mechanism to promote positive behaviors educational interests of all youth in the facility. with rewards and incentives in the classroom and carried over to the living unit. We have seen the successes of PBIS as a collaboration with school and probation staff. The TCSOS offers a complete and comprehensive curriculum, including culinary food handler’s certification, DMV licenses for eligible youth, gardening, and personal reading goals via the Book Club. Additionally, for those youth with an active IEP, youth receive services via a counselor in addition to specialized instruction. TCSOS continues to provide a Psychologist one time per week to work with the sex offender population. The on-site teacher, Ashley Chambeaux, is engaged in the classroom and works individually with youth to grow their education opportunities. The program is 270 minutes each day except for every Wednesday has a late start to allow Ms. Chambeaux to participate in MDT meetings. 7716 Tuolumne MLRJDF PRO 23-24 54 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Required Elements The facility school program shall comply with the State Section VI, Number 1, Policy III-A Education Code and County Board of Education Section VI, Number 1, Policy III-B policies, all applicable federal education statutes and regulations and provide for an annual evaluation of the Section VI, Number 1, Policy III-C educational program offerings. As stated in the 2009 California Standards for the Teaching Profession, ☒ ☐ ☐ Section VI, Number 1, Policy III-D teachers shall establish and maintain learning Section VI, Number 1, Policy III-E environments that are physically, emotionally, and intellectually safe. Youth shall be provided a rigorous, quality educational program that responds to the different learning styles and abilities of students and prepares them for high school graduation, career entry, and post-secondary education. All youth shall be treated equally, and the education program shall be free from discriminatory action. Staff Section VI, Number 1, Policy III-F shall refer to transgender, intersex and gender- ☒ ☐ ☐ nonconforming youth by their preferred name and gender. (1) The course of study shall comply with the State Education Code and include, but not be limited to, ☒ ☐ ☐ Section VI, Number 1, Policy III-A courses required for high school graduation. (2) Information and preparation for the High School Equivalency Test as approved by the California ☒ ☐ ☐ Section VI, Number 1, Policy III-I Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education and vocational opportunities. ☒ ☐ ☐ Section VI, Number 1, Policy III-J (4) Administration of the High School Equivalency Tests as approved by the California Department of Education, ☒ ☐ ☐ Section VI, Number 1, Policy III-K shall be made available when possible. (5) Supplemental instruction shall be afforded to youth who do not demonstrate sufficient progress towards ☒ ☐ ☐ Section VI, Number 1, Policy III-L grade level standards. (6) The minimum school day shall be consistent with State Education Code Requirements for juvenile court Section VI, Number 1, Policy III-G schools. The facility administrator, in conjunction with education staff, must ensure that operational ☒ ☐ ☐ procedures do not interfere with the time afforded for the minimum instructional day. Absences, time out of class or educational instruction, both excused and unexcused, shall be documented. 7716 Tuolumne MLRJDF PRO 23-24 55 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (7) Education shall be provided to all youth regardless of classification, housing, security status, disciplinary or Section VI, Number 1, Policy III-O separation status, including room confinement, except when providing education poses an immediate threat to ☒ ☐ ☐ the safety of self or others. Education includes, but is not limited to, related services as provided in a youth’s Section 504 Plan or Individualized Education Program (IEP). (c) School Discipline (1) Positive behavior management will be implemented Section VI, Number 1, Policy IV-A ☒ ☐ ☐ to reduce the need for disciplinary action in the school setting and be integrated into the facility's overall behavioral management plan and security system. (2) School staff shall be advised of administrative decisions made by probation staff that may affect the ☒ ☐ ☐ Section VI, Number 1, Policy IV-B educational programming of students. (3) Except as otherwise provided by the State Education Code, expulsion/suspension from school shall be Section VI, Number 1, Policy IV-C imposed only when other means of correction fails to bring about proper conduct. School staff shall follow the appropriate due process safeguards as set forth in the ☒ ☐ ☐ State Education Code including the rights of students with special needs. School staff shall document the other means of correction used prior to imposing expulsion/ suspension if an expulsion/suspension is ultimately imposed. (4) The facility administrator, in conjunction with education staff will develop policies and procedures that ☒ ☐ ☐ Section VI, Number 1, Policy IV-D address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations (1) State and federal laws and regulations shall be observed for all individuals with disabilities or suspected Section VI, Number 1, Policy V-A disabilities. This includes but is not limited to child find, ☒ ☐ ☐ assessment, continuum of alternative placements, manifestation determination reviews, and implementation of Section 504 Plans and Individualized Education Programs. (2) Youth identified as English Learners (EL) shall be afforded an educational program that addresses their language needs pursuant to all applicable state and ☒ ☐ ☐ Section VI, Number 1, Policy V-B federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission (1) Youth shall be interviewed after admittance and a ☒ ☐ ☐ record maintained that documents a youth's educational Section VI, Number 1, Policy VI-A history, including but not limited to: 7716 Tuolumne MLRJDF PRO 23-24 56 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (A) School progress/school history; ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 1 (B) Home Language Survey and the results of the State Test used for English language proficiency; ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 2 (C) Needs and services of special populations as defined by the State Education Code, including but not ☒ ☐ ☐ limited to, students with special needs. Section VI, Number 1, Policy VI-A, 3 (D) Discipline problems. ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 4 (2) Youth will be immediately enrolled in school. Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning Section VI, Number 1, Policy VI-B levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary education plan shall be developed for each youth within five school ☒ ☐ ☐ days. Section VI, Number 1, Policy VI-C (4) Upon enrollment, education staff shall comply with the State Education Code and request the youth's records from his/her prior school(s), including, but not Section VI, Number 1, Policy VI-D limited to, transcripts, Individual Education Program (IEP), 504 Plan, state language assessment scores, ☒ ☐ ☐ immunization records, exit grades, and partial credits. Upon receipt of the transcripts, the youth's educational plan shall be reviewed with the youth and modified as needed. Youth should be informed of the credits they need to graduate. (f) Educational Reporting (1) The complete facility educational record of the youth ☒ ☐ ☐ shall be forwarded to the next educational placement in Section VI, Number 1, Policy VII-A accordance with the State Education Code. (2) The County Superintendent of Schools shall provide appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance Section VI, Number 1, Policy VII-B with the State Education Code. (g) Transition and Re-Entry Planning (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies and Section VI, Number 1, Policy VIII-A procedures to meet the transition needs of youth, ☒ ☐ ☐ including the development of an education transition plan, in accordance with the State Education Code and in alignment with Title 15, Minimum Standards for Juvenile Facilities, Section 1355. 7716 Tuolumne MLRJDF PRO 23-24 57 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Post-Secondary Education Opportunities (1) The school and facility administrator should, whenever possible, collaborate with local post- Section VI, Number 1, Policy IX-A secondary education providers to facilitate access to ☒ ☐ ☐ educational and vocational opportunities for youth that considers the use of technology to implement these programs. 7716 Tuolumne MLRJDF PRO 23-24 58 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1371 PROGRAMS, RECREATION, AND EXERCISE. The facility administrator shall develop and implement Section VI, Number 3, Policy I-A 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 The facility has many programming options their bed area. for youth, including: Aggression Replacement Training (ART); Interactive Journaling; Boys Council; Girls Circle; Parenting Education; Independent Living Skills; 4H-Master Gardner’s; Harvest of the Month (Health and Nutrition); Art Therapy; Tools for Success; Mindfulness and Meditation; Book Club; Religious Services and Bible Study; Prison Education Project (PEP); Mentoring; Drug and Alcohol Prevention Groups; Ready Now Recovery; Tai Chi; and Drum Circle. The agency was just awarded a grant through 4-H to develop a Meditation Pond and Hydroponic Garden. The project was just approved by the county and electricians were on site when we were there. ☒ ☐ ☐ Facility staff work on ‘Check In, Check Out’ (CICO) with youth to document positive and negative behaviors which teach the elements of PBIS. This tool provides incentive-based opportunities for youth. TCBH has begun providing individual/group counseling to youth and Individual Psychotherapy weekly. They have been present for MDT and case treatment plans and have a Case Manager who works with Clinicians locally to provide treatment to this population on a more consistent basis. The Superintendent of the facility, Annie Hockett, is a licensed Clinician and responds to crisis events at the facility. Providers include TCBH, TCSOS, facility staff, 4-H, Master Gardner’s, Hidden Treasures, and local volunteers. Juvenile facilities shall provide the opportunity for programs, recreation, and exercise a minimum of three Section VI, Number 3, Policy I-B and C hours a day during the week and five hours a day each ☒ ☐ ☐ Saturday, Sunday or other non-school days, of which one hour shall be an outdoor activity, weather permitting. 7716 Tuolumne MLRJDF PRO 23-24 59 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS A youth’s participation in programs, recreation, and exercise may be suspended only upon a written finding Section VI, Number 3, Policy I-D by the administrator/manager or designee that a youth ☒ ☐ ☐ represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall be posted in the living units. ☒ ☐ ☐ Section VI, Number 3, Policy I-E There will be a written annual review of the programs, recreation, and exercise by the responsible agency to ☒ ☐ ☐ Section VI, Number 3, Policy I-F ensure content offered is current, consistent, and relevant to the population. (a) Programs. All youth shall be provided with the opportunity for at least one hour of daily programming to Section VI, Number 3, Policy I-G include, but not be limited to, trauma focused, cognitive, evidence-based, best practice interventions that are culturally relevant and linguistically appropriate, or pro- social interventions and activities designed to reduce recidivism. These programs should be based on the youth’s individual needs as required by Sections 1355 ☒ ☐ ☐ and 1356. Such programs may be provided under the direction of the Chief Probation Officer or the County Office of Education and can be administered by county partners such as mental health agencies, community based organizations, faith-based organizations or Probation staff. Programs may include but are not limited to: 7716 Tuolumne MLRJDF PRO 23-24 60 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; Section VI, Number 3, Policy I-G, 1-17 (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. (b) Recreation. All youth shall be provided the opportunity for at least one hour of daily access to Section VI, Number 3, Policy I-H unscheduled activities such as leisure reading, letter ☒ ☐ ☐ writing, and entertainment. Activities shall be supervised Section VI, Number 3, Policy I-K and include orientation and may include coaching of youth. (c) Exercise. All youth shall be provided with the opportunity for at least one hour of large muscle activity ☒ ☐ ☐ Section VI, Number 3, Policy I-I each day. The administrator/manager may suspend, for a period not to exceed 24 hours, access to recreation and Section VI, Number 3, Policy I-J programs. The administrator/manager shall document ☒ ☐ ☐ the reasons why suspension of recreation and programs occurs. 7716 Tuolumne MLRJDF PRO 23-24 61 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1372 RELIGIOUS PROGRAM The facility administrator shall provide access to Section VI, Number 7, Policy I-C religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth Section VI, Number 7, Policy I-D ☒ ☐ ☐ shall be allowed to participate in an activity outside of their room if he/she elects not to participate in religious programs. Religious programs shall provide for: Section VI, Number 7, Policy I-A (a) opportunity for religious services and practices; ☒ ☐ ☐ Section VI, Number 7, Policy I-B (b) availability of clergy; and, ☒ ☐ ☐ Section VI, Number 7, Policy I-B (c) availability of religious diets. ☒ ☐ ☐ Section VI, Number 7, Policy I-B 1373 WORK PROGRAM The facility administrator shall develop policies and Section VI, Number 8 procedures regarding the fair and consistent assignment of youth to work programs. Work assigned to a youth shall be meaningful, constructive and related to The agency allows youth that meet specific vocational training or increasing a youth's sense of criteria to work outside the secure perimeter. responsibility. Work programs shall not be imposed as a Youth in detention are responsible for daily disciplinary measure chores of cleaning their room and the unit. Yard maintenance and classroom cleaning is completed by more senior youth who have reached a certain level in the facility with ☒ ☐ ☐ good behavior. Youth over 16 can receive their food handler’s certificate and they are responsible for serving the meals which come over from the jail. Lastly, youth committed to Steps to Success can work outside the facility perimeter to maintain the cleanliness of the building and grounds. 7716 Tuolumne MLRJDF PRO 23-24 62 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1374 VISITING The facility administrator shall develop and implement Section VI, Number 9, Policy I-A written policies and procedures for visiting, that include provisions for special visits. Youth shall be allowed to Section VI, Number 9, Policy I-B receive visits by parents, guardians or persons standing in loco parentis, and children of youth. Other family members, such as grandparents and siblings, and The facility continues to accommodate all supportive adults, may be allowed to visit with the visits, allowing any person the opportunity to approval of the facility administrator or designee, and in visit a youth that offers a positive impact on conjunction with the youth’s case plan or in the best behavior, or influence for good transition. interest of the youth. This includes any family member or ☒ ☐ ☐ supportive adult, generally working within the visitor’s schedule if outside normal visiting hours. The visiting schedule is robust with specific providers, clinicians, and community persons visiting youth regularly, not to mention while on site there were four youth from Mariposa, Inyo, and Calaveras Counties in custody. All visits shall occur at reasonable times, subject only to the limitations necessary to maintain order and security. Section VI, Number 9, Policy I-A Visitation shall not be denied solely based on the visitor’s criminal history. The staff shall determine in each case, Section VI, Number 9, Policy I-R whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ the safety of 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 hours per week. Visits may be supervised, but ☒ ☐ ☐ Section VI, Number 9, Policy I-E conversations shall not be monitored unless there is a security or safety need. Section VI, Number 9, Policy I-G Provisions for special visits, in addition to the two-hour minimum and/or outside of the regular visiting hours, Section VI, Number 9, Policy I-H shall be accommodated as necessary and within the discretion of the facility administrator or designee. Section VI, Number 9, Policy I-I ☒ ☐ ☐ Family therapy and professional visits shall be accommodated outside the provisions of this regulation. Facilities may provide visitation opportunities outside of normal visiting hours to accommodate special visits. The facility may provide access to technology as an alternative, but not as a replacement, to in-person ☒ ☐ ☐ Section VI, Number 9, Policy I-S visiting. 7716 Tuolumne MLRJDF PRO 23-24 63 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1375 CORRESPONDENCE The facility administrator shall develop and implement ☒ ☐ ☐ Section VI, Number 10 written policies and procedures for correspondence which provide that: (a) there is no limitation on the volume of mail that youth may send or receive; ☒ ☐ ☐ Section VI, Number 10, Policy I-A (b) youth may send two letters per week postage free; Section VI, Number 10, Policy I-B ☒ ☐ ☐ All youth mail is sent postage-free. (c) youth may correspond confidentially with state and federal courts, any member of the State Bar or holder of Section VI, Number 10, Policy I-C public office, and the Board; however, authorized facility ☒ ☐ ☐ staff may open and inspect such mail only to search for contraband and in the presence of the youth; and, (d) incoming and outgoing mail, other than that described in (c), may be read by staff only when there is ☒ ☐ ☐ Section VI, Number 10, Policy I-F reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS The administrator of each juvenile facility shall develop Section VI, Number 11 and implement written policies and procedures to ☒ ☐ ☐ provide youth with access to telephone communications. 1377 ACCESS TO LEGAL SERVICES The facility administrator shall develop written Section VI, Number 12 procedures to ensure the right of youth to have access ☒ ☐ ☐ to the courts and legal services. Such access shall include: (a) access, upon request by the youth, to licensed attorneys and their authorized representatives; ☒ ☐ ☐ Section VI, Number 12, Policy I-A (b) provision for confidential consultation with attorneys; and, ☒ ☐ ☐ Section VI, Number 12, Policy I-B 7716 Tuolumne MLRJDF PRO 23-24 64 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) unlimited postage free, legal correspondence and cost-free telephone access as appropriate. ☒ ☐ ☐ Section VI, Number 12, Policy I-C 7716 Tuolumne MLRJDF PRO 23-24 65 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1390 DISCIPLINE The facility administrator shall develop and implement Section VII, Number 1, Policy I-A written policies and procedures for the discipline of youth that shall promote acceptable behavior; including the Section VII, Number 1, Policy I-B use of positive behavior interventions and supports. Discipline shall be imposed at the least restrictive level which promotes the desired behavior and shall not The facility’s rules and sanctions are clearly include corporal punishment, group punishment, identified in many forms for all youth. The physical or psychological degradation. Deprivation of sanction matrix is rarely used, only for high- the following is not permitted: risk behaviors and incidents which are rare. The PBIS model of respect, responsibility, and safety is visually and verbally present throughout the facility. Youth are more interested in earning points for commissary, which works to promote the tenets of PBIS. We observed youth in unit activities and the classroom, noting the staff efforts to have conversations with youth routinely as part of their overall philosophy to promote PBIS. The point sheets are tallied daily so youth know where they stand in terms of bedtime, participation in late activities, and incentive ☒ ☐ ☐ options. These pro-social activities and efforts are on full display evidenced by the by the low number of high-risk incidents and behaviors. We interviewed 5 youth while on site in each of the programs and found they seem to trust staff and feel like they are treated well. Staff continue to promote positive decision choices, offering options and compromise, which allow a youth to see the benefits of good behavior. Accountability and teaching moments are principles used in the daily operations facility-wide. The agency modified their rule and sanction system to only include minor and major rule violations. We noted Due Process is completed on every rule violation as they use the tool to enhance conversation and promote positive choices. 7716 Tuolumne MLRJDF PRO 23-24 66 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) bed and bedding; ☒ ☐ ☐ Section VII, Number 1, Policy I-C,1 (b) daily shower, access to drinking fountain, toilet ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 2 and personal hygiene items, and clean clothing; (c) full nutrition; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 3 (d) contact with parent or attorney; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 4 (e) exercise; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 5 (f) medical services and counseling; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 6 (g) religious services; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 7 (h) clean and sanitary living conditions; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 8 (i) the right to send and receive mail; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 9 (j) education; and, ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 10 7716 Tuolumne MLRJDF PRO 23-24 67 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (k) rehabilitative programming. ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 11 The facility administrator shall establish rules of conduct and disciplinary penalties to guide the conduct of youth. Section VII, Number 1, Policy I-E Such rules and penalties shall include both major violations and minor violations, be stated simply and Section VII, Number 1, Policy I-F ☒ ☐ ☐ affirmatively, and be made available to all youth. Provision shall be made to provide accessible information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS The facility administrator shall develop and implement Section VII, Number 2 written policies and procedures for the administration of discipline which shall include, but not be limited to: We reviewed 61 Due Process incidents since October 2022 and found less than 35% were actual rule violations. Of those, 59 were accepted without hearing and 2 were appealed. The process and outcome were appropriate for the behavior and the documentation was clear. ☒ ☐ ☐ The facility continues to over-use DP for minor rule violations and separation incidents. We again provided technical assistance to suggest the daily point sheet be the document to address minor rule violations and separation. However, the intent is to allow for more conversations with youth regarding the behavior resulting in any rule violation which, due to their low population, affords youth and staff to build on relationships promoting positive behavior and supports (PBIS). (a) designation of personnel authorized to impose discipline for violation of rules; ☒ ☐ ☐ Section VII, Number 2, Procedure I-A (b) prohibiting discipline to be delegated to any youth; ☒ ☐ ☐ Section VII, Number 2, Policy I-F 7716 Tuolumne MLRJDF PRO 23-24 68 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) definition of major and minor rule violations and their consequences, and due process requirements; Section VII, Number 1, Procedure IV-A ☒ ☐ ☐ Section VII, Number 1, Procedure IV-B Section VII, Number 1, Procedure IV-C (d) trauma-informed approaches and positive behavior interventions; ☒ ☐ ☐ Section VII, Number 2, Policy I-D (e) minor rule violations may be handled informally by counseling, advising the youth of expected conduct Section VII, Number 1, Procedure IV-A imposing a minor consequence. Discipline shall be ☒ ☐ ☐ accompanied by written documentation and a policy of review and appeal to a supervisor; and, (f) major rule violations and the discipline process shall ☒ ☐ ☐ be documented and require the following: (1) written notice of violation prior to a hearing; ☒ ☐ ☐ Section VII, Number 2, Procedure I-B (2) accommodations provided to youth with disabilities, limited literacy, and English language ☒ ☐ ☐ Section VII, Number 2, Policy I-B learners; (3) hearing by a person who is not a party to the ☒ ☐ ☐ Section VII, Number 2, Procedure I-D incident; (4) opportunity for the youth to be heard, present ☒ ☐ ☐ Section VII, Number 2, Procedure I-F evidence and testimony; (5) provision for youth to be assisted by staff in the ☒ ☐ ☐ Section VII, Number 2, Procedure I-F hearing process; (6) provision for administrative review. ☒ ☐ ☐ Section VII, Number 2, Procedure I-H 7716 Tuolumne MLRJDF PRO 23-24 69 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) violations that result in a removal from camp or commitment program, but not a return to court, will ☒ ☐ ☐ Section VII, Number 2, Procedure II-G follow the due process provisions in subsection (e) above. 1410 MANAGEMENT OF COMMUNICABLE DISEASES. Tuolumne County MLRJDF Section VIII, The health administrator/responsible physician, in Number 1: Management of Communicable cooperation with the facility administrator and the local Diseases health officer, shall develop written policies and ☒ ☐ ☐ procedures to address the identification, treatment, control and follow-up management of communicable This is a comprehensive policy outlining the diseases. The policies and procedures shall address, agency’s response to communicable but not be limited to: disease. Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 1 Intake Health screening procedures. MLRJDF COVID-19 Screening Form (a) Intake health screening procedures; ☒ ☐ ☐ Wellpath Coronavirus Supplemental Screening Form Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedures 7716 Tuolumne MLRJDF PRO 23-24 70 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 2: Identification of Relevant Symptoms. MLRJDF COVID-19 Screening Form MLRJDF Daily COVID-19 Screening Form (b) Identification of relevant symptoms; ☒ ☐ ☐ Wellpath Coronavirus Supplemental Screening Form Wellpath Patient Monitoring for Positive or Suspected COVID-19 Form Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedure #2 Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 3: Referral for Medical Evaluation Wellpath MLRJDF COVID-19 Outbreak (c) Referral for medical evaluation; ☒ ☐ ☐ Control Plan - Booking and Intake Procedure #5 Wellpath Nursing Triage for Complaints related to COVID-19 7716 Tuolumne MLRJDF PRO 23-24 71 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 4: Treatment Responsibilities during Detention Tuolumne County MLRJDF Section VIII, (d) Treatment responsibilities during detention; ☒ ☐ ☐ Number 1; Procedure I-C Wellpath MLRJDF COVID-19 Outbreak Control Plan - General Quarantine Procedures Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 5: Coordination with Public and Private Community Based resources for follow-up treatment. Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-G (e) Coordination with public and private community- ☒ ☐ ☐ Tuolumne County Public Health Referral based resources for follow-up treatment; Form Wellpath COVID-19 Discharge Instructions Wellpath COVID-19 Patient Education Wellpath COVID-19 Supplemental Discharge 7716 Tuolumne MLRJDF PRO 23-24 72 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 6: Applicable Reporting Requirements Tuolumne County MLRJDF Section VIII, (f) Applicable reporting requirements; and, ☒ ☐ ☐ Number 1; Procedure I-G Wellpath MLRJDF COVID-19 Outbreak Control Plan - Communication #3 Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 7: Strategies for Handling Disease Outbreaks (g) Strategies for handling disease outbreaks. ☒ ☐ ☐ Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-E and H Wellpath MLRJDF COVID-19 Outbreak Control Plan The policies and procedures shall be updated as necessary to reflect communicable disease priorities The agency works closely with Wellpath identified by the local health officer and currently staff and the local public health agency to recommended public health interventions. ☒ ☐ ☐ ensure proper protocols and processes are in place to address all COVID-19 youth. 1433 REQUESTS FOR HEALTH CARE SERVICES (EXCERPT) Section VIII, Number 12, Procedure I-C The health administrator, in cooperation with the facility administrator, shall develop policy and procedures to ☒ ☐ ☐ establish a daily routine for youth to convey requests for emergency and non-emergency medical, dental and behavioral/mental health care services. 1480 STANDARD FACILTY CLOTHING ISSUE The youth’s personal clothing, undergarments and Section X, Number 1 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: 7716 Tuolumne MLRJDF PRO 23-24 73 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Clothing is clean, reasonably fitted, durable, easily laundered, in good repair, and free of holes and tears. ☒ ☐ ☐ Section X, Number 1, Procedure I-B (b) The standard issue of climatically suitable clothing for youth shall consist of but not be limited to: ☒ ☐ ☐ (1) Socks and serviceable footwear; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 1 (2) Outer garments; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 2 and 3 (3) New non-disposable underwear which shall remain with the youth throughout their stay, and; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 4 (4) Undergarments, that are freshly laundered and free of stains, including tee shirts and bras. ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 5 (c) Clothing is laundered at the temperature required by local ordinances for the commercial laundries and dried Section X, Number 1, Procedure 1-D completely in a mechanical dryer or other laundry ☒ ☐ ☐ method approved by the local health officer. (d) Suitable clothing is issued to pregnant youth. ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 9 1482 CLOTHING EXCHANGE The facility administrator shall develop and implement Section X, Number 1, Procedure I written policies and site-specific procedures for the cleaning and scheduled exchange of clothing. Unless work, climatic conditions, or illness necessitates more ☒ ☐ ☐ frequent 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. 7716 Tuolumne MLRJDF PRO 23-24 74 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1484 CONTROL OF VERMIN IN YOUTH’S PERSONAL CLOTHING Section X, Number 2 There shall be written policies and site-specific procedures developed and implemented by the facility administrator to control the contamination and/or ☒ ☐ ☐ spread of vermin and ecto-parasites in all youth’s personal clothing. Infested clothing shall be cleaned or stored in a closed container so as to eradicate or stop the spread of the vermin. 1485 ISSUE OF PERSONAL CARE ITEMS There shall be written policies and site-specific Section X, Number 3, Procedure I-A procedures developed and implemented by the facility administrator for the availability of personal 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; (a) Toothbrush; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (b) Toothpaste; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (c) Soap; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (d) Comb; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (e) Shaving implements; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (f) Deodorant; ☒ ☐ ☐ Section X, Number 3, Procedure I-A 7716 Tuolumne MLRJDF PRO 23-24 75 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) Lotion; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (h) Shampoo; and, ☒ ☐ ☐ Section X, Number 3, Procedure I-A (i) Post-shower conditioning hair products. ☒ ☐ ☐ Section X, Number 3, Procedure I-A Youth shall not be required to share any personal care items listed in items (a) through (d). Liquid soap Section X, Number 3, Procedure I-A provided through a common dispenser is permitted. Youth shall not share disposable razors. Double edged Section X, Number 3, Procedure I-E safety razors, electric razors, and other shaving ☒ ☐ ☐ instruments capable of breaking the skin, when shared Section X, Number 3, Procedure I-G 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. 1486 PERSONAL HYGIENE There shall be written policies and site specific Section X, Number 3, Procedure I-B procedures developed and implemented by the facility administrator for showering/bathing and brushing of Section X, Number 3, Procedure I-C ☒ ☐ ☐ teeth. Youth shall be permitted to shower/bathe up on assignment to a housing unit and on a daily basis thereafter and given an opportunity to brush their teeth after each meal. 1487 SHAVING Youth shall have access to a razor daily, unless their Section X, Number 3, Procedure IV appearance must be maintained for reasons of identification in Court. All youth shall have equal ☒ ☐ ☐ opportunity to shave face and body hair. The facility administrator may suspend this requirement in relation to youth who are considered to be a danger to themselves or others. 1488 HAIR CARE SERVICES (EXCERPT) Hair care services shall be available in all juvenile Section X, Number 3, Procedure V facilities. Youth shall receive hair care services ☒ ☐ ☐ monthly. Equipment shall be cleaned and disinfected after each haircut or procedure, by a method approved by the State Board of Barbering and Cosmetology. 7716 Tuolumne MLRJDF PRO 23-24 76 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1500 STANDARD BEDDING AND LINEN ISSUE Clean laundered, suitable bedding and linens, in good Section XI, Number 1 repair, shall be provided for each youth entering a living ☒ ☐ ☐ area who is expected to remain overnight, shall include, but not be limited to: (a) One mattress or mattress-pillow combination which meets the requirements of Section 1502 of these ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 1 regulations; (b) One pillow and a pillow case unless provided for in (a) above; ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 1 (c) One mattress cover and a sheet or two sheets; ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 2 (d) One towel; and, ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 4 (e) One blanket or more, up on request ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 3 1501 BEDDING LINEN EXCHANGE The facility administrator shall develop and implement Section XI, Number 1, Procedure I site specific written policies and procedures for the scheduled exchange of laundered bedding and linen ☒ ☐ ☐ issued to each youth housed. Washable items such as sheets, mattress covers, pillow cases and towels shall be exchanged for clean replacement at least once each week. The covering blanket shall be cleaned or laundered once a month. ☒ ☐ ☐ Section XI, Number 1, Procedure I-E 7716 Tuolumne MLRJDF PRO 23-24 77 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1510 FACILITY SANITATION, SAFETY AND MAINTENANCE Section XII, Number 1 The facility administrator shall develop and implement written policies and site-specific procedures for the maintenance of an acceptable level of cleanliness, repair and safety throughout the facility. The plan shall provide for a regular schedule of housekeeping tasks, ☒ ☐ ☐ equipment, including restraint devices, and physical plant maintenance and inspections to identify and correct unsanitary or unsafe conditions or work practices in a timely manner. The use of chemicals shall be done in accordance to the product label and Safety Data Sheet which may include the use of Personal Protection Equipment (PPE). REVIEW OF NON REGULATORY REQUIREMENTS GRANT FUNDING OR CODE REFERENCE YES NO N/A P/P REFERENCE - COMMENTS JUVENILE PROBATION AND CAMPS FUNDING (JPCF) (Camps Only) The programs/services identified on the JPCF Camp Eligibility Form are being provided at the facility. ☒ ☐ ☐ (Refer to the JPCF Camp Eligibility Form) 208.5 WIC CONTACT BETWEEN PERSONS UNDER THE JUVENILE COURT AGES 19- 20 AND MINORS IN THE FACILITY The facility houses Juvenile Court Wards 19 years of ☒ ☐ ☐ age and older. The facility has been approved to hold persons under ☒ ☐ ☐ the juvenile court who are ages 19 through 21. The facility continues to comply with the requirements of 208.5 WIC (programming, capacity and security of ☒ ☐ ☐ the facility) as outlined in the county’s application. JUVENILE JUSTICE DELINQUENCY PREVENTION ACT MONITORING (JJDPA) WIC 206 SEPARATE FACILITIES FOR WIC 300 MINORS ☐ ☐ Dependent or neglected minors who are defined ☒ under Section 300 of the Welfare and Institutions Violation Code (WIC) are held only in non-secure, separate and segregated facilities. DETENTION OF STATUS OFFENDERS (WIC 601) AND FEDERAL MINORS ☐ ☒ ☐ Status Offenders (WIC 601) are held in the facility. Status Offenders (WIC 601) are kept separate from ☐ ☒ ☐ Juvenile Delinquents (WIC 602)? (WIC 207[d]). Violation 7716 Tuolumne MLRJDF PRO 23-24 78 A453 JUV PRO eff. 1/2019 (23-24).dot Federal Minors (ICE Holds or ORR Contract) are held ☐ ☒ ☐ in the facility. If yes to the above, the Monthly Report on the Detention of Status Offenders/Federal Minors is ☐ ☐ ☒ submitted to the BSCC. WIC 208 SEPARATION OF MINORS AND ADULT INMATES (JJDPA 42 USC 5633, Sec 223, State Plans (a)[12]) Are adult inmates held in the facility? (When a person ☐ ☒ ☐ in detention is proceeding through the adult court, AND that person is 18 years of age or older that person is an adult inmate.) If adult inmates are held, they are appropriately ☐ ☐ ☒ separated from minors. Violation Adult inmates from an adult facility (e.g. inmate ☐ ☒ workers or “Scared Straight” programs) are not ☐ allowed in the facility in a manner that allows contact Violation with minors. 7716 Tuolumne MLRJDF PRO 23-24 79 A453 JUV PRO eff. 1/2019 (23-24).dot JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7718 FACILITY NAME: Tuolumne County Steps to Success (S2S) FACILITY TYPE: Camp Mother Lode Regional Juvenile Detention Facility PERSON(S) INTERVIEWED: Dan Hawks, Chief Probation Officer; Annie Hockett, Assistant Chief Probation Officer; Christie Schultze, Supervising Probation Officer; Will Nielsen, Supervising Probation Officer; Ashley Champeaux, Teacher - Gold Ridge School; Kayla Rolfe, Transition Specialist, TCSOS; Cheyne Turberville, RN Wellpath Health Services - Juvenile Facility; Matt Horton, Juvenile Corrections Officer II; Youth: Jacob Z, age 17; Zach D, age 17; Blanca, age 17. FIELD REPRESENTATIVE: Elizabeth Gong DATE: November 7-8, 2023 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1313 COUNTY INSPECTION AND EVALUATION OF BUILDING AND GROUNDS September 6, 2022 On an annual basis, or as otherwise required by law, July 21, 2023 each juvenile facility administrator shall obtain a ☒ ☐ ☐ documented inspection and evaluation from the following: (a) county building inspector or person designated by the Board of Supervisors to approve building safety; (b) fire authority having jurisdiction, including a fire clearance as required by Health and Safety Code Section ☒ ☐ ☐ September 2, 2022 13146.1(a) and (b); July 31, 2023 (c) local health officer, inspection in accordance with Health and Safety Code Section 101045; 2022: Environmental Health: October 21, 2022 Medical/Mental Health: October 24, 2022 Nutritional Health: November 22, 2022 ☒ ☐ ☐ 2023: Environmental Health: October 24, 2023 Medical/Mental Health: November 2, 2023 Nutritional Health: October 23, 2023 (d) county superintendent of schools on the adequacy of educational services and facilities as required in Section ☒ ☐ ☐ July 28, 2022 1370; July 27, 2023 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. 