Los Angeles County (2018-2020 inspection cycle)

February 11, 2021 Adolfo Gonzales, Chief Probation Officer Los Angeles County Probation Department 9150 East Imperial Highway Downey, CA 90242 RE: 2018 - 2020 BIENNIAL INSPECTION OF LOS ANGELES PROBATION DEPARTMENT, WELFARE AND INSTITUTIONS CODE SECTION 209; JUVENILE JUSTICE AND DELINQUENCY PREVENTION ACT Dear Chief Gonzales: Pursuant to the California Welfare and Institutions Code Section 209, the BSCC shall conduct a biennial inspection of each juvenile facility used for confinement of minors for more than 24 hours. These inspections are performed to determine compliance with the Minimum Standards for Local Detention Facilities as outlined in Titles 15 and 24, California Code of Regulations. Statewide regional trainings were held in preparation of new regulatory revisions. These trainings were held in December 2018 to introduce and educate staff of the new regulations and to provide technical assistance and direction. An onsite, pre inspection briefing (see below table for dates) was held for facility staff responsible for the inspection process and additional, individual local technical assistance briefings were held to provide the facility staff an opportunity to ask site specific questions about any areas of concern they may have had or to seek additional guidance. A policy review was initiated and completed for both Detention Services Bureau and Residential Services Bureau facilities as part of this inspection. Documentation was requested and received from all facilities as if we were onsite for our review. Documentation was subsequently reviewed by virtual desk audit due to the Coronavirus pandemic, the issuance of statewide stay at home orders and local public health guidelines that precluded BSCC staff from conducting on‐site inspections. The complete BSCC inspection report is enclosed and consists of this transmittal letter, the Title 15 Procedures Checklists for each facility outlining applicable minimum standards; a Physical Plant Evaluation for each facility outlining Title 24 requirements for design; and a Living Area Space Evaluation for each facility summarizing the physical plant configuration and showing the capacity of each facility. These documents are provided for information only as Bureau staff have provided all updates or indicated no changes made from the from last cycle. Please refer to the Title 15 procedures checklist for indication of facility compliance status and evidence used to determine compliance. 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 2 Facility Barry J. Central Camp Camp Camp Campus Camp Camp Nidorf Juvenile Afflerbaugh Paige Rockey Kilpatrick Scott Dorothy Juvenile Hall Kirby Hall Center Pre- 06/27/19 06/28/19 07/03/19 07/03/19 07/03/19 07/02/19 07/02/19 07/02/19 Inspection Briefing: Policy 06/02/20 06/02/20 06/26/20 06/26/20 06/26/20 06/26/20 06/26/20 06/26/20 Review: Local Inspections In addition to the biennial inspection by the BSCC, Title 15, Section 1313 and statute also require an annual local inspection from the following: county building inspector or person designated by the Board of Supervisors, annual local health officer, annual county Superintendent of Schools; Juvenile Court and the Juvenile Justice Commission. A biennial inspection is required from the fire authority having jurisdiction. Please refer to the Title 15 procedures checklist for dates and specific notes regarding these inspections and consider our report in conjunction with all other local reports received by your agency for a comprehensive perspective of your facility. There are several areas that are non-compliant and are noted specifically in the individual procedures’ checklists by facility. These items will require corrective action. We have been provided with and have accepted corrective documentation from the agency in the past; however, the inspecting body has indicated some of these same issues still exist in the most recent reports. It is unknown if those corrections were ever implemented. We will require notice from the inspecting body that all areas of non-compliance have been resolved to clear the non-compliance. Inspection Scope and Results Title 15, CCR Minimum Standards Prior to the document inspection, we began with a review of the Los Angeles County Probation Department Policy and Procedure Manuals. Our evaluation consists of reviewing only those policies and procedures specifically related to the Juvenile Halls (DSB) and Residential Treatment Services Bureau (RTSB) facilities and the applicable regulations included in Title 15, CCR1. During our review, we noted that several policies were missing information or were inconsistent with the revised requirements of the regulations in both DSB and RTSB manuals. These policies required various levels of improvement and corrective action. Corrections have been made in each identified area, except for Section 1354, Separation, Section 1354.5, Room Confinement and Section 1390, Discipline Due Process. There are other areas of policy that were updated to current requirements; however, either proof of practice was not provided for our review, final procedure is pending implementation, or we could not verify compliance. These Sections will need to be included in Corrective Action review for both Bureaus. All updates have been made available to staff. Please see Procedures Checklist for details of those sections. We reviewed documentation which included facility incident reports including suicide watch, use of force, use of force with the use of OC and restraints for movement within the facility. We reviewed room confinement forms, 1 BSCC does not review all policies and procedures. We do not “approve” policies and procedures, nor do we review them for constitutional or legal issues. We recommend agencies seek review through their legal advisor, risk manager and other persons deemed appropriate. 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 3 grievances, programming sheets, admission, release and classification documents, assessments and case plans, unit schedules, due process, and safety checks. All documentation was readily available for our review to ensure compliance with Title 15 regulations and to ensure facility operations and policy/practice are consistent with regulatory mandates. We certainly miss the opportunity to tour the facility, observe the daily programs, activities and operations, conduct face to face interviews with the residents, facility partners, staff and the ability to observe and make a determination of the environment of the facility, to meet one on one to debrief our findings and to allow for technical assistance and best practice suggestions to be implemented if appropriate. Areas Where We Were Unable to Determine Compliance Completing an inspection remotely and virtually does not allow for our regular onsite observations that assist in the overall determination of compliance, as such there are areas in the report that are marked as unknown. In these instances, we were unable to make a determination of compliance based upon the information we had access to. It is likely, if we had been onsite, we would have been able to seek additional documentation or some other way verify compliance. The chart below identifies areas of Title 15 where we were unable to determine compliance. Please see the attached Procedures Checklist for detailed description; if you can provide information that will allow us to make a final determination of compliance, please do so as soon as possible. Upon receipt and confirmation, we will update our records. Any items left unresolved at the time the Corrective Action Plan is submitted, will also be considered non-compliant and must be included in the Corrective Action Plan. Areas where compliance is unable to be determined Regulation Regulation Section (Refer to the Checklist for BJN CJH CBA CJP CVK DKC CJS CGR information) 1321(a) Staffing U U 1321(c) Staffing U U 1324(e) Policy and Procedure Manual U U U U U U U U 1354(c) Separation U U U U 1355(a) Institutional Assessment and U U U U U U Plan 1355(2)A Institutional Assessment and U U Plan 1355(2)B Institutional Assessment and U U U U U Plan 1357(a)5 Use of Force-Debriefing U U U U U U U U 1358 Use of Physical Restraints- U 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 4 Areas where compliance is unable to be determined Regulation Regulation Section (Refer to the Checklist for BJN CJH CBA CJP CVK DKC CJS CGR information) 1358 Use of Physical Restraints-MH U U consult 1358 Use of Physical Restraints- U U Cont. Direct Vis. 1358 Use of Physical Restraints- U U Mgr. approval 1358 Use of Physical Restraints- U U Med Opinion 1391(f)2 Discipline Process U U U U U U U U 1391(f)3 Discipline Process U U U U U U U 1391(f)4 Discipline Process U U U U U U U U 1391(f)5 Discipline Process U U U U U U U U 1391(f)6 Discipline Process U U U U U U U U Outstanding Items of Noncompliance and Corrective Action Required Upon final review of all documentation and upon the conclusion of this report, we identified the outstanding items of noncompliance listed in the chart below. We want to thank your administrative team for the time and efforts made to ensure we had all the necessary documentation to show compliance as indicated. Please refer to the individual Procedures Checklists for detailed information related to each item of noncompliance. Corrective Action Required Please provide a Corrective Action Plan (CAP) within 60 days of receipt of this report, informing us how you intend to correct the areas of non-compliance. The CAP shall outline how the agency plans to correct the issues of non-compliance. Upon receipt of your Corrective Action Plan, we will provide you with further instructions regarding the date your corrective action must be completed. You will have 90 days to implement your Corrective Action Plan. Failure to meet your commitment to resolve non-compliance issues outlined in the corrective action plan, could result in the Board making a determination of suitability at the next scheduled Board meeting. 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 5 Areas of Non-Compliance Regulation Regulation Section (Refer to the Checklist for BJN CJH CBA CJP CVK DKC CJS CGR information) 1313(A) Building Inspections X X X X X X X 1313(B) Fire X 1313(C) Local Health Inspections X X X X X X X 1313(F) Probation Commission X X X Inspection 1321(b) Staffing X X 1325(e) Fire Safety Plan X X X 1327(f) Emergency Procedures X X X X 1329(f)1 Suicide Prevention Plan X X X 1350(a)1 Admittance Procedures X 1350(a)2 Admittance Procedures X X X 1350(a)4 Admittance Procedures X X X 1350.5 Screening for The Risk of X X X X X X X X Sexual Abuse (All) 1352 Classification (All) X X 1353 Orientation- Not oriented prior X to placement in living unit 1354/1354(a) Separation X X X X X X X X 1354.5(a) Room Confinement X X X X X X 1354.5(a)1 Room Confinement X X X 1354.5 (a)2 Room Confinement X X X X X X 1354.5 (a)3 Room Confinement X X 1354.5 (b)1 Room Confinement X X 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 6 Areas of Non-Compliance Regulation Regulation Section (Refer to the Checklist for BJN CJH CBA CJP CVK DKC CJS CGR information) 1354.5 (b)2 Room Confinement X X X X X X 1354.5 (b)3 Room Confinement X X X X X X 1354.5 (4)A Room Confinement X X X 1354.5 (4)B Room Confinement X X X X X 1354.5 (4)C Room Confinement X X X X 1355(a) Institutional Assessment and X X Plan 1355(b)1 Institutional Assessment and X X Plan 1355(2)A Institutional Assessment and Plan 1355(2)B Institutional Assessment and X X Plan 1355(3) Institutional Assessment and X X Plan 1357(a)7 Use of Force-Notice to X X Parents 1358 Use of Physical Restraints- X MH Consultation 1358 Use of Physical Restraints- X Continuous Direct Observation Use of Restraint Devices for X X X X X X X X Movement/Transportation 1358.5(b) within Facility 1358.5(c) Use of Restraint Devices for X X X X X X X X Movement/Transportation within Facility 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 7 Areas of Non-Compliance Regulation Regulation Section (Refer to the Checklist for BJN CJH CBA CJP CVK DKC CJS CGR information) 1360(a) Searches X X 1361(d) Grievances X X X 1361(d)1 Grievances X 1361(d)2 Grievances X 1361(e) Grievances X 1361(f) Grievances X 1361(g) Grievances X 1371 Programs, Recreation and X X X X X X X X Exercise -3/5 hr. 1371 Programs, Recreation and X X Exercise -Annual Reviews 1371 Programs, Recreation and X X X X X X X X Exercise -1 Hr. Program 1371 Programs, Recreation and X X X X X X X X Exercise -1 Hr. Recreation 1371 Programs, Recreation and X X Exercise -1 Hr. Exercise 1391(e) Discipline Process X X X X X 1391(f)1 Discipline Process X X X X X X X X Title 24, CCR Physical Plant Since the last BSCC biennial inspection, the youth from Camp Scott have been relocated to Camp Dorothy Kirby Center and are being housed in the Amethyst and Jade Cottages. They are now known as Camp Scott at DKC. The rated capacity of Camp Dorothy Kirby Center has been updated. Camp Scott in Santa Clarita is currently vacant. 7420+ Los Angeles JH Camp 18-20 Chief Gonzales Los Angeles County Probation Page 8 The rated capacity for the following facilities is as follows: BJN CJH CBA CJP CVK DKC CJS CGR Facility 7204 7198 7207 7255 7232 7234 7267 7261 584 556 105 116 120 80 20 125 As we were unable to conduct in person inspections, we were unable to conduct Title 24 reviews. Copies of the 2016-2018 inspection year documents were provided for review and updated with only the information known to us. We will update these checklists when we return to the facilities. Please refer to the Physical Plant Checklist for detailed information. Training The most recent Standards and Training for Corrections audit reports that the Los Angeles County Probation Department compliant with all relevant regulations and mandates. Juvenile Justice and Delinquency Prevention Act Compliance Monitoring There have been no violations of JJDPA this inspection cycle and no areas of non-compliance were noted. This concludes the 2018-2020 biennial inspection cycle report for the Los Angeles County Probation Department. We would like to express our gratitude to Director Jose Villar, Deputy Probation Officer II Lizet Barboza and Program Analyst Neena Boelter. We appreciate the time and energy spent preparing for, organizing and participating in the inspection. All worked tirelessly to make the inspection process seamless and represented the facility in an exemplary manner. We look forward to working together in the future. If you should have any questions, please contact me at (916) 322-1638 or email at lisa.southwell@bscc.ca.gov. Sincerely, Lisa Southwell Field Representative Facilities Standards and Operations Division Enclosures cc: Presiding Judge, Juvenile Court, Los Angeles County* Chair, Probation Commission, Los Angeles County* Chair, Board of Supervisors, Los Angeles County* County Administrator, Los Angeles County* * Complete copies of this inspection are available upon request and at www.bscc.ca.gov 7420+ Los Angeles JH Camp 18-20 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7204, 7198 FACILITY NAME: FACILITY TYPE: Barry J. Nidorf Juvenile Hall Juvenile Hall Central Juvenile Hall Juvenile Hall PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, Deputy Probation Officer 2; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell Manual Review-June 2, 2020 Virtual Documentation Review Compliance for each facility is indicated as Y, noncompliance as N. TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND EVALUATION OF BUILDING AND GROUNDS On an annual basis, or as otherwise required by law, each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Los Angeles County Probation Department the Board of Supervisors to approve building safety; Detention Services Bureau Manual Section 203: County Inspections of Buildings and Grounds Los Angeles County Department of Public Works conducted their inspections of the Juvenile Halls as noted below. The building inspections were completed by Tennyson D’Sena. 2018 inspections were verified to have occurred. The 2019 inspections are noted as follows: Barry J. Nidorf Juvenile Hall Completed on August 29, 2019. Corrections are N N required. Central Juvenile Hall Completed on 09/03/2019 Corrections were required. Proof of Corrections are required. The inspector noted one issue to be a repeat finding. 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. 7204,7198 Los Angeles JH 18 20 PRO - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (B) Fire authority having jurisdiction, including a fire Los Angeles County Probation Department clearance as required by Health and Safety Code Detention Services Bureau Manual Section 203: Section 13146.1 (a) and (b); County Inspections of Buildings and Grounds Los Angeles County Fire Department conducted their inspections of the Juvenile Halls as noted below. Barry J. Nidorf Juvenile Hall Completed on November 29, 2018 Fire clearance was granted** Central Juvenile Hall Completed on May 19, 2020 Fire clearance was granted** Technical assistance provided to facility administration that fire clearance should be obtained and received at a minimum of every 2 years. Agency must take into consideration unanticipated delays and ensure that clearances are obtained within the two-year timeline. **Proper documents provided for future use. Y Y 7204,7198 Los Angeles JH 18 20 PRO - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (C) Local health officer, inspection in accordance with Los Angeles County Probation Department Health and Safety Code Section 101045; Detention Services Bureau Manual Section 203: County Inspections of Buildings and Grounds Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the Environmental Health (EH) inspections as noted below. 2018 Inspections were verified to have occurred. 2019 Inspections are noted as follows: Barry J. Nidorf Juvenile Hall MMH: January 29 and 30, 2019 and February 13 and 15, 2019 N: February 13, 2019 EH: February 13 and15, 2019. The 2020 inspection was completed on February 5, 2020. Nutritional Health: There are no outstanding corrections necessary. N N Environmental Health: Corrections are required. Medical/Mental Health: Corrections are required. The evaluator notes that “This will be verified and confirmed during next year’s inspection cycle”; however, we noted that the inspector noted in the report that most are repeat findings that have occurred over the course of several years and have not been corrected. These areas are considered non- compliant until corrected. Central Juvenile Hall MMH: January 29-30 and February 7-8, 2019. N: February 7, 2019. EH: February 7 and 8, 2019. Nutritional Health: There are no outstanding corrections necessary. Environmental Health: Corrections are required. Medical/Mental Health: Corrections are required. The evaluator notes that “this will be verified and confirmed during next year’s inspection cycle”; however, we noted that the inspector noted in the report that most are repeat findings that have occurred over the course of several years and have not been corrected. These areas are considered non- compliant until corrected. 7204,7198 Los Angeles JH 18 20 PRO - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (D) County superintendent of schools on the adequacy of Los Angeles County Probation Department educational services and facilities as required in Detention Services Bureau Manual Section 203: Section 1370; County Inspections of Buildings and Grounds Barry J. Nidorf Juvenile Hall: The education program was evaluated Rene Wheeler, Director Juvenile Court and Community Schools, Santa Barbara County Education Office on June 12, 2019. Y Y Ms. Wheeler found the education program to comply with all regulatory requirements. Central Juvenile Hall: The education program was evaluated by Susan Connolly, Executive Director of Student Services Placer County Office of Education on June 26, 2019. Ms. Connolly found the education program to comply with all regulatory requirements. (E) Juvenile court as required by Section 209 of the Welfare Los Angeles County Probation Department and Institutions Code Detention Services Bureau Manual Section 203: County Inspections of Buildings and Grounds The Juvenile Halls were inspected as noted below. Barry J. Nidorf Juvenile Hall: Inspected by Presiding Judge Hon. Morton Rochman on January 29, 2020. The Juvenile Hall was not inspected in 2019. Central Juvenile Hall: Inspected Y Y by Supervising Judge Hon. John Lawson on November 9, 2020 and provided prior to the writing of this report. The Juvenile Hall was not inspected in 2019. Technical assistance provided to agency administration that we will accept these inspections for 2020; however, in the future, it is necessary to ensure that the facility is inspected annually. It is the responsibility of the facility administrator to ensure that the inspections are completed. Any further failure to provide annual inspections will be noted as non-compliant. 7204,7198 Los Angeles JH 18 20 PRO - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (F) Juvenile Justice Commission as required by Section Los Angeles County Probation Department 229 of the Welfare and Institutions Code or Probation Detention Services Bureau Manual Section 203: Commission as required by Section 240 of the Welfare County Inspections of Buildings and Grounds and Institutions Code. Los Angeles County Probation Commission is to conduct annual inspections of each facility. The Juvenile Halls were inspected as noted below. Barry J. Nidorf Juvenile Hall: The facility was inspected on October 8, 2018 and a visit was made on April 25, 2019 with a follow-up letter to Chief McDonald to report concerns of staff regarding the conditions at the facility and lack of staff. There was no report provided for the visit on October 8,2018 but a response dated December 10, 2018 from Probation (Sheila Mitchell, Chief Deputy Probation Officer was provided. A copy of the 2019 letter was provided. No follow up was received. The Commission is currently in the process of scheduling the 2020 inspection and will complete it before the end of the year. Central Juvenile Hall: The facility was inspected on Y Y October 2, 2018, January 16, 2020 and February 5, 2020 and was visited on August 19, 2019 with a follow up letter sent to Deputy Chief Dominquez to report the commissioners experience during a 30- youth fight incident during church services. The commissioner opined the incident was in part due to low moral due to staff call outs and too many hold overs refusing to stay which caused staff injury. There was no report provided for the visit on October 2, 2018 but a response dated February 12, 2019 from Probation (Sheila Mitchell, Chief Deputy Probation Officer was provided. A copy of the 2019 letter was provided. No follow up was received. Neither Probation nor the Commission had a copy of either of the 2018 reports to provide. 2019 reports consist of correspondence and documentation provided to the Chief Probation Officer and the Bureau Chief for visits conducted to the facilities. Facility Administration should work collaboratively with commissioners to ensure this requirement is met and all documentation is received and maintained. 7204,7198 Los Angeles JH 18 20 PRO - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is determined received from Chief Probation Officer Terri by receipt of the Chief Probation Officer’s certification McDonald certifying that appointments and qualifications of agency staff comply with all letter confirming that all elements of regulation are met. elements of regulation. (a) Appointment Y Y 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 Y Y Each facility shall: (1) recruit and hire employees who possess knowledge, skills and abilities appropriate to their job classification Y Y 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 evaluation for Y Y immunity to contagious illnesses of childhood (i.e., diphtheria, rubeola, rubella, and mumps); (3) adhere to the minimum standards for the selection and Y Y training requirements adopted by the Board pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in Y Y accordance with Section 1031 et seq. of the Government Code. (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract personnel, employees of the facility, who may be present at the volunteers and other non-employees participate in facility, shall have such clearance and qualifications as background checks and are approved through each may be required by law, and their presence at the Y Y facility for entrance with the exception of LACOE who conducts their own criminal records review as facility shall be subject to the approval and control of required by the Probation Department. Probation the facility manager. maintains control as to who has access into the facility. 7204,7198 Los Angeles JH 18 20 PRO - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1321 STAFFING Documentation provided included staff daily schedules for 2 full random weeks, facility staffing Each juvenile facility shall: rosters for non-sworn staff. BJN provided their individual staffing profile review. Compliance in this area is based on both a staffing ratio and on maintaining an overall staffing profile that ensures the facility is operated safely and securely for all youth and staff and meets all required regulations including those that ensure programming and activities for the youth. If compliance were based on ratio numbers alone, the agency would be compliant; however, compliance is based also on ensuring adequate staffing for full facility operations. We were unable to determine compliance based on the information available to us remotely. The documentation provided does not provide a clear depiction of overall facility staffing levels and youth populations. More information is necessary to determine compliance as youth populations were not noted and staff numbers do not appear to be consistently documented. Facility operational post positions must be accounted for, noted and counted. i.e., Level 3’s (1on 1’s and small group supervision), and other staffing expectations that pull staffing resources are not consistently noted from shift to shift. We noted high numbers of staff out for various reasons which impacts and necessitates the need for overtime and hold overs from previous shifts. We viewed several incidents throughout your documentation in which staff and youth reported through various documentation, a lack of staff either impeded operations in one way or another or youth did not receive activities and programming as a result of lack of staff. When this occurs, this is non-compliant. We are unable to determine at this time, how often this occurs and the level of seriousness. We will be looking closely at this issue upon our return to the facility. a) have an adequate number of personnel sufficient to Los Angeles County Probation Department carry out the overall facility operation and its Detention Services Bureau Manual Section 206: programming, to provide for safety and security of UNK UNK Staffing Requirements and Ratios youth and staff, and meet established standards and regulations; See above. 7204,7198 Los Angeles JH 18 20 PRO - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS b) ensure that no required services shall be denied Los Angeles County Probation Department because of insufficient numbers of staff on duty absent Detention Services Bureau Manual Section 206: exigent circumstances; N N Staffing Requirements and Ratios See above. c) have a sufficient number of supervisory level staff to Los Angeles County Probation Department ensure adequate supervision of all staff members; Detention Services Bureau Manual Section 206: Staffing Requirements and Ratios Policy notes that facility will have supervisors on duty who are responsible for the supervision of all staff members. UNK UNK Barry J. Nidorf Juvenile Hall staffing profile noted supervisors are in the buildings and on duty; however, provided no back up documentation of who was on the shifts, where they were assigned or their responsibilities. Central Juvenile Hall did not provide documentation that noted supervisors are in the buildings, on duty or their responsibilities. d) have a clearly identified person on duty at all times who Los Angeles County Probation Department is responsible for operations and activities and has Detention Services Bureau Manual Section 206: completed the Juvenile Corrections Officer Core Staffing Requirements and Ratios Course and PC 832 training; Y Y The Officer of the Day is responsible for the operations and the activities of the facility. Facility staff are responsible for the unit activities of the youth. e) have at least one staff member present on each living Los Angeles County Probation Department unit whenever there are youth in the living unit; Detention Services Bureau Manual Section 206: Staffing Requirements and Ratios Y Y There is always one staff in a building with youth. f) have sufficient food service personnel relative to the Los Angeles County Probation Department number and security of living units, including staff Detention Services Bureau Manual Section 206: qualified and available to: plan menus meeting Staffing Requirements and Ratios nutritional requirements of youth; provide kitchen Y Y supervision; direct food preparation and servings; conduct related training programs for culinary staff; and maintain necessary records; or, a facility may serve food that meets nutritional standards prepared by an outside source; 7204,7198 Los Angeles JH 18 20 PRO - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS g) have sufficient administrative, clerical, recreational, Los Angeles County Probation Department medical, dental, mental health, building maintenance, Detention Services Bureau Manual Section 206: transportation, control room, facility security and other Y Y Staffing Requirements and Ratios support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Los Angeles County Probation Department continuous wide-awake supervision of youth, subject Detention Services Bureau Manual Section 206: to temporary variations in staff assignments to meet Y Y Staffing Requirements and Ratios special program needs. Staffing shall be in compliance with a minimum youth-staff ratio for the following facility types: (1) Juvenile Halls (minimum youth-staff ratio) Los Angeles County Probation Department (A) during the hours that youth are awake, one wide-awake Detention Services Bureau Manual Section 206: Y Y youth supervision staff member on duty for each 10 Staffing Requirements and Ratios youth in detention; (B) during the hours that youth are confined to their Los Angeles County Probation Department room for the purpose of sleeping, one wide-awake Detention Services Bureau Manual Section 206: Y Y youth supervision staff member on duty for each 30 Staffing Requirements and Ratios youth in detention; (C) at least two wide-awake youth supervision staff Los Angeles County Probation Department members on duty at all times, regardless of the Detention Services Bureau Manual Section 206: number of youth in detention, unless an Y Y Staffing Requirements and Ratios 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 Los Angeles County Probation Department who is the same gender as youth housed in the facility. Detention Services Bureau Manual Section 206: Staffing Requirements and Ratios Y Y There are always male and female staff on duty in the facility. (E) personnel with primary responsibility for other duties Los Angeles County Probation Department such as administration, supervision of personnel, Detention Services Bureau Manual Section 206: academic or trade instruction, clerical, kitchen or Staffing Requirements and Ratios maintenance shall not be classified as youth Y Y supervision staff positions. Only youth supervision staff provide supervision of the youth. (Compliance based on policy) (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile Hall staff ratio) NA NA (A) during hours that youth are awake, one wide-awake youth supervision staff member is 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 NA NA supervision staff member on duty for each 30 youth in detention; 7204,7198 Los Angeles JH 18 20 PRO - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff members on duty at all times, regardless of the number NA NA 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 NA NA 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, NA NA academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Facility is not a Camp (A) during the hours that youth are awake, one wide-awake NA NA 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 NA NA 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 NA NA 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 NA NA 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 NA NA 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, NA NA kitchen or maintenance shall not be classified as youth supervision staff positions. 7204,7198 Los Angeles JH 18 20 PRO - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1322 YOUTH SUPERVISION STAFF Los Angeles County Probation Department ORIENTATION AND TRAINING Detention Services Bureau Manual Section 205: (a) Prior to assuming any responsibilities each youth Youth Supervision Staff Orientation and Training supervision staff member shall be properly oriented to All staff assigned to DSB have completed their duties, including: Correctional Officer CORE training prior to reporting to the facility. Upon reporting to the Y Y facility, they are assigned to a training officer who assist in their orientation and training. Training records provided as verification of required training which includes CORE; however, we were unable to view site training files as not on site. Compliance is based on policy alone. We will verify training documents when back on site. (1) youth supervision duties; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (2) scope of decisions they shall make; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (3) the identity of their supervisor; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (4) the identity of persons who are responsible to Los Angeles County Probation Department them; Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (5) persons to contact for decisions that are beyond Los Angeles County Probation Department their responsibility; and Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (6) ethical responsibilities. Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (b) Prior to assuming any responsibility for the supervision Los Angeles County Probation Department of youth, each youth supervision staff member shall Detention Services Bureau Manual Section 205: Y Y receive a minimum of 40 hours of facility-specific Youth Supervision Staff Orientation and Training orientation, including: (1) individual and group supervision techniques; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (2) regulations and policies relating to discipline and Los Angeles County Probation Department rights of youth pursuant to law and the provisions Y Y Detention Services Bureau Manual Section 205: of this chapter; Youth Supervision Staff Orientation and Training (3) basic health, sanitation and safety measures; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (4) suicide prevention and response to suicide Los Angeles County Probation Department attempts Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training 7204,7198 Los Angeles JH 18 20 PRO - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (5) policies regarding use of force, de-escalation Los Angeles County Probation Department techniques, chemical agents, mechanical and Y Y Detention Services Bureau Manual Section 205: physical restraints; Youth Supervision Staff Orientation and Training (6) review of policies and procedures referencing Los Angeles County Probation Department trauma and trauma-informed approaches; Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (7) procedures to follow in the event of emergencies; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (8) routine security measures, including facility Los Angeles County Probation Department perimeter and grounds; Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (9) crisis intervention and mental health referrals to Los Angeles County Probation Department mental health services; Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (10) documentation; and Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (11) fire/life safety training Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 205: Youth Supervision Staff Orientation and Training (c) Prior to assuming sole supervision of youth, each youth Los Angeles County Probation Department supervision staff member shall successfully complete Detention Services Bureau Manual Section 205: Y Y the requirements of the Juvenile Corrections Officer Youth Supervision Staff Orientation and Training Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer youth Los Angeles County Probation Department supervision staff shall successfully complete training Y Y Detention Services Bureau Manual Section 205: pursuant to Section 830 et seq. of the Penal Code. Youth Supervision Staff Orientation and Training 1323 FIRE AND LIFE SAFETY Los Angeles County Probation Department Detention Services Bureau Manual Section 206: Whenever there is a youth in a juvenile facility, there shall Staffing Requirements and Ratios: Fire and Life be at least one wide awake person on duty at all times who Y Y Safety meets the training standards established by the Board for general fire and life safety which relate specifically to the facility. 7204,7198 Los Angeles JH 18 20 PRO - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1324 POLICY AND PROCEDURES MANUAL Los Angeles County Probation Department All facility administrators shall develop, publish, and Detention Services Bureau Manual Section 1202: implement a manual of written policies and procedures that Policy and Procedures Manual address, at a minimum, all regulations that are applicable to the facility. Such a manual shall be made available to all The Policy and Procedure Manual is specific to employees, reviewed by all employees, and shall be Detention Services Bureau and to the Juvenile administratively reviewed at a minimum every two years, Hall’s Operations. The manual is reviewed and and updated, as necessary. Those records relating to the updated at least every 2 years and was last standards and requirements set forth in these regulations reviewed and updated in June 2020. shall be accessible to the Board on request. The manual shall include: The BSCC has reviewed the agency Policy and Procedure specific to regulations and has Y Y confirmed the required policies and procedure exist specific to required regulations; however, there may be cites noted in the comments that may not match due to updates that were unable to be reverified. Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is still no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. (a) table of organization, including channels of Los Angeles County Probation Department communications and a description of job Detention Services Bureau Manual Sections: classifications; 201: Administrative Structure and Chain of Command 202: Administrative Structure and Responsibilities. Y Y 208: Duty Statement- Supervising Detention Services Officer 209: Duty Statement- Senior Detention Services Officer 210: Duty Statement- Detention Services Officer 211: Group Supervisor Nights 212: Organizational Chart (b) responsibility of the probation department, purpose of Los Angeles County Probation Department programs, relationship to the juvenile court, the Detention Services Bureau Manual Sections: Juvenile Justice/Delinquency Prevention Commission Y Y or Probation Committee, probation staff, school Section 103: Role of the Juvenile Halls personnel and other agencies that are involved in Section 1801: Ancillary Programs juvenile facility programs; 7204,7198 Los Angeles JH 18 20 PRO - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (c) responsibilities of all employees; Los Angeles County Probation Department Detention Services Bureau Manual Sections: 202: Administrative Structure and Responsibilities. 208: Duty Statement- Supervising Detention Y Y Services Officer 209: Duty Statement- Senior Detention Services Officer 210: Duty Statement- Detention Services Officer 211: Group Supervisor Nights (d) initial orientation and training program for employees; Los Angeles County Probation Department Detention Services Bureau Manual Section 205: Y Y Youth Supervision Staff Orientation and Training See Section 1322 (e) initial orientation, including safety and security issues Los Angeles County Probation Department and anti-discrimination policies, for support staff, Detention Services Bureau Manual Section 2400: contract employees, school, mental/behavioral health Non-Sworn Personnel and Partner Agencies and medical staff, program providers and volunteers; Handbook UNK UNK We were unable to view employee training files as not on site. We will verify training documents when back on site. (f) maintenance of record-keeping, statistics and Los Angeles County Probation Department communication system to ensure: Detention Services Bureau Manual Sections 1900: Reports and Records (Group to include:) 1902: Probation Case Management System (PCMS) Y Y 1903: Daily Reports 1904: Behavior Record 1905: Charting 1909: Detention Observation Report Form (1) efficient operation of the juvenile facility; Los Angeles County Probation Department Detention Services Bureau Manual Section 1900: Y Y Reports and Records (Group to include all of the above) (2) legal and proper care of youth; Los Angeles County Probation Department Detention Services Bureau Manual Section 1900: Y Y Reports and Records (Group to include all of the above) (3) maintenance of individual youth's records; Los Angeles County Probation Department Detention Services Bureau Manual Section 1900: Y Y Reports and Records (Group to include all of the above) (4) supply of information to the juvenile court and Los Angeles County Probation Department those authorized by the court or by the law; and, Detention Services Bureau Manual Section 1900: Y Y Reports and Records (Group to include all of the above) 7204,7198 Los Angeles JH 18 20 PRO - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (5) release of information regarding youth. Los Angeles County Probation Department Detention Services Bureau Manual Section 1900: Y Y Reports and Records (Group to include all of the above) (g) ethical responsibilities; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 2349: Employee Honesty (h) trauma-informed approaches; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 207: General Staff Responsibilities (i) culturally responsive approaches; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 207: General Staff Responsibilities (j) gender responsive approaches; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 630 Promoting Dignity for Female Youth (k) a non-discrimination provision that provides that all Los Angeles County Probation Department youth within the facility shall have fair and equal Detention Services Bureau Manual Section 402: access to all available services, placement, care, Non-Discrimination 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 Y Y identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Los Angeles County Probation Department chemical agents related security devices, and weapons Detention Services Bureau Manual Section 1013: and ammunition, where applicable; Use of Oleoresin Capsicum (OC) Spray Strategies Y Y The Department is phasing out OC spray. There are no other weapons or ammunition. (m) establishment of procedures for collection of Medi-Cal Los Angeles County Probation Department eligibility information and enrollment of eligible Y Y Detention Services Bureau Manual Section 1716: youth; and, Medi-Cal Administrative Activities (n) establishment of a policy that prohibits all forms of Los Angeles County Probation Department sexual abuse, sexual assault and sexual harassment. Detention Services Bureau Manual Section 1500 The policy shall include an approach to preventing, Series: Prison Rape Elimination Act (PREA) detecting and responding to such conduct and any Y Y retaliation for reporting such conduct, as well as a provision for reporting such conduct by youth, staff or a third party. 1325 FIRE SAFETY PLAN The facility administrator shall consult with the local fire department having jurisdiction over the facility, or with the State Fire Marshal, in developing a plan for fire safety which shall include, but not be limited to: 7204,7198 Los Angeles JH 18 20 PRO - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS a) a fire prevention plan to be included as part of the Los Angeles County Probation Department manual of policy and procedures; Detention Services Bureau Manual Section 911: Fire Prevention and Suppression Y Y Policy requires a fire prevention plan. b) monthly fire and life safety inspections by facility Los Angeles County Probation Department staff with two- year retention of the inspection record; Detention Services Bureau Manual Section 911: Fire Prevention and Suppression Y Y Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. c) fire prevention inspections as required by Health and Los Angeles County Probation Department Safety Code Section 13146.1(a) and (b); Detention Services Bureau Manual Section 911: Y Y Fire Prevention and Suppression See Section 1322 Above (NC noted above) d) an evacuation plan; Los Angeles County Probation Department Detention Services Bureau Manual Section 920: Y Y Emergency Evacuation and County of Los Angeles Building Emergency Plan of County Buildings. e) documented fire drills not less than quarterly; Los Angeles County Probation Department Detention Services Bureau Manual Section 911: Fire Prevention and Suppression Fire drills are to be completed facility wide each quarter. At a minimum, there should be 8 drills completed over the course of the cycle. Barry J. Nidorf: At inspection, no documentation was provided for any fire drills completed this cycle. Facility administration provided a corrective action memo noting scheduled drills and directives N N to ensure they completed pending drills effective May 2020. As of the writing of this report, 2 buildings completed fire drills in May 2020 and SIR’s were completed for drills completed in June and August 2020. Central Juvenile Hall: Documentation was provided for 1 full fire drill and 4 drills for random buildings at CJH. Fire drills have not been completed as required and none included partner agencies. This is non- compliant. 7204,7198 Los Angeles JH 18 20 PRO - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS f) a written plan for the emergency housing of youth in Los Angeles County Probation Department the case of fire; and, Detention Services Bureau Manual Section 921: Operation FLEE and the County of Los Angeles Building Emergency Plan of County Buildings. Y Y Emergency housing will always be at the other Juvenile Hall first if possible or to other camps as directed by headquarters based on the location of the emergency and availability. Los Padrinos will be the emergency backup site for all facilities. g) development of a fire suppression pre-plan in Los Angeles County Probation Department cooperation with the local fire department. Detention Services Bureau Manual Section 911: Fire Prevention and Suppression Fire suppression pre plans were completed as follows with the local fire departments. Y Y Barry J. Nidorf Juvenile Hall: The facility administrator consulted with Jared Kearns from Los Angeles City Fire Department on October 22, 2020. Central Juvenile Hall: The facility Administrator consulted with Alejandro Medina from Los Angeles City Fire Department on November 7, 2019. 1326 SECURITY REVIEW Los Angeles County Probation Department Detention Services Bureau Manual Section 516: Each facility administrator shall develop policies and Security Procedures procedures to annually review, evaluate, and document security of the facility. The review and evaluation shall Barry J. Nidorf Juvenile Hall: Completed by include internal and external security, including, but not Y Y Norberto Zaragoza on May 7, 2020. limited to, key control, equipment, and staff training. Central Juvenile Hall: Completed by Superintendent Nieto and Director Montes on June 7, 2019. 1327 EMERGENCY PROCEDURES Los Angeles County Probation Department Detention Services Bureau Manual Section 900: The facility administrator shall develop facility-specific Y Y Emergency Procedures policies and procedures for emergencies that shall include, but not be limited to: (a) escape, disturbances, and the taking of hostages; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 906: Escapes (Code Green) 908: (Code Red) 915: Hostages 7204,7198 Los Angeles JH 18 20 PRO - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) civil disturbance, active shooter and terrorist attack; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Section 907: Outside Intruder (Code Yellow) Y Y Section 917: Active Shooter Section 918: Terrorist Attack Section 919: Civil disturbance (c) fire and natural disasters; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 911: Fire Prevention and Suppression 913: Power Failure 915: Earthquakes (d) periodic testing of emergency equipment; Los Angeles County Probation Department Detention Services Bureau Manual Section 910: Y Y Testing of Emergency Equipment (e) emergency evacuation of the facility; and Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 920: Emergency Evacuation (f) a program to provide all youth supervision staff with Los Angeles County Probation Department an annual review of emergency procedures. Detention Services Bureau Manual Section 920: Emergency Evacuation DSB Managers are to ensure that each staff member reviews all emergency procedures annually at the time of their performance evaluation review. Barry J. Nidorf Juvenile Hall: Memo provided dated 6/20 that facility staff are working on N N accomplishing the review. No follow up provided and no documentation provided documenting that this review took place. This section is non- compliant Central Juvenile Hall: Memo dated 5/20 that facility staff are working on accomplishing the review. No follow up provided and no documentation provided documenting that this review took place. This section is non-compliant 7204,7198 Los Angeles JH 18 20 PRO - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1328 SAFETY CHECKS Los Angeles County Probation Department Detention Services Bureau Manual Sections: The facility administrator shall develop and implement policy and procedures that provide for direct visual 208: Duty Statement- Supervising Detention observation of youth at a minimum of every 15 minutes, Services Officer at random or varied intervals during hours when youth are 209: Duty Statement- Senior Detention Services asleep or when youth are in their rooms, confined in Officer holding cells or confined to their bed in a dormitory. 210: Duty Statement- Detention Services Officer Supervision is not replaced, but may be supplemented by, 211: Group Supervisor Nights an audio/visual electronic surveillance system designed to 628: Safety Checks detect overt, aggressive or assaultive behavior and to summon aid in emergencies. All safety checks shall be documented with the actual time the check is completed. We reviewed random safety checks from the documentation provided of random blocks of dates and times from both Barry J. Nidorf Juvenile Hall and Central Juvenile Hall. We found through our review of safety check documentation that checks are being made consistent to regulatory time expectations with minimal discrepancies. This section is compliant with regulation. Y Y Agency policy requires a supervisor to make an unannounced inspection once a shift and to note with a red pen on the log (below that last check) to show that supervisors are completing rounds and to ensure that staff are completing checks within policy. We were unable to confirm if this was being done on a consistent basis. BJN had also provided a corrective action memo which was sent to all supervisors prior to our inspection to remind and ensure oversight activities were occurring. We also found that at Central Juvenile Hall we were unable to determine if this oversight step was occurring with consistency. We requested additional documentation and noted slight improvements. This is inconsistent with agency policy but not with regulation. Technical assistance provided to enhance safety checks to ensure continued random and varied intervals and suggested a more detailed and robust quality assurance process. 7204,7198 Los Angeles JH 18 20 PRO - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Los Angeles County Probation Department The facility administrator, in collaboration with the Detention Services Bureau Manual Section 1601: healthcare and behavioral/mental health administrators, Suicide Prevention-Introduction shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. The Suicide Prevention Plan was developed in The plan shall consider the needs of youth experiencing Y Y collaboration with Juvenile Court Health Services past or current trauma. (JCHS) and Department of Mental Health (DMH) administrators. Suicide prevention responses shall be respectful and in the least invasive manner consistent with the level of suicide risk. The plan shall include the following elements: (a) Suicide prevention training as required in Section Los Angeles County Probation Department 1322, Youth Supervision Staff Orientation, and Detention Services Bureau Manual Section1604: Training and the Juvenile Corrections Officer Training Core Course. Y Y All staff assigned to DSB are trained by certified trainers in recognition, screening and handling of potentially suicidal youth in CORE. CORE training occurs prior to assignment in the facility. 4 hours of refresher training will occur annually. (b) Screening, Identification Assessment and Los Angeles County Probation Department Precautionary Protocols Detention Services Bureau Manual Sections: (1) All youth shall be screened for risk of suicide at intake and as needed during detention. 1606: Identification and Referral of At-Risk Youth Youth are screened for risk of suicide at intake. Intake screening includes a medical and mental health assessment. Youth are screened with a “Unified Arrestee Medical and Mental Health Assessment Form” Law enforcement complete the form and intake staff review the form and ask Y Y appropriate questions. Youth are screened at intake by IDC staff, by medical and again by mental health with the MAYSI II-Massachusetts Youth Screening Instrument. 1608: Intervention to Prevent Self- Harming or Suicidal Behavior (ongoing) Youth are screened on going to ensure their safety. Staff pay close attention to a youth’s daily behaviors. 7204,7198 Los Angeles JH 18 20 PRO - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (2) All youth supervision staff who perform Los Angeles County Probation Department intake processes shall be trained in screening Detention Services Bureau Manual Section1604: youth for risk of suicide. Training All staff assigned to DSB are trained in recognition, Y Y screening and handling of potentially suicidal youth in CORE. CORE training occurs prior to assignment in the facility. 4 hours of refresher training will occur annually. Staff are trained by their assigned trainers in training classes. (3) All youth who have been identified during the Los Angeles County Probation Department intake screening process to be at risk of Detention Services Bureau Manual Section 1606: suicide shall be referred to behavioral/mental Identification and Referral of At-Risk Youth Y Y health staff for a suicide risk assessment. If a youth has been identified to be at risk of suicide, they are to be referred to MH via a Request for Mental Health Consultation form. (4) Precautionary protocols shall be developed to Los Angeles County Probation Department ensure the youth’s safety pending the Detention Services Bureau Manual Section 1606: behavioral/mental health assessment. Identification and Referral of At-Risk Youth If staff believe for any reason that a youth may Y Y cause any harm to themselves, they are placed on an Enhanced Supervision Level 3 to ensure their safety. The Duty Supervisor is notified and a request for mental health evaluation is completed and submitted. (c) Referral process to behavioral/mental health staff Los Angeles County Probation Department for assessment and/or services. Detention Services Bureau Manual Section 1607: Interagency Communication Regarding Self- Y Y Harming Youth Request for Mental Health Consultation Form (d) Procedures for monitoring of youth identified at Los Angeles County Probation Department risk for suicide. Detention Services Bureau Manual Sections: Y Y 1405: Level 2 Enhanced Supervision Requirements 1406: Level 3 Enhanced Supervision Requirements (e) Safety Interventions Los Angeles County Probation Department (1) Procedures to address intervention protocols Detention Services Bureau Manual Sections: for youth identified at risk for suicide which may include, but are not limited to: 1601: Suicide Prevention-Introduction Y Y 1608: Intervention to Prevent Self-Harming or Suicidal Behavior 7204,7198 Los Angeles JH 18 20 PRO - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS A. Housing consideration Los Angeles County Probation Department Detention Services Bureau Manual Sections: 1403: Enhanced and Specialized Supervision Procedure Y Y 1601: Suicide Prevention-Introduction The duty supervisor will direct the appropriate type of housing and level of supervision for the youth pending assessment by the DMH clinician. B. Treatment strategies including Los Angeles County Probation Department trauma-informed approaches Detention Services Bureau Manual Sections: Y Y 1600: Suicide Prevention 1608: Intervention to Prevent Self-Harming or Suicidal Behavior (2) Procedures to instruct youth supervision staff Los Angeles County Probation Department how to respond to youth who exhibit suicidal Detention Services Bureau Manual Sections: behaviors. Y Y 1601: Introduction 1608: Suicide Attempt Emergency Procedures 1403: Enhanced and Specialized Supervision (f) Communication Los Angeles County Probation Department (1) The intake process shall include Detention Services Bureau Manual Section 1607: communication with the arresting officer and Interagency Communication Regarding Self- family guardians regarding the youth’s past or Harming Youth present suicidal ideations, behaviors or attempts. Communication occurs between IDC and Institution staff. In previous inspections, we provided technical Y Y assistance regarding formalizing processes between the two divisions. We were not provided with documentation beyond the Arrestee Medical Screening form as other operational functions occur with IDC. Subsequent documentation was ultimately provided to show that parents were contacted regarding any history of suicide ideation behaviors or attempts. (2) Procedures for clear and current information Los Angeles County Probation Department sharing about youth at risk for suicide with Y Y Detention Services Bureau Manual Section 1607: youth supervision, healthcare, and Interagency Communication Regarding Self- behavioral/mental health staff. Harming Youth 7204,7198 Los Angeles JH 18 20 PRO - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (g) Debriefing of Critical Incidents Related to Los Angeles County Probation Department Suicides or Attempts Detention Services Bureau Manual Section 1610: (1) Process for administrative review of the Mortality/Morbidity Review Process and Section circumstances and responses proceeding, 1913: Critical Incident Review Process during and after the critical incident. Policy 1610 requires a debriefing only in the event of a death or if the suicide attempt requires hospitalization. Documented suicide attempts we viewed did not require hospitalization and as such, youth and staff did not receive a de brief. We provided technical assistance in this area. Policy1610 was immediately updated and is now specific to deaths and to events that require hospitalization. Policy 1913: Critical Incident Y Y Review Process was immediately updated to include specific events such as serious suicide attempts but that do not include hospitalization. These reviews will require a review of the circumstances and responses proceeding during and after the critical incident, and a process for debriefing the event with affected staff and youth. Policy requires a critical stress briefing in which supervisors meet individually with involved youth and staff to review the incident and make and assessment to determine the need for counselling for youth. Documentation provided for our review of a Critical Stress Review completed for an incident that occurred at BJN. (2) Process for a debriefing event with affected Los Angeles County Probation Department staff. Detention Services Bureau Manual Section 1610: Mortality/Morbidity Review Process and Section Y Y 1913: Critical Incident Review Process See note above. We will review at next inspection to ensure proper follow up. (3) Process for a debriefing event with affected Los Angeles County Probation Department youth. Detention Services Bureau Manual Section 1610: Mortality/Morbidity Review Process and Section Y Y 1913: Critical Incident Review Process See note above. We will review at next inspection to ensure proper follow up. 7204,7198 Los Angeles JH 18 20 PRO - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (h) Documentation Los Angeles County Probation Department (1) Documentation processes shall be developed Detention Services Bureau Manual Sections: to ensure compliance with this regulation Documentation is completed though a Special Incident Report (SIR) or a Physical Intervention Report (PIN) Depending on the circumstances the following may Y Y also be appropriate. Section 1913: Critical Incident Review (CIR) Process Section 1912: Preliminary and Follow Up Incident Notification Procedures Both facilities have the same extensive Safe Crisis Management documentation process. Youth identified at risk for suicide shall not be denied the Los Angeles County Probation Department opportunity to participate in facility programs, services Detention Services Bureau Manual Section 1606: and activities which are available to other non-suicidal Identification and Referral of At-Risk Youth youth, unless deemed necessary for the safety of the youth Y Y or security of the facility. Any deprivation of programs, services or activities for youth at risk of suicide shall be Youth at risk for suicide are included in all documented and approved by the facility manager. programs and activities unless an active safety issue. 1340 REPORTING OF LEGAL ACTIONS Los Angeles County Probation Department Detention Services Bureau Manual Section 202: Each facility shall submit to the Board a letter of Administrative Structure and Responsibilities notification on each legal action, pertaining to conditions of Y Y confinement, filed against persons or legal entities No legal actions have been reported to the BSCC responsible for juvenile facility operation. this cycle. 1341 DEATH AND SERIOUS ILLNESS OR Los Angeles County Probation Department INJURY OF A YOUTH WHILE DETAINED Detention Services Bureau Manual Section 2001: (1) Death of a Youth. Special Situations Introduction and Section 2002: (a) The facility administrator, in cooperation with the Deaths health administrator and the behavioral/mental health director, shall develop written policies and procedures Y Y The policy was developed in cooperation with in the event of the death of a youth while detained, Juvenile Court Health Services (JCHS) and which include notifications to necessary parties, Department of Mental Health (DMH). which may include the Juvenile Court, the parent, All compliance based on policy. guardian or person standing in loco parentis and the youth’s attorney of record. 7204,7198 Los Angeles JH 18 20 PRO - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) The health administrator, in cooperation with the Los Angeles County Probation Department facility administrator, shall develop written policies Detention Services Bureau Manual Section 2002: and procedures to assure there is a medical and Deaths operational review of every in-custody death of a youth. Y Y 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 Los Angeles County Probation Department Board a copy of the report submitted to the Attorney Detention Services Bureau Manual Section 2002: General under Government Code Section 12525. A Y Y Deaths 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 Los Angeles County Probation Department the administrator, the Board may within 30 calendar Detention Services Bureau Manual Section 2002: days inspect and evaluate the juvenile facility, jail, Deaths lockup or court holding facility pursuant to the Y Y 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 Los Angeles County Probation Department (a) The facility administrator, in cooperation with the Detention Services Bureau Manual Sections: health administrator, shall develop written policies 1609: Reporting and Investigation Suicide Attempts and procedures for the notification to necessary or Suicides parties, which may include the Juvenile Court, the Y Y 1912: Preliminary and Follow Incident Notification parent, guardian or person standing in loco parentis Procedures and the youth’s attorney of record in the case of a 1919: Detention Observation Report Form serious illness or injury of a youth. Report to Court to report a serious illness or serious injury or attempted suicide. 1342 POPULATION ACCOUNTING Los Angeles County Probation Department Detention Services Bureau Manual Section: 202: Each juvenile facility shall submit required population Y Y Administrative Structure and Responsibilities. 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 Los Angeles County Probation Department Detention Services Bureau Manual Section: 202: When the number of youth detained in a living unit of a Administrative Structure and Responsibilities. juvenile facility exceeds its rated capacity for more than Y Y fifteen (15) calendar days in a month, the facility administrator shall provide a crowding report to the Board Facility has not exceeded their rated capacity this in a format provided by the Board. cycle. 7204,7198 Los Angeles JH 18 20 PRO - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Los Angeles County Probation Department The facility administrator shall develop and implement Detention Services Bureau Manual Section 403: written policies and procedures for admittance of youth Procedures for Newly Admitted Youth that emphasize respectful and humane engagement with youth and reflect that the admission process may be Admittance documentation provided for our review. traumatic to youth who may have already experienced Some processes unable to be confirmed due to trauma. Policies shall be trauma-informed, culturally operations outside of the institution and inspection relevant, and responsive to the language and literacy process being virtual. needs of youth. In addition to the requirements of Sections Y Y 1324 and 1430 of these regulations: Intake/Detention Control (IDC) processes are not included in facility documentation. This was brought to the attention of administration last cycle to resolve. It is unknown if this issue has been resolved as the documentation was not provided for our review and as we are not onsite to verify, we are unable to review all the necessary documentation in the computer. (a) the admittance process shall include: Los Angeles County Probation Department (1) Access to two free phone calls within one hour of Detention Services Bureau Manual Section 403: admittance in accordance with the provisions of Procedures for Newly Admitted Youth Welfare and Institution Code Section 627; Y Y Copies of IDC screens in PCMC were shared for our review. (2) Offer of a shower; Los Angeles County Probation Department Detention Services Bureau Manual Section 403: Procedures for Newly Admitted Youth N N This section is non-compliant as documentation provided for both facilities did not provide information that this occurred. (3) Documented secure storage of personal Los Angeles County Probation Department belongings; Detention Services Bureau Manual Section 409: Procedures for Handling and Processing Personal Y Y Property Documentation of property slips provided. (4) Offer of food upon arrival; Los Angeles County Probation Department Detention Services Bureau Manual Section 403: Procedures for Newly Admitted Youth N N This section is non-compliant as documentation provided for both facilities did not provide information that this occurred. 7204,7198 Los Angeles JH 18 20 PRO - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health and Los Angeles County Probation Department safety issues, intellectual or developmental Detention Services Bureau Manual Section 403: disabilities; Procedures for Newly Admitted Youth. Section 404: Special Needs Screening Procedures, 405: Accommodation Procedures for Hearing Impaired Youth and 414: Identification, Referral, Collaborative Care, Habilitative Treatment, Management and Discharge of Youths with or Suspected of Having a Developmental Disability Admitted to Juvenile Hall Youth are screened for physical and behavioral Y Y health and safety issues, intellectual or developmental disabilities. Arresting officers complete a Arrest Medical Screening Form prior to arrival that is reviewed for admission and IDC staff interview youth for safety concerns. Facilty staff complete the Initial Intake Screeening Questionaire which includes infectious disease risk assessment, a PREA risk assessment, a medical assessment, a mental health assessment and education assessment (6) Screening for physical and developmental Los Angeles County Probation Department disabilities in accordance with Sections 1329, Detention Services Bureau Manual Section 404: 1418, and 1430 of these regulations; Special Needs Screening Procedures, Section 408: Probation Electronic Medical Records System (PEMRS) Probation and Initial Intake Y Y Screening/Referral Questionnaire Form and 414: Identification, Referral, Collaborative Care, Habilitative Treatment, Management and Discharge of Youths with or Suspected of Having a Developmental Disability Admitted to Juvenile Hall (7) Contact with Regional Center for the Los Angeles County Probation Department Developmentally Disabled for youth that are Detention Services Bureau Manual Section 415: suspected of or identified as having a Y Y Identification, Referral, Collaborative Care, developmental disability, pursuant to Section Habilitative Treatment, Management and Discharge 1418; and, of youths with or Suspected of having a Developmental Disability Admitted to Juvenile Hall 7204,7198 Los Angeles JH 18 20 PRO - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (8) Procedures consistent with Section 1352.5. Los Angeles County Probation Department Detention Services Bureau Manual Section 403: Procedures for Newly Admitted Youth 629: Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex (LGBTQI) Y Y Youth Medical staff screen youth as part of the initial intake assessment screening for PREA and included is sexual orientation to ensure their safety. (b) juvenile hall administrators shall establish written Los Angeles County Probation Department criteria for detention that considers the least Detention Services Bureau Manual Section 407: restrictive environment. Los Angeles County Detention Screening (LADS) Assessment Tool Y Y The LADS tool is a detention screening assessment tool that is used to screen all youth to make recommendation for immediate detention or for consideration for alternative detention. This is completed by IDC. Copies of IDC screens in PCMC were shared for our review. (c) juvenile camps and post-dispositional programs in Los Angeles County Probation Department juvenile halls shall develop policies and procedures Detention Services Bureau Manual Section 421: that advise the youth of the estimated length of stay, Estimated Length of Stay NA NA inform them of program guidelines and provide written screening criteria for inclusion and exclusion There are no post dispositional programs other than from the program. camps or placement at either of the Juvenile Halls. (d) juvenile halls shall develop policies and procedures Los Angeles County Probation Department that advise any committed youth of the estimated Detention Services Bureau Manual Section 421: length of his/her stay. Estimated Length of Stay There are no lengths of stay given except to post dispositional youth who are required to be provide Y Y with notification. Per Bureau staff, the only committed the youth are placement youth who would be notified by their Probation Officer or a Camp youth who would be notified during their camp orientation. 7204,7198 Los Angeles JH 18 20 PRO - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Los Angeles County Probation Department ABUSE Detention Services Bureau Manual Section 1509: The facility administrator shall develop and implement Screening for Risk of Sexual Victimization and written policies and procedures to reduce the risk of Abusiveness sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of At inspection, we noted the agency had developed a admission based on the following information: N N partial policy and procedure (Section 1509 as noted above) and noted that youth are asked a series of “PREA” questions during the intake screening assessment. While these questions are important, they do not meet the requirements of the regulation. This section is non-compliant due to lack of policy and proof of practice to current regulation. (a) Prior sexual victimization or abusiveness; This section is non-compliant due to lack of policy N N and due to no proof of practice. (b) Gender nonconforming appearance or manner; or This section is non-compliant due to lack of policy identification as lesbian, gay or bisexual, and due to no proof of practice. transgender, queer or intersex, and whether the N N youth may, therefore, be vulnerable to sexual abuse; (c) Current charges and offense history; This section is non-compliant due to lack of policy N N and due to no proof of practice. (d) Age; This section is non-compliant due to lack of policy N N and due to no proof of practice. (e) Level of emotional and cognitive development; This section is non-compliant due to lack of policy N N and due to no proof of practice. (f) Physical size and stature; This section is non-compliant due to lack of policy N N and due to no proof of practice. (g) Mental illness or mental disabilities; This section is non-compliant due to lack of policy N N and due to no proof of practice. (h) Intellectual or developmental disabilities; This section is non-compliant due to lack of policy N N and due to no proof of practice. (i) Physical disabilities; This section is non-compliant due to lack of policy N N and due to no proof of practice. (j) The youth’s perception of vulnerability; and, This section is non-compliant due to lack of policy N N and due to no proof of practice. (k) Any other specific information about the This section is non-compliant due to lack of policy individual youth that may indicate heightened and due to no proof of practice. N N needs for supervision, additional safety precautions, or separation from certain other youth. Staff shall ascertain this information through Los Angeles County Probation Department conversations with the youth during the admittance Detention Services Bureau Manual Section 1509: process, medical and behavioral health screenings; during Screening for Risk of Sexual Victimization and classification assessments; and by reviewing court N N Abusiveness records, case files, facility behavioral records, and other relevant documentation from the youth’s files. This section is non-compliant due to no proof of practice. 7204,7198 Los Angeles JH 18 20 PRO - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS The facility administrator shall implement appropriate Los Angeles County Probation Department controls on the dissemination of information within the Detention Services Bureau Manual Section 1509: facility relative to responses received pursuant to this Screening for Risk of Sexual Victimization and assessment in order to ensure that sensitive information is N N Abusiveness not exploited to the youth’s detriment by staff or other youth. This section is non-compliant due to no proof of practice. 1351 RELEASE PROCEDURES Los Angeles County Probation Department Detention Services Bureau Manual Section 307: The facility administrator shall develop and implement Release Procedures Y Y written policies and procedures for release of youth from custody which provide for: Unable to confirm release documentation onsite. All compliance based on policy. (a) verification of identity/release papers; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 307: Release Procedures (b) return of personal clothing and valuables; Los Angeles County Probation Department Detention Services Bureau Manual Section 307: Y Y Release Procedures Documentation of returned property provided. (c) notification to the youth's parents or guardian; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 307: Release Procedures (d) notification to the facility health care provider in Los Angeles County Probation Department accordance with Sections 1408 and 1437 of these Detention Services Bureau Manual Section 307: Y Y regulations, for coordination with outside agencies; Release Procedures and, (e) notification of school staff; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 307: Release Procedures (f) notification of facility mental health personnel. Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 307: Release Procedures The facility administrator shall develop and implement Los Angeles County Probation Department policies and procedures for post-disposition youth to Detention Services Bureau Manual Section 307: coordinate the provision of transitional and reentry services including, but not limited to, medical and Per facility administration, there are no post NA NA behavioral health, education, probation supervision and dispositional youth held in the Juvenile Halls. community-based services. Camp youth are transported directly to camp and a case plan is developed for them via MDT upon arrival. The facility administrator shall develop and implement Los Angeles County Probation Department written policies and procedures for the furlough of youth Y Y Detention Services Bureau Manual Section 308: from custody. Youth Furloughs 7204,7198 Los Angeles JH 18 20 PRO - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1352 CLASSIFICATION Los Angeles County Probation Department Detention Services Bureau Manual Section 412: The facility administrator shall develop and implement Classification and Assignment of Youth written policies and procedures on classification of youth for the purpose of determining housing placement in the Each facility has an intake unit where youth are facility. held pending clearances and unit assignment. N N While there is an informal classification process Such procedures shall: operationally, there is no proof of practice. No classification documentation was provided for our review from either facility. This section is non- compliant. (a) provide for the safety of the youth, other youth, Los Angeles County Probation Department facility staff, and the public by placing youth in the Detention Services Bureau Manual Section 412: appropriate, least restrictive housing and program N N Classification and Assignment of Youth 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 Los Angeles County Probation Department the facility; N N Detention Services Bureau Manual Section 412: Classification and Assignment of Youth (c) provide that a youth shall be classified upon Los Angeles County Probation Department admittance to the facility; classification factors shall Detention Services Bureau Manual Section 412: include, but not be limited to: age, maturity, Classification and Assignment of Youth sophistication, emotional stability, program needs, N N legal status, public safety considerations, medical/mental health considerations, gender and gender identity of the youth; (d) provide for periodic classification reviews, including Los Angeles County Probation Department provisions that consider the level of supervision and Detention Services Bureau Manual Section 412: N N the youth's behavior while in custody; and, Classification and Assignment of Youth (e) provide that facility staff shall not separate youth from Los Angeles County Probation Department the general population or assign youth to a single Detention Services Bureau Manual Section 412: occupancy room based solely on the youth's actual or Classification and Assignment of Youth perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, gender expression, N N mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, bisexual, Los Angeles County Probation Department transgender, questioning or intersex identification or Detention Services Bureau Manual Section 412: N N status as an indicator of likelihood of being sexually Classification and Assignment of Youth abusive. 7204,7198 Los Angeles JH 18 20 PRO - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1352.5 TRANSGENDER AND INTERSEX YOUTH. Los Angeles County Probation Department Detention Services Bureau Manual Section 629: The facility administrator shall develop written policies Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Y Y Transgender, Questioning and Intersex (LGBTQI) treatment of transgender and intersex youth. The policies Youth shall provide that: All compliance based on policy. (a) Facility staff shall respect every youth’s gender Los Angeles County Probation Department identity and shall refer to the youth by the youth’s Detention Services Bureau Manual Section 629: preferred name and gender pronoun, regardless of the Supervision of Lesbian, Gay, Bisexual, youth’s legal name. Facilities may prohibit the use of Y Y Transgender, Questioning and Intersex (LGBTQI) gang or slang names or names that otherwise Youth 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 Los Angeles County Probation Department themselves in a manner consistent with their gender Detention Services Bureau Manual Section 629: identity and shall provide youth with the institution’s Y Y Supervision of Lesbian, Gay, Bisexual, clothing and undergarments consistent with their Transgender, Questioning and Intersex (LGBTQI) gender identity. Youth (c) Facility staff shall house youth in the unit or room that Los Angeles County Probation Department best meets their individual needs and promotes their Detention Services Bureau Manual Section 629: safety and well-being. Staff may not automatically Supervision of Lesbian, Gay, Bisexual, house youth according to their external anatomy and Transgender, Questioning and Intersex (LGBTQI) shall document the reasons for any decision to house Youth youth in a unit that does not match their gender If a youth requests a different housing unit other identity. In making a housing decision, staff shall than the one that would be assigned for their consider the youth’s preferences, as well as any “gender at birth”, an MDT is convened, a plan is recommendations from the youth’s health or Y Y developed and implemented for the youth. This behavioral health provider. plan is then emailed to the facility Superintendent for approval and during this time the youth is held in the medical unit pending the approval. If approved by the supervisor, the coordinator will ensure that all necessary paperwork is completed. (d) Facility administrators shall ensure that transgender Los Angeles County Probation Department and intersex youth have access to medical and Detention Services Bureau Manual Section 629: behavioral health providers qualified to provide care Y Y Supervision of Lesbian, Gay, Bisexual, and treatment to transgender and intersex youth. Transgender, Questioning and Intersex (LGBTQI) Youth 7204,7198 Los Angeles JH 18 20 PRO - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (e) Consistent with the facility’s reasonable and Los Angeles County Probation Department necessary security considerations and physical plant, Detention Services Bureau Manual Section 629: facility staff shall make every effort to ensure the Supervision of Lesbian, Gay, Bisexual, safety and privacy of transgender and intersex youth Transgender, Questioning and Intersex (LGBTQI) when the youth are using the bathroom or shower or Youth dressing or undressing. Y Y Transgender youth would have the option to shower at a different time from the other youth and would be provided with additional privacy to dress and undress when showering or using the restroom. Facility staff shall not conduct physical searches of any Los Angeles County Probation Department youth for the purpose of determining the youth’s Detention Services Bureau Manual Section 629: anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of the Transgender, Questioning and Intersex (LGBTQI) staff member who conducts any search of the youth. Youth Policy notes that youth are provided with the option to choose the gender of the staff they wish to search Y Y them. Policy also notes that the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy. 7204,7198 Los Angeles JH 18 20 PRO - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1353 ORIENTATION Los Angeles County Probation Department Detention Services Bureau Manual Section 416: The facility administrator shall develop and implement Orientation Process for Detained Youth written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Orientation handbooks have recently been updated information shall be provided and supplemented with but are now complete. video orientation if feasible. Provision shall be made to Barry J. Nidorf Juvenile Hall: Documentation was provide accessible orientation information to all detained provided of completed orientations. Orientation is youth including those with disabilities, limited literacy, or required to occur prior to placement in a living area. English language learners. Orientation shall include It was noted that orientations were completed next information that addresses: day even when there was ample time or when no N Y extenuating circumstances or late-night entry occurred. This is non-compliant. Central Juvenile Hall: Documentation was provided of completed orientations. Technical assistance provided and suggested to update all forms and signoffs to current standards and regulations as they are outdated. Agency updated policy and the handbook and the signoffs should mirror the handbook and should be consistent. (a) facility rules including contraband and searches and Los Angeles County Probation Department disciplinary procedures; Y Y Detention Services Bureau Manual Section 416: Orientation Process for Detained Youth (b) facility’s system of positive behavior interventions Los Angeles County Probation Department and supports, including behavior expectations, Detention Services Bureau Manual Section 416: incentives that youth will receive for complying with Y Y Orientation Process for Detained Youth facility rules, and consequences that may result when youth violate the rules of the facility; (c) age appropriate information that explains the Los Angeles County Probation Department facility’s policy prohibiting sexual abuse and sexual Detention Services Bureau Manual Section 416: Y Y harassment and how to report incidents or suspicions Orientation Process for Detained Youth of sexual abuse or sexual harassment; (d) identification of key staff and their roles; Los Angeles County Probation Department Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (e) the existence of the grievance procedure, the steps Los Angeles County Probation Department that must be taken to use it, the youth’s right to be free Detention Services Bureau Manual Section 416: of retaliation for reporting a grievance, and the name Y Y Orientation Process for Detained Youth of the person or position designated to resolve the issue; (f) access to legal services and information on the court Los Angeles County Probation Department process; Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth 7204,7198 Los Angeles JH 18 20 PRO - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (g) access to routine and emergency health and mental Los Angeles County Probation Department health care; Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (h) access to education, religious services, and Los Angeles County Probation Department recreational activities; Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (i) housing assignments; Los Angeles County Probation Department Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (j) opportunity for personal hygiene and daily showers Los Angeles County Probation Department including the availability of personal care items Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (k) rules and access to correspondence, visits and Los Angeles County Probation Department telephone use; Y Y Detention Services Bureau Manual Section 416: Orientation Process for Detained Youth (l) availability of reading materials, programming, and Los Angeles County Probation Department other activities; Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (m) facility policies on the use of force, use of restraints, Los Angeles County Probation Department chemical agents and room confinement; Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (n) immigration legal services; Los Angeles County Probation Department Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (o) emergencies including evacuation procedures; Los Angeles County Probation Department Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (p) non-discrimination policy and the right to be free Los Angeles County Probation Department from physical, verbal or sexual abuse and harassment Detention Services Bureau Manual Section 416: Y Y by other youth and staff; Orientation Process for Detained Youth (q) availability of services and programs in a language Los Angeles County Probation Department other than English if appropriate; Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth (r) the process for requesting different housing, Section 417 pg. 400-112. Request for Probation Y Y education, programming and work assignments; Services form pg. Section 1703 pg. 1700-5 (s) a process for which parents/guardians receive Los Angeles County Probation Department information regarding the youth’s stay in the facility Detention Services Bureau Manual Section 416: that at a minimum includes answers to frequently Orientation Process for Detained Youth asked questions and provides contact information for Y Y the facility, medical, school and mental health; and, A Parent Handbook was created. Parents receive the handbook at visiting and it may be viewed online. 7204,7198 Los Angeles JH 18 20 PRO - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (t) a process by which youth may request access to Title Los Angeles County Probation Department 15 Minimum Standards for Juvenile Facilities. Detention Services Bureau Manual Section 416: Y Y Orientation Process for Detained Youth 1354 SEPARATION Los Angeles County Probation Department The facility administrator shall develop and implement Detention Services Bureau Manual Sections: written policies and procedures that address: 1302: The Healing and Opportunities and Positive engagement (Hope)Center 1303: Enhanced Supervision Unit (ESU 1304: CARE Unit 1305: Elite Family Unit (EFU) 1408: Specialized Supervision Requirements 7204,7198 Los Angeles JH 18 20 PRO - 36 - J453 JUV PRO-Eff. 01-01-2019 (a) separation of youth for reasons that include, but are Los Angeles County Probation Department not be limited to, medical and mental health Detention Services Bureau Manual Sections: conditions, assaultive behavior, disciplinary 1302: The Healing and Opportunities and Positive engagement (Hope)Center consequences and protective custody. 1303: Enhanced Supervision Unit (ESU 1304: CARE Unit 1305: Elite Family Unit (EFU) 1408: Specialized Supervision Requirements The Enhanced Supervision Unit houses suicidal youth who are under constant supervision in effort to keep them in a safe and more supervised environment. The CARE Unit houses youth with serious emotional health issues create disruptive behaviors within a general population unit. The EFU is for youth who are either dual jurisdiction or have had a past case with DCFS. Each of these units are specialty units designed to separate specialized populations of youth for specialized purposes. The HOPE Center houses youth who require individual separation for a variety of purposes N N including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation for brief periods in effort to stabilize behaviors and de-escalation and allow the youth to reintegrate into the general population and programs. Current policy for the HOPE Center is not clear or specific in defining the separation policy and must be updated concurrently with the room confinement policy to ensure consistency and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Documentation for BJN JH consisted of 3 Specialized Supervision Plans (SSP)’s and a Major Administrative Action. No incident reports or any other documentation provided to determine the purpose, length etc. of the separation. No documentation of programming. Documentation for Central JH consisted of 3 SSP’s. No incident reports or any other documentation provided to determine the purpose, length etc. of the separation. No documentation of programming. 7204,7198 Los Angeles JH 18 20 PRO - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) consideration of positive youth development and Los Angeles County Probation Department trauma-informed care. Detention Services Bureau Manual Section 1301: Specialized Living Units and Programs- Introduction 1302: The Healing and Opportunity and Positive Y Y engagement (HOPE) Center 1303: Enhanced Supervision Unit (ESU 1304: CARE Unit 1305: Elite Family Unit (EFU) Compliance based on policy review (c) separated youth shall not be denied normal privileges Los Angeles County Probation Department available at the facility, except when necessary to Detention Services Bureau Manual Section 1301: accomplish the objective of separation. Specialized Living Units and Programs- Y Y Introduction Compliance based on policy review (d) when the objective of the separation is discipline, Title Los Angeles County Probation Department 15 Section 1390 shall apply. Detention Services Bureau Manual Section 1301: Specialized Living Units and Programs- Y Y Introduction Compliance based on policy review (e) when separation results in room confinement, the Los Angeles County Probation Department separation shall occur in accordance with Welfare and Detention Services Bureau Manual Section 1301: Institutions Code Section 208.3 and Section1354.5 of Specialized Living Units and Programs- Y Y these regulations. Introduction See Comment in 1354. (a) and in 1354.5(a) (f) policies and procedures shall ensure a daily review of Los Angeles County Probation Department separated youth to determine if separation remains Detention Services Bureau Manual Section 1301: necessary. Specialized Living Units and Programs- Introduction and Section 1302: The Healing and Y Y Opportunity and Positive engagement (HOPE) Center Compliance based on policy review 7204,7198 Los Angeles JH 18 20 PRO - 38 - J453 JUV PRO-Eff. 01-01-2019 1354.5 ROOM CONFINEMENT Los Angeles County Probation Department Detention Services Bureau Manual Sections: 607: (a) The facility administrator shall develop and Modified Program, 1020: Room Confinement implement written policies and procedures addressing Following Use of Physical Intervention (Newly the confinement of youth in their room that are Added Policy) and Section 1302: The Healing and consistent with Welfare and Institutions Code Section Opportunity and Positive engagement (HOPE) 208.3. The placement of a youth in room confinement Center shall be accomplished in accordance with the following guidelines: We requested documentation specific to Modified program and were provided with only one incident report from BJN in which two youth were arguing and were placed on separate programs (one in room and one out). It is unknown when they returned to regular programming based on documentation received. We were provided with one incident from CJH in which one youth requested to remain in his room however, it was unknown when he rejoined the group. While one incident does not make an agency non- compliant, we are unable to determine without proper documentation that your practices are compliant in this area. The agency was notified at inspection that split N N program and modified program as currently provided were both non-compliant. As of the time of the completion of this report, no changes have been made to the process and both facilities have indicated they have no other modified program documentation to provide. We find that the use of a modified program allows for staff to place youth in their rooms without providing all aspects of 1354.5 requirements. When this occurs, this is non- compliant. The HOPE Center historically receives youth for a variety of reasons which include separation or cool down, decontamination, administrative holds, housing, mental health, and for safety and security purposes. With the implementation of the Room Confinement regulations and the implementation of specific requirements, the documentation received for review was problematic, as it does not consistently provide proof of compliant practices nor are we able to determine which youth are held under room confinement expectations. In many cases, we were unable to determine if the youth was placed in a locked room therefore, we were unable to determine what requirements and documentation were necessary. 7204,7198 Los Angeles JH 18 20 PRO - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS Policy, procedure and documentation will need to be reviewed and updated to achieve compliance. Room confinement and separation policies should be revised concurrently to ensure consistency as well as to ensure compliance with all pieces of this regulation. (1) Room confinement shall not be used before other, Los Angeles County Probation Department less restrictive, options have been attempted and Detention Services Bureau Manual Section 1302: exhausted, unless attempting those options poses The Healing and Opportunity and Positive a threat to the safety or security of any youth or engagement (HOPE) Center staff. Y Y Per policy, youth are separated from others for a brief cool down to de-escalate and to stabilize their behavior. If a youth is brought to the HOPE Center for a cool down, they are not to be placed in a locked room. (2) Room confinement shall not be used for the Los Angeles County Probation Department purposes of punishment, coercion, convenience, Detention Services Bureau Manual Section 1302: or retaliation by staff. The Healing and Opportunity and Positive engagement (HOPE) Center N N Documentation was not always clear as to if the youth was an active safety or security threat and documentation was not clear if the youth was in a locked room. For these reasons, this section is non- compliant. (3) Room confinement shall not be used to the extent Los Angeles County Probation Department that it compromises the mental and physical Detention Services Bureau Manual Section 1302: Y Y health of the youth. The Healing and Opportunity and Positive engagement (HOPE) Center 7204,7198 Los Angeles JH 18 20 PRO - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) A youth may be held up to four hours in room Los Angeles County Probation Department confinement. After the youth has been held in room Detention Services Bureau Manual Section 1302: confinement for a period of four hours, staff shall do The Healing and Opportunity and Positive one or more of the following: engagement (HOPE) Center Documentation provided from both facilities was inconsistent as were the logs that are kept and provided. Per policy, the readiness for release form provides the opportunity for the supervisor to review with youth every 2 hours if they are ready to return to their unit. Central Juvenile Hall staff provided 6 samples for our review. Of the 6 samples, 2 were blank, 2 were either just at 4 hours or under and the other 2 were not completed per policy requirements. Barry J. Nidorf Juvenile Hall Provided 20 samples for our review of which we reviewed 6 randomly. Most were either returned to their units at 2 hours or were placed on an SSP and the Readiness for Release discontinued. (1) Return the youth to general population. Los Angeles County Probation Department Detention Services Bureau Manual Section 1302: The Healing and Opportunity and Positive engagement (HOPE) Center Y N Documentation reviewed for both BJNJH and CJH. Per policy, supervisors must meet with the youth once every 2 hours to determine if they are ready for return to their unit. This did not occur at CJH. This is non-compliant. (2) Consult with mental health or medical staff. Los Angeles County Probation Department Detention Services Bureau Manual Section 1302: The Healing and Opportunity and Positive engagement (HOPE) Center Per policy, DMH meets with youth who are sent to N N the HOPE Center and placed behind a locked door. We were unable to determine if the youth were placed behind locked doors as the form was not marked and we saw no documentation of a consultation with mental health or medical staff in the documentation we viewed. 7204,7198 Los Angeles JH 18 20 PRO - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (3) Develop an individualized plan that includes the Los Angeles County Probation Department goals and objectives to be met in order to Detention Services Bureau Manual Section 1302: reintegrate the youth to general population. The Healing and Opportunity and Positive engagement (HOPE) Center Per policy, a re-integration plan will be developed for each youth who remains in the HOPE center longer than 4 hours. N N Barry J. Nidorf: We were not provided with any ready for release documents longer than 2 hours but were provided with Ready for Release’s with SSP’s. None noted any goals or objectives. SSP’s are specific to supervision. Central Juvenile Hall: We were not provided with any reintegration plans to view. This section is non-compliant (4) If room confinement must be extended beyond four hours, staff shall do each of the following: (A) Document the reasons for room confinement Los Angeles County Probation Department and the basis for the extension, the date and Detention Services Bureau Manual Section 1302: time the youth was first placed in room Y Y The Healing and Opportunity and Positive confinement, and when he or she is engagement (HOPE) Center eventually released from room confinement. (B) Develop an individualized plan that includes Los Angeles County Probation Department the goals and objectives to be met in order to Detention Services Bureau Manual Section 1302: integrate the youth to general population. The Healing and Opportunity and Positive N N engagement (HOPE) Center Same comment as above. This section is non- compliant. (C) Obtain documented authorization by the Los Angeles County Probation Department facility superintendent or his or her designee Detention Services Bureau Manual Section 1302: every four hours thereafter. The Healing and Opportunity and Positive engagement (HOPE) Center When stabilization exceeds 4 hours, authorization must be obtained from the facility superintendent or N N director. This must be noted on the individual reintegration plans. No documentation was provided that noted approvals beyond 4 hours by either the superintendent, the assistant superintendent or a director of either the RFR or the SSP’s. This section is non-compliant. 7204,7198 Los Angeles JH 18 20 PRO - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (5) This section is not intended to limit the use of Los Angeles County Probation Department single-person rooms or cells for the housing of Detention Services Bureau Manual Section 1302: youth in juvenile facilities and does not apply to Y Y The Healing and Opportunity and Positive normal sleeping hours. engagement (HOPE) Center (6) This section does not apply to youth or wards in Los Angeles County Probation Department court holding facilities or adult facilities. Detention Services Bureau Manual Section 1302: Y Y The Healing and Opportunity and Positive engagement (HOPE) Center (7) Nothing in this section shall be construed to Los Angeles County Probation Department conflict with any law providing greater or Detention Services Bureau Manual Section 1302: additional protections to youth. Y Y The Healing and Opportunity and Positive engagement (HOPE) Center (8) This section does not apply during an Los Angeles County Probation Department extraordinary emergency circumstance that Detention Services Bureau Manual Section 1302: requires a significant departure from normal The Healing and Opportunity and Positive institutional operations, including a natural engagement (HOPE) Center Y Y 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 Los Angeles County Probation Department placed in a locked cell or sleeping room to treat Detention Services Bureau Manual Section 1302: and protect against the spread of a communicable The Healing and Opportunity and Positive disease for the shortest amount of time required engagement (HOPE) Center 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 Y Y 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. 7204,7198 Los Angeles JH 18 20 PRO - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1355 INSTITUTIONAL ASSESSMENT AND PLAN Los Angeles County Probation Department Detention Services Bureau Manual Section 413: The facility administrator shall develop and implement Institutional Assessment, Case Plan and Periodic written policies and procedures for assessment and case Review planning. During the 2016-2018 cycle, it was suggested that policy and procedure and the assessment, case plan and periodic review forms be updated to be current Y Y and consistent with best practices and compliant with regulatory changes. We noted that changes had been made and new forms were implemented effective July 2019. All documentation received from both Barry J. Nidorf Juvenile Hall and Central Juvenile Hall were all on the old forms. (a) Assessment: Los Angeles County Probation Department The assessment is based on information collected Detention Services Bureau Manual Section 413: during the admission process with periodic review, Institutional Assessment, Case Plan and Periodic which includes the youth's risk factors, needs and Review strengths including, but not limited to, identification Documentation reviewed. Assessment information of substance abuse history, educational, vocational, is completed during orientation as admission is counseling, behavioral health, consideration of completed by a different service. known history of trauma, and family strengths and N N needs. Several areas required by new regulation were missing from the old assessment form. New forms were updated in July 2019. These areas include needs and strengths, considerations of trauma, and family strengths and needs. These areas were not addressed in each youth assessment for either facility as facilities used old forms. This section is non-compliant. 7204,7198 Los Angeles JH 18 20 PRO - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) Institutional Case Plan: Los Angeles County Probation Department (1) A case plan shall be developed for each youth held Detention Services Bureau Manual Section 413: for at least 30 days or more and created within 40 Institutional Assessment, Case Plan and Periodic days of admission. Review Policy directs that a case plan shall be completed for youth held for 30 days or more within 40 days. Case plans were provided for our review from both facilities. N N Barry J. Nidorf: We viewed 19 assessments and 19 case plans. 12 of the case plans were timely. Central Juvenile Hall: We viewed 20 assessments and 20 case plans. 8 of the case plans were timely. This section is non-compliant due to case plans being late. The facilities did not utilize the new forms that are required in policy. (2) The institutional plan shall include, but not be Los Angeles County Probation Department limited to, written documentation that provides: Detention Services Bureau Manual Section 413: Institutional Assessment, Case Plan and Periodic Review (A) objectives and time frame for the resolution of Los Angeles County Probation Department problems identified in the assessment; Detention Services Bureau Manual Section 413: Institutional Assessment, Case Plan and Periodic Review The objectives are pre identified as substance abuse, education, behavioral health and counseling and family reunification. Time frames are embedded in Y Y the objective such as daily school attendance or weekly visits. In the new form, it was added that each youth is to have an individual service plan in addition to the prefilled objectives that meets their individual needs. Specific time frames may be added as appropriate. 7204,7198 Los Angeles JH 18 20 PRO - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (B) a plan for meeting the objectives that includes Los Angeles County Probation Department a description of program resources needed Detention Services Bureau Manual Section 413: and individuals responsible for assuring that Institutional Assessment, Case Plan and Periodic the plan is implemented; Review Individuals responsible to ensure the plan was N N implemented were not previously identified however, policy was updated to include that this shall be identified in the service plan. Technical assistance provided to update the form to ensure consistency to capture this directive. New policy not adhered to and new forms not utilized. (3) periodic evaluation of progress towards meeting Los Angeles County Probation Department the objectives, including periodic review and Detention Services Bureau Manual Section 413: discussion of the plan with the youth; Institutional Assessment, Case Plan and Periodic Review Documentation of efforts made by both facilities. Y Y Reviews were completed with the youth and were signed by the youth. Policy indicates that new forms were available and in policy in July 2019. None of the documentation provided was completed on the current, updated forms. (4) a transition plan, the contents of which shall be Los Angeles County Probation Department subject to existing resources, shall be developed Detention Services Bureau Manual Section 413: for post dispositional youth in accordance with Institutional Assessment, Case Plan and Periodic NA NA Section 1351; and, Review See Section 1351. (5) in as much as possible and if appropriate, the plan, Los Angeles County Probation Department including the transition plan, shall be developed Detention Services Bureau Manual Section 413: with input from the family, supportive adults, Institutional Assessment, Case Plan and Periodic Y Y youth, and Regional Center for the Review Developmentally Disabled. Every youth upon release is referred to 1356 COUNSELING AND CASEWORK Los Angeles County Probation Department SERVICES Detention Services Bureau Manual Section 207 General Staff responsibilities The facility administrator shall develop and implement Y Y written policies and procedures ensuring the availability Staff are expected to meet the needs of all youth in of appropriate counseling and casework services for all their care from counseling, to mentoring to youth. Policies and procedures shall ensure: advocating for their needs. (a) youth will receive assistance with needs or concerns Los Angeles County Probation Department that may arise; Y Y Detention Services Bureau Manual Section 207 General Staff responsibilities 7204,7198 Los Angeles JH 18 20 PRO - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) youth will receive assistance in requesting contact Los Angeles County Probation Department with parents, other supportive adults, attorney, clergy, Y Y Detention Services Bureau Manual Section 207 probation officer, or other public official; and, General Staff responsibilities (c) youth will be provided access to available resources Los Angeles County Probation Department to meet the youth’s needs. Detention Services Bureau Manual Section 207 General Staff responsibilities Y Y Staff encourage all youth to request referrals as appropriate for desired services. Staff should make contact on the youth’s behalf for medical, mental health or other needs as they arise for emergent situations. 1357 USE OF FORCE Los Angeles County Probation Department Detention Services Bureau Manual Section 1001: The facility administrator, In cooperation with the Use of Force responsible physician, shall develop and implement written policies and procedures for the use of force, which Y Y Policy was developed with the Juvenile Court may include chemical agents. Force shall never be applied Health Services (JCHS) and includes Use of OC as punishment, discipline, retaliation or treatment. and the use of soft restraints. (a) At a minimum, each facility shall develop policies and procedures which: (1) restricts the use of force to that which is deemed Los Angeles County Probation Department reasonable and necessary, as defined in Section Detention Services Bureau Manual Section 1004: 1302 to ensure the safety and security of youth, Objectively Reasonable Determinations staff, others and the facility. Y Y All documentation reviewed were incidents that were fights, assaults by youth on other youth or assaults on staff by youth. All incidents viewed appeared appropriate and to be reasonable and necessary. (2) outline the force options available to staff Los Angeles County Probation Department including both physical and non-physical options Detention Services Bureau Manual Section 1010: and define when those force options are De-Escalation Strategies, Section 1011: Physical Y Y Intervention Determinations and Strategies and appropriate. 1012: Authorized Levels of Physical Intervention (3) describe force options or techniques that are Los Angeles County Probation Department expressly prohibited by the facility. Detention Services Bureau Manual Section 1005: Y Y Inappropriate/Prohibited Uses of Force and Conduct (4) describe the requirements of staff to report any Los Angeles County Probation Department inappropriate use of force, and to take affirmative Detention Services Bureau Manual Section 1005: Y Y action to immediately stop it. Inappropriate/Prohibited Uses of Force and Conduct 7204,7198 Los Angeles JH 18 20 PRO - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (5) define a standardized reporting format that Los Angeles County Probation Department includes time period and procedure for Detention Services Bureau Manual Section 1022: documenting and reporting the use of force, Safe Crisis Management- Physical Intervention including reporting requirements of management Reports (PIR and SUP-PIR) and line staff and procedures for reviewing and Los Angeles County Probation Department tracking use of force incidents by supervisory and Detention Services Bureau Manual Section 1027: or management staff, which include procedures for Debriefings debriefing a particular incident with staff and/or youth for the purposes of training as well as Los Angeles County has a very detailed format for mitigating the effects of trauma that may have been reporting and follow up. A PIR or SIR is written experienced by staff and /or the youth involved. with much of the required documentation contained in prefilled sections to ensure all areas are UNK UNK addressed and are a part of the agency PCMS case management system. Additional documentation is addressed in hard copy forms such as the Mental Health Referrals with prefilled reasons for requests, Enhanced Supervision Observation Forms, Child Safety Assessments, Youth Violence Avoidance Contracts, Incident Questionnaire and Sanctions and Appeals Forms. We did not see any reference to debriefing of incidents; however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further into this issue when on site at the next inspection. (6) Include an administrative review and a system for Los Angeles County Probation Department investigating unreasonable use of force. Detention Services Bureau Manual Section 1022: Safe Crisis Management- Physical Intervention Reports (PIR and SUP-PIR) Each SCM Incident that occurs that involves a physical or chemical intervention is independently Y Y reviewed by the facilities SCM supervising coordinator who interviews all witness, the involved youth etc. the coordinator makes a determination if all was performed within policy and makes a recommendation to the facility superintendent or to the Probation Departments Special Investigations Unit as appropriate. 7204,7198 Los Angeles JH 18 20 PRO - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Los Angeles County Probation Department procedures required after use of force incidents for Detention Services Bureau Manual Sections: medical, mental health staff and parents or legal 1023: Medical Assessment of Youth guardians. 1024: Mental Health Involvement and Assessment of Youth 1026: Notifications We found that in all incident reports and in documentation reviewed we found that youth were medically cleared, and a mental health referral was submitted on the youth’s behalf for follow up. Technical assistance provided to address mental health policy of referrals vs seeing youth immediately. At inspection we did not see any Y N reference to contact of a youth’s parent if the child was involved in a use of force incident; however, as we were not on site, we are unable to confirm if this was occurring in other facility processes. We later found that it was, but only for emergencies or for use of OC. Bureau Administrators subsequently provided a directive to all staff to begin notifications immediately. Documentation was again requested for review. Barry J. Nidorf staff have corrected their procedures and subsequent documentation reviewed noted this correction. Central Juvenile Hall documentation has been checked electronically and staff have not made any changes to address this issue. This section remains non-compliant. (8) describe the limitations of use of force on pregnant Los Angeles County Probation Department youth in accordance with Penal Code Section Detention Services Bureau Manual Section 1011: 6030(f) and Welfare and Institutions Code Section Y Y Pregnant and Post-Partum Recovering Youth 222. No incidents viewed involved pregnant youth. (b) Facilities that authorize chemical agents as a force Los Angeles County Probation Department option shall include policies and procedures that: Detention Services Bureau Manual Section 1013: Use of Oleoresin Capsicum (OC)Spray Strategies - Y Y Application of OC Spray BJN and CJH still use pepper spray in the facilities and documentation was provided for our review. 