7718 Tuolumne Steps to Success PRO 23-24 1 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) juvenile court as required by Section 209 of the Welfare and Institutions Code; and, ☒ ☐ ☐ May 27, 2021 December 8, 2022 (f) the Juvenile Justice Commission as required by Section 229 of the Welfare and Institutions Code or ☒ ☐ ☐ February 25, 2022 Probation Commission as required by Section 240 of the February 3, 2023 Welfare and Institutions Code. 1320 APPOINTMENT AND QUALIFICATIONS Section III, Number 1, Procedure I-A BSCC Note: Compliance with this section is determined by receipt of the Chief Probation Officer’s certification The elements of this regulation are addressed letter confirming that all elements of regulation are met. in a memorandum completed on March 3, 2023, by Chief Probation Officer Dan Hawks. (a) Appointment ☒ ☐ ☐ In each juvenile facility there shall be a superintendent, director or facility manager in charge of its program and employees. Such superintendent, director, facility manager and other employees of the facility shall be appointed by the facility administrator pursuant to applicable provisions of law. (b) Employee Qualifications Each facility shall: Section III, Number 1, Procedure II (1) recruit and hire employees who possess ☒ ☐ ☐ Section III, Number 1, Procedure II-1 knowledge, skills and abilities appropriate to their job classification and duties in accordance with applicable civil service or merit system rules; (2) require a medical evaluation and physical examination including tuberculosis screening test and Section III, Number 1, Procedure II-2 evaluation for immunity to contagious illnesses of ☒ ☐ ☐ childhood (i.e., diphtheria, rubeola, rubella, and mumps); (3) adhere to the minimum standards for the selection and training requirements adopted by the Board ☒ ☐ ☐ Section III, Number 1, Procedure II-3 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in Section III, Number 1, Procedure II-4 ☒ ☐ ☐ accordance with Section 1031 of the Government Code. (c) Contract personnel, volunteers, and other non- employees of the facility, who may be present at the Section III, Number 1, Procedure II-5 facility, shall have such clearance and qualifications as ☒ ☐ ☐ may be required by law, and their presence at the facility shall be subject to the approval and control of the facility manager. 7718 Tuolumne Steps to Success PRO 23-24 2 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1321 STAFFING Each juvenile facility shall: Section III, Number 2 (a) have an adequate number of personnel sufficient to Section III, Number 2, Procedure I-A carry out the overall facility operation and its programming, to provide for safety and security of youth and staff, and meet established standards and The facility has self-capped their population at regulations; 16 youth, applying a staffing ratio of 1:8. ☒ ☐ ☐ The facility currently has 2 Supervising Juvenile Corrections Officers (JCO). There are 4 Senior JCO’s plus one relief Senior (Extra Help), and 8-line JCO staff, with two other staff in background to fill the vacancies. A Field Probation Officer is assigned to the facility to assist with the Steps 2 Success Camp Program and Summit SYTF Program. (b) ensure that no required services shall be denied because of insufficient numbers of staff on duty absent ☒ ☐ ☐ Section III, Number 2, Procedure I-A exigent circumstances; (c) have a sufficient number of supervisory level staff to ensure adequate supervision of all staff members; ☒ ☐ ☐ Section III, Number 2, Procedure I-B (d) have a clearly identified person on duty at all times who is responsible for operations and activities and has Section III, Number 2, Procedure I-C completed the Juvenile Corrections Officer Core Course and PC 832 training; ☒ ☐ ☐ There is a Supervisor, Senior JCO, or designated lead staff on duty and in charge of the facility when the Superintendent is not on duty. (e) have at least one staff member present on each living unit whenever there are youth in the living unit; ☒ ☐ ☐ Section III, Number 2, Procedure I-D 7718 Tuolumne Steps to Success PRO 23-24 3 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) have sufficient food service personnel relative to the number and security of living units, including staff Section III, Number 2, Procedure I-E 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 Meals are provided by Summit Foods through records; or, a facility may serve food that meets nutritional the Tuolumne County Jail and served by standards prepared by an outside source; serve-safe certified JCO staff and/or youth. (g) have sufficient administrative, clerical, recreational, medical, dental, mental health, building maintenance, Section III, Number 2, Procedure I-F 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, Support staff and ancillary personnel are not part of youth supervision staff. (h) assign sufficient youth supervision staff to provide continuous wide awake supervision of youth, subject to Section III, Number 2, Procedure I-G temporary variations in staff assignments to meet special program needs. Staffing shall be in compliance with a minimum youth-staff ratio for the following facility types: ☒ ☐ ☐ The facility has made the decision to staff at a 1:8 ratio. (1) Juvenile Halls (A) during the hours that youth are awake, one ☐ ☐ ☒ wide-awake youth supervision staff member on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number of youth in detention, unless an ☐ ☐ ☒ arrangement has been made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty who is the same gender as youth housed in ☐ ☐ ☒ the facility. (E) personnel with primary responsibility for other duties such as administration, supervision of personnel, academic or trade instruction, clerical, ☐ ☐ ☒ kitchen or maintenance shall not be classified as youth supervision staff positions. 7718 Tuolumne Steps to Success PRO 23-24 4 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) Special Purpose Juvenile Halls (A) during hours that youth are awake, one wide- ☐ ☐ ☒ awake youth supervision staff member on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number of youth in detention, unless an ☐ ☐ ☒ arrangement has been made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty who is the same gender as youth housed in ☐ ☐ ☒ the facility. (E) personnel with primary responsibility for other duties such as administration, supervision of personnel, academic or trade instruction, clerical, ☐ ☐ ☒ kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (A) during the hours that youth are awake, one Section III, Number 2, I-H wide-awake youth supervision staff member on duty for each 15 youth in the camp population; ☒ ☐ ☐ The facility staffs the facility at 1:8 during waking hours. (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake Section III, Number 2, I-I youth supervision staff member on duty for each 30 youth present in the facility; ☒ ☐ ☐ The facility staffs the facility at a 1:16 ratio during sleeping hours. (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the Section III, Number 2, J number of youth in residence, unless ☒ ☐ ☐ arrangements have been made for backup support services which allow for immediate response to emergencies; 7718 Tuolumne Steps to Success PRO 23-24 5 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (D) at least one youth supervision staff member on duty who is the same gender as youth housed in ☒ ☐ ☐ Section III, Number 2, I-K the facility; (E) in addition to the minimum staff to youth ratio required in (h)(3)(A)-(B), consideration shall be The facility has dedicated five beds within the given to the size, design, and location of the camp; JH unit as Camp beds for the Steps to types of youth committed to the camp; and the ☒ ☐ ☐ Success Program. The physical plant is within function of the camp in determining the level of the more restrictive staffing ratios established supervision necessary to maintain the safety and by policy, 1:8. welfare of youth and staff; (F) personnel with primary responsibility for other duties such as administration, supervision of Section III, Number 2, I-F personnel, academic or trade instruction, clerical, farm, forestry, kitchen or maintenance shall not be ☒ ☐ ☐ classified as youth supervision staff positions. Only JCO staff assigned to the living units supervise youth in detention. 1322 YOUTH SUPERVISION STAFF ORIENTATION AND TRAINING Section III, Number 4, Procedure I-A (a) Prior to assuming any responsibilities each youth supervision staff member shall be properly oriented to Section III, Number 4, Procedure I-B their duties, including: Section III, Number 4, Procedure I-B, 1 (1) youth supervision duties; Section III, Number 4, Procedure I-C Section III, Number 4, Procedure I-D The agency spends three weeks to train to specific facility responsibilities and to ensure ☒ ☐ ☐ they are ready for all youth supervision duties. A Training Checklist Sign-Off is completed by the staff and trainer. The facility administration has implemented a curriculum ensuring staff and ancillary personnel working with and/or supervising youth are aware of their role and responsibilities. We reviewed the training checklists for the 3 newly hired JCO’s and found the curriculum within regulatory standards. (2) scope of decisions they shall make; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 2 7718 Tuolumne Steps to Success PRO 23-24 6 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (3) the identity of their supervisor; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 3 (4) the identity of persons who are responsible to them; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 4 (5) persons to contact for decisions that are beyond their responsibility; and ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 5 (6) ethical responsibilities. ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 6 (b) Prior to assuming any responsibility for the supervision of youth, each youth supervision staff Section III, Number 4, Procedure I-A member shall receive a minimum of 40 hours of facility- specific orientation, including: The facility has a detailed staff orientation which includes internal training by a ‘Field ☒ ☐ ☐ Training Officer’ mentoring and training new staff in facility operations. The trainer and staff initial a checklist after each component, including many areas which exceed T15 requirements. (1) individual and group supervision techniques; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 2 (2) regulations and policies relating to discipline and rights of youth pursuant to law and the provisions of ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 3 this chapter; (3) basic health, sanitation and safety measures; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 8 (4) suicide prevention and response to suicide ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 9 attempts 7718 Tuolumne Steps to Success PRO 23-24 7 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) policies regarding use of force, de-escalation techniques, chemical agents, mechanical and ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 4 physical restraints; (6) review of policies and procedures referencing ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 5 trauma and trauma-informed approaches; Section III, Number 4, Procedure I-C, 6 (7) procedures to follow in the event of emergencies; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 7 (8) routine security measures, including facility ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 13 perimeter and grounds; Section III, Number 4, Procedure I-C, 9 Section III, Number 4, Procedure I-C, 10 There is a TCBH Case Manager assigned to the facility who designates county BH Clinicians to complete groups and individual counseling for in-custody youth. The facility Superintendent is a Licensed Clinician and (9) crisis intervention and mental health referrals to provides Crisis Counseling if BH staff are not ☒ ☐ ☐ mental health services; on site. We were unable to meet with any BH Clinicians but did observe an MDT meeting for a youth and the BH Case manager was on site. The facility Superintendent confirmed TCBH staff are responsive to youth needs. Interviews with youth also indicated they receive services as needed from their ‘therapist.’ (10) documentation; and ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 11 7718 Tuolumne Steps to Success PRO 23-24 8 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (11) fire/life safety training ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 12 (c) Prior to assuming sole supervision of youth, each youth supervision staff member shall successfully Section III, Number 4, Procedure I-B complete the requirements of the Juvenile Corrections Officer Core Course pursuant to Penal Code Section 6035. Of the current Senior and line JCO’s responsible for youth supervision, all 10 are ☒ ☐ ☐ core-trained. The agency has two vacancies with both positions in background. There are two extra-help line staff, one extra help senior, and a DPO that assist in covering necessary shifts. (d) Prior to exercising the powers of a peace officer youth supervision staff shall successfully complete training Section III, Number 4, Procedure I-C pursuant to Section 830 et seq. of the Penal Code. ☒ ☐ ☐ All 10 youth supervision staff and both Supervisors have completed PC 830. 1323 FIRE AND LIFE SAFETY Whenever there is a youth in a juvenile facility, there shall Section III, Number 22, Procedure I-A be at least one wide awake person on duty at all times who meets the training standards established by the Board for general fire and life safety which relate ☒ ☐ ☐ All cored youth supervision staff and specifically to the facility. Supervisors received Fire and Life Safety training in JCO Core. 1324 POLICY AND PROCEDURES MANUAL All facility administrators shall develop, publish, and Section III, Number 23, Procedure I implement a manual of written policies and procedures that address, at a minimum, all regulations that are applicable to the facility. Such a manual shall be made The facility Policy and Procedure Manual was available to all employees, reviewed by all employees, ☒ ☐ ☐ last reviewed on July 30, 2023. Facility staff and shall be administratively reviewed at a minimum are required to read the manual each year, every two years, and updated, as necessary. Those signing a document kept in their personnel file records relating to the standards and requirements set to verify compliance for this policy forth in these regulations shall be accessible to the Board requirement. on request. The manual shall include: 7718 Tuolumne Steps to Success PRO 23-24 9 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) table of organization, including channels of communications and a description of job classifications; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 1 (b) responsibility of the probation department, purpose of programs, relationship to the juvenile court, the Juvenile Section III, Number 23, Procedure II-B, 2 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; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 3 (d) initial orientation and training program for employees; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 4 (e) initial orientation, including safety and security issues and anti-discrimination policies, for support staff, contract ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 5 employees, school, mental/behavioral health and medical staff, program providers and volunteers; (f) maintenance of record-keeping, statistics and communication system to ensure: ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6 (1) efficient operation of the juvenile facility; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-a (2) legal and proper care of youth; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-b (3) maintenance of individual youth's records; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-c (4) supply of information to the juvenile court and ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-d those authorized by the court or by the law; and, 7718 Tuolumne Steps to Success PRO 23-24 10 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) release of information regarding youth. ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-e (g) ethical responsibilities; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-f (h) trauma-informed approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 7 (i) culturally responsive approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 8 (j) gender responsive approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 9 (k) a non-discrimination provision that provides that all youth within the facility shall have fair and equal access Section III, Number 23, Procedure II-B, 10 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, ☒ ☐ ☐ The Non-Discrimination Policy is in the Youth national origin, immigration status, color, religion, gender, Handbook and in the procedures for sexual orientation, gender identity, gender expression, admission, classification, and due process. It mental or physical disability, or HIV status, including is also posted in the living unit. 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 Section III, Number 23, Procedure II-B, 11 and ammunition, where applicable; ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 8 (m) establishment of procedures for collection of Medi- Cal eligibility information and enrollment of eligible youth; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 12 and, 7718 Tuolumne Steps to Success PRO 23-24 11 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (n) establishment of a policy that prohibits all forms of sexual abuse, sexual assault and sexual harassment. Section III, Number 23, Procedure II-B, 13 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 ☒ ☐ ☐ The facility has a comprehensive PREA third party. policy, including staffing the facility at 1:8 and 1:16 based on a self-imposed cap of population. 1325 FIRE SAFETY PLAN The facility administrator shall consult with the local fire Section III, Chapter 22 department having jurisdiction over the facility, or with the State Fire Marshal, in developing a plan for fire safety ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 1 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; (b) monthly fire and life safety inspections by facility staff with two-year retention of the inspection record; Section III, Number 22, Procedure IV-A, 2 The facility has an assigned safety officer that conducts these inspections monthly. We ☒ ☐ ☐ reviewed all the monthly inspections from October 2022 to October 2023. The form and inspection process for recording deficiencies or need for repair are well-documented and addressed by maintenance if necessary. (c) fire prevention inspections as required by Health and Safety Code Section 13146.1(a) and (b); ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 3 (d) an evacuation plan; ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 4 7718 Tuolumne Steps to Success PRO 23-24 12 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) documented fire drills not less than quarterly; Section III, Number 22, Procedure IV-A, 5 ☒ ☐ ☐ We reviewed fire drills from October 2022 to October 2023. The agency completes drills more frequently than required in regulation. (f) a written plan for the emergency housing of youth in the case of fire; and, Section III, Number 22, Procedure IV-A, 6 Section III, Number 22, Procedure IX-C, 1-c ☒ ☐ ☐ The facility has an agreement in effect for Stanislaus County Probation to accept all youth detained in the event of an emergency evacuation. (g) development of a fire suppression pre-plan in cooperation with the local fire department. ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 7 7718 Tuolumne Steps to Success PRO 23-24 13 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1326 SECURITY REVIEW Each facility administrator shall develop policies and Section III, Number 24 procedures to annually review, evaluate, and document security of the facility. The review and evaluation shall Section III, Number 33 Security Procedures include internal and external security, including, but not Section III, Number 34 Key Control limited to, key control, equipment, and staff training. Section III, Number 22, Procedure III-E Annual Review A Security Review memo was completed by Supervisor William Neilsen on March 20, ☒ ☐ ☐ 2023, outlining the security practices and needs for the facility. The memo identified the most current issues, the need to better secure the stairwell leading outside from the upper tier, and updating cameras, are part of their SB 823 Infrastructure Grant dollars. County Contractors were on-site during our inspection and have a timeline to complete the SB 823 projects by year-end. 1327 EMERGENCY PROCEDURES The facility administrator shall develop facility-specific Section III, Number 22 policies and procedures for emergencies that shall include, but not be limited to: ☒ ☐ ☐ An emergency procedure memo was completed by Assistant Chief Probation Officer/Facility Superintendent Annie Hockett on March 1, 2023. Section III, Number 25 Hostages (a) escape, disturbances, and the taking of hostages; ☒ ☐ ☐ Section III, Number 26 Escapes Section III, Number 32 Firearms in the Facility 7718 Tuolumne Steps to Success PRO 23-24 14 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section III, Number 22, X Civil Disturbance, Active Shooter, Terrorist Attack (b) civil disturbance, active shooter and terrorist ☒ ☐ ☐ attack; Section III, Number 28 Bomb Threat Section III, Number 30 Riot Control Section III, Number 22 Section III, Number 27 Hazard Mat Response (c) fire and natural disasters; ☒ ☐ ☐ Section III, Number 22, Procedure VIII Earthquake Section III, Number 22, Procedure IX Flood (d) periodic testing of emergency equipment; ☒ ☐ ☐ Section III, Number 29 Power Failure Section III, Number 22, Procedure IV-A, 4 (e) emergency evacuation of the facility; and ☒ ☐ ☐ Section III, Number 22, Procedure XI Evacuation Section III, Number 22, Procedure IV-C Initial Orientation (f) a program to provide all youth supervision staff ☒ ☐ ☐ with an annual review of emergency procedures. Facility staff are required to read the facility policy manual each year, which outlines all Emergency Procedures in all situations. 7718 Tuolumne Steps to Success PRO 23-24 15 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1328 SAFETY CHECKS The facility administrator shall develop and implement Section III, Number 31 Safety Checks policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, at random or varied intervals during hours when youth The facility has implemented a better are asleep or when youth are in their rooms, confined in electronic safety check system and completes holding cells or confined to their bed in a dormitory. regular audits to ensure the checks are Supervision is not replaced, but may be supplemented random and varied. Audits are done weekly by, an audio/visual electronic surveillance system with a randomizer program and video review designed to detect overt, aggressive or assaultive to capture why the check was late. behavior and to summon aid in emergencies. All safety checks shall be documented with the actual time the check is completed. The system allows for deactivation when youth are “all out” and no check is needed. If ☒ ☐ ☐ there is a late check, facility administration is notified and staff are required to make an entry in the unit log the reason for the late check. We reviewed safety check audits for the months of October 2022 and January and July 2023. We found few late checks out of over 10,000 checks required in the 3-month period. The audit process in place is effective and any consistent patterns are handled administratively, per policy. 7718 Tuolumne Steps to Success PRO 23-24 16 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN The facility administrator, in collaboration with the Section III, Number 36 healthcare and behavioral/mental health administrators, shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. The Suicide Prevention Plan and policy are a The plan shall consider the needs of youth experiencing collaboration with WellPath Medical and past or current trauma. Suicide prevention responses Tuolumne County Behavioral Health, which shall be respectful and in the least invasive manner includes very specific roles and consistent with the level of suicide risk. The plan shall responsibilities for medical, behavior health, include the following elements: and probation facility staff. The facility policy and annual training in suicide prevention are comprehensive and inclusive of all elements in regulation. The agency has an on-site Behavior Health Case Manager and multiple Clinicians with the ☒ ☐ ☐ agency to address and see youth as necessary. ACPO Annie Hockett continues to provide crisis counseling when necessary. There have not been any suicide attempts this cycle, however, there have been five incidents to place a youth on safety watch status due to ideation or suicidal gestures, three involving one youth. We reviewed two incident reports and found the agency compliant. Behavior Health is more involved in individual and follow-up for these behaviors but the facility Superintendent, who is a licensed Clinician, provides most of the immediate crisis intervention to diffuse and address these behaviors. (a) Suicide prevention training as required in Section 1322, Youth Supervision Staff Orientation, and Training ☒ ☐ ☐ Section III, Number 36, Procedure I-B and the Juvenile Corrections Officer Core Course. 7718 Tuolumne Steps to Success PRO 23-24 17 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Screening, Identification Assessment and Precautionary Protocols Section III, Number 36, Procedure I-C (1) All youth shall be screened for risk of suicide at intake and as needed during detention. Section III, Number 36, Procedure I-D The facility uses the MAYSI prior to housing youth at intake, which assesses the youth’s likeliness to have suicidal behaviors or ideations while in detention. The tool provides a caution or warning status which places a youth, per policy, on a special watch pending review and being seen by Behavior Health. ☒ ☐ ☐ The agency also has adapted the SAFE-T Assessment to identify certain suicide behaviors, which is implemented by Behavior Health. Behavior Health has a Case Manager and assigned clinicians to see youth on-site, a positive change from last cycle. Superintendent Annie Hockett continues to provide crisis interventions when TCBH is not on-site or available to respond immediately. (2) All youth supervision staff who perform intake processes shall be trained in screening youth for risk Section III, Number 36, Procedure I-B of suicide. ☒ ☐ ☐ The agency provides eight hours of initial training and an annual 2-hour refresher training for all youth supervision staff. (3) All youth who have been identified during the intake screening process to be at risk of suicide shall ☒ ☐ ☐ Section III, Number 36, Procedure I-D be referred to behavioral/mental health staff for a suicide risk assessment. (4) Precautionary protocols shall be developed to ensure the youth’s safety pending the Section III, Number 36, Procedure II behavioral/mental health assessment. ☒ ☐ ☐ Youth are placed on a Safety Watch pending review or being seen by a BH or MH personnel. 7718 Tuolumne Steps to Success PRO 23-24 18 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Referral process to behavioral/mental health staff for assessment and/or services. Section III, Number 36, Procedure II-A ☒ ☐ ☐ Section III, Number 36, Procedure II-B (d) Procedures for monitoring of youth identified at risk for suicide. Section III, Number 36, Procedure II ☒ ☐ ☐ The facility proactively provides direct visual supervision of all youth who are identified as at risk of actively attempting or verbally discussing suicide. (e) Safety Interventions (1) Procedures to address intervention protocols for ☒ ☐ ☐ youth identified at risk for suicide which may include, Section III, Number 36, Procedure II-C but are not limited to: (A) Housing consideration Section III, Number 36, Procedure II-C, 1-3 ☒ ☐ ☐ The facility has a comprehensive suicide risk/needs assessment as well as the MAYSI Screening tool utilized for each intake. (B) Treatment strategies including trauma- informed approaches Section III, Number 36, Procedure III-G The facility provides treatment strategies ☒ ☐ ☐ based on a training curriculum and policy, which references how staff address and supervise youth at risk, defined by the assessment. 7718 Tuolumne Steps to Success PRO 23-24 19 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) Procedures to instruct youth supervision staff how to respond to youth who exhibit suicidal Section III, Number 36, Procedure II-D behaviors. Each of the incidents we reviewed revealed compliance with regulation and policy, as well ☒ ☐ ☐ as a vested interest in helping the youth. The forms, process, and administrative involvement/review are debriefed and used as a training tool for staff. Facility staff are very aware of the risks and responses of suicidal behavior based on extensive training. (f) Communication (1) The intake process shall include communication Section III, Number 36, Procedure I-C with the arresting officer and family guardians regarding the youth’s past or present suicidal Section III, Number 36, Procedure I-E ideations, behaviors or attempts. ☒ ☐ ☐ The admission forms include several referenced areas that include communication with the officer and family. (2) Procedures for clear and current information sharing about youth at risk for suicide with youth ☒ ☐ ☐ Section III, Number 36, Procedure I-E supervision, healthcare, and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Suicides or Attempts Section III, Number 26, Procedure III-H (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 ☒ ☐ ☐ Section III, Number 36, Procedure III-G staff. (3) Process for a debriefing event with affected youth. ☒ ☐ ☐ Section III, Number 36, Procedure III-G 7718 Tuolumne Steps to Success PRO 23-24 20 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Documentation (1) Documentation processes shall be developed to ☒ ☐ ☐ Section III, Number 36, Procedure III-F ensure compliance with this regulation Youth identified at risk for suicide shall not be denied the opportunity to participate in facility programs, services Section III, Number 36, Procedure II-G and activities which are available to other non-suicidal youth, unless deemed necessary for the safety of the Section III, Number 36, Procedure II-I 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 The facility staff work within policy to identify facility manager. the youth’s specific housing needs, programming elements, and engagement with other youth. 1340 REPORTING OF LEGAL ACTIONS Each facility shall submit to the Board a letter of Section IV, Number 1 notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities responsible for juvenile facility operation. ☒ ☐ ☐ There are no pending legal actions against the Tuolumne County Motherlode Regional Juvenile Detention Facility. 1341 DEATH AND SERIOUS ILLNESS OR INJURY OF A YOUTH WHILE DETAINED Section IV, Number 3, I-F (1) Death of a Youth. (a) The facility administrator, in cooperation with Section IV, Number 3, I-A the health administrator and the behavioral/mental health director, shall develop written policies and ☒ ☐ ☐ procedures in the event of the death of a youth while detained, which include notifications to necessary parties, which may include the Juvenile Court, the parent, guardian or person standing in loco parentis and the youth’s attorney of record. (b) The health administrator, in cooperation with the facility administrator, shall develop written Section IV, Number 3, I-B policies and procedures to assure there is a medical and operational review of every in-custody death of Section IV, Number 3, I-C a youth. The review team shall include the facility ☒ ☐ ☐ administrator and/or facility manager, the health administrator, the responsible physician and other health care and supervision staff who are relevant to the incident. 7718 Tuolumne Steps to Success PRO 23-24 21 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) The administrator of the facility shall provide to the Board a copy of the report submitted to the Section IV, Number 3, I-D Attorney General under Government Code Section ☒ ☐ ☐ 12525. A copy of the report shall be submitted to the Board within 10 calendar days after the death. (d) Upon receipt of a report of the death of a youth from the administrator, the Board may within 30 Section IV, Number 3, I-E calendar days inspect and evaluate the juvenile facility, jail, lockup or court holding facility pursuant ☒ ☐ ☐ to the provisions of this subchapter. Any inquiry made by the Board shall be limited to the standards and requirements set forth in these regulations. (2) Serious Illness or Injury of Youth. (a) The facility administrator, in cooperation with Section IV, Number 3, I-H the health administrator, shall develop written policies and procedures for the notification to ☒ ☐ ☐ necessary parties, which may include the Juvenile Court, the parent, guardian or person standing in loco parentis and the youth’s attorney of record in the case of a serious illness or injury of a youth. 1342 POPULATION ACCOUNTING Each juvenile facility shall submit required population ☒ ☐ ☐ Section IV, Number 4 and profile survey reports to the Board within 10 working days after the end of each reporting period, in a format to be provided by the Board. 1343 JUVENILE FACILITY CAPACITY (EXCERPT) When the number of youth detained in a living unit of a Section IV, Number 5 juvenile facility exceeds its rated capacity for more than ☒ ☐ ☐ fifteen (15) calendar days in a month, the facility administrator shall provide a crowding report to the Board in a format provided by the Board. 7718 Tuolumne Steps to Success PRO 23-24 22 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1350 ADMITTANCE PROCEDURES The facility administrator shall develop and implement Section V, Number 1 Purpose written policies and procedures for admittance of youth that emphasize respectful and humane engagement Section V, Number 1-C with youth, and reflect that the admission process may be traumatic to youth who may have already experienced trauma. Policies shall be trauma-informed, The agency has a comprehensive intake culturally relevant, and responsive to the language and process for youth and includes an “Intake literacy needs of youth. In addition to the requirements Checklist” to ensure all procedural elements of Sections 1324 and 1430 of these regulations: are met. The facility only accepts youth identified with risks to community safety or themselves, as screened from the Detention Risk Assessment Instrument (DRAI), the MAYSI, and an internal risk/needs screening tool. ☒ ☐ ☐ We reviewed 10 comprehensive intake packets that included the checklist; the Intake Health Screening; Property Inventory; the Youth Strengthening Admissions Assessment (Trauma, emotional, risks and needs); PREA Acknowledgment; Language and Gender Preference Forms; Admission Report; Consent for Medical Treatment; Dental Permission Slip; and MAYSI/DRAI Assessments. The process is inclusive of information to assist staff and agency partners for youth care while in custody. The facility is a one-unit living unit so there are no further processes when a youth is committed to the S2S program. (a) the admittance process shall include: (1) Access to two free phone calls within one hour of ☒ ☐ ☐ Section V, Number 1, Procedure I-S admittance in accordance with the provisions of Welfare and Institution Code Section 627; (2) Offer of a shower; ☒ ☐ ☐ Section V, Number 1, Procedure I-M Section V, Number 1, Procedure I-L (3) Documented secure storage of personal ☒ ☐ ☐ belongings; Section V, Number IV 7718 Tuolumne Steps to Success PRO 23-24 23 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) Offer of food upon arrival; ☒ ☐ ☐ Section V, Number 1, Procedure I-M (5) Screening for physical and behavioral health and safety issues, intellectual or developmental ☒ ☐ ☐ Section V, Number 1, Procedure I-F disabilities; (6) Screening for physical and developmental disabilities in accordance with Sections 1329, 1413, ☒ ☐ ☐ Section V, Number1, Procedure I-C and 1430 of these regulations; (7) Contact with Regional Center for the Developmentally Disabled for youth that are Section V, Number 1, Procedure I-D suspected of or identified as having a ☒ ☐ ☐ developmental disability, pursuant to Section 1413; and, (8) Procedures consistent with Section 1352.5. ☒ ☐ ☐ Section V, Number 6 (b) juvenile hall administrators shall establish written criteria for detention that considers the least restrictive Section V, Number 1, Procedure I-III environment. ☒ ☐ ☐ The facility has specific criteria for detention, which allows for an override if justified. (c) juvenile camps and post-dispositional programs in juvenile halls shall develop policies and procedures that Section V, Number I-N advise the youth of the estimated length of stay, inform ☒ ☐ ☐ them of program guidelines and provide written screening criteria for inclusion and exclusion from the program. (d) juvenile halls shall develop policies and procedures that advise any committed youth of the estimated length ☒ ☐ ☐ Section V, Number I-N of his/her stay. 7718 Tuolumne Steps to Success PRO 23-24 24 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1350.5 SCREENING FOR THE RISK OF SEXUAL ABUSE Section V, Number 6 The facility administrator shall develop and implement written policies and procedures to reduce the risk of sexual abuse by or upon youth. The policy shall require The facility developed a tool, the Youth facility staff to assess each youth within 72 hours of ☒ ☐ ☐ Strengthening Admissions Assessment, admission based on the following information: within their classification screening instrument to address youth who are potential perpetrators or victims of sexual assault or abuse. (a) Prior sexual victimization or abusiveness; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (b) Gender nonconforming appearance or manner; or identification as lesbian, gay or bisexual, transgender, ☒ ☐ ☐ Section V, Number 6, Procedure I-B queer or intersex, and whether the youth may, therefore, be vulnerable to sexual abuse; (c) Current charges and offense history; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (d) Age; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (e) Level of emotional and cognitive development; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (f) Physical size and stature; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (g) Mental illness or mental disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (h) Intellectual or developmental disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B 7718 Tuolumne Steps to Success PRO 23-24 25 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (i) Physical disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (j) The youth’s perception of vulnerability; and, ☒ ☐ ☐ Section V, Number 6, Procedure I-B (k) Any other specific information about the individual youth that may indicate heightened needs for The Classification/Youth Housing Screening supervision, additional safety precautions, or separation tool, and the Youth Strengthening Admissions from certain other youth. Assessment, were developed in coordination ☒ ☐ ☐ with BH to establish and identify information which could or would assist in all safety elements. Staff shall ascertain this information through conversations with the youth during the admittance Section V, Number 6, Procedure I-A process, medical and behavioral health screenings; during classification assessments; and by reviewing court records, case files, facility behavioral records, and ☒ ☐ ☐ other relevant documentation from the youth’s files. The admission risk/needs assessment is used to assist in classification of all admitted youth. The facility administrator shall implement appropriate controls on the dissemination of information within the Section V, Number 6, Policy I-B facility relative to responses received pursuant to this ☒ ☐ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other youth. 7718 Tuolumne Steps to Success PRO 23-24 26 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1351 RELEASE PROCEDURES The facility administrator shall develop and implement Section V, Number 7 written policies and procedures for release of youth from custody which provide for: The agency conducts weekly Multi- Disciplinary Team meetings with the Behavior Health Case Manager, Wellpath Medical staff, and the on-site teaching staff prior to release and during the youth’s stay. Transition planning and ongoing services in the community are addressed. The meetings continue to occur weekly for detention and commitment youth. ☒ ☐ ☐ We reviewed numerous release documents indicating compliance of all elements related to the release process. While on-site, we attended a MDT for a youth soon to be released. There were 13 different attendees for youth transition services, including the Office of Education, Behavior Health, Wellpath staff, Probation officers and youth supervision staff, both Facility Supervisors, and the facility Superintendent. (a) verification of identity/release papers; ☒ ☐ ☐ Section V, Number 7, Procedure I-A (b) return of personal clothing and valuables; ☒ ☐ ☐ Section V, Number 7, Procedure I-F (c) notification to the youth's parents or guardian; ☒ ☐ ☐ Section V, Number 7, Procedure I-D (d) notification to the facility health care provider in accordance with Sections 1408 and 1437 of these ☒ ☐ ☐ Section V, Number 7, Procedure I-C regulations, for coordination with outside agencies; and, (e) notification of school staff; ☒ ☐ ☐ Section V, Number 7, Procedure I-H 7718 Tuolumne Steps to Success PRO 23-24 27 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) notification of facility mental health personnel. ☒ ☐ ☐ Section V, Number 7, Procedure I-G The facility administrator shall develop and implement policies and procedures for post-disposition youth to Section V, Number 7, Procedure I-A coordinate the provision of transitional and reentry ☒ ☐ ☐ services including, but not limited to, medical and behavioral health, education, probation supervision and community-based services. The facility administrator shall develop and implement written policies and procedures for the furlough of youth The facility does not furlough youth from from custody. ☒ ☐ ☐ custody. 1352 CLASSIFICATION The facility administrator shall develop and implement Section V, Number 9 written policies and procedures on classification of youth ☒ ☐ ☐ for the purpose of determining housing placement in the facility. Such procedures shall: (a) provide for the safety of the youth, other youth, facility staff, and the public by placing youth in the Section V, Number 9, Procedure I-A appropriate, least restrictive housing and program ☒ ☐ ☐ settings. Housing assignments shall consider the need for single, double or dormitory assignment or location within the dormitory; (b) consider facility populations and physical design of the facility; ☒ ☐ ☐ Section V, Number 9, Procedure I-A 7718 Tuolumne Steps to Success PRO 23-24 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) provide that a youth shall be classified upon admittance to the facility; classification factors shall Section V, Number 9, Procedure I-B include, but not be limited to: age, maturity, sophistication, emotional stability, program needs, legal Section V, Number 9, Procedure C-1 to 12 status, public safety considerations, medical/mental health considerations, gender and gender identity of the youth; The Classification/Youth Housing Screening Tool and the Youth Strengthening Admissions Assessment continue to be used to evaluate a youth’s classification needs. The facility has one unit with 30 beds, so determining ☒ ☐ ☐ appropriate housing is important to ensure staff contact and observation needs can be easily met. For S2S youth, they are housed on the upper tier with designated camp rooms. The screening tools were developed in coordination with BH to establish and identify all safety elements to address youth needs and behaviors. (d) provide for periodic classification reviews, including provisions that consider the level of supervision and the Section V, Number 9, Procedure I-E youth's behavior while in custody; and, ☒ ☐ ☐ The reviews occur weekly. (e) provide that facility staff shall not separate youth from the general population or assign youth to a single Section V, Number 9, Procedure I-F occupancy room based solely on the youth's actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, gender expression, mental ☒ ☐ ☐ Staff have the ability to override or determine or physical disability, or HIV status. This section does particular housing needs based on the overall not prohibit staff from placing youth in a single circumstances from the numerous admission occupancy room at the youth's specific request or in and classification screening tools. accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, bisexual, transgender, questioning or intersex identification or ☒ ☐ ☐ Section V, Number 9, Procedure I-G status as an indicator of likelihood of being sexually abusive. 7718 Tuolumne Steps to Success PRO 23-24 29 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1352.5 TRANSGENDER AND INTERSEX YOUTH. The facility administrator shall develop written policies Section V, Number 10 and procedures ensuring respectful and equitable treatment of transgender and intersex youth. The policies shall provide that: The facility developed a gender preference form which includes staff having a conversation with youth at admission and a signature from the youth after the gender preferences are identified to ensure responsiveness to their requested preferences as it relates to search, housing, and clothing. This is also communicated to ancillary staff to have consistent gender references. ☒ ☐ ☐ While on-site, there were 2 youth who have identified as Transgender Females. The agency does a good job in addressing the youth’s needs. One youth is from Tuolumne County and is currently involved with Wellpath Medical assistance. The other youth is from Mariposa County and is being seen by Mariposa Medical and Behavior Health staff. Our observations of these youth, one in an interview, revealed staff and facility partners are providing good and caring services. (a) Facility staff shall respect every youth’s gender identity and shall refer to the youth by the youth’s Section V, Number 10, Procedure I-A preferred name and gender pronoun, regardless of the youth’s legal name. Facilities may prohibit the use of ☒ ☐ ☐ gang or slang names or names that otherwise compromise facility operations as determined by the facility manager or designee, and shall document any decision made on this basis. (b) Facility staff shall permit youth to dress and present themselves in a manner consistent with their gender ☒ ☐ ☐ Section V, Number 10, Procedure I-B identity and shall provide youth with the institution’s clothing and undergarments consistent with their gender identity. 7718 Tuolumne Steps to Success PRO 23-24 30 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Facility staff shall house youth in the unit or room that best meets their individual needs and promotes their Section V, Number 10, Procedure I-C safety and well-being. Staff may not automatically house youth according to their external anatomy and shall ☒ ☐ ☐ document the reasons for any decision to house youth in a unit that does not match their gender identity. In making a housing decision, staff shall consider the youth’s preferences, as well as any recommendations from the youth’s health or behavioral health provider. (d) Facility administrators shall ensure that transgender and intersex youth have access to medical and ☒ ☐ ☐ Section V, Number 10, Procedure I-D behavioral health providers qualified to provide care and treatment to transgender and intersex youth. (e) Consistent with the facility’s reasonable and necessary security considerations and physical plant, Section V, Number 10, Procedure I-E facility staff shall make every effort to ensure the safety ☒ ☐ ☐ and privacy of transgender and intersex youth when the youth are using the bathroom or shower, or dressing or undressing. Facility staff shall not conduct physical searches of any youth for the purpose of determining the youth’s Section V, Number 10, Procedure I-F anatomical sex. Whenever feasible, the facility shall ☒ ☐ ☐ respect the youth’s preference regarding the gender of Section V, Number 10, Procedure I-G the staff member who conducts any search of the youth. 7718 Tuolumne Steps to Success PRO 23-24 31 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1353 ORIENTATION The facility administrator shall develop and implement Section V, Number 11, I-a, D and E written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Section V, Number 10, Procedure I-D, information shall be provided and supplemented with 1 and 2 video orientation if feasible. Provision shall be made to provide accessible orientation information to all detained youth including those with disabilities, limited literacy, or Youth are provided with a Handbook at English language learners. Orientation shall include admission containing all elements of this information that addresses: regulation as well as a PREA Pamphlet. We reviewed the handbook and found the explanation of all elements was easy for youth ☒ ☐ ☐ to understand. It provides an operational understanding for youth expectations, rights, and how to address any identified needs that may arise during their stay. We also reviewed the Orientation Sign Off document youth sign when admitted and oriented to the facility, acknowledging their understanding of the facility guidelines, expectations, and processes. We interviewed 3 of the 11 youth in custody and they acknowledged they understood the handbook and their ability to ask staff questions regarding their stay. (a) facility rules including contraband and searches and disciplinary procedures; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 1 (b) facility’s system of positive behavior interventions and supports, including behavior expectations, Section V, Number 10, Procedure I-B, 2 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 ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 3 harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 4 7718 Tuolumne Steps to Success PRO 23-24 32 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) the existence of the grievance procedure, the steps that must be taken to use it, the youth’s right to be free ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 5 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 ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 6 court process; (g) access to routine and emergency health and mental ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 7 health care; (h) access to education, religious services, and ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 8 recreational activities; (i) housing assignments; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 9 (j) opportunity for personal hygiene and daily showers including the availability of personal care items ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 10 (k) rules and access to correspondence, visits and telephone use; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 11 (l) availability of reading materials, programming, and other activities; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 12 (m) facility policies on the use of force, use of restraints, chemical agents and room confinement; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 13 (n) immigration legal services; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 14 7718 Tuolumne Steps to Success PRO 23-24 33 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (o) emergencies including evacuation procedures; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 15 (p) non-discrimination policy and the right to be free from physical, verbal or sexual abuse and harassment by ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 21 other youth and staff; (q) availability of services and programs in a language other than English if appropriate; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 16 (r) the process for requesting different housing, education, programming and work assignments; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 18 (s) a process for which parents/guardians receive information regarding the youth’s stay in the facility that Section V, Number 10, Procedure I-B, 17 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. ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 19 7718 Tuolumne Steps to Success PRO 23-24 34 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354 SEPARATION The facility administrator shall develop and implement Section V, Number 13 written policies and procedures that address: We reviewed 15 incidents of Separation from October 2022 to October 2023, two of which were Voluntary Separation. In total, the agency had 91 Separation incidents, 5 Voluntary Separations. The agency documents behavior separation in an Activity Report or Incident Report, prompting staff to document the reason for and efforts to return the youth to programming. Youth go to the library (second classroom not in use and in the unit), to reflect on the behavior resulting in the separation. ☒ ☐ ☐ The agency uses the CICO (Check in, Check out) Daily Point Sheet to document incidents that result in behavior separation but not a violation of a major rule. The form allows for points (0-2) based on the Positive Behavior and Supports (PBIS) model for respectful, responsible, and safe behaviors. This form is completed for each youth daily and allows for the recording of incidents that do not represent the PBIS model. This is tracked to have the information recorded for case planning and counseling services while the youth is in custody. (a) separation of youth for reasons that include, but are not be limited to, medical and mental health conditions, ☒ ☐ ☐ Section V, Number 13, I-A, 1-6 assaultive behavior, disciplinary consequences and protective custody. (b) consideration of positive youth development and trauma-informed care. ☒ ☐ ☐ Section V, Number 13, I-C (c) separated youth shall not be denied normal privileges available at the facility, except when ☒ ☐ ☐ Section V, Number 13, I-B and E necessary to accomplish the objective of separation. 7718 Tuolumne Steps to Success PRO 23-24 35 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) when the objective of the separation is discipline, Title 15 Section 1390 shall apply. Section V, Number 13, I Disciplinary Separation The facility makes good use of the space in the single unit facility for separation, using the not occupied classroom, which allows a full ☒ ☐ ☐ visual of the youth while in the separated location. This space allows youth a cooldown period to reflect on the behaviors that necessitated a separation but not to the level of room confinement. The process is working and accomplishing the goal in regulation, despite their physical plant. (e) when separation results in room confinement, the separation shall occur in accordance with Welfare and ☒ ☐ ☐ Section V, Number 13, Procedure I-E Institutions Code Section 208.3 and Section 1354.5 of these regulations. (f) policies and procedures shall ensure a daily review of separated youth to determine if separation remains The facility only separates youth for short necessary. periods of time to re-focus behavior. Our review of all incidents revealed most were poor decisions that are not aligned with the PBIS Model of behavior with others. The agency only uses this tool when they have exhausted every verbal counseling attempt. The youth are evaluated regularly ☒ ☐ ☐ and returned to normal programming in most cases, less than an hour after separation began. We note the agency completes a Reintegration Plan in each incident to allow for conversations about the behavior leading to the separation and discussion of how the youth’s actions could be different. The agency also allows for Due Process when a youth is separated for discipline, including minor rule violations. 7718 Tuolumne Steps to Success PRO 23-24 36 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT (a) The facility administrator shall develop and Section V, Number 14 implement written policies and procedures addressing the confinement of youth in their room that are consistent with Welfare and Institutions Code Section The facility has had 35 incidents of RC from 208.3. The placement of a youth in room confinement October 2022 through October 2023, with four shall be accomplished in accordance with the following involving one youth for self-harm-related guidelines: behavior. Four of the incidents involved Steps for Success youth. The agency has a process to ensure staff document all efforts to reintegrate and follow the RC form prompts. Incident report ☒ ☐ ☐ documentation for the reason of room confinement was clear in each incident we reviewed. No youth were on RC for more than 3 hours and 30 minutes (1), 2-3 hours (7), 1-2 hours (17), and 12 youth under 30 minutes. Each youth participated in a Reintegration Plan, allowing staff to communicate and have a conversation about the incident, what could have been done differently, and a review of the Due Process process for the behavior leading to the RC. (1) Room confinement shall not be used before other, less restrictive, options have been attempted Section V, Number 14, I-A and exhausted, unless attempting those options ☒ ☐ ☐ poses a threat to the safety or security of any youth Section V, Number 14, Procedure II-A or staff. (2) Room confinement shall not be used for the purposes of punishment, coercion, convenience, or ☒ ☐ ☐ Section V, Number 14, I-B retaliation by staff. (3) Room confinement shall not be used to the extent that it compromises the mental and physical health Section V, Number 14, I-C of the youth. ☒ ☐ ☐ Section V, Number 14, Procedure II-B (b) A youth may be held up to four hours in room confinement. After the youth has been held in room ☒ ☐ ☐ Section V, Number 14, Procedure II-C confinement for a period of four hours, staff shall do one or more of the following: 7718 Tuolumne Steps to Success PRO 23-24 37 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section V, Number 14, I-E, 1 (1) Return the youth to general population. ☒ ☐ ☐ Section V, Number 14, Procedure II-D, 1 Section V, Number 14, I-E, 3 (2) Consult with mental health or medical staff. ☒ ☐ ☐ Section V, Number 14, Procedure II-D, 2 (3) Develop an individualized plan that includes the goals and objectives to be met in order to reintegrate Section V, Number 14, I-E, 6 the youth to general population. Section V, Number 14, Procedure II-D, 3 ☒ ☐ ☐ As soon as a youth is placed on RC, an individual plan form is developed with the youth and attempts to follow through are made. (4) If room confinement must be extended beyond four hours, staff shall do each of the following: Section V, Number 14, Procedure II-D, 4 ☒ ☐ ☐ Each component is addressed in policy and documentation review included the elements required to extend. (A) Document the reasons for room confinement and the basis for the extension, the date and time Section V, Number 14, I-E, 2 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 ☒ ☐ ☐ Section V, Number 14, I-E, 6 integrate the youth to general population. (C) Obtain documented authorization by the facility superintendent or his or her designee ☒ ☐ ☐ Section V, Number 14, I-E, 5 every four hours thereafter. 7718 Tuolumne Steps to Success PRO 23-24 38 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) This section is not intended to limit the use of single-person rooms or cells for the housing of youth ☒ ☐ ☐ Section V, Number 14, I-I 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. ☒ ☐ ☐ Section V, Number 14, I-J (7) Nothing in this section shall be construed to conflict with any law providing greater or additional ☒ ☐ ☐ Section V, Number 14 Policy Statement protections to youth. (8) This section does not apply during an extraordinary emergency circumstance that requires Section V, Number 14, I-K a significant departure from normal institutional operations, including a natural disaster or facility- ☒ ☐ ☐ wide threat that poses an imminent and substantial risk of harm to multiple staff or youth. This exception shall apply for the shortest amount of time needed to address this imminent and substantial risk of harm. (9) This section does not apply when a youth is placed in a locked cell or sleeping room to treat and Section V, Number 14, I-L 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. 1355 INSTITUTIONAL ASSESSMENT AND PLAN The facility administrator shall develop and implement ☒ ☐ ☐ Section V, Number 16 written policies and procedures for assessment and case planning. 7718 Tuolumne Steps to Success PRO 23-24 39 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Assessment: The assessment is based on information collected Section V, Number 16, Policy I-A during the admission process with periodic review, which includes the youth's risk factors, needs and strengths including, but not limited to, identification of substance abuse history, educational, vocational, We reviewed a sampling of IAP’s for youth counseling, behavioral health, consideration of known including an initial, updated, 3-month, 6- history of trauma, and family strengths and needs. month, Change in Treatment, and Transition Plans, each focusing on the identified needs and service approach while in or transitioning out of custody. The plans focus on a Youth Strength and Needs Assessment, which incorporates information from the following areas: Emotional/Behavioral Health; Cognitive Development and Functioning; Social Development and Functioning; Physical Health/Disabilities; Education; Trauma/ Resiliency; Family Relationships; Alcohol/ Drugs; Prior/Current Offense; Adult Relationships; and any other information which impacts a youth’s strengths or needs. A ☒ ☐ ☐ Treatment Plan is developed based on responses to the Assessment, which is scored, to identify the top three needs and strengths. We found each assessment to be detailed and informative, as well as individualized to each youth. The process is inclusive of required elements and documentation of timelines, which are more than required in policy and regulation. Staff work within the plan to provide reachable and attainable goals, both for in-custody treatment and upon release into the community. We reviewed one youth’s Individual Rehabilitation Plan, which is established and facilitated by the Probation Officer. The facility has a great collaborative approach for their commitment and Summit youth. 7718 Tuolumne Steps to Success PRO 23-24 40 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Institutional Case Plan: (1) A case plan shall be developed for each youth Section V, Number 16, Policy I-B held for at least 30 days or more and created within 40 days of admission. ☒ ☐ ☐ IAP’s are completed at 14 days or sooner, with follow-up assessments at the 3-month, 6- month, 9-month, 12-month, and transition planning timelines. (2) The institutional plan shall include, but not be ☒ ☐ ☐ limited to, written documentation that provides: (A) objectives and time frame for the resolution of problems identified in the assessment; ☒ ☐ ☐ Section V, Number 16, Procedure II-A (B) a plan for meeting the objectives that includes a description of program resources needed and ☒ ☐ ☐ Section V, Number 16, Procedure II-B, 1-3 individuals responsible for assuring that the plan is implemented; (3) periodic evaluation of progress towards meeting the objectives, including periodic review and ☒ ☐ ☐ Section V, Number 16, Procedure II-C discussion of the plan with the youth; (4) a transition plan, the contents of which shall be subject to existing resources, shall be developed for ☒ ☐ ☐ Section V, Number 16, Procedure II-D post dispositional youth in accordance with Section 1351; and, (5) in as much as possible and if appropriate, the plan, including the transition plan, shall be developed Section V, Number 16, Procedure II-E with input from the family, supportive adults, youth, ☒ ☐ ☐ and Regional Center for the Developmentally Disabled. 7718 Tuolumne Steps to Success PRO 23-24 41 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1356 COUNSELING AND CASEWORK SERVICES The facility administrator shall develop and implement Section V, Number 16, Procedure V-A written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: Facility staff document behavior, both positive and negative, in the youth’s ‘Check in, Check out’ (CICO) Daily Point sheets. This identifies ☒ ☐ ☐ their behavior each shift, as well as their participation in all T15 requirements. We reviewed daily/weekly summaries and phone call status for each youth in custody recorded on the CICO sheets. This daily documentation reveals the positive and negative activities as it relates to all areas of a youth’s program. (a) youth will receive assistance with needs or concerns that may arise; ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 1 (b) youth will receive assistance in requesting contact with parents, other supportive adults, attorney, clergy, ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 2 probation officer, or other public official; and, (c) youth will be provided access to available resources to meet the youth’s needs. ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 3 7718 Tuolumne Steps to Success PRO 23-24 42 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1357 USE OF FORCE The facility administrator, in cooperation with the Section V, Number 17 (UF) responsible physician, shall develop and implement written policies and procedures for the use of force, Section V, Number 17, Procedure II-B, 5 which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. We reviewed 10 of the 11 incidents involving the use of force from October 2022 through (a) At a minimum, each facility shall develop policies and October 2023. The reports provided clear and procedures which: relevant information based on the narrative in the report and accompanied by additional documentation if the incident involved Room Confinement (if appropriate), Separation, Use of Restraints, Due Process, or a response from agency partners. Most involved unit ☒ ☐ ☐ disturbances or assaultive behavior from youth. Two of the incidents involved the use of OC Spray and 8 youth were restrained following a UF incident for movement to their room or intake holding. Senior and supervisory staff review and debrief incidents along with involved staff and the superintendent. Documentation and forms were complete and articulate in terms of all necessary requirements. (1) restricts the use of force to that which is deemed reasonable and necessary, as defined in Section ☒ ☐ ☐ Section V, Number 17, Procedure I-B 1302 to ensure the safety and security of youth, staff, others and the facility. (2) outline the force options available to staff including both physical and non-physical options and define ☒ ☐ ☐ Section V, Number 17, Procedure V-A, 1-6 when those force options are appropriate. (3) describe force options or techniques that are expressly prohibited by the facility. ☒ ☐ ☐ Section V, Number 17, Procedure V-B, 1-8 (4) describe the requirements of staff to report any inappropriate use of force, and to take affirmative ☒ ☐ ☐ Section V, Number 17, Procedure II-B, 7 action to immediately stop it. 7718 Tuolumne Steps to Success PRO 23-24 43 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) define a standardized reporting format that includes time period and procedure for documenting Section V, Number 17, Procedure V 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. ☒ ☐ ☐ Section V, Number 17, Procedure V-C (7) define the role, notification, and follow-up procedures required after use of force incidents for ☒ ☐ ☐ Section V, Number 17, Procedure VI-A, B and medical, mental health staff and parents or legal C guardians. (8) describe the limitations of use of force on pregnant youth in accordance with Penal Code Section 6030(f) ☒ ☐ ☐ Section V, Number 17, Procedure III and Welfare and Institutions Code Section 222. (b) Facilities that authorize chemical agents as a force option shall include policies and procedures that: Section V, Number 18 (1) identify who is approved to carry and/or utilize chemical agents in the facility and the type, size and Section V, Number 18, Procedure I-A the approved method of deployment for those chemical agents. ☒ ☐ ☐ Only senior staff are permitted to carry OC spray in the facility. It is important to note there have been two chemical spray incidents since October of 2022, involving one youth. (2) mandate that chemical agents only be used when there is an imminent threat to the youth’s safety or the ☒ ☐ ☐ Section V, Number 18, Procedure I-B 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. Section V, Number 18, Use I-F This shall include that youth who have been exposed ☒ ☐ ☐ to chemical agents shall not be left unattended until Section V, Number 18, Use I-H, 5 and 6 that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. Section V, Number 18, Use I-I, 1 through 8 7718 Tuolumne Steps to Success PRO 23-24 44 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) define the role, notification, and follow-up procedures required after use of force incidents Section V, Number 18, Use I-E (CFMG) involving chemical agents for medical, mental health staff and parents or legal guardians. ☒ ☐ ☐ Section V, Number 18, Use I-F (BH and parent/legal guardian) (5) provide for the documentation of each incident of use of chemical agents, including the reasons for Section V, Number 18, Use I-G, 1-5 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 which require that agencies provide initial and regular training Section V, Number 17, Procedure IV in use of force and chemical agents when appropriate that address: ☒ ☐ ☐ Senior staff are only authorized to carry OC Spray. Staff are trained annually by certified STC Instructor. (1) known medical and behavioral health conditions that would contraindicate certain types of force; ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 6 (2) acceptable chemical agents and the methods of application. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 2 (3) signs or symptoms that should result in immediate referral to medical or behavioral health. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 7 (4) instruction on the Constitutional Limitations of Use of Force. Section V, Number 18, Procedure I-B ☒ ☐ ☐ This is part of the training curriculum for Use of Force. 7718 Tuolumne Steps to Success PRO 23-24 45 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) physical training force options that may require the use of perishable skills. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B (6) timelines the facility uses to define regular training. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B 1358 USE OF PHYSICAL RESTRAINTS The facility administrator, in cooperation with the Section V, Number 19 and 20 responsible physician and mental health director, shall develop and implement written policies and procedures for the use of restraint devices. Restraint devices The facility has the WRAP as a restraint with include any devices which immobilize a youth's ☒ ☐ ☐ very specific limitations on its use. extremities and/or prevent the youth from being ambulatory. There has been no use of the WRAP since July 2022. Physical restraints may be used only for those youth who present an immediate danger to themselves or Section V, Number 19, Policy I-B 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 Section V, Number 19, Policy I-F restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through affixing ☒ ☐ ☐ Section V, Number 19, Policy I-Q of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is Section V, Number 19, Policy I-R limited in accordance with Penal Code Section 6030(f) Section V, Number 19, Policy I-S and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of handcuffs, shackles or other restraint devices when used Section V, Number 19, Policy I-C 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. 7718 Tuolumne Steps to Success PRO 23-24 46 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Youth shall be placed in restraints only with the approval of the facility manager or designee. The facility manager Section V, Number 19, Policy I-B may delegate authority to place a youth in restraints to a physician. Reasons for continued retention in restraints Section V, Number 19, Policy I-V shall be reviewed and documented at a minimum of every hour. Section V, Number 19, Policy I-W ☒ ☐ ☐ Senior JCO’s are designated to approve placement of restraints in the absence of the facility Superintendent. The WRAP must have Superintendent approval. A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no Section V, Number 19, Policy I-J 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 soon as possible, but in no case longer than four hours from the ☒ ☐ ☐ Section V, Number 19, Policy I-K time of placement, to assess the need for mental health treatment. Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and Section V, Number 19, Policy I-N to ensure the safety and well-being of the youth. ☒ ☐ ☐ Observations of the youth's behavior and any staff Section V, Number 19, Procedure I-B interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. Section V, Number 19, Procedure I-J In addition to the requirements above, policies and procedures shall address: ☒ ☐ ☐ Section V, Number 19, Procedure I-M (a) documentation of the circumstances leading to an application of restraints. (b) known medical conditions that would contraindicate certain restraint devices and/or techniques. ☒ ☐ ☐ Section V, Number 19, Policy I-M (c) acceptable restraint devices. ☒ ☐ ☐ Section V, Number 19, Policy I-B (d) signs or symptoms which should result in immediate medical/mental health referral. ☒ ☐ ☐ Section V, Number 19, Procedure I-J 7718 Tuolumne Steps to Success PRO 23-24 47 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) availability of cardiopulmonary resuscitation equipment. ☒ ☐ ☐ Section V, Number 19, Procedure I-D (f) protective housing of restrained youth. While in restraint devices, all youth shall be housed alone or in a ☒ ☐ ☐ Section V, Number 19, Policy I-H specified housing area for restrained youth which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. ☒ ☐ ☐ Section V, Number 19, Policy I-H (h) exercising of extremities. ☒ ☐ ☐ Section V, Number 19, Policy I-H 1358.5 USE OF RESTRAINT DEVICES FOR MOVEMENT AND TRANSPORTATION Section V, Number 21 WITHIN THE FACILITY. The Facility Administrator, in cooperation with the responsible physician and behavioral/mental health Staff are trained to use control holds at escort director, shall develop and implement written policies and must get authorization to use other force and procedures for the use of restraint devices when the for movement. There were 8 incidents purpose is for movement or transportation within the ☒ ☐ ☐ involving the use of restraints for movement of facility that shall include the following: a youth to their room. All were 2-3 minutes, except for one incident where a youth was in restraints for 7 minutes as he remained combative. One incident involved a S2S youth. (a) identification of acceptable restraint devices, staff approved to utilize restraint devices and the required Section V, Number 19, Policy I-B training. ☒ ☐ ☐ Staff are trained annually by certified STC Instructor. (b) the circumstances leading to the application of restraints must be documented. ☒ ☐ ☐ Section V, Number 21, Procedure A 7718 Tuolumne Steps to Success PRO 23-24 48 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) an individual assessment of the need to apply restraints for movement or transportation that includes Section V, Number 21, Procedure B consideration of less restrictive alternatives, consideration of a youth’s known medical or mental ☒ ☐ ☐ health conditions, trauma informed approaches, and a process for documentation and supervisor review and approval. (d) consideration of safety and security of the facility, with a clearly defined expectation that restraint devices ☒ ☐ ☐ Section V, Number 21 Procedure C 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 ☒ ☐ ☐ Section V, Number 21 Procedure D Welfare and Institutions Code Section 222. 1359 SAFETY ROOM PROCEDURES (a) The facility administrator, and where applicable, in The facility does not have a Safety Room. cooperation with the responsible physician, shall develop and implement written policies and procedures governing the use of safety rooms, as described in Title 24, Part 2, Section 1230.1.13. The room shall be used to hold only 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. A safety room shall not be used for punishment or discipline, or as a substitute for treatment. Policies and procedures shall: (1) include provisions for administration of necessary nutrition and fluids, access to a toilet, and suitable ☐ ☐ ☒ clothing to provide for privacy; (2) provide for approval of the facility manager, or designee, before a youth is placed into a safety ☐ ☐ ☒ room; (3) provide for continuous direct visual supervision and documentation of the youth's behavior and any ☐ ☐ ☒ staff interventions every 15 minutes, with actual time recorded; (4) provide that the youth shall be evaluated by the ☐ ☐ ☒ facility manager, or designee, every four hours; (5) provide for immediate medical assessment, where appropriate, or an assessment at the next ☐ ☐ ☒ daily sick call; and, (6) provide a process for documenting the reason for placement, including attempts to use less restrictive ☐ ☐ ☒ means of control, and decisions to continue and end placement. 7718 Tuolumne Steps to Success PRO 23-24 49 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The placement of a youth in the safety room shall be ☐ ☐ ☒ accomplished in accordance with the following: (1) safety room 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. (2) safety room shall not be used for the purposes of punishment, coercion, convenience, or retaliation by ☐ ☐ ☒ staff. (3) safety room shall not be used to the extent that it compromises the mental and physical health of the ☐ ☐ ☒ youth. (c) A youth may be held up to four hours in the safety room. After the youth has been held in the safety room ☐ ☐ ☒ 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. (d) If confinement in the safety room must be extended beyond four hours, staff shall develop an individualized plan that includes the requirements of Section 1354.5 ☐ ☐ ☒ and the goals and objectives to be met in order to integrate the youth to general population. 1360 SEARCHES , The facility administrator shall develop and implement Section V, Number 23 written policies and procedures governing the search of youth, the facility, and visitors. Policies and procedures ☒ ☐ ☐ Section V, Number 23, Procedure IX Room shall provide that: Section V, Number 23, Procedure X Facility Section V, Number 23, Procedure XI Visitor (a) Searches shall be conducted to ensure the safety and security of the facility, public, visitors, youth, and ☒ ☐ ☐ Section V, Number 23, Policy I-A and B staff. (b) Searches shall be conducted in a manner that preserves the privacy and dignity of the person being ☒ ☐ ☐ Section V, Number 23, Policy I-C searched and shall not be conducted for harassment or as a form of discipline or punishment. 