7204,7198 Los Angeles JH 18 20 PRO - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (1) identify who is approved to carry and/or utilize Los Angeles County Probation Department chemical agents in the facility and the type, size Detention Services Bureau Manual Section 1013: and the approved method of deployment for those Use of Oleoresin Capsicum (OC)Spray Strategies - chemical agents. Y Y Application of OC Spray Sworn Probation Officers Only who have been appropriately trained are permitted to use chemical interventions. (2) mandate that chemical agents only be used when Los Angeles County Probation Department there is an imminent threat to the youth’s safety or Detention Services Bureau Manual Section 1013: the safety of others and only when de-escalation Y Y Use of Oleoresin Capsicum (OC)Spray Strategies - efforts have been unsuccessful or are not Application of OC Spray reasonably possible. (3) outline the facility’s approved methods and Los Angeles County Probation Department timelines for decontamination from chemical Detention Services Bureau Manual Section 1014: agents. This shall include that youth who have Post OC Spray Application Protocols been exposed to chemical agents shall not be left Documentation was provided for our review and we unattended until that youth is fully decontaminated Y Y found, there is no set timeline for the time spent or is no longer suffering the effects of the chemical under the water or fan and that for each youth and agent. incident it varied. We also noted that each youth was provided with clean clothes and was placed on a level 3 one on one supervision for 1 hour which was clearly documented. (4) define the role, notification, and follow-up Los Angeles County Probation Department procedures required after use of force incidents Detention Services Bureau Manual Sections: involving chemical agents for medical, mental 1013: Use of Oleoresin Capsicum (OC) Spray health staff and parents or legal guardians. Strategies 1014: Post OC Spray Application Protocols 1026: Notifications Y Y All youth were seen by the nurse and a mental health referral was submitted on their behalf. The youth’s parents or guardian is notified if their child is involved in an incident that involves the use of OC. (5) provide for the documentation of each incident of Los Angeles County Probation Department use of chemical agents, including the reasons for Detention Services Bureau Manual Section 1022: which it was used, efforts to de-escalate prior to Safe Crisis Management- Physical Intervention use, youth and staff involved, the date, time and Y Y Reports (PIR and SUP-PIR) location of use, decontamination procedures See comment 1357a(5). All OC information is applied and identification of any injuries embedded in the incident report. sustained as a result of such use. 7204,7198 Los Angeles JH 18 20 PRO - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (c) Facilities shall develop policies and procedure which Los Angeles County Probation Department require that agencies provide initial and regular Detention Services Bureau Manual Section 1002: training in use of force and chemical agents when Training Y Y appropriate that address: Initial training and annual refresher training is provided. (1) known medical and behavioral health conditions Los Angeles County Probation Department that would contraindicate certain types of force; Y Y Detention Services Bureau Manual Section 1002: Training (2) acceptable chemical agents and the methods of Los Angeles County Probation Department application. Y Y Detention Services Bureau Manual Section 1002: Training (3) signs or symptoms that should result in immediate Los Angeles County Probation Department referral to medical or behavioral health. Y Y Detention Services Bureau Manual Section 1002: Training (4) instruction on the Constitutional Limitations of Los Angeles County Probation Department Use of Force. Y Y Detention Services Bureau Manual Section 1002: Training (5) physical training force options that may require Los Angeles County Probation Department the use of perishable skills. Y Y Detention Services Bureau Manual Section 1002: Training (6) timelines the facility uses to define regular Los Angeles County Probation Department training. Detention Services Bureau Manual Section 1002: Training Y Y All sworn officers assigned to DSB receive initial physical intervention training and then ongoing on an annual basis. 1358 USE OF PHYSICAL RESTRAINTS Los Angeles County Probation Department Detention Services Bureau Manual Section 1019: The facility administrator, In cooperation with the Mechanical/Soft Restraints responsible physician and mental health director, shall Y Y develop and implement written policies and procedures for the use of restraint devices. Restraint devices include any devices which immobilize a youth's extremities and/or prevent the youth from being ambulatory. Physical restraints may be used only for those youth who Los Angeles County Probation Department present an immediate danger to themselves or others, who Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints exhibit behavior which results in the destruction of property or reveals the intent to cause self-inflicted Y Y Faculties have option of restraints from handcuffs, physical harm. Physical restraints should be utilized only flex cuffs and soft restraints and helmets. Staff are when it appears less restrictive alternatives would be to use the least restrictive to control the youth’s ineffective in controlling the youth’s behavior. behavior. 7204,7198 Los Angeles JH 18 20 PRO - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS In no case shall restraints be used as punishment or Los Angeles County Probation Department discipline, or as a substitute for treatment. The use of Detention Services Bureau Manual Section 1019: restraint devices that attach a youth to a wall, floor or other Mechanical/Soft Restraints fixture, including a restraint chair, or through affixing of Y Y hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Los Angeles County Probation Department handcuffs, shackles or other restraint devices when used to Detention Services Bureau Manual Section 1019: restrain youth for movement or transportation within the Mechanical/Soft Restraints facility. Movement within the facility shall be governed by Y Y This policy is section is covered in Section 809: Section 1358.5, Use of Restraint Devices for Movement The Use of Mechanical Restraints for Movement Within the Facility. and Transport Within the Facility Youth shall be placed in restraints only with the approval Los Angeles County Probation Department of the facility manager or designee. The facility manager Detention Services Bureau Manual Section 1019: may delegate authority to place a youth in restraints to a Y Y Mechanical/Soft Restraints physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. A medical opinion on the safety of placement and retention Los Angeles County Probation Department shall be secured as soon as possible, but no later than two Detention Services Bureau Manual Section 1019: hours from the time of placement. The youth shall be Mechanical/Soft Restraints medically cleared for continued retention at least every Medical staff are on duty 24 hours a day 7 days a three hours thereafter. Y Y week in the Juvenile Halls. Medical is contacted immediately and youth are seen to ensure safety and to check for circulation. Youth are also assessed once restraints are removed. Documentation noted that youth are seen by nursing as required. A mental health consultation shall be secured as soon as Los Angeles County Probation Department possible, but in no case longer than four hours from the time Detention Services Bureau Manual Section 1019: of placement, to assess the need for mental health Mechanical/Soft Restraints treatment. Barry J. Nidorf: Documentation consisted of mental health referrals and in some cases consultations N Y with the youth. Consultations were not completed within four hours. Central Juvenile Hall: Documentation consisted of a restraint log that included information regarding the referral to the mental health consultation as well as documentation of the consultation. 7204,7198 Los Angeles JH 18 20 PRO - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS Continuous direct visual supervision shall be conducted to Los Angeles County Probation Department ensure that the restraints are properly employed, and to Detention Services Bureau Manual Section 1019: ensure the safety and well-being of the youth. Observations Mechanical/Soft Restraints of the youth's behavior and any staff interventions shall be Documentation was provided from both facilities. documented at least every 15 minutes, with actual time of We noted the application and documentation of the documentation recorded. restraints pursuant to this section of regulation was N Y not consistent between the two facilities. BJN JH was lacking the restraint log that contains much of the required areas required to be documented. CJH used the restraint log and when it was missing, a counseling memo was provided for our review. In addition to the requirements above, policies and procedures shall address: (a) documentation of the circumstances leading to an Los Angeles County Probation Department application of restraints. Y Y Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints (b) known medical conditions that would contraindicate Los Angeles County Probation Department certain restraint devices and/or techniques. Y Y Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints (c) acceptable restraint devices. Los Angeles County Probation Department Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints Y Y Authorized restraint devices for use by the Department consist of hard mechanical restraints (i.e., handcuffs, leg irons, waist-chains, plastic flexicuffs) and soft mechanical restraints (i.e. padded leather wrist and ankle restraints and safety helmets) (d) signs or symptoms which should result in immediate Los Angeles County Probation Department medical/mental health referral. Y Y Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints (e) availability of cardiopulmonary resuscitation Los Angeles County Probation Department equipment. Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints Y Y Section 517: Use of Cardiopulmonary Resuscitation (CPR) Equipment and First Aid All facilities are equipped with AEDS and staff have been trained in their use. 7204,7198 Los Angeles JH 18 20 PRO - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (f) protective housing of restrained youth. While in Los Angeles County Probation Department restraint devices, all youth shall be housed alone or in Detention Services Bureau Manual Section 1019: a specified housing area for restrained youth which Y Y Mechanical/Soft Restraints makes provision to protect the youth from abuse. All youth reviewed were housed alone and were appropriately supervised by staff. (g) provision for hydration and sanitation needs. Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints (h) exercising of extremities. Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 1019: Mechanical/Soft Restraints 1358.5 USE OF RESTRAINT DEVICES FOR Los Angeles County Probation Department MOVEMENT AND TRANSPORTATION WITHIN Detention Services Bureau Manual Section 809: THE FACILITY. The Use of Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, in cooperation with the responsible physician and behavioral/mental health Policy was developed in cooperation with Juvenile director, shall develop and implement written policies and Court Health Services (JCHS) and the Department procedures for the use of restraint devices when the of Mental Health (DMH). purpose is for movement or transportation within the facility that shall include the following: No documentation was provided for our review. No proof of practice provided. (a) identification of acceptable restraint devices, staff Los Angeles County Probation Department approved to utilize restraint devices and the required Detention Services Bureau Manual Section 809: training. The Use of Mechanical Restraints for Movement Y Y and Transport Within the Facility (b) the circumstances leading to the application of Los Angeles County Probation Department restraints must be documented. Detention Services Bureau Manual Section 809: N N The Use of Mechanical Restraints for Movement and Transport Within the Facility (c) an individual assessment of the need to apply Los Angeles County Probation Department restraints for movement or transportation that Detention Services Bureau Manual Section 809: includes consideration of less restrictive alternatives, The Use of Mechanical Restraints for Movement consideration of a youth’s known medical or mental and Transport Within the Facility health conditions, trauma informed approaches, and a Mechanical Restraint Assessment is conducted process for documentation and supervisor review and upon initial entry or updated as needed during the approval. N N youths stay. Youth are assessed for security needs for nighttime restraint and movement/transport. Daytime movement/transport is only conducted under exigent circumstances. No proof of practice provided. 7204,7198 Los Angeles JH 18 20 PRO - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (d) consideration of safety and security of the facility, Los Angeles County Probation Department with a clearly defined expectation that restraint Detention Services Bureau Manual Section 809: Y Y devices shall not be used for the purposes of The Use of Mechanical Restraints for Movement discipline or retaliation. and Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Los Angeles County Probation Department accordance with Penal Code Section6030(f) and Detention Services Bureau Manual Section 809: Y Y Welfare and Institutions Code Section 222. The Use of Mechanical Restraints for Movement and Transport Within the Facility 1359 SAFETY ROOM PROCEDURES Neither facility has a safety room. (a) The facility administrator, and where applicable, In 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 NA NA 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 NA NA necessary nutrition and fluids, access to a toilet, and suitable clothing to provide for privacy; (2) provide for approval of the facility manager, or NA NA 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 NA NA any staff interventions every 15 minutes, with actual time recorded; (4) provide that the youth shall be evaluated by the NA NA facility manager, or designee, every four hours; (5) provide for immediate medical assessment, where NA NA 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 NA NA restrictive means of control, and decisions to continue and end placement. (b) The placement of a youth in the safety room shall be NA NA accomplished in accordance with the following: (1) safety room shall not be used before other less restrictive options have been attempted and NA NA exhausted, unless attempting those options poses a threat to the safety or security of any youth or staff. 7204,7198 Los Angeles JH 18 20 PRO - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (2) safety room shall not be used for the purposes of NA NA punishment, coercion, convenience, or retaliation by staff. (3) safety room shall not be used to the extent that it NA NA 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 NA NA room for a period of four hours, staff shall do one or more of the following: (1) return the youth to general population. NA NA (2) consult with mental health or medical staff, NA NA (3) develop an individualized plan that includes the NA NA 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 NA NA 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 Los Angeles County Probation Department Detention Services Bureau Manual Sections 701- The facility administrator shall develop and implement 719 provide direction for searches. Below sections written policies and procedures governing the search of are specific to regulatory expectations. youth, the facility, and visitors. Policies and procedures Y Y shall provide that: Los Angeles County Probation Department Detention Services Bureau Manual Section 701: Searches, Section 717: Searches of the Facility and Section 718: Searches of Visitors (a) Searches shall be conducted to ensure the safety and Los Angeles County Probation Department security of the facility, public, visitors, youth, and Detention Services Bureau Manual Section 701: staff. Searches All youth are searched upon entry, transfer and as needed. Policy also requires each shift to conduct at N N least two unit searches each week. Both facilities provided copies of search documentation logs. Documentation provided was not consistent with policy requirements. This is non-compliant. (b) Searches shall be conducted in a manner that Los Angeles County Probation Department preserves the privacy and dignity of the person being Y Y Detention Services Bureau Manual Section 701: searched, and shall not be conducted for harassment Searches or as a form of discipline or punishment. 7204,7198 Los Angeles JH 18 20 PRO - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (c) Strip searches and visual or physical body cavity Los Angeles County Probation Department searches shall comply with Penal Code Section 4030. Detention Services Bureau Manual Section 701: Searches and 709: Completing a Strip Search Y Y Authorization Form, 711: Admissions Procedures- Strip Search and/or Visual Body Cavity Search (d) Physical body cavity searches shall only be conducted Los Angeles County Probation Department by a medical professional. Detention Services Bureau Manual Section 702: Y Y Types of Searches and Definitions and Section 711: Admissions Procedures- Strip Searcy and/or Visual Body Cavity Search (e) Any youth held after a detention hearing shall only be Los Angeles County Probation Department strip searched with prior approval of a supervisor Detention Services Bureau Manual Section 703: when there is reasonable suspicion based on specific Searches of Youth Housed in Juvenile Facilities- and articulable facts to believe that youth is General Information concealing contraband. The reasonable suspicion Policy requires a Strip Search Authorization Form shall be documented. on all youth. If a youth is not subject to a strip Y Y search, the box is marked no. Strip search authorization forms are routinely completed at intake but not currently provided to the orientation officers to be included as part of the orientation packet. Technical assistance provided and discussed that this documentation should be provided for inclusion in the packet in the future. (f) Searches of transgender and intersex youth shall Los Angeles County Probation Department comply with Section 1352.5. Detention Services Bureau Manual Section 706: Transgender Youth Searches Y Y Section 706 references policy 629: Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth See note in Section 1352.5 (g) Cross-gender pat-down searches and strip searches Los Angeles County Probation Department are prohibited except in exigent circumstances or Y Y Detention Services Bureau Manual Section 705: when conducted by a medical professional. Such Cross Gender Searches searches must be justified and documented in writing. 7204,7198 Los Angeles JH 18 20 PRO - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1361 GRIEVANCE PROCEDURE Los Angeles County Probation Department Detention Services Bureau Manual Section 1715: The facility administrator shall develop and implement Youth Grievance Procedures written policies and procedures whereby any youth may appeal and have resolved grievances relating to any Grievance samples were provided from March, July condition of confinement, including but not limited to and October 2019 were provided for our review. health care services, classification decisions, program Y Y Compliance noted from policy and through participation, telephone, mail or visiting procedures, food, conversation with administrative staff and clothing, bedding, mistreatment, harassment or violations documentation review. We were not onsite to view of the nondiscrimination policy. There shall be no time the process. limit on filing grievances. Policies and procedures shall include provisions whereby the facility manager ensures: (a) a grievance form and instructions for registering a Los Angeles County Probation Department grievance, which includes provisions for the youth to Detention Services Bureau Manual Section 1715: have free access to the form; Youth Grievance Procedures Youth may receive a grievance form in their unit, medical, and in the classroom. Per bureau consultant staff, youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same, but we noted that 1 youth who submitted 3 grievances Y Y via his laptop while in class at Central JH, his grievances were not completed correctly through the process. These were the only electronic documents we viewed as part of the documentation received. As this is a new process, newly implemented and only 1 instance from one youth, we do not find this to rise to the level of noncompliance but suggest that the agency address this issue and look further into the incident to ensure that it is not a more widespread issue. This particular issue occurred on 10/8/2019. 7204,7198 Los Angeles JH 18 20 PRO - 58 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) the youth shall have the option to confidentially file Los Angeles County Probation Department the grievance or to deliver the form to any youth Detention Services Bureau Manual Section 1715: supervision staff working in the facility; Youth Grievance Procedures According to Bureau staff, youth may choose which staff to provide their grievance to including the staff they are grieving or with the supervisor directly. They may also choose to place the grievance in the locked confidential box so grievance is not viewed by any unit staff member and goes to the Grievance Officer for processing. Y Y Numerous grievances were viewed, and all were addressed by the grievance officer. We are unable to determine if this is because youth are again being directed to place the grievance in the confidential box which would be non-compliant or if they are in fact placing their grievance in the confidential box without making efforts to resolve the issues at lower levels. Without being on site, we are unable to make this determination. We will follow up with this issue upon our return to the facility. Compliance based on policy. (c) resolution of the grievance at the lowest appropriate Los Angeles County Probation Department staff level; Detention Services Bureau Manual Section 1715: Y Y Youth Grievance Procedures See note in 1361(b) (d) provision for a prompt review and initial response to Los Angeles County Probation Department grievances within three (3) business days, grievances Detention Services Bureau Manual Section 1715: that relate to health and safety issues must be Youth Grievance Procedures addressed immediately; Barry J. Nidorf Juvenile Hall: The majority of the grievances viewed were found to be responded to Y N within the 3-day requirement. Central Juvenile Hall: The majority of the grievances viewed were found to not be responded to within the 3-day requirement. This section is non-compliant. (1) The youth may elect to be present to explain Los Angeles County Probation Department his/her version of the grievance to a person not Detention Services Bureau Manual Section 1715: Y Y directly involved in the circumstances which led Youth Grievance Procedures to the grievance. (2) Provision for a staff representative approved by Los Angeles County Probation Department Y Y the facility administrator to assist the youth. Detention Services Bureau Manual Section 1715: Youth Grievance Procedures 7204,7198 Los Angeles JH 18 20 PRO - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (e) provision for a written response to the grievance Los Angeles County Probation Department which includes the reasons for the decisions; Detention Services Bureau Manual Section 1715: Y Y Youth Grievance Procedures (f) a system which provides that any appeal of a Los Angeles County Probation Department grievance shall be heard by a person not directly Detention Services Bureau Manual Section 1715: Y Y involved in the circumstances which led to the Youth Grievance Procedures grievance; (g) resolution of the grievance must occur within ten (10) Los Angeles County Probation Department business days unless circumstances dictate a longer Detention Services Bureau Manual Section 1715: time frame. The youth shall be notified of any delay; Youth Grievance Procedures and, Barry J. Nidorf Juvenile Hall: There were some grievance resolutions that were found to have occurred over the 10-day requirement however, there was not a pattern and practice to be deemed non-compliant and others that were not timely in Y Y October 2019 due to evacuation/relocation to Los Padrinos due to fire. Central Juvenile Hall: There were some resolutions in October that were found to be late however, it appears this may be due to how staff documented the physical plant work orders. March and July grievances were all timely. Technical assistance provided for enhanced tracking. These are compliant at this time. (h) the policy shall provide multiple internal and external Los Angeles County Probation Department methods to report sexual abuse and sexual Detention Services Bureau Manual Section 1715: harassment. Youth Grievance Procedures Youth may report via a grievance, to any staff Y Y (probation or others) or to the Ombudsman or their parent/guardian. Section 1511: Reporting Sexual Abuse and Harassment Whether or not associated with a grievance, concerns of Los Angeles County Probation Department parents, guardians, staff or other parties shall be addressed Detention Services Bureau Manual Section 1715: and documented in accordance with written policies and Youth Grievance Procedures procedures within a specified timeframe. Facility supervisors or administrators should resolve any complaints or concerns in a timely Y Y manner. If resolution is not possible, the agency Ombudsman maybe contacted to provide feedback or recommendation. The County also has a citizen complaint process that may be utilized. The intent would be to provide response within 10 days of the initial complaint. 7204,7198 Los Angeles JH 18 20 PRO - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1362 REPORTING OF INCIDENTS Los Angeles County Probation Department Detention Services Bureau Manual Sections: A written report of all incidents which result in physical harm, use of force, serious threat of physical harm, or death 1022: Safe Crisis Management of an employee, youth or other person(s) shall be Y Y 1907: Special Incident Report Form maintained. Such written record shall be prepared by the 1909: Detention Observation Report (DOR) Form staff and submitted to the facility manager by the end of the 1912: Preliminary and Follow Up Incident shift, unless additional time is necessary and authorized by Notification Procedures the facility manager or designee. 1363 USE OF REASONABLE FORCE TO Los Angeles County Probation Department COLLECT DNA SPECIMENS, SAMPLES, Detention Services Bureau Manual Section 306: IMPRESSIONS Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law The Juvenile Halls are responsible for the collection enforcement, custodial, or corrections personnel of DNA samples for all detained and non- detained Y Y including peace officers, may employ reasonable youth. Per policy, force will not be used to obtain force to collect blood specimens, saliva samples, and DNA samples unless ordered by the court. If a thumb or palm print impressions from individuals youth refuses to cooperate, this information is who are required to provide such samples, specimens provided to the court. 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 Los Angeles County Probation Department reasonable force” shall be defined as the force that an Detention Services Bureau Manual Section 306: objective, trained and competent correctional Y Y Juvenile Collection of DNA Samples 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 Los Angeles County Probation Department efforts to secure voluntary compliance. Efforts to Detention Services Bureau Manual Section 306: secure voluntary compliance shall be documented and Y Y Juvenile Collection of DNA Samples include an advisement of the legal obligation to provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Los Angeles County Probation Department authorization of the supervising officer on duty. The Detention Services Bureau Manual Section 306: authorization shall include information that reflects Y Y Juvenile Collection of DNA Samples the fact that the offender was asked to provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Los Angeles County Probation Department extraction, the extraction shall be videotaped. Detention Services Bureau Manual Section 306: Video shall be directed at the cell extraction Juvenile Collection of DNA Samples event. The videotape shall be retained by the Y Y agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7204,7198 Los Angeles JH 18 20 PRO - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County Probation and Los (a) School Programs Angeles County Office of Education: Juvenile The County Board of Education shall provide for the Courts and Community Schools. administration and operation of juvenile court schools A Matrix was provided for our review from Sr. in conjunction with the Chief Probation Officer, or Director Dr. Jesus Coral that detailed all areas of designee pursuant to applicable State laws. The school Section 1370. All policy areas for this section are and facility administrators shall develop and either noted in the LACOE Board Policy or are in implement written policy and procedures to ensure the DSB Policy. communication and coordination between educators and probation staff. Culturally responsive and trauma- BSCC Field Representatives do not inspect the informed approaches should be applied when education program for compliance with Title 15. providing instruction. Education staff should Title 15 requires the Superintendent of Schools to conduct this review in conjunction with a qualified collaborate with the facility administrator to use outside agency or individual. technology to facilitate learning and ensure safe Y Y technology practices. The facility administrator shall The education program of the Barry J. Nidorf request an annual review of each required element of Juvenile Hall was evaluated Rene Wheeler, the program by the Superintendent of Schools, and a Director Juvenile Court and Community Schools, report or review checklist on compliance, deficiencies, Santa Barbara County Education Office on June 12, and corrective action needed to achieve compliance 2019. Ms. Wheeler found the education program to with this section. Such a review, when conducted, comply with all regulatory requirements. cannot be delegated to the principal or any other staff of any juvenile court school site. The Superintendent The education program of the Central Juvenile Hall of Schools shall conduct this review in conjunction was evaluated by Susan Connolly, Executive with a qualified outside agency or individual. Upon Director of Student Services Placer County Office receipt of the review, the facility administrator or of Education on June 26, 2019. Ms. Connolly found the education program to comply with all regulatory designee shall review each item with the requirements. Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the State BP 6011 Instruction, BP 0460 Philosophy, Goals, Education Code and County Board of Education Objectives and Comprehensive Plans policies, all applicable federal education statutes and BP 005 Philosophy, Goals, Objectives and regulations and provide for an annual evaluation of the Comprehensive Plans Item 3,4,5 educational program offerings. As stated in the 2009 California Standards for the Teaching Profession, Y Y teachers shall establish and maintain learning 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. 7204,7198 Los Angeles JH 18 20 PRO - 62 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. Staff Y Y 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Y Y Comprehensive Plans Item 3,4,5 courses required for high school graduation. (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California Y Y Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) Y Y and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of Y Y Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth who AR-6179 Instruction BPP 5149 do not demonstrate sufficient progress towards grade Y Y level standards. (6) The minimum school day shall be consistent with State BP 6112 Instruction Education Code Requirements for juvenile court schools. The facility administrator, in conjunction with education staff, must ensure that operational Y Y 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 BP 6112 Instruction Partially address requirement; classification, housing, security status, disciplinary or AR 5131 separation status, including room confinement, except when providing education poses an immediate threat to Y Y 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 AR 5144 Students (1) Positive behavior management will be implemented to Y Y 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 BP 5021 Students CF 6020 Y Y made by probation staff that may affect the educational programming of students. 7204,7198 Los Angeles JH 18 20 PRO - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension and Code, expulsion/suspension from school shall be Expulsion/Due Process (Students with imposed only when other means of correction fails to Disabilities) bring about proper conduct. School staff shall follow the appropriate due process safeguards as set forth in Y Y 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 BP 5144 education staff will develop policies and procedures Y Y that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or suspected Y Y 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 BP 6174 Instruction afforded an educational program that addresses their Y Y language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement Y Y (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction Y Y (B) Home Language Survey and the results of the State AR 6174 Instruction Y Y Test used for English language proficiency; (C) Needs and services of special populations as defined by BP 6162.5 Instruction Y Y the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. Y Y BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to Y Y determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary education BP 6162.5 Instruction Y Y plan shall be developed for each youth within five school days. 7204,7198 Los Angeles JH 18 20 PRO - 64 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with the AR 5125 Students State Education Code and request the youth's records from his/her prior school(s), including, but not limited to, transcripts, Individual Education Program (IEP), 504 Plan, state language assessment scores, Y Y 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 AR 5125 Students Y Y (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work Y Y completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies and Y Y 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever Y Y possible, collaborate with local post-secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Los Angeles County Probation Department EXERCISE. Detention Services Bureau Manual Section 621: Recreation and Exercise and 1204: Programs The facility administrator shall develop and implement Y Y written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7204,7198 Los Angeles JH 18 20 PRO - 65 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Los Angeles County Probation Department programs, recreation, and exercise a minimum of three Detention Services Bureau Manual Section 621: hours a day during the week and five hours a day each Recreation and Exercise and Section 1204: Saturday, Sunday or other non-school days, of which one Programs hour shall be an outdoor activity, weather permitting. Documentation provided by both facilities is ineffective to demonstrate compliance in this area. Activity calendars for one month were provided and daily program logs for other time frames were provided. Daily program logs utilized are not specific to regulatory requirements and we are unable to confirm the specific activity scheduled was attended to confirm compliance. N N Barry J. Nidorf: Documentation is not clear as to what activities are occurring, specifically programming. Outdoor recreation (exercise) is being routinely modified to indoor recreation for reasons other than weather due to lack of staffing. This appears to be an ongoing issue that occurs as a result of a few youth that modifies full units as a result. Central Juvenile Hall: Documentation is not clear as to what activities are occurring, specifically programming and the amount of time spent in all activities, programs, exercise and recreation. Scheduled program row is routinely left blank as are other areas of the forms and some days are also left blank. A youth’s participation in programs, recreation, and Los Angeles County Probation Department exercise may be suspended only upon a written finding by Detention Services Bureau Manual Section 621: Y Y the administrator/manager or designee that a youth Recreation and Exercise and 1204: Programs represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall be Los Angeles County Probation Department posted in the living units. Detention Services Bureau Manual Section 1205: Y Y Monthly Activity Calendar 7204,7198 Los Angeles JH 18 20 PRO - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS There will be a written annual review of the programs, Los Angeles County Probation Department recreation, and exercise by the responsible agency to Detention Services Bureau Manual Section 621: ensure content offered is current, consistent, and relevant Recreation and Exercise and 1204: Programs to the population. The following 2020 Program Reviews were provided for our review. We were not provided with the 2019 reviews. Technical assistance provided that these are to be provided annually. If they are not done annually in the future, this section will be marked as non-compliant. We understand that due to COVID that not all programs may be active or that letters may be able to be received. Barry J. Nidorf Juvenile Hall: Y Y • Arts for Incarcerated Youth • Alcoholics Anonymous • Minors Therapeutic Skills and Mentorship Classes • Drumming for Life Central Juvenile Hall: • Arts for Incarcerated Youth • Drumming for Life The Probation Department provided an additional review documenting all Community Based Organizational programs, all DMH programs, recreation and exercise. All were found to be current, consistent and relevant. Programming has been provided virtually since March 2020. 7204,7198 Los Angeles JH 18 20 PRO - 67 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (a) Programs. All youth shall be provided with the Los Angeles County Probation Department opportunity for at least one hour of daily programming Detention Services Bureau Manual Section 1204: to include, but not be limited to, trauma focused, Programs cognitive, evidence-based, best practice interventions See note above. 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: (1) Cognitive Behavior Interventions; N N (2) Management of Stress and Trauma; (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 Los Angeles County Probation Department for at least one hour of daily access to unscheduled Detention Services Bureau Manual Section 621: activities such as leisure reading, letter writing, and N N Recreation and Exercise entertainment. Activities shall be supervised and See note above. include orientation and may include coaching of youth. (c) Exercise. All youth shall be provided with the Los Angeles County Probation Department opportunity for at least one hour of large muscle Detention Services Bureau Manual Section 621: activity each day. Recreation and Exercise N N See note above. Exercise is often modified to indoor recreation. The administrator/manager may suspend, for a period not Los Angeles County Probation Department to exceed 24 hours, access to recreation and programs. The Detention Services Bureau Manual Section 621: Y Y administrator/manager shall document the reasons why Recreation and Exercise and 1204: Programs suspension of recreation and programs occurs. 7204,7198 Los Angeles JH 18 20 PRO - 68 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1372 RELIGIOUS PROGRAM Los Angeles County Probation Department Detention Services Bureau Manual Section 1803: The facility administrator shall provide access to religious Religious Services services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth shall be Per policy youth may attend one service a week but allowed to participate in an activity outside of their room may request and see any of the chaplains for if he/she elects not to participate in religious programs. Y Y counseling regardless of their faith. Religious programs shall provide for: There were some grievances noted from BJN in which did not attend church services due to staffing. There was follow up from the unit supervisor that this was not to occur and all youth who wished to attend church should attend. (a) opportunity for religious services and practices; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 1803: Religious Services (b) availability of clergy; and, Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 1803: Religious Services (c) availability of religious diets. Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 1803: Religious Services 1373 WORK PROGRAM Los Angeles County Probation Department Detention Services Bureau Manual Section 505: The facility administrator shall develop policies and Housekeeping procedures regarding the fair and consistent assignment of youth to work programs. Work assigned to a youth shall be Documentation provided is noted below for meaningful, constructive and related to vocational training programs outside of the facilities. Youth may be or increasing a youth's sense of responsibility. Work referred for after detention. programs shall not be imposed as a disciplinary measure. Y Y Barry J. Nidorf: Workforce Development, Aging and Community Services Youth Employment Services. Central Juvenile Hall: Transition Partnership Programs (TPP) in collaboration with LACOE is a grant program that provides work experience for students with disabilities in special education. 7204,7198 Los Angeles JH 18 20 PRO - 69 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1374 VISITING Los Angeles County Probation Department Detention Services Bureau Manual Section 304: The facility administrator shall develop and implement Visiting written policies and procedures for visiting, that include provisions for special visits. Youth shall be allowed to Visiting hours are every Saturday from 1:00 P.M. receive visits by parents, guardians or persons standing in until 3:00 P.M. and Sunday from 1:00 P.M. until loco parentis, and children of youth. Other family 4:00 P.M members, such as grandparents and siblings, and Y Y Documentation of facility visiting logs were supportive adults, may be allowed to visit with the approval provided for our review. of the facility administrator or designee, and in conjunction with the youth’s case plan or in the best interest of the A sample of a letter that is sent to parents of youth youth. detained in both the Juvenile Halls and the camps was provided for our review. The letter was dated in September 2019 and contained information that was not updated to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to the Los Angeles County Probation Department limitations necessary to maintain order and security. Detention Services Bureau Manual Section 304: Visitation shall not be denied solely based on the visitor’s Visiting criminal history. The staff shall determine in each case, Y Y Visitation occurs from 1:00 PM to 3:00 PM on whether the visitor’s criminal history represents a risk to Saturday and 1:00 PM to 4:00 PM on Sundays for the safety of youth or staff in the facility. Any denial of both Juvenile Halls. 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 Los Angeles County Probation Department per week. Visits may be supervised, but conversations shall Y Y Detention Services Bureau Manual Section 304: not be monitored unless there is a security or safety need. Visiting Provisions for special visits, in addition to the two-hour Los Angeles County Probation Department minimum and/or outside of the regular visiting hours, shall Detention Services Bureau Manual Section 304: be accommodated as necessary and within the discretion of Visiting the facility administrator or designee. Family therapy and Y Y professional visits shall be accommodated outside the provisions of this regulation. Facilities may provide Documentation provided for review of special visits visitation opportunities outside of normal visiting hours to for both facilities. accommodate special visits. The facility may provide access to technology as an Los Angeles County Probation Department alternative, but not as a replacement, to in-person visiting. Y Y Detention Services Bureau Manual Section 304: Visiting 1375 CORRESPONDENCE Los Angeles County Probation Department Detention Services Bureau Manual Section 511: The facility administrator shall develop and implement Mail Y Y written policies and procedures for correspondence which provide that: Youth are provided with opportunity to write letters daily. Youth are provided with all (a) there is no limitation on the volume of mail that youth Los Angeles County Probation Department may send or receive; Y Y Detention Services Bureau Manual Section 511: Mail 7204,7198 Los Angeles JH 18 20 PRO - 70 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (b) youth may send two letters per week postage free; Los Angeles County Probation Department Y Y Detention Services Bureau Manual Section 511: Mail (c) youth may correspond confidentially with state and Los Angeles County Probation Department federal courts, any member of the State Bar or holder Detention Services Bureau Manual Section 511: of public office, and the Board; however, authorized Mail Y Y 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 Los Angeles County Probation Department in (c), may be read by staff only when there is Detention Services Bureau Manual Section 511: Y Y reasonable cause to believe facility safety and security, Mail public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Los Angeles County Probation Department Detention Services Bureau Manual Section 512: The administrator of each juvenile facility shall develop Y Y Telephone Use and implement written policies and procedures to provide youth with access to telephone communications. All compliance based on policy. 1377 ACCESS TO LEGAL SERVICES Los Angeles County Probation Department Detention Services Bureau Manual Section 513: The facility administrator shall develop written procedures Access to Legal Services to ensure the right of youth to have access to the courts and legal services. Such access shall include: Los Angeles County Probation allows youth to contact their attorney or the Court, by County telephone or by mail. Attorneys also visit youth Y Y Monday through Friday, 9:00 to 11:30 a.m. and 1:00 to 4:00 p.m. Technical assistance provided and discussed to ensure that this section be separated from the Telephone section as they are separate sections. All compliance based on policy. (a) access, upon request by the youth, to licensed Los Angeles County Probation Department attorneys and their authorized representatives; Detention Services Bureau Manual Section 513: Y Y Access to Legal Services (b) provision for confidential consultation with attorneys; Los Angeles County Probation Department and, Detention Services Bureau Manual Section 513: Y Y Access to Legal Services (c) unlimited postage free, legal correspondence and Los Angeles County Probation Department cost-free telephone access as appropriate. Y Y Detention Services Bureau Manual Section 513: Access to Legal Services 7204,7198 Los Angeles JH 18 20 PRO - 71 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS 1390 DISCIPLINE Los Angeles County Probation Department Detention Services Bureau Manual Sections: The facility administrator shall develop and implement written policies and procedures for the discipline of youth 609: Prohibited Methods of Discipline that shall promote acceptable behavior; including the use of 1103: Discipline Guidelines positive behavior interventions and supports. Discipline Y Y 1104: Corporal Punishment shall be imposed at the least restrictive level which promotes the desired behavior and shall not include corporal punishment, group punishment, physical or psychological degradation. Deprivation of the following is not permitted: (a) bed and bedding; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (b) daily shower, access to drinking fountain, toilet and Los Angeles County Probation Department personal hygiene items, and clean clothing; Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (c) full nutrition; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (d) contact with parent or attorney; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (e) exercise; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (f) medical services and counseling; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (g) religious services; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (h) clean and sanitary living conditions; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines 7204,7198 Los Angeles JH 18 20 PRO - 72 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (i) the right to send and receive mail; Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (j) education; and, Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines (k) rehabilitative programming. Los Angeles County Probation Department Detention Services Bureau Manual Sections: Y Y 609: Prohibited Methods of Discipline 1103: Discipline Guidelines The facility administrator shall establish rules of conduct Los Angeles County Probation Department and disciplinary penalties to guide the conduct of youth. Detention Services Bureau Manual Sections: Such rules and penalties shall include both major violations 1103: Discipline Guidelines and minor violations, be stated simply and affirmatively, 1106: Rules and Regulations and be made available to all youth. Provision shall be made Y Y to provide accessible information to youth with disabilities, Mildly and moderately disruptive rule violations are limited English proficiency, or limited literacy. considered minor rule violations. Severely disruptive behavior is considered major rule violations. 1391 DISCIPLINE PROCESS Los Angeles County Probation Department Detention Services Bureau Manual Sections: The facility administrator shall develop and implement 1106: Rules and Regulations written policies and procedures for the administration of 1107: Due Process discipline which shall include, but not be limited to: In all instances where a youth is involved in an SIR or PIR that involves a behavior issue, a Sanctions and Appeal form (“Attachment A”) shall also be Y Y submitted by one of the staff completing the Special Incident Report (SIR) or Physical Intervention Report (PIR) and attached to the incident packet. The purpose of this form is for the staff to recommend sanctions against the youth and allow him/her their right to due process. Each incident report reviewed had a sanctions and appeals form included. (a) designation of personnel authorized to impose Los Angeles County Probation Department discipline for violation of rules; Detention Services Bureau Manual Section 1106: Y Y Rules and Regulations (b) prohibiting discipline to be delegated to any youth; Los Angeles County Probation Department Detention Services Bureau Manual Section 1106: Y Y Rules and Regulations 7204,7198 Los Angeles JH 18 20 PRO - 73 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (c) definition of major and minor rule violations and their Los Angeles County Probation Department consequences, and due process requirements; Detention Services Bureau Manual Section 1106: Y Y Rules and Regulations (d) trauma-informed approaches and positive behavior Los Angeles County Probation Department interventions; Y Y Detention Services Bureau Manual Section 1106: Rules and Regulations (e) minor rule violations may be handled informally by Los Angeles County Probation Department counseling, advising the youth of expected conduct Detention Services Bureau Manual Section 1107: imposing a minor consequence. Discipline shall be Y Y Due Process and 1108: Minor Rule Violations accompanied by written documentation and a policy of review and appeal to a supervisor; and, (f) major rule violations and the discipline process shall Los Angeles County Probation Department be documented and require the following: Detention Services Bureau Manual Section 1107: Due Process (1) written notice of violation prior to a hearing; Los Angeles County Probation Department Detention Services Bureau Manual Section 1107: Due Process All major rule violations are required to be accompanied by written documentation via an SIR and Sanctions and Appeals Form. If a major violation occurs, the process for the hearing will take place. We reviewed multiple sanctions and appeal forms as provided for this section as well as sanctions and appeals as included in multiple use of force packets. N N We found that the form was reformatted. Box E contained the recommended sanctions. Directions are provided in Box E that state if the violation is a Major rule violation, staff are to complete section G, if not, to complete section F. We found that this direction was not consistently followed. We found that in most incidents, the youth refused to sign at the notice of sanction in Box E. We found the forms to not be consistently completed and we found that if the youth refused to sign at any given point of the process, the required hearing was not provided, or the process was stopped. The intent of the regulation and due process is not being met. (2) accommodations provided to youth with Los Angeles County Probation Department disabilities, limited literacy, and English Detention Services Bureau Manual Section 1107: language learners; UNK UNK Due Process Unable to confirm any hearing practice as there were not hearings documented. 7204,7198 Los Angeles JH 18 20 PRO - 74 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION BJN CJH P/P REFERENCE - COMMENTS (3) hearing by a person who is not a party to the Los Angeles County Probation Department incident; Detention Services Bureau Manual Section 1107: UNK UNK Due Process Unable to confirm any hearing practice as there were not hearings documented. (4) opportunity for the youth to be heard, present Los Angeles County Probation Department evidence and testimony; Detention Services Bureau Manual Section 1107: UNK UNK Due Process Unable to confirm any hearing practice as there were not hearings documented. (5) provision for youth to be assisted by staff in the Los Angeles County Probation Department hearing process; Detention Services Bureau Manual Section 1107: UNK UNK Due Process Unable to confirm any hearing practice as there were not hearings documented. (6) provision for administrative review. Los Angeles County Probation Department Detention Services Bureau Manual Section 1107: UNK UNK Due Process Unable to confirm any hearing practice as there were not hearings documented. (g) violations that result in a removal from camp or The facility is not a camp or commitment facility. commitment program, but not a return to court, will NA NA follow the due process provisions in subsection (e) above. f 7204,7198 Los Angeles JH 18 20 PRO - 75 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the facility. ☐ ☒ ☐ (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Viol Dependent or neglected minors who are defined under Section ☒ ☐ ation 300 of the Welfare and Institutions 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 ☐Viol ☐ ☒ Delinquents (WIC 602)? (WIC 207[d]). ation 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 ☐Viol ☐ ☒ from minors. ation Adult inmates from an adult facility (e.g. inmate workers or ☐Viol “Scared Straight” programs) are not allowed in the facility in a ☐ ☒ ation manner that allows contact with minors. 7204,7198 Los Angeles JH 18 20 PRO - 76 - J453 JUV PRO-Eff. 01-01-2019 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 BSCC Code: 7204 FACILITY NAME: Barry J. Nidorf Juvenile Hall FACILITY TYPE: JH APPLICABLE REGULATIONS (Check All That 4/98: X 2001: 2003: OTHER: pre-98 Apply): FIELD REPRESENTATIVE: Lisa Southwell DATE: June 2, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS Reception/Intake Admission (JH; 1.1) ✓ Contains a weapons locker as specified in these regulations Contains a secure room for the confinement of ✓ minors pending admission to JH Provides access to a shower ✓ Provides a secure vault or storage space for minor's ✓ valuables Provides telephone access to minors ✓ Provides staff access to hot and cold running water ✓ Locked Holding Room (1.2) ✓ Contains a minimum of 15 square feet of floor area per minor Provides no less than 45 square feet of floor area ✓ Contains seating to accommodate all minors as ✓ specified in these regulations 98: Provides access to a toilet, washbasin and drinking fountain as specified in these regulations 03: Be equipped with a toilet, washbasin and drinking ✓ fountain unless a procedure is in effect to provide access Maximizes staff visual supervision ✓ 03: Outward swinging or lateral sliding door required ✓ Natural Light (1.3) Visual access to natural light is provided in locked ✓ sleeping rooms, single and double occupancy sleeping rooms, dormitories and dayrooms. 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 1 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Corridors (1.4) Corridors in living areas are at least eight feet wide. When doors are staggered or if rooms are located ✓ only on one side, corridors may be at least six feet wide. Living Unit (JH; 1.5) JH living units do not exceed 30 minors and contain ✓ sleeping areas and plumbing fixtures, commensurate with the number of minors housed. Locked Sleeping Rooms (1.6) 98: Have a toilet, wash basin and drinking fountain unless a procedure is in effect to provide other ✓ access to these fixtures 03: Toilet, washbasin and drinking fountain required in locked sleeping rooms Single Occupancy Sleeping Rooms (1.7) Pre-98 construction contains single- occupancy rooms. 98: Minimum of 63 square feet of floor area and a ✓ clear ceiling height of eight feet 03: Minimum of 70 square feet of floor area and a clear ceiling height of eight feet 98: A door view panel is constructed of security glazing and is a maximum of 144 square inches. 01: View panel size changed to a minimum of 144 ✓ inches. 03: Outward swinging or lateral sliding door required ✓ Double Occupancy Sleeping Rooms (1.8) Through prior agreement with CYA, these rooms are recognized as being in Minimum of 100 square feet floor area, a clear ceiling ✓ compliance. height of eight feet, and a minimum width of seven feet 98: A door view panel is constructed of security glazing and is a maximum of 144 square inches. 01: View panel size changed to a minimum of 144 ✓ inches 03: Outward swinging or lateral sliding door required ✓ Dormitories (1.9) There are no dormitories in this facility. In JHs and camps, there is a minimum of 50 square feet of floor area per minor, with a minimum dormitory ✓ size of 200 square feet and a minimum clear ceiling height of eight feet. 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 2 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS In JHs and camps, dormitories are designed for no ✓ fewer than four minors. 98: JH dormitories for detained minors are designed for no more than 15 minors (NA camps). ✓ 03: This subsection deleted, eliminating the 15 minor limitation. (See below.) 