7718 Tuolumne Steps to Success PRO 23-24 50 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Strip searches and visual or physical body cavity searches shall comply with Penal Code Section 4030. Section V, Number 23, Policy I-D ☒ ☐ ☐ There have been no strip searches at the facility from July 2022 to October 2023, only 3 since the facility opened in 2017. (d) Physical body cavity searches shall only be conducted by a medical professional. ☒ ☐ ☐ Section V, Number 23, Policy I-E (e) Any youth held after a detention hearing shall only be strip searched with prior approval of a supervisor Section V, Number 23, Procedure II, III, IV when there is reasonable suspicion based on specific ☒ ☐ ☐ and articulable facts to believe that youth is concealing contraband. The reasonable suspicion shall be documented. (f) Searches of transgender and intersex youth shall comply with Section 1352.5. ☒ ☐ ☐ Section V, Number 23, Procedure V-D (g) Cross-gender pat-down searches and strip searches are prohibited except in exigent circumstances or when ☒ ☐ ☐ Section V, Number 23, Policy I-J and K conducted by a medical professional. Such searches must be justified and documented in writing. 1361 GRIEVANCE PROCEDURE The facility administrator shall develop and implement Section V, Number 30 written policies and procedures whereby any youth may appeal and have resolved grievances relating to any condition of confinement, including but not limited to The facility has had 34 grievances filed from health care services, classification decisions, program July 2022 to October 2023, most of which participation, telephone, mail or visiting procedures, were resolved by staff with two being food, clothing, bedding, mistreatment, harassment or appealed to the Superintendent. violations of the nondiscrimination policy. There shall be ☒ ☐ ☐ no time limit on filing grievances. Policies and procedures shall include provisions whereby the facility Of the youth we interviewed, each understood manager ensures: the process and felt the resolution was fair. The forms are step-by-step based and compliant with policy and regulation. 7718 Tuolumne Steps to Success PRO 23-24 51 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) a grievance form and instructions for registering a grievance, which includes provisions for the youth to Section V, Number 30, Policy I-A have free access to the form; ☒ ☐ ☐ Section V, Number 30, Policy I-B (b) the youth shall have the option to confidentially file the grievance or to deliver the form to any youth ☒ ☐ ☐ Section V, Number 30, Policy I-D supervision staff working in the facility; (c) resolution of the grievance at the lowest appropriate staff level; ☒ ☐ ☐ Section V, Number 30, Policy I-F (d) provision for a prompt review and initial response to grievances within three (3) business days, grievances ☒ ☐ ☐ Section V, Number 30, Procedure I-C that relate to health and safety issues must be addressed immediately; (1) The youth may elect to be present to explain his/her version of the grievance to a person not ☒ ☐ ☐ Section V, Number 30, Procedure I-D 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. ☒ ☐ ☐ Section V, Number 30, Policy I-C (e) provision for a written response to the grievance which includes the reasons for the decisions; ☒ ☐ ☐ Section V, Number 30, Policy I-F (f) a system which provides that any appeal of a grievance shall be heard by a person not directly ☒ ☐ ☐ Section V, Number 30, Procedure I-F involved in the circumstances which led to the grievance; Section V, Number 30, Procedure I-G (g) resolution of the grievance must occur within ten (10) business days unless circumstances dictate a longer ☒ ☐ ☐ Section V, Number 30, Procedure I-H time frame. The youth shall be notified of any delay; and, 7718 Tuolumne Steps to Success PRO 23-24 52 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) the policy shall provide multiple internal and external methods to report sexual abuse and sexual harassment. Section V, Number 30, Procedure I-G Section V, Number 30, Procedure I-H ☒ ☐ ☐ Section V, Number 30, Procedure I-I Section V, Number 30, Procedure I-J Whether or not associated with a grievance, concerns of parents, guardians, staff or other parties shall be ☒ ☐ ☐ Section V, Number 30, Procedure I-N addressed and documented in accordance with written policies and procedures within a specified timeframe. 1362 REPORTING OF INCIDENTS A written report of all incidents which result in physical Section V, Number 32 harm, use of force, serious threat of physical harm, or death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the We reviewed numerous incident reports staff and submitted to the facility manager by the end of involving UF, UR, RC, and Separation. the shift, unless additional time is necessary and authorized by the facility manager or designee. 1363 USE OF REASONABLE FORCE TO COLLECT DNA SPECIMENS, SAMPLES, IMPRESSIONS Section V, Number 33, Procedure III-A (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections personnel including peace officers, may employ reasonable force ☒ ☐ ☐ The facility has not had to use force to collect to collect blood specimens, saliva samples, and thumb DNA since 2017. or palm print impressions from individuals who are required to provide such samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request. (1) For the purpose of this section, the “use of reasonable force” shall be defined as the force that Section V, Number 33, Procedure III-B an objective, trained and competent correctional ☒ ☐ ☐ employee, faced with similar facts and circumstances, would consider necessary and reasonable to gain compliance with this section. (2) The use of reasonable force shall be preceded by efforts to secure voluntary compliance. Efforts to Section V, Number 33, Procedure III-B secure voluntary compliance shall be documented ☒ ☐ ☐ and include an advisement of the legal obligation to provide the requisite specimen, sample or impression and the consequences of refusal. 7718 Tuolumne Steps to Success PRO 23-24 53 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The force shall not be used without the prior written authorization of the supervising officer on duty. The Section V, Number 33, Procedure III-C authorization shall include information that reflects the fact that the offender was asked to provide the requisite specimen, sample, or impression and refused. ☒ ☐ ☐ The use of force for this regulation requires authorization from the Facility Superintendent. (1) If the use of reasonable force includes a cell extraction, the extraction shall be videotaped. Video Section V, Number 33, Procedure IV-A shall be directed at the cell extraction event. The videotape shall be retained by the agency for the ☒ ☐ ☐ Section V, Number 33, Procedure IV-B length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7718 Tuolumne Steps to Success PRO 23-24 54 A453 JUV PRO eff. 1/2019 (23-24).dot 1370 EDUCATION PROGRAM (a) School Programs Section VI, Number 1, Policy II-A The County Board of Education shall provide for the administration and operation of juvenile court schools in conjunction with the Chief Probation Officer, or designee The Tuolumne County Superintendent of pursuant to applicable State laws. The school and facility Schools provides educational and vocational administrators shall develop and implement written policy opportunities via the Golden Ridge and procedures to ensure communication and Educational Center (GREC) onsite, online coordination between educators and probation staff. college through Columbia Community Culturally responsive and trauma-informed approaches College, and vocational opportunities through should be applied when providing instruction. Education the Motherlode Job Training for Tuolumne staff should collaborate with the facility administrator to County. A TCSOS Transition Specialist use technology to facilitate learning and ensure safe assists with youth exiting the facility and technology practices. The facility administrator shall returning to schools in the community as well request an annual review of each required element of the as with enrollment and curriculum oversight, in program by the Superintendent of Schools, and a report Columbia College, a community college or review checklist on compliance, deficiencies, and nearby. It is noted youth eligible for Dual corrective action needed to achieve compliance with this enrollment are attending online classes at the section. Such a review, when conducted, cannot be college as well. The SOS last received WASC delegated to the principal or any other staff of any juvenile Accreditation in 2022. court school site. The Superintendent of Schools shall conduct this review in conjunction with a qualified outside agency or individual. Upon receipt of the review, the PBIS was trained to all new staff initially but facility administrator or designee shall review each item most have moved on since 2017. The TCSOS with the Superintendent of Schools and shall take plans to revitalize PBIS as a mechanism to whatever corrective action is necessary to address each promote positive behaviors with rewards and ☒ ☐ ☐ deficiency and to fully protect the educational interests of incentives in the classroom and carried over all youth in the facility. to the living unit. We have seen the successes of PBIS as a collaboration with school and probation staff. The TCSOS offers a complete and comprehensive curriculum, including culinary food handler’s certification, DMV licenses for eligible youth, gardening, and personal reading goals via the Book Club. Additionally, for those youth with an active IEP, youth receive services via a counselor in addition to specialized instruction. TCSOS continues to provide a Psychologist one time per week to work with the sex offender population. The on-site teacher, Ashley Chambeaux, is engaged in the classroom and works individually with youth to grow their education opportunities. The program is 270 minutes each day except for every Wednesday has a late start to allow Ms. Chambeaux to participate in MDT meetings. 7718 Tuolumne Steps to Success PRO 23-24 55 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Required Elements The facility school program shall comply with the State Section VI, Number 1, Policy III-A Education Code and County Board of Education policies, Section VI, Number 1, Policy III-B all applicable federal education statutes and regulations and provide for an annual evaluation of the educational Section VI, Number 1, Policy III-C program offerings. As stated in the 2009 California Standards for the Teaching Profession, teachers shall ☒ ☐ ☐ Section VI, Number 1, Policy III-D establish and maintain learning environments that are Section VI, Number 1, Policy III-E physically, emotionally, and intellectually safe. Youth shall be provided a rigorous, quality educational program that responds to the different learning styles and abilities of students and prepares them for high school graduation, career entry, and post-secondary education. All youth shall be treated equally, and the education program shall be free from discriminatory action. Staff Section VI, Number 1, Policy III-F shall refer to transgender, intersex and gender- ☒ ☐ ☐ nonconforming youth by their preferred name and gender. (1) The course of study shall comply with the State Education Code and include, but not be limited to, ☒ ☐ ☐ Section VI, Number 1, Policy III-A courses required for high school graduation. (2) Information and preparation for the High School Equivalency Test as approved by the California ☒ ☐ ☐ Section VI, Number 1, Policy III-I Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education and vocational opportunities. ☒ ☐ ☐ Section VI, Number 1, Policy III-J (4) Administration of the High School Equivalency Tests as approved by the California Department of ☒ ☐ ☐ Section VI, Number 1, Policy III-K Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth who do not demonstrate sufficient progress towards ☒ ☐ ☐ Section VI, Number 1, Policy III-L grade level standards. (6) The minimum school day shall be consistent with State Education Code Requirements for juvenile court Section VI, Number 1, Policy III-G schools. The facility administrator, in conjunction with education staff, must ensure that operational ☒ ☐ ☐ procedures do not interfere with the time afforded for the minimum instructional day. Absences, time out of class or educational instruction, both excused and unexcused, shall be documented. 7718 Tuolumne Steps to Success PRO 23-24 56 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (7) Education shall be provided to all youth regardless of classification, housing, security status, disciplinary Section VI, Number 1, Policy III-O or separation status, including room confinement, except when providing education poses an immediate ☒ ☐ ☐ threat to the safety of self or others. Education includes, but is not limited to, related services as provided in a youth’s Section 504 Plan or Individualized Education Program (IEP). (c) School Discipline (1) Positive behavior management will be Section VI, Number 1, Policy IV-A implemented to reduce the need for disciplinary action ☒ ☐ ☐ in the school setting and be integrated into the facility's overall behavioral management plan and security system. (2) School staff shall be advised of administrative decisions made by probation staff that may affect the ☒ ☐ ☐ Section VI, Number 1, Policy IV-B educational programming of students. (3) Except as otherwise provided by the State Education Code, expulsion/suspension from school Section VI, Number 1, Policy IV-C shall be imposed only when other means of correction fails to bring about proper conduct. School staff shall follow the appropriate due process safeguards as set ☒ ☐ ☐ forth in the State Education Code including the rights of students with special needs. School staff shall document the other means of correction used prior to imposing expulsion/ suspension if an expulsion/suspension is ultimately imposed. (4) The facility administrator, in conjunction with education staff will develop policies and procedures ☒ ☐ ☐ Section VI, Number 1, Policy IV-D that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations (1) State and federal laws and regulations shall be observed for all individuals with disabilities or Section VI, Number 1, Policy V-A suspected disabilities. This includes but is not limited ☒ ☐ ☐ to child find, assessment, continuum of alternative placements, manifestation determination reviews, and implementation of Section 504 Plans and Individualized Education Programs. (2) Youth identified as English Learners (EL) shall be afforded an educational program that addresses their language needs pursuant to all applicable state and ☒ ☐ ☐ Section VI, Number 1, Policy V-B federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission (1) Youth shall be interviewed after admittance and a ☒ ☐ ☐ record maintained that documents a youth's Section VI, Number 1, Policy VI-A educational history, including but not limited to: 7718 Tuolumne Steps to Success PRO 23-24 57 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (A) School progress/school history; ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 1 (B) Home Language Survey and the results of the State Test used for English language proficiency; ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 2 (C) Needs and services of special populations as defined by the State Education Code, including but ☒ ☐ ☐ not limited to, students with special needs. Section VI, Number 1, Policy VI-A, 3 (D) Discipline problems. ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 4 (2) Youth will be immediately enrolled in school. Educational staff shall conduct an assessment to determine the youth's general academic functioning ☒ ☐ ☐ Section VI, Number 1, Policy VI-B levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary education plan shall be developed for each youth ☒ ☐ ☐ within five school days. Section VI, Number 1, Policy VI-C (4) Upon enrollment, education staff shall comply with the State Education Code and request the youth's records from his/her prior school(s), including, but not Section VI, Number 1, Policy VI-D limited to, transcripts, Individual Education Program (IEP), 504 Plan, state language assessment scores, ☒ ☐ ☐ immunization records, exit grades, and partial credits. Upon receipt of the transcripts, the youth's educational plan shall be reviewed with the youth and modified as needed. Youth should be informed of the credits they need to graduate. (f) Educational Reporting (1) The complete facility educational record of the youth shall be forwarded to the next educational ☒ ☐ ☐ Section VI, Number 1, Policy VII-A placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide appropriate credit (full or partial) for course ☒ ☐ ☐ work completed while in juvenile court school in Section VI, Number 1, Policy VII-B accordance with the State Education Code. (g) Transition and Re-Entry Planning (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies Section VI, Number 1, Policy VIII-A and procedures to meet the transition needs of youth, ☒ ☐ ☐ including the development of an education transition plan, in accordance with the State Education Code and in alignment with Title 15, Minimum Standards for Juvenile Facilities, Section 1355. 7718 Tuolumne Steps to Success PRO 23-24 58 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Post-Secondary Education Opportunities (1) The school and facility administrator should, whenever possible, collaborate with local post- Section VI, Number 1, Policy IX-A secondary education providers to facilitate access to ☒ ☐ ☐ educational and vocational opportunities for youth that considers the use of technology to implement these programs. 7718 Tuolumne Steps to Success PRO 23-24 59 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1371 PROGRAMS, RECREATION, AND EXERCISE. Section VI, Number 3, Policy I-A The facility administrator shall develop and implement written policies and procedures for programs, recreation, and exercise for all youth. The intent is to The facility has many programming options for minimize the amount of time youth are in their rooms or youth, including: their bed area. Aggression Replacement Training (ART); Interactive Journaling; Boys Council; Girls Circle; Parenting Education; Independent Living Skills; 4H-Master Gardner’s; Harvest of the Month (Health and Nutrition); Art Therapy; Tools for Success; Mindfulness and Meditation; Book Club; Religious Services and Bible Study; Prison Education Project (PEP); Mentoring; Drug and Alcohol Prevention Groups; Ready Now Recovery; Tai Chi; and Drum Circle. The agency was just awarded a grant through 4-H to develop a Meditation Pond and Hydroponic Garden. The project was just approved by the county and electricians were on-site when we were ☒ ☐ ☐ there. Facility staff work on ‘Check In, Check Out’ (CICO) with youth to document positive and negative behaviors which teach the elements of PBIS. This tool provides incentive-based opportunities for youth. TCBH has begun providing individual/group counseling to youth and Individual Psychotherapy weekly. They have been present for MDT and case treatment plans, and have a Case Manager who works with Clinicians locally to provide treatment to this population on a more consistent basis. The Superintendent of the facility, Annie Hockett, is a licensed Clinician and responds to crisis events at the facility. Providers include TCBH, TCSOS, facility staff, 4-H, Master Gardner’s, Hidden Treasures, and local volunteers. 7718 Tuolumne Steps to Success PRO 23-24 60 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Juvenile facilities shall provide the opportunity for programs, recreation, and exercise a minimum of three Section VI, Number 3, Policy I-B and C hours a day during the week and five hours a day each ☒ ☐ ☐ Saturday, Sunday or other non-school days, of which one hour shall be an outdoor activity, weather permitting. A youth’s participation in programs, recreation, and exercise may be suspended only upon a written finding Section VI, Number 3, Policy I-D by the administrator/manager or designee that a youth ☒ ☐ ☐ represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall be posted in the living units. ☒ ☐ ☐ Section VI, Number 3, Policy I-E There will be a written annual review of the programs, recreation, and exercise by the responsible agency to ☒ ☐ ☐ Section VI, Number 3, Policy I-F ensure content offered is current, consistent, and relevant to the population. (a) Programs. All youth shall be provided with the opportunity for at least one hour of daily programming to Section VI, Number 3, Policy I-G include, but not be limited to, trauma focused, cognitive, evidence-based, best practice interventions that are culturally relevant and linguistically appropriate, or pro- social interventions and activities designed to reduce recidivism. These programs should be based on the youth’s individual needs as required by Sections 1355 ☒ ☐ ☐ and 1356. Such programs may be provided under the direction of the Chief Probation Officer or the County Office of Education and can be administered by county partners such as mental health agencies, community based organizations, faith-based organizations or Probation staff. Programs may include but are not limited to: 7718 Tuolumne Steps to Success PRO 23-24 61 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; Section VI, Number 3, Policy I-G, 1-17 (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. (b) Recreation. All youth shall be provided the opportunity for at least one hour of daily access to unscheduled Section VI, Number 3, Policy I-H activities such as leisure reading, letter writing, and ☒ ☐ ☐ entertainment. Activities shall be supervised and include Section VI, Number 3, Policy I-K orientation and may include coaching of youth. (c) Exercise. All youth shall be provided with the opportunity for at least one hour of large muscle activity ☒ ☐ ☐ Section VI, Number 3, Policy I-I each day. The administrator/manager may suspend, for a period not to exceed 24 hours, access to recreation and Section VI, Number 3, Policy I-J programs. The administrator/manager shall document ☒ ☐ ☐ the reasons why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM The facility administrator shall provide access to religious Section VI, Number 7, Policy I-C services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth shall be ☒ ☐ ☐ Section VI, Number 7, Policy I-D allowed to participate in an activity outside of their room if he/she elects not to participate in religious programs. Religious programs shall provide for: 7718 Tuolumne Steps to Success PRO 23-24 62 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section VI, Number 7, Policy I-A (a) opportunity for religious services and practices; ☒ ☐ ☐ Section VI, Number 7, Policy I-B (b) availability of clergy; and, ☒ ☐ ☐ Section VI, Number 7, Policy I-B (c) availability of religious diets. ☒ ☐ ☐ Section VI, Number 7, Policy I-B 1373 WORK PROGRAM The facility administrator shall develop policies and Section VI, Number 8 procedures regarding the fair and consistent assignment of youth to work programs. Work assigned to a youth shall be meaningful, constructive and related to The agency allows youth that meet specific vocational training or increasing a youth's sense of criteria to work outside the secure perimeter. responsibility. Work programs shall not be imposed as a Youth in detention are responsible for daily disciplinary measure chores of cleaning their room and the unit. Yard maintenance and classroom cleaning is completed by more senior youth who have reached a certain level in the facility with good behavior. ☒ ☐ ☐ Youth over 16 can receive their food handler’s certificate and they are responsible for serving the meals which come over from the jail. Lastly, youth committed to Steps to Success can work outside the facility perimeter to maintain the cleanliness of the building and grounds. S2S youth do work around the facility and off-site in the community when they attain a certain level. They are also able to work for local businesses in the community after attaining a certain level in the program. 7718 Tuolumne Steps to Success PRO 23-24 63 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1374 VISITING The facility administrator shall develop and implement Section VI, Number 9, Policy I-A written policies and procedures for visiting, that include provisions for special visits. Youth shall be allowed to Section VI, Number 9, Policy I-B receive visits by parents, guardians or persons standing in loco parentis, and children of youth. Other family members, such as grandparents and siblings, and The facility continues to accommodate all supportive adults, may be allowed to visit with the visits, allowing any person the opportunity to approval of the facility administrator or designee, and in visit a youth that offers a positive impact on conjunction with the youth’s case plan or in the best behavior or influence for good transition. This interest of the youth. ☒ ☐ ☐ includes any family member or supportive adult, generally working within the visitor’s schedule if outside normal visiting hours. The visiting schedule is robust with specific providers, clinicians, and community persons visiting youth regularly, not to mention while on-site there were four youth from Mariposa, Inyo, and Calaveras Counties in custody. All visits shall occur at reasonable times, subject only to the limitations necessary to maintain order and security. Section VI, Number 9, Policy I-A Visitation shall not be denied solely based on the visitor’s criminal history. The staff shall determine in each case, Section VI, Number 9, Policy I-R whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ the safety of 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 hours per week. Visits may be supervised, but conversations ☒ ☐ ☐ Section VI, Number 9, Policy I-E shall not be monitored unless there is a security or safety need. Section VI, Number 9, Policy I-G Provisions for special visits, in addition to the two-hour minimum and/or outside of the regular visiting hours, shall Section VI, Number 9, Policy I-H be accommodated as necessary and within the discretion of the facility administrator or designee. Family therapy ☒ ☐ ☐ Section VI, Number 9, Policy I-I and professional visits shall be accommodated outside the provisions of this regulation. Facilities may provide visitation opportunities outside of normal visiting hours to accommodate special visits. The facility may provide access to technology as an alternative, but not as a replacement, to in-person visiting. ☒ ☐ ☐ Section VI, Number 9, Policy I-S 7718 Tuolumne Steps to Success PRO 23-24 64 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1375 CORRESPONDENCE The facility administrator shall develop and implement ☒ ☐ ☐ Section VI, Number 10 written policies and procedures for correspondence which provide that: (a) there is no limitation on the volume of mail that youth may send or receive; ☒ ☐ ☐ Section VI, Number 10, Policy I-A (b) youth may send two letters per week postage free; Section VI, Number 10, Policy I-B ☒ ☐ ☐ All youth mail is sent postage-free. (c) youth may correspond confidentially with state and federal courts, any member of the State Bar or holder of Section VI, Number 10, Policy I-C public office, and the Board; however, authorized facility ☒ ☐ ☐ staff may open and inspect such mail only to search for contraband and in the presence of the youth; and, (d) incoming and outgoing mail, other than that described in (c), may be read by staff only when there is reasonable ☒ ☐ ☐ Section VI, Number 10, Policy I-F cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS The administrator of each juvenile facility shall develop ☒ ☐ ☐ Section VI, Number 11 and implement written policies and procedures to provide youth with access to telephone communications. 1377 ACCESS TO LEGAL SERVICES The facility administrator shall develop written procedures ☒ ☐ ☐ Section VI, Number 12 to ensure the right of youth to have access to the courts and legal services. Such access shall include: (a) access, upon request by the youth, to licensed attorneys and their authorized representatives; ☒ ☐ ☐ Section VI, Number 12, Policy I-A (b) provision for confidential consultation with attorneys; and, ☒ ☐ ☐ Section VI, Number 12, Policy I-B 7718 Tuolumne Steps to Success PRO 23-24 65 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) unlimited postage free, legal correspondence and cost-free telephone access as appropriate. ☒ ☐ ☐ Section VI, Number 12, Policy I-C 7718 Tuolumne Steps to Success PRO 23-24 66 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1390 DISCIPLINE The facility administrator shall develop and implement Section VII, Number 1, Policy I-A written policies and procedures for the discipline of youth that shall promote acceptable behavior; including the use Section VII, Number 1, Policy I-B of positive behavior interventions and supports. Discipline shall be imposed at the least restrictive level which promotes the desired behavior and shall not include The facility’s rules and sanctions are clearly corporal punishment, group punishment, physical or identified in many forms for all youth. The psychological degradation. Deprivation of the following is sanction matrix is rarely used, only for high- not permitted: risk behaviors and incidents which are rare. The PBIS model of respect, responsibility, and safety is visually and verbally present throughout the facility. Youth are more interested in earning points for commissary, which works to promote the tenets of PBIS. We observed youth in unit activities and the classroom, noting the staff efforts to have conversations with youth routinely as part of their overall philosophy to promote PBIS. The point sheets are tallied daily so youth know where they stand in terms of bedtime, ☒ ☐ ☐ participation in late activities, and incentive options. These pro-social activities and efforts are on full display, evidenced by the low number of high-risk incidents and behaviors. We interviewed 3 youth while on-site, in each of the programs, and found they seem to trust staff and feel like they are treated well. Staff continue to promote positive decision choices, offering options and compromise, which allow a youth to see the benefits of good behavior. Accountability and teaching moments are principles used in the daily operations facility- wide. The agency modified their rule and sanction system to only include minor and major rule violations. We noted Due Process is completed on every rule violation as they use the tool to enhance conversation and promote positive choices. 7718 Tuolumne Steps to Success PRO 23-24 67 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) bed and bedding; ☒ ☐ ☐ Section VII, Number 1, Policy I-C,1 (b) daily shower, access to drinking fountain, toilet and ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 2 personal hygiene items, and clean clothing; (c) full nutrition; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 3 (d) contact with parent or attorney; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 4 (e) exercise; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 5 (f) medical services and counseling; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 6 (g) religious services; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 7 (h) clean and sanitary living conditions; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 8 (i) the right to send and receive mail; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 9 (j) education; and, ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 10 7718 Tuolumne Steps to Success PRO 23-24 68 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (k) rehabilitative programming. ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 11 The facility administrator shall establish rules of conduct and disciplinary penalties to guide the conduct of youth. Section VII, Number 1, Policy I-E Such rules and penalties shall include both major violations and minor violations, be stated simply and ☒ ☐ ☐ Section VII, Number 1, Policy I-F affirmatively, and be made available to all youth. Provision shall be made to provide accessible information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS The facility administrator shall develop and implement Section VII, Number 2 written policies and procedures for the administration of discipline which shall include, but not be limited to: We reviewed 61 DP incidents since October 2022 and found less than 35% were actual rule violations. Of those, 59 were accepted without hearing and 2 were appealed. The process and outcome were appropriate for the behavior and the documentation was clear. ☒ ☐ ☐ The facility continues to over-use DP for minor rule violations and separation incidents. We again provided technical assistance to suggest the daily point sheet be the document to address minor rule violations and separation. However, the intent is to allow for more conversations with youth regarding the behavior resulting in any rule violation, which due to their low population, affords youth and staff to build on relationships promoting positive behavior and supports (PBIS). (a) designation of personnel authorized to impose discipline for violation of rules; ☒ ☐ ☐ Section VII, Number 2, Procedure I-A (b) prohibiting discipline to be delegated to any youth; ☒ ☐ ☐ Section VII, Number 2, Policy I-F 7718 Tuolumne Steps to Success PRO 23-24 69 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) definition of major and minor rule violations and their consequences, and due process requirements; Section VII, Number 1, Procedure IV-A ☒ ☐ ☐ Section VII, Number 1, Procedure IV-B Section VII, Number 1, Procedure IV-C (d) trauma-informed approaches and positive behavior interventions; ☒ ☐ ☐ Section VII, Number 2, Policy I-D (e) minor rule violations may be handled informally by counseling, advising the youth of expected conduct Section VII, Number 1, Procedure IV-A imposing a minor consequence. Discipline shall be ☒ ☐ ☐ accompanied by written documentation and a policy of review and appeal to a supervisor; and, (f) major rule violations and the discipline process shall ☒ ☐ ☐ be documented and require the following: (1) written notice of violation prior to a hearing; ☒ ☐ ☐ Section VII, Number 2, Procedure I-B (2) accommodations provided to youth with disabilities, limited literacy, and English language ☒ ☐ ☐ Section VII, Number 2, Policy I-B learners; (3) hearing by a person who is not a party to the ☒ ☐ ☐ Section VII, Number 2, Procedure I-D incident; (4) opportunity for the youth to be heard, present ☒ ☐ ☐ Section VII, Number 2, Procedure I-F evidence and testimony; (5) provision for youth to be assisted by staff in the ☒ ☐ ☐ Section VII, Number 2, Procedure I-F hearing process; (6) provision for administrative review. ☒ ☐ ☐ Section VII, Number 2, Procedure I-H 7718 Tuolumne Steps to Success PRO 23-24 70 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) violations that result in a removal from camp or commitment program, but not a return to court, will ☒ ☐ ☐ Section VII, Number 2, Procedure II-G follow the due process provisions in subsection (e) above. 1410 MANAGEMENT OF COMMUNICABLE DISEASES. Tuolumne County MLRJDF Section VIII, The health administrator/responsible physician, in Number 1: Management of Communicable cooperation with the facility administrator and the local Diseases health officer, shall develop written policies and ☒ ☐ ☐ procedures to address the identification, treatment, control and follow-up management of communicable This is a comprehensive policy outlining the diseases. The policies and procedures shall address, agency response to communicable disease. but not be limited to: Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 1 Intake Health screening procedures. MLRJDF COVID-19 Screening Form (a) Intake health screening procedures; ☒ ☐ ☐ Wellpath Coronavirus Supplemental Screening Form Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedures 7718 Tuolumne Steps to Success PRO 23-24 71 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 2: Identification of Relevant Symptoms. MLRJDF COVID-19 Screening Form MLRJDF Daily COVID-19 Screening Form (b) Identification of relevant symptoms; ☒ ☐ ☐ Wellpath Coronavirus Supplemental Screening Form Wellpath Patient Monitoring for Positive or Suspected COVID-19 Form Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedure #2 Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 3: Referral for Medical Evaluation (c) Referral for medical evaluation; ☒ ☐ ☐ Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedure #5 Wellpath Nursing Triage for Complaints related to COVID-19 7718 Tuolumne Steps to Success PRO 23-24 72 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 4: Treatment Responsibilities during Detention Tuolumne County MLRJDF Section VIII, (d) Treatment responsibilities during detention; ☒ ☐ ☐ Number 1; Procedure I-C Wellpath MLRJDF COVID-19 Outbreak Control Plan - General Quarantine Procedures Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 5: Coordination with Public and Private Community Based resources for follow-up treatment. Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-G (e) Coordination with public and private community- ☒ ☐ ☐ Tuolumne County Public Health Referral based resources for follow-up treatment; Form Wellpath COVID-19 Discharge Instructions Wellpath COVID-19 Patient Education Wellpath COVID-19 Supplemental Discharge 7718 Tuolumne Steps to Success PRO 23-24 73 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 6: Applicable Reporting Requirements (f) Applicable reporting requirements; and, ☒ ☐ ☐ Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-G Wellpath MLRJDF COVID-19 Outbreak Control Plan - Communication #3 Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 7: Strategies for Handling Disease Outbreaks (g) Strategies for handling disease outbreaks. ☒ ☐ ☐ Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-E and H Wellpath MLRJDF COVID-19 Outbreak Control Plan The policies and procedures shall be updated as necessary to reflect communicable disease priorities The agency works closely with Wellpath staff identified by the local health officer and currently and the local public health agency to ensure recommended public health interventions. ☒ ☐ ☐ proper protocols and processes are in place to address all COVID-19 youth. 1433 REQUESTS FOR HEALTH CARE SERVICES (EXCERPT) Section VIII, Number 12, Procedure I-C The health administrator, in cooperation with the facility administrator, shall develop policy and procedures to ☒ ☐ ☐ establish a daily routine for youth to convey requests for emergency and non-emergency medical, dental and behavioral/mental health care services. 1480 STANDARD FACILTY CLOTHING ISSUE The youth’s personal clothing, undergarments and Section X, Number 1 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: 7718 Tuolumne Steps to Success PRO 23-24 74 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Clothing is clean, reasonably fitted, durable, easily laundered, in good repair, and free of holes and tears. ☒ ☐ ☐ Section X, Number 1, Procedure I-B (b) The standard issue of climatically suitable clothing for youth shall consist of but not be limited to: ☒ ☐ ☐ (1) Socks and serviceable footwear; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 1 (2) Outer garments; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 2 and 3 (3) New non-disposable underwear which shall remain with the youth throughout their stay, and; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 4 (4) Undergarments, that are freshly laundered and free of stains, including tee shirts and bras. ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 5 (c) Clothing is laundered at the temperature required by local ordinances for the commercial laundries and dried Section X, Number 1, Procedure 1-D completely in a mechanical dryer or other laundry ☒ ☐ ☐ method approved by the local health officer. (d) Suitable clothing is issued to pregnant youth. ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 9 1482 CLOTHING EXCHANGE The facility administrator shall develop and implement Section X, Number 1, Procedure I written policies and site-specific procedures for the cleaning and scheduled exchange of clothing. Unless work, climatic conditions, or illness necessitates more ☒ ☐ ☐ frequent 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. 7718 Tuolumne Steps to Success PRO 23-24 75 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1484 CONTROL OF VERMIN IN YOUTH’S PERSONAL CLOTHING Section X, Number 2 There shall be written policies and site-specific procedures developed and implemented by the facility administrator to control the contamination and/or spread ☒ ☐ ☐ of vermin and ecto-parasites in all youth’s personal clothing. Infested clothing shall be cleaned or stored in a closed container so as to eradicate or stop the spread of the vermin. 1485 ISSUE OF PERSONAL CARE ITEMS There shall be written policies and site-specific Section X, Number 3, Procedure I-A procedures developed and implemented by the facility administrator for the availability of personal 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; (a) Toothbrush; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (b) Toothpaste; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (c) Soap; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (d) Comb; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (e) Shaving implements; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (f) Deodorant; ☒ ☐ ☐ Section X, Number 3, Procedure I-A 7718 Tuolumne Steps to Success PRO 23-24 76 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) Lotion; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (h) Shampoo; and, ☒ ☐ ☐ Section X, Number 3, Procedure I-A (i) Post-shower conditioning hair products. ☒ ☐ ☐ Section X, Number 3, Procedure I-A Youth shall not be required to share any personal care items listed in items (a) through (d). Liquid soap Section X, Number 3, Procedure I-A provided through a common dispenser is permitted. Youth shall not share disposable razors. Double edged Section X, Number 3, Procedure I-E safety razors, electric razors, and other shaving ☒ ☐ ☐ instruments capable of breaking the skin, when shared Section X, Number 3, Procedure I-G 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. 1486 PERSONAL HYGIENE There shall be written policies and site specific Section X, Number 3, Procedure I-B procedures developed and implemented by the facility administrator for showering/bathing and brushing of ☒ ☐ ☐ Section X, Number 3, Procedure I-C teeth. Youth shall be permitted to shower/bathe up on assignment to a housing unit and on a daily basis thereafter and given an opportunity to brush their teeth after each meal. 1487 SHAVING Youth shall have access to a razor daily, unless their Section X, Number 3, Procedure IV appearance must be maintained for reasons of identification in Court. All youth shall have equal ☒ ☐ ☐ opportunity to shave face and body hair. The facility administrator may suspend this requirement in relation to youth who are considered to be a danger to themselves or others. 1488 HAIR CARE SERVICES (EXCERPT) Hair care services shall be available in all juvenile Section X, Number 3, Procedure V facilities. Youth shall receive hair care services monthly. ☒ ☐ ☐ Equipment shall be cleaned and disinfected after each haircut or procedure, by a method approved by the State Board of Barbering and Cosmetology. 7718 Tuolumne Steps to Success PRO 23-24 77 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1500 STANDARD BEDDING AND LINEN ISSUE Clean laundered, suitable bedding and linens, in good Section XI, Number 1 repair, shall be provided for each youth entering a living ☒ ☐ ☐ area who is expected to remain overnight, shall include, but not be limited to: (a) One mattress or mattress-pillow combination which meets the requirements of Section 1502 of these ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 1 regulations; (b) One pillow and a pillow case unless provided for in (a) above; ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 1 (c) One mattress cover and a sheet or two sheets; ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 2 (d) One towel; and, ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 4 (e) One blanket or more, up on request ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 3 1501 BEDDING LINEN EXCHANGE The facility administrator shall develop and implement Section XI, Number 1, Procedure I site specific written policies and procedures for the scheduled exchange of laundered bedding and linen ☒ ☐ ☐ issued to each youth housed. Washable items such as sheets, mattress covers, pillow cases and towels shall be exchanged for clean replacement at least once each week. The covering blanket shall be cleaned or laundered once a month. ☒ ☐ ☐ Section XI, Number 1, Procedure I-E 7718 Tuolumne Steps to Success PRO 23-24 78 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1510 FACILITY SANITATION, SAFETY AND MAINTENANCE Section XII, Number 1 The facility administrator shall develop and implement written policies and site-specific procedures for the maintenance of an acceptable level of cleanliness, repair and safety throughout the facility. The plan shall provide for a regular schedule of housekeeping tasks, ☒ ☐ ☐ equipment, including restraint devices, and physical plant maintenance and inspections to identify and correct unsanitary or unsafe conditions or work practices in a timely manner. The use of chemicals shall be done in accordance to the product label and Safety Data Sheet which may include the use of Personal Protection Equipment (PPE). REVIEW OF NON REGULATORY REQUIREMENTS RANT FUNDING OR CODE REFERENCE YES NO N/A P/P REFERENCE - COMMENTS JUVENILE PROBATION AND CAMPS FUNDING (JPCF) (Camps Only) The programs/services identified on the JPCF Camp Eligibility Form are being provided at the facility. (Refer ☒ ☐ ☐ to the JPCF Camp Eligibility Form) 208.5 WIC CONTACT BETWEEN PERSONS UNDER THE JUVENILE COURT AGES 19- 20 AND MINORS IN THE FACILITY The facility houses Juvenile Court Wards 19 years of ☒ ☐ ☐ age and older. The facility has been approved to hold persons under ☒ ☐ ☐ the juvenile court who are ages 19 through 21. The facility continues to comply with the requirements of 208.5 WIC (programming, capacity and security of ☒ ☐ ☐ the facility) as outlined in the county’s application. JUVENILE JUSTICE DELINQUENCY PREVENTION ACT MONITORING (JJDPA) WIC 206 SEPARATE FACILITIES FOR WIC 300 MINORS ☐ ☐ ☒ Dependent or neglected minors who are defined under Section 300 of the Welfare and Institutions Code (WIC) Violation are held only in non-secure, separate and segregated facilities. DETENTION OF STATUS OFFENDERS (WIC 601) AND FEDERAL MINORS ☐ ☒ ☐ Status Offenders (WIC 601) are held in the facility. Status Offenders (WIC 601) are kept separate from ☐ ☐ ☒ Juvenile Delinquents (WIC 602)? (WIC 207[d]). Violation 7718 Tuolumne Steps to Success PRO 23-24 79 A453 JUV PRO eff. 1/2019 (23-24).dot Federal Minors (ICE Holds or ORR Contract) are held ☐ ☒ ☐ in the facility. If yes to the above, the Monthly Report on the Detention of Status Offenders/Federal Minors is ☐ ☐ ☒ submitted to the BSCC. WIC 208 SEPARATION OF MINORS AND ADULT INMATES (JJDPA 42 USC 5633, Sec 223, State Plans (a)[12]) ☐ ☒ ☐ Are adult inmates held in the facility? (When a person in detention is proceeding through the adult court, AND that person is 18 years of age or older that person is an adult inmate.) If adult inmates are held, they are appropriately ☐ ☐ ☒ separated from minors. Violation Adult inmates from an adult facility (e.g. inmate workers ☐ or “Scared Straight” programs) are not allowed in the ☐ ☒ facility in a manner that allows contact with minors. Violation 7718 Tuolumne Steps to Success PRO 23-24 80 A453 JUV PRO eff. 1/2019 (23-24).dot JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7717 FACILITY NAME: Tuolumne County Summit SYTF Program FACILITY TYPE: SYTF Mother Lode Regional Juvenile Detention Facility PERSON(S) INTERVIEWED: Dan Hawks, Chief Probation Officer; Annie Hockett, Assistant Chief Probation Officer; Christie Schultze, Supervising Probation Officer; Will Nielsen, Supervising Probation Officer; Ashley Champeaux, Teacher - Gold Ridge School; Kayla Rolfe, Transition Specialist, TCSOS; Cheyne Turberville, RN Wellpath Health Services - Juvenile Facility; Matt Horton, Juvenile Corrections Officer II; Youth: Jacob Z, age 17; Zach D, age 17; Blanca, age 17. FIELD REPRESENTATIVE: Elizabeth Gong DATE: November 7-8, 2023 TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1313 COUNTY INSPECTION AND EVALUATION OF BUILDING AND GROUNDS September 6, 2022 On an annual basis, or as otherwise required by law, July 21, 2023 each juvenile facility administrator shall obtain a ☐ ☒ ☐ documented inspection and evaluation from the following: (a) county building inspector or person designated by the Board of Supervisors to approve building safety; (b) fire authority having jurisdiction, including a fire clearance as required by Health and Safety Code Section ☒ ☐ ☐ September 2, 2022 13146.1(a) and (b); July 31, 2023 (c) local health officer, inspection in accordance with Health and Safety Code Section 101045; 2022: Environmental Health: October 21, 2022 Medical/Mental Health: October 24, 2022 Nutritional Health: November 22, 2022 ☒ ☐ ☐ 2023: Environmental Health: October 24, 2023 Medical/Mental Health: November 2, 2023 Nutritional Health: October 23, 2023 (d) county superintendent of schools on the adequacy of educational services and facilities as required in Section ☒ ☐ ☐ July 28, 2022 1370; July 27, 2023 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. 7717 Tuolumne Summit Program PRO 23-24 1 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) juvenile court as required by Section 209 of the Welfare and Institutions Code; and, ☒ ☐ ☐ May 27, 2021 December 8, 2022 (f) the Juvenile Justice Commission as required by Section 229 of the Welfare and Institutions Code or ☒ ☐ ☐ February 25, 2022 Probation Commission as required by Section 240 of the February 3, 2023 Welfare and Institutions Code. 1320 APPOINTMENT AND QUALIFICATIONS Section III, Number 1, Procedure I-A BSCC Note: Compliance with this section is determined by receipt of the Chief Probation Officer’s certification The elements of this regulation are addressed letter confirming that all elements of regulation are met. in a memorandum completed on March 3, 2023, by Chief Probation Officer Dan Hawks. (a) Appointment ☒ ☐ ☐ In each juvenile facility there shall be a superintendent, director or facility manager in charge of its program and employees. Such superintendent, director, facility manager and other employees of the facility shall be appointed by the facility administrator pursuant to applicable provisions of law. (b) Employee Qualifications Each facility shall: Section III, Number 1, Procedure II (1) recruit and hire employees who possess ☒ ☐ ☐ Section III, Number 1, Procedure II-1 knowledge, skills and abilities appropriate to their job classification and duties in accordance with applicable civil service or merit system rules; (2) require a medical evaluation and physical examination including tuberculosis screening test and Section III, Number 1, Procedure II-2 evaluation for immunity to contagious illnesses of ☒ ☐ ☐ childhood (i.e., diphtheria, rubeola, rubella, and mumps); (3) adhere to the minimum standards for the selection and training requirements adopted by the Board ☒ ☐ ☐ Section III, Number 1, Procedure II-3 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in Section III, Number 1, Procedure II-4 ☒ ☐ ☐ accordance with Section 1031 of the Government Code. (c) Contract personnel, volunteers, and other non- employees of the facility, who may be present at the Section III, Number 1, Procedure II-5 facility, shall have such clearance and qualifications as ☒ ☐ ☐ may be required by law, and their presence at the facility shall be subject to the approval and control of the facility manager. 7717 Tuolumne Summit Program PRO 23-24 2 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1321 STAFFING Each juvenile facility shall: Section III, Number 2 (a) have an adequate number of personnel sufficient to Section III, Number 2, Procedure I-A carry out the overall facility operation and its programming, to provide for safety and security of youth and staff, and meet established standards and The facility has self-capped their population at regulations; 20 youth, applying a staffing ratio of 1:8. ☒ ☐ ☐ The facility currently has 2 Supervising Juvenile Corrections Officers (JCO). There are 4 Senior JCO’s plus one relief Senior (Extra Help), and 8-line JCO staff, with two other staff in background to fill the vacancies. A Field Probation Officer is assigned to the facility to assist with the Steps 2 Success Camp Program and Summit SYTF Program. (b) ensure that no required services shall be denied because of insufficient numbers of staff on duty absent ☒ ☐ ☐ Section III, Number 2, Procedure I-A exigent circumstances; (c) have a sufficient number of supervisory level staff to ensure adequate supervision of all staff members; ☒ ☐ ☐ Section III, Number 2, Procedure I-B (d) have a clearly identified person on duty at all times who is responsible for operations and activities and has Section III, Number 2, Procedure I-C completed the Juvenile Corrections Officer Core Course and PC 832 training; ☒ ☐ ☐ There is a Supervisor, Senior JCO, or designated lead staff on duty and in charge of the facility when the Superintendent is not on duty. (e) have at least one staff member present on each living unit whenever there are youth in the living unit; ☒ ☐ ☐ Section III, Number 2, Procedure I-D 7717 Tuolumne Summit Program PRO 23-24 3 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (f) have sufficient food service personnel relative to the number and security of living units, including staff Section III, Number 2, Procedure I-E 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 Meals are provided by Summit Foods through records; or, a facility may serve food that meets nutritional the Tuolumne County Jail and served by standards prepared by an outside source; serve-safe certified JCO staff and/or youth. (g) have sufficient administrative, clerical, recreational, medical, dental, mental health, building maintenance, Section III, Number 2, Procedure I-F 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, Support staff and ancillary personnel are not part of youth supervision staff. (h) assign sufficient youth supervision staff to provide continuous wide awake supervision of youth, subject to Section III, Number 2, Procedure I-G temporary variations in staff assignments to meet special program needs. Staffing shall be in compliance with a minimum youth-staff ratio for the following facility types: ☒ ☐ ☐ The facility has made the decision to staff at a 1:8 ratio. (1) Juvenile Halls (A) during the hours that youth are awake, one Section III, Number 2, Procedure I-H wide-awake youth supervision staff member on duty for each 10 youth in detention; ☒ ☐ ☐ The facility staffs the facility at 1:8 during waking hours. (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake Section III, Number 2, Procedure I-I youth supervision staff member on duty for each 30 youth in detention; ☒ ☐ ☐ The facility staffs the facility at a 1:16 ratio during sleeping hours. (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the Section III, Number 2, Procedure I-J number of youth in detention, unless an ☒ ☐ ☐ arrangement has been made for backup support services which allow for immediate response to emergencies; and, 7717 Tuolumne Summit Program PRO 23-24 4 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (D) at least one youth supervision staff member on duty who is the same gender as youth housed in ☒ ☐ ☐ Section III, Number 2, Procedure I-K the facility. (E) personnel with primary responsibility for other duties such as administration, supervision of Section III, Number 2, Procedure I-F personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. ☒ ☐ ☐ Only JCO staff assigned to the living units supervise youth in detention. (2) Special Purpose Juvenile Halls (A) during hours that youth are awake, one wide- ☐ ☐ ☒ awake youth supervision staff member on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number of youth in detention, unless an ☐ ☐ ☒ arrangement has been made for backup support services which allow for immediate response to emergencies; and, (D) at least one youth supervision staff member on duty who is the same gender as youth housed in ☐ ☐ ☒ the facility. (E) personnel with primary responsibility for other duties such as administration, supervision of personnel, academic or trade instruction, clerical, ☐ ☐ ☒ kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (A) during the hours that youth are awake, one ☐ ☐ ☒ wide-awake youth supervision staff member on duty for each 15 youth in the camp population; (B) during the hours that youth are confined to their room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth present in the facility; 7717 Tuolumne Summit Program PRO 23-24 5 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number of youth in residence, unless ☐ ☐ ☒ arrangements have been made for backup support services which allow for immediate response to emergencies; (D) at least one youth supervision staff member on duty who is the same gender as youth housed in ☐ ☐ ☒ the facility; (E) in addition to the minimum staff to youth ratio required in (h)(3)(A)-(B), consideration shall be given to the size, design, and location of the camp; types of youth committed to the camp; and the ☐ ☐ ☒ function of the camp in determining the level of supervision necessary to maintain the safety and welfare of youth and staff; (F) personnel with primary responsibility for other duties such as administration, supervision of personnel, academic or trade instruction, clerical, ☐ ☐ ☒ farm, forestry, kitchen or maintenance shall not be classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF ORIENTATION AND TRAINING Section III, Number 4, Procedure I-A (a) Prior to assuming any responsibilities each youth supervision staff member shall be properly oriented to Section III, Number 4, Procedure I-B their duties, including: Section III, Number 4, Procedure I-B, 1 (1) youth supervision duties; Section III, Number 4, Procedure I-C Section III, Number 4, Procedure I-D The agency spends three weeks to train to specific facility responsibilities and to ensure ☒ ☐ ☐ they are ready for all youth supervision duties. A Training Checklist Sign-Off is completed by the staff and trainer. The facility administration has implemented a curriculum ensuring staff and ancillary personnel working with and/or supervising youth are aware of their role and responsibilities. We reviewed the training checklists for the 3 newly hired JCO’s and found the curriculum within regulatory standards. 7717 Tuolumne Summit Program PRO 23-24 6 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) scope of decisions they shall make; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 2 (3) the identity of their supervisor; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 3 (4) the identity of persons who are responsible to them; ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 4 (5) persons to contact for decisions that are beyond their responsibility; and ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 5 (6) ethical responsibilities. ☒ ☐ ☐ Section III, Number 4, Procedure I-B, 6 (b) Prior to assuming any responsibility for the supervision of youth, each youth supervision staff Section III, Number 4, Procedure I-A member shall receive a minimum of 40 hours of facility- specific orientation, including: The facility has a detailed staff orientation which includes internal training by a ‘Field ☒ ☐ ☐ Training Officer’, mentoring and training new staff in facility operations. The trainer and staff initial a checklist after each component, including many areas which exceed T15 requirements. (1) individual and group supervision techniques; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 2 (2) regulations and policies relating to discipline and rights of youth pursuant to law and the provisions of ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 3 this chapter; (3) basic health, sanitation and safety measures; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 8 7717 Tuolumne Summit Program PRO 23-24 7 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) suicide prevention and response to suicide ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 9 attempts (5) policies regarding use of force, de-escalation techniques, chemical agents, mechanical and ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 4 physical restraints; (6) review of policies and procedures referencing ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 5 trauma and trauma-informed approaches; Section III, Number 4, Procedure I-C, 6 (7) procedures to follow in the event of emergencies; ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 7 (8) routine security measures, including facility ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 13 perimeter and grounds; Section III, Number 4, Procedure I-C, 9 Section III, Number 4, Procedure I-C, 10 (9) crisis intervention and mental health referrals to There is a TCBH Case Manager assigned to ☒ ☐ ☐ mental health services; the facility who designates county BH Clinicians to complete groups and individual counseling for in-custody youth. The facility Superintendent is a Licensed Clinician and provides Crisis Counseling if BH staff are not on site. (10) documentation; and ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 11 (11) fire/life safety training ☒ ☐ ☐ Section III, Number 4, Procedure I-C, 12 7717 Tuolumne Summit Program PRO 23-24 8 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Prior to assuming sole supervision of youth, each youth supervision staff member shall successfully Section III, Number 4, Procedure I-B complete the requirements of the Juvenile Corrections Officer Core Course pursuant to Penal Code Section 6035. Of the current Senior and line JCO’s responsible for youth supervision, all 10 are ☒ ☐ ☐ core-trained. The agency has two vacancies with both positions in background. There are two extra-help line staff, one extra help senior, and a DPO that assist in covering necessary shifts. (d) Prior to exercising the powers of a peace officer youth supervision staff shall successfully complete training Section III, Number 4, Procedure I-C pursuant to Section 830 et seq. of the Penal Code. ☒ ☐ ☐ All 10 youth supervision staff and both Supervisors have completed PC 830. 1323 FIRE AND LIFE SAFETY Whenever there is a youth in a juvenile facility, there shall Section III, Number 22, Procedure I-A be at least one wide awake person on duty at all times who meets the training standards established by the Board for general fire and life safety which relate ☒ ☐ ☐ All cored youth supervision staff and specifically to the facility. Supervisors received Fire and Life Safety training in JCO Core. 1324 POLICY AND PROCEDURES MANUAL All facility administrators shall develop, publish, and Section III, Number 23, Procedure I implement a manual of written policies and procedures that address, at a minimum, all regulations that are applicable to the facility. Such a manual shall be made The facility Policy and Procedure Manual was available to all employees, reviewed by all employees, ☒ ☐ ☐ last reviewed on July 30, 2023. Facility staff and shall be administratively reviewed at a minimum are required to read the manual each year, every two years, and updated, as necessary. Those signing a document kept in their personnel file records relating to the standards and requirements set to verify compliance for this policy forth in these regulations shall be accessible to the Board requirement. on request. The manual shall include: (a) table of organization, including channels of communications and a description of job classifications; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 1 7717 Tuolumne Summit Program PRO 23-24 9 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) responsibility of the probation department, purpose of programs, relationship to the juvenile court, the Juvenile Section III, Number 23, Procedure II-B, 2 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; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 3 (d) initial orientation and training program for employees; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 4 (e) initial orientation, including safety and security issues and anti-discrimination policies, for support staff, contract ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 5 employees, school, mental/behavioral health and medical staff, program providers and volunteers; (f) maintenance of record-keeping, statistics and communication system to ensure: ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6 (1) efficient operation of the juvenile facility; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-a (2) legal and proper care of youth; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-b (3) maintenance of individual youth's records; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-c (4) supply of information to the juvenile court and ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-d those authorized by the court or by the law; and, (5) release of information regarding youth. ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-e 7717 Tuolumne Summit Program PRO 23-24 10 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) ethical responsibilities; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 6-f (h) trauma-informed approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 7 (i) culturally responsive approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 8 (j) gender responsive approaches; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 9 (k) a non-discrimination provision that provides that all youth within the facility shall have fair and equal access Section III, Number 23, Procedure II-B, 10 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, ☒ ☐ ☐ The Non-Discrimination Policy is in the Youth national origin, immigration status, color, religion, gender, Handbook and in the procedures of sexual orientation, gender identity, gender expression, admission, classification, and due process. It mental or physical disability, or HIV status, including is also posted in the living unit. 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 Section III, Number 23, Procedure II-B, 11 and ammunition, where applicable; ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 8 (m) establishment of procedures for collection of Medi- Cal eligibility information and enrollment of eligible youth; ☒ ☐ ☐ Section III, Number 23, Procedure II-B, 12 and, 7717 Tuolumne Summit Program PRO 23-24 11 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (n) establishment of a policy that prohibits all forms of sexual abuse, sexual assault and sexual harassment. Section III, Number 23, Procedure II-B, 13 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 ☒ ☐ ☐ The facility has a comprehensive PREA third party. policy, including staffing the facility at 1:8 and 1:16, based on a self-imposed cap of population. 1325 FIRE SAFETY PLAN The facility administrator shall consult with the local fire Section III, Chapter 22 department having jurisdiction over the facility, or with the State Fire Marshal, in developing a plan for fire safety ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 1 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; (b) monthly fire and life safety inspections by facility staff with two-year retention of the inspection record; Section III, Number 22, Procedure IV-A, 2 The facility has an assigned safety officer that conducts these inspections monthly. We ☒ ☐ ☐ reviewed all the monthly inspections from October 2022 to October 2023. The form and inspection process for recording deficiencies or need for repair are well documented and addressed by maintenance if necessary. (c) fire prevention inspections as required by Health and Safety Code Section 13146.1(a) and (b); ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 3 (d) an evacuation plan; ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 4 7717 Tuolumne Summit Program PRO 23-24 12 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) documented fire drills not less than quarterly; Section III, Number 22, Procedure IV-A, 5 ☒ ☐ ☐ We reviewed fire drills from October 2022 to October 2023. The agency completes drills more frequently than required in regulation. (f) a written plan for the emergency housing of youth in the case of fire; and, Section III, Number 22, Procedure IV-A, 6 Section III, Number 22, Procedure IX-C, 1-c ☒ ☐ ☐ The facility has an agreement in effect for Stanislaus County Probation to accept all youth detained in the event of an emergency evacuation. (g) development of a fire suppression pre-plan in cooperation with the local fire department. ☒ ☐ ☐ Section III, Number 22, Procedure IV-A, 7 7717 Tuolumne Summit Program PRO 23-24 13 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1326 SECURITY REVIEW Each facility administrator shall develop policies and Section III, Number 24 procedures to annually review, evaluate, and document security of the facility. The review and evaluation shall Section III, Number 33 Security Procedures include internal and external security, including, but not Section III, Number 34 Key Control limited to, key control, equipment, and staff training. Section III, Number 22, Procedure III-E Annual Review A Security Review memo was completed by Supervisor William Neilsen on March 20, ☒ ☐ ☐ 2023, outlining the security practices and needs for the facility. The memo identified the most current issues, the need to better secure the stairwell leading outside from the upper tier, and updating cameras, with the SB 823 Infrastructure Grant dollars. County Contractors were on-site during our inspection and have a timeline to complete the SB 823 projects by year-end. 1327 EMERGENCY PROCEDURES The facility administrator shall develop facility-specific Section III, Number 22 policies and procedures for emergencies that shall include, but not be limited to: ☒ ☐ ☐ An emergency procedure memo was completed by Assistant Chief Probation Officer/Facility Superintendent Annie Hockett on March 1, 2023. Section III, Number 25 Hostages (a) escape, disturbances, and the taking of hostages; ☒ ☐ ☐ Section III, Number 26 Escapes Section III, Number 32 Firearms in the Facility 7717 Tuolumne Summit Program PRO 23-24 14 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section III, Number 22, X Civil Disturbance, Active Shooter, Terrorist Attack (b) civil disturbance, active shooter and terrorist ☒ ☐ ☐ attack; Section III, Number 28 Bomb Threat Section III, Number 30 Riot Control Section III, Number 22 Section III, Number 27 Hazard Mat Response (c) fire and natural disasters; ☒ ☐ ☐ Section III, Number 22, Procedure VIII Earthquake Section III, Number 22, Procedure IX Flood (d) periodic testing of emergency equipment; ☒ ☐ ☐ Section III, Number 29 Power Failure Section III, Number 22, Procedure IV-A, 4 (e) emergency evacuation of the facility; and ☒ ☐ ☐ Section III, Number 22, Procedure XI Evacuation Section III, Number 22, Procedure IV-C Initial Orientation (f) a program to provide all youth supervision staff ☒ ☐ ☐ with an annual review of emergency procedures. Facility staff are required to read the facility policy manual each year, which outline all Emergency Procedures in all situations. 7717 Tuolumne Summit Program PRO 23-24 15 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1328 SAFETY CHECKS The facility administrator shall develop and implement Section III, Number 31 Safety Checks policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, at random or varied intervals during hours when youth The facility has implemented a better are asleep or when youth are in their rooms, confined in electronic safety check system and completes holding cells or confined to their bed in a dormitory. regular audits to ensure the checks are Supervision is not replaced, but may be supplemented random and varied. Audits are done weekly by, an audio/visual electronic surveillance system with a randomizer program and video review designed to detect overt, aggressive or assaultive to capture why the check was late. behavior and to summon aid in emergencies. All safety checks shall be documented with the actual time the check is completed. The system allows for deactivation when youth are “all out” and no check is needed. If ☒ ☐ ☐ there is a late check, facility administration is notified and staff are required to make an entry in the unit log of the reason for the late check. We reviewed safety check audits for the months of October 2022 and January and July 2023. We found few late checks out of over 10,000 checks required in the 3-month period. The audit process in place is effective and any consistent patterns are handled administratively, per policy. 7717 Tuolumne Summit Program PRO 23-24 16 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1329 SUICIDE PREVENTION PLAN The facility administrator, in collaboration with the Section III, Number 36 healthcare and behavioral/mental health administrators, shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. The Suicide Prevention Plan and policy are a The plan shall consider the needs of youth experiencing collaboration with WellPath Medical and past or current trauma. Suicide prevention responses Tuolumne County Behavioral Health, which shall be respectful and in the least invasive manner includes very specific roles and consistent with the level of suicide risk. The plan shall responsibilities for medical, behavior health, include the following elements: and probation facility staff. The facility policy and annual training in suicide prevention is comprehensive and inclusive of all elements in regulation. The agency has an on-site Behavior Health Case Manager and multiple Clinicians with the agency to address and see youth as ☒ ☐ ☐ necessary. ACPO Annie Hockett continues to provide crisis counseling when necessary. There have not been any suicide attempts this cycle, however, there have been five incidents to place a youth on safety watch status due to ideation or suicidal gestures, three involving one youth. We reviewed two incident reports and found the agency compliant. Behavior Health is more involved in individual and follow-up for these behaviors but the facility Superintendent, who is a licensed Clinician, provides most of the immediate crisis intervention to diffuse and address these behaviors. None of the incidents involved the sole Summit SYTF youth. (a) Suicide prevention training as required in Section 1322, Youth Supervision Staff Orientation, and Training ☒ ☐ ☐ Section III, Number 36, Procedure I-B and the Juvenile Corrections Officer Core Course. 7717 Tuolumne Summit Program PRO 23-24 17 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Screening, Identification Assessment and Precautionary Protocols Section III, Number 36, Procedure I-C (1) All youth shall be screened for risk of suicide at intake and as needed during detention. Section III, Number 36, Procedure I-D The facility uses the MAYSI prior to housing youth at intake, which assesses the youth’s likeliness to have suicidal behaviors or ideations while in detention. The tool provides a caution or warning status which places a youth, per policy, on a special watch pending review and being seen by Behavior Health. ☒ ☐ ☐ The agency also has adapted the SAFE-T Assessment to identify certain suicide behaviors, which is implemented by Behavior Health. Behavior Health has a Case Manager and assigned clinicians to see youth on-site, a positive change from last cycle. Superintendent Annie Hockett continues to provide crisis interventions when TCBH is not on-site or available to respond immediately. (2) All youth supervision staff who perform intake processes shall be trained in screening youth for risk Section III, Number 36, Procedure I-B of suicide. ☒ ☐ ☐ The agency provides eight hours of initial training and an annual 2-hour refresher training for all youth supervision staff. (3) All youth who have been identified during the intake screening process to be at risk of suicide shall ☒ ☐ ☐ Section III, Number 36, Procedure I-D be referred to behavioral/mental health staff for a suicide risk assessment. (4) Precautionary protocols shall be developed to ensure the youth’s safety pending the Section III, Number 36, Procedure II behavioral/mental health assessment. ☒ ☐ ☐ Youth are placed on a Safety Watch pending review or being seen by a BH or MH personnel. 7717 Tuolumne Summit Program PRO 23-24 18 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Referral process to behavioral/mental health staff for assessment and/or services. Section III, Number 36, Procedure II-A ☒ ☐ ☐ Section III, Number 36, Procedure II-B (d) Procedures for monitoring of youth identified at risk for suicide. Section III, Number 36, Procedure II ☒ ☐ ☐ The facility proactively provides direct visual supervision of all youth who are identified as at risk of actively attempting or verbally discussing suicide. (e) Safety Interventions (1) Procedures to address intervention protocols for ☒ ☐ ☐ youth identified at risk for suicide which may include, Section III, Number 36, Procedure II-C but are not limited to: (A) Housing consideration Section III, Number 36, Procedure II-C, 1-3 ☒ ☐ ☐ The facility has a comprehensive suicide risk/needs assessment as well as the MAYSI Screening tool utilized for each intake. (B) Treatment strategies including trauma- informed approaches Section III, Number 36, Procedure III-G The facility provides treatment strategies ☒ ☐ ☐ based on a training curriculum and policy, which references how staff address and supervise youth at risk, defined by the assessment. 7717 Tuolumne Summit Program PRO 23-24 19 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) Procedures to instruct youth supervision staff how to respond to youth who exhibit suicidal Section III, Number 36, Procedure II-D behaviors. Each of the incidents we reviewed revealed compliance with regulation and policy, as well ☒ ☐ ☐ as a vested interest in helping the youth. The forms, process, and administrative involvement/review are debriefed and used as a training tool for staff. Facility staff are very aware of the risks and responses of suicidal behavior based on extensive training. (f) Communication (1) The intake process shall include communication Section III, Number 36, Procedure I-C with the arresting officer and family guardians regarding the youth’s past or present suicidal Section III, Number 36, Procedure I-E ideations, behaviors or attempts. ☒ ☐ ☐ The admission forms include several referenced areas that include communication with the officer and family. (2) Procedures for clear and current information sharing about youth at risk for suicide with youth ☒ ☐ ☐ Section III, Number 36, Procedure I-E supervision, healthcare, and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Suicides or Attempts Section III, Number 26, Procedure III-H (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 ☒ ☐ ☐ Section III, Number 36, Procedure III-G staff. (3) Process for a debriefing event with affected youth. ☒ ☐ ☐ Section III, Number 36, Procedure III-G 7717 Tuolumne Summit Program PRO 23-24 20 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Documentation (1) Documentation processes shall be developed to ☒ ☐ ☐ Section III, Number 36, Procedure III-F ensure compliance with this regulation Youth identified at risk for suicide shall not be denied the opportunity to participate in facility programs, services Section III, Number 36, Procedure II-G and activities which are available to other non-suicidal youth, unless deemed necessary for the safety of the Section III, Number 36, Procedure II-I 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 The facility staff work within policy to identify facility manager. the youth’s specific housing needs, programming elements, and engagement with other youth. 1340 REPORTING OF LEGAL ACTIONS Each facility shall submit to the Board a letter of Section IV, Number 1 notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities responsible for juvenile facility operation. ☒ ☐ ☐ There are no pending legal actions against the Tuolumne County Motherlode Regional Juvenile Detention Facility. 1341 DEATH AND SERIOUS ILLNESS OR INJURY OF A YOUTH WHILE DETAINED Section IV, Number 3, I-F (1) Death of a Youth. (a) The facility administrator, in cooperation with Section IV, Number 3, I-A the health administrator and the behavioral/mental health director, shall develop written policies and ☒ ☐ ☐ procedures in the event of the death of a youth while detained, which include notifications to necessary parties, which may include the Juvenile Court, the parent, guardian or person standing in loco parentis and the youth’s attorney of record. (b) The health administrator, in cooperation with the facility administrator, shall develop written Section IV, Number 3, I-B policies and procedures to assure there is a medical and operational review of every in-custody death of Section IV, Number 3, I-C a youth. The review team shall include the facility ☒ ☐ ☐ administrator and/or facility manager, the health administrator, the responsible physician and other health care and supervision staff who are relevant to the incident. 7717 Tuolumne Summit Program PRO 23-24 21 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) The administrator of the facility shall provide to the Board a copy of the report submitted to the Section IV, Number 3, I-D Attorney General under Government Code Section ☒ ☐ ☐ 12525. A copy of the report shall be submitted to the Board within 10 calendar days after the death. (d) Upon receipt of a report of the death of a youth from the administrator, the Board may within 30 Section IV, Number 3, I-E calendar days inspect and evaluate the juvenile facility, jail, lockup or court holding facility pursuant ☒ ☐ ☐ to the provisions of this subchapter. Any inquiry made by the Board shall be limited to the standards and requirements set forth in these regulations. (2) Serious Illness or Injury of Youth. (a) The facility administrator, in cooperation with Section IV, Number 3, I-H the health administrator, shall develop written policies and procedures for the notification to ☒ ☐ ☐ necessary parties, which may include the Juvenile Court, the parent, guardian or person standing in loco parentis and the youth’s attorney of record in the case of a serious illness or injury of a youth. 1342 POPULATION ACCOUNTING Each juvenile facility shall submit required population ☒ ☐ ☐ Section IV, Number 4 and profile survey reports to the Board within 10 working days after the end of each reporting period, in a format to be provided by the Board. 1343 JUVENILE FACILITY CAPACITY (EXCERPT) When the number of youth detained in a living unit of a Section IV, Number 5 juvenile facility exceeds its rated capacity for more than ☒ ☐ ☐ fifteen (15) calendar days in a month, the facility administrator shall provide a crowding report to the Board in a format provided by the Board. 7717 Tuolumne Summit Program PRO 23-24 22 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1350 ADMITTANCE PROCEDURES The facility administrator shall develop and implement Section V, Number 1 Purpose written policies and procedures for admittance of youth that emphasize respectful and humane engagement Section V, Number 1-C with youth, and reflect that the admission process may be traumatic to youth who may have already experienced trauma. Policies shall be trauma-informed, The agency has a comprehensive intake culturally relevant, and responsive to the language and process for youth and includes an “Intake literacy needs of youth. In addition to the requirements Checklist” to ensure all procedural elements of Sections 1324 and 1430 of these regulations: are met. The facility only accepts youth identified with risks to community safety or themselves, as screened from the Detention Risk Assessment Instrument (DRAI), the MAYSI, and an internal risk/needs screening tool. We reviewed 10 comprehensive intake ☒ ☐ ☐ packets that included the checklist; the Intake Health Screening; Property Inventory; the Youth Strengthening Admissions Assessment (Trauma, emotional, risks, and needs); PREA Acknowledgement; Language and Gender Preference Forms; Admission Report; Consent for Medical Treatment; Dental Permission Slip; and MAYSI/DRAI Assessments. The process is inclusive of information to assist staff and agency partners for youth care while in custody. The agency has one SYTF Summit commitment. There are no special admission procedures for this population as the youth are housed in one living unit. (a) the admittance process shall include: (1) Access to two free phone calls within one hour of ☒ ☐ ☐ Section V, Number 1, Procedure I-S admittance in accordance with the provisions of Welfare and Institution Code Section 627; (2) Offer of a shower; ☒ ☐ ☐ Section V, Number 1, Procedure I-M 7717 Tuolumne Summit Program PRO 23-24 23 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section V, Number 1, Procedure I-L (3) Documented secure storage of personal ☒ ☐ ☐ belongings; Section V, Number IV (4) Offer of food upon arrival; ☒ ☐ ☐ Section V, Number 1, Procedure I-M (5) Screening for physical and behavioral health and safety issues, intellectual or developmental ☒ ☐ ☐ Section V, Number 1, Procedure I-F disabilities; (6) Screening for physical and developmental disabilities in accordance with Sections 1329, 1413, ☒ ☐ ☐ Section V, Number 1, Procedure I-C and 1430 of these regulations; (7) Contact with Regional Center for the Developmentally Disabled for youth that are Section V, Number 1, Procedure I-D suspected of or identified as having a ☒ ☐ ☐ developmental disability, pursuant to Section 1413; and, (8) Procedures consistent with Section 1352.5. ☒ ☐ ☐ Section V, Number 6 (b) juvenile hall administrators shall establish written criteria for detention that considers the least restrictive Section V, Number 1, Procedure I-III environment. ☒ ☐ ☐ The facility has specific criteria for detention, which allows for an override if justified. (c) juvenile camps and post-dispositional programs in juvenile halls shall develop policies and procedures that Section V, Number I-N advise the youth of the estimated length of stay, inform them of program guidelines and provide written screening criteria for inclusion and exclusion from the program. The S2S and Summit youth have regular ☒ ☐ ☐ MDT’s to assist with information on release. The SYTF youth has an Individual Rehabilitation Plan every 6 months and appears before the Court to determine time lessened or added to the initial base term. 7717 Tuolumne Summit Program PRO 23-24 24 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) juvenile halls shall develop policies and procedures that advise any committed youth of the estimated length ☒ ☐ ☐ Section V, Number I-N of his/her stay. 1350.5 SCREENING FOR THE RISK OF SEXUAL ABUSE Section V, Number 6 The facility administrator shall develop and implement written policies and procedures to reduce the risk of sexual abuse by or upon youth. The policy shall require The facility developed a tool, the Youth facility staff to assess each youth within 72 hours of ☒ ☐ ☐ Strengthening Admissions Assessment, admission based on the following information: within their classification screening instrument to address youth who are potential perpetrators or victims of sexual assault or abuse. (a) Prior sexual victimization or abusiveness; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (b) Gender nonconforming appearance or manner; or identification as lesbian, gay or bisexual, transgender, ☒ ☐ ☐ Section V, Number 6, Procedure I-B queer or intersex, and whether the youth may, therefore, be vulnerable to sexual abuse; (c) Current charges and offense history; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (d) Age; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (e) Level of emotional and cognitive development; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (f) Physical size and stature; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (g) Mental illness or mental disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B 7717 Tuolumne Summit Program PRO 23-24 25 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) Intellectual or developmental disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (i) Physical disabilities; ☒ ☐ ☐ Section V, Number 6, Procedure I-B (j) The youth’s perception of vulnerability; and, ☒ ☐ ☐ Section V, Number 6, Procedure I-B (k) Any other specific information about the individual youth that may indicate heightened needs for The Classification/Youth Housing Screening supervision, additional safety precautions, or separation tool and the Youth Strengthening Admissions from certain other youth. Assessment were developed in coordination ☒ ☐ ☐ with BH to establish and identify information which could or would assist in all safety elements. Staff shall ascertain this information through conversations with the youth during the admittance Section V, Number 6, Procedure I-A process, medical and behavioral health screenings; during classification assessments; and by reviewing court records, case files, facility behavioral records, and ☒ ☐ ☐ other relevant documentation from the youth’s files. The admission risk/needs assessment is used to assist in classification of all admitted youth. The facility administrator shall implement appropriate controls on the dissemination of information within the Section V, Number 6, Policy I-B facility relative to responses received pursuant to this ☒ ☐ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other youth. 7717 Tuolumne Summit Program PRO 23-24 26 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1351 RELEASE PROCEDURES The facility administrator shall develop and implement Section V, Number 7 written policies and procedures for release of youth from custody which provide for: The agency conducts weekly Multi- Disciplinary Team meetings with the Behavior Health Case Manager, Wellpath Medical staff, and the on-site teaching staff prior to release and during the youth’s stay. Transition planning and ongoing services in the community are addressed. The meetings continue to occur weekly for detention and commitment youth. ☒ ☐ ☐ We reviewed numerous release documents indicating compliance of all elements related to the release process. Weekly MDT’s and Transition Planning meetings assist committed youth in realizing their release date. For Summit youth, the Probation Officer prepares an Individual Rehabilitation Plan to update the Court on the youth’s progress to determine a transition and release date. (a) verification of identity/release papers; ☒ ☐ ☐ Section V, Number 7, Procedure I-A (b) return of personal clothing and valuables; ☒ ☐ ☐ Section V, Number 7, Procedure I-F (c) notification to the youth's parents or guardian; ☒ ☐ ☐ Section V, Number 7, Procedure I-D (d) notification to the facility health care provider in accordance with Sections 1408 and 1437 of these ☒ ☐ ☐ Section V, Number 7, Procedure I-C regulations, for coordination with outside agencies; and, 7717 Tuolumne Summit Program PRO 23-24 27 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) notification of school staff; ☒ ☐ ☐ Section V, Number 7, Procedure I-H (f) notification of facility mental health personnel. ☒ ☐ ☐ Section V, Number 7, Procedure I-G The facility administrator shall develop and implement policies and procedures for post-disposition youth to Section V, Number 7, Procedure I-A coordinate the provision of transitional and reentry ☒ ☐ ☐ services including, but not limited to, medical and behavioral health, education, probation supervision and community-based services. The facility administrator shall develop and implement written policies and procedures for the furlough of youth The facility does not furlough youth from from custody. ☒ ☐ ☐ custody. 1352 CLASSIFICATION The facility administrator shall develop and implement Section V, Number 9 written policies and procedures on classification of youth ☒ ☐ ☐ for the purpose of determining housing placement in the facility. Such procedures shall: (a) provide for the safety of the youth, other youth, facility staff, and the public by placing youth in the Section V, Number 9, Procedure I-A appropriate, least restrictive housing and program ☒ ☐ ☐ settings. Housing assignments shall consider the need for single, double or dormitory assignment or location within the dormitory; (b) consider facility populations and physical design of the facility; ☒ ☐ ☐ Section V, Number 9, Procedure I-A 7717 Tuolumne Summit Program PRO 23-24 28 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) provide that a youth shall be classified upon admittance to the facility; classification factors shall Section V, Number 9, Procedure I-B include, but not be limited to: age, maturity, sophistication, emotional stability, program needs, legal Section V, Number 9, Procedure C-1 to 12 status, public safety considerations, medical/mental health considerations, gender and gender identity of the youth; The Classification/Youth Housing Screening Tool and the Youth Strengthening Admissions Assessment continue to be used to evaluate a youth’s classification needs. The facility has one unit with 30 beds, so determining ☒ ☐ ☐ appropriate housing is important to ensure staff contact and observation needs can be easily met. The screening tools were developed in coordination with BH to establish and identify all safety elements to address youth needs and behaviors. Summit Program youth have 2 rooms accessible for their stay, designated as SYTF on the door to their room. (d) provide for periodic classification reviews, including provisions that consider the level of supervision and the Section V, Number 9, Procedure I-E youth's behavior while in custody; and, ☒ ☐ ☐ The reviews occur weekly. (e) provide that facility staff shall not separate youth from the general population or assign youth to a single Section V, Number 9, Procedure I-F occupancy room based solely on the youth's actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, gender expression, mental ☒ ☐ ☐ Staff have the ability to override or determine or physical disability, or HIV status. This section does particular housing needs based on the overall not prohibit staff from placing youth in a single circumstances from the numerous admission occupancy room at the youth's specific request or in and classification screening tools. accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, bisexual, transgender, questioning or intersex identification or ☒ ☐ ☐ Section V, Number 9, Procedure I-G status as an indicator of likelihood of being sexually abusive. 7717 Tuolumne Summit Program PRO 23-24 29 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1352.5 TRANSGENDER AND INTERSEX YOUTH. The facility administrator shall develop written policies Section V, Number 10 and procedures ensuring respectful and equitable treatment of transgender and intersex youth. The policies shall provide that: The facility developed a gender preference form which includes staff having a conversation with youth at admission and a signature from the youth after the gender preferences are identified to ensure responsiveness to their requested ☒ ☐ ☐ preferences as it relates to search, housing, and clothing. This is also communicated to ancillary staff to have consistent gender references. Our interviews with these youth revealed staff and facility partners are providing good and caring services. (a) Facility staff shall respect every youth’s gender identity and shall refer to the youth by the youth’s Section V, Number 10, Procedure I-A preferred name and gender pronoun, regardless of the youth’s legal name. Facilities may prohibit the use of ☒ ☐ ☐ gang or slang names or names that otherwise compromise facility operations as determined by the facility manager or designee, and shall document any decision made on this basis. (b) Facility staff shall permit youth to dress and present themselves in a manner consistent with their gender ☒ ☐ ☐ Section V, Number 10, Procedure I-B identity and shall provide youth with the institution’s clothing and undergarments consistent with their gender identity. (c) Facility staff shall house youth in the unit or room that best meets their individual needs and promotes their Section V, Number 10, Procedure I-C safety and well-being. Staff may not automatically house youth according to their external anatomy and shall ☒ ☐ ☐ document the reasons for any decision to house youth in a unit that does not match their gender identity. In making a housing decision, staff shall consider the youth’s preferences, as well as any recommendations from the youth’s health or behavioral health provider. (d) Facility administrators shall ensure that transgender and intersex youth have access to medical and ☒ ☐ ☐ Section V, Number 10, Procedure I-D behavioral health providers qualified to provide care and treatment to transgender and intersex youth. 7717 Tuolumne Summit Program PRO 23-24 30 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) Consistent with the facility’s reasonable and necessary security considerations and physical plant, Section V, Number 10, Procedure I-E facility staff shall make every effort to ensure the safety ☒ ☐ ☐ and privacy of transgender and intersex youth when the youth are using the bathroom or shower, or dressing or undressing. Facility staff shall not conduct physical searches of any youth for the purpose of determining the youth’s Section V, Number 10, Procedure I-F anatomical sex. Whenever feasible, the facility shall ☒ ☐ ☐ respect the youth’s preference regarding the gender of Section V, Number 10, Procedure I-G the staff member who conducts any search of the youth. 1353 ORIENTATION The facility administrator shall develop and implement Section V, Number 11, I-a, D and E written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Section V, Number 10, Procedure I-D, information shall be provided and supplemented with 1 and 2 video orientation if feasible. Provision shall be made to provide accessible orientation information to all detained youth including those with disabilities, limited literacy, or Youth are provided with a Handbook at English language learners. Orientation shall include admission containing all elements of this information that addresses: regulation as well as a PREA Pamphlet. We reviewed the handbook and found the explanation of all elements was easy for youth to understand. It provides an operational ☒ ☐ ☐ understanding for youth expectations, rights, and how to address any identified needs that may arise during their stay. We also reviewed the Orientation Sign-Off document youth sign when admitted and oriented to the facility, acknowledging their understanding of the facility guidelines, expectations, and processes. We interviewed 3 of the 11 youth in custody and they acknowledged they understood the handbook and their ability to ask staff questions regarding their stay. (a) facility rules including contraband and searches and disciplinary procedures; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 1 7717 Tuolumne Summit Program PRO 23-24 31 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) facility’s system of positive behavior interventions and supports, including behavior expectations, Section V, Number 10, Procedure I-B, 2 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 ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 3 harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 4 (e) the existence of the grievance procedure, the steps that must be taken to use it, the youth’s right to be free ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 5 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 ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 6 court process; (g) access to routine and emergency health and mental ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 7 health care; (h) access to education, religious services, and ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 8 recreational activities; (i) housing assignments; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 9 (j) opportunity for personal hygiene and daily showers including the availability of personal care items ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 10 (k) rules and access to correspondence, visits and telephone use; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 11 7717 Tuolumne Summit Program PRO 23-24 32 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (l) availability of reading materials, programming, and other activities; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 12 (m) facility policies on the use of force, use of restraints, chemical agents and room confinement; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 13 (n) immigration legal services; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 14 (o) emergencies including evacuation procedures; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 15 (p) non-discrimination policy and the right to be free from physical, verbal or sexual abuse and harassment by ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 21 other youth and staff; (q) availability of services and programs in a language other than English if appropriate; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 16 (r) the process for requesting different housing, education, programming and work assignments; ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 18 (s) a process for which parents/guardians receive information regarding the youth’s stay in the facility that Section V, Number 10, Procedure I-B, 17 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. ☒ ☐ ☐ Section V, Number 10, Procedure I-B, 19 7717 Tuolumne Summit Program PRO 23-24 33 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354 SEPARATION The facility administrator shall develop and implement Section V, Number 13 written policies and procedures that address: We reviewed 15 incidents of Separation from October 2022 to October 2023, two of which were Voluntary Separation. In total, the agency had 91 Separation incidents, 5 Voluntary Separations. The agency documents behavior separation in an Activity Report or Incident Report, prompting staff to document the reason for and efforts to return the youth to programming. Youth go to the library (second classroom not in use and in the unit), to reflect on the behavior resulting in the separation. ☒ ☐ ☐ The agency uses the CICO (Check-in, Check- out) Daily Point Sheet to document incidents that result in behavior separation but are not a violation of a major rule. The form allows for points (0-2) based on the Positive Behavior and Supports (PBIS) model for respectful, responsible, and safe behaviors. This form is completed for each youth daily and allows for the recording of incidents that do not represent the PBIS model. This is tracked to have the information recorded for case planning and counseling services while the youth is in custody. (a) separation of youth for reasons that include, but are not be limited to, medical and mental health conditions, ☒ ☐ ☐ Section V, Number 13, I-A, 1-6 assaultive behavior, disciplinary consequences and protective custody. (b) consideration of positive youth development and trauma-informed care. ☒ ☐ ☐ Section V, Number 13, I-C (c) separated youth shall not be denied normal privileges available at the facility, except when ☒ ☐ ☐ Section V, Number 13, I-B and E necessary to accomplish the objective of separation. 7717 Tuolumne Summit Program PRO 23-24 34 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (d) when the objective of the separation is discipline, Title 15 Section 1390 shall apply. Section V, Number 13, I Disciplinary Separation The facility makes good use of the space in the single unit facility for separation, using the not-occupied classroom, which allows a full ☒ ☐ ☐ visual of the youth while in the separated location. This space allows youth a cool-down period to reflect on the behaviors that necessitated a separation but not to the level of room confinement. The process is working and accomplishing the goal in regulation, despite their physical plant. (e) when separation results in room confinement, the separation shall occur in accordance with Welfare and ☒ ☐ ☐ Section V, Number 13, Procedure I-E Institutions Code Section 208.3 and Section 1354.5 of these regulations. (f) policies and procedures shall ensure a daily review of separated youth to determine if separation remains The facility only separates youth for short necessary. periods of time to re-focus behavior. Our review of all incidents revealed most were poor decisions that are not aligned with the PBIS Model of behavior with others. The agency only uses this tool when they have exhausted every verbal counseling attempt. The youth are evaluated regularly ☒ ☐ ☐ and returned to normal programming in most cases, less than an hour after separation began. We note the agency completes a Reintegration Plan in each incident to allow for conversations about the behavior leading to the separation and discussion of how the youth’s actions could be different. The agency also allows for Due Process when a youth is separated for discipline, including minor rule violations. 7717 Tuolumne Summit Program PRO 23-24 35 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1354.5 ROOM CONFINEMENT (a) The facility administrator shall develop and Section V, Number 14 implement written policies and procedures addressing the confinement of youth in their room that are consistent with Welfare and Institutions Code Section The facility has had 35 incidents of RC from 208.3. The placement of a youth in room confinement October 2022 through October 2023, with four shall be accomplished in accordance with the following involving one youth for self-harm-related guidelines: behavior. Of the 35 incidents, 2 involved SYTF youth. The agency has a process to ensure staff document all efforts to reintegrate and follow the RC form prompts. Incident report ☒ ☐ ☐ documentation for the reason of room confinement was clear in each incident we reviewed. No youth were on RC for more than 3 hours and 30 minutes (1), 2-3 hours (7), 1-2 hours (17), and 12 youth under 30 minutes. Each youth participated in a Reintegration Plan, allowing staff to communicate and have a conversation about the incident, what could have been done differently, and a review of the Due Process process for the behavior leading to the RC. (1) Room confinement shall not be used before other, less restrictive, options have been attempted Section V, Number 14, I-A and exhausted, unless attempting those options ☒ ☐ ☐ poses a threat to the safety or security of any youth Section V, Number 14, Procedure II-A or staff. (2) Room confinement shall not be used for the purposes of punishment, coercion, convenience, or ☒ ☐ ☐ Section V, Number 14, I-B retaliation by staff. (3) Room confinement shall not be used to the extent that it compromises the mental and physical health Section V, Number 14, I-C of the youth. ☒ ☐ ☐ Section V, Number 14, Procedure II-B (b) A youth may be held up to four hours in room confinement. After the youth has been held in room ☒ ☐ ☐ Section V, Number 14, Procedure II-C confinement for a period of four hours, staff shall do one or more of the following: 7717 Tuolumne Summit Program PRO 23-24 36 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section V, Number 14, I-E, 1 (1) Return the youth to general population. ☒ ☐ ☐ Section V, Number 14, Procedure II-D, 1 Section V, Number 14, I-E, 3 (2) Consult with mental health or medical staff. ☒ ☐ ☐ Section V, Number 14, Procedure II-D, 2 (3) Develop an individualized plan that includes the goals and objectives to be met in order to reintegrate Section V, Number 14, I-E, 6 the youth to general population. Section V, Number 14, Procedure II-D, 3 ☒ ☐ ☐ As soon as a youth is placed on RC, an individual plan form is developed with the youth and attempts to follow through are made. (4) If room confinement must be extended beyond four hours, staff shall do each of the following: Section V, Number 14, Procedure II-D, 4 ☒ ☐ ☐ Each component is addressed in policy and documentation review included the elements required to extend. (A) Document the reasons for room confinement and the basis for the extension, the date and time Section V, Number 14, I-E, 2 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 ☒ ☐ ☐ Section V, Number 14, I-E, 6 integrate the youth to general population. (C) Obtain documented authorization by the facility superintendent or his or her designee ☒ ☐ ☐ Section V, Number 14, I-E, 5 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 ☒ ☐ ☐ Section V, Number 14, I-I in juvenile facilities and does not apply to normal sleeping hours. 7717 Tuolumne Summit Program PRO 23-24 37 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (6) This section does not apply to youth or wards in court holding facilities or adult facilities. ☒ ☐ ☐ Section V, Number 14, I-J (7) Nothing in this section shall be construed to conflict with any law providing greater or additional ☒ ☐ ☐ Section V, Number 14 Policy Statement protections to youth. (8) This section does not apply during an extraordinary emergency circumstance that requires Section V, Number 14, I-K a significant departure from normal institutional operations, including a natural disaster or facility- ☒ ☐ ☐ wide threat that poses an imminent and substantial risk of harm to multiple staff or youth. This exception shall apply for the shortest amount of time needed to address this imminent and substantial risk of harm. (9) This section does not apply when a youth is placed in a locked cell or sleeping room to treat and Section V, Number 14, I-L 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. 1355 INSTITUTIONAL ASSESSMENT AND PLAN The facility administrator shall develop and implement ☒ ☐ ☐ Section V, Number 16 written policies and procedures for assessment and case planning. 7717 Tuolumne Summit Program PRO 23-24 38 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Assessment: The assessment is based on information collected Section V, Number 16, Policy I-A during the admission process with periodic review, which includes the youth's risk factors, needs and strengths including, but not limited to, identification of substance abuse history, educational, vocational, We reviewed a sampling of IAP’s for youth counseling, behavioral health, consideration of known including an initial, updated, 3-month, 6- history of trauma, and family strengths and needs. month, Change in Treatment, and Transition Plans, each focusing on the identified needs and service approach while in or transitioning out of custody. The plans focus on a Youth Strength and Needs Assessment, which incorporates information from the following areas: Emotional/Behavioral Health; Cognitive Development and Functioning; Social Development and Functioning; Physical Health/Disabilities; Education; Trauma/ Resiliency; Family Relationships; Alcohol/ Drugs; Prior/Current Offense; Adult ☒ ☐ ☐ Relationships; and any other information which impacts a youth’s strengths or needs. A Treatment Plan is developed based on responses to the Assessment, which is scored to identify the top three needs and strengths. The Individual Rehabilitation Plan is prepared for the Summit youth prior to their 6-month review and contains all the required information from the assessment. We found each assessment to be detailed and informative, as well as individualized to each youth. The process is inclusive of required elements and documentation of timelines, which are more than required in policy and regulation. Staff work within the plan to provide reachable and attainable goals, both for in-custody treatment and upon release into the community. 7717 Tuolumne Summit Program PRO 23-24 39 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) Institutional Case Plan: (1) A case plan shall be developed for each youth Section V, Number 16, Policy I-B held for at least 30 days or more and created within 40 days of admission. IAP’s are completed at 14 days or sooner, with ☒ ☐ ☐ follow-up assessments at the 3-month, 6- month, 9-month, 12-month, and transition planning timelines. Summit SYTF youth have Individual Rehabilitation Plans prepared every 6 months throughout their stay. (2) The institutional plan shall include, but not be ☒ ☐ ☐ limited to, written documentation that provides: (A) objectives and time frame for the resolution of problems identified in the assessment; ☒ ☐ ☐ Section V, Number 16, Procedure II-A (B) a plan for meeting the objectives that includes a description of program resources needed and ☒ ☐ ☐ Section V, Number 16, Procedure II-B, 1-3 individuals responsible for assuring that the plan is implemented; (3) periodic evaluation of progress towards meeting the objectives, including periodic review and ☒ ☐ ☐ Section V, Number 16, Procedure II-C discussion of the plan with the youth; (4) a transition plan, the contents of which shall be subject to existing resources, shall be developed for ☒ ☐ ☐ Section V, Number 16, Procedure II-D post dispositional youth in accordance with Section 1351; and, (5) in as much as possible and if appropriate, the plan, including the transition plan, shall be developed Section V, Number 16, Procedure II-E with input from the family, supportive adults, youth, ☒ ☐ ☐ and Regional Center for the Developmentally Disabled. 7717 Tuolumne Summit Program PRO 23-24 40 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1356 COUNSELING AND CASEWORK SERVICES The facility administrator shall develop and implement Section V, Number 16, Procedure V-A written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: Facility staff document behavior, both positive and negative, in the youth’s ‘Check in, Check out’ (CICO) Daily Point sheets. This identifies ☒ ☐ ☐ their behavior each shift, as well as their participation in all T15 requirements. We reviewed daily/weekly summaries and phone call status for each youth in custody recorded on the CICO sheets. This daily documentation reveals the positive and negative activities as it relates to all areas of a youth’s program. (a) youth will receive assistance with needs or concerns that may arise; ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 1 (b) youth will receive assistance in requesting contact with parents, other supportive adults, attorney, clergy, ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 2 probation officer, or other public official; and, (c) youth will be provided access to available resources to meet the youth’s needs. ☒ ☐ ☐ Section V, Number 16, Procedure V-A, 3 7717 Tuolumne Summit Program PRO 23-24 41 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1357 USE OF FORCE The facility administrator, in cooperation with the Section V, Number 17 (UF) responsible physician, shall develop and implement written policies and procedures for the use of force, Section V, Number 17, Procedure II-B, 5 which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. We reviewed 10 of the 11 incidents involving the use of force from October 2022 through (a) At a minimum, each facility shall develop policies and October 2023. The reports provided clear and procedures which: relevant information based on the narrative in the report and accompanied by additional documentation if the incident involved Room Confinement (if appropriate), Separation, Use of Restraints, Due Process, or a response from agency partners. Most involved unit disturbances or assaultive behavior from ☒ ☐ ☐ youth. Two of the incidents involved the use of OC Spray and 8 youth were restrained following a UF incident for movement to their room or intake holding. Senior and supervisory staff review and debrief incidents along with involved staff and the superintendent. Documentation and forms were complete and articulate in terms of all necessary requirements. (1) restricts the use of force to that which is deemed reasonable and necessary, as defined in Section ☒ ☐ ☐ Section V, Number 17, Procedure I-B 1302 to ensure the safety and security of youth, staff, others and the facility. (2) outline the force options available to staff including both physical and non-physical options and define ☒ ☐ ☐ Section V, Number 17, Procedure V-A, 1-6 when those force options are appropriate. (3) describe force options or techniques that are expressly prohibited by the facility. ☒ ☐ ☐ Section V, Number 17, Procedure V-B, 1-8 (4) describe the requirements of staff to report any inappropriate use of force, and to take affirmative ☒ ☐ ☐ Section V, Number 17, Procedure II-B, 7 action to immediately stop it. 7717 Tuolumne Summit Program PRO 23-24 42 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) define a standardized reporting format that includes time period and procedure for documenting Section V, Number 17, Procedure V 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. ☒ ☐ ☐ Section V, Number 17, Procedure V-C (7) define the role, notification, and follow-up procedures required after use of force incidents for ☒ ☐ ☐ Section V, Number 17, Procedure VI-A, B and medical, mental health staff and parents or legal C guardians. (8) describe the limitations of use of force on pregnant youth in accordance with Penal Code Section 6030(f) ☒ ☐ ☐ Section V, Number 17, Procedure III and Welfare and Institutions Code Section 222. (b) Facilities that authorize chemical agents as a force option shall include policies and procedures that: Section V, Number 18 (1) identify who is approved to carry and/or utilize chemical agents in the facility and the type, size and Section V, Number 18, Procedure I-A the approved method of deployment for those chemical agents. ☒ ☐ ☐ Only senior staff are permitted to carry OC spray in the facility. It is important to note there have been two chemical spray incidents since October of 2022, involving one youth. (2) mandate that chemical agents only be used when there is an imminent threat to the youth’s safety or the ☒ ☐ ☐ Section V, Number 18, Procedure I-B 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. Section V, Number 18, Use I-F This shall include that youth who have been exposed ☒ ☐ ☐ to chemical agents shall not be left unattended until Section V, Number 18, Use I-H, 5 and 6 that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. Section V, Number 18, Use I-I, 1 through 8 7717 Tuolumne Summit Program PRO 23-24 43 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (4) define the role, notification, and follow-up procedures required after use of force incidents Section V, Number 18, Use I-E (CFMG) involving chemical agents for medical, mental health staff and parents or legal guardians. ☒ ☐ ☐ Section V, Number 18, Use I-F (BH and parent/legal guardian) (5) provide for the documentation of each incident of use of chemical agents, including the reasons for Section V, Number 18, Use I-G, 1-5 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 which require that agencies provide initial and regular training Section V, Number 17, Procedure IV in use of force and chemical agents when appropriate that address: ☒ ☐ ☐ Senior staff are only authorized to carry OC Spray. Staff are trained annually by certified STC Instructor. (1) known medical and behavioral health conditions that would contraindicate certain types of force; ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 6 (2) acceptable chemical agents and the methods of application. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 2 (3) signs or symptoms that should result in immediate referral to medical or behavioral health. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B, 7 (4) instruction on the Constitutional Limitations of Use of Force. Section V, Number 18, Procedure I-B ☒ ☐ ☐ This is part of the training curriculum for Use of Force. 7717 Tuolumne Summit Program PRO 23-24 44 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (5) physical training force options that may require the use of perishable skills. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B (6) timelines the facility uses to define regular training. ☒ ☐ ☐ Section V, Number 17, Procedure IV-B 1358 USE OF PHYSICAL RESTRAINTS The facility administrator, in cooperation with the Section V, Number 19 and 20 responsible physician and mental health director, shall develop and implement written policies and procedures for the use of restraint devices. Restraint devices The facility has the WRAP as a restraint with include any devices which immobilize a youth's ☒ ☐ ☐ very specific limitations on its use. extremities and/or prevent the youth from being ambulatory. There has been no use of the WRAP since July 2022. Physical restraints may be used only for those youth who present an immediate danger to themselves or Section V, Number 19, Policy I-B 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 Section V, Number 19, Policy I-F restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through affixing ☒ ☐ ☐ Section V, Number 19, Policy I-Q of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is Section V, Number 19, Policy I-R limited in accordance with Penal Code Section 6030(f) Section V, Number 19, Policy I-S and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of handcuffs, shackles or other restraint devices when used Section V, Number 19, Policy I-C 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. 7717 Tuolumne Summit Program PRO 23-24 45 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Youth shall be placed in restraints only with the approval of the facility manager or designee. The facility manager Section V, Number 19, Policy I-B may delegate authority to place a youth in restraints to a physician. Reasons for continued retention in restraints Section V, Number 19, Policy I-V shall be reviewed and documented at a minimum of every hour. Section V, Number 19, Policy I-W ☒ ☐ ☐ Senior JCO’s are designated to approve placement of restraints in the absence of the facility Superintendent. The WRAP must have Superintendent approval. A medical opinion on the safety of placement and retention shall be secured as soon as possible, but no Section V, Number 19, Policy I-J 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 soon as possible, but in no case longer than four hours from the ☒ ☐ ☐ Section V, Number 19, Policy I-K time of placement, to assess the need for mental health treatment. Continuous direct visual supervision shall be conducted to ensure that the restraints are properly employed, and Section V, Number 19, Policy I-N to ensure the safety and well-being of the youth. ☒ ☐ ☐ Observations of the youth's behavior and any staff Section V, Number 19, Procedure I-B interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. Section V, Number 19, Procedure I-J In addition to the requirements above, policies and procedures shall address: ☒ ☐ ☐ Section V, Number 19, Procedure I-M (a) documentation of the circumstances leading to an application of restraints. (b) known medical conditions that would contraindicate certain restraint devices and/or techniques. ☒ ☐ ☐ Section V, Number 19, Policy I-M (c) acceptable restraint devices. ☒ ☐ ☐ Section V, Number 19, Policy I-B (d) signs or symptoms which should result in immediate medical/mental health referral. ☒ ☐ ☐ Section V, Number 19, Procedure I-J 7717 Tuolumne Summit Program PRO 23-24 46 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (e) availability of cardiopulmonary resuscitation equipment. ☒ ☐ ☐ Section V, Number 19, Procedure I-D (f) protective housing of restrained youth. While in restraint devices, all youth shall be housed alone or in a ☒ ☐ ☐ Section V, Number 19, Policy I-H specified housing area for restrained youth which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. ☒ ☐ ☐ Section V, Number 19, Policy I-H (h) exercising of extremities. ☒ ☐ ☐ Section V, Number 19, Policy I-H 1358.5 USE OF RESTRAINT DEVICES FOR MOVEMENT AND TRANSPORTATION Section V, Number 21 WITHIN THE FACILITY. The Facility Administrator, in cooperation with the responsible physician and behavioral/mental health Staff are trained to use control holds at escort director, shall develop and implement written policies and must get authorization to use other force and procedures for the use of restraint devices when the ☒ ☐ ☐ for movement. There were 8 incidents purpose is for movement or transportation within the involving the use of restraints for movement of facility that shall include the following: a youth to their room, one time for a SYTF youth. All were 2-3 minutes, except for one incident where a youth was in restraints for 7 minutes as he remained combative. (a) identification of acceptable restraint devices, staff approved to utilize restraint devices and the required Section V, Number 19, Policy I-B training. ☒ ☐ ☐ Staff are trained annually by certified STC Instructor. (b) the circumstances leading to the application of restraints must be documented. ☒ ☐ ☐ Section V, Number 21, Procedure A 7717 Tuolumne Summit Program PRO 23-24 47 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) an individual assessment of the need to apply restraints for movement or transportation that includes Section V, Number 21, Procedure B consideration of less restrictive alternatives, consideration of a youth’s known medical or mental ☒ ☐ ☐ health conditions, trauma informed approaches, and a process for documentation and supervisor review and approval. (d) consideration of safety and security of the facility, with a clearly defined expectation that restraint devices ☒ ☐ ☐ Section V, Number 21 Procedure C 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 ☒ ☐ ☐ Section V, Number 21 Procedure D Welfare and Institutions Code Section 222. 1359 SAFETY ROOM PROCEDURES (a) The facility administrator, and where applicable, in The facility does not have a Safety Room. cooperation with the responsible physician, shall develop and implement written policies and procedures governing the use of safety rooms, as described in Title 24, Part 2, Section 1230.1.13. The room shall be used to hold only 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. A safety room shall not be used for punishment or discipline, or as a substitute for treatment. Policies and procedures shall: (1) include provisions for administration of necessary nutrition and fluids, access to a toilet, and suitable ☐ ☐ ☒ clothing to provide for privacy; (2) provide for approval of the facility manager, or designee, before a youth is placed into a safety ☐ ☐ ☒ room; (3) provide for continuous direct visual supervision and documentation of the youth's behavior and any ☐ ☐ ☒ staff interventions every 15 minutes, with actual time recorded; (4) provide that the youth shall be evaluated by the ☐ ☐ ☒ facility manager, or designee, every four hours; (5) provide for immediate medical assessment, where appropriate, or an assessment at the next ☐ ☐ ☒ daily sick call; and, (6) provide a process for documenting the reason for placement, including attempts to use less restrictive ☐ ☐ ☒ means of control, and decisions to continue and end placement. 7717 Tuolumne Summit Program PRO 23-24 48 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The placement of a youth in the safety room shall be ☐ ☐ ☒ accomplished in accordance with the following: (1) safety room 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. (2) safety room shall not be used for the purposes of punishment, coercion, convenience, or retaliation by ☐ ☐ ☒ staff. (3) safety room shall not be used to the extent that it compromises the mental and physical health of the ☐ ☐ ☒ youth. (c) A youth may be held up to four hours in the safety room. After the youth has been held in the safety room ☐ ☐ ☒ 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. (d) If confinement in the safety room must be extended beyond four hours, staff shall develop an individualized plan that includes the requirements of Section 1354.5 ☐ ☐ ☒ and the goals and objectives to be met in order to integrate the youth to general population. 1360 SEARCHES , The facility administrator shall develop and implement Section V, Number 23 written policies and procedures governing the search of youth, the facility, and visitors. Policies and procedures ☒ ☐ ☐ Section V, Number 23, Procedure IX Room shall provide that: Section V, Number 23, Procedure X Facility Section V, Number 23, Procedure XI Visitor (a) Searches shall be conducted to ensure the safety and security of the facility, public, visitors, youth, and ☒ ☐ ☐ Section V, Number 23, Policy I-A and B staff. (b) Searches shall be conducted in a manner that preserves the privacy and dignity of the person being ☒ ☐ ☐ Section V, Number 23, Policy I-C searched and shall not be conducted for harassment or as a form of discipline or punishment. 7717 Tuolumne Summit Program PRO 23-24 49 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) Strip searches and visual or physical body cavity searches shall comply with Penal Code Section 4030. Section V, Number 23, Policy I-D ☒ ☐ ☐ There have been no strip searches at the facility from July 2022 to October 2023, only 3 since the facility opened in 2017. (d) Physical body cavity searches shall only be conducted by a medical professional. ☒ ☐ ☐ Section V, Number 23, Policy I-E (e) Any youth held after a detention hearing shall only be strip searched with prior approval of a supervisor Section V, Number 23, Procedure II, III, IV when there is reasonable suspicion based on specific ☒ ☐ ☐ and articulable facts to believe that youth is concealing contraband. The reasonable suspicion shall be documented. (f) Searches of transgender and intersex youth shall comply with Section 1352.5. ☒ ☐ ☐ Section V, Number 23, Procedure V-D (g) Cross-gender pat-down searches and strip searches are prohibited except in exigent circumstances or when ☒ ☐ ☐ Section V, Number 23, Policy I-J and K conducted by a medical professional. Such searches must be justified and documented in writing. 1361 GRIEVANCE PROCEDURE The facility administrator shall develop and implement Section V, Number 30 written policies and procedures whereby any youth may appeal and have resolved grievances relating to any condition of confinement, including but not limited to The facility has had 34 grievances filed from health care services, classification decisions, program July 2022 to October 2023, most of which participation, telephone, mail or visiting procedures, were resolved by staff with two being food, clothing, bedding, mistreatment, harassment or appealed to the Superintendent. violations of the nondiscrimination policy. There shall be ☒ ☐ ☐ no time limit on filing grievances. Policies and procedures shall include provisions whereby the facility Of the youth we interviewed, each understood manager ensures: the process and felt the resolution was fair. The forms are step-by-step based and compliant with policy and regulation. 7717 Tuolumne Summit Program PRO 23-24 50 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) a grievance form and instructions for registering a grievance, which includes provisions for the youth to Section V, Number 30, Policy I-A have free access to the form; ☒ ☐ ☐ Section V, Number 30, Policy I-B (b) the youth shall have the option to confidentially file the grievance or to deliver the form to any youth ☒ ☐ ☐ Section V, Number 30, Policy I-D supervision staff working in the facility; (c) resolution of the grievance at the lowest appropriate staff level; ☒ ☐ ☐ Section V, Number 30, Policy I-F (d) provision for a prompt review and initial response to grievances within three (3) business days, grievances ☒ ☐ ☐ Section V, Number 30, Procedure I-C that relate to health and safety issues must be addressed immediately; (1) The youth may elect to be present to explain his/her version of the grievance to a person not ☒ ☐ ☐ Section V, Number 30, Procedure I-D 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. ☒ ☐ ☐ Section V, Number 30, Policy I-C (e) provision for a written response to the grievance which includes the reasons for the decisions; ☒ ☐ ☐ Section V, Number 30, Policy I-F (f) a system which provides that any appeal of a grievance shall be heard by a person not directly ☒ ☐ ☐ Section V, Number 30, Procedure I-F involved in the circumstances which led to the grievance; Section V, Number 30, Procedure I-G (g) resolution of the grievance must occur within ten (10) business days unless circumstances dictate a longer ☒ ☐ ☐ Section V, Number 30, Procedure I-H time frame. The youth shall be notified of any delay; and, 7717 Tuolumne Summit Program PRO 23-24 51 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (h) the policy shall provide multiple internal and external methods to report sexual abuse and sexual harassment. Section V, Number 30, Procedure I-G Section V, Number 30, Procedure I-H ☒ ☐ ☐ Section V, Number 30, Procedure I-I Section V, Number 30, Procedure I-J Whether or not associated with a grievance, concerns of parents, guardians, staff or other parties shall be ☒ ☐ ☐ Section V, Number 30, Procedure I-N addressed and documented in accordance with written policies and procedures within a specified timeframe. 1362 REPORTING OF INCIDENTS A written report of all incidents which result in physical Section V, Number 32 harm, use of force, serious threat of physical harm, or death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the We reviewed numerous incident reports staff and submitted to the facility manager by the end of involving UF, UR, RC, and Separation. the shift, unless additional time is necessary and authorized by the facility manager or designee. 1363 USE OF REASONABLE FORCE TO COLLECT DNA SPECIMENS, SAMPLES, IMPRESSIONS Section V, Number 33, Procedure III-A (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections personnel including peace officers, may employ reasonable force ☒ ☐ ☐ The facility has not had to use force to collect to collect blood specimens, saliva samples, and thumb DNA since 2017. or palm print impressions from individuals who are required to provide such samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request. (1) For the purpose of this section, the “use of reasonable force” shall be defined as the force that Section V, Number 33, Procedure III-B an objective, trained and competent correctional ☒ ☐ ☐ employee, faced with similar facts and circumstances, would consider necessary and reasonable to gain compliance with this section. (2) The use of reasonable force shall be preceded by efforts to secure voluntary compliance. Efforts to Section V, Number 33, Procedure III-B secure voluntary compliance shall be documented ☒ ☐ ☐ and include an advisement of the legal obligation to provide the requisite specimen, sample or impression and the consequences of refusal. 7717 Tuolumne Summit Program PRO 23-24 52 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (b) The force shall not be used without the prior written authorization of the supervising officer on duty. The Section V, Number 33, Procedure III-C authorization shall include information that reflects the fact that the offender was asked to provide the requisite specimen, sample, or impression and refused. ☒ ☐ ☐ The use of force for this regulation requires authorization from the Facility Superintendent. (1) If the use of reasonable force includes a cell extraction, the extraction shall be videotaped. Video Section V, Number 33, Procedure IV-A shall be directed at the cell extraction event. The videotape shall be retained by the agency for the ☒ ☐ ☐ Section V, Number 33, Procedure IV-B length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7717 Tuolumne Summit Program PRO 23-24 53 A453 JUV PRO eff. 1/2019 (23-24).dot 1370 EDUCATION PROGRAM (a) School Programs Section VI, Number 1, Policy II-A The County Board of Education shall provide for the administration and operation of juvenile court schools in conjunction with the Chief Probation Officer, or designee The Tuolumne County Superintendent of pursuant to applicable State laws. The school and facility Schools provides educational and vocational administrators shall develop and implement written policy opportunities via the Golden Ridge and procedures to ensure communication and Educational Center (GREC) onsite, online coordination between educators and probation staff. college through Columbia Community Culturally responsive and trauma-informed approaches College, and vocational opportunities through should be applied when providing instruction. Education the Motherlode Job Training for Tuolumne staff should collaborate with the facility administrator to County. A TCSOS Transition Specialist use technology to facilitate learning and ensure safe assists with youth exiting the facility and technology practices. The facility administrator shall returning to schools in the community as well request an annual review of each required element of the as with enrollment and curriculum oversight, in program by the Superintendent of Schools, and a report Columbia College, a community college or review checklist on compliance, deficiencies, and nearby. It is noted youth eligible for Dual corrective action needed to achieve compliance with this enrollment are attending online classes at the section. Such a review, when conducted, cannot be college as well. The SOS last received WASC delegated to the principal or any other staff of any juvenile Accreditation in 2022. court school site. The Superintendent of Schools shall conduct this review in conjunction with a qualified outside agency or individual. Upon receipt of the review, the PBIS was trained to all new staff initially but facility administrator or designee shall review each item most have moved on since 2017. The TCSOS with the Superintendent of Schools and shall take plans to revitalize PBIS as a mechanism to whatever corrective action is necessary to address each promote positive behaviors with rewards and ☒ ☐ ☐ deficiency and to fully protect the educational interests of incentives in the classroom and carried over all youth in the facility. to the living unit. We have seen the successes of PBIS as a collaboration with school and probation staff. The TCSOS offers a complete and comprehensive curriculum, including culinary food handler’s certification, DMV licenses for eligible youth, gardening, and personal reading goals via the Book Club. Additionally, for those youth with an active IEP, youth receive services via a counselor in addition to specialized instruction. TCSOS continues to provide a Psychologist one time per week to work with the sex offender population. The on-site teacher, Ashley Chambeaux, is engaged in the classroom and works individually with youth to grow their education opportunities. The program is 270 minutes each day except for every Wednesday has a late start to allow Ms. Chambeaux to participate in MDT meetings. 7717 Tuolumne Summit Program PRO 23-24 54 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Graduated youth have the options for continued college enrollment and vocational education opportunities, with the ability to leave the site for working in the community. Summit SYTF youth will earn their way to offsite school and work throughout their stay. (b) Required Elements The facility school program shall comply with the State Section VI, Number 1, Policy III-A Education Code and County Board of Education policies, Section VI, Number 1, Policy III-B all applicable federal education statutes and regulations and provide for an annual evaluation of the educational Section VI, Number 1, Policy III-C program offerings. As stated in the 2009 California Standards for the Teaching Profession, teachers shall ☒ ☐ ☐ Section VI, Number 1, Policy III-D establish and maintain learning environments that are Section VI, Number 1, Policy III-E physically, emotionally, and intellectually safe. Youth shall be provided a rigorous, quality educational program that responds to the different learning styles and abilities of students and prepares them for high school graduation, career entry, and post-secondary education. All youth shall be treated equally, and the education program shall be free from discriminatory action. Staff Section VI, Number 1, Policy III-F shall refer to transgender, intersex and gender- ☒ ☐ ☐ nonconforming youth by their preferred name and gender. (1) The course of study shall comply with the State Education Code and include, but not be limited to, ☒ ☐ ☐ Section VI, Number 1, Policy III-A courses required for high school graduation. (2) Information and preparation for the High School Equivalency Test as approved by the California ☒ ☐ ☐ Section VI, Number 1, Policy III-I Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education and vocational opportunities. ☒ ☐ ☐ Section VI, Number 1, Policy III-J (4) Administration of the High School Equivalency Tests as approved by the California Department of ☒ ☐ ☐ Section VI, Number 1, Policy III-K Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth who do not demonstrate sufficient progress towards ☒ ☐ ☐ Section VI, Number 1, Policy III-L grade level standards. 7717 Tuolumne Summit Program PRO 23-24 55 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (6) The minimum school day shall be consistent with State Education Code Requirements for juvenile court Section VI, Number 1, Policy III-G schools. The facility administrator, in conjunction with education staff, must ensure that operational ☒ ☐ ☐ procedures do not interfere with the time afforded for the minimum instructional day. Absences, time out of class or educational instruction, both excused and unexcused, shall be documented. (7) Education shall be provided to all youth regardless of classification, housing, security status, disciplinary Section VI, Number 1, Policy III-O or separation status, including room confinement, except when providing education poses an immediate ☒ ☐ ☐ threat to the safety of self or others. Education includes, but is not limited to, related services as provided in a youth’s Section 504 Plan or Individualized Education Program (IEP). (c) School Discipline (1) Positive behavior management will be Section VI, Number 1, Policy IV-A implemented to reduce the need for disciplinary action ☒ ☐ ☐ in the school setting and be integrated into the facility's overall behavioral management plan and security system. (2) School staff shall be advised of administrative decisions made by probation staff that may affect the ☒ ☐ ☐ Section VI, Number 1, Policy IV-B educational programming of students. (3) Except as otherwise provided by the State Education Code, expulsion/suspension from school Section VI, Number 1, Policy IV-C shall be imposed only when other means of correction fails to bring about proper conduct. School staff shall follow the appropriate due process safeguards as set ☒ ☐ ☐ forth in the State Education Code including the rights of students with special needs. School staff shall document the other means of correction used prior to imposing expulsion/ suspension if an expulsion/suspension is ultimately imposed. (4) The facility administrator, in conjunction with education staff will develop policies and procedures ☒ ☐ ☐ Section VI, Number 1, Policy IV-D that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations (1) State and federal laws and regulations shall be observed for all individuals with disabilities or Section VI, Number 1, Policy V-A suspected disabilities. This includes but is not limited ☒ ☐ ☐ to child find, assessment, continuum of alternative placements, manifestation determination reviews, and implementation of Section 504 Plans and Individualized Education Programs. 7717 Tuolumne Summit Program PRO 23-24 56 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (2) Youth identified as English Learners (EL) shall be afforded an educational program that addresses their language needs pursuant to all applicable state and ☒ ☐ ☐ Section VI, Number 1, Policy V-B federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission (1) Youth shall be interviewed after admittance and a ☒ ☐ ☐ record maintained that documents a youth's Section VI, Number 1, Policy VI-A educational history, including but not limited to: (A) School progress/school history; ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 1 (B) Home Language Survey and the results of the State Test used for English language proficiency; ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 2 (C) Needs and services of special populations as defined by the State Education Code, including but ☒ ☐ ☐ not limited to, students with special needs. Section VI, Number 1, Policy VI-A, 3 (D) Discipline problems. ☒ ☐ ☐ Section VI, Number 1, Policy VI-A, 4 (2) Youth will be immediately enrolled in school. Educational staff shall conduct an assessment to determine the youth's general academic functioning ☒ ☐ ☐ Section VI, Number 1, Policy VI-B levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary education plan shall be developed for each youth ☒ ☐ ☐ within five school days. Section VI, Number 1, Policy VI-C (4) Upon enrollment, education staff shall comply with the State Education Code and request the youth's records from his/her prior school(s), including, but not Section VI, Number 1, Policy VI-D limited to, transcripts, Individual Education Program (IEP), 504 Plan, state language assessment scores, ☒ ☐ ☐ immunization records, exit grades, and partial credits. Upon receipt of the transcripts, the youth's educational plan shall be reviewed with the youth and modified as needed. Youth should be informed of the credits they need to graduate. (f) Educational Reporting (1) The complete facility educational record of the youth shall be forwarded to the next educational ☒ ☐ ☐ Section VI, Number 1, Policy VII-A placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide appropriate credit (full or partial) for course ☒ ☐ ☐ work completed while in juvenile court school in Section VI, Number 1, Policy VII-B accordance with the State Education Code. 7717 Tuolumne Summit Program PRO 23-24 57 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) Transition and Re-Entry Planning (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies Section VI, Number 1, Policy VIII-A and procedures to meet the transition needs of youth, ☒ ☐ ☐ including the development of an education transition plan, in accordance with the State Education Code and in alignment with Title 15, Minimum Standards for Juvenile Facilities, Section 1355. (h) Post-Secondary Education Opportunities (1) The school and facility administrator should, whenever possible, collaborate with local post- Section VI, Number 1, Policy IX-A secondary education providers to facilitate access to ☒ ☐ ☐ educational and vocational opportunities for youth that considers the use of technology to implement these programs. 7717 Tuolumne Summit Program PRO 23-24 58 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1371 PROGRAMS, RECREATION, AND EXERCISE. Section VI, Number 3, Policy I-A The facility administrator shall develop and implement written policies and procedures for programs, recreation, and exercise for all youth. The intent is to The facility has many programming options for minimize the amount of time youth are in their rooms or youth, including: their bed area. Aggression Replacement Training (ART); Interactive Journaling; Boys Council; Girls Circle; Parenting Education; Independent Living Skills; 4H-Master Gardner’s; Harvest of the Month (Health and Nutrition); Art Therapy; Tools for Success; Mindfulness and Meditation; Book Club; Religious Services and Bible Study; Prison Education Project (PEP); Mentoring; Drug and Alcohol Prevention Groups; Ready Now Recovery; Tai Chi; and Drum Circle. The agency was just awarded a grant through 4-H to develop a Meditation Pond and Hydroponic Garden. The project was just approved by the county and electricians were on-site when we were there. ☒ ☐ ☐ Facility staff work on ‘Check In, Check Out’ (CICO) with youth to document positive and negative behaviors, which teach the elements of PBIS. This tool provides incentive-based opportunities for youth. TCBH has begun providing individual/group counseling to youth and Individual Psychotherapy weekly. They have been present for MDT and case treatment plans and have a Case Manager who works with Clinicians locally to provide treatment to this population on a more consistent basis. The Superintendent of the facility, Annie Hockett, is a licensed Clinician and responds to crisis events at the facility. Providers include TCBH, TCSOS, facility staff, 4-H, Master Gardner’s, Hidden Treasures, and local volunteers. Juvenile facilities shall provide the opportunity for programs, recreation, and exercise a minimum of three Section VI, Number 3, Policy I-B and C hours a day during the week and five hours a day each ☒ ☐ ☐ Saturday, Sunday or other non-school days, of which one hour shall be an outdoor activity, weather permitting. 7717 Tuolumne Summit Program PRO 23-24 59 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS A youth’s participation in programs, recreation, and exercise may be suspended only upon a written finding Section VI, Number 3, Policy I-D by the administrator/manager or designee that a youth ☒ ☐ ☐ represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall be posted in the living units. ☒ ☐ ☐ Section VI, Number 3, Policy I-E There will be a written annual review of the programs, recreation, and exercise by the responsible agency to ☒ ☐ ☐ Section VI, Number 3, Policy I-F ensure content offered is current, consistent, and relevant to the population. (a) Programs. All youth shall be provided with the opportunity for at least one hour of daily programming to Section VI, Number 3, Policy I-G include, but not be limited to, trauma focused, cognitive, evidence-based, best practice interventions that are culturally relevant and linguistically appropriate, or pro- social interventions and activities designed to reduce recidivism. These programs should be based on the youth’s individual needs as required by Sections 1355 ☒ ☐ ☐ and 1356. Such programs may be provided under the direction of the Chief Probation Officer or the County Office of Education and can be administered by county partners such as mental health agencies, community based organizations, faith-based organizations or Probation staff. Programs may include but are not limited to: 7717 Tuolumne Summit Program PRO 23-24 60 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; Section VI, Number 3, Policy I-G, 1-17 (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. (b) Recreation. All youth shall be provided the opportunity for at least one hour of daily access to unscheduled Section VI, Number 3, Policy I-H activities such as leisure reading, letter writing, and ☒ ☐ ☐ entertainment. Activities shall be supervised and include Section VI, Number 3, Policy I-K orientation and may include coaching of youth. (c) Exercise. All youth shall be provided with the opportunity for at least one hour of large muscle activity ☒ ☐ ☐ Section VI, Number 3, Policy I-I each day. The administrator/manager may suspend, for a period not to exceed 24 hours, access to recreation and Section VI, Number 3, Policy I-J programs. The administrator/manager shall document ☒ ☐ ☐ the reasons why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM The facility administrator shall provide access to religious Section VI, Number 7, Policy I-C services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth shall be ☒ ☐ ☐ Section VI, Number 7, Policy I-D allowed to participate in an activity outside of their room if he/she elects not to participate in religious programs. Religious programs shall provide for: 7717 Tuolumne Summit Program PRO 23-24 61 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Section VI, Number 7, Policy I-A (a) opportunity for religious services and practices; ☒ ☐ ☐ Section VI, Number 7, Policy I-B (b) availability of clergy; and, ☒ ☐ ☐ Section VI, Number 7, Policy I-B (c) availability of religious diets. ☒ ☐ ☐ Section VI, Number 7, Policy I-B 1373 WORK PROGRAM The facility administrator shall develop policies and Section VI, Number 8 procedures regarding the fair and consistent assignment of youth to work programs. Work assigned to a youth shall be meaningful, constructive and related to The agency allows youth that meet specific vocational training or increasing a youth's sense of criteria to work outside the secure perimeter. responsibility. Work programs shall not be imposed as a Youth in detention are responsible for daily disciplinary measure chores of cleaning their room and the unit. Yard maintenance and classroom cleaning are completed by more senior youth who have reached a certain level in the facility with good behavior. ☒ ☐ ☐ Youth over 16 can receive their food handler’s certificate and they are responsible for serving the meals which come over from the jail. Lastly, youth committed to Steps to Success can work outside the facility perimeter to maintain the cleanliness of the building and grounds. Summit SYTF youth will earn their way to a lesser restrictive program as they progress in the program, including the opportunity to work off-site. 7717 Tuolumne Summit Program PRO 23-24 62 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1374 VISITING The facility administrator shall develop and implement Section VI, Number 9, Policy I-A written policies and procedures for visiting, that include provisions for special visits. Youth shall be allowed to Section VI, Number 9, Policy I-B receive visits by parents, guardians or persons standing in loco parentis, and children of youth. Other family members, such as grandparents and siblings, and The facility continues to accommodate all supportive adults, may be allowed to visit with the visits, allowing any person the opportunity to approval of the facility administrator or designee, and in visit a youth that offers a positive impact on conjunction with the youth’s case plan or in the best behavior, or influence for good transition. This interest of the youth. ☒ ☐ ☐ includes any family member or supportive adult, generally working within the visitor’s schedule if outside normal visiting hours. The visiting schedule is robust with specific providers, clinicians and community persons visiting youth regularly, not to mention while on-site, there were four youth from Mariposa, Inyo, and Calaveras Counties in custody. All visits shall occur at reasonable times, subject only to the limitations necessary to maintain order and security. Section VI, Number 9, Policy I-A Visitation shall not be denied solely based on the visitor’s criminal history. The staff shall determine in each case, Section VI, Number 9, Policy I-R whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ the safety of 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 hours per week. Visits may be supervised, but conversations ☒ ☐ ☐ Section VI, Number 9, Policy I-E shall not be monitored unless there is a security or safety need. Section VI, Number 9, Policy I-G Provisions for special visits, in addition to the two-hour minimum and/or outside of the regular visiting hours, shall Section VI, Number 9, Policy I-H be accommodated as necessary and within the discretion of the facility administrator or designee. Family therapy Section VI, Number 9, Policy I-I ☒ ☐ ☐ and professional visits shall be accommodated outside the provisions of this regulation. Facilities may provide visitation opportunities outside of normal visiting hours to accommodate special visits. The facility may provide access to technology as an alternative, but not as a replacement, to in-person visiting. ☒ ☐ ☐ Section VI, Number 9, Policy I-S 7717 Tuolumne Summit Program PRO 23-24 63 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1375 CORRESPONDENCE The facility administrator shall develop and implement ☒ ☐ ☐ Section VI, Number 10 written policies and procedures for correspondence which provide that: (a) there is no limitation on the volume of mail that youth may send or receive; ☒ ☐ ☐ Section VI, Number 10, Policy I-A (b) youth may send two letters per week postage free; Section VI, Number 10, Policy I-B ☒ ☐ ☐ All youth mail is sent postage-free. (c) youth may correspond confidentially with state and federal courts, any member of the State Bar or holder of Section VI, Number 10, Policy I-C public office, and the Board; however, authorized facility ☒ ☐ ☐ staff may open and inspect such mail only to search for contraband and in the presence of the youth; and, (d) incoming and outgoing mail, other than that described in (c), may be read by staff only when there is reasonable ☒ ☐ ☐ Section VI, Number 10, Policy I-F cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS The administrator of each juvenile facility shall develop ☒ ☐ ☐ Section VI, Number 11 and implement written policies and procedures to provide youth with access to telephone communications. 1377 ACCESS TO LEGAL SERVICES The facility administrator shall develop written procedures ☒ ☐ ☐ Section VI, Number 12 to ensure the right of youth to have access to the courts and legal services. Such access shall include: (a) access, upon request by the youth, to licensed attorneys and their authorized representatives; ☒ ☐ ☐ Section VI, Number 12, Policy I-A (b) provision for confidential consultation with attorneys; and, ☒ ☐ ☐ Section VI, Number 12, Policy I-B (c) unlimited postage free, legal correspondence and cost-free telephone access as appropriate. ☒ ☐ ☐ Section VI, Number 12, Policy I-C 7717 Tuolumne Summit Program PRO 23-24 64 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1390 DISCIPLINE The facility administrator shall develop and implement Section VII, Number 1, Policy I-A written policies and procedures for the discipline of youth that shall promote acceptable behavior; including the use Section VII, Number 1, Policy I-B of positive behavior interventions and supports. Discipline shall be imposed at the least restrictive level which promotes the desired behavior and shall not include The facility’s rules and sanctions are clearly corporal punishment, group punishment, physical or identified in many forms for all youth. The psychological degradation. Deprivation of the following is sanction matrix is rarely used, only for high- not permitted: risk behaviors and incidents which are rare. The PBIS model of respect, responsibility and safety is visually and verbally present throughout the facility. Youth are more interested in earning points for commissary, which works to promote the tenets of PBIS. We observed youth in unit activities and the classroom, noting the staff efforts to have conversations with youth routinely as part of their overall philosophy to promote PBIS. The point sheets are tallied daily so youth know where they stand in terms of bedtime, ☒ ☐ ☐ participation in late activities, and incentive options. These pro-social activities and efforts are on full display evidenced by the low number of high-risk incidents and behaviors. We interviewed 5 youth, while on site, in each of the programs and found they seem to trust staff and feel like they are treated well. Staff continue to promote positive decision choices, offering options and compromise, which allow a youth to see the benefits of good behavior. Accountability and teaching moments are principles used in the daily operations facility- wide. The agency modified their rule and sanction system to only include minor and major rule violations. We noted Due Process is completed on every rule violation as they use the tool to enhance conversation and promote positive choices. 