98: JH dormitories for court commitments are designed for no more than 30 minors (NA Camps). 03: No JH dormitory can be designed for more than ✓ 30 minors (regardless of whether it is for court commitments or other detained minors). Dayrooms (1.10) Through prior agreement with CYA, these rooms are recognized as being in ✓ compliance. JH dayrooms contain 35 square feet of floor area per minor. Dayrooms in camps and SPJHs contain 30 square ✓ feet of floor area per minor. All dayrooms provide access to toilets, wash basins, drinking fountains and showers. ✓ Physical Activity and Recreation Spaces (NA SPJH; 1.11) 98: Facilities with a capacity of less than 41 minors have a minimum of 9,000 square feet dedicated ✓ indoor-outdoor space. 01: Facilities with a capacity of 40 minors or less have a minimum of 9000 square feet dedicated indoor-outdoor space. 98: Facilities with a capacity of 41 to 100 minors have a minimum of 9,000 square feet dedicated indoor-outdoor space, plus a field area. The field area contains a minimum of one acre with a ✓ minimum dimension of 100 feet. 01: Facilities with a capacity of 41-274 minors have a minimum of 225 square feet of dedicated indoor- outdoor space per minor, up to 61,650 feet. 98: Facilities with a capacity over 100 minors have a minimum of 18,000 square feet dedicated indoor- outdoor space, plus a field area. The field area contains a minimum of one acre with a minimum dimension of 100 feet. ✓ 01: Facilities with a capacity of 275 or more minors have 61,650 square feet dedicated indoor- outdoor space, plus 145 square feet for each minor beyond 274 (up to a maximum of 87,120 square feet). 98: At least one half of the dedicated indoor-outdoor space is a paved or "like" surface. ✓ 01: Changed from one-half to one-quarter of the space 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 3 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS A portion of the dedicated physical activity and recreation space is out-of-doors, and is equipped and ✓ of a sufficient size to comply with Title 15, § 1371. 01: The required recreation area has no single ✓ dimension less than 40 feet. Outdoor recreation area lighting allows for evening activities and provides security. ✓ Academic Classrooms (NA SPJH; 1.12) ✓ Classrooms are designed for a maximum of 20 minors. There is a minimum of one classroom in each facility 2001: Dedicated classroom space is available for ✓ every juvenile in the facility. The primary purpose for the academic classroom is for education. Each classroom contains a minimum of 160 square feet of floor space for the teacher's desk and work ✓ area, and a minimum of 28 square feet floor space per minor. There is a communication system in each classroom that allows for immediate response to emergencies. ✓ Safety Room (1.13) This facility does not contain safety rooms. ✓ Provides a minimum of 63 square feet of floor space and a minimum clear ceiling height of eight feet Limited to one minor ✓ Padded as specified in these regulations ✓ There are one or more vertical view panels constructed of security glazing. Panels provide a ✓ view of the entire room and are no more than four inches wide and at least 24 inches long. Audio monitoring system as specified in these ✓ regulations Access to a toilet, wash basin and drinking fountain is ✓ provided. 03: Be equipped with a variable intensity security- type lighting fixture, with controls outside the ✓ room 03: Any wall- or ceiling-mounted devices are designed to prohibit the occupant’s access. ✓ Medical Examination Room (NA SPJH; 1.14) There is a minimum of one suitably equipped medical ✓ examination room in every juvenile facility. The examination room provides the following: Space for routine and emergency examinations ✓ that is used for no other purpose; Privacy for minors; ✓ Lockable storage for medical supplies; ✓ 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 4 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Not less than 144 square feet floor space with no ✓ single dimension less than seven feet; Hot and cold running water; and, ✓ 01: Smooth, non-porous, washable surfaces. ✓ Pharmaceutical Storage (1.15) There is lockable storage space for medical supplies ✓ and pharmaceutical preparations as specified by Title 15 § 1438. Dining Areas (NA SPJH; 1.16) There is a minimum of 15 square feet floor space and ✓ sufficient tables and seating for each person being fed (including minors, staff and visitors). Dining areas do not contain toilets or showers in the same room, unless there is an appropriate visual ✓ barrier. Visiting Space (1.17) ✓ Visiting space is provided. Institutional Storage (1.18) There is a minimum of 80 cubic feet of storage space per minor for institutional clothing, bedding, supplies ✓ and activity equipment, in one or more storage rooms. Personal Storage (1.19) Each minor has a minimum of nine cubic feet of ✓ secure storage space for personal clothing and belongings. Safety Equipment Storage (1.20) There is a secure area for storing safety equipment, such as fire extinguishers, self-contained breathing ✓ apparatus, wire and bar cutters, emergency lights, etc. Janitor Closet (1.21) There is at least one securely lockable janitorial ✓ closet containing a mop sink and sufficient area for storing cleaning implements within the security area. 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 5 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Audio Monitoring System (1.22) There is an audio monitoring system capable of actuation by the minor to alert staff in: safety rooms; locked holding rooms, locked sleeping rooms; single ✓ and double occupancy sleeping rooms and dormitories of JHs and in locked sleeping rooms and single occupancy rooms of secure camps. Emergency Power (1.23) There is an emergency power source capable of providing minimal lighting in all living units, activity areas, corridors, stairs, and central control points, to ✓ maintain fire and life safety, security, communications and alarm systems. The power source conforms to the requirements specified in Title 24, Part 3, Article 700, California Electrical Code (CCR). Confidential Interview Room (1.24) ✓ Contain a minimum of 60 square feet of floor area and provide for confidential consultation with minors There is a minimum of one suitably furnished ✓ interview room for each 30 minors in JHs. There is a minimum of one suitably furnished interview room in each camp. ✓ Court Holding Room for Minors (1.26) ✓ Contains a minimum of 10 square feet of floor area per minor Limited to no more than 16 minors ✓ Provides 40 square feet of floor area and a minimum ✓ clear ceiling height of eight feet Contains seating to accommodate all minors ✓ Contains a toilet, wash basin and drinking fountain as ✓ specified in these regulations Maximizes staffs' visual supervision of minors ✓ Toilets/Urinals (2.1) Through agreements with CYA, portions of the facility constructed prior to 1998 were allowed to operate as if in compliance. Toilets are available on living units in a ratio of 1:6 in JH; 1:10 in camps; and, 1:8 in locked holding rooms. ✓ One toilet and one urinal may be substituted for every 15 boys. Toilet areas provide modesty for the minors without mitigating staff’s ability to supervise. 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 6 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Wash basins (2.2) Through agreements with CYA, portions of the facility constructed prior to 1998 were allowed to operate as if in compliance. Wash basins must provide hot and cold or tempered water and be available on living units in a ratio of 1:6 ✓ in JH; 1:10 in camps; and, 1:8 in locked sleeping rooms. Drinking Fountains (2.3) Drinking fountains are accessible to minors and staff ✓ in living areas and indoor-outdoor recreation areas. 01: The drinking fountain bubbler is activated by mechanical means and is at an angle that prevents waste water from flowing over the ✓ bubbler. Showers (2.4) Through agreements with CYA, portions of the facility constructed prior to 1998 were Showers provide tempered water and are available ✓ allowed to operate as if in compliance. on living units at a ratio of at least one shower or bathtub to every six minors. Shower areas provide for inmate privacy without mitigating staff's ability to supervise. ✓ Beds (2.5) Beds are at least 30 inches wide and 76 long and are ✓ of a pan-bottom type or constructed of concrete. Beds are at least 12 inches of the floor and spaced no less than 36 inches apart. ✓ Lighting (2.6) There is at least 20 foot-candles (216 1x) of illumination at desk level in locked sleeping rooms, ✓ single and double occupancy rooms, dormitories, dayrooms and activity areas. Night lighting in the above areas provides good visibility and is conducive to sleep. ✓ Padding (2.7) This facility does not contain safety rooms. Padding in safety rooms covers the floor, door and ✓ walls to a clear height of eight feet. Benches or platforms are not placed on the floor of safety rooms. Padded rooms are equipped with a tamper-resistant fire sprinkler as approved by the State Fire Marshal ✓ (SFM). The padding is approved by the SFM and is: non- porous; at least one-half inch thick; of a unitary or laminated construction; firmly bonded to all padded ✓ surfaces; and, is without exposed seams. 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 7 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Seating (2.8) Seating is designed for the level of security. When bench seating is used, 18 inches of bench seating is ✓ allowed for each person. Weapons Locker (2.9) Weapons lockers are located outside the security ✓ perimeter of the facility. (Personnel do not bring any weapon into the security area.) Lockers are equipped with individual compartments, each with their own locking device. ✓ Assess for New Construction/Remodel or Repair: ✓ Security Glazing (2.10) (Added in 2003) (Note to inspector: This will typically be assessed from specifications provided at plan review.) Security glazing complies with the minimum requirements of one of the following test standards: ✓ American Society for Testing and Materials, ASTM F 1233-98, Class III glass; California Department of Corrections, CDC 860-94d, Class C glass; or, H. P. White Laboratory, Inc., HPW-TP-0500.02, Forced Entry Level III. Design Requirements (201(c)6) Design requirements as specified in Title 24, Part 1, 201(c)6 are met. ✓ (Note to inspector: See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility type and construction date in the "comments" section.) 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18-20 PHY - 8 - J456 PHY 98 01 03.dot (10/03) BOARD OF STATE AND COMMUNITY CORRECTIONS - BIENNIAL INSPECTION JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION BSCC Code: 7204 FACILITY: Los Angeles County Probation Department Barry J. Nidorf Juvenile Hall TYPE: Juvenile Hall RC: 584 FIELD REPRESENTATIVE: Lisa Southwell DATE: June 2, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ALL DIMENSIONS BASED ON CYA DATA UNLESS OTHERWISE DESIGNATED. ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Holding Girls Two benches, each 6’ ¾” long. H Pre-1998 1 _ (8) (8) 156 square feet 1 1 2 2 Holding Add 1 Handicap Shower- total of 2 Boys Two benches, each 6’ ¾” long. H Pre-1998 1 _ (8) (8) 156 square feet 1 1 2 2 Holding Add 1 Handicap Shower- total of 2 Unit A Single Pre-1998 18 1 1 18 88 square feet Dry rooms. 18 Beds, 1 Storage- Decrease by 2 Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 993 square feet 1 m Unit B Single Pre-1998 18 1 1 18 88 square feet Dry rooms. 18 beds 1 Storage 1 Office Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit C Single Pre-1998 19 1 1 19 88 square feet Dry rooms.19 beds 1 Storage Decrease 1 Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 1 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Unit D Dry rooms. 17 beds, 1 Office, 1 MH Office Single Pre-1998 17 1 1 17 88 square feet Decrease 1 Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit E Single Pre-1998 19 1 1 19 88 square feet Dry rooms. 19 beds, 2 Offices Restroo Pre-1998 1 5 0 5 4 Increase Toilets by 2, decrease urinal by 2 m Dayroo Pre-1998 1 993 square feet 1 m Unit F Single Pre-1998 18 1 1 18 88 square feet Dry rooms.18 beds, storage Restroo Pre-1998 1 5 0 5 4 Increase Toilets by 2, decrease urinal by 2 m Dayroo Pre-1998 1 993 square feet 1 m Unit G Single Pre-1998 16 1 1 16 88 square feet Dry rooms. 16 beds, Storage Decrease by 3 Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit H Single Pre-1998 17 1 1 17 88 square feet Dry rooms. 17 beds 1 office Decrease by 1 Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit I 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 2 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Infirmar Pre-1998 11 1 1 (11) 88 square feet 1 1 Wet rooms. y Dayroo Pre-1998 2 Total = 408 Sq ft 2 m Unit J Single Pre-1998 20 1 1 20 88 square feet Dry rooms. Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit K Dry rooms. 17 beds, 1 MH office and 1 storage Single Pre-1998 17 1 1 17 88 square feet Decrease by 1 Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit L Dry rooms. 16 beds, 1 storage and 3 mental Single Pre-1998 16 1 1 16 88 square feet health offices. Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Unit M Single Pre-1998 17 1 1 17 88 square feet Dry rooms 17 beds, 2 storage areas Restroo Pre-1998 1 3 2 5 4 m Dayroo Pre-1998 1 993 square feet 1 m Girls SHU Single Pre-1998 10 1 1 10 73 square feet 1 1 1 Wet rooms. 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 3 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Restroo Pre-1998 1 1 1 2 m Dayroo Pre-1998 1 253 square feet m Boys SHU Wet rooms. 25 beds, 1 Mental Health Office Single Pre-1998 25 1 1 25 73 square feet 1 1 1 Decrease 1 Restroo Pre-1998 1 1 1 5 m Dayroo Pre-1998 1 1 m Unit N Single Pre-1998 17 1 1 17 82 Square feet 17 beds, storage Decrease by 2 Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 691 square feet 1 m Unit O Single Pre-1998 19 1 1 19 82 square feet 19 beds, Mental Health Office Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 691 square feet 1 m Unit R Single Pre-1998 19 1 1 19 82 square feet 17 beds, 3 storage Decrease by 2 Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 691 square feet 1 m Unit S Single Pre-1998 17 1 1 18 82 square feet 19 beds, 1 MH office Increase 1 Restroo Pre-1998 1 5 5 4 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 4 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet m Dayroo Pre-1998 1 691 square feet 1 m Unit T Single Pre-1998 18 1 1 18 82 square feet 18 beds, 2 MH Offices, 1 Storage Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 691 square feet 1 m Unit V Single Pre-1998 19 1 1 19 82 square feet 19 beds, 1 MH Office Restroo Pre-1998 1 5 5 4 m Dayroo Pre-1998 1 691 square feet 1 m Unit W-1 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Single 1998 13 1 1 13 102 square feet Dry rooms. Rooms 3-5, 7, 9, 10, 12, 13, 16-20. Double 1998 7 2 2 14 102 square feet Dry rooms. Rooms 1, 2, 6, 8, 11, 14, 15. Restroo 1998 1 5 5 5 m Dayroo 1998 1 2592 square feet 1 m Unit W-2 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Single 1998 7 1 1 6 102 square feet Dry rooms. Rooms 36, 40, 45, 47, 50, 53, 54. Dry rooms. Rooms 37-39, 41-44, 46, 48, 49, 51, Double 1998 13 2 2 24 102 square feet 52, and 55. Restroo 1998 1 5 5 5 m 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 5 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Dayroo 1998 1 2592 square feet 1 m Unit X-1 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Double 1998 20 2 2 30 102 square feet Restroo 1998 1 5 5 5 m Dayroo 1998 1 2592 square feet 1 m Unit X-2 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Double 1998 20 2 2 30 102 Square feet Restroo 1998 1 5 5 5 m Dayroo 1998 1 2592 square feet 1 m Unit Y-1 (SHU for the Compound) Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Single 1998 20 1 1 20 102 square feet Dry rooms. Restroo 1998 1 5 5 5 m Dayroo 1998 1 2592 square feet 1 m Unit Y-2 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Single 1998 7 1 1 6 102 square feet Dry rooms. Rooms 37, 43, 45, 47, 50, 51, 54. Dry rooms. Rooms 36, 38-42, 44, 46, 48, 49, Double 1998 13 2 2 24 102 square feet 52, 53, 55. Restroo 1998 1 5 5 5 m Dayroo 1998 1 2592 square feet 1 m 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 6 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Unit Z-1 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Single 1998 9 1 1 8 102 square feet Dry rooms. Rooms 2, 7, 10, 12, 13, 15, 18-20. Double 1998 11 2 2 22 102 square feet Dry rooms. Rooms 1, 3-6, 8, 9, 11, 14, 16, 17. Restroo 1998 1 5 5 5 m Dayroo 1998 1 2592 square feet 1 m Unit Z-2 Holding 1998 4 1 1 (4) 79 square feet 1 1 1 Single 1998 8 1 1 8 102 square feet Dry rooms. Rooms 35-38, 41, 49, 50, 52. Double 1998 12 2 2 22 102 square feet Dry rooms. Rooms 39, 40, 42-48, 51, 53, 54. Restroo 1998 1 5 5 5 m Dayroom 1998 1 2592 square feet 1 . 2008/2010 The “Compound” (units W, X, Y and Z) were designed and constructed as a camp program with 20 double occupancy rooms each. These units subsequently became part of the juvenile hall requiring that the capacity of each unit not exceed 30 minors. Prior to the 2008/10 inspection cycle, the County removed one of the beds from some of the double occupancy rooms. As a result, during the 2008/10 inspection cycle, the capacity of these units (based on number of beds) was reevaluated. Unit W-2: RC of this unit was reevaluated. Because the capacity of each unit cannot exceed 30 minors, the RC of the single rooms was reduced to 6 and the RC of the double rooms was reduced to 24. Unit Y-2: RC of this unit was reevaluated. Because the capacity of each unit cannot exceed 30 minors, the RC of the single rooms was reduced to 6 and the RC of the double rooms was reduced to 24. Unit Z-1: RC of this unit was reevaluated. Because the capacity of each unit cannot exceed 30 minors, the RC of the single rooms was reduced to 8. Unit Z-2: Because the capacity of each unit cannot exceed 30 minors, the RC of the double rooms was reduced to 22. 2010/12: Unit S: Two empty rooms/beds removed 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 7 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet 2012/2014 Unit B: One sleeping room converted to a mental health office Unit D: One sleeping room converted to a mental health office. Unit E: One sleeping room converted to a mental health office. Unit F: One sleeping room converted to an office Unit G: One sleeping room converted to a mental health office. Unit H: One sleeping room converted into office Unit K: One sleeping room converted to a mental health office. Unit L: Three sleeping rooms converted to mental health offices and one unusable due to earthquake damage. Unit M: Rooms 1 & 2 red tagged; used as storage. Boys SHU: One mental health office. Unit N: One mental health office. Unit S: # of rooms increased by one. Unit T: Two mental health offices. Unit V: One mental health office. Unit W-1: Holding rooms not used. Unit W-2: Holding rooms not used. Unit X-1: Holding rooms not used. Unit X-2: Holding rooms not used. Unit Y-1: Holding rooms not used. Unit Y-2: Holding rooms not used. Unit Z-1: Holding rooms not used. Unit Z-2: Holding rooms not used. During the 2012/14 Inspection the following units were unoccupied: Unit A, Unit B, Unit C, Unit D, Unit E, Unit F, Units Z-1 and Z-2. Girls SHU: Note: During the 2008/10 inspection cycle, the RC of this unit was changed from 9 to 10 to reflect Youth Authority documentation. 2012/14 inspection cycle, this building, though still named “Girls SHU” is used for other purposes. 2014/2016 Unit A: Dry rooms. 18 Rooms, 1 Storage- Decrease by 2 Unit B: Dry rooms. 18 rooms 1 Storage 1 Office 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 8 ROOMS EACH ROOM Unit # Each Room Size (L x W x H) FIXTURES* Room Applicable Total COMMENTS Designatio Room # or Square/Cubic Type Standards RC RC T U W F S n s Beds Feet Unit C: Dry rooms.19 Rooms 1 Storage Decrease by 1 Unit D: Dry rooms. 17 beds, 1 Office, 1 MH Office Decrease by 1 Unit E: Dry rooms. 19 rooms, 2 Offices Increase Toilets by 2, decrease urinal by 2 Unit F: Dry rooms.18 rooms, storage Increase Toilets by 2, decrease urinal by 2 Unit G: Dry rooms. 16 beds, Storage Decrease by 3 Unit H: Dry rooms. 17 beds 1 office Decrease by 1 Unit K: Dry rooms. 17 rooms, 1 MH office and 1 storage Decrease by 1 Unit L: Dry rooms. 16 rooms, 1 storage and 3 mental health offices. Unit M: Dry rooms 17 rooms, 2 storage areas Boys SHU: Wet rooms. 25 rooms, 1 Mental Health Office Decrease 1 Unit N: 17 beds, storage Decrease by 2 Unit O: 19 beds, Mental Health Office Unit R: 17 beds, 3 Storage Decrease by 2 Unit S: 19 beds, 1 MH office Increase 1 Unit T: 18 beds, 2 MH Offices, 1 Storage Unit V: 19 beds, 1 MH Office 2016/2018: No Change to RC. Discussed pending changes. Will complete full review upon completion. **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** 7204 Los Angeles Barry J. Nidorf Juvenile Hall 18 20 LASE 9 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 BSCC Code: 7198 FACILITY NAME: Central Juvenile Hall FACILITY TYPE: JH APPLICABLE REGULATIONS (Check All That 4/98: 2001: X 2003: OTHER: pre-98 Apply): FIELD REPRESENTATIVE: Lisa Southwell DATE: June 2, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS Reception/Intake Admission (JH; 1.1) ✓ Contains a weapons locker as specified in these regulations Contains a secure room for the confinement of ✓ minors pending admission to JH Provides access to a shower ✓ Provides a secure vault or storage space for minor's ✓ valuables Provides telephone access to minors ✓ Provides staff access to hot and cold running water ✓ Locked Holding Room (1.2) ✓ Contains a minimum of 15 square feet of floor area per minor Provides no less than 45 square feet of floor area ✓ Contains seating to accommodate all minors as ✓ specified in these regulations 98: Provides access to a toilet, washbasin and drinking fountain as specified in these regulations 03: Be equipped with a toilet, washbasin and drinking ✓ fountain unless a procedure is in effect to provide access Maximizes staff visual supervision ✓ 03: Outward swinging or lateral sliding door required ✓ Natural Light (1.3) Visual access to natural light is provided in locked ✓ sleeping rooms, single and double occupancy sleeping rooms, dormitories and dayrooms. 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 1 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Corridors (1.4) Corridors in living areas are at least eight feet wide. When doors are staggered or if rooms are located ✓ only on one side, corridors may be at least six feet wide. Living Unit (JH; 1.5) JH living units do not exceed 30 minors and contain ✓ sleeping areas and plumbing fixtures, commensurate with the number of minors housed. Locked Sleeping Rooms (1.6) 98: Have a toilet, wash basin and drinking fountain unless a procedure is in effect to provide other ✓ access to these fixtures 03: Toilet, washbasin and drinking fountain required in locked sleeping rooms Single Occupancy Sleeping Rooms (1.7) Pre-98 construction contains single- occupancy rooms. 98: Minimum of 63 square feet of floor area and a ✓ clear ceiling height of eight feet 03: Minimum of 70 square feet of floor area and a clear ceiling height of eight feet 98: A door view panel is constructed of security glazing and is a maximum of 144 square inches. 01: View panel size changed to a minimum of 144 ✓ inches. 03: Outward swinging or lateral sliding door required ✓ Double Occupancy Sleeping Rooms (1.8) Newer construction (Units A, B, C, D, P, Q, R, S) is in compliance with 2001 regulations. Remainder of the facility was constructed Minimum of 100 square feet floor area, a clear ceiling ✓ prior to 1998 and through prior agreement height of eight feet, and a minimum width of seven with CYA is recognized as being in feet compliance. 98: A door view panel is constructed of security glazing and is a maximum of 144 square inches. 01: View panel size changed to a minimum of 144 ✓ inches 03: Outward swinging or lateral sliding door required ✓ 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 2 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Dormitories (1.9) There are dormitories in the modular units. In JHs and camps, there is a minimum of 50 square feet of floor area per minor, with a minimum dormitory ✓ size of 200 square feet and a minimum clear ceiling height of eight feet. In JHs and camps, dormitories are designed for no ✓ fewer than four minors. 98: JH dormitories for detained minors are designed for no more than 15 minors (NA camps). ✓ 03: This subsection deleted, eliminating the 15 minor limitation. (See below.) 98: JH dormitories for court commitments are designed for no more than 30 minors (NA Camps). 03: No JH dormitory can be designed for more than ✓ 30 minors (regardless of whether it is for court commitments or other detained minors). Dayrooms (1.10) Newer construction (Units A, B, C, D, P, Q, R, S) is in compliance with 2001 regulations. Remainder of the facility was constructed JH dayrooms contain 35 square feet of floor area per ✓ prior to 1998 and through agreements with minor. CYA was allowed to operate as if in compliance. Dayrooms in camps and SPJHs contain 30 square ✓ feet of floor area per minor. All dayrooms provide access to toilets, wash basins, drinking fountains and showers. ✓ Physical Activity and Recreation Spaces (NA SPJH; 1.11) 98: Facilities with a capacity of less than 41 minors have a minimum of 9,000 square feet dedicated ✓ indoor-outdoor space. 01: Facilities with a capacity of 40 minors or less have a minimum of 9000 square feet dedicated indoor-outdoor space. 98: Facilities with a capacity of 41 to 100 minors have a minimum of 9,000 square feet dedicated indoor-outdoor space, plus a field area. The field area contains a minimum of one acre with a ✓ minimum dimension of 100 feet. 01: Facilities with a capacity of 41-274 minors have a minimum of 225 square feet of dedicated indoor- outdoor space per minor, up to 61,650 feet. 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 3 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS 98: Facilities with a capacity over 100 minors have a minimum of 18,000 square feet dedicated indoor- outdoor space, plus a field area. The field area contains a minimum of one acre with a minimum dimension of 100 feet. ✓ 01: Facilities with a capacity of 275 or more minors have 61,650 square feet dedicated indoor- outdoor space, plus 145 square feet for each minor beyond 274 (up to a maximum of 87,120 square feet). 98: At least one half of the dedicated indoor-outdoor space is a paved or "like" surface. ✓ 01: Changed from one-half to one-quarter of the space A portion of the dedicated physical activity and recreation space is out-of-doors, and is equipped and of a sufficient size to comply with Title 15, § 1371. ✓ 01: The required recreation area has no single dimension less than 40 feet. ✓ Outdoor recreation area lighting allows for evening activities and provides security. ✓ Academic Classrooms (NA SPJH; 1.12) ✓ Classrooms are designed for a maximum of 20 minors. There is a minimum of one classroom in each facility 2001: Dedicated classroom space is available for ✓ every juvenile in the facility. The primary purpose for the academic classroom is for education. Each classroom contains a minimum of 160 square feet of floor space for the teacher's desk and work ✓ area, and a minimum of 28 square feet floor space per minor. There is a communication system in each classroom that allows for immediate response to emergencies. ✓ Safety Room (1.13) This facility does not contain safety rooms. ✓ Provides a minimum of 63 square feet of floor space and a minimum clear ceiling height of eight feet Limited to one minor ✓ Padded as specified in these regulations ✓ There are one or more vertical view panels constructed of security glazing. Panels provide a ✓ view of the entire room and are no more than four inches wide and at least 24 inches long. 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 4 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Audio monitoring system as specified in these ✓ regulations Access to a toilet, wash basin and drinking fountain is ✓ provided. 03: Be equipped with a variable intensity security- type lighting fixture, with controls outside the ✓ room 03: Any wall- or ceiling-mounted devices are designed to prohibit the occupant’s access. ✓ Medical Examination Room (NA SPJH; 1.14) There is a minimum of one suitably equipped medical ✓ examination room in every juvenile facility. The examination room provides the following: Space for routine and emergency examinations ✓ that is used for no other purpose; Privacy for minors; ✓ Lockable storage for medical supplies; ✓ Not less than 144 square feet floor space with no ✓ single dimension less than seven feet; Hot and cold running water; and, ✓ 01: Smooth, non-porous, washable surfaces. ✓ Pharmaceutical Storage (1.15) There is lockable storage space for medical supplies ✓ and pharmaceutical preparations as specified by Title 15 § 1438. Dining Areas (NA SPJH; 1.16) There is a minimum of 15 square feet floor space and ✓ sufficient tables and seating for each person being fed (including minors, staff and visitors). Dining areas do not contain toilets or showers in the same room, unless there is an appropriate visual ✓ barrier. Visiting Space (1.17) ✓ Visiting space is provided. Institutional Storage (1.18) There is a minimum of 80 cubic feet of storage space per minor for institutional clothing, bedding, supplies ✓ and activity equipment, in one or more storage rooms. 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 5 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Personal Storage (1.19) Each minor has a minimum of nine cubic feet of secure storage space for personal clothing and belongings. ✓ Safety Equipment Storage (1.20) There is a secure area for storing safety equipment, such as fire extinguishers, self-contained breathing ✓ apparatus, wire and bar cutters, emergency lights, etc. Janitor Closet (1.21) There is at least one securely lockable janitorial ✓ closet containing a mop sink and sufficient area for storing cleaning implements within the security area. Audio Monitoring System (1.22) There is an audio monitoring system capable of actuation by the minor to alert staff in: safety rooms; locked holding rooms, locked sleeping rooms; single ✓ and double occupancy sleeping rooms and dormitories of JHs and in locked sleeping rooms and single occupancy rooms of secure camps. Emergency Power (1.23) There is an emergency power source capable of providing minimal lighting in all living units, activity areas, corridors, stairs, and central control points, to ✓ maintain fire and life safety, security, communications and alarm systems. The power source conforms to the requirements specified in Title 24, Part 3, Article 700, California Electrical Code (CCR). Confidential Interview Room (1.24) ✓ Contain a minimum of 60 square feet of floor area and provide for confidential consultation with minors There is a minimum of one suitably furnished ✓ interview room for each 30 minors in JHs. 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 6 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS There is a minimum of one suitably furnished interview room in each camp. ✓ Court Holding Room for Minors (1.26) ✓ Contains a minimum of 10 square feet of floor area per minor Limited to no more than 16 minors ✓ Provides 40 square feet of floor area and a minimum ✓ clear ceiling height of eight feet Contains seating to accommodate all minors ✓ Contains a toilet, wash basin and drinking fountain as ✓ specified in these regulations Maximizes staffs' visual supervision of minors ✓ Toilets/Urinals (2.1) Newer construction (Units A, B, C, D, P, Q, R, S) is in compliance with 2001 regulations. Remainder of the facility was constructed Toilets are available on living units in a ratio of 1:6 in prior to 1998 and through agreements with JH; 1:10 in camps; and, 1:8 in locked holding rooms. ✓ CYA was allowed to operate as if in One toilet and one urinal may be substituted for every compliance. 15 boys. Toilet areas provide modesty for the minors without mitigating staff’s ability to supervise. Wash basins (2.2) Newer construction (Units A, B, C, D, P, Q, R, S) is in compliance with 2001 regulations. Remainder of the facility was constructed Wash basins must provide hot and cold or tempered water and be available on living units in a ratio of 1:6 ✓ prior to 1998 and through agreements with CYA was allowed to operate as if in in JH; 1:10 in camps; and, 1:8 in locked sleeping compliance. rooms. Drinking Fountains (2.3) Drinking fountains are accessible to minors and staff ✓ in living areas and indoor-outdoor recreation areas. 01: The drinking fountain bubbler is activated by mechanical means and is at an angle that prevents waste water from flowing over the ✓ bubbler. Showers (2.4) Newer construction (Units A, B, C, D, P, Q, R, S) is in compliance with 2001 regulations. Remainder of the facility was constructed Showers provide tempered water and are available ✓ prior to 1998 and through agreements with on living units at a ratio of at least one shower or CYA was allowed to operate as if in bathtub to every six minors. compliance. Shower areas provide for inmate privacy without mitigating staff's ability to supervise. ✓ 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 7 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Beds (2.5) Beds are at least 30 inches wide and 76 long and are ✓ of a pan-bottom type or constructed of concrete. Beds are at least 12 inches of the floor and spaced no less than 36 inches apart. ✓ Lighting (2.6) There is at least 20 foot-candles (216 1x) of illumination at desk level in locked sleeping rooms, ✓ single and double occupancy rooms, dormitories, dayrooms and activity areas. Night lighting in the above areas provides good visibility and is conducive to sleep. ✓ Padding (2.7) This facility does not contain safety rooms. Padding in safety rooms covers the floor, door and ✓ walls to a clear height of eight feet. Benches or platforms are not placed on the floor of safety rooms. Padded rooms are equipped with a tamper-resistant fire sprinkler as approved by the State Fire Marshal ✓ (SFM). The padding is approved by the SFM and is: non- porous; at least one-half inch thick; of a unitary or laminated construction; firmly bonded to all padded ✓ surfaces; and, is without exposed seams. Seating (2.8) Seating is designed for the level of security. When bench seating is used, 18 inches of bench seating is ✓ allowed for each person. Weapons Locker (2.9) Weapons lockers are located outside the security ✓ perimeter of the facility. (Personnel do not bring any weapon into the security area.) Lockers are equipped with individual compartments, each with their own locking device. ✓ Assess for New Construction/Remodel or Repair: ✓ Security Glazing (2.10) (Added in 2003) (Note to inspector: This will typically be assessed from specifications provided at plan review.) Security glazing complies with the minimum requirements of one of the following test standards: ✓ American Society for Testing and Materials, ASTM F 1233-98, Class III glass; California Department of Corrections, CDC 860-94d, Class C glass; or, H. P. White Laboratory, Inc., HPW-TP-0500.02, Forced Entry Level III. 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 8 - J456 PHY 98 01 03.dot (10/03) TITLE 24 SECTION YES NO N/A COMMENTS Design Requirements (201(c)6) Design requirements as specified in Title 24, Part 1, 201(c)6 are met. ✓ (Note to inspector: See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility type and construction date in the "comments" section.) 7198 Los Angeles Central Juvenile Hall 18-20 PHY - 9 - J456 PHY 98 01 03.dot (10/03) BOARD OF STATE AND COMMUNITY CORRECTIONS - BIENNIAL INSPECTION JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION BSCC Code: 7198 FACILITY: TYPE: RC: Los Angeles County Probation: Central Juvenile Hall Juvenile Hall 556 RC and 33 NR FIELD REPRESENTATIVE: Lisa Southwell DATE: June 2, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ALL DIMENSIONS BASED ON CYA DATA UNLESS OTHERWISE DESIGNATED. ROOMS EACH ROOM EACH FIXTURES* Unit Room Applicable # ROOM Total DIMENSIONS COMMENTS Designation Type Standards Rms # RC (L x W x H) RC T U W F S Beds Boys Receiving Single Pre 98 9 1 1 9 1 1 1 All wet rooms. Space used for Maysi/Interview and Staff Office. Dorm Pre 98 1 4 4 0 0 0 0 Decrease by 4. Bathroom Pre 98 1 2 3 2 3 Medical Observation Unit (Non-Rated Space) All wet rooms. Two Rooms have no bed. Single Pre 98 9 1 1 (9) 1 1 1 Decrease by 2 Two single rooms share one bathroom. Current Single Pre 98 2 1 1 (0) 1 1 1 use for storage. Decrease by 2 Dorm Pre 98 1 5 5 (5) Bathroom Pre 98 1 2 1 1 3 Boys Care Unit Single Pre 98 12 1 1 12 1 1 1 All wet rooms. Bathroom Pre 98 1 3 2 2 4 Girls Care Unit All wet rooms. Correction of one additional room Single Pre 98 9 1 1 9 1 1 1 to RC Two single rooms that shared one bathroom is Single Pre 98 1 1 1 1 1 1 1 now 1 room due to only one bed. Decrease by 1. Bathroom Pre 98 1 2 1 2 3 *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. 7198 LA Central Juvenile Hall 18-20 LASE - 1 - ROOMS EACH ROOM EACH FIXTURES* Unit Room Applicable # ROOM Total DIMENSIONS COMMENTS Designation Type Standards Rms # RC (L x W x H) RC T U W F S Beds Unit A First Floor Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms. 75 x 46.5 = 3,487 Dayroom 2001 1 1 1 2 5 sf Classroo 2 classrooms serve units A & B. 1 classroom is an 2001 3 30.5 x 26 = 793 sf ms office. Unit B (Boys ESU) First Floor Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms. 75 x 46.5 = 3,487 Dayroom 2001 1 1 1 2 5 sf Unit C Second Floor Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms. 75 x 46.5 = 3,487 Dayroom 2001 1 1 1 2 5 sf Classroo 2001 3 30.5 x 26 = 793 sf These three classrooms serve units C and D. ms Unit D Second Floor Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms. 75 x 46.5 = 3,487 Dayroom 2001 1 1 1 2 5 sf Unit E First Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit F First Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit G Second Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit H Second Floor *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. 7198 LA Central Juvenile Hall 18-20 LASE - 2 - ROOMS EACH ROOM EACH FIXTURES* Unit Room Applicable # ROOM Total DIMENSIONS COMMENTS Designation Type Standards Rms # RC (L x W x H) RC T U W F S Beds Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit J Single Pre 98 16 1 1 16 1 1 1 All wet rooms. Dayroom Pre 98 1 2 2 1 2 Unit K First Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 4 2 4 1 4 Unit L First Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit M Second Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit N Second Floor Single Pre 98 20 1 1 20 80 square feet. Dry rooms. Dayroom Pre 98 1 4 2 4 1 4 Unit O All wet rooms. One room converted to an office. Single Pre 98 14 1 1 14 1 1 1 Decrease by 1 Dayroom Pre-98 1 2 2 1 2 Unit P First Floor (Boys SHU) Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms. 75 x 46.5 = 3,487 Dayroom 2001 1 1 1 2 5 sf Classroo 2001 3 30.5 x 26 = 793 sf These classrooms serve units P and Q. ms Unit Q First Floor (Boys SHU) Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms Dayroom 2001 1 75 x 46.5 = 3,487 1 1 2 5 *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. 7198 LA Central Juvenile Hall 18-20 LASE - 3 - ROOMS EACH ROOM EACH FIXTURES* Unit Room Applicable # ROOM Total DIMENSIONS COMMENTS Designation Type Standards Rms # RC (L x W x H) RC T U W F S Beds sf Unit R Second Floor (Special Needs) Double 2001 15 2 2 30 103 sq Ft each 1 1 1 All wet rooms. 75 x 46.5 = 3,487 Dayroom 2001 1 1 2 1 5 sf Classroo 2001 3 30.5 x 26 = 793 sf These classrooms serve units R and S. ms Unit S Second Floor (Special Needs) Double 2001 15 2 2 30 103 sf each 1 1 1 All wet rooms 75 x 46.5 = 3,487 Dayroom 2001 1 1 1 2 5 sf Unit Omega Modular Space Dorm Pre 98 1 30 30 30 2 2 5 5 Unit Alpha Modular Space Dorm Pre 98 1 26 26 26 2 2 5 1 5 4 beds not used. Decrease of 4 Unit 10 A1 Single Pre 98 19 1 1 19 1 1 1 All wet rooms. Unit 10 B2 Single Pre 98 20 1 1 20 1 1 1 3 All wet rooms. Note: Previous LASE showed facility RC as 627. With adjustments to the RC of Girls Receiving, Girls Care and Unit V, RC revised to 623 in 2008/10. Movement Control Boys 4 metal benches 6.75 feet, 7.25 feet, 5 feet and Pre 98 1 (14) 20’ x 17.5 x 8’ Holding 5.6 feet long Girls Pre 98 1 (5) 9.5’ x 11.8” x 8” 1 metal bench, 8 feet long. Holding 1 Previously known as Unit X and also as IIU 1, the facility has now designated the unit as “10 A”. 2 Previously known as Unit Y and also as IIU 2, the facility has now designated the unit as “10 B”. *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. 7198 LA Central Juvenile Hall 18-20 LASE - 4 - ROOMS EACH ROOM EACH FIXTURES* Unit Room Applicable # ROOM Total DIMENSIONS COMMENTS Designation Type Standards Rms # RC (L x W x H) RC T U W F S Beds Historical: 2008/10 Inspection: • Previous LASE (Medical Observation Unit) showed one double room and 13 single rooms. This was corrected to show two single rooms sharing one bathroom and 11 single rooms. • Previous Girls Care Unit LASE showed one double room and 9 single rooms. This was corrected to show two single rooms sharing one bathroom and 8 single rooms. Verify number of showers at next inspection. 2010/2012 Inspection: • The holding areas were added to the 2010/12 LASE. • Unit R-One fountain noted and added 2012/14 inspection. • Unit S- Fountain total increased by one 2010/12 inspection. • Unit A: 2nd fountain noted and added to LASE 2010/12. • Unit B: 2nd fountain noted and added to LASE 2010/12. • 10a1: The toilet was removed from one of the 20 single sleeping rooms and it is now in use as an office. For the 2010/12 inspection RC was reduced to 19. 2012/14 Inspection: • Unit B: 2nd fountain noted and added to LASE 2010/12. • Unit C: 2nd fountain noted and added to LASE 2010/12. • Unit D: 2nd fountain noted and added to LASE 2012/14. One fountain inoperative 2012/14 inspection. • Medical Observation Units were closed for security enhancements. • Units 10 A and 10 B, also referred to as Unit W 1&2, were vacant and beds were being removed. • 9/3/13: Notification received of conversion of Medical Observation Units (MOU), also called Units X and Y, to Girls Receiving and Girls Special Handling Unit. Previously nonrated space, this adds 16 beds to the Rated Capacity. However, by also converting the area previously housing Girls Receiving and Girls Special Handling Unit (Rated Capacity 18) to a Medical Observation Unit, there is a net loss to the Rated Capacity, as medical observation is nonrated space. The resultant Rated Capacity of 620 shows a net loss of 2 beds. • Medical Observation Unit (MOU) designation was formalized in communications with Bureau Chief Harada 9/3/13. In previous years, it served as Girls Receiving and Girls Special Handling Unit. • Medical Observation Unit Number of fountains reduced by one 2012/14. • Dorm converted to mental health space in Boys Care Unit. 2nd fountain noted and added in Girls Care Unit 2014/2016 Inspection: • Unit O: Fountain total increased by one 2014/2016 inspection. • Unit P: Fountain total increased by one 2014/2016 inspection. • Unit Q: Fountain total increased by one 2014/2016 inspection. • Boys Receiving: Decrease by 4- See notes above *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. 7198 LA Central Juvenile Hall 18-20 LASE - 5 - ROOMS EACH ROOM EACH FIXTURES* Unit Room Applicable # ROOM Total DIMENSIONS COMMENTS Designation Type Standards Rms # RC (L x W x H) RC T U W F S Beds • Medical Observation Unit: Decrease by 4- Non-rated space. See notes above • Girls CARE Unit: Correction of 1 additional bed. See Notes above • Girls CARE Unit: Decrease by 1 See notes above • Unit O: Decrease by 1 See Notes above • Units T and V: Removed from LASE. County does not plan to ever use that space again as rated beds. Decrease by 39 • Unit X and Y Removed from LASE. County does not plan to ever use this area as rated space in future. Decrease by 16 • Unit Alpha- Decrease by 4 See Notes 2016/2018: No Change to RC. Discussed pending changes. Will complete full review upon completion. ‘ *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. 7198 LA Central Juvenile Hall 18-20 LASE - 6 - JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7207 FACILITY NAME: Camp Clinton Afflerbaugh FACILITY TYPE: Juvenile Camp PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, DPO II; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell Manual Reviewed-June 26, 2020 Virtual Documentation Review TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND Residential Treatment Services Bureau EVALUATION OF BUILDING AND GROUNDS (RTSB) Manual Section -2001: Inspections On an annual basis, or as otherwise required by law, and Evaluation of Building and Grounds each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Residential Treatment Services Bureau the Board of Supervisors to approve building safety; (RTSB) Manual Section -2002: Types of Inspections and Evaluations 2018 inspections were verified to have ☐ ☒ ☐ occurred. The 2019 inspection is noted as follows: 2019 The facility was inspected on August 13, 2019. Corrections are required (B) Fire authority having jurisdiction, including a fire Residential Treatment Services Bureau clearance as required by Health and Safety Code (RTSB) Manual Section -2002: Types of Section 13146.1 (a) and (b); Inspections and Evaluations ☒ ☐ ☐ The fire inspection was completed by Inspector Kaulback of Los Angeles County Fire Department, Whittier Office, Schools and Institutions Unit on 12/06/19. Fire Clearance was granted. 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. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Local health officer, inspection in accordance with Residential Treatment Services Bureau Health and Safety Code Section 101045; (RTSB) Manual Section -2002: Types of Inspections and Evaluations Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the Environmental Health (EH) inspections as ☐ ☒ ☐ noted below. 2018 Inspections were verified to have occurred. The 2019 Inspection is noted as follows: Environmental Health: January 8,2019: No corrections required. Nutritional Health: January 8, 2019 Medical/Mental Health: January 8, January 29-30. Corrections are required for both the Nutrition and Medical/Mental Health Inspections. (D) County superintendent of schools on the adequacy Residential Treatment Services Bureau of educational services and facilities as required in (RTSB) Manual Section -2002: Types of Section 1370; Inspections and Evaluations Education for the is provided by the Los Angeles County Office of Education. ☒ ☐ ☐ 2019 The education program was evaluated by Bruce E. Petersen, Executive Director, San Diego County Office of Education on June 3, 2019. Mr. Petersen found the educational program to be compliant with all regulations. (E) Juvenile court as required by Section 209 of the Residential Treatment Services Bureau Welfare and Institutions Code (RTSB) Manual Section -2002: Types of ☐ ☐ ☒ Inspections and Evaluations No documentation provided. Not required for Juvenile Camps. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (F) Juvenile Justice Commission as required by Section Residential Treatment Services Bureau 229 of the Welfare and Institutions Code or (RTSB) Manual Section -2002: Types of Probation Commission as required by Section 240 of Inspections and Evaluations the Welfare and Institutions Code. ☒ ☐ ☐ An inspection was completed September 24, 2019 by Commissioners Swartz and Gardner. These concerns were formally responded to by the Probation Department. 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is received from Chief Probation Officer Terri determined by receipt of the Chief Probation Officer’s McDonald certifying that appointments and qualifications of agency staff comply with all certification letter confirming that all elements of elements of regulation. regulation are met. (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: (1) recruit and hire employees who possess 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 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 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ accordance with Section 1031 et seq. of the Government Code. (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract employees of the facility, who may be present at the personnel, volunteers and other non- facility, shall have such clearance and qualifications employees participate in background checks and are approved through each facility for as may be required by law, and their presence at the ☒ ☐ ☐ entrance except for LACOE, who conducts facility shall be subject to the approval and control of their own criminal records review as the facility manager. required by the Probation Department. Probation maintains control as to who has access into the facility. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1321 STAFFING Residential Treatment Services Bureau (RTSB) Manual Section -206: Staffing Each juvenile facility shall: Documentation was provided of master staff schedules, facility schedules with supervisors assigned and collaborative staff rosters. Off duty staff sleep on site and are available for emergencies. Random dates were requested throughout the cycle to determine adequacy of staffing levels. Master questionnaire was not provided. a) have an adequate number of personnel sufficient to Residential Treatment Services Bureau carry out the overall facility operation and its (RTSB) Manual Section -206: Staffing programming, to provide for safety and security of ☒ ☐ ☐ youth and staff, and meet established standards and regulations; b) ensure that no required services shall be denied Residential Treatment Services Bureau because of insufficient numbers of staff on duty ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing absent exigent circumstances; c) have a sufficient number of supervisory level staff to Residential Treatment Services Bureau ensure adequate supervision of all staff members; (RTSB) Manual Section -206: Staffing At the time of inspection, Camp Afflerbaugh ☒ ☐ ☐ had 6 supervisors assigned to the facility. When a SDPO is unavailable a DPOII is assigned as an acting Supervisor. We will continue to monitor this when back on site. d) have a clearly identified person on duty at all times Residential Treatment Services Bureau who is responsible for operations and activities and (RTSB) Manual Section -206: Staffing has completed the Juvenile Corrections Officer Core Course and PC 832 training; ☒ ☐ ☐ The facility director is responsible for the overall operations of the facility, but the supervisor is responsible for the daily operations of the facility. e) have at least one staff member present on each living Residential Treatment Services Bureau unit whenever there are youth in the living unit; (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ There is always a staff present in the dorm or where a youth is present. Youth are never left alone per consultant staff. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS f) have sufficient food service personnel relative to the Residential Treatment Services Bureau number and security of living units, including staff (RTSB) Manual Section -206: Staffing qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen The facility has a full dining hall. All youth supervision; direct food preparation and servings; ☒ ☐ ☐ eat their meals in the dining hall unless they conduct related training programs for culinary staff; refuse to leave the dorm. The dining hall is and maintain necessary records; or, a facility may staffed by facility cooks who plan and serve food that meets nutritional standards prepared prepare all meals. Cooks do not supervise by an outside source; youth. g) have sufficient administrative, clerical, recreational, Residential Treatment Services Bureau medical, dental, mental health, building (RTSB) Manual Section -206: Staffing maintenance, transportation, control room, facility ☒ ☐ ☐ security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Residential Treatment Services Bureau continuous wide-awake supervision of youth, (RTSB) Manual Section -206: Staffing subject to 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: (1) Juvenile Halls (minimum youth-staff ratio) Facility is not a Juvenile Hall. (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 Facility is not a Juvenile Hall. 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 Facility is not a Juvenile Hall 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 Facility is not a Juvenile Hall ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other Facility is not a Juvenile Hall duties such as administration, supervision of ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile staff ratio) Hall ☐ ☐ ☒ (A) during hours that youth are awake, one wide-awake youth supervision staff member is on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room Facility is not a Special Purpose Juvenile for the purpose of sleeping, one wide-awake youth ☐ ☐ ☒ Hall supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff Facility is not a Special Purpose Juvenile members on duty at all times, regardless of the Hall ☐ ☐ ☒ 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 Facility is not a Special Purpose Juvenile who is the same gender as youth housed in the Hall ☐ ☐ ☒ facility. (E) personnel with primary responsibility for other Facility is not a Special Purpose Juvenile duties such as administration, supervision of Hall ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Residential Treatment Services Bureau (A) during the hours that youth are awake, one wide- ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau room for the purpose of sleeping, one wide-awake ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing youth supervision staff member on duty for each 30- youth present in the facility; (C) at least two wide-awake youth supervision staff Residential Treatment Services Bureau members on duty at all times, regardless of the (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau who is the same gender as youth housed in the (RTSB) Manual Section -206: Staffing facility; ☒ ☐ ☐ There are always male and female staff on duty. (E) in addition to the minimum staff to youth ratio Residential Treatment Services Bureau required in (h)(3)(A)-(B), consideration shall be (RTSB) Manual Section -206: Staffing 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; 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (F) personnel with primary responsibility for other Residential Treatment Services Bureau duties such as administration, supervision of (RTSB) Manual Section -206: Staffing personnel, academic or trade instruction, clerical, ☒ ☐ ☐ Only youth supervision staff provide farm, forestry, kitchen or maintenance shall not be supervision of the youth. classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF Residential Treatment Services Bureau ORIENTATION AND TRAINING (RTSB) Manual -2104: Professional (a) Prior to assuming any responsibilities each youth Development and Training supervision staff member shall be properly oriented to their duties, including: All staff assigned to RTSB have completed Correctional Officer CORE training prior to reporting to the facility. Upon assignment, each staff is paired with a onsite training officer who assists them in ☒ ☐ ☐ their orientation and training. Training transcripts were provided as verification of required training which includes CORE. These training transcripts documented the mandated trainings We were unable to view individual training files for the specific location training as we were not on site due to COVID 19. Compliance is based on policy. We will verify training documents when back on site. (1) youth supervision duties; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) scope of decisions they shall make; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (3) the identity of their supervisor; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) the identity of persons who are responsible to Residential Treatment Services Bureau them; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) persons to contact for decisions that are beyond Residential Treatment Services Bureau their responsibility; and ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (6) ethical responsibilities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (b) Prior to assuming any responsibility for the Residential Treatment Services Bureau supervision of youth, each youth supervision staff (RTSB) Manual -2104: Professional ☒ ☐ ☐ member shall receive a minimum of 40 hours of Development and Training facility-specific orientation, including: 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) individual and group supervision techniques; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) regulations and policies relating to discipline and Residential Treatment Services Bureau rights of youth pursuant to law and the ☒ ☐ ☐ (RTSB) Manual -2104: Professional provisions of this chapter; Development and Training (3) basic health, sanitation and safety measures; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) suicide prevention and response to suicide Residential Treatment Services Bureau attempts ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) policies regarding use of force, de-escalation Residential Treatment Services Bureau techniques, chemical agents, mechanical and (RTSB) Manual -2104: Professional physical restraints; Development and Training ☒ ☐ ☐ The facility does not use chemical agents in the camp setting. (6) review of policies and procedures referencing Residential Treatment Services Bureau trauma and trauma-informed approaches; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (7) procedures to follow in the event of Residential Treatment Services Bureau emergencies; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (8) routine security measures, including facility Residential Treatment Services Bureau perimeter and grounds; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (9) crisis intervention and mental health referrals to Residential Treatment Services Bureau mental health services; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (10) documentation; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (11) fire/life safety training Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (c) Prior to assuming sole supervision of youth, each Residential Treatment Services Bureau youth supervision staff member shall successfully (RTSB) Manual -2104: Professional complete the requirements of the Juvenile ☒ ☐ ☐ Development and Training Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer Residential Treatment Services Bureau youth supervision staff shall successfully complete (RTSB) Manual -2104: Professional ☒ ☐ ☐ training pursuant to Section 830 et seq. of the Penal Development and Training Code. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1323 FIRE AND LIFE SAFETY Residential Treatment Services Bureau (RTSB) Manual -2104: Professional Whenever there is a youth in a juvenile facility, there Development and Training shall be at least one wide awake person on duty at all ☒ ☐ ☐ times who meets the training standards established by the All staff are trained in fire and life safety in Board for general fire and life safety which relate CORE training. All Supervisors have been specifically to the facility. trained. There will always be a supervisor or an acting supervisor on duty. 1324 POLICY AND PROCEDURES MANUAL The agency manual is specific to RTSB and All facility administrators shall develop, publish, and camp operations and has been provided to the implement a manual of written policies and procedures BSCC for review. The manual was last that address, at a minimum, all regulations that are reviewed and updated in June 2020. applicable to the facility. Such a manual shall be made available to all employees, reviewed by all employees, The BSCC has reviewed the agency Policy and shall be administratively reviewed at a minimum and Procedure as provided to us specific to every two years, and updated, as necessary. Those regulations and has confirmed the policies records relating to the standards and requirements set and procedure exist as cited. There may be forth in these regulations shall be accessible to the Board cites noted in the comments that may not on request. match due to updates that were unable to be The manual shall include: reverified. ☒ ☐ ☐ Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. In all cases, copies of policies and directives were provided that were not from the current manual. Technical assistance provided and discussed that this should be rectified. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) table of organization, including channels of Residential Treatment Services Bureau communications and a description of job (RTSB) Manual Sections: classifications; • 101: Vision, Mission, and Core Values • 102: Role of the Camp System • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff • 207: Organizational Chart The manual has a table of contents. The agency’s channel of communication follows chain of command. (b) responsibility of the probation department, purpose Residential Treatment Services Bureau of programs, relationship to the juvenile court, the (RTSB) Manual Sections: Juvenile Justice/Delinquency Prevention • 101: Vision, Mission, and Core Commission or Probation Committee, probation Values staff, school personnel and other agencies that are • 102: Role of Camp System involved in juvenile facility programs; ☒ ☐ ☐ • 908: Medical Services • 909: Mental Health Services • 910: Educational Services • 1005: Community Based Organizations • 1006: Volunteers (c) responsibilities of all employees; Residential Treatment Services Bureau (RTSB) Manual Sections: • 202: RTSB Administrative Structure 203: Duty Statements, RTSB ☒ ☐ ☐ Management • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff (d) initial orientation and training program for Residential Treatment Services Bureau employees; (RTSB) Manual -2104: Professional Development and Training ☒ ☐ ☐ See Section 1322 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) initial orientation, including safety and security Residential Treatment Services Bureau issues and anti-discrimination policies, for support (RTSB) Manual -2200: Non-Sworn staff, contract employees, school, mental/behavioral Personnel and Partner Agencies Handbook health and medical staff, program providers and ☒ ☐ UNK Unable to view employee training files as not volunteers; on site. Compliance is based on policy. We will verify training documents when back on site. (f) maintenance of record-keeping, statistics and Residential Treatment Services Bureau communication system to ensure: (RTSB) Manual 701: Case Planning and Procedures and 702-General Duties and Responsibilities RTSB maintains an extensive record- keeping system (PCMS) to record operations and to report on the youth in its’ care. Through these reports, the RTSB is able to document and retrieve accurate ☒ ☐ ☐ accounts of specific incidents or operations and to develop a database for statistical analysis. The assigned camp DPO is responsible for the casework functions while the youth is in the camp setting. The supervisor is responsible to ensure that all information is thoroughly documented within the Probation Case Management System. (1) efficient operation of the juvenile facility; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (2) legal and proper care of youth; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (3) maintenance of individual youth's records; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (4) supply of information to the juvenile court and Residential Treatment Services Bureau those authorized by the court or by the law; and, (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (5) release of information regarding youth. Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (g) ethical responsibilities; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-2130: Employee Honesty (h) trauma-informed approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-518: Trauma Informed Approaches (i) culturally responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-519: Culturally Responsive Approaches (j) gender responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-517: Promoting Dignity for Female Youth Housed in RTSB (k) a non-discrimination provision that provides that all Residential Treatment Services Bureau youth within the facility shall have fair and equal (RTSB) Manual-2110: Non-Discrimination access to all available services, placement, care, Policy treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group ☒ ☐ ☐ identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Residential Treatment Services Bureau chemical agents related security devices, and (RTSB) Manual-1922: Weapons and ☒ ☐ ☐ weapons and ammunition, where applicable; Ammunition (m) establishment of procedures for collection of Medi- Residential Treatment Services Bureau Cal eligibility information and enrollment of eligible ☒ ☐ ☐ (RTSB) Manual-706: Case Plan Activities youth; and, (n) establishment of a policy that prohibits all forms of Residential Treatment Services Bureau sexual abuse, sexual assault and sexual harassment. (RTSB) Manual-1600: Prison Rape The policy shall include an approach to preventing, Elimination Act detecting and responding to such conduct and any retaliation for reporting such conduct, as well as a ☒ ☐ ☐ Staff are trained in PREA within their first provision for reporting such conduct by youth, staff year of employment and every two years or a third party. thereafter. 1325 FIRE SAFETY PLAN Residential Treatment Services Bureau The facility administrator shall consult with the local fire (RTSB) Manual-1910: Fire Prevention and department having jurisdiction over the facility, or with ☒ ☐ ☐ Suppression and 1917: Emergency the State Fire Marshal, in developing a plan for fire safety Evacuation which shall include, but not be limited to: a) a fire prevention plan to be included as part of the Residential Treatment Services Bureau manual of policy and procedures; (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS b) monthly fire and life safety inspections by facility Residential Treatment Services Bureau staff with two- year retention of the inspection (RTSB) Manual-1910: Fire Prevention and record; Suppression ☒ ☐ ☐ Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. c) fire prevention inspections as required by Health Residential Treatment Services Bureau and Safety Code Section 13146.1(a) and (b); (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression See Section 1313 d) an evacuation plan; Residential Treatment Services Bureau (RTSB) Manual Sections: 1910: Fire Prevention and Suppression 1917: Emergency Evacuation ☒ ☐ ☐ Facility provided County of Los Angeles Building Emergency Plan with site evacuation maps for our review. e) documented fire drills not less than quarterly; Residential Treatment Services Bureau (RTSB) Manual-1910: Fire Prevention and Suppression ☒ ☐ ☐ All drills have been completed. f) a written plan for the emergency housing of youth in Residential Treatment Services Bureau the case of fire; and, (RTSB) Manual-1917: Emergency Evacuation ☒ ☐ ☐ Emergency housing will always be at one of the camps or juvenile halls dependent on location of the fire and a safe route of travel. g) development of a fire suppression pre-plan In Residential Treatment Services Bureau cooperation with the local fire department. (RTSB) Manual-1910: Fire Prevention and Suppression ☒ ☐ ☐ The County of Los Angeles Building Emergency Plan for Camp Afflerbaugh was signed by LACO Fire Captain Giesler on March 2, 2020. 1326 SECURITY REVIEW Residential Treatment Services Bureau (RTSB) Manual- 1312: Security Checks Each facility administrator shall develop policies and procedures to annually review, evaluate, and document ☒ ☐ ☐ Security review was completed April 1, 2020 security of the facility. The review and evaluation shall by Director Mendez. include internal and external security, including, but not limited to, key control, equipment, and staff training. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1327 EMERGENCY PROCEDURES Facility provided and utilizes (in addition to the Bureau Policy Manual), the County of The facility administrator shall develop facility-specific Los Angeles Building Emergency Plan. Both policies and procedures for emergencies that shall documents have emergency procedures include, but not be limited to: ☒ ☐ ☐ regarding the facilities. We did not review the documents for comparison and suggest that the agency review and compare to ensure there are no inconsistencies. (a) escape, disturbances, and the taking of hostages; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1907 Escapes 1909: Major Disturbances 1914: Hostages (b) civil disturbance, active shooter and terrorist attack; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1908: Outside Intruder 1915: Active Shooter 1916: Terrorist Attack (c) fire and natural disasters; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1910: Fire Prevention and Suppression 1913: Earthquake (d) periodic testing of emergency equipment; Residential Treatment Services Bureau (RTSB) Manual Sections: 1321: Testing of Emergency Equipment ☒ ☐ ☐ Internal Services Department (ISD) conducts monthly and as needed testing in coordination with MSB. (e) emergency evacuation of the facility; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections: 1917: Emergency Evacuation (f) a program to provide all youth supervision staff Residential Treatment Services Bureau with an annual review of emergency procedures. (RTSB) Manual Sections: 1903: Staff Roles and Responsibilities ☒ ☐ ☐ An emergency sign off sheet was provided for our review that listed all staff. Staff were listed by name. This review was completed in June and July 2019. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1328 SAFETY CHECKS Residential Treatment Services Bureau (RTSB) Manual Sections: 1313: Safety The facility administrator shall develop and implement Checks and Section 1119 policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, Documentation of Safety Checks were at random or varied intervals during hours when youth provided for September and November 2019. are asleep or when youth are in their rooms, confined in We reviewed random checks from the holding cells or confined to their bed in a dormitory. documentation provided and found that Supervision is not replaced, but may be supplemented overall, checks were completed within 15 by, an audio/visual electronic surveillance system minutes with minimal discrepancies. There designed to detect overt, aggressive or assaultive were some instances of nonrandom and non- behavior and to summon aid in emergencies. All safety varied checks; however, facility checks shall be documented with the actual time the administration addressed the issue through a check is completed. corrective action and work instruction memo prior to inspection. Technical assistance provided regarding enhancing supervision through the use of less time between checks. ☒ ☐ ☐ Policy also requires supervisors to regularly audit safety check logs by making unannounced inspections at least once a shift of the Safety Check Sheets in the buildings under their supervision. Supervisors are to ensure compliance and to assure that staff are completing the checks according to policy. Supervisors are to document their name, date, time of the audit under the last check. Facility managers corrected this issue also through their own review and provided a work instruction memo. We reviewed subsequent checks and noted improvement in both areas. We will be sure to review these issues to ensure continued compliance in the future. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Residential Treatment Services Bureau The facility administrator, in collaboration with the (RTSB) Manual Sections: 1201: Suicide healthcare and behavioral/mental health administrators, Prevention Plan shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. 1201: Suicide prevention Plan 1202 Enhanced and Specialized Supervision The plan shall consider the needs of youth experiencing Requirements for Youths in Juvenile past or current trauma. Facilities Suicide prevention responses shall be respectful and in 1203: Suicide Prevention Policy for Juvenile the least invasive manner consistent with the level of Facilities (Cross ref with directive 1186) suicide risk. Policy was developed in collaboration with The plan shall include the following elements: Juvenile Court Health Services (JCHS) and ☒ ☐ ☐ the Department of Mental Health (DMH). There were no incidents or documentation of suicide attempts or suicide behavior provided for our review for this section. The Juvenile Justice report also noted no suicide or suicide attempts reported in the year since their last visit. Compliance is based on policy and admission/intake documents. We will follow up when on site to ensure continued compliance in the future. (a) Suicide prevention training as required in Residential Treatment Services Bureau Section 1322, Youth Supervision Staff (RTSB) Manual Sections: 1203: Suicide Orientation, and Training and the Juvenile Prevention Policy for Juvenile Facilities and Corrections Officer Core Course. 2104: Professional Development and ☒ ☐ ☐ Training. Staff are trained in CORE training and annual refresher training. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Screening, Identification Assessment and Residential Treatment Services Bureau Precautionary Protocols (RTSB) Manual Sections:1202: Enhanced (1) All youth shall be screened for risk of and Specialized Supervision Requirements suicide at intake and as needed during of Youth in Juvenile Facilities and 1203: detention. Suicide Prevention Policy for Juvenile Facilities All youth are screened prior to entry by DMH who conduct a Juvenile Justice Child/Adolescent Assessment. A DPOII ☒ ☐ ☐ Clinician and DMH staff member interview youth at Juvenile Hall prior to arrival to the Camp. Once at camp all youth are screened again at intake with the Initial Intake, Screening and Referral Questionnaire. DMH work with youth throughout their stay, assessing them for risk and will adjust their supervision level as needed. All files we reviewed had screenings completed at intake/admission. (2) All youth supervision staff who perform Residential Treatment Services Bureau intake processes shall be trained in (RTSB) Manual Sections: 1203: Suicide screening youth for risk of suicide. Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Staff who complete intake/admissions are trained in completing them. Suicide update training is completed annually as part of the Enhanced Supervision Training. (3) All youth who have been identified during Residential Treatment Services Bureau the intake screening process to be at risk of (RTSB) Manual Section: 1203: Suicide suicide shall be referred to Prevention Policy for Juvenile Facilities behavioral/mental health staff for a suicide risk assessment. ☒ ☐ ☐ We did not find any youth to be suicidal at intake based on the documentation we reviewed; however, bureau staff stated that youth would be referred to DMH for follow up. (4) Precautionary protocols shall be developed Residential Treatment Services Bureau to ensure the youth’s safety pending the (RTSB) Manual Sections:1202: Enhanced behavioral/mental health assessment. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Referral process to behavioral/mental health Residential Treatment Services Bureau staff for assessment and/or services. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Policy requires all facility staff to complete a “Request for Mental Health Consultation” when appropriate. This would occur at any time throughout detention. (d) Procedures for monitoring of youth identified Residential Treatment Services Bureau at risk for suicide. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Per policy, enhanced supervision Levels 1-4 determine the level of supervision a youth receives. Level 4 requires a constant supervision until a youth can be transported out to emergency hospitalization, Level 3 is a constant visual 1:1 supervision, Level 2; is 10-minute safety check and Level 1 is regular 15-minute safety checks. (e) Safety Interventions Residential Treatment Services Bureau (1) Procedures to address intervention (RTSB) Manual Sections:1202: Enhanced protocols for youth identified at risk for and Specialized Supervision Requirements suicide which may include, but are not of Youth in Juvenile Facilities limited to: ☒ ☐ ☐ A. Housing consideration Youth are placed on a Specialized Supervision Plan-SSP. Supervision and housing direction are included on the forms. B. Treatment strategies including Residential Treatment Services Bureau trauma-informed approaches (RTSB) Manual Section: 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Procedures to instruct youth supervision Residential Treatment Services Bureau staff how to respond to youth who exhibit (RTSB) Manual Sections:1202: Enhanced suicidal behaviors. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. (f) Communication Residential Treatment Services Bureau (1) The intake process shall include (RTSB) Manual Section: 1203: Suicide communication with the arresting officer Prevention Policy for Juvenile Facilities and family guardians regarding the youth’s past or present suicidal ideations, behaviors Youth are transported directly from the or attempts. Juvenile Hall to the camp. Policy states that the intake officer shall contact the youth’s parent and/or guardians via telephone during ☒ ☐ ☐ the initial intake process to gather information regarding the youth’s past or present suicidal ideations, behaviors or attempts. Documentation reviewed noted that youth’s parents were contacted regarding suicide history. (2) Procedures for clear and current Residential Treatment Services Bureau information sharing about youth at risk for (RTSB) Manual Section: 1203: Suicide suicide with youth supervision, healthcare, ☒ ☐ ☐ Prevention Policy for Juvenile Facilities and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Residential Treatment Services Bureau Suicides or Attempts (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ (1) Process for administrative review of the Prevention Policy for Juvenile Facilities circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected Residential Treatment Services Bureau staff. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities (3) Process for a debriefing event with affected Residential Treatment Services Bureau youth. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Documentation Residential Treatment Services Bureau (1) Documentation processes shall be (RTSB) Manual Sections:1202: Enhanced developed to ensure compliance with this and Specialized Supervision Requirements regulation of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities Youth identified at risk for suicide shall not be denied Residential Treatment Services Bureau the opportunity to participate in facility programs, (RTSB) Manual Section: 1202: Enhanced services and activities which are available to other non- and Specialized Supervision Requirements suicidal youth, unless deemed necessary for the safety ☒ ☐ ☐ for Youths in Juvenile Facilities of the youth or security of the facility. Any deprivation of programs, services or activities for youth at risk of suicide shall be documented and approved by the facility manager. 1340 REPORTING OF LEGAL ACTIONS Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each facility shall submit to the Board a letter of Statements, RTSB Management notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities ☒ ☐ ☐ The Camp Director is responsible to ensure responsible for juvenile facility operation. that all reporting is completed. No legal actions have been reported to the BSCC this cycle. 1341 DEATH AND SERIOUS ILLNESS OR Residential Treatment Services Bureau INJURY OF A YOUTH WHILE (RTSB) Manual Sections:1919: Deaths at DETAINED Camp Facilities (1) Death of a Youth. Policy was developed in collaboration with (a) The facility administrator, In cooperation with the Juvenile Court Health Services (JCHS) and health administrator and the behavioral/mental ☒ ☐ ☐ the Department of Mental Health (DMH), 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 Residential Treatment Services Bureau facility administrator, shall develop written policies (RTSB) Manual Sections:1919: Deaths at and procedures to assure there is a medical and Camp Facilities operational review of every in-custody death of 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. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) The administrator of the facility shall provide to the Residential Treatment Services Bureau Board a copy of the report submitted to the Attorney (RTSB) Manual Sections:1919: Deaths at General under Government Code Section 12525. A ☒ ☐ ☐ Camp Facilities 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 Residential Treatment Services Bureau the administrator, the Board may within 30 calendar (RTSB) Manual Sections:1919: Deaths at days inspect and evaluate the juvenile facility, jail, Camp Facilities 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 Residential Treatment Services Bureau (a) The facility administrator, In cooperation with the (RTSB) Manual Section 1920: Serious health administrator, shall develop written policies Illness or Injury of a Youth While Detained 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 Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each juvenile facility shall submit required population Statements, RTSB Management and profile survey reports to the Board within 10 working days after the end of each reporting period, in ☒ ☐ ☐ The Camp Director is responsible to ensure a format to be provided by the Board. that all reporting is completed. All population reports were completed in a timely manner. 1343 JUVENILE FACILITY CAPACITY Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty When the number of youth detained in a living unit of a Statements, RTSB Management juvenile facility exceeds its rated capacity for more than fifteen (15) calendar days in a month, the facility ☒ ☐ ☐ The Camp Director is responsible to ensure administrator shall provide a crowding report to the that all reporting is completed. Board in a format provided by the Board. Facility has not exceeded their rated capacity this cycle. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 400: Camp written policies and procedures for admittance of youth Admissions and Section 502: Orientation that emphasize respectful and humane engagement with Process and Handbook youth and reflect that the admission process may be The Admission process for camp youth traumatic to youth who may have already experienced begins before youth arrive on campus. trauma. Policies shall be trauma-informed, culturally ☒ ☐ ☐ Youth are assessed and screened at Camp relevant, and responsive to the language and literacy Headquarters and again by camp staff, needs of youth. In addition to the requirements of medical and mental health before the youth Sections 1324 and 1430 of these regulations: even arrive. Upon arrival, youth are admitted and oriented by camp staff. Documentation of admission/intake paperwork for 20 random youth was provided for our review. (a) the admittance process shall include: Residential Treatment Services Bureau (1) Access to two free phone calls within one hour (RTSB) Manual Sections:502: Orientation of admittance in accordance with the provisions Process and Handbook of Welfare and Institution Code Section 627; By policy, youth are to be provided with a ☒ ☐ ☐ phone call to notify their parent or guardian that they have been transferred to the Camp. All files noted phone calls were made to the parent/guardian of the youth. (2) Offer of a shower; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ All youth were offered a shower upon arrival. (3) Documented secure storage of personal Residential Treatment Services Bureau belongings; (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Youth are transported to camp in juvenile hall clothing with only their juvenile hall personals. All personal clothing and belongings are released to their parents or guardians from the juvenile hall. (4) Offer of food upon arrival; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ All youth were offered food upon arrival to the camp. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health Residential Treatment Services Bureau and safety issues, intellectual or developmental (RTSB) Manual Sections:402: Assessment disabilities; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (6) Screening for physical and developmental Residential Treatment Services Bureau disabilities in accordance with Sections 1329, (RTSB) Manual Sections:402: Assessment 1418, and 1430 of these regulations; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (7) Contact with Regional Center for the Youth that are Regional Center Clients Developmentally Disabled for youth that are would not likely be ordered to a camp ☒ ☐ ☐ suspected of or identified as having a commit. developmental disability, pursuant to Section 1418; and, (8) Procedures consistent with Section 1352.5. Residential Treatment Services Bureau (RTSB) Manual Sections:403: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (b) juvenile hall administrators shall establish written Not Applicable criteria for detention that considers the least ☒ ☐ ☐ restrictive environment. (c) juvenile camps and post-dispositional programs in Residential Treatment Services Bureau juvenile halls shall develop policies and procedures (RTSB) Manual Sections:502: Orientation that advise the youth of the estimated length of Process and Handbook stay, inform them of program guidelines and ☒ ☐ ☐ provide written screening criteria for inclusion and Estimated length of stay estimates were exclusion from the program. consistently completed and documentation provided in packets provided. (d) juvenile halls shall develop policies and procedures Not Applicable that advise any committed youth of the estimated ☐ ☐ ☒ length of his/her stay. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Residential Treatment Services Bureau ABUSE (RTSB) Manual Sections: 402: Assessment The facility administrator shall develop and implement and Classification and 503: Screening for the written policies and procedures to reduce the risk of Risk of Sexual Abuse sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of Policy is in place; however, documentation admission based on the following information: provided consists of PREA Risk questions on the intake screening assessment that are ☐ ☒ ☐ not consistent with regulation requirements. Technical assistance will be provided as requested. No proof of practice provided. This section is non-compliant as the documentation process has not yet been implemented. Agency is in the process of finalizing and rolling out the new procedure. (a) Prior sexual victimization or abusiveness; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (b) Gender nonconforming appearance or manner; Residential Treatment Services Bureau or identification as lesbian, gay or bisexual, (RTSB) Manual Sections: 402: Assessment transgender, queer or intersex, and whether the ☐ ☒ ☐ and Classification and 503: Screening for the youth may, therefore, be vulnerable to sexual Risk of Sexual Abuse abuse; (c) Current charges and offense history; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (d) Age; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (e) Level of emotional and cognitive development; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (f) Physical size and stature; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (g) Mental illness or mental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Intellectual or developmental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (i) Physical disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (j) The youth’s perception of vulnerability; and, Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (k) Any other specific information about the Residential Treatment Services Bureau individual youth that may indicate heightened (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ needs for supervision, additional safety and Classification and 503: Screening for the precautions, or separation from certain other Risk of Sexual Abuse youth. Staff shall ascertain this information through Residential Treatment Services Bureau conversations with the youth during the admittance (RTSB) Manual Sections:503: Screening for process, medical and behavioral health screenings; the Risk of Sexual Abuse ☐ ☒ ☐ during classification assessments; and by reviewing court records, case files, facility behavioral records, and Current procedure has not been other relevant documentation from the youth’s files. implemented. The facility administrator shall implement appropriate Residential Treatment Services Bureau controls on the dissemination of information within the (RTSB) Manual Sections:503: Screening for facility relative to responses received pursuant to this the Risk of Sexual Abuse ☐ ☒ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other It is unknown how the facility will ensure youth. documents are kept confidential. 1351 RELEASE PROCEDURES Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release The facility administrator shall develop and implement ☒ ☐ ☐ Procedures written policies and procedures for release of youth from custody which provide for: (a) verification of identity/release papers; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures (b) return of personal clothing and valuables; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures ☒ ☐ ☐ Compliance reviewed through Juvenile Hall property receipts viewed. Parents/guardian bring clothing for youth to be released in on day of release. (c) notification to the youth's parents or guardian; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) notification to the facility health care provider in Residential Treatment Services Bureau accordance with Sections 1408 and 1437 of these (RTSB) Manual Sections:809: Release regulations, for coordination with outside agencies; Procedures and, ☒ ☐ ☐ Health care is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (e) notification of school staff; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Education is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (f) notification of facility mental health personnel. Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Mental Health is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. The facility administrator shall develop and implement Residential Treatment Services Bureau policies and procedures for post-disposition youth to (RTSB) Manual Section: 703: MDT Process coordinate the provision of transitional and reentry services including, but not limited to, medical and Each youth has a Transition MDT 45-60 behavioral health, education, probation supervision and days prior to release that addresses all community-based services. required services and other pertinent areas. All facility partners and the PO are present ☒ ☐ ☐ with the youth to discuss the plan. The youth’s parents or guardian are invited to participate and either attend in person or via a conference call. (Reference Regulation 1355) Seven transition plans were reviewed and met all regulatory requirements. The facility administrator shall develop and implement Residential Treatment Services Bureau written policies and procedures for the furlough of (RTSB) Manual Section: 1802: Private youth from custody. Appointments ☒ ☐ ☐ The agency has no formal furlough policy; however, staff will transport youth to private appointments for exigent circumstances such as funerals or hospital visits with a court order. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1352 CLASSIFICATION Residential Treatment Services Bureau (RTSB) Manual Sections:402: Assessment The facility administrator shall develop and implement and Classification Policy and Section 408: written policies and procedures on classification of Classification youth for the purpose of determining housing placement ☒ ☐ ☐ in the facility. Documentation provided for our review for 20 youth. All classifications were Such procedures shall: completed, several with SSP’s attached for additional instruction for specialized supervision or housing needs. (a) provide for the safety of the youth, other youth, Residential Treatment Services Bureau facility staff, and the public by placing youth in the (RTSB) Manual Sections:402: Assessment appropriate, least restrictive housing and program and Classification Policy settings. Housing assignments shall consider the Youth are assessed by the Camp Assessment need for single, double or dormitory assignment or Unit (CAU) after being ordered to camp by location within the dormitory; ☒ ☐ ☐ the court. The CAU determines which camp is the appropriate camp for the youth based on classification factors and camp population. This decision is made based on several different factors and includes an interview and input from the youth. (b) consider facility populations and physical design of Residential Treatment Services Bureau the facility; (RTSB) Manual Sections:402: Assessment and Classification Policy ☒ ☐ ☐ Youth are classified to a camp based on classification factors and then assigned to a location within the dorm. (c) provide that a youth shall be classified upon Residential Treatment Services Bureau admittance to the facility; classification factors (RTSB) Manual Sections:402: Assessment shall include, but not be limited to: age, maturity, and Classification Policy sophistication, emotional stability, program needs, ☒ ☐ ☐ Youth are classified to a camp based on legal status, public safety considerations, classification factors. medical/mental health considerations, gender and gender identity of the youth; (d) provide for periodic classification reviews, Residential Treatment Services Bureau including provisions that consider the level of (RTSB) Manual Sections:402: Assessment supervision and the youth's behavior while in and Classification Policy custody; and, All youth who are placed on an SSP are ☒ ☐ ☐ reviewed within 30 days. All other youth are considered for review at the time of any incident, upon request, or as needed. If any change is to occur, an SSP is initiated. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provide that facility staff shall not separate youth Residential Treatment Services Bureau from the general population or assign youth to a (RTSB) Manual Sections:402: Assessment single occupancy room based solely on the youth's and Classification Policy actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, ☒ ☐ ☐ gender expression, mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, Residential Treatment Services Bureau bisexual, transgender, questioning or intersex (RTSB) Manual Sections:402: Assessment ☒ ☐ ☐ identification or status as an indicator of likelihood and Classification Policy of being sexually abusive. 1352.5 TRANSGENDER AND INTERSEX YOUTH. Residential Treatment Services Bureau (RTSB) Manual Sections: 403: Juvenile The facility administrator shall develop written policies ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Transgender, Questioning and Intersex treatment of transgender and intersex youth. The Youth in an Institutional Setting policies shall provide that: (a) Facility staff shall respect every youth’s gender Residential Treatment Services Bureau identity and shall refer to the youth by the youth’s (RTSB) Manual Sections: 403: Juvenile preferred name and gender pronoun, regardless of Supervision of Lesbian, Gay, Bisexual, the youth’s legal name. Facilities may prohibit the ☒ ☐ ☐ Transgender, Questioning and Intersex use of gang or slang names or names that otherwise Youth in an Institutional Setting 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 Residential Treatment Services Bureau themselves in a manner consistent with their gender (RTSB) Manual Sections: 403: Juvenile identity and shall provide youth with the ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, institution’s clothing and undergarments consistent Transgender, Questioning and Intersex with their gender identity. Youth in an Institutional Setting (c) Facility staff shall house youth in the unit or room Residential Treatment Services Bureau that best meets their individual needs, and promotes (RTSB) Manual Sections: 403: Juvenile their safety and well-being. Staff may not Supervision of Lesbian, Gay, Bisexual, automatically house youth according to their Transgender, Questioning and Intersex external anatomy, and shall document the reasons Youth in an Institutional Setting for any decision to house youth in a unit that does If a youth request to reside in another unit not match their gender identity. In making a ☒ ☐ ☐ other than the unit that coincides with the housing decision, staff shall consider the youth’s youth’s biological sex, a medical referral is preferences, as well as any recommendations from made, and an MDT is held. Pending a the youth’s health or behavioral health provider. decision, the youth will be housed in the medical unit. (This process occurs before arrival at the camp due to lack of alternate housing.) 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Facility administrators shall ensure that transgender Residential Treatment Services Bureau and intersex youth have access to medical and (RTSB) Manual Sections: 403: Juvenile behavioral health providers qualified to provide Supervision of Lesbian, Gay, Bisexual, care and treatment to transgender and intersex Transgender, Questioning and Intersex youth. Youth in an Institutional Setting ☒ ☐ ☐ Upon entry, youth are asked If they identify with LGBTQI and if so, they are referred to medical for continuation and coordination of gender affirming services. (e) Consistent with the facility’s reasonable and Residential Treatment Services Bureau necessary security considerations and physical (RTSB) Manual Sections: 403: Juvenile plant, facility staff shall make every effort to ensure ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, the safety and privacy of transgender and intersex Transgender, Questioning and Intersex youth when the youth are using the bathroom or Youth in an Institutional Setting shower, or dressing or undressing. Facility staff shall not conduct physical searches of any Residential Treatment Services Bureau youth for the purpose of determining the youth’s (RTSB) Manual Sections: 403: Juvenile anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of Transgender, Questioning and Intersex the staff member who conducts any search of the youth. Youth in an Institutional Setting Policy notes that youth are provided with the option to choose the gender of the staff they wish to search them. Policy also notes that ☒ ☐ ☐ the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy alone. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1353 ORIENTATION Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation The facility administrator shall develop and implement Process and Handbook written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Documentation was provided for 20 youth information shall be provided and supplemented with and all orientations were found to be video orientation if feasible. Provision shall be made to completed timely and consistent with provide accessible orientation information to all regulation. ☒ ☐ ☐ detained youth including those with disabilities, limited We noted at inspection that the RTSB literacy, or English language learners. Orientation shall orientation handbook was not updated to all include information that addresses: current regulatory requirements. This issue was quickly addressed and corrected, and the updated handbook has since been implemented and contains all areas of required regulation. (a) facility rules including contraband and searches and Residential Treatment Services Bureau disciplinary procedures; ☒ ☐ ☐ (RTSB) Manual Section: 502: Orientation Process and Handbook (b) facility’s system of positive behavior interventions Residential Treatment Services Bureau and supports, including behavior expectations, (RTSB) Manual Section: 502: Orientation incentives that youth will receive for complying Process and Handbook with facility rules, and consequences that may ☒ ☐ ☐ Youth are provided with a copy of the result when youth violate the rules of the facility; Behavior Management Program Handbook at orientation. This process is reviewed during orientation. (c) age appropriate information that explains the Residential Treatment Services Bureau facility’s policy prohibiting sexual abuse and sexual (RTSB) Manual Section: 1600: PREA ☒ ☐ ☐ harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (e) the existence of the grievance procedure, the steps Residential Treatment Services Bureau that must be taken to use it, the youth’s right to be (RTSB) Manual Section: 502: Orientation free of retaliation for reporting a grievance, and the Process and Handbook ☒ ☐ ☐ name of the person or position designated to resolve the issue; (f) access to legal services and information on the court Residential Treatment Services Bureau process; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (g) access to routine and emergency health and mental Residential Treatment Services Bureau health care; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) access to education, religious services, and Residential Treatment Services Bureau recreational activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (i) housing assignments; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (j) opportunity for personal hygiene and daily showers Residential Treatment Services Bureau including the availability of personal care items (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (k) rules and access to correspondence, visits and Residential Treatment Services Bureau telephone use; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (l) availability of reading materials, programming, and Residential Treatment Services Bureau other activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (m) facility policies on the use of force, use of restraints, Residential Treatment Services Bureau chemical agents and room confinement; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (n) immigration legal services; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (o) emergencies including evacuation procedures; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (p) non-discrimination policy and the right to be free Residential Treatment Services Bureau from physical, verbal or sexual abuse and (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ harassment by other youth and staff; Process and Handbook (q) availability of services and programs in a language Residential Treatment Services Bureau other than English if appropriate; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (r) the process for requesting different housing, Residential Treatment Services Bureau education, programming and work assignments; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (s) a process for which parents/guardians receive Residential Treatment Services Bureau information regarding the youth’s stay in the (RTSB) Manual Section: 502: Orientation facility that at a minimum includes answers to Process and Handbook frequently asked questions and provides contact A parent handbook is available for parents information for the facility, medical, school and and can be accessed online or a copy may be mental health; and, ☒ ☐ ☐ received at any facility. The Orienting officer also provides the youth’s parent with information during the initial contact. (t) a process by which youth may request access to Residential Treatment Services Bureau Title 15 Minimum Standards for Juvenile Facilities. (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 1354 SEPARATION Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 514: Separation, written policies and procedures that address: 515: Room Confinement and Section 1400: ☒ ☐ ☐ The Healing Opportunities and Positive Engagement (HOPE) Center 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) separation of youth for reasons that include, but are Residential Treatment Services Bureau not be limited to, medical and mental health (RTSB) Manual Section: 514: Separation, conditions, assaultive behavior, disciplinary 515: Room Confinement and Section 1400: consequences and protective custody. The Healing Opportunities and Positive Engagement (HOPE) Center Agency HOPE Centers are operationally utilized for youth who require separation for a variety of purposes including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation to provide time for the youth to deescalate and adjust their behavior to return to the program. Current policies are not clear and although collectively, policy and procedure outline regulation requirements, operationally, do not meet requirements. Separation policy must be updated concurrently with Room Confinement policy to ensure consistency ☐ ☒ ☐ and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Agency policy requires due process for any separation. Currently, due process only occurs as a result of the incident which precipitated the separation. While not non- compliant with regulation, this is inconsistent with agency policy. Camp Afflerbaugh does not have a HOPE Center but if camp youth need to be separated for any reason, they are transported to Camp Rockey for separation or Room Confinement. All paperwork and documentation occurs at that camp. Technical assistance provided that this information should also be included in the agency policy/procedure. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) consideration of positive youth development and Residential Treatment Services Bureau trauma-informed care. (RTSB) Manual Section: 514: Separation Camp Afflerbaugh does not have a HOPE Center but per administration, have implemented designated self-separation areas within the camp setting. Youth may request to self-separate and may go to these areas for a time out. They remain under supervision and may return to the program at any time. This is designed to deescalate a situation and is promoted for positive youth development. ☒ ☐ ☐ Staff and managers should be proud of this outside the box problem solving for both youth and staff. This process was not noted in policy or procedures. We were not provided with any documentation to view and noted mostly that youth were counseled by the Supervisor and that most separation occurred on the bench in the Administration building, allowing the youth to deescalate and rejoin the group. (c) separated youth shall not be denied normal Residential Treatment Services Bureau privileges available at the facility, except when (RTSB) Manual Section: 514: Separation necessary to accomplish the objective of separation. ☐ ☐ ☒ Documentation is maintained at the receiving camp (d) when the objective of the separation is discipline, Residential Treatment Services Bureau Title 15 Section 1390 shall apply. (RTSB) Manual Section: 514: Separation ☐ ☐ ☒ Documentation is maintained at the receiving camp (e) when separation results in room confinement, the Residential Treatment Services Bureau separation shall occur in accordance with Welfare (RTSB) Manual Section: 514: Separation and Institutions Code Section 208.3 and ☐ ☐ ☒ Documentation is maintained at the receiving Section1354.5 of these regulations. camp (f) policies and procedures shall ensure a daily review Residential Treatment Services Bureau of separated youth to determine if separation (RTSB) Manual Section: 514: Separation remains necessary. ☐ ☐ ☒ Documentation is maintained at the receiving camp 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354.5 ROOM CONFINEMENT Residential Treatment Services Bureau (RTSB) Manual Section: 515: Room (a) The facility administrator shall develop and Confinement and Section 1400: The Healing implement written policies and procedures Opportunities and Positive Engagement addressing the confinement of youth in their room (HOPE) Center that are consistent with Welfare and Institutions Code Section 208.3. The placement of a youth in Camp Afflerbaugh does not have a HOPE room confinement shall be accomplished in Center and there is no Room Confinement accordance with the following guidelines: that occurs at the camp; however, youth from Camp Afflerbaugh will be transported to the HOPE Center at Camp Rockey as needed for some separations and room confinement needs. All documentation and expectations of the regulations are addressed by Camp Rockey. ☐ ☐ ☒ See Camp Rockey for more information. Policy, procedure and documentation will need to be reviewed and updated to achieve compliance for the bureau. Room confinement and separation policies should be revised concurrently to ensure consistency as well as to ensure compliance with all pieces of this regulation. While Camp Afflerbaugh does not have a HOPE Center, it is imperative that staff have a full understanding as their youth are housed in the Rockey HOPE Center and they should ensure that all documentation is completed correctly to assist in the QA. (1) Room confinement shall not be used before Residential Treatment Services Bureau other, less restrictive, options have been (RTSB) Manual Section: 515: Room attempted and exhausted, unless attempting ☐ ☐ ☒ Confinement and Section 1400: The Healing those options poses a threat to the safety or Opportunities and Positive Engagement security of any youth or staff. (HOPE) Center (2) Room confinement shall not be used for the Residential Treatment Services Bureau purposes of punishment, coercion, (RTSB) Manual Section: 515: Room convenience, or retaliation by staff. Confinement and Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (3) Room confinement shall not be used to the Residential Treatment Services Bureau extent that it compromises the mental and ☐ ☐ ☒ (RTSB) Manual Section: 515: Room physical health of the youth. Confinement (b) A youth may be held up to four hours in room Residential Treatment Services Bureau confinement. After the youth has been held in room (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ confinement for a period of four hours, staff shall Opportunities and Positive Engagement do one or more of the following: (HOPE) Center 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Return the youth to general population. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (2) Consult with mental health or medical staff. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (3) Develop an individualized plan that includes Residential Treatment Services Bureau the goals and objectives to be met in order to (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ reintegrate the youth to general population. Opportunities and Positive Engagement (HOPE) Center (4) If room confinement must be extended beyond Residential Treatment Services Bureau four hours, staff shall do each of the following: (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (A) Document the reasons for room Residential Treatment Services Bureau confinement and the basis for the (RTSB) Manual Section 1400: The Healing extension, the date and time the youth was Opportunities and Positive Engagement ☐ ☐ ☒ first placed in room confinement, and when (HOPE) Center he or she is eventually released from room confinement. (B) Develop an individualized plan that Residential Treatment Services Bureau includes the goals and objectives to be met (RTSB) Manual Section 1400: The Healing in order to integrate the youth to general Opportunities and Positive Engagement ☐ ☐ ☒ population. (HOPE) Center . (C) Obtain documented authorization by the Residential Treatment Services Bureau facility superintendent or his or her (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ designee every four hours thereafter. Opportunities and Positive Engagement (HOPE) Center (5) This section is not intended to limit the use of Residential Treatment Services Bureau single-person rooms or cells for the housing of (RTSB) Manual Section: 515: Room youth in juvenile facilities and does not apply Confinement ☐ ☐ ☒ to normal sleeping hours. (6) This section does not apply to youth or wards Residential Treatment Services Bureau in court holding facilities or adult facilities. (RTSB) Manual Section: 515: Room ☐ ☐ ☒ Confinement (7) Nothing in this section shall be construed to Residential Treatment Services Bureau conflict with any law providing greater or (RTSB) Manual Section: 515: Room ☐ ☐ ☒ additional protections to youth. Confinement 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 36 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (8) This section does not apply during an Residential Treatment Services Bureau extraordinary emergency circumstance that (RTSB) Manual Section: 515: Room requires a significant departure from normal Confinement 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 Residential Treatment Services Bureau placed in a locked cell or sleeping room to treat (RTSB) Manual Section: 515: Room and protect against the spread of a Confinement 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 Residential Treatment Services Bureau PLAN (RTSB) Manual Section 402: Assessment and Classification and 703: The MDT The facility administrator shall develop and implement Process written policies and procedures for assessment and case planning. The process of assessment begins upon a youth being ordered to a camp. A youth is assessed by the Camp Assessment Unit and by the facility upon arrival. The case plan is completed at the initial MTD and is developed through a collaborative multi- ☒ ☐ ☐ disciplinary team made up of staff representation from Probation, Department of Mental Health, Education, Health Care, Social Services as appropriate and any others as necessary based on the youth or family needs. A transition MDT is also completed as the youth gets closer to release. MDT’s are completed as needed throughout detention as the need arises. Periodic review is completed by the assigned casework Probation Officer. The transition plan is completed by the collaborative multi- disciplinary team. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Assessment: Residential Treatment Services Bureau (RTSB) Manual Section 703: The MDT The assessment is based on information collected Process during the admission process with periodic review, which includes the youth's risk factors, needs and strengths including, but not limited to, identification of The process of case planning begins with the substance abuse history, educational, vocational, assessment process. 10 Initial and 7 counseling, behavioral health, consideration of known Transitional MDT packets were reviewed. history of trauma, and family strengths and needs. The Camp Assessment Unit completes all assessments on the youth prior to transfer. The assessment summary was not provided for our review in the case notes; however, it is practice and completed for all youth for RTSB per Bureau staff. ☐ ☐ UNK At inspection, we were unable to determine compliance in this area at this time without seeing the assessment, speaking to staff and youth. Prior to writing this report, we have been notified that the agency has updated their policy and has corrected their forms and documentation to be consistent with regulation and to provide a more clear and efficient process for the youth and their families. Staff training occurred in August 2020 and the new process was implemented in September 2020. We will follow up with this section to review for compliance upon our return to the facility. (b) Institutional Case Plan: Residential Treatment Services Bureau (1) A case plan shall be developed for each youth (RTSB) Manual Section 703: The MDT held for at least 30 days or more and created Process within 40 days of admission. We reviewed 17 Initial and 8 Transitional MDT packets. ☒ ☐ ☐ The initial MDT acts as the youth’s case plan and provides direction as to what programs they will participate in. Most programs are automatic as they are court ordered. The MDT is targeted to be completed within the first 2 weeks of a youth’s arrival at camp. All MDT’s occurred within the time allotted by regulation. (2) The institutional plan shall include, but not be Residential Treatment Services Bureau limited to, written documentation that provides: ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 38 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (A) objectives and time frame for the resolution Residential Treatment Services Bureau of problems identified in the assessment; (RTSB) Manual Section 705: Ongoing Case Management Activities The MDT process and format provides the structure for the youth’s case plan. Objectives are based on the assessment. We do not have enough information at this ☐ ☐ UNK time to make a final decision on compliance. With the change in regulation, the assessment drives the objectives and goals and the case plans are more individualized and not solely based on a court order or camp program. RTSB has enhanced their process. We will follow up with this section and determine compliance upon our return to the facility. (B) a plan for meeting the objectives that Residential Treatment Services Bureau includes a description of program resources (RTSB) Manual Section 705: Ongoing Case needed and individuals responsible for Management Activities assuring that the plan is implemented; We found the current plan and timelines are embedded within the camp program expectations or court orders i.e. 10 weeks substance abuse program, individual counseling or family counseling weekly or 16-week DBT. ☒ ☐ ☐ Technical assistance provided and discussed to ensure these programs and other assessed needs are documented more consistently so the youth’s other needs are individual to the youth. We need more information to determine compliance. We will follow up with this section and determine compliance upon our return to the facility. (3) periodic evaluation of progress towards meeting Residential Treatment Services Bureau the objectives, including periodic review and (RTSB) Manual Section 705: Ongoing Case discussion of the plan with the youth; Management Activities ☒ ☐ ☐ Documentation was provided for our review. Periodic review consisted of case notes of face to face contacts. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) a transition plan, the contents of which shall be Residential Treatment Services Bureau subject to existing resources, shall be developed (RTSB) Manual Section 706: Case Plan for post dispositional youth in accordance with Activities- Pre- Release Section 1351; and, ☒ ☐ ☐ Transition MDT’s are completed for all youth and contain all areas required by regulation. (5) in as much as possible and if appropriate, the Residential Treatment Services Bureau plan, including the transition plan, shall be (RTSB) Manual Section 705: Ongoing Case developed with input from the family, Management Activities supportive adults, youth, and Regional Center ☒ ☐ ☐ The youth’s parent or guardian is invited to for the Developmentally Disabled. attend the MDT. The family is contacted by phone and by letter to attend. 1356 COUNSELING AND CASEWORK Residential Treatment Services Bureau SERVICES (RTSB) Manual Section 705: Ongoing Case Management Activities The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: (a) youth will receive assistance with needs or concerns Residential Treatment Services Bureau that may arise; ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities (b) youth will receive assistance in requesting contact Residential Treatment Services Bureau with parents, other supportive adults, attorney, (RTSB) Manual Section 705: Ongoing Case clergy, probation officer, or other public official; Management Activities ☒ ☐ ☐ and, (c) youth will be provided access to available resources Residential Treatment Services Bureau to meet the youth’s needs. ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1357 USE OF FORCE Residential Treatment Services Bureau (RTSB) Manual Section 1701: Physical The facility administrator, In cooperation with the intervention Policy for Juvenile Facilities responsible physician, shall develop and implement and the Transportation Section written policies and procedures for the use of force, which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. ☒ ☐ ☐ Policy was developed with the Juvenile Court Health Services (JCHS) and includes (a) At a minimum, each facility shall develop policies the use of soft restraints. OC is not used in and procedures which: the camps. Documentation was provided from throughout the cycle. 15 incidents were selected for review. (1) restricts the use of force to that which is deemed Residential Treatment Services Bureau reasonable and necessary, as defined in Section (RTSB) Manual Section 1704: Safe Crisis 1302 to ensure the safety and security of youth, Management and Physical Intervention staff, others and the facility. Procedures Documentation noted staff gave direction to ☒ ☐ ☐ stop and attempts were made to deescalate the situations before force was used. All incidents reviewed appeared appropriate and to be reasonable and necessary for the safety of staff and youth. (2) outline the force options available to staff Residential Treatment Services Bureau including both physical and non-physical (RTSB) Manual Section 1704: Safe Crisis options and define when those force options are Management and Physical Intervention appropriate. Procedures ☒ ☐ ☐ Non-Physical Options: De-escalation Techniques Physical Options: Authorized Levels of Physical Interventions (3) describe force options or techniques that are Residential Treatment Services Bureau expressly prohibited by the facility. (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ Management and Physical Intervention Procedures (4) describe the requirements of staff to report any Residential Treatment Services Bureau inappropriate use of force, and to take (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ affirmative action to immediately stop it. Management and Physical Intervention Procedures 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) define a standardized reporting format that Residential Treatment Services Bureau includes time period and procedure for (RTSB) Manual Section 1703: Safe Crisis documenting and reporting the use of force, Management-Physical Intervention Report including reporting requirements of Forms, 1704: Safe Crisis Management and management and line staff and procedures for Physical Intervention Procedures and 1706: reviewing and tracking use of force incidents by Safe Crisis Management Physical supervisory and or management staff, which Intervention Reports include procedures for debriefing a particular Facilities keep a use of force log. Incident incident with staff and/or youth for the purposes reports are completed before going off shift. of training as well as mitigating the effects of trauma that may have been experienced by staff Every incident is reviewed by the duty and /or the youth involved. supervisor and again reviewed by the Safe Crisis Management reviewing supervisor and ☐ ☐ UNK signed off by the facility Manager. Facility administration provided us with this SCM review. We appreciate the additional effort to provide us with all documentation for clarity and transparency in the SCM process, especially given that the review was being conducted virtually. We did not see any reference to debriefing of incidents however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further into this issue when on site at the next inspection. (6) Include an administrative review and a system Residential Treatment Services Bureau for investigating unreasonable use of force. (RTSB) Manual Section 1706: Safe Crisis Management Physical Intervention Reports Any incident that falls outside of agency ☒ ☐ ☐ policy is referred to the facility director for referral for an administrative review or referral to the Probation Departments Special Investigation Unit for further review. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Residential Treatment Services Bureau procedures required after use of force incidents (RTSB) Manual Section 1704: Safe Crisis for medical, mental health staff and parents or Management and Physical Intervention legal guardians. Procedures and 1706: Safe Crisis Management Physical Intervention Reports We found that in all incident reports and in documentation reviewed we found that youth were medically cleared and were either seen by mental health or a mental health referral was submitted on the youth’s behalf for ☒ ☐ ☐ follow up. At inspection, we did not see any reference in the PIR as required by policy for a contact being made of the youth’s parent if the child was involved in a use of force incident. Technical assistance provided and additional documentation was subsequently requested for review. This issue was corrected, and we were provided with documentation of corrective action and proof of contact being made and documentation being completed. (8) describe the limitations of use of force on Residential Treatment Services Bureau pregnant youth in accordance with Penal Code (RTSB) Manual Section 1704: Safe Crisis Section 6030(f) and Welfare and Institutions Management and Physical Intervention ☒ ☐ ☐ Code Section 222. Procedures (b) Facilities that authorize chemical agents as a force Residential Treatment Services Bureau option shall include policies and procedures that: (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (1) identify who is approved to carry and/or utilize NA chemical agents in the facility and the type, size ☐ ☐ ☒ and the approved method of deployment for those chemical agents. (2) mandate that chemical agents only be used when NA there is an imminent threat to the youth’s safety ☐ ☐ ☒ or the safety of others and only when de- escalation efforts have been unsuccessful or are not reasonably possible. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) outline the facility’s approved methods and NA timelines for decontamination from chemical agents. This shall include that youth who have ☐ ☐ ☒ been exposed to chemical agents shall not be left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. (4) define the role, notification, and follow-up NA procedures required after use of force incidents ☐ ☐ ☒ involving chemical agents for medical, mental health staff and parents or legal guardians. (5) provide for the documentation of each incident NA of use of chemical agents, including the reasons for which it was used, efforts to de-escalate ☐ ☐ ☒ prior to use, youth and staff involved, the date, time and location of use, decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure Residential Treatment Services Bureau which require that agencies provide initial and ☒ ☐ ☐ (RTSB) Manual Section 1702: Training regular training in use of force and chemical agents when appropriate that address: (1) known medical and behavioral health Residential Treatment Services Bureau conditions that would contraindicate certain ☒ ☐ ☐ (RTSB) Manual Section 1702: Training types of force; (2) acceptable chemical agents and the methods of Residential Treatment Services Bureau application. (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (3) signs or symptoms that should result in Residential Treatment Services Bureau immediate referral to medical or behavioral ☒ ☐ ☐ (RTSB) Manual Section 1702: Training health. (4) instruction on the Constitutional Limitations of Residential Treatment Services Bureau ☒ ☐ ☐ Use of Force. (RTSB) Manual Section 1702: Training (5) physical training force options that may require Residential Treatment Services Bureau ☒ ☐ ☐ the use of perishable skills. (RTSB) Manual Section 1702: Training (6) timelines the facility uses to define regular Residential Treatment Services Bureau training. (RTSB) Manual Section 1702: Training ☒ ☐ ☐ Initial training occurs in CORE and regular training is held through annual refresher training. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358 USE OF PHYSICAL RESTRAINTS Residential Treatment Services Bureau (RTSB) Manual Section 1705: Restraints The facility administrator, In cooperation with the responsible physician and mental health director, shall The policy was developed in cooperation with DMH and JCHS develop and implement written policies and procedures for the use of restraint devices. Restraint devices Facility did not provide any documentation include any devices which immobilize a youth's of Use of Physical Restraints. extremities and/or prevent the youth from being There were no incidents or documentation of ambulatory. physical restraints provided for our review ☐ ☐ UNK for this section. We cannot determine compliance as it is unknown if there were truly no incidents of Use of Restraints pursuant to this section for the two-year cycle. We will follow up with the facility when back on site. Areas that would require documentation are marked as UNK. All other compliance is noted through policy only. Physical restraints may be used only for those youth Residential Treatment Services Bureau who present an immediate danger to themselves or (RTSB) Manual Section 1705: Restraints 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 Residential Treatment Services Bureau discipline, or as a substitute for treatment. The use of (RTSB) Manual Section 1705: Restraints restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through ☒ ☐ ☐ affixing of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Residential Treatment Services Bureau handcuffs, shackles or other restraint devices when used (RTSB) Manual Section 1705: Restraints 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. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Youth shall be placed in restraints only with the approval Residential Treatment Services Bureau of the facility manager or designee. The facility manager (RTSB) Manual Section 1705: Restraints may delegate authority to place a youth in restraints to a ☐ ☐ UNK physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. A medical opinion on the safety of placement and Residential Treatment Services Bureau retention shall be secured as soon as possible, but no later (RTSB) Manual Section 1705: Restraints ☐ ☐ UNK 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 Residential Treatment Services Bureau possible, but in no case longer than four hours from the (RTSB) Manual Section 1705: Restraints ☐ ☐ UNK time of placement, to assess the need for mental health treatment. Continuous direct visual supervision shall be conducted Residential Treatment Services Bureau to ensure that the restraints are properly employed, and (RTSB) Manual Section 1705: Restraints to ensure the safety and well-being of the youth. ☐ ☐ UNK Observations of the youth's behavior and any staff interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. In addition to the requirements above, policies and Residential Treatment Services Bureau procedures shall address: (RTSB) Manual Section 1705: Restraints (a) documentation of the circumstances leading to an Residential Treatment Services Bureau ☒ ☐ ☐ application of restraints. (RTSB) Manual Section 1705: Restraints (b) known medical conditions that would Residential Treatment Services Bureau contraindicate certain restraint devices and/or ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints techniques. (c) acceptable restraint devices. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (d) signs or symptoms which should result in Residential Treatment Services Bureau ☒ ☐ ☐ immediate medical/mental health referral. (RTSB) Manual Section 1705: Restraints (e) availability of cardiopulmonary resuscitation Residential Treatment Services Bureau ☒ ☐ ☐ equipment. (RTSB) Manual Section 1705: Restraints (f) protective housing of restrained youth. While in Residential Treatment Services Bureau restraint devices, all youth shall be housed alone or (RTSB) Manual Section 1705: Restraints in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (h) exercising of extremities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358.5 USE OF RESTRAINT DEVICES FOR Residential Treatment Services Bureau MOVEMENT AND TRANSPORTATION WITHIN (RTSB) Manual Section 1709: The Use of THE FACILITY. Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, In cooperation with the responsible physician and behavioral/mental health The policy was developed in cooperation director, shall develop and implement written policies with DMH and JCHS. and procedures for the use of restraint devices when the purpose is for movement or transportation within the Policy is in place but not yet trained and facility that shall include the following: implemented. The below areas are non- compliant. (a) identification of acceptable restraint devices, staff Residential Treatment Services Bureau approved to utilize restraint devices and the (RTSB) Manual Section 1709: The Use of required training. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility Handcuffs are authorized for regular use and flex cuffs in emergency situations. (b) the circumstances leading to the application of Residential Treatment Services Bureau restraints must be documented. (RTSB) Manual Section 1709: The Use of Mechanical Restraints for Movement and ☐ ☒ ☐ Transport Within the Facility No documentation was provided for our review. This section is non-compliant. (c) an individual assessment of the need to apply Residential Treatment Services Bureau restraints for movement or transportation that (RTSB) Manual Section 1709: The Use of includes consideration of less restrictive Mechanical Restraints for Movement and alternatives, consideration of a youth’s known ☐ ☒ ☐ Transport Within the Facility medical or mental health conditions, trauma No documentation was provided for our informed approaches, and a process for review. This section is non-compliant. documentation and supervisor review and approval. (d) consideration of safety and security of the facility, Residential Treatment Services Bureau with a clearly defined expectation that restraint (RTSB) Manual Section 1710: The Use of devices shall not be used for the purposes of Mechanical Restraints for Movement and ☒ ☐ ☐ discipline or retaliation. Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Residential Treatment Services Bureau accordance with Penal Code Section6030(f) and (RTSB) Manual Section 1709: The Use of Welfare and Institutions Code Section 222. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1359 SAFETY ROOM PROCEDURES There is no safety room in the camps. Does not apply. (a) The facility administrator, and where applicable, In 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. (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. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (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 Residential Treatment Services Bureau (RTSB) Manual Sections: The facility administrator shall develop and implement 1316: Searches in Detention Facilities written policies and procedures governing the search of 1317: Body Searches (Pat- Down, Strip, and youth, the facility, and visitors. Policies and procedures Body Cavity Searches) shall provide that: Various samples of search documents from 2019 and 2020 were provided for our review. These included dorm inspections, strip ☒ ☐ ☐ search log and authorizations, K-9 inspections, A Facility Entrance Report-, Inspection for Contraband and a Living Quarters Inspection were provided for our review. These search efforts resulted in the confiscation of contraband. Good efforts by staff and managers to ensure the safety and security of the youth and the facility. (a) Searches shall be conducted to ensure the safety and Residential Treatment Services Bureau security of the facility, public, visitors, youth, and (RTSB) Manual Sections 1316: Searches in staff. ☒ ☐ ☐ Detention Facilities (b) Searches shall be conducted in a manner that Residential Treatment Services Bureau preserves the privacy and dignity of the person (RTSB) Manual Sections 1316: Searches in being searched and shall not be conducted for ☒ ☐ ☐ Detention Facilities harassment or as a form of discipline or punishment. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Strip searches and visual or physical body cavity Residential Treatment Services Bureau searches shall comply with Penal Code Section (RTSB) Manual Sections: ☒ ☐ ☐ 4030. 1316: Searches in Detention Facilities 1317: Body Searches (Pat- Down, Strip, and Body Cavity Searches) (d) Physical body cavity searches shall only be Residential Treatment Services Bureau conducted by a medical professional. (RTSB) Manual Section 1317: Body ☒ ☐ ☐ Searches (Pat- Down, Strip, and Body Cavity Searches) (e) Any youth held after a detention hearing shall only Residential Treatment Services Bureau be strip searched with prior approval of a supervisor (RTSB) Manual Section 1317: Body when there is reasonable suspicion based on Searches (Pat- Down, Strip, and Body Cavity ☒ ☐ ☐ specific and articulable facts to believe that youth is Searches) concealing contraband. The reasonable suspicion All youth are post disposition. shall be documented. (f) Searches of transgender and intersex youth shall Residential Treatment Services Bureau comply with Section 1352.5. (RTSB) Manual Section 1303: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (g) Cross-gender pat-down searches and strip searches Residential Treatment Services Bureau are prohibited except in exigent circumstances or (RTSB) Manual Section 1317: Body ☒ ☐ ☐ when conducted by a medical professional. Such Searches (Pat- Down, Strip, and Body Cavity searches must be justified and documented in Searches) writing. 1361 GRIEVANCE PROCEDURE Residential Treatment Services Bureau (RTSB) Manual Section 508: Grievance The facility administrator shall develop and Procedures implement written policies and procedures whereby any youth may appeal and have resolved grievances Grievance samples were provided from April relating to any condition of confinement, including and November 2019 for our review. Camp but not limited to health care services, classification Afflerbaugh had only 2 grievances for the decisions, program participation, telephone, mail or ☒ ☐ ☐ entire year. This was also noted/confirmed visiting procedures, food, clothing, bedding, in the Probation Commission report. Both mistreatment, harassment or violations of the were addressed in a timely manner. nondiscrimination policy. There shall be no time Compliance noted through review of limit on filing grievances. Policies and procedures documentation, from policy and through shall include provisions whereby the facility conversation with consultant staff. We were manager ensures: not onsite to view the full process. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) a grievance form and instructions for registering a Residential Treatment Services Bureau grievance, which includes provisions for the youth (RTSB) Manual Section 508: Grievance to have free access to the form; Procedures Per bureau consultant staff, grievance forms ☒ ☐ ☐ and the instructions are available in the dorms and in other areas around the facility. Youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same. (b) the youth shall have the option to confidentially file Residential Treatment Services Bureau the grievance or to deliver the form to any youth (RTSB) Manual Section 508: Grievance supervision staff working in the facility; Procedures Per bureau consultant staff, youth may submit to any staff member or submit the ☒ ☐ ☐ grievance in the confidential box or directly to the Supervisor. Youth may also submit grievances through the JIGS system. This is through LACOE laptops. Once the youth submits the grievance, it is addressed like any other paper grievance per staff we spoke with. (c) resolution of the grievance at the lowest appropriate Residential Treatment Services Bureau staff level; (RTSB) Manual Section 508: Grievance Procedures ☒ ☐ ☐ Per policy, youth may submit to any staff member, submit through the confidential box or directly to the Supervisor. In the documentation reviewed, we noted that both grievances were addressed by a supervisor. (d) provision for a prompt review and initial response Residential Treatment Services Bureau to grievances within three (3) business days, (RTSB) Manual Section 508: Grievance grievances that relate to health and safety issues Procedures ☒ ☐ ☐ must be addressed immediately; Both grievances were addressed the next day. (1) The youth may elect to be present to explain Residential Treatment Services Bureau his/her version of the grievance to a person not (RTSB) Manual Section 508: Grievance directly involved in the circumstances which ☒ ☐ ☐ Procedures led to the grievance. Neither youth requested an appeal. (2) Provision for a staff representative approved by Residential Treatment Services Bureau the facility administrator to assist the youth. ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provision for a written response to the grievance Residential Treatment Services Bureau which includes the reasons for the decisions; ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures (f) a system which provides that any appeal of a Residential Treatment Services Bureau grievance shall be heard by a person not directly (RTSB) Manual Section 508: Grievance involved in the circumstances which led to the ☒ ☐ ☐ Procedures grievance; There were no parent complaints to view. (g) resolution of the grievance must occur within ten Residential Treatment Services Bureau (10) business days unless circumstances dictate a ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance longer time frame. The youth shall be notified of Procedures any delay; and, (h) the policy shall provide multiple internal and Residential Treatment Services Bureau external methods to report sexual abuse and sexual ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance harassment. Procedures Whether or not associated with a grievance, concerns of Residential Treatment Services Bureau parents, guardians, staff or other parties shall be (RTSB) Manual Section 508: Grievance addressed and documented in accordance with written ☒ ☐ ☐ Procedures policies and procedures within a specified timeframe. There was no documentation to view. 1362 REPORTING OF INCIDENTS Residential Treatment Services Bureau (RTSB) Manual Section 1120: Reducing A written report of all incidents which result in physical Youth on Youth on Violence and 1919: harm, use of force, serious threat of physical harm, or Deaths at Camp Facilities death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the Facility administration provided multiple staff and submitted to the facility manager by the end of incident reports for incidents involving found the shift, unless additional time is necessary and contraband, youth out of bounds, unobserved authorized by the facility manager or designee. injury, school suspensions etc. All incident reports were submitted timely. 1363 USE OF REASONABLE FORCE TO Residential Treatment Services Bureau COLLECT DNA SPECIMENS, SAMPLES, (RTSB) Manual Section 306: Live Scan and IMPRESSIONS DNA Collection and 1122: Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections RTSB does not collect DNA samples. If a personnel including peace officers, may employ ☐ ☐ ☒ sample is needed, youth are transported back reasonable force to collect blood specimens, saliva to the JH’s. DSB personnel are responsible samples, and thumb or palm print impressions from for conducting all DNA Collection. The individuals who are required to provide such remaining sections are all marked as NA. samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) For the purpose of this section, the “use of Residential Treatment Services Bureau reasonable force” shall be defined as the force that (RTSB) Manual Section 306: Live Scan and an objective, trained and competent correctional DNA Collection and 1122: Juvenile employee, faced with similar facts and Collection of DNA Samples circumstances, would consider necessary and The Juvenile Halls are responsible for the reasonable to gain compliance with this section. collection of DNA samples for all detained ☐ ☐ ☒ and non- detained youth. Per policy, force will not be used to obtain DNA samples unless ordered by the court. If a youth refuses to cooperate, this information is provided to the court for further determination. (2) The use of reasonable force shall be preceded by Residential Treatment Services Bureau efforts to secure voluntary compliance. Efforts to (RTSB) Manual Section 306: Live Scan and secure voluntary compliance shall be documented DNA Collection and 1122: Juvenile ☐ ☐ ☒ and include an advisement of the legal obligation to Collection of DNA Samples provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Residential Treatment Services Bureau authorization of the supervising officer on duty. (RTSB) Manual Section 306: Live Scan and The authorization shall include information that DNA Collection and 1122: Juvenile ☐ ☐ ☒ reflects the fact that the offender was asked to Collection of DNA Samples provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Residential Treatment Services Bureau extraction, the extraction shall be videotaped. (RTSB) Manual Section 306: Live Scan and Video shall be directed at the cell extraction DNA Collection and 1122: Juvenile event. The videotape shall be retained by the Collection of DNA Samples ☐ ☐ ☒ agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County (a) School Programs Probation and Los Angeles County Office of The County Board of Education shall provide for the Education: Juvenile Courts and Community administration and operation of juvenile court Schools. schools in conjunction with the Chief Probation A Matrix was provided for our review from Officer, or designee pursuant to applicable State Sr. Director Dr. Jesus Coral that detailed all laws. The school and facility administrators shall areas of Section 1370. All policy areas for develop and implement written policy and this section are either noted in the LACOE procedures to ensure communication and Board Policy or are in the RTSB Policy. coordination between educators and probation staff. Culturally responsive and trauma-informed BSCC Field Representatives do not inspect approaches should be applied when providing the education program for compliance with instruction. Education staff should collaborate with Title 15. Title 15 requires the Superintendent of Schools to conduct this the facility administrator to use technology to review in conjunction with a qualified facilitate learning and ensure safe technology ☒ ☐ ☐ outside agency or individual. practices. The facility administrator shall request an annual review of each required element of the The education program was evaluated by program by the Superintendent of Schools, and a Kim Herrera and Karen Loucks, Principals report or review checklist on compliance, from Taft California found the education deficiencies, and corrective action needed to achieve program to comply with all regulatory compliance with this section. Such a review, when requirements. conducted, cannot be delegated to the principal or any other staff of any juvenile 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 facility administrator or designee shall review each item with the Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the BP 6011 Instruction, BP 0460 Philosophy, State Education Code and County Board of Goals, Objectives and Comprehensive Plans Education policies, all applicable federal education BP 005 Philosophy, Goals, Objectives and statutes and regulations and provide for an annual Comprehensive Plans Item 3,4,5 evaluation of the educational program offerings. As stated in the 2009 California Standards for the ☒ ☐ ☐ Teaching Profession, teachers shall establish and maintain learning 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. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. ☒ ☐ ☐ Staff 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Comprehensive Plans ☒ ☐ ☐ courses required for high school graduation. Item 3,4,5 (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California ☒ ☐ ☐ Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) ☒ ☐ ☐ and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of ☒ ☐ ☐ Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth AR-6179 Instruction BPP 5149 who do not demonstrate sufficient progress towards ☒ ☐ ☐ grade level standards. (6) The minimum school day shall be consistent with BP 6112 Instruction State Education Code Requirements for juvenile court 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 BP 6112 Instruction Partially address classification, housing, security status, disciplinary requirement; AR 5131 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 AR 5144 Students (1) Positive behavior management will be 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 BP 5021 Students CF 6020 ☒ ☐ ☐ decisions made by probation staff that may affect the educational programming of students. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension Code, expulsion/suspension from school shall be and Expulsion/Due Process (Students with imposed only when other means of correction fails Disabilities) 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 BP 5144 education staff will develop policies and procedures ☒ ☐ ☐ that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or ☒ ☐ ☐ 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 BP 6174 Instruction afforded an educational program that addresses their ☒ ☐ ☐ language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement ☒ ☐ ☐ (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction ☒ ☐ ☐ (B) Home Language Survey and the results of the State AR 6174 Instruction ☒ ☐ ☐ Test used for English language proficiency; (C) Needs and services of special populations as defined BP 6162.5 Instruction ☒ ☐ ☐ by the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. ☒ ☐ ☐ BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary BP 6162.5 Instruction ☒ ☐ ☐ education plan shall be developed for each youth within five school days. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with AR 5125 Students the State Education Code and request the youth's records from his/her prior school(s), including, but not 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 AR 5125 Students ☒ ☐ ☐ (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies ☒ ☐ ☐ 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever possible, collaborate with local post- ☒ ☐ ☐ secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Residential Treatment Services Bureau EXERCISE. (RTSB) Manual Section 1306: Programs, recreation and Exercise The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Residential Treatment Services Bureau programs, recreation, and exercise a minimum of three (RTSB) Manual Section 1306: Programs, hours a day during the week and five hours a day each recreation and Exercise Saturday, Sunday or other non-school days, of which Based on documentation provided, we are one hour shall be an outdoor activity, weather unable to determine if the Camp is providing permitting. ☐ ☒ ☐ the opportunity for programs, recreation and exercise a minimum of 3 hours during the week and 5 hours on weekends and other non-school days, one hour of which shall be out doors weather permitting. This section is non-compliant. A youth’s participation in programs, recreation, and Residential Treatment Services Bureau exercise may be suspended only upon a written finding (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ by the administrator/manager or designee that a youth recreation and Exercise represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall Residential Treatment Services Bureau be posted in the living units. (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ recreation and Exercise 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 58 - J453 JUV PRO-Eff. 01-01-2019 There will be a written annual review of the programs, Residential Treatment Services Bureau recreation, and exercise by the responsible agency to (RTSB) Manual Section 1306: Programs, ensure content offered is current, consistent, and recreation and Exercise relevant to the population. Facility administration provided a memo noting programs offered at the facility in coordination with DMH, LACOE and by Probation noting that the programs were appropriate for the youth. Programming is extensive and the listing specific to the needs of the youth. DMH provides: • Individual and Family Treatment • De-escalation and Crisis Intervention • Adaptive Dialectical Behavioral Therapy (DBT) • Substance Abuse Groups • Seeking Safety Group • Psychiatric Care as appropriate • Aftercare Planning as appropriate Probation Education Services provides: • Post-Secondary College Courses in coordination with local colleges ☒ ☐ ☐ • Work Programs • Transitional Partnership Programs • Voter Registration • Selective Services information • R.I.S.E. Curriculum Community Based Organizations provide: • Urban Strategies • Asian Youth Center-Conflict Resolution Education Training The facility provided additional documentation of programs that come into the facility, however, did not have letters to review. • Religious Services • AA • Actors’ Gang • Operation Read • LA Dads • Youth Council • Alma Family Services • Book Clubs Technical Assistance: Due to COVID, we understand the difficulties of getting documents for annual reviews. Please ensure that all reviews are available for the next 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS onsite inspection for all programs and providers. (a) Programs. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of daily (RTSB) Manual Section 1306: Programs, programming to include, but not be limited to, recreation and Exercise trauma focused, cognitive, evidence-based, best Youth are to be provided with the practice interventions that are culturally relevant and opportunity to participate in at least one hour linguistically appropriate, or pro-social interventions of programming that is rehabilitational daily. and activities designed to reduce recidivism. These A dorm calendar was provided but programs should be based on the youth’s individual documentation provided did not show needs as required by Sections 1355 and 1356. Such compliance with regulation expectations programs may be provided under the direction of the (program and time) or that the program Chief Probation Officer or the County Office of occurred. This section is non-compliant 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: ☐ ☒ ☐ (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; (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 Residential Treatment Services Bureau opportunity for at least one hour of daily access to (RTSB) Manual Section 1306: Programs, unscheduled activities such as leisure reading, letter recreation and Exercise writing, and entertainment. Activities shall be Youth are to be provided with the supervised and include orientation and may include opportunity to participate in at least one hour coaching of youth. ☐ ☒ ☐ of recreation (Known as “Free Time” in your documentation) Documentation provided notes that free time activities are provided but does not note the hour requirement. This is non-compliant. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Exercise. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of large muscle (RTSB) Manual Section 1306: Programs, activity each day. recreation and Exercise Youth are to be provided with the ☒ ☐ ☐ opportunity to participate in at least one hour of exercise. Documentation provided noted that youth receive an hour of exercise daily. The administrator/manager may suspend, for a period not Residential Treatment Services Bureau to exceed 24 hours, access to recreation and programs. (RTSB) Manual Section 1306: Programs, The administrator/manager shall document the reasons ☒ ☐ ☐ recreation and Exercise why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1004: Religious The facility administrator shall provide access to Services religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth ☒ ☐ ☐ Services are provided for both Catholic and shall be allowed to participate in an activity outside of Protestant religions. their room if he/she elects not to participate in religious programs. Religious programs shall provide for: (a) opportunity for religious services and practices; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (b) availability of clergy; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (c) availability of religious diets. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services 1373 WORK PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1003: Work Crews The facility administrator shall develop policies and procedures regarding the fair and consistent assignment • Transition Partnership Program of youth to work programs. Work assigned to a youth (TPP) ☒ ☐ ☐ shall be meaningful, constructive and related to • AJCC vocational training or increasing a youth's sense of Youth have access to 2 work programs at the responsibility. Work programs shall not be imposed as a Camp. Youth are paid and receive training disciplinary measure. through Education staff. Paychecks are provided upon release. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1374 VISITING Residential Treatment Services Bureau (RTSB) Manual Section 902: Visiting The facility administrator shall develop and implement Procedures, 903: Saturday and Sunday written policies and procedures for visiting, that include Visiting and 904: Special Visits provisions for special visits. Youth shall be allowed to receive visits by parents, guardians or persons standing Documentation provided was an individual in loco parentis, and children of youth. Other family visiting log for each youth. This form is an members, such as grandparents and siblings, and outstanding way to document all visitors that supportive adults, may be allowed to visit with the ☒ ☐ ☐ each youth had while detained in the facility. approval of the facility administrator or designee, and in A sample of a letter that is sent to parents of conjunction with the youth’s case plan or in the best youth detained in both the Juvenile Halls and interest of the youth. the camps was provided for our review. The letter was dated in September 2019 and contained information that was not updated to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to Residential Treatment Services Bureau the limitations necessary to maintain order and security. (RTSB) Manual Section 902: Visiting Visitation shall not be denied solely based on the visitor’s Procedures, 903: Saturday and Sunday criminal history. The staff shall determine in each case, Visiting and 904: Special Visits whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ Visitation occurs on Sundays from 1:00PM the safety of youth or staff in the facility. Any denial of to 4:00PM. visitation or limitation on visitations shall be communicated to the youth, person denied and facility Administration will always make exceptions administrator. for those that cannot make it on the weekend. Opportunity for visitation shall be a minimum of two Residential Treatment Services Bureau hours per week. Visits may be supervised, but (RTSB) Manual Section 902 and Visiting conversations shall not be monitored unless there is a Procedures, 903: Saturday and Sunday security or safety need. Visiting ☒ ☐ ☐ Youth have over 2 hours of visitation opportunity on the weekends and administration will make arrangements during the week for youth to have the same amount of time if needed. Provisions for special visits, in addition to the two-hour Residential Treatment Services Bureau minimum and/or outside of the regular visiting hours, (RTSB) Manual Section 902: Visiting shall be accommodated as necessary and within the Procedures, 903: Saturday and Sunday discretion of the facility administrator or designee. ☒ ☐ ☐ Visiting and 904: Special Visits 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 Residential Treatment Services Bureau alternative, but not as a replacement, to in-person (RTSB) Manual Section 902: Visiting visiting. ☒ ☐ ☐ Procedures 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 62 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1375 CORRESPONDENCE Residential Treatment Services Bureau (RTSB) Manual Section 510: Mail The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for correspondence Youth can write letters daily. Mail is also which provide that: distributed daily. (a) there is no limitation on the volume of mail that youth Residential Treatment Services Bureau may send or receive; ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (b) youth may send two letters per week postage free; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (c) youth may correspond confidentially with state and Residential Treatment Services Bureau federal courts, any member of the State Bar or holder (RTSB) Manual Section 510: Mail of 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 Residential Treatment Services Bureau in (c), may be read by staff only when there is (RTSB) Manual Section 510: Mail ☒ ☐ ☐ reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Residential Treatment Services Bureau (RTSB) Manual Section 509: Telephone The administrator of each juvenile facility shall develop ☒ ☐ ☐ Calls and implement written policies and procedures to provide youth with access to telephone communications. Youth may call home weekly. 1377 ACCESS TO LEGAL SERVICES Residential Treatment Services Bureau (RTSB) Manual Section 520: Access to The facility administrator shall develop written ☒ ☐ ☐ Legal Services 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 Residential Treatment Services Bureau attorneys and their authorized representatives; ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (b) provision for confidential consultation with Residential Treatment Services Bureau attorneys; and, ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (c) unlimited postage free, legal correspondence and Residential Treatment Services Bureau cost-free telephone access as appropriate. ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 1390 DISCIPLINE Residential Treatment Services Bureau (RTSB) Manual Section 601: Discipline, The facility administrator shall develop and implement 602: Facility Rules and 603: Behavior written policies and procedures for the discipline of Management Program youth that shall promote acceptable behavior; including ☒ ☐ ☐ the use of positive behavior interventions and supports. Discipline shall be imposed at the least restrictive level which promotes the desired behavior and Deprivation of the following is not permitted: 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) bed and bedding; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (b) daily shower, access to drinking fountain, toilet and Residential Treatment Services Bureau ☒ ☐ ☐ personal hygiene items, and clean clothing; (RTSB) Manual Section 601: Discipline (c) full nutrition; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (d) contact with parent or attorney; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (e) exercise; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (f) medical services and counseling; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (g) religious services; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (h) clean and sanitary living conditions; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (i) the right to send and receive mail; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (j) education; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (k) rehabilitative programming. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline The facility administrator shall establish rules of conduct Residential Treatment Services Bureau and disciplinary penalties to guide the conduct of youth. (RTSB) Manual Section 604: Continuum of Such rules and penalties shall include both major Correction violations and minor violations, be stated simply and ☒ ☐ ☐ Information regarding the rules is provided affirmatively, and be made available to all youth. in the orientation and BMP handbooks that Provision shall be made to provide accessible are provided to the youth at orientation. information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS Residential Treatment Services Bureau (RTSB) Manual Section 604: Continuum of The facility administrator shall develop and implement ☒ ☐ ☐ Correction and 606: Due Process written policies and procedures for the administration of discipline which shall include, but not be limited to: (a) designation of personnel authorized to impose Residential Treatment Services Bureau discipline for violation of rules; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (b) prohibiting discipline to be delegated to any youth; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (c) definition of major and minor rule violations and Residential Treatment Services Bureau their consequences, and due process requirements; ☒ ☐ ☐ (RTSB) Manual Section 604: Continuum of Correction (d) trauma-informed approaches and positive behavior Residential Treatment Services Bureau interventions; ☒ ☐ ☐ (RTSB) Manual Section 602: Facility Rules and 604: Continuum of Correction 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 64 - J453 JUV PRO-Eff. 01-01-2019 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections Applicable Title 24 Regulations: Pre-1998* BSCC Code: 7207 FACILITY NAME: FACILITY TYPE: Camp Clinton Afflerbaugh Camp CONSTRUCTION/REMODEL DATE(S): 1960 IDENTIFY FACILITY PHYSICAL PLANT MODIFICATIONS SINCE 1992: FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS RECEPTION AREA (JH) This applies only to Juvenile Halls. ✓ Holding Rooms: Contain 15 square feet per minor; Have sufficient seating to accommodate the rated ✓ capacity based on floor space; Provide access to water closets and wash basins ✓ at a ratio of a 1:8; and Provide access to drinking fountain. ✓ Provide access to telephone. ✓ Provide access to private room(s) for interviews. ✓ MEDICAL EXAM SPACE (JH & CAMP) Space or room(s) afford privacy, are equipped to carry ✓ out routine examinations and emergency care and have sufficient locked storage space for medical supplies. LIVING UNITS (JH AND SPJH) ✓ Living units are designed to accommodate no more than 30 minors and contain: Showers at a ratio of 1:6; ✓ Washbasins at a ratio of 1:6; ✓ Water closets at a ratio of 1:6 or water closet and ✓ one urinal for every 15 boys; and, Access to a drinking fountain by minors and staff. ✓ Doors of each sleeping room have a view panel (maximum of 144 square inches of shatter-proof glass ✓ or plastic materials) that allows the visual supervision of all parts of the room. Hallways in the detention living units are at least eight feet wide. If rooms are located on only one side, or if ✓ room doors are staggered, hallways are at least six feet wide. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7207 Los Angeles Camp Afflerbaugh 18-20 PHY - 1 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SINGLE ROOMS (JH, SPJH & CAMP) Contain a minimum of 500 cubic feet of air space and ✓ 63 cubic feet of floor space. DOUBLE ROOMS (JH, SPJH & CAMP) ✓ Contain a minimum of 800 cubic feet of airspace and 100 square feet of floor space. DORMITORY SLEEPING AREAS (JH & CAMP) ✓ Contain a minimum of 400 cubic feet of airspace and 50 square feet of floor space per minor. LOCKED SLEEPING ROOMS (JH, SPJH & CAMP) Contain an individual or combination drinking fountain, ✓ wash basin and toilet, unless a communication system or procedure is in effect to give minor immediate access to these fixtures. PLUMBING FIXTURES (CAMP) The following plumbing fixtures are adjacent to each ✓ sleeping area: Shower or bathtub at a ratio of 1:6; Washbasins at a ratio of 1:10; ✓ Access to toilets at a ratio of 1:10 or toilet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain. ✓ BEDS AND MATTRESSES (JH, SPJH & CAMP) Beds and mattresses are: ✓ A least 30 inches wide and 76 inches long; Spaced at least 36 inches apart and at least 12 ✓ inches off the floor; and, Mattresses are made of a fire-retardant material. ✓ INTERVIEW ROOMS (JH, SPJH & CAMP) ✓ There is one interview room for each detention unit in juvenile halls and special purpose juvenile halls. There is a private room suitably equipped for ✓ conferences and interviews in each camp. LIGHTING (JH, SPJH & CAMP) There are at least 50-foot candles of illumination at ✓ desk level and, at night, there is a maximum illumination of two foot candles at bed level in individual and multiple occupancy rooms. ACADEMIC CLASSROOM (JH & CAMP) Camps Afflerbaugh and Paige share the academic classrooms. Each classroom contains a minimum of 160 square feet with a teacher's desk and work area, and a ✓ minimum of 28 square feet per student. Classrooms should be designed for no more than 15 students. 98: Designed for no more than 20 students *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7207 Los Angeles Camp Afflerbaugh 18-20 PHY - 2 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS DINING SPACE (JH & CAMP) ✓ There is a minimum of 15 square feet of space for each person being fed at any given time. PHYSICAL ACTIVITY SPACE (JH & CAMP) (See 2001 regulations for revised calculations.) There is indoor space consisting of at least 30 square ✓ feet of clear space for each minor, which may be included in a day room, a recreational building, or a multipurpose space (gymnasium). There is outdoor and/or multipurpose (gymnasium) space consisting of: ✓ No less than the equivalent of 90' X 100' outdoor and /or multipurpose space (gymnasium) for a facility with a capacity of 40 or less. No less than the equivalent of 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40, and a juvenile hall with a capacity between 41 to 100 minors. No less than the equivalent of two 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40 and a juvenile hall with a capacity in excess of 101 minors. Lighting is adequate for security and evening ✓ recreational activities in camps. STORAGE SPACE (JH, SPJH & CAMP) ✓ Each minor is provided 9 cubic feet of secure storage space for personal clothing and belongings. Camps shall have adequate space (12 square feet of floor area is recommended) for bulk and activity ✓ storage equipment. MULTIPURPOSE SPACE OR ROOM (SPJH) This applies only to Special Purpose Juvenile Halls. There is a multipurpose space or room that provides space for reception, dining, recreation, exercise and/or ✓ education. This room contains a minimum of: 30 square feet of clear floor space per minor in the ✓ room; 10 feet by 20 feet floor dimensions; and, ✓ 1600 cubic feet of air space with a minimum ✓ ceiling height of eight feet. SPECIAL PURPOSE JH EXEMPTIONS SPJHs are exempt from the following Pre-1998 Title 15 regulations: ✓ Section 4272(b) Medical exam rooms Section 4272(m) Academic classrooms Section 4272(n) Dining space Section 4272(o) Physical activities space *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7207 Los Angeles Camp Afflerbaugh 18-20 PHY - 3 - J455 PHY Pre-98.dot (03/01) TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) minor rule violations may be handled informally by Residential Treatment Services Bureau counseling, advising the youth of expected conduct (RTSB) Manual Section 604: Continuum of imposing a minor consequence. Discipline shall be Correction accompanied by written documentation and a ☐ ☒ ☐ policy of review and appeal to a supervisor; and, No documentation of minor rule violations provided separate than sanctions and appeals form with PIR’s (f) major rule violations and the discipline process Residential Treatment Services Bureau shall be documented and require the following: ☒ ☐ ☐ (RTSB) Manual Section 606: Due Process 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 65 - J453 JUV PRO-Eff. 01-01-2019 (1) written notice of violation prior to a hearing; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process There is no location/space for notice of violation on the current form. Policy is consistent with regulation requirements; documentation is not. Facility staff provided Sanctions and Appeals forms that are required for all PIR SCM packets. Technical assistance has previously been provided and discussed with Bureau Management regarding the sanctions and appeal form and the need to revise and change the form to ensure compliance. We were assured this would be revised/updated to be more consistent to address the regulation requirements. This issue was addressed with the Prior Bureau Chief and consultant staff and it was agreed a new form would be implemented for this next cycle. The form does not provide proof of notice of violation and the recommendations noted are not the actual sanctions being recommended or imposed. All sanctions must be noted and ☐ ☒ ☐ made a part of this process and Youth must have the option of a due process hearing on the actual consequences and sanctions they receive. We have confirmed agency staff have corrected policy and forms to correct this issue however, we are unable to determine implementation. This is currently non- compliant. We appreciate the efforts that have been made and look forward to reviewing documentation in the near future to review for compliance. We will continue to follow up with the agency to provide support and technical assistance as needed. Documentation provided from Camp Afflerbaugh as well as other camps was completed on the same forms as previously used in past cycles. Due process is being conducted on removals to the HOPE Center, DMH referrals and in some cases, on no action at all. In addition, policy requires staff to document the major rule violation on the incident report which we did not find evidence of and policy states that all 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS penalties are held in abeyance pending the outcome of the hearing. (2) accommodations provided to youth with Residential Treatment Services Bureau disabilities, limited literacy, and English (RTSB) Manual Section 606: Due Process language learners; Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (3) hearing by a person who is not a party to the Residential Treatment Services Bureau incident; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK (4) opportunity for the youth to be heard, present Residential Treatment Services Bureau evidence and testimony; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (5) provision for youth to be assisted by staff in the Residential Treatment Services Bureau hearing process; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. . (6) provision for administrative review. Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (g) violations that result in a removal from camp or Residential Treatment Services Bureau commitment program, but not a return to court, will (RTSB) Manual Section 604: Continuum of ☒ ☐ ☐ follow the due process provisions in subsection (e) Correction above. f 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 67 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the ☒ ☐ ☐ facility. (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Viol Dependent or neglected minors who are defined under ☐ ☐ ation Section 300 of the Welfare and Institutions 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 ☐Viol ☐ ☒ Juvenile Delinquents (WIC 602)? (WIC 207[d]). ation 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 ☐Viol ☐ ☒ from minors. ation Adult inmates from an adult facility (e.g. inmate workers or ☐Viol “Scared Straight” programs) are not allowed in the facility ☐ ☒ ation in a manner that allows contact with minors. 7207 Los Angeles Camp Afflerbaugh 18-20 PRO - 68 - J453 JUV PRO-Eff. 01-01-2019 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections Applicable Title 24 Regulations: Pre-1998* BSCC Code: 7207 FACILITY NAME: FACILITY TYPE: Camp Clinton Afflerbaugh Camp CONSTRUCTION/REMODEL DATE(S): 1960 IDENTIFY FACILITY PHYSICAL PLANT MODIFICATIONS SINCE 1992: FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS RECEPTION AREA (JH) This applies only to Juvenile Halls. ✓ Holding Rooms: Contain 15 square feet per minor; Have sufficient seating to accommodate the rated ✓ capacity based on floor space; Provide access to water closets and wash basins ✓ at a ratio of a 1:8; and Provide access to drinking fountain. ✓ Provide access to telephone. ✓ Provide access to private room(s) for interviews. ✓ MEDICAL EXAM SPACE (JH & CAMP) Space or room(s) afford privacy, are equipped to carry ✓ out routine examinations and emergency care and have sufficient locked storage space for medical supplies. LIVING UNITS (JH AND SPJH) ✓ Living units are designed to accommodate no more than 30 minors and contain: Showers at a ratio of 1:6; ✓ Washbasins at a ratio of 1:6; ✓ Water closets at a ratio of 1:6 or water closet and ✓ one urinal for every 15 boys; and, Access to a drinking fountain by minors and staff. ✓ Doors of each sleeping room have a view panel (maximum of 144 square inches of shatter-proof glass ✓ or plastic materials) that allows the visual supervision of all parts of the room. Hallways in the detention living units are at least eight feet wide. If rooms are located on only one side, or if ✓ room doors are staggered, hallways are at least six feet wide. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7207 Los Angeles Camp Afflerbaugh 18-20 PHY - 1 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SINGLE ROOMS (JH, SPJH & CAMP) Contain a minimum of 500 cubic feet of air space and ✓ 63 cubic feet of floor space. DOUBLE ROOMS (JH, SPJH & CAMP) ✓ Contain a minimum of 800 cubic feet of airspace and 100 square feet of floor space. DORMITORY SLEEPING AREAS (JH & CAMP) ✓ Contain a minimum of 400 cubic feet of airspace and 50 square feet of floor space per minor. LOCKED SLEEPING ROOMS (JH, SPJH & CAMP) Contain an individual or combination drinking fountain, ✓ wash basin and toilet, unless a communication system or procedure is in effect to give minor immediate access to these fixtures. PLUMBING FIXTURES (CAMP) The following plumbing fixtures are adjacent to each ✓ sleeping area: Shower or bathtub at a ratio of 1:6; Washbasins at a ratio of 1:10; ✓ Access to toilets at a ratio of 1:10 or toilet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain. ✓ BEDS AND MATTRESSES (JH, SPJH & CAMP) Beds and mattresses are: ✓ A least 30 inches wide and 76 inches long; Spaced at least 36 inches apart and at least 12 ✓ inches off the floor; and, Mattresses are made of a fire-retardant material. ✓ INTERVIEW ROOMS (JH, SPJH & CAMP) ✓ There is one interview room for each detention unit in juvenile halls and special purpose juvenile halls. There is a private room suitably equipped for ✓ conferences and interviews in each camp. LIGHTING (JH, SPJH & CAMP) There are at least 50-foot candles of illumination at ✓ desk level and, at night, there is a maximum illumination of two foot candles at bed level in individual and multiple occupancy rooms. ACADEMIC CLASSROOM (JH & CAMP) Camps Afflerbaugh and Paige share the academic classrooms. Each classroom contains a minimum of 160 square feet with a teacher's desk and work area, and a ✓ minimum of 28 square feet per student. Classrooms should be designed for no more than 15 students. 98: Designed for no more than 20 students *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7207 Los Angeles Camp Afflerbaugh 18-20 PHY - 2 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS DINING SPACE (JH & CAMP) ✓ There is a minimum of 15 square feet of space for each person being fed at any given time. PHYSICAL ACTIVITY SPACE (JH & CAMP) (See 2001 regulations for revised calculations.) There is indoor space consisting of at least 30 square ✓ feet of clear space for each minor, which may be included in a day room, a recreational building, or a multipurpose space (gymnasium). There is outdoor and/or multipurpose (gymnasium) space consisting of: ✓ No less than the equivalent of 90' X 100' outdoor and /or multipurpose space (gymnasium) for a facility with a capacity of 40 or less. No less than the equivalent of 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40, and a juvenile hall with a capacity between 41 to 100 minors. No less than the equivalent of two 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40 and a juvenile hall with a capacity in excess of 101 minors. Lighting is adequate for security and evening ✓ recreational activities in camps. STORAGE SPACE (JH, SPJH & CAMP) ✓ Each minor is provided 9 cubic feet of secure storage space for personal clothing and belongings. Camps shall have adequate space (12 square feet of floor area is recommended) for bulk and activity ✓ storage equipment. MULTIPURPOSE SPACE OR ROOM (SPJH) This applies only to Special Purpose Juvenile Halls. There is a multipurpose space or room that provides space for reception, dining, recreation, exercise and/or ✓ education. This room contains a minimum of: 30 square feet of clear floor space per minor in the ✓ room; 10 feet by 20 feet floor dimensions; and, ✓ 1600 cubic feet of air space with a minimum ✓ ceiling height of eight feet. SPECIAL PURPOSE JH EXEMPTIONS SPJHs are exempt from the following Pre-1998 Title 15 regulations: ✓ Section 4272(b) Medical exam rooms Section 4272(m) Academic classrooms Section 4272(n) Dining space Section 4272(o) Physical activities space *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7207 Los Angeles Camp Afflerbaugh 18-20 PHY - 3 - J455 PHY Pre-98.dot (03/01) JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION Board of State and Community Corrections Inspection BSCC Code: 7207 FACILITY: TYPE: RC: Camp Clinton Afflerbaugh Camp 105 FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ROOMS EACH ROOM Applicabl Each Room Size (L x W x H) FIXTURES* Unit # Room e # RC Total or T U W F S COMMENTS Designati Room Type Standard Beds RC Square/Cubic on s s Feet Dormitory Dorm Pre-98 1 105 105 105 160’ x 39’ 2 Workstation –13’ x 14’ =6,058 Dayroo Pre-98 19’ x 40’ = 760 m Restroo Pre-98 1 9 1 2 1 m 2 4 7 Historical Notes: Camps Afflerbaugh and Paige share academic classrooms. 2011: The original construction included a double occupancy room. That space was adjacent to the Nurse’s office and has been converted to additional medical space. There is no intention to return it to its original purpose. It has been removed from the LASE. 2013: One of the toilets was inoperable on the date of the inspection. 2014-2016 Inspection Cycle Notes: RC stands at 105 however the facility has removed beds to provide for programing space, mental health staff offices etc. Changes have occurred in a way beds can be re installed in a matter of a few days. 2016-2018 Inspection Cycle Notes: RC is 105 however only 61 beds were present. Dorm is set up in groups- Alpha, Bravo, Charlie and Delta 2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only. *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. 7207 Los Angeles Camp Afflerbaugh 18-20 LAS - 1 - J460 LAS JUV-05.dot (8/05) JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7232 FACILITY NAME: FACILITY TYPE: Campus Kilpatrick Juvenile Camp PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, DPO II; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 Virtual Documentation Review TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND Residential Treatment Services Bureau EVALUATION OF BUILDING AND GROUNDS (RTSB) Manual Section -2001: Inspections On an annual basis, or as otherwise required by law, and Evaluation of Building and Grounds each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Residential Treatment Services Bureau the Board of Supervisors to approve building safety; (RTSB) Manual Section -2002: Types of Inspections and Evaluations 2018 inspections were verified to have occurred. ☐ ☐ ☒ 2019 Campus Kilpatrick was evacuated and vacant from November 9, 2018 to July 17, 2020 due to fire and damage to the grounds from the Woolsey Fire. The facility was not inspected in 2019. The facility will be inspected as part of the upcoming inspections as the facility is again operational at this time. (B) Fire authority having jurisdiction, including a fire Residential Treatment Services Bureau clearance as required by Health and Safety Code (RTSB) Manual Section -2002: Types of Section 13146.1 (a) and (b); Inspections and Evaluations ☒ ☐ ☐ The fire inspection was completed by Los Angeles County Fire Department on 12/12/19. 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. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Local health officer, inspection in accordance with Residential Treatment Services Bureau Health and Safety Code Section 101045; (RTSB) Manual Section -2002: Types of Inspections and Evaluations Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the Environmental Health (EH) inspections as noted below. 2018 Inspections were verified to have occurred. The 2019 Inspection is noted as follows: ☐ ☒ ☐ Campus Kilpatrick was evacuated and vacant from November 9, 2018 to July 17, 2020 due to fire and damage to the grounds from the Woolsey Fire. The facility was not inspected in 2019. The facility will be inspected as part of the upcoming inspections as the facility is again operational as at this time. Youth were housed temporarily at the Challenger Youth Memorial Camp. That facility was inspected by Public Health as follows: Environmental Health: February 20-21, 2019. Nutritional Health: February 20-21, 2019. Medical/Mental Health: January 29-30 and February 20-21, 2019. There are outstanding corrections necessary for all inspections. (D) County superintendent of schools on the adequacy Residential Treatment Services Bureau of educational services and facilities as required in (RTSB) Manual Section -2002: Types of Section 1370; Inspections and Evaluations Education for the is provided by the Los Angeles County Office of Education. ☒ ☐ ☐ 2019 The education program was evaluated by Kim Herrera and Karen Loucks, Principals from Taft California found the education program to comply with all regulatory requirements. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (E) Juvenile court as required by Section 209 of the Residential Treatment Services Bureau Welfare and Institutions Code (RTSB) Manual Section -2002: Types of ☐ ☐ ☒ Inspections and Evaluations No documentation provided. Not required for Juvenile Camps. (F) Juvenile Justice Commission as required by Section Residential Treatment Services Bureau 229 of the Welfare and Institutions Code or (RTSB) Manual Section -2002: Types of Probation Commission as required by Section 240 of Inspections and Evaluations the Welfare and Institutions Code. ☐ ☒ ☐ A report was not completed for Campus Kilpatrick. The youth were housed at Challenger temporarily due to being evacuated. A report was not completed for either site. 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is received from Chief Probation Officer Terri determined by receipt of the Chief Probation Officer’s McDonald certifying that appointments and qualifications of agency staff comply with all certification letter confirming that all elements of elements of regulation. regulation are met. (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: (1) recruit and hire employees who possess 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 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 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ accordance with Section 1031 et seq. of the Government Code. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract employees of the facility, who may be present at the personnel, volunteers and other non- facility, shall have such clearance and qualifications employees participate in background checks and are approved through each facility for as may be required by law, and their presence at the ☒ ☐ ☐ entrance except for LACOE who conducts facility shall be subject to the approval and control of their own criminal records review as the facility manager. required by the Probation Department. Probation maintains control as to who has access into the facility. 1321 STAFFING Residential Treatment Services Bureau (RTSB) Manual Section -206: Staffing Each juvenile facility shall: Random dates were requested throughout the cycle for review. Documentation was provided from October 2019 and December 2019 of facility staffing schedules. Staffing schedules noted population in the dorm, staffing levels and noted the supervisor on duty. Also provided were facility staffing lists including vacancies and DMH clinician caseloads and schedules were provided to determine adequacy of staffing levels. It appears the facility was staffed appropriately for the number of youth housed. a) have an adequate number of personnel sufficient to Residential Treatment Services Bureau carry out the overall facility operation and its (RTSB) Manual Section -206: Staffing programming, to provide for safety and security of ☒ ☐ ☐ youth and staff, and meet established standards and regulations; b) ensure that no required services shall be denied Residential Treatment Services Bureau because of insufficient numbers of staff on duty ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing absent exigent circumstances; c) have a sufficient number of supervisory level staff to Residential Treatment Services Bureau ensure adequate supervision of all staff members; (RTSB) Manual Section -206: Staffing At the time of inspection, Campus Kilpatrick ☒ ☐ ☐ had 11 supervisors assigned to the facility with one vacancy. The facility has an awake supervisor on duty throughout the late-night hours. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS d) have a clearly identified person on duty at all times Residential Treatment Services Bureau who is responsible for operations and activities and (RTSB) Manual Section -206: Staffing has completed the Juvenile Corrections Officer Core Course and PC 832 training; The facility director is responsible for the ☒ ☐ ☐ overall operations of the facility, but the duty supervisor is responsible for the daily operations of the facility. Campus Kilpatrick also identifies a group leader for each cottage. e) have at least one staff member present on each living Residential Treatment Services Bureau unit whenever there are youth in the living unit; (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ There is always a staff present in the dorm or where a youth is present. Youth are never left alone per consultant staff. f) have sufficient food service personnel relative to the Residential Treatment Services Bureau number and security of living units, including staff (RTSB) Manual Section -206: Staffing qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen The facility has a full dining hall. All youth supervision; direct food preparation and servings; ☒ ☐ ☐ eat their meals in the dining hall unless they conduct related training programs for culinary staff; refuse to leave the dorm. The dining hall is and maintain necessary records; or, a facility may staffed by facility cooks who plan and serve food that meets nutritional standards prepared prepare all meals. Cooks do not supervise by an outside source; youth. g) have sufficient administrative, clerical, recreational, Residential Treatment Services Bureau medical, dental, mental health, building (RTSB) Manual Section -206: Staffing maintenance, transportation, control room, facility ☒ ☐ ☐ security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Residential Treatment Services Bureau continuous wide-awake supervision of youth, (RTSB) Manual Section -206: Staffing subject to 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: (1) Juvenile Halls (minimum youth-staff ratio) Facility is not a Juvenile Hall. (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 Facility is not a Juvenile Hall. room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth in detention; 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff Facility is not a Juvenile Hall 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 Facility is not a Juvenile Hall ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other Facility is not a Juvenile Hall duties such as administration, supervision of ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile staff ratio) Hall ☐ ☐ ☒ (A) during hours that youth are awake, one wide-awake youth supervision staff member is on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room Facility is not a Special Purpose Juvenile for the purpose of sleeping, one wide-awake youth ☐ ☐ ☒ Hall supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff Facility is not a Special Purpose Juvenile members on duty at all times, regardless of the Hall ☐ ☐ ☒ 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 Facility is not a Special Purpose Juvenile who is the same gender as youth housed in the Hall ☐ ☐ ☒ facility. (E) personnel with primary responsibility for other Facility is not a Special Purpose Juvenile duties such as administration, supervision of Hall ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Residential Treatment Services Bureau (A) during the hours that youth are awake, one wide- ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau room for the purpose of sleeping, one wide-awake ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing youth supervision staff member on duty for each 30- youth present in the facility; 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff Residential Treatment Services Bureau members on duty at all times, regardless of the (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau who is the same gender as youth housed in the (RTSB) Manual Section -206: Staffing facility; ☒ ☐ ☐ There are always male and female staff on duty. (E) in addition to the minimum staff to youth ratio Residential Treatment Services Bureau required in (h)(3)(A)-(B), consideration shall be (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau duties such as administration, supervision of (RTSB) Manual Section -206: Staffing personnel, academic or trade instruction, clerical, ☒ ☐ ☐ Only youth supervision staff provide farm, forestry, kitchen or maintenance shall not be supervision of the youth. classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF Residential Treatment Services Bureau ORIENTATION AND TRAINING (RTSB) Manual -2104: Professional (a) Prior to assuming any responsibilities each youth Development and Training (policy is supervision staff member shall be properly oriented compliant) to their duties, including: All staff assigned to RTSB have completed Correctional Officer CORE training prior to reporting to the facility. Upon assignment, each staff is paired with a onsite training officer who assists them in ☒ ☐ ☐ their orientation and training. Training transcripts were provided as verification of required training which includes CORE. These training transcripts documented the mandated trainings We were unable to view individual training files for the specific location training as we were not on site. Compliance is based on policy. We will verify training documents when back on site. (1) youth supervision duties; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) scope of decisions they shall make; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (3) the identity of their supervisor; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) the identity of persons who are responsible to Residential Treatment Services Bureau them; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) persons to contact for decisions that are beyond Residential Treatment Services Bureau their responsibility; and ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (6) ethical responsibilities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (b) Prior to assuming any responsibility for the Residential Treatment Services Bureau supervision of youth, each youth supervision staff (RTSB) Manual -2104: Professional ☒ ☐ ☐ member shall receive a minimum of 40 hours of Development and Training facility-specific orientation, including: (1) individual and group supervision techniques; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) regulations and policies relating to discipline and Residential Treatment Services Bureau rights of youth pursuant to law and the ☒ ☐ ☐ (RTSB) Manual -2104: Professional provisions of this chapter; Development and Training (3) basic health, sanitation and safety measures; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) suicide prevention and response to suicide Residential Treatment Services Bureau attempts ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) policies regarding use of force, de-escalation Residential Treatment Services Bureau techniques, chemical agents, mechanical and (RTSB) Manual -2104: Professional physical restraints; Development and Training ☒ ☐ ☐ The facility does not use chemical agents in the camp setting. (6) review of policies and procedures referencing Residential Treatment Services Bureau trauma and trauma-informed approaches; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (7) procedures to follow in the event of Residential Treatment Services Bureau emergencies; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (8) routine security measures, including facility Residential Treatment Services Bureau perimeter and grounds; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (9) crisis intervention and mental health referrals to Residential Treatment Services Bureau mental health services; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (10) documentation; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (11) fire/life safety training Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (c) Prior to assuming sole supervision of youth, each Residential Treatment Services Bureau youth supervision staff member shall successfully (RTSB) Manual -2104: Professional complete the requirements of the Juvenile ☒ ☐ ☐ Development and Training Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer Residential Treatment Services Bureau youth supervision staff shall successfully complete (RTSB) Manual -2104: Professional ☒ ☐ ☐ training pursuant to Section 830 et seq. of the Penal Development and Training Code. 1323 FIRE AND LIFE SAFETY Residential Treatment Services Bureau (RTSB) Manual -2104: Professional Whenever there is a youth in a juvenile facility, there Development and Training shall be at least one wide awake person on duty at all ☒ ☐ ☐ times who meets the training standards established by the All staff are trained in fire and life safety in Board for general fire and life safety which relate CORE training. All Supervisors have been specifically to the facility. trained. There will always be a supervisor on duty. 1324 POLICY AND PROCEDURES MANUAL The agency manual is specific to RTSB and All facility administrators shall develop, publish, and camp operations and has been provided to the implement a manual of written policies and procedures BSCC for review. The manual was last that address, at a minimum, all regulations that are reviewed and updated in June 2020. applicable to the facility. Such a manual shall be made available to all employees, reviewed by all employees, The BSCC has reviewed the agency Policy and shall be administratively reviewed at a minimum and Procedure as provided to us specific to every two years, and updated, as necessary. Those regulations and has confirmed the policies records relating to the standards and requirements set and procedure exist as cited. There may be forth in these regulations shall be accessible to the Board cites noted in the comments that may not on request. match due to updates that were unable to be The manual shall include: reverified. ☒ ☐ ☐ Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. In all cases, copies of policies and directives were provided that were not from the current manual. Technical assistance provided and discussed that this should be rectified. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) table of organization, including channels of Residential Treatment Services Bureau communications and a description of job (RTSB) Manual Sections: classifications; • 101: Vision, Mission, and Core Values • 102: Role of the Camp System • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff • 207: Organizational Chart The manual has a table of contents. They agency channel of communication follows chain of command. (b) responsibility of the probation department, purpose Residential Treatment Services Bureau of programs, relationship to the juvenile court, the (RTSB) Manual Sections: Juvenile Justice/Delinquency Prevention • 101: Vision, Mission, and Core Commission or Probation Committee, probation Values staff, school personnel and other agencies that are • 102: Role of Camp System involved in juvenile facility programs; • 908: Medical Services ☒ ☐ ☐ • 909: Mental Health Services • 910: Educational Services • 1005: Community Based Organizations • 1006: Volunteers (c) responsibilities of all employees; Residential Treatment Services Bureau (RTSB) Manual Sections: • 202: RTSB Administrative Structure 203: Duty Statements, RTSB ☒ ☐ ☐ Management • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff (d) initial orientation and training program for Residential Treatment Services Bureau employees; (RTSB) Manual -2104: Professional Development and Training ☒ ☐ ☐ See Section 1322 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) initial orientation, including safety and security Residential Treatment Services Bureau issues and anti-discrimination policies, for support (RTSB) Manual -2200: Non-Sworn staff, contract employees, school, mental/behavioral Personnel and Partner Agencies Handbook health and medical staff, program providers and ☐ ☐ UNK Unable to view employee training files as not volunteers; on site. Compliance is based on policy. We will verify training documents when back on site. (f) maintenance of record-keeping, statistics and Residential Treatment Services Bureau communication system to ensure: (RTSB) Manual 701: Case Planning and Procedures and 702-General Duties and Responsibilities RTSB maintains an extensive record- keeping system (PCMS) to record operations and to report on the youth in its’ care. Through these reports, the RTSB is able to document and retrieve accurate ☒ ☐ ☐ accounts of specific incidents or operations and to develop a database for statistical analysis. The assigned camp DPO is responsible for the casework functions while the youth is in the camp setting. The supervisor is responsible to ensure that all information is thoroughly documented within the Probation Case Management System. (1) efficient operation of the juvenile facility; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (2) legal and proper care of youth; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (3) maintenance of individual youth's records; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (4) supply of information to the juvenile court and Residential Treatment Services Bureau those authorized by the court or by the law; and, (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (5) release of information regarding youth. Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (g) ethical responsibilities; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-2130: Employee Honesty (h) trauma-informed approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-518: Trauma Informed Approaches (i) culturally responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-519: Culturally Responsive Approaches (j) gender responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-517: Promoting Dignity for Female Youth Housed in RTSB (k) a non-discrimination provision that provides that all Residential Treatment Services Bureau youth within the facility shall have fair and equal (RTSB) Manual-2110: Non-Discrimination access to all available services, placement, care, Policy treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group ☒ ☐ ☐ identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Residential Treatment Services Bureau chemical agents related security devices, and (RTSB) Manual-1922: Weapons and ☒ ☐ ☐ weapons and ammunition, where applicable; Ammunition (m) establishment of procedures for collection of Medi- Residential Treatment Services Bureau Cal eligibility information and enrollment of eligible ☒ ☐ ☐ (RTSB) Manual-706: Case Plan Activities youth; and, (n) establishment of a policy that prohibits all forms of Residential Treatment Services Bureau sexual abuse, sexual assault and sexual harassment. (RTSB) Manual-1600: Prison Rape The policy shall include an approach to preventing, Elimination Act detecting and responding to such conduct and any retaliation for reporting such conduct, as well as a ☒ ☐ ☐ Staff are trained in PREA within their first provision for reporting such conduct by youth, staff year of employment and every two years or a third party. thereafter. 1325 FIRE SAFETY PLAN Residential Treatment Services Bureau The facility administrator shall consult with the local fire (RTSB) Manual-1910: Fire Prevention and department having jurisdiction over the facility, or with ☒ ☐ ☐ Suppression and 1917: Emergency the State Fire Marshal, in developing a plan for fire safety Evacuation which shall include, but not be limited to: a) a fire prevention plan to be included as part of the Residential Treatment Services Bureau manual of policy and procedures; (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS b) monthly fire and life safety inspections by facility Residential Treatment Services Bureau staff with two- year retention of the inspection (RTSB) Manual-1910: Fire Prevention and record; Suppression ☒ ☐ ☐ Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. c) fire prevention inspections as required by Health Residential Treatment Services Bureau and Safety Code Section 13146.1(a) and (b); (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression See Section 1313 d) an evacuation plan; Residential Treatment Services Bureau (RTSB) Manual Sections: 1910: Fire Prevention and Suppression 1917: Emergency Evacuation ☒ ☐ ☐ Facility provided County of Los Angeles Building Emergency Plan with site evacuation maps for our review. e) documented fire drills not less than quarterly; Residential Treatment Services Bureau (RTSB) Manual-1910: Fire Prevention and Suppression ☒ ☐ ☐ Fire drills are completed quarterly. All drills were completed except for one. Facility had to evacuate the full facility during that quarter and did not return for 18 months. f) a written plan for the emergency housing of youth in Residential Treatment Services Bureau the case of fire; and, (RTSB) Manual-1917: Emergency Evacuation ☒ ☐ ☐ Emergency housing will always be at one of the camps or juvenile halls dependent on location of the fire and a safe route of travel. g) development of a fire suppression pre-plan in Residential Treatment Services Bureau cooperation with the local fire department. (RTSB) Manual-1910: Fire Prevention and Suppression ☒ ☐ ☐ The County of Los Angeles Building Emergency Plan for Campus Kilpatrick. was signed by Fire Inspector Norris on April 3, 2020. 1326 SECURITY REVIEW Residential Treatment Services Bureau (RTSB) Manual- 1312: Security Checks Each facility administrator shall develop policies and procedures to annually review, evaluate, and document ☒ ☐ ☐ Security review was completed March 16, security of the facility. The review and evaluation shall 2019 by Directors Beigh and Williams. include internal and external security, including, but not limited to, key control, equipment, and staff training. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1327 EMERGENCY PROCEDURES Facility provided and utilizes (in addition to the Bureau Policy Manual), the County of The facility administrator shall develop facility-specific Los Angeles Building Emergency Plan. Both policies and procedures for emergencies that shall documents have emergency procedures include, but not be limited to: ☒ ☐ ☐ regarding the facilities. We did not review the documents for comparison and suggest that the agency review and compare to ensure there are no inconsistencies. (a) escape, disturbances, and the taking of hostages; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1907 Escapes 1909: Major Disturbances 1914: Hostages (b) civil disturbance, active shooter and terrorist attack; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1908: Outside Intruder 1915: Active Shooter 1916: Terrorist Attack (c) fire and natural disasters; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1910: Fire Prevention and Suppression 1913: Earthquake (d) periodic testing of emergency equipment; Residential Treatment Services Bureau (RTSB) Manual Sections: 1321: Testing of Emergency Equipment ☒ ☐ ☐ Internal Services Department (ISD) conducts monthly and as needed testing in coordination with MSB. (e) emergency evacuation of the facility; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections: 1917: Emergency Evacuation (f) a program to provide all youth supervision staff Residential Treatment Services Bureau with an annual review of emergency procedures. (RTSB) Manual Sections: 1903: Staff Roles and Responsibilities A Memo was provided dated September 9th, ☒ ☐ ☐ 2019, from Assistant Director Anthony Lewis stating that all staff have been trained on the Annual Emergency Procedures Review. Staff were listed by name and by unit. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1328 SAFETY CHECKS Residential Treatment Services Bureau (RTSB) Manual Sections: 1313: Safety The facility administrator shall develop and implement Checks and Section 1119 policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, Documentation of Safety Checks were at random or varied intervals during hours when youth provided for September and November 2019. are asleep or when youth are in their rooms, confined in We reviewed random checks from the holding cells or confined to their bed in a dormitory. documentation provided and found that they Supervision is not replaced, but may be supplemented were not consistently completed at random by, an audio/visual electronic surveillance system and varied intervals per regulation designed to detect overt, aggressive or assaultive requirements. behavior and to summon aid in emergencies. All safety In preparation for inspection, facility checks shall be documented with the actual time the managers noted areas of deficiency. check is completed. Corrective action was initiated which included correction with supervisors. Subsequent documentation was reviewed and there was improvement noted. Technical assistance provided to further improve ☒ ☐ ☐ enhance the quality of the checks for when we return on site. Policy also requires supervisors to regularly audit safety check logs by making unannounced inspections at least once a shift of the Safety Check Sheets in the buildings under their supervision. Supervisors are to ensure compliance and to assure that staff are completing the checks according to policy. Supervisors are to document their name, date, time of the audit under the last check. We noted that supervisors were not completing their regular audits of safety checks as required by policy as required. This too was noted in the corrective action plan. We noted in the subsequent documentation we viewed to be much better. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Residential Treatment Services Bureau The facility administrator, in collaboration with the (RTSB) Manual Sections: 1201: Suicide healthcare and behavioral/mental health administrators, Prevention Plan shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. 1201: Suicide prevention Plan 1202 Enhanced and Specialized Supervision The plan shall consider the needs of youth experiencing Requirements for Youths in Juvenile past or current trauma. Facilities Suicide prevention responses shall be respectful and in 1203: Suicide Prevention Policy for Juvenile the least invasive manner consistent with the level of Facilities (Cross ref with directive 1186) suicide risk. Policy was developed in collaboration with The plan shall include the following elements: Juvenile Court Health Services (JCHS) and the Department of Mental Health (DMH). There were no incidents or documentation of ☒ ☐ ☐ suicide attempts or suicide behavior provided for our review for this section; however we did find one incident report that was provided in the Use of Force documentation that involved a youth who threatened to jump from the roof of a shed and to use a sharp object to cut his throat. As only one incident report was viewed, technical assistance provided to administration to ensure proper classification of documentation in the future. We will review more closely upon return to the facility. Compliance in subsequent areas are based on policy and admission/intake documents. (a) Suicide prevention training as required in Residential Treatment Services Bureau Section 1322, Youth Supervision Staff (RTSB) Manual Sections: 1203: Suicide Orientation, and Training and the Juvenile Prevention Policy for Juvenile Facilities and Corrections Officer Core Course. 2104: Professional Development and ☒ ☐ ☐ Training. Staff are trained in CORE training and annual refresher training. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Screening, Identification Assessment and Residential Treatment Services Bureau Precautionary Protocols (RTSB) Manual Sections:1202: Enhanced (1) All youth shall be screened for risk of and Specialized Supervision Requirements suicide at intake and as needed during of Youth in Juvenile Facilities and 1203: detention. Suicide Prevention Policy for Juvenile Facilities All youth are screened prior to entry by DMH staff member who conduct a Juvenile ☒ ☐ ☐ Justice Child/Adolescent Assessment. A DPOII Clinician and DMH interview youth at Juvenile Hall prior to arrival to the Camp. Once at camp all youth are screened again at intake with the Initial Intake, Screening and Referral Questionnaire. DMH work with youth throughout their stay, assessing them for risk and will adjust their supervision level as needed. Youth files we reviewed had screening forms. (2) All youth supervision staff who perform Residential Treatment Services Bureau intake processes shall be trained in (RTSB) Manual Sections: 1203: Suicide screening youth for risk of suicide. Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Staff who complete intake/admissions are trained in completing them. Suicide update training is completed annually as part of the Enhanced Supervision Training. (3) All youth who have been identified during Residential Treatment Services Bureau the intake screening process to be at risk of (RTSB) Manual Section: 1203: Suicide suicide shall be referred to Prevention Policy for Juvenile Facilities behavioral/mental health staff for a suicide risk assessment. ☒ ☐ ☐ We did not find any youth to be suicidal at intake based on the documentation we reviewed; however, bureau staff stated that youth would be referred to DMH for follow up. (4) Precautionary protocols shall be developed Residential Treatment Services Bureau to ensure the youth’s safety pending the (RTSB) Manual Sections:1202: Enhanced behavioral/mental health assessment. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Referral process to behavioral/mental health Residential Treatment Services Bureau staff for assessment and/or services. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Policy requires all facility staff to complete a “Request for Mental Health Consultation” when appropriate. In the incident we viewed, staff ensured the youth was seen immediately. (d) Procedures for monitoring of youth identified Residential Treatment Services Bureau at risk for suicide. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities Per policy, enhanced supervision Levels 1-4 determine the level of supervision a youth ☒ ☐ ☐ receives. Level 4 requires a constant supervision until a youth can be transported out to emergency hospitalization, Level 3 is a constant visual 1:1 supervision, Level 2; is 10-minute safety check and Level 1 is regular 15-minute safety checks. In the incident we reviewed the youth was placed on a Level 4 and transported to the hospital. (e) Safety Interventions Residential Treatment Services Bureau (1) Procedures to address intervention (RTSB) Manual Sections:1202: Enhanced protocols for youth identified at risk for and Specialized Supervision Requirements suicide which may include, but are not of Youth in Juvenile Facilities ☒ ☐ ☐ limited to: A. Housing consideration Youth are placed on a SSP. Supervision and housing direction are included on the forms. B. Treatment strategies including Residential Treatment Services Bureau trauma-informed approaches (RTSB) Manual Section: 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Procedures to instruct youth supervision Residential Treatment Services Bureau staff how to respond to youth who exhibit (RTSB) Manual Sections:1202: Enhanced suicidal behaviors. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. (f) Communication Residential Treatment Services Bureau (1) The intake process shall include (RTSB) Manual Section: 1203: Suicide communication with the arresting officer Prevention Policy for Juvenile Facilities and family guardians regarding the youth’s past or present suicidal ideations, behaviors Youth are transported directly from the or attempts. Juvenile Hall to the camp. Policy states that the intake officer shall contact the youth’s ☐ ☒ ☐ parent and/or guardians via telephone during the initial intake process to gather information regarding the youth’s past or present suicidal ideations, behaviors or attempts. There was no documentation provided to show that this contact was made. (2) Procedures for clear and current Residential Treatment Services Bureau information sharing about youth at risk for (RTSB) Manual Section: 1203: Suicide suicide with youth supervision, healthcare, ☒ ☐ ☐ Prevention Policy for Juvenile Facilities and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Residential Treatment Services Bureau Suicides or Attempts (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ (1) Process for administrative review of the Prevention Policy for Juvenile Facilities circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected Residential Treatment Services Bureau staff. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities (3) Process for a debriefing event with affected Residential Treatment Services Bureau youth. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Documentation Residential Treatment Services Bureau (1) Documentation processes shall be (RTSB) Manual Sections:1202: Enhanced developed to ensure compliance with this and Specialized Supervision Requirements regulation of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities Youth identified at risk for suicide shall not be denied Residential Treatment Services Bureau the opportunity to participate in facility programs, (RTSB) Manual Section: 1202: Enhanced services and activities which are available to other non- and Specialized Supervision Requirements suicidal youth, unless deemed necessary for the safety ☒ ☐ ☐ for Youths in Juvenile Facilities of the youth or security of the facility. Any deprivation of programs, services or activities for youth at risk of suicide shall be documented and approved by the facility manager. 1340 REPORTING OF LEGAL ACTIONS Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each facility shall submit to the Board a letter of Statements, RTSB Management notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities ☒ ☐ ☐ The Camp Director is responsible to ensure responsible for juvenile facility operation. that all reporting is completed. No legal actions have been reported to the BSCC this cycle for this facility. 1341 DEATH AND SERIOUS ILLNESS OR Residential Treatment Services Bureau INJURY OF A YOUTH WHILE (RTSB) Manual Sections:1919: Deaths at DETAINED Camp Facilities (1) Death of a Youth. Policy was developed in collaboration with (a) The facility administrator, In cooperation with the Juvenile Court Health Services (JCHS) and health administrator and the behavioral/mental ☒ ☐ ☐ the Department of Mental Health (DMH), 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 Residential Treatment Services Bureau facility administrator, shall develop written policies (RTSB) Manual Sections:1919: Deaths at and procedures to assure there is a medical and Camp Facilities operational review of every in-custody death of 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. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) The administrator of the facility shall provide to the Residential Treatment Services Bureau Board a copy of the report submitted to the Attorney (RTSB) Manual Sections:1919: Deaths at General under Government Code Section 12525. A ☒ ☐ ☐ Camp Facilities 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 Residential Treatment Services Bureau the administrator, the Board may within 30 calendar (RTSB) Manual Sections:1919: Deaths at days inspect and evaluate the juvenile facility, jail, Camp Facilities 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 Residential Treatment Services Bureau (a) The facility administrator, In cooperation with the (RTSB) Manual Section 1920: Serious health administrator, shall develop written policies Illness or Injury of a Youth While Detained 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 Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each juvenile facility shall submit required population Statements, RTSB Management and profile survey reports to the Board within 10 working days after the end of each reporting period, in ☒ ☐ ☐ Both the Camp Director is responsible to a format to be provided by the Board. ensure that all reporting is completed. All population reports were completed in a timely manner. 1343 JUVENILE FACILITY CAPACITY Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty When the number of youth detained in a living unit of a Statements, RTSB Management juvenile facility exceeds its rated capacity for more than fifteen (15) calendar days in a month, the facility ☒ ☐ ☐ The Camp Director is responsible to ensure administrator shall provide a crowding report to the that all reporting is completed. Board in a format provided by the Board. The facility has not exceeded their rated capacity this cycle. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 400: Camp written policies and procedures for admittance of youth Admissions and Section 502: Orientation that emphasize respectful and humane engagement with Process and Handbook youth and reflect that the admission process may be The Admission process for camp youth traumatic to youth who may have already experienced begins before the youth arrive on campus. trauma. Policies shall be trauma-informed, culturally ☒ ☐ ☐ Youth are assessed and screened at Camp relevant, and responsive to the language and literacy Headquarters and again by camp staff, needs of youth. In addition to the requirements of medical and mental health before the youth Sections 1324 and 1430 of these regulations: even arrive. Upon arrival, youth are admitted and oriented by camp staff. Documentation of admission/intake paperwork for 20 random youth was provided for our review. (a) the admittance process shall include: Residential Treatment Services Bureau (1) Access to two free phone calls within one hour (RTSB) Manual Sections:502: Orientation of admittance in accordance with the provisions Process and Handbook of Welfare and Institution Code Section 627; By policy, youth are to be provided with a phone call to notify their parent or guardian ☐ ☒ ☐ that they have been transferred to the Camp. Unable to verify if this occurred based on documentation provided. Technical assistance provided that this call could be documented with intake notes. (2) Offer of a shower; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☐ ☒ ☐ Unable to verify if this occurred based on documentation provided. (3) Documented secure storage of personal Residential Treatment Services Bureau belongings; (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Youth are transported to camp in juvenile hall clothing with only their juvenile hall personals. All personal clothing and belongings are released to their parents or guardians from the juvenile hall. (4) Offer of food upon arrival; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☐ ☒ ☐ Unable to verify if this occurred based on documentation provided. This is non- compliant. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health Residential Treatment Services Bureau and safety issues, intellectual or developmental (RTSB) Manual Sections:402: Assessment disabilities; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (6) Screening for physical and developmental Residential Treatment Services Bureau disabilities in accordance with Sections 1329, (RTSB) Manual Sections:402: Assessment 1418, and 1430 of these regulations; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (7) Contact with Regional Center for the Youth that are Regional Center Clients Developmentally Disabled for youth that are would not likely be ordered to a camp ☒ ☐ ☐ suspected of or identified as having a commit. developmental disability, pursuant to Section 1418; and, (8) Procedures consistent with Section 1352.5. Residential Treatment Services Bureau (RTSB) Manual Sections:403: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (b) juvenile hall administrators shall establish written Not Applicable criteria for detention that considers the least ☒ ☐ ☐ restrictive environment. (c) juvenile camps and post-dispositional programs in Residential Treatment Services Bureau juvenile halls shall develop policies and procedures (RTSB) Manual Sections:502: Orientation that advise the youth of the estimated length of Process and Handbook stay, inform them of program guidelines and ☒ ☐ ☐ provide written screening criteria for inclusion and Estimated length of stay estimates were exclusion from the program. consistently completed and documentation provided in packets provided. (d) juvenile halls shall develop policies and procedures Not Applicable that advise any committed youth of the estimated ☐ ☐ ☒ length of his/her stay. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Residential Treatment Services Bureau ABUSE (RTSB) Manual Sections: 402: Assessment The facility administrator shall develop and implement and Classification and 503: Screening for the written policies and procedures to reduce the risk of Risk of Sexual Abuse sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of Policy is in place; however, documentation admission based on the following information: provided consists of PREA Risk questions ☐ ☒ ☐ on the intake screening assessment that are not consistent with regulation requirements. This section is non-compliant as the documentation process has not yet been implemented. Agency is in the process of finalizing and rolling out the new procedure. (a) Prior sexual victimization or abusiveness; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (b) Gender nonconforming appearance or manner; Residential Treatment Services Bureau or identification as lesbian, gay or bisexual, (RTSB) Manual Sections: 402: Assessment transgender, queer or intersex, and whether the ☐ ☒ ☐ and Classification and 503: Screening for the youth may, therefore, be vulnerable to sexual Risk of Sexual Abuse abuse; (c) Current charges and offense history; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (d) Age; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (e) Level of emotional and cognitive development; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (f) Physical size and stature; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (g) Mental illness or mental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (h) Intellectual or developmental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (i) Physical disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (j) The youth’s perception of vulnerability; and, Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (k) Any other specific information about the Residential Treatment Services Bureau individual youth that may indicate heightened (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ needs for supervision, additional safety and Classification and 503: Screening for the precautions, or separation from certain other Risk of Sexual Abuse youth. Staff shall ascertain this information through Residential Treatment Services Bureau conversations with the youth during the admittance (RTSB) Manual Sections:503: Screening for process, medical and behavioral health screenings; the Risk of Sexual Abuse ☐ ☒ ☐ during classification assessments; and by reviewing court records, case files, facility behavioral records, and Current procedure has not been other relevant documentation from the youth’s files. implemented. The facility administrator shall implement appropriate Residential Treatment Services Bureau controls on the dissemination of information within the (RTSB) Manual Sections:503: Screening for facility relative to responses received pursuant to this the Risk of Sexual Abuse ☐ ☒ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other It is unknown how the facility will ensure youth. documents are kept confidential. 1351 RELEASE PROCEDURES Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release The facility administrator shall develop and implement ☒ ☐ ☐ Procedures written policies and procedures for release of youth from custody which provide for: (a) verification of identity/release papers; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures (b) return of personal clothing and valuables; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures ☒ ☐ ☐ Compliance reviewed through Juvenile Hall Property Receipts. Parents/guardian bring clothing for youth to be released in on day of release. (c) notification to the youth's parents or guardian; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) notification to the facility health care provider in Residential Treatment Services Bureau accordance with Sections 1408 and 1437 of these (RTSB) Manual Sections:809: Release regulations, for coordination with outside agencies; Procedures and, ☒ ☐ ☐ Health care is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (e) notification of school staff; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Education is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (f) notification of facility mental health personnel. Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Mental Health is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. The facility administrator shall develop and implement Residential Treatment Services Bureau policies and procedures for post-disposition youth to (RTSB) Manual Section: 703: MDT Process coordinate the provision of transitional and reentry services including, but not limited to, medical and Each youth has a Transition MDT 45-60 behavioral health, education, probation supervision and days prior to release that addresses all community-based services. required services and other pertinent areas. All facility partners and the PO are present ☐ ☐ ☒ with the youth to discuss the plan. The youth’s parents or guardian are invited to participate and either attend in person or via a conference call. (Reference Regulation 1355) The Transition plans provided were detailed and well documented. The facility administrator shall develop and implement Residential Treatment Services Bureau written policies and procedures for the furlough of (RTSB) Manual Section: 1802: Private youth from custody. Appointments ☒ ☐ ☐ The agency has no formal furlough policy; however, will transport youth to private appointments for exigent circumstances such as funerals or hospital visits with a court order. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1352 CLASSIFICATION Residential Treatment Services Bureau (RTSB) Manual Sections:402: Assessment The facility administrator shall develop and implement and Classification Policy and Section 408: written policies and procedures on classification of Classification youth for the purpose of determining housing placement ☒ ☐ ☐ in the facility. Documentation provided for our review for 20 youth. Several youth had SSP’s attached Such procedures shall: which provided additional instruction for specialized supervision or housing needs. (a) provide for the safety of the youth, other youth, Residential Treatment Services Bureau facility staff, and the public by placing youth in the (RTSB) Manual Sections:402: Assessment appropriate, least restrictive housing and program and Classification Policy settings. Housing assignments shall consider the Youth are assessed by the Camp Assessment need for single, double or dormitory assignment or Unit (CAU) after being ordered to Camp by location within the dormitory; ☒ ☐ ☐ the court. The CAU determines which camp is the appropriate camp for the youth based on classification factors and camp programs. This decision is made based on several different factors and includes an interview and input from the youth. (b) consider facility populations and physical design of Residential Treatment Services Bureau the facility; (RTSB) Manual Sections:402: Assessment and Classification Policy ☒ ☐ ☐ Youth are classified to a camp based on classification factors and then assigned to a location within the dorm. (c) provide that a youth shall be classified upon Residential Treatment Services Bureau admittance to the facility; classification factors (RTSB) Manual Sections:402: Assessment shall include, but not be limited to: age, maturity, and Classification Policy sophistication, emotional stability, program needs, ☒ ☐ ☐ Youth are classified to a camp based on legal status, public safety considerations, classification factors. medical/mental health considerations, gender and gender identity of the youth; (d) provide for periodic classification reviews, Residential Treatment Services Bureau including provisions that consider the level of (RTSB) Manual Sections:402: Assessment supervision and the youth's behavior while in and Classification Policy custody; and, All youth who are placed on an SSP are ☒ ☐ ☐ reviewed within 30 days. All other youth are considered for review at the time of any incident, upon request, or as needed. If any change is to occur, an SSP is initiated. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provide that facility staff shall not separate youth Residential Treatment Services Bureau from the general population or assign youth to a (RTSB) Manual Sections:402: Assessment single occupancy room based solely on the youth's and Classification Policy actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, ☒ ☐ ☐ gender expression, mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, Residential Treatment Services Bureau bisexual, transgender, questioning or intersex (RTSB) Manual Sections:402: Assessment ☒ ☐ ☐ identification or status as an indicator of likelihood and Classification Policy of being sexually abusive. 1352.5 TRANSGENDER AND INTERSEX YOUTH. Residential Treatment Services Bureau (RTSB) Manual Sections: 403: Juvenile The facility administrator shall develop written policies ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Transgender, Questioning and Intersex treatment of transgender and intersex youth. The Youth in an Institutional Setting policies shall provide that: (a) Facility staff shall respect every youth’s gender Residential Treatment Services Bureau identity and shall refer to the youth by the youth’s (RTSB) Manual Sections: 403: Juvenile preferred name and gender pronoun, regardless of Supervision of Lesbian, Gay, Bisexual, the youth’s legal name. Facilities may prohibit the ☒ ☐ ☐ Transgender, Questioning and Intersex use of gang or slang names or names that otherwise Youth in an Institutional Setting 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 Residential Treatment Services Bureau themselves in a manner consistent with their gender (RTSB) Manual Sections: 403: Juvenile identity and shall provide youth with the ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, institution’s clothing and undergarments consistent Transgender, Questioning and Intersex with their gender identity. Youth in an Institutional Setting (c) Facility staff shall house youth in the unit or room Residential Treatment Services Bureau that best meets their individual needs and promotes (RTSB) Manual Sections: 403: Juvenile their safety and well-being. Staff may not Supervision of Lesbian, Gay, Bisexual, automatically house youth according to their Transgender, Questioning and Intersex external anatomy and shall document the reasons Youth in an Institutional Setting 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 ☒ ☐ ☐ If a youth request to reside in another unit preferences, as well as any recommendations from other than the unit that coincides with the the youth’s health or behavioral health provider. youth’s biological sex, a medical referral is made, and an MDT is held. Pending a decision, the youth will be housed in the medical unit. (This process occurs before arrival at the camp due to lack of alternate housing.) 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Facility administrators shall ensure that transgender Residential Treatment Services Bureau and intersex youth have access to medical and (RTSB) Manual Sections: 403: Juvenile behavioral health providers qualified to provide Supervision of Lesbian, Gay, Bisexual, care and treatment to transgender and intersex Transgender, Questioning and Intersex youth. Youth in an Institutional Setting ☒ ☐ ☐ Upon entry, youth are asked If they identify with LGBTQI and if so, they are referred to medical for continuation and coordination of gender affirming services. (e) Consistent with the facility’s reasonable and Residential Treatment Services Bureau necessary security considerations and physical (RTSB) Manual Sections: 403: Juvenile plant, facility staff shall make every effort to ensure ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, the safety and privacy of transgender and intersex Transgender, Questioning and Intersex youth when the youth are using the bathroom or Youth in an Institutional Setting shower, or dressing or undressing. Facility staff shall not conduct physical searches of any Residential Treatment Services Bureau youth for the purpose of determining the youth’s (RTSB) Manual Sections: 403: Juvenile anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of Transgender, Questioning and Intersex the staff member who conducts any search of the youth. Youth in an Institutional Setting Policy notes that youth are provided with the option to choose the gender of the staff they wish to search them. Policy also notes that ☒ ☐ ☐ the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy alone. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1353 ORIENTATION Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation The facility administrator shall develop and implement Process and Handbook written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Documentation was provided for 20 youth information shall be provided and supplemented with and all orientations were found to be video orientation if feasible. Provision shall be made to completed timely. We noted at inspection provide accessible orientation information to all that the RTSB orientation handbook was not detained youth including those with disabilities, limited updated to all current regulatory literacy, or English language learners. Orientation shall requirements. This issue was addressed and include information that addresses: corrected, and the updated handbook has ☒ ☐ ☐ since been implemented and contains all areas of required regulation. We also noted that there is an additional Campus Kilpatrick Youth Handbook that is not updated to all of the current regulatory requirements however, it is used as part of orientation to help with the philosophy of the LA Model. We have confirmed with bureau consultant staff that the RTSB handbook is the primary handbook utilized. (a) facility rules including contraband and searches and Residential Treatment Services Bureau disciplinary procedures; ☒ ☐ ☐ (RTSB) Manual Section: 502: Orientation Process and Handbook (b) facility’s system of positive behavior interventions Residential Treatment Services Bureau and supports, including behavior expectations, (RTSB) Manual Section: 502: Orientation incentives that youth will receive for complying Process and Handbook with facility rules, and consequences that may ☒ ☐ ☐ Youth are provided with a copy of the result when youth violate the rules of the facility; Behavior Management Program Handbook at orientation. This process is reviewed during orientation. (c) age appropriate information that explains the Residential Treatment Services Bureau facility’s policy prohibiting sexual abuse and sexual (RTSB) Manual Section: 1600: PREA ☒ ☐ ☐ harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (e) the existence of the grievance procedure, the steps Residential Treatment Services Bureau that must be taken to use it, the youth’s right to be (RTSB) Manual Section: 502: Orientation free of retaliation for reporting a grievance, and the Process and Handbook ☒ ☐ ☐ name of the person or position designated to resolve the issue; 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) access to legal services and information on the court Residential Treatment Services Bureau process; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (g) access to routine and emergency health and mental Residential Treatment Services Bureau health care; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (h) access to education, religious services, and Residential Treatment Services Bureau recreational activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (i) housing assignments; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (j) opportunity for personal hygiene and daily showers Residential Treatment Services Bureau including the availability of personal care items (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (k) rules and access to correspondence, visits and Residential Treatment Services Bureau telephone use; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (l) availability of reading materials, programming, and Residential Treatment Services Bureau other activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (m) facility policies on the use of force, use of restraints, Residential Treatment Services Bureau chemical agents and room confinement; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (n) immigration legal services; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (o) emergencies including evacuation procedures; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (p) non-discrimination policy and the right to be free Residential Treatment Services Bureau from physical, verbal or sexual abuse and (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ harassment by other youth and staff; Process and Handbook (q) availability of services and programs in a language Residential Treatment Services Bureau other than English if appropriate; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (r) the process for requesting different housing, Residential Treatment Services Bureau education, programming and work assignments; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (s) a process for which parents/guardians receive Residential Treatment Services Bureau information regarding the youth’s stay in the (RTSB) Manual Section: 502: Orientation facility that at a minimum includes answers to Process and Handbook ☒ ☐ ☐ frequently asked questions and provides contact Orienting officer provides parent info and information for the facility, medical, school and provides contact info. mental health; and, (t) a process by which youth may request access to Residential Treatment Services Bureau Title 15 Minimum Standards for Juvenile Facilities. (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 1354 SEPARATION Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 514: Separation, written policies and procedures that address: 515: Room Confinement and Section 1400: ☒ ☐ ☐ The Healing Opportunities and Positive Engagement (HOPE) Center (a) separation of youth for reasons that include, but are Residential Treatment Services Bureau not be limited to, medical and mental health (RTSB) Manual Section: 514: Separation, conditions, assaultive behavior, disciplinary 515: Room Confinement and Section 1400: consequences and protective custody. The Healing Opportunities and Positive Engagement (HOPE) Center Agency HOPE Centers are operationally utilized for youth who require separation for a variety of purposes including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation to provide time for the youth to deescalate and adjust their behavior to return to the program. Current policies are not clear and although ☐ ☒ ☐ collectively, policy and procedure outline regulation requirements, operationally, do not meet requirements. Separation policy must be updated concurrently with Room Confinement policy to ensure consistency and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Agency policy requires due process for any separation. Currently, due process only occurs as a result of the incident which precipitated the separation. While not non- compliant with regulation, this is inconsistent with agency policy. (b) consideration of positive youth development and Residential Treatment Services Bureau trauma-informed care. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) separated youth shall not be denied normal Residential Treatment Services Bureau privileges available at the facility, except when (RTSB) Manual Section: 514: Separation necessary to accomplish the objective of separation. If a youth is not on active Room Confinement due to imminent safety or security, he or she should be considered as full program and be fully integrated into a full general like population program as appropriate based on his or her needs and receive all programming and activities in the HOPE Center as appropriate or returned to the dorm. ☐ ☐ UNK We were unable to determine which youth present in the HOPE Center were eligible for programming; however, two documents were provided for our review, both were for youth assigned temporary separation. We were provided no other documentation of programming for separated youth. We are unable to make a determination of compliance at this time. We will review this further when we return on site. (d) when the objective of the separation is discipline, Residential Treatment Services Bureau Title 15 Section 1390 shall apply. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation (e) when separation results in room confinement, the Residential Treatment Services Bureau separation shall occur in accordance with Welfare (RTSB) Manual Section: 514: Separation ☒ ☐ ☐ and Institutions Code Section 208.3 and Section1354.5 of these regulations. (f) policies and procedures shall ensure a daily review Residential Treatment Services Bureau of separated youth to determine if separation (RTSB) Manual Section: 514: Separation remains necessary. and Section 1400: The Healing Opportunities ☒ ☐ ☐ and Positive Engagement (HOPE) Center 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354.5 ROOM CONFINEMENT Residential Treatment Services Bureau (RTSB) Manual Section: 515: Room (a) The facility administrator shall develop and Confinement and Section 1400: The Healing implement written policies and procedures Opportunities and Positive Engagement addressing the confinement of youth in their room (HOPE) Center that are consistent with Welfare and Institutions Code Section 208.3. The placement of a youth in Campus Kilpatrick was evacuated to room confinement shall be accomplished in Challenger Youth Memorial Camp and accordance with the following guidelines: utilized the HOPE Center at CYMC for Campus Kilpatrick youth only. This is not something that was done operationally at Campus Kilpatrick previously. The HOPE Center receives youth for a variety of reasons which include separation or cool down, decontamination, administrative holds, housing, mental health, and for safety and security purposes. Youth who are in need of Room Confinement, are also moved to the HOPE Center. ☐ ☒ ☐ With the implementation of the Room Confinement regulations and the implementation of specific requirements, the documentation received for review was problematic, as it does not consistently provide proof of compliant practices nor are, we able to determine which youth are held under room confinement expectations. In many cases, we were unable to determine if the youth was placed in a locked room therefore, we were unable to determine what requirements and documentation were necessary. Policy, procedure and documentation will need to be reviewed and updated to achieve compliance. Room confinement and separation policies should be revised concurrently to ensure consistency as well as to ensure compliance with all pieces of this regulation. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Room confinement shall not be used before Residential Treatment Services Bureau other, less restrictive, options have been (RTSB) Manual Section: 515: Room attempted and exhausted, unless attempting Confinement and Section 1400: The Healing those options poses a threat to the safety or Opportunities and Positive Engagement security of any youth or staff. (HOPE) Center 11 Hope Center packets were provided for our review. Most of the packets reviewed, lacked an incident report to provide a complete picture of the incident and ☐ ☒ ☐ circumstances that precipitated the youth being moved to the Hope Center. What information we found was determined through pieces and parts of the documentation that was provided. It is unknown what efforts were made if any, to de-escalate the situation prior to the youth being admitted to the Hope Center. This section is non-compliant. (2) Room confinement shall not be used for the Residential Treatment Services Bureau purposes of punishment, coercion, (RTSB) Manual Section: 515: Room convenience, or retaliation by staff. Confinement and Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center ☐ ☒ ☐ Documentation provided does not clearly document the reason the youth requires isolation to minimize the threat to the safety and security of youth or staff once separated from the incident. Documentation of some safety checks had gaps of time missing or in some cases were illegible. This section is non-compliant. (3) Room confinement shall not be used to the Residential Treatment Services Bureau extent that it compromises the mental and (RTSB) Manual Section: 515: Room physical health of the youth. Confinement Policy requires that all youth placed in room confinement (isolation) are to be assessed by ☐ ☒ ☐ a clinician from the Department of Mental Health. Very few mental health referrals or consultations were provided for our review. All youth were cleared by medical staff immediately following the incident. This section is non-compliant. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) A youth may be held up to four hours in room Residential Treatment Services Bureau confinement. After the youth has been held in room (RTSB) Manual Section 1400: The Healing confinement for a period of four hours, staff shall Opportunities and Positive Engagement ☒ ☐ ☐ do one or more of the following: (HOPE) Center (1) Return the youth to general population. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☒ ☐ ☐ Opportunities and Positive Engagement (HOPE) Center (2) Consult with mental health or medical staff. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center Policy and procedure must be updated to include consultation with mental health or medical staff for youth who are held beyond 4 hours. Policy also requires that any youth ☐ ☒ ☐ placed on room confinement shall complete a Behavior Chain Analysis (BCA’s) and be assessed by DMH as part of the stabilization process. Currently, mental health staff respond and see youth as a result of the precipitating incident, but not due to the isolation. This is non-compliant. There were no incident reports provided or mental health consultations reviewed. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 36 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Develop an individualized plan that includes Residential Treatment Services Bureau the goals and objectives to be met in order to (RTSB) Manual Section 1400: The Healing reintegrate the youth to general population. Opportunities and Positive Engagement (HOPE) Center Policy notes that youth shall not remain assigned to the HOPE Center for longer than 4 hours without the initiation of a formal Major Administrative Action Review reviewed by the facility Director or designee and must include an individualized plan that includes goals and objectives to be met to ☐ ☒ ☐ reintegrate the youth back to general population. They must be documented on the SSP. The SSP addresses supervision issues and does not include goals and objectives to reintegrate the youth to general population for this purpose. No documentation of any individualized plans that included goals and objectives to reintegrate the youth to general population was provided. This section is non-compliant. (4) If room confinement must be extended beyond Residential Treatment Services Bureau four hours, staff shall do each of the following: (RTSB) Manual Section 1400: The Healing ☒ ☐ ☐ Opportunities and Positive Engagement (HOPE) Center (A) Document the reasons for room Residential Treatment Services Bureau confinement and the basis for the (RTSB) Manual Section 1400: The Healing extension, the date and time the youth was Opportunities and Positive Engagement ☐ ☒ ☐ first placed in room confinement, and when (HOPE) Center he or she is eventually released from room confinement. No documentation provided for this section. (B) Develop an individualized plan that Residential Treatment Services Bureau includes the goals and objectives to be met (RTSB) Manual Section 1400: The Healing in order to integrate the youth to general Opportunities and Positive Engagement population. (HOPE) Center ☐ ☒ ☐ See above B(3) There were no individualized plans provided. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Obtain documented authorization by the Residential Treatment Services Bureau facility superintendent or his or her (RTSB) Manual Section 1400: The Healing designee every four hours thereafter. Opportunities and Positive Engagement ☐ ☒ ☐ (HOPE) Center It is unknown if any of the youth were extended beyond four hours (5) This section is not intended to limit the use of Residential Treatment Services Bureau single-person rooms or cells for the housing of (RTSB) Manual Section: 515: Room ☒ ☐ ☐ youth in juvenile facilities and does not apply Confinement to normal sleeping hours. (6) This section does not apply to youth or wards Residential Treatment Services Bureau in court holding facilities or adult facilities. (RTSB) Manual Section: 515: Room ☒ ☐ ☐ Confinement (7) Nothing in this section shall be construed to Residential Treatment Services Bureau conflict with any law providing greater or (RTSB) Manual Section: 515: Room ☒ ☐ ☐ additional protections to youth. Confinement (8) This section does not apply during an Residential Treatment Services Bureau extraordinary emergency circumstance that (RTSB) Manual Section: 515: Room requires a significant departure from normal Confinement 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 Residential Treatment Services Bureau placed in a locked cell or sleeping room to treat (RTSB) Manual Section: 515: Room and protect against the spread of a Confinement 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. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 38 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1355 INSTITUTIONAL ASSESSMENT AND Residential Treatment Services Bureau PLAN (RTSB) Manual Section 402: Assessment and Classification and 703: The MDT The facility administrator shall develop and implement Process written policies and procedures for assessment and case planning. The process of assessment begins upon a youth being ordered to a camp. A youth is assessed by the Camp Assessment Unit and by the facility upon arrival. The case plan is completed at the initial MTD and is developed through a collaborative multi- ☒ ☐ ☐ disciplinary Team made up of staff representation from Probation, Department of Mental Health, Education, Health Care, Social Services as appropriate and any others as necessary based on the youth or family needs. A transition MDT is also completed as the youth gets closer to release. MDT’s are completed as needed throughout detention as the need arises. Periodic review is completed by the assigned casework Probation Officer. The transition plan is completed by the collaborative multi- disciplinary team. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Assessment: Residential Treatment Services Bureau (RTSB) Manual Section 703: The MDT The assessment is based on information collected Process during the admission process with periodic review, which includes the youth's risk factors, needs and The process of case planning begins with the strengths including, but not limited to, identification of assessment process. 10 Initial and substance abuse history, educational, vocational, Transitional MDT packets were reviewed. counseling, behavioral health, consideration of known The Camp Assessment Unit completes all history of trauma, and family strengths and needs. assessments on the youth prior to transfer. The assessment summary was not provided for our review nor was it in the case notes; however, it is practice and is completed for all youth in RTSB per Bureau staff. At inspection, we were unable to determine ☐ ☐ UNK compliance in this area at this time without seeing the assessment, speaking to staff and youth. Prior to writing this report, we have been notified that the agency has updated their policy and has corrected their forms and documentation to be consistent with regulation and to provide a more clear and efficient process for the youth and their families. Staff training occurred in August 2020 and the new process was implemented in September 2020. We will follow up with this section to review for compliance upon our return to the facility. (b) Institutional Case Plan: Residential Treatment Services Bureau (1) A case plan shall be developed for each youth (RTSB) Manual Section 703: The MDT held for at least 30 days or more and created Process within 40 days of admission. The initial MDT acts as the youth’s case plan and provides direction as to what programs ☒ ☐ ☐ they will participate in. Some programs are automatic as they are court ordered. The MDT is targeted to be completed within the first 2 weeks of a youth’s arrival at camp. All MDT’s occurred within the time allotted by regulation. (2) The institutional plan shall include, but not be Residential Treatment Services Bureau limited to, written documentation that provides: ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (A) objectives and time frame for the resolution Residential Treatment Services Bureau of problems identified in the assessment; (RTSB) Manual Section 705: Ongoing Case Management Activities The MDT process and format provides the structure for the youth’s case plan. Objectives are based on the assessment. Those programs that are ordered and are camp required programs, the timelines are noted as part of the program i.e. 10 weeks substance abuse program or 16-week DBT Program. Technical Assistance regarding the ☒ ☐ ☐ structure of the process and making the plans more individualized in the coming cycle. With the change in regulation, the assessment drives the objectives and goals and the case plans are more individualized and not solely based on a court order or camp program. RTSB has enhanced their process. We will follow up with this section and determine compliance upon our return to the facility (B) a plan for meeting the objectives that Residential Treatment Services Bureau includes a description of program resources (RTSB) Manual Section 705: Ongoing Case needed and individuals responsible for Management Activities assuring that the plan is implemented; We found the current plan and timelines are embedded within the camp program expectations or court orders i.e. 10 weeks substance abuse program, individual counseling or family counseling weekly or 16-week DBT. ☐ ☐ UNK Discussed need to ensure these programs and other assessed needs are documented more consistently so the youth’s other needs are individual to the youth. We need more information to determine compliance. We will follow up with this section and determine compliance upon our return to the facility. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) periodic evaluation of progress towards meeting Residential Treatment Services Bureau the objectives, including periodic review and (RTSB) Manual Section 705: Ongoing Case discussion of the plan with the youth; Management Activities Regulation requires periodic review and discussion with the youth of their progress towards meeting their objectives. Periodic review is completed weekly by the assigned camp casework officer who completes the ☐ ☒ ☐ casework notes in the electronic database (PCMS). Based on the collective set of case notes, there were very few that were noted as completed with the youth. We are unable to determine if the youth are present with the staff during this review or if the conversation is held at a later time. (4) a transition plan, the contents of which shall be Residential Treatment Services Bureau subject to existing resources, shall be developed (RTSB) Manual Section 706: Case Plan for post dispositional youth in accordance with Activities- Pre- Release Section 1351; and, ☒ ☐ ☐ Transition MDT’s are completed for all youth and contain all areas required by regulation. (5) in as much as possible and if appropriate, the Residential Treatment Services Bureau plan, including the transition plan, shall be (RTSB) Manual Section 705: Ongoing Case developed with input from the family, Management Activities supportive adults, youth, and Regional Center ☒ ☐ ☐ The youth’s parent or guardian is invited to for the Developmentally Disabled. attend the MDT. The family is contacted by phone and by letter to attend. 1356 COUNSELING AND CASEWORK Residential Treatment Services Bureau SERVICES (RTSB) Manual Section 705: Ongoing Case Management Activities The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: (a) youth will receive assistance with needs or concerns Residential Treatment Services Bureau that may arise; ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) youth will receive assistance in requesting contact Residential Treatment Services Bureau with parents, other supportive adults, attorney, (RTSB) Manual Section 705: Ongoing Case clergy, probation officer, or other public official; Management Activities ☒ ☐ ☐ and, (c) youth will be provided access to available resources Residential Treatment Services Bureau to meet the youth’s needs. ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 1357 USE OF FORCE Residential Treatment Services Bureau (RTSB) Manual Section 1701: Physical The facility administrator, In cooperation with the intervention Policy for Juvenile Facilities responsible physician, shall develop and implement and the Transportation Section written policies and procedures for the use of force, which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. ☒ ☐ ☐ Policy was developed with the Juvenile Court Health Services (JCHS) and includes (a) At a minimum, each facility shall develop policies the use of soft restraints. OC is not used in and procedures which: the camps. Documentation was provided from throughout the cycle. 15 Incidents were selected for review from multiple months. (1) restricts the use of force to that which is deemed Residential Treatment Services Bureau reasonable and necessary, as defined in Section (RTSB) Manual Section 1704: Safe Crisis 1302 to ensure the safety and security of youth, Management and Physical Intervention staff, others and the facility. Procedures All documentation reviewed were assaults on staff, mutual fights, near fights, fights involving multiple youth and one youth who ☒ ☐ ☐ climbed onto a roof and threated self-harm who had to be restrained and brought down. Documentation noted staff gave direction to stop and attempts were made to deescalate the situations before force was used. All incidents viewed appeared appropriate and to be reasonable and necessary. (2) outline the force options available to staff Residential Treatment Services Bureau including both physical and non-physical (RTSB) Manual Section 1704: Safe Crisis options and define when those force options are Management and Physical Intervention appropriate. Procedures ☒ ☐ ☐ Non-Physical Options: De-escalation Techniques Physical Options: Authorized Levels of Physical Interventions 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) describe force options or techniques that are Residential Treatment Services Bureau expressly prohibited by the facility. (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ Management and Physical Intervention Procedures (4) describe the requirements of staff to report any Residential Treatment Services Bureau inappropriate use of force, and to take (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ affirmative action to immediately stop it. Management and Physical Intervention Procedures (5) define a standardized reporting format that Residential Treatment Services Bureau includes time period and procedure for (RTSB) Manual Section 1703: Safe Crisis documenting and reporting the use of force, Management-Physical Intervention Report including reporting requirements of Forms, 1704: Safe Crisis Management and management and line staff and procedures for Physical Intervention Procedures and 1706: reviewing and tracking use of force incidents by Safe Crisis Management Physical supervisory and or management staff, which Intervention Reports include procedures for debriefing a particular Every incident is reviewed by the duty incident with staff and/or youth for the purposes supervisor and again reviewed by the Safe of training as well as mitigating the effects of Crisis Management Supervisor whose trauma that may have been experienced by staff ☐ ☐ UNK responsibility is to review for violation of and /or the youth involved. policy and procedures. This review also includes interviews with all youth involved and other witnesses as appropriate. We did not see any reference to debriefing of incidents however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further into this issue when on site at the next inspection. (6) Include an administrative review and a system Residential Treatment Services Bureau for investigating unreasonable use of force. (RTSB) Manual Section 1706: Safe Crisis Management Physical Intervention Reports Any incident that falls outside of agency ☒ ☐ ☐ policy is referred to the facility director for referral for an administrative review or referral to the Probation Departments Special Investigation Unit for further review. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Residential Treatment Services Bureau procedures required after use of force incidents (RTSB) Manual Section 1704: Safe Crisis for medical, mental health staff and parents or Management and Physical Intervention legal guardians. Procedures and 1706: Safe Crisis Management Physical Intervention Reports We found that in all incident reports and in documentation reviewed, youth were medically cleared and were either seen by ☐ ☒ ☐ mental health or a mental health referral was submitted on the youth’s behalf for follow up. We did not see any reference in the PIR or in any other area, that the youth’s parent was contacted regarding the use of force incident. Technical assistance was provided, and subsequent documentation was provided and the area was not corrected. (8) describe the limitations of use of force on Residential Treatment Services Bureau pregnant youth in accordance with Penal Code (RTSB) Manual Section 1704: Safe Crisis Section 6030(f) and Welfare and Institutions Management and Physical Intervention ☒ ☐ ☐ Code Section 222. Procedures (b) Facilities that authorize chemical agents as a force Residential Treatment Services Bureau option shall include policies and procedures that: (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (1) identify who is approved to carry and/or utilize NA chemical agents in the facility and the type, size ☐ ☐ ☒ and the approved method of deployment for those chemical agents. (2) mandate that chemical agents only be used when NA there is an imminent threat to the youth’s safety ☐ ☐ ☒ or the safety of others and only when de- escalation efforts have been unsuccessful or are not reasonably possible. (3) outline the facility’s approved methods and NA timelines for decontamination from chemical agents. This shall include that youth who have ☐ ☐ ☒ been exposed to chemical agents shall not be left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) define the role, notification, and follow-up NA procedures required after use of force incidents ☐ ☐ ☒ involving chemical agents for medical, mental health staff and parents or legal guardians. (5) provide for the documentation of each incident NA of use of chemical agents, including the reasons for which it was used, efforts to de-escalate ☐ ☐ ☒ prior to use, youth and staff involved, the date, time and location of use, decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure Residential Treatment Services Bureau which require that agencies provide initial and (RTSB) Manual Section 1702: Training ☒ ☐ ☐ regular training in use of force and chemical agents when appropriate that address: (1) known medical and behavioral health Residential Treatment Services Bureau conditions that would contraindicate certain ☒ ☐ ☐ (RTSB) Manual Section 1702: Training types of force; (2) acceptable chemical agents and the methods of Residential Treatment Services Bureau application. (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (3) signs or symptoms that should result in Residential Treatment Services Bureau immediate referral to medical or behavioral ☒ ☐ ☐ (RTSB) Manual Section 1702: Training health. (4) instruction on the Constitutional Limitations of Residential Treatment Services Bureau ☒ ☐ ☐ Use of Force. (RTSB) Manual Section 1702: Training (5) physical training force options that may require Residential Treatment Services Bureau ☒ ☐ ☐ the use of perishable skills. (RTSB) Manual Section 1702: Training (6) timelines the facility uses to define regular Residential Treatment Services Bureau training. (RTSB) Manual Section 1702: Training ☒ ☐ ☐ Initial training occurs in CORE and regular training is held through annual refresher training. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358 USE OF PHYSICAL RESTRAINTS Residential Treatment Services Bureau (RTSB) Manual Section 1705: Restraints The facility administrator, In cooperation with the responsible physician and mental health director, shall The policy was developed in cooperation with DMH and JCHS develop and implement written policies and procedures for the use of restraint devices. Restraint devices Facility did not provide any documentation include any devices which immobilize a youth's of Use of Physical Restraints. extremities and/or prevent the youth from being There were no incidents or documentation of ambulatory. physical restraints provided for our review for this section; however, we did note one incident report that was provided in the Use ☐ ☐ UNK of Force documentation in which a youth was in restraints we would consider applicable to this section. We cannot determine compliance as it is unknown if there were more incidents of Use of Restraints pursuant to this section or if there were no other incidents that occurred in the two-year cycle. We will follow up with the facility when back on site. Areas that would require documentation are marked as UNK. All compliance is noted through policy only. Physical restraints may be used only for those youth Residential Treatment Services Bureau who present an immediate danger to themselves or (RTSB) Manual Section 1705: Restraints 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 Residential Treatment Services Bureau discipline, or as a substitute for treatment. The use of (RTSB) Manual Section 1705: Restraints restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through ☒ ☐ ☐ affixing of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Residential Treatment Services Bureau handcuffs, shackles or other restraint devices when used (RTSB) Manual Section 1705: Restraints 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. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Youth shall be placed in restraints only with the approval Residential Treatment Services Bureau of the facility manager or designee. The facility manager (RTSB) Manual Section 1705: Restraints may delegate authority to place a youth in restraints to a ☒ ☐ UNK physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. A medical opinion on the safety of placement and Residential Treatment Services Bureau retention shall be secured as soon as possible, but no later (RTSB) Manual Section 1705: Restraints than two hours from the time of placement. The youth ☒ ☐ UNK Youth was seen by the nurse immediately shall be medically cleared for continued retention at least following incident and at the conclusion of every three hours thereafter. the incident. A mental health consultation shall be secured as soon as Residential Treatment Services Bureau possible, but in no case longer than four hours from the (RTSB) Manual Section 1705: Restraints time of placement, to assess the need for mental health ☒ ☐ UNK Youth was counselled by a DMH Dr. who treatment. was on site at the time of the incident. Continuous direct visual supervision shall be conducted Residential Treatment Services Bureau to ensure that the restraints are properly employed, and (RTSB) Manual Section 1705: Restraints to ensure the safety and well-being of the youth. ☒ ☐ UNK Direct visual supervision was provided. Observations of the youth's behavior and any staff interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. In addition to the requirements above, policies and Residential Treatment Services Bureau procedures shall address: (RTSB) Manual Section 1705: Restraints (a) documentation of the circumstances leading to an Residential Treatment Services Bureau ☒ ☐ ☐ application of restraints. (RTSB) Manual Section 1705: Restraints (b) known medical conditions that would Residential Treatment Services Bureau contraindicate certain restraint devices and/or ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints techniques. (c) acceptable restraint devices. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (d) signs or symptoms which should result in Residential Treatment Services Bureau ☒ ☐ ☐ immediate medical/mental health referral. (RTSB) Manual Section 1705: Restraints (e) availability of cardiopulmonary resuscitation Residential Treatment Services Bureau ☒ ☐ ☐ equipment. (RTSB) Manual Section 1705: Restraints (f) protective housing of restrained youth. While in Residential Treatment Services Bureau restraint devices, all youth shall be housed alone or (RTSB) Manual Section 1705: Restraints in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) exercising of extremities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 1358.5 USE OF RESTRAINT DEVICES FOR Residential Treatment Services Bureau MOVEMENT AND TRANSPORTATION WITHIN (RTSB) Manual Section 1709: The Use of THE FACILITY. Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, In cooperation with the responsible physician and behavioral/mental health The policy was developed in cooperation director, shall develop and implement written policies with DMH and JCHS. and procedures for the use of restraint devices when the purpose is for movement or transportation within the Policy is in place and are marked facility that shall include the following: accordingly. No documentation was provided for our review. The below areas are non-compliant. (a) identification of acceptable restraint devices, staff Residential Treatment Services Bureau approved to utilize restraint devices and the (RTSB) Manual Section 1709: The Use of required training. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility Handcuffs are authorized for regular use and flex cuffs in emergency situations. (b) the circumstances leading to the application of Residential Treatment Services Bureau restraints must be documented. (RTSB) Manual Section 1709: The Use of Mechanical Restraints for Movement and Transport Within the Facility ☐ ☒ ☐ No documentation was provided for our review. This section is non-compliant. (c) an individual assessment of the need to apply Residential Treatment Services Bureau restraints for movement or transportation that (RTSB) Manual Section 1709: The Use of includes consideration of less restrictive Mechanical Restraints for Movement and alternatives, consideration of a youth’s known ☐ ☒ ☐ Transport Within the Facility medical or mental health conditions, trauma No documentation was provided for our informed approaches, and a process for review. This section is non-compliant. documentation and supervisor review and approval. (d) consideration of safety and security of the facility, Residential Treatment Services Bureau with a clearly defined expectation that restraint (RTSB) Manual Section 1710: The Use of devices shall not be used for the purposes of Mechanical Restraints for Movement and ☒ ☐ ☐ discipline or retaliation. Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Residential Treatment Services Bureau accordance with Penal Code Section6030(f) and (RTSB) Manual Section 1709: The Use of Welfare and Institutions Code Section 222. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1359 SAFETY ROOM PROCEDURES There is no safety room in the camps. Does not apply. (a) The facility administrator, and where applicable, In 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. (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. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (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 Residential Treatment Services Bureau (RTSB) Manual Sections: The facility administrator shall develop and implement 1316: Searches in Detention Facilities written policies and procedures governing the search of 1317: Body Searches (Pat- Down, Strip, and youth, the facility, and visitors. Policies and procedures Body Cavity Searches) shall provide that: Various samples of search documents were ☒ ☐ ☐ provided for our review from July2019- January 2020. A Facility Entrance Report- Consumption of Alcohol/Contraband, Inspection for Contraband, School Inspection, Living Quarters Inspection, K-9 Searches and Dorm (a) Searches shall be conducted to ensure the safety and Residential Treatment Services Bureau security of the facility, public, visitors, youth, and ☒ ☐ ☐ (RTSB) Manual Sections 1316: Searches in staff. Detention Facilities (b) Searches shall be conducted in a manner that Residential Treatment Services Bureau preserves the privacy and dignity of the person (RTSB) Manual Sections 1316: Searches in being searched and shall not be conducted for ☒ ☐ ☐ Detention Facilities harassment or as a form of discipline or punishment. (c) Strip searches and visual or physical body cavity Residential Treatment Services Bureau searches shall comply with Penal Code Section (RTSB) Manual Sections: ☒ ☐ ☐ 4030. 1316: Searches in Detention Facilities 1317: Body Searches (Pat- Down, Strip, and Body Cavity Searches) (d) Physical body cavity searches shall only be Residential Treatment Services Bureau conducted by a medical professional. (RTSB) Manual Section 1317: Body ☒ ☐ ☐ Searches (Pat- Down, Strip, and Body Cavity Searches) 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) Any youth held after a detention hearing shall only Residential Treatment Services Bureau be strip searched with prior approval of a supervisor (RTSB) Manual Section 1317: Body when there is reasonable suspicion based on Searches (Pat- Down, Strip, and Body Cavity ☒ ☐ ☐ specific and articulable facts to believe that youth is Searches) concealing contraband. The reasonable suspicion All youth are post disposition. shall be documented. (f) Searches of transgender and intersex youth shall Residential Treatment Services Bureau comply with Section 1352.5. (RTSB) Manual Section 1303: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (g) Cross-gender pat-down searches and strip searches Residential Treatment Services Bureau are prohibited except in exigent circumstances or (RTSB) Manual Section 1317: Body ☒ ☐ ☐ when conducted by a medical professional. Such Searches (Pat- Down, Strip, and Body Cavity searches must be justified and documented in Searches) writing. 1361 GRIEVANCE PROCEDURE Residential Treatment Services Bureau (RTSB) Manual Section 508: Grievance The facility administrator shall develop and Procedures implement written policies and procedures whereby any youth may appeal and have resolved grievances Grievance samples were provided from relating to any condition of confinement, including March, July and October 2019 were but not limited to health care services, classification provided for our review. ☒ ☐ ☐ decisions, program participation, telephone, mail or Compliance noted through review of visiting procedures, food, clothing, bedding, documentation, from policy and through mistreatment, harassment or violations of the conversation with consultant staff. We were nondiscrimination policy. There shall be no time not onsite to view the process. limit on filing grievances. Policies and procedures shall include provisions whereby the facility manager ensures: (a) a grievance form and instructions for registering a Residential Treatment Services Bureau grievance, which includes provisions for the youth (RTSB) Manual Section 508: Grievance to have free access to the form; Procedures Per bureau consultant staff, grievance forms and the instructions are available in the ☒ ☐ ☐ dorms and in other areas around the facility. Youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same. We viewed both paper grievances and electronic grievances. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) the youth shall have the option to confidentially file Residential Treatment Services Bureau the grievance or to deliver the form to any youth (RTSB) Manual Section 508: Grievance supervision staff working in the facility; Procedures Per bureau consultant staff, youth may submit to any staff member or submit the ☒ ☐ ☐ grievance in the confidential box or directly to the Supervisor. Youth may also submit grievances through the JIGS system. This is through LACOE laptops. Once the youth submits the grievance, it is addressed like any other paper grievance per staff we spoke with. (c) resolution of the grievance at the lowest appropriate Residential Treatment Services Bureau staff level; (RTSB) Manual Section 508: Grievance Procedures Per policy, youth may submit to any staff ☒ ☐ ☐ member, submit through the confidential box or directly to the Supervisor. In the documentation reviewed, we noted that all grievances were addressed by either a DPO II or a supervisor. (d) provision for a prompt review and initial response Residential Treatment Services Bureau to grievances within three (3) business days, (RTSB) Manual Section 508: Grievance grievances that relate to health and safety issues Procedures must be addressed immediately; There were 11 grievances in total provided for our review. Health and safety issues are ☐ ☒ ☐ to be addressed immediately and all others are to be addressed within 3 business days. 4 of the grievances were health and safety related and were not addressed immediately. Only one of the 7 remaining grievances was addressed in a timely manner. This section is non-compliant. (1) The youth may elect to be present to explain Residential Treatment Services Bureau his/her version of the grievance to a person not (RTSB) Manual Section 508: Grievance directly involved in the circumstances which Procedures ☒ ☐ ☐ led to the grievance. Youth spoke directly to the Director regarding his compliant with staff. (2) Provision for a staff representative approved by Residential Treatment Services Bureau the facility administrator to assist the youth. ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures (e) provision for a written response to the grievance Residential Treatment Services Bureau which includes the reasons for the decisions; ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) a system which provides that any appeal of a Residential Treatment Services Bureau grievance shall be heard by a person not directly (RTSB) Manual Section 508: Grievance involved in the circumstances which led to the ☒ ☐ ☐ Procedures grievance; (g) resolution of the grievance must occur within ten Residential Treatment Services Bureau (10) business days unless circumstances dictate a (RTSB) Manual Section 508: Grievance longer time frame. The youth shall be notified of Procedures ☒ ☐ ☐ any delay; and, All grievances but 1 were resolved within 10 days. (h) the policy shall provide multiple internal and Residential Treatment Services Bureau external methods to report sexual abuse and sexual ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance harassment. Procedures Whether or not associated with a grievance, concerns of Residential Treatment Services Bureau parents, guardians, staff or other parties shall be (RTSB) Manual Section 508: Grievance addressed and documented in accordance with written ☒ ☐ ☐ Procedures policies and procedures within a specified timeframe. There was no documentation to view. 1362 REPORTING OF INCIDENTS Residential Treatment Services Bureau (RTSB) Manual Section 1120: Reducing A written report of all incidents which result in physical Youth on Youth on Violence and 1919: harm, use of force, serious threat of physical harm, or Deaths at Camp Facilities death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the Several SIR’s regarding moving mental staff and submitted to the facility manager by the end of health levels were provided. These reports the shift, unless additional time is necessary and were initiated due to DMH actions and were authorized by the facility manager or designee. accompanied by mental health recording forms. Reports were submitted timely. 1363 USE OF REASONABLE FORCE TO Residential Treatment Services Bureau COLLECT DNA SPECIMENS, SAMPLES, (RTSB) Manual Section 306: Live Scan and IMPRESSIONS DNA Collection and 1122: Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections RTSB does not collect DNA samples. If a personnel including peace officers, may employ ☐ ☐ ☒ sample is needed, youth are transported back reasonable force to collect blood specimens, saliva to the JH’s. DSB personnel are responsible samples, and thumb or palm print impressions from for conducting all DNA Collection. The individuals who are required to provide such remaining sections are all marked as NA. samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) For the purpose of this section, the “use of Residential Treatment Services Bureau reasonable force” shall be defined as the force that (RTSB) Manual Section 306: Live Scan and an objective, trained and competent correctional DNA Collection and 1122: Juvenile employee, faced with similar facts and Collection of DNA Samples circumstances, would consider necessary and The Juvenile Halls are responsible for the reasonable to gain compliance with this section. collection of DNA samples for all detained ☐ ☐ ☒ and non- detained youth. Per policy, force will not be used to obtain DNA samples unless ordered by the court. If a youth refuses to cooperate, this information is provided to the court for further determination. (2) The use of reasonable force shall be preceded by Residential Treatment Services Bureau efforts to secure voluntary compliance. Efforts to (RTSB) Manual Section 306: Live Scan and secure voluntary compliance shall be documented DNA Collection and 1122: Juvenile ☐ ☐ ☒ and include an advisement of the legal obligation to Collection of DNA Samples provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Residential Treatment Services Bureau authorization of the supervising officer on duty. (RTSB) Manual Section 306: Live Scan and The authorization shall include information that DNA Collection and 1122: Juvenile ☐ ☐ ☒ reflects the fact that the offender was asked to Collection of DNA Samples provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Residential Treatment Services Bureau extraction, the extraction shall be videotaped. (RTSB) Manual Section 306: Live Scan and Video shall be directed at the cell extraction DNA Collection and 1122: Juvenile event. The videotape shall be retained by the Collection of DNA Samples ☐ ☐ ☒ agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County (a) School Programs Probation and Los Angeles County Office of The County Board of Education shall provide for the Education: Juvenile Courts and Community administration and operation of juvenile court Schools. schools in conjunction with the Chief Probation A Matrix was provided for our review from Officer, or designee pursuant to applicable State Sr. Director Dr. Jesus Coral that detailed all laws. The school and facility administrators shall areas of Section 1370. All policy areas for develop and implement written policy and this section are either noted in the LACOE procedures to ensure communication and Board Policy or are in the RTSB Policy. coordination between educators and probation staff. Culturally responsive and trauma-informed BSCC Field Representatives do not inspect approaches should be applied when providing the education program for compliance with instruction. Education staff should collaborate with Title 15. Title 15 requires the Superintendent of Schools to conduct this the facility administrator to use technology to review in conjunction with a qualified facilitate learning and ensure safe technology ☒ ☐ ☐ outside agency or individual. practices. The facility administrator shall request an annual review of each required element of the The education program was evaluated by program by the Superintendent of Schools, and a Kim Herrera and Karen Loucks, Principals report or review checklist on compliance, from Taft California found the education deficiencies, and corrective action needed to achieve program to comply with all regulatory compliance with this section. Such a review, when requirements. conducted, cannot be delegated to the principal or any other staff of any juvenile 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 facility administrator or designee shall review each item with the Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the BP 6011 Instruction, BP 0460 Philosophy, State Education Code and County Board of Goals, Objectives and Comprehensive Plans Education policies, all applicable federal education BP 005 Philosophy, Goals, Objectives and statutes and regulations and provide for an annual Comprehensive Plans Item 3,4,5 evaluation of the educational program offerings. As stated in the 2009 California Standards for the ☒ ☐ ☐ Teaching Profession, teachers shall establish and maintain learning 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. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. ☒ ☐ ☐ Staff 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Comprehensive Plans ☒ ☐ ☐ courses required for high school graduation. Item 3,4,5 (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California ☒ ☐ ☐ Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) ☒ ☐ ☐ and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of ☒ ☐ ☐ Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth AR-6179 Instruction BPP 5149 who do not demonstrate sufficient progress towards ☒ ☐ ☐ grade level standards. (6) The minimum school day shall be consistent with BP 6112 Instruction State Education Code Requirements for juvenile court 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 BP 6112 Instruction Partially address classification, housing, security status, disciplinary requirement; AR 5131 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 AR 5144 Students (1) Positive behavior management will be 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 BP 5021 Students CF 6020 ☒ ☐ ☐ decisions made by probation staff that may affect the educational programming of students. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension Code, expulsion/suspension from school shall be and Expulsion/Due Process (Students with imposed only when other means of correction fails Disabilities) 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 BP 5144 education staff will develop policies and procedures ☒ ☐ ☐ that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or ☒ ☐ ☐ 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 BP 6174 Instruction afforded an educational program that addresses their ☒ ☐ ☐ language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement ☒ ☐ ☐ (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction ☒ ☐ ☐ (B) Home Language Survey and the results of the State AR 6174 Instruction ☒ ☐ ☐ Test used for English language proficiency; (C) Needs and services of special populations as defined BP 6162.5 Instruction ☒ ☐ ☐ by the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. ☒ ☐ ☐ BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary BP 6162.5 Instruction ☒ ☐ ☐ education plan shall be developed for each youth within five school days. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 58 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with AR 5125 Students the State Education Code and request the youth's records from his/her prior school(s), including, but not 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 AR 5125 Students ☒ ☐ ☐ (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies ☒ ☐ ☐ 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever possible, collaborate with local post- ☒ ☐ ☐ secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Residential Treatment Services Bureau EXERCISE. (RTSB) Manual Section 1306: Programs, recreation and Exercise The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Residential Treatment Services Bureau programs, recreation, and exercise a minimum of three (RTSB) Manual Section 1306: Programs, hours a day during the week and five hours a day each recreation and Exercise Saturday, Sunday or other non-school days, of which The time spent in the programs or activities one hour shall be an outdoor activity, weather ☐ ☒ ☐ are not documented to confirm the minimum permitting. 3 hours during the week and 5 hours minimum on weekends and other non-school days. Documentation must reflect this. This section is non-compliant. A youth’s participation in programs, recreation, and Residential Treatment Services Bureau exercise may be suspended only upon a written finding (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ by the administrator/manager or designee that a youth recreation and Exercise represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall Residential Treatment Services Bureau be posted in the living units. ☒ ☐ ☐ (RTSB) Manual Section 1306: Programs, recreation and Exercise There will be a written annual review of the programs, Residential Treatment Services Bureau recreation, and exercise by the responsible agency to (RTSB) Manual Section 1306: Programs, ensure content offered is current, consistent, and recreation and Exercise relevant to the population. Facility administration provided a memo with a listing of all programs offered at the facility in coordination with DMH, LACOE and by Probation staff noting that the programs were appropriate for the youth. • Arts for Incarcerated Youth Network • Drumming for Life • New Earth Organization • Operation Read • Religious Volunteers ☒ ☐ ☐ Drumming for Life and Arts for Incarcerated Youth Network Provided a review; however, we noted that the letters were not dated. Technical assistance was provided and discussed that reviews must be provided annually and are needed from all program providers at the next inspection and they must be dated for the current year they are for. Technical Assistance: Due to COVID, we understand the difficulties of getting documents for annual reviews. Please ensure that all reviews are available for the next onsite inspection for all programs and providers. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Programs. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of daily (RTSB) Manual Section 1306: Programs, programming to include, but not be limited to, recreation and Exercise trauma focused, cognitive, evidence-based, best Youth are to be provided with the practice interventions that are culturally relevant and opportunity to participate in at least one hour linguistically appropriate, or pro-social interventions of programming that is rehabilitational daily. and activities designed to reduce recidivism. These We did not see that this occurred. programs should be based on the youth’s individual needs as required by Sections 1355 and 1356. Such Youth are to be provided with the programs may be provided under the direction of the opportunity to participate in at least one hour Chief Probation Officer or the County Office of of programming that is rehabilitational daily. Education and can be administered by county A dorm calendar was provided but partners such as mental health agencies, community- documentation provided did not show based organizations, faith-based organizations or compliance with regulation expectations Probation staff. (program and time) or that the program Programs may include but are not limited to: occurred. This section is non-compliant ☐ ☒ ☐ (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; (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 Residential Treatment Services Bureau opportunity for at least one hour of daily access to (RTSB) Manual Section 1306: Programs, unscheduled activities such as leisure reading, letter recreation and Exercise writing, and entertainment. Activities shall be Youth are to be provided with the supervised and include orientation and may include opportunity to participate in at least one hour coaching of youth. ☐ ☒ ☐ of recreation (Known as “Free Time” in your documentation) Documentation provided notes that