7717 Tuolumne Summit Program PRO 23-24 65 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) bed and bedding; ☒ ☐ ☐ Section VII, Number 1, Policy I-C,1 (b) daily shower, access to drinking fountain, toilet and ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 2 personal hygiene items, and clean clothing; (c) full nutrition; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 3 (d) contact with parent or attorney; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 4 (e) exercise; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 5 (f) medical services and counseling; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 6 (g) religious services; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 7 (h) clean and sanitary living conditions; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 8 (i) the right to send and receive mail; ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 9 (j) education; and, ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 10 7717 Tuolumne Summit Program PRO 23-24 66 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (k) rehabilitative programming. ☒ ☐ ☐ Section VII, Number 1, Policy I-C, 11 The facility administrator shall establish rules of conduct and disciplinary penalties to guide the conduct of youth. Section VII, Number 1, Policy I-E Such rules and penalties shall include both major violations and minor violations, be stated simply and Section VII, Number 1, Policy I-F ☒ ☐ ☐ affirmatively, and be made available to all youth. Provision shall be made to provide accessible information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS The facility administrator shall develop and implement Section VII, Number 2 written policies and procedures for the administration of discipline which shall include, but not be limited to: We reviewed 61 DP incidents since October 2022 and found less than 35% were actual rule violations. Of those, 59 were accepted without hearing and 2 were appealed. The process and outcome were appropriate for the behavior and the documentation was clear. ☒ ☐ ☐ The facility continues to over-use DP for minor rule violations and separation incidents. We again provided technical assistance to suggest the daily point sheet be the document to address minor rule violations and separation. However, the intent is to allow for more conversations with youth regarding the behavior resulting in any rule violation which, due to their low population, affords youth and staff to build on relationships promoting positive behavior and supports (PBIS). (a) designation of personnel authorized to impose discipline for violation of rules; ☒ ☐ ☐ Section VII, Number 2, Procedure I-A (b) prohibiting discipline to be delegated to any youth; ☒ ☐ ☐ Section VII, Number 2, Policy I-F 7717 Tuolumne Summit Program PRO 23-24 67 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (c) definition of major and minor rule violations and their consequences, and due process requirements; Section VII, Number 1, Procedure IV-A ☒ ☐ ☐ Section VII, Number 1, Procedure IV-B Section VII, Number 1, Procedure IV-C (d) trauma-informed approaches and positive behavior interventions; ☒ ☐ ☐ Section VII, Number 2, Policy I-D (e) minor rule violations may be handled informally by counseling, advising the youth of expected conduct Section VII, Number 1, Procedure IV-A imposing a minor consequence. Discipline shall be ☒ ☐ ☐ accompanied by written documentation and a policy of review and appeal to a supervisor; and, (f) major rule violations and the discipline process shall ☒ ☐ ☐ be documented and require the following: (1) written notice of violation prior to a hearing; ☒ ☐ ☐ Section VII, Number 2, Procedure I-B (2) accommodations provided to youth with disabilities, limited literacy, and English language ☒ ☐ ☐ Section VII, Number 2, Policy I-B learners; (3) hearing by a person who is not a party to the ☒ ☐ ☐ Section VII, Number 2, Procedure I-D incident; (4) opportunity for the youth to be heard, present ☒ ☐ ☐ Section VII, Number 2, Procedure I-F evidence and testimony; (5) provision for youth to be assisted by staff in the ☒ ☐ ☐ Section VII, Number 2, Procedure I-F hearing process; (6) provision for administrative review. ☒ ☐ ☐ Section VII, Number 2, Procedure I-H 7717 Tuolumne Summit Program PRO 23-24 68 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) violations that result in a removal from camp or commitment program, but not a return to court, will ☒ ☐ ☐ Section VII, Number 2, Procedure II-G follow the due process provisions in subsection (e) above. 1410 MANAGEMENT OF COMMUNICABLE DISEASES. Tuolumne County MLRJDF Section VIII, The health administrator/responsible physician, in Number 1: Management of Communicable cooperation with the facility administrator and the local Diseases health officer, shall develop written policies and ☒ ☐ ☐ procedures to address the identification, treatment, control and follow-up management of communicable This is a comprehensive policy outlining the diseases. The policies and procedures shall address, agency response to communicable disease. but not be limited to: Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 1 Intake Health screening procedures. MLRJDF COVID-19 Screening Form (a) Intake health screening procedures; ☒ ☐ ☐ Wellpath Coronavirus Supplemental Screening Form Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedures 7717 Tuolumne Summit Program PRO 23-24 69 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 2: Identification of Relevant Symptoms. MLRJDF COVID-19 Screening Form MLRJDF Daily COVID-19 Screening Form (b) Identification of relevant symptoms; ☒ ☐ ☐ Wellpath Coronavirus Supplemental Screening Form Wellpath Patient Monitoring for Positive or Suspected COVID-19 Form Wellpath MLRJDF COVID-19 Outbreak Control Plan - Booking and Intake Procedure #2 Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 3: Referral for Medical Evaluation Wellpath MLRJDF COVID-19 Outbreak (c) Referral for medical evaluation; ☒ ☐ ☐ Control Plan - Booking and Intake Procedure #5 Wellpath Nursing Triage for Complaints related to COVID-19 7717 Tuolumne Summit Program PRO 23-24 70 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 4: Treatment Responsibilities during Detention Tuolumne County MLRJDF Section VIII, (d) Treatment responsibilities during detention; ☒ ☐ ☐ Number 1; Procedure I-C Wellpath MLRJDF COVID-19 Outbreak Control Plan - General Quarantine Procedures Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 5: Coordination with Public and Private Community Based resources for follow-up treatment. Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-G (e) Coordination with public and private community- Tuolumne County Public Health Referral ☒ ☐ ☐ based resources for follow-up treatment; Form Wellpath COVID-19 Discharge Instructions Wellpath COVID-19 Patient Education Wellpath COVID-19 Supplemental Discharge 7717 Tuolumne Summit Program PRO 23-24 71 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 6: Applicable Reporting Requirements Tuolumne County MLRJDF Section VIII, (f) Applicable reporting requirements; and, ☒ ☐ ☐ Number 1; Procedure I-G Wellpath MLRJDF COVID-19 Outbreak Control Plan - Communication #3 Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-A, 7: Strategies for Handling Disease Outbreaks (g) Strategies for handling disease outbreaks. ☒ ☐ ☐ Tuolumne County MLRJDF Section VIII, Number 1; Procedure I-E and H Wellpath MLRJDF COVID-19 Outbreak Control Plan The policies and procedures shall be updated as necessary to reflect communicable disease priorities The agency works closely with Wellpath staff identified by the local health officer and currently and the local public health agency to ensure recommended public health interventions. ☒ ☐ ☐ proper protocols and processes are in place to address all COVID-19 youth. 1433 REQUESTS FOR HEALTH CARE SERVICES (EXCERPT) Section VIII, Number 12, Procedure I-C The health administrator, in cooperation with the facility administrator, shall develop policy and procedures to ☒ ☐ ☐ establish a daily routine for youth to convey requests for emergency and non-emergency medical, dental and behavioral/mental health care services. 1480 STANDARD FACILTY CLOTHING ISSUE The youth’s personal clothing, undergarments and Section X, Number 1 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: 7717 Tuolumne Summit Program PRO 23-24 72 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (a) Clothing is clean, reasonably fitted, durable, easily laundered, in good repair, and free of holes and tears. ☒ ☐ ☐ Section X, Number 1, Procedure I-B (b) The standard issue of climatically suitable clothing for youth shall consist of but not be limited to: ☒ ☐ ☐ (1) Socks and serviceable footwear; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 1 (2) Outer garments; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 2 and 3 (3) New non-disposable underwear which shall remain with the youth throughout their stay, and; ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 4 (4) Undergarments, that are freshly laundered and free of stains, including tee shirts and bras. ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 5 (c) Clothing is laundered at the temperature required by local ordinances for the commercial laundries and dried Section X, Number 1, Procedure 1-D completely in a mechanical dryer or other laundry ☒ ☐ ☐ method approved by the local health officer. (d) Suitable clothing is issued to pregnant youth. ☒ ☐ ☐ Section X, Number 1, Procedure I-C, 9 1482 CLOTHING EXCHANGE The facility administrator shall develop and implement Section X, Number 1, Procedure I written policies and site-specific procedures for the cleaning and scheduled exchange of clothing. Unless work, climatic conditions, or illness necessitates more ☒ ☐ ☐ frequent 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. 7717 Tuolumne Summit Program PRO 23-24 73 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1484 CONTROL OF VERMIN IN YOUTH’S PERSONAL CLOTHING Section X, Number 2 There shall be written policies and site-specific procedures developed and implemented by the facility administrator to control the contamination and/or spread ☒ ☐ ☐ of vermin and ecto-parasites in all youth’s personal clothing. Infested clothing shall be cleaned or stored in a closed container so as to eradicate or stop the spread of the vermin. 1485 ISSUE OF PERSONAL CARE ITEMS There shall be written policies and site-specific Section X, Number 3, Procedure I-A procedures developed and implemented by the facility administrator for the availability of personal 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; (a) Toothbrush; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (b) Toothpaste; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (c) Soap; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (d) Comb; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (e) Shaving implements; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (f) Deodorant; ☒ ☐ ☐ Section X, Number 3, Procedure I-A 7717 Tuolumne Summit Program PRO 23-24 74 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS (g) Lotion; ☒ ☐ ☐ Section X, Number 3, Procedure I-A (h) Shampoo; and, ☒ ☐ ☐ Section X, Number 3, Procedure I-A (i) Post-shower conditioning hair products. ☒ ☐ ☐ Section X, Number 3, Procedure I-A Youth shall not be required to share any personal care items listed in items (a) through (d). Liquid soap Section X, Number 3, Procedure I-A provided through a common dispenser is permitted. Youth shall not share disposable razors. Double edged Section X, Number 3, Procedure I-E safety razors, electric razors, and other shaving ☒ ☐ ☐ instruments capable of breaking the skin, when shared Section X, Number 3, Procedure I-G 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. 1486 PERSONAL HYGIENE There shall be written policies and site specific Section X, Number 3, Procedure I-B procedures developed and implemented by the facility administrator for showering/bathing and brushing of Section X, Number 3, Procedure I-C ☒ ☐ ☐ teeth. Youth shall be permitted to shower/bathe up on assignment to a housing unit and on a daily basis thereafter and given an opportunity to brush their teeth after each meal. 1487 SHAVING Youth shall have access to a razor daily, unless their Section X, Number 3, Procedure IV appearance must be maintained for reasons of identification in Court. All youth shall have equal ☒ ☐ ☐ opportunity to shave face and body hair. The facility administrator may suspend this requirement in relation to youth who are considered to be a danger to themselves or others. 1488 HAIR CARE SERVICES (EXCERPT) Hair care services shall be available in all juvenile Section X, Number 3, Procedure V facilities. Youth shall receive hair care services monthly. ☒ ☐ ☐ Equipment shall be cleaned and disinfected after each haircut or procedure, by a method approved by the State Board of Barbering and Cosmetology. 7717 Tuolumne Summit Program PRO 23-24 75 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1500 STANDARD BEDDING AND LINEN ISSUE Clean laundered, suitable bedding and linens, in good Section XI, Number 1 repair, shall be provided for each youth entering a living ☒ ☐ ☐ area who is expected to remain overnight, shall include, but not be limited to: (a) One mattress or mattress-pillow combination which meets the requirements of Section 1502 of these ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 1 regulations; (b) One pillow and a pillow case unless provided for in (a) above; ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 1 (c) One mattress cover and a sheet or two sheets; ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 2 (d) One towel; and, ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 4 (e) One blanket or more, up on request ☒ ☐ ☐ Section XI, Number 1, Procedure I-B, 3 1501 BEDDING LINEN EXCHANGE The facility administrator shall develop and implement Section XI, Number 1, Procedure I site specific written policies and procedures for the scheduled exchange of laundered bedding and linen ☒ ☐ ☐ issued to each youth housed. Washable items such as sheets, mattress covers, pillow cases and towels shall be exchanged for clean replacement at least once each week. The covering blanket shall be cleaned or laundered once a month. ☒ ☐ ☐ Section XI, Number 1, Procedure I-E 7717 Tuolumne Summit Program PRO 23-24 76 A453 JUV PRO eff. 1/2019 (23-24).dot TITLE 15 SECTION YES NO N/A P/P REFERENCE – COMMENTS 1510 FACILITY SANITATION, SAFETY AND MAINTENANCE Section XII, Number 1 The facility administrator shall develop and implement written policies and site-specific procedures for the maintenance of an acceptable level of cleanliness, repair and safety throughout the facility. The plan shall provide for a regular schedule of housekeeping tasks, ☒ ☐ ☐ equipment, including restraint devices, and physical plant maintenance and inspections to identify and correct unsanitary or unsafe conditions or work practices in a timely manner. The use of chemicals shall be done in accordance to the product label and Safety Data Sheet which may include the use of Personal Protection Equipment (PPE). REVIEW OF NON REGULATORY REQUIREMENTS GRANT FUNDING OR CODE REFERENCE YES NO N/A P/P REFERENCE - COMMENTS JUVENILE PROBATION AND CAMPS FUNDING (JPCF) (Camps Only) The programs/services identified on the JPCF Camp Eligibility Form are being provided at the facility. (Refer ☒ ☐ ☐ to the JPCF Camp Eligibility Form) 208.5 WIC CONTACT BETWEEN PERSONS UNDER THE JUVENILE COURT AGES 19- 20 AND MINORS IN THE FACILITY The facility houses Juvenile Court Wards 19 years of ☒ ☐ ☐ age and older. The facility has been approved to hold persons under ☒ ☐ ☐ the juvenile court who are ages 19 through 21. The facility continues to comply with the requirements of 208.5 WIC (programming, capacity and security of ☒ ☐ ☐ the facility) as outlined in the county’s application. JUVENILE JUSTICE DELINQUENCY PREVENTION ACT MONITORING (JJDPA) WIC 206 SEPARATE FACILITIES FOR WIC 300 MINORS ☐ ☐ ☒ Dependent or neglected minors who are defined under Section 300 of the Welfare and Institutions Code (WIC) Violation are held only in non-secure, separate and segregated facilities. DETENTION OF STATUS OFFENDERS (WIC 601) AND FEDERAL MINORS ☐ ☒ ☐ Status Offenders (WIC 601) are held in the facility. Status Offenders (WIC 601) are kept separate from ☐ ☐ ☒ Juvenile Delinquents (WIC 602)? (WIC 207[d]). Violation 7717 Tuolumne Summit Program PRO 23-24 77 A453 JUV PRO eff. 1/2019 (23-24).dot Federal Minors (ICE Holds or ORR Contract) are held ☐ ☒ ☐ in the facility. If yes to the above, the Monthly Report on the Detention of Status Offenders/Federal Minors is ☐ ☐ ☒ submitted to the BSCC. WIC 208 SEPARATION OF MINORS AND ADULT INMATES (JJDPA 42 USC 5633, Sec 223, State Plans (a)[12]) ☐ ☒ ☐ Are adult inmates held in the facility? (When a person in detention is proceeding through the adult court, AND that person is 18 years of age or older that person is an adult inmate.) If adult inmates are held, they are appropriately ☐ ☐ ☒ separated from minors. Violation Adult inmates from an adult facility (e.g. inmate workers ☐ ☐ ☒ or “Scared Straight” programs) are not allowed in the facility in a manner that allows contact with minors. Violation 7717 Tuolumne Summit Program PRO 23-24 78 A453 JUV PRO eff. 1/2019 (23-24).dot JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections APPLICABLE TITLE 24 REGULATIONS: 4/98; 2001; 2003; 2009; 2014; 2018 BSCC Code: 7716 7718 7717 FACILITY NAME: Tuolumne County Regional Mother Lode Juvenile Detention Facility FACILITY TYPE: JH Steps to Success Camp Summit Program Secure Youth Treatment Facility SYTF 4/98: 2001: 2003: 2009: 2014: 2018: APPLICABLE REGULATIONS (Check All That Apply): XX FIELD REPRESENTATIVE: Elizabeth Gong DATE: November 8, 2023 TITLE 24 SECTION YES NO N/A COMMENTS 1230.1.1 Reception/intake admission. In each juvenile hall, space used for the reception of youth pending admission to juvenile hall shall have the following space and equipment: 1. Weapons lockers as specified in Section 1230.2.9; ☒ ☐ ☐ There are 10-gun lockers in the sally port. 2. A secure room for the confinement of youth pending admission to juvenile hall as specified in Section There are three holding rooms in the 1230.1.2; intake/booking area, all with a toilet combo In each juvenile hall, camp and ranch, space used ☒ ☐ ☐ unit. for the reception of youth pending admission to these facilities shall have the following space and equipment: 3. Access to a shower; There is an Intake shower in booking area, ☒ ☐ ☐ adjacent to the holding rooms and next to clothing storage and inventory. 4. A secure vault or storage space for youth, valuables; ☒ ☐ ☐ 5. Telephone accessible to youth; and ☒ ☐ ☐ 6. Access to hot and cold running water for staff use. ☒ ☐ ☐ 1230.1.2 Locked holding room. There are three holding rooms in the A locked holding room shall: Intake/Booking area. 1. Contain a minimum of 15 square feet of floor area ☒ ☐ ☐ per youth; 2. Provide no less than 45 square feet of floor space ☒ ☐ ☐ and have a clear ceiling height of 8 feet or more; 3. Contain seating to accommodate all youth as ☒ ☐ ☐ specified in Section 1230.2.8; 4. Be equipped with a toilet, wash basin, mirror and drinking fountain unless as specified in Section 1230.2, unless a procedure is in effect to give the ☒ ☐ ☐ youth access to a toilet, wash basin and drinking fountain; 7716+ Tuolumne Probation PHY 23-24 - 1 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 5. Maximize visual supervision of youth by staff; and ☒ ☐ ☐ 6. Have an outward swinging or lateral sliding door. ☒ ☐ ☐ 1230.1.3 Natural light. Outer-facing exterior windows where youth’s privacy is not at risk shall be provided in locked sleeping rooms, single occupancy sleeping rooms, double occupancy ☒ ☐ ☐ sleeping rooms, dormitories and dayrooms. Natural light may be provided by, but is not limited to, skylights or windows in dayrooms, windows in adjacent exterior exercise areas, and in sleeping rooms and/or dormitories. 1230.1.4 Corridors ☒ ☐ ☐ Corridors in living areas shall be at least eight feet wide. 1230.1.5 Living unit. A living unit shall be a self-contained unit containing locked sleeping rooms, single and double occupancy ☒ ☐ ☐ sleeping rooms, or dormitories, dayroom space, toilet, wash basins, drinking fountains and showers commensurate to the number of youth housed. A living unit shall not be divided in a way that hinders direct access, supervision, immediate intervention or ☒ ☐ ☐ other action if needed. In juvenile halls, the number of youth housed in a living unit shall not exceed 30. 1230.1.6 Locked sleeping rooms. The individual rooms are in excess of required Locked sleeping rooms shall be equipped with an ☒ ☐ ☐ space. individual or combination toilet, wash basin, mirror and drinking fountain. Doors to locked sleeping rooms shall swing outward or ☒ ☐ ☐ slide laterally. 1230.1.7 Single occupancy sleeping rooms. The individual rooms are in excess of required Single occupancy sleeping rooms shall provide the ☒ ☐ ☐ space. following: 1. A minimum of 70 square feet of floor area; 2. A minimum ceiling height of eight feet; and, ☒ ☐ ☐ 3. The door into this room shall swing outward or slide laterally and be provided with a view panel, a ☒ ☐ ☐ minimum of 144 square inches, constructed of security glazing. 4. Contain a bed as specified in 1230.2.5. ☒ ☐ ☐ 1230.1.8 Double occupancy sleeping rooms. The double rooms are in excess of required Double occupancy sleeping rooms shall provide the ☒ ☐ ☐ space. following: 1. A minimum of 100 square feet of floor area; 2. A minimum clear ceiling height of 8 feet and a ☒ ☐ ☐ minimum width of 7 feet; and, 7716+ Tuolumne Probation PHY 23-24 - 2 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 3. The door into this room shall swing outward or slide laterally and be provided with a view panel, a ☒ ☐ ☐ minimum of 144 square inches, constructed of security glazing. 4. Contain a bed as specified in 1230.2.5. ☒ ☐ ☐ 1230.1.9 Dormitories Dormitories shall provide the following: 1. A minimum of 50 square feet of floor area per ☒ ☐ ☐ youth with the minimum size of a dormitory being 200 square feet of floor area and a minimum 8- foot clear ceiling height; 2. Designed for no fewer than four youth; ☒ ☐ ☐ 3. Dormitories in juvenile halls shall be designed for ☒ ☐ ☐ no more than 30 youth; 4. Camps shall conform to Items 1 and 2. ☒ ☐ ☐ 1230.1.10 Dayrooms The dayroom space exceeds minimum Dayrooms shall contain 35 square feet of floor area per standards and the design promotes ☒ ☐ ☐ youth, contain tables and seating to accommodate the comfortable living and recreation space. maximum numbers of youth allowed access at a given time. Access must be provided to toilets, wash basins, drinking fountains and showers as specified in Section ☒ ☐ ☐ 1230.2. 1230.1.11 Physical activity and recreation areas. Indoor and outdoor space exceeds minimum Indoor/outdoor physical activity and recreation areas standards for rated space. shall be designed as follows: 1. Minimum indoor outdoor recreation space for ☒ ☐ ☐ facility capacity: 40 or less is 9,000 square feet; 41-274 is 225 square feet per youth up to 61,650 square feet; 275 or more is 61,650 square feet, plus 145 square feet for each youth beyond 274 [up to a maximum of 87,120 square feet] 1.1 At least one quarter of the dedicated indoor/outdoor space shall be a paved or like There is a full basketball space in the ☒ ☐ ☐ surface. recreation space. 1.2 The required recreation area shall contain no ☒ ☐ ☐ single dimension less than 40 feet. 2. A portion of the dedicated space for physical activity and recreation shall be out-of-doors and be sufficient size and equipped in such a manner to allow ☒ ☐ ☐ compliance with Title 15, Section 1371, which requires at least one hour per day of outdoor activity for each detained youth. 3. Lighting of outdoor recreation areas shall be provided to allow for evening activities and to provide ☒ ☐ ☐ security. 4. Access must be provided to a toilet, wash basin and drinking fountain as specified in Section 1230.2. There is a drinking fountain and sink outdoors, ☒ ☐ ☐ youth needing to use the restroom are taken inside the facility. 7716+ Tuolumne Probation PHY 23-24 - 3 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 1230.1.12 Academic classrooms. ☒ ☐ ☐ There shall be a dedicated classroom space for every juvenile in every facility. The primary purpose for the academic classroom shall ☒ ☐ ☐ be for education. Each academic classroom shall contain a minimum of 160 square feet of floor space for the teacher’s desk Each classroom is 693’ and exceeds minimum and work area and a minimum of 28 square feet of ☒ ☐ ☐ space requirements. The second classroom floor space per minor. has been transformed into a library. A communication system shall be provided in each classroom to allow for immediate response to ☒ ☐ ☐ emergencies. The classroom shall be designed for a maximum of 20 ☒ ☐ ☐ minors. There shall be space available in every juvenile facility that may be used for specialized, one-on-one or small ☒ ☐ ☐ group educational purposes. 1230.1.13 Safety room. There is no safety room at the facility. A safety room shall: ☐ ☐ ☒ 1. Contain a minimum of 48 square feet of floor area and a minimum clear ceiling height of 8 feet; 2. Be limited to one youth; ☐ ☐ ☒ 3. Be padded as specified in Section 1230.2.7; ☐ ☐ ☒ 4. Provide one or more vertical view panels constructed of security glazing. These view panels shall be no more than 4 inches wide nor less than 24 ☐ ☐ ☒ inches long, which shall provide a view of the entire room; 5. Provide an audio monitoring system as specified ☐ ☐ ☒ in Section 1230.1.22; 6. Contain a flushing ring toilet, capable of accepting solid waste, mounted flush with the floor, the controls ☐ ☐ ☒ for which must be located outside of the room; 7. Be equipped with a variable intensity, security- type lighting fixture with controls located outside the ☐ ☐ ☒ room; 8. Any wall or ceiling-mounted devices must be designed to prohibit access to the youth occupant; ☐ ☐ ☒ and, 9. Provide a food pass with lockable shutter, no more than 4 inches high, and located between 26 inches ☐ ☐ ☒ and 32 inches as measured from the bottom of the food pass to the floor. 1230.1.14 Medical examination room. ☒ ☐ ☐ There must be a minimum of one suitably equipped medical examination room in every juvenile facility. 7716+ Tuolumne Probation PHY 23-24 - 4 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS Medical examination rooms shall provide the following: 1. Space for carrying out routine medical ☒ ☐ ☐ examinations and emergency care and used for no other purpose; 2. Privacy for youth; ☒ ☐ ☐ 3. Lockable storage space for medical supplies; ☒ ☐ ☐ 4. Not less than 144 square feet of floor space with no single dimension less than 7 feet; ☒ ☐ ☐ The exam room is 9’ x 18’. 5. Hot and cold running water; ☒ ☐ ☐ 6. Smooth, nonporous, washable surface; ☒ ☐ ☐ 7. A medical exam table; and, ☒ ☐ ☐ 8. Adequate lighting. ☒ ☐ ☐ 1230.1.15 Pharmaceutical storage. There are two locked refrigerator/freezers and Provide lockable storage space for medical supplies ☒ ☐ ☐ numerous locking cabinets in the locked and pharmaceutical preparations as specified by Title Pharmacy. 15, Section 1438. 1230.1.16 Dining areas. Youth consume meals in the dayroom space. Dining areas in juvenile facilities shall contain a ☒ ☐ ☐ minimum of 15 square feet of floor space and sufficient tables and seating for each person being fed. Persons being fed include youth, staff and visitors. ☒ ☐ ☐ Dining areas shall not contain toilets or showers in the ☒ ☐ ☐ same room without appropriate visual barrier. 1230.1.17 Visiting space. Space shall be provided in all juvenile facilities for in- ☒ ☐ ☐ person visiting which shall be unobstructed by barriers such as, but not limited to, security glazing for mesh. 1230.1.18 Institutional storage. Youth’s personal property is stored in a sealed One or more storage rooms shall be provided to ☒ ☐ ☐ bag in the Property Storage room at Intake. accommodate a minimum of 80 cubic feet of storage space per minor. Items to be stored shall be institutional clothing, ☒ ☐ ☐ bedding, supplies and activity equipment. 1230.1.19 Personal storage. There is sufficient storage for youth property, Each youth in a juvenile facility shall be provided with ☒ ☐ ☐ with vermin protocols in the same location. a minimum of 9 cubic feet of secure storage space for personal clothing and belongings. 1230.1.20 Safety equipment storage. In all juvenile facilities, a secure area shall be provided ☒ ☐ ☐ for the storage of safety equipment, such as fire extinguishers, self-contained breathing apparatus, wire and bar cutters, emergency lights, etc. 7716+ Tuolumne Probation PHY 23-24 - 5 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 1230.1.21 Janitorial closet. In all juvenile facilities, at least one securely lockable ☒ ☐ ☐ janitorial closet, containing a mop sink and sufficient area for the storage of cleaning implements, must be provided within a security area of the facility. 1230.1.22 Audio monitoring system. In safety rooms, locked holding rooms, locked sleeping rooms, single and double occupancy rooms ☒ ☐ ☐ and dormitories, there must be an audio monitoring system capable of actuation by the minor that alerts personnel. 1230.1.23 Emergency power. There shall be a source of emergency power in all juvenile facilities capable of providing minimal lighting ☒ ☐ ☐ in all living units, activities areas, corridors, stairs and central control points, and to maintain fire and life safety, security, communications and alarm systems (Title 24, Part 2, Chapter 27). Such an emergency power source shall conform to the requirements specified in Title, 24, Part 3, Article 700, ☒ ☐ ☐ California Electrical Code, California Code of Regulations. 1230.1.24 Confidential interview room. There are three separate interview rooms in Confidential interview rooms shall contain a minimum ☒ ☐ ☐ the booking area, two of which allow for no- of 60 square feet of floor area. contact visiting and other interview needs. In juvenile halls there shall be a minimum of one ☒ ☐ ☐ suitably furnished interview room for each 30 youth. In camps there shall be a minimum of one suitably ☒ ☐ ☐ furnished interview room for each facility. This interview room shall provide for confidential ☒ ☐ ☐ consultations with youth. 1230.1.25 Special-purpose juvenile halls. Special-purpose juvenile halls shall conform to all ☐ ☐ ☒ minimum standards for juvenile facilities contained in this section with the following exceptions: 1. Physical activity and recreation areas as specified ☐ ☐ ☒ in Section 1230.1.11; 2. Academic classrooms as specified in Section ☐ ☐ ☒ 1230.1.12; 3. Medical examination room as specified in Section ☐ ☐ ☒ 1230.1.14; and, 4. Dining areas as specified in Section 1230.1.16. ☐ ☐ ☒ 1230.1.26 Court holding room for youth. A court holding room shall: ☐ ☐ ☒ 1. Contain a minimum of 10 square feet of floor area per youth; 2. Be limited to no more than 16 youth; ☐ ☐ ☒ 7716+ Tuolumne Probation PHY 23-24 - 6 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 3. Provide no less than 40 square feet of floor area ☐ ☐ ☒ and have a ceiling height of 8 feet or more; 4. Contain seating to accommodate all youth as ☐ ☐ ☒ specified in Section 1230.2.8; 5. Contain a toilet, wash basin and drinking fountain ☐ ☐ ☒ as specified in Section 1230.2; 6. Maximize visual supervision of youth by staff; and, ☐ ☐ ☒ 7. A mirror of material appropriate to the level of security shall be provided as specified in Section ☐ ☐ ☒ 1230.2.11. 1230.1.27 Programs and activity areas. All juvenile facilities shall include adequate space for ☒ ☐ ☐ specific programs in addition to recreation and exercise areas. 1230.2.1 Toilets/urinals. All toilet areas shall provide privacy for the youth and ☒ ☐ ☐ help reduce the risk of voyeurism without mitigating staff’s ability to supervise. Toilets must be available in a ratio to youth as follows: ☒ ☐ ☐ 1. Juvenile halls 1:6; 2. Camps 1:10; and ☒ ☐ ☐ 3. Locked holding rooms 1:8: ☒ ☐ ☐ One toilet and one urinal may be substituted for every ☒ ☐ ☐ 15 males. 1230.2.2 Wash basins. In living units, wash basins must be available in a ratio ☒ ☐ ☐ to youth as follows: 1. Juvenile halls 1:6; 2. Camps 1:10; and ☒ ☐ ☐ 3. Locked holding rooms 1:8: ☒ ☐ ☐ Wash basis must be provided with hot and cold or ☒ ☐ ☐ tempered water. 1230.2.3 Drinking fountains. In living areas and indoor and outdoor recreation ☒ ☐ ☐ areas, drinking fountains must be accessible to youth and to staff. 1. The drinking fountain bubbler shall be on an angle which prevents waste water from flowing over the ☒ ☐ ☐ drinking bubbler; and, 2. The water flow shall be actuated by a mechanical ☒ ☐ ☐ means. 1230.2.4 Showers. Shower areas shall provide privacy for the youth and ☒ ☐ ☐ help reduce the risk of voyeurism without mitigating staff’s ability to supervise. Showers shall be available to all youth on a ratio of at least one shower or bathtub to every six youth. ☒ ☐ ☐ Showers shall be provided with tempered water. 7716+ Tuolumne Probation PHY 23-24 - 7 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 1230.2.5 Beds. ☒ ☐ ☐ Beds shall be at least 30 inches wide and 76 inches long and be of the solid bottom type. Beds shall be at least 12 inches off the floor and ☒ ☐ ☐ spaced no less than 36 inches apart Bunk beds must have no less than 33 inches vertically ☒ ☐ ☐ between the solid bottoms. In secure facilities, the bunks shall be securely ☒ ☐ ☐ anchored and flushed against the floor and/or wall. 1230.2.6 Lighting. Lighting in locked sleeping rooms, single occupancy ☒ ☐ ☐ rooms, double occupancy rooms, dormitories, day rooms and activity areas shall provide not less than 20 foot candles of illumination at desk level. Night lighting is required in these areas to provide for good visibility for supervision and be conducive to ☒ ☐ ☐ sleep. 1230.2.7 Padding. Padding in safety rooms, padding shall cover the ☐ ☐ ☒ entire floor, door, walls and everything on walls to a clear height of eight feet. Benches or platforms are not to be placed on the floor ☐ ☐ ☒ of this room. All padded rooms must be equipped with a tamper resistant fire sprinkler as approved by the State Fire ☐ ☐ ☒ Marshal. All padding must be: ☐ ☐ ☒ 1. Approved for use by the State Fire Marshal; 2. Nonporous to facilitate cleaning; ☐ ☐ ☒ 3. At least 112 inch thick; ☐ ☐ ☒ 4. Of a unitary or laminated construction to prevent its destruction by teeth, hand tearing or small metal ☐ ☐ ☒ objects; 5. Firmly bonded to all padded surfaces to prevent ☐ ☐ ☒ tearing or ripping; and, 6. Without any exposed seams susceptible to tearing ☐ ☐ ☒ or ripping. 1230.2.8 Seating. ☒ ☐ ☐ Seating shall be designed for the level of security. When bench seating is used, 18 inches of bench is ☒ ☐ ☐ seating for one person. 1230.2.9 Weapons lockers. Weapons lockers are required in all secure juvenile ☒ ☐ ☐ facilities and shall be located outside the secure area of the facility. Weapons lockers shall be equipped with individual ☒ ☐ ☐ compartments, each with an individual locking device. 7716+ Tuolumne Probation PHY 23-24 - 8 - J456 PHY 98 01 03 09 14 18 dot TITLE 24 SECTION YES NO N/A COMMENTS 1230.2.10 Security glazing. Security glazing shall comply with the minimum requirements of one of the following test standards: American Society for Testing and Materials, ASTM F ☒ ☐ ☐ 1233-98, Class III glass, or; California Department of Corrections, CDC 860-94d, Class C glass or; H.P. White Laboratory, Inc., HPW-TP-0500.02, Forced Entry Level III. 1230.2.11 Mirrors. A mirror of a material appropriate to the level of ☒ ☐ ☐ security must be provided near each wash basin specified in these regulations. 7716+ Tuolumne Probation PHY 23-24 - 9 - J456 PHY 98 01 03 09 14 18 dot JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS, AND CAMPS LIVING AREA SPACE EVALUATION Board of State and Community Corrections BSCC Code: 7716 7718 7717 FACILITY: Tuolumne County Mother Lode Regional Juvenile Detention Facility TYPE: JH RC: 23 Steps to Success Camp 5 Summit Program Secure Youth Treatment Facility SYTF 2 TOTAL 30 FIELD REPRESENTATIVE: Elizabeth Gong DATE: November 7-8, 2023 ROOMS EACH ROOM Unit Room Applicable # EACH ROOM Total DIMENSIONS FIXTURES* Designation Type Standards Rooms # Beds RC RC (L x W x H) T U W F S Intake/Booking #C123 Holding 2009 1 7’x10’8”x8’2” 1 1 1 #C124 Holding 2009 1 7’1”x10’8”x8’2” 1 1 1 #C125 Holding 2009 1 11’11”x10’8”x8’2” 1 1 1 Note: There is one contact visiting room in Intake/Booking (C122) that is being used as an office for the facility-assigned Behavior Health staff/Deputy Probation Officer who responds to new bookings. There are three no-contact visiting spaces in Intake/Booking (C119-C120), one of which is ADA-compliant (C121). First Floor Rooms #101 Double 2009 1 2 2 2 9’6” x 11’4” x 8’2” 1 1 1 #102 Double 2009 1 2 2 2 9’6” x 11’4” x 8’2” 1 1 1 #103 Double 2009 1 2 2 2 9’9” x 11’4” x 8’2” 1 1 1 #104 Double 2009 1 2 2 2 9’9” x 11’4” x 8’2” 1 1 1 #105 Single 2009 1 1 1 1 6’11” x 11’4” x 8’2” 1 1 1 #106 Single 2009 1 1 1 1 9’6” x 11’4” x 8’2” 1 1 1 #107 Single 2009 1 1 1 1 6’10” x 11’4” x 8’2” 1 1 1 #108 Single 2009 1 1 1 1 9’6” x 11’4” x 8’2” 1 1 1 Note: Room 106 is an ADA cell. Second Floor Rooms #201 Double 2009 1 2 2 2 9’6” x 11’4” x 8’2” 1 1 1 #202 Double 2009 1 2 2 2 9’6” x 11’4” x 8’2” 1 1 1 #203 Double 2009 1 1 1 1 9’6” x 11’4” x 8’2” 1 1 1 *T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit. If "Total RC" appears in brackets ( ), it is not part of the facility's rated capacity. 7716+ Tuolumne Probation LASE 23-24 - 1 - J460 LAS JUV-05.dot (rev.12/2022) ROOMS EACH ROOM Unit Room Applicable # EACH ROOM Total DIMENSIONS FIXTURES* Designation Type Standards Rooms # Beds RC RC (L x W x H) T U W F S 200 Double 2009 1 1 1 1 9’9” x 11’4” x 8’2” 1 1 1 #205 Double 2009 1 2 2 2 10’5” x 11’4” x 8’2” 1 1 1 #206 Double 2009 1 2 2 2 10’5” x 11’4” x 8’2” 1 1 1 #207 Single 2009 1 2 2 2 6’11” x 11’4” x 8’2” 1 1 1 #208 Single 2009 1 2 2 2 7’3” x 11’4” x 8’2” 1 1 1 #209 Double 2009 1 2 2 2 9’6” x 11’4” x 8’2” 1 1 1 #210 Double 2009 1 2 2 2 9’6” x 11’4” x 8’2” 1 1 1 Living Area Dayroom 2009 43’8” x 64’ 4 4 5 Note: The day room is 2794’, less the control station and stairwell. Youth use this space for dining and indoor activities. There is 1 ADA shower. Indoor 2009 22’7” x 40’ 1 1 Rec Note: This space is 903’2” and used for indoor recreation or large muscle in the event of inclement weather. Classroom 2009 2 22’ x 31’5” Note: The facility is only using one classroom due to low population, however, the facility has turned the other classroom into a Library. There is sufficient classroom space, 693 square feet, just off the dayroom. The facility has significant outdoor spaces, both grass and cement, including basketball court, garden area, and soccer field. *T = Toilets; U = Urinals; W = Wash Basins; F = Fountains; S = Showers in unit. If "Total RC" appears in brackets ( ), it is not part of the facility's rated capacity. 7716+ Tuolumne Probation LASE 23-24 - 2 - J460 LAS JUV-05.dot (rev.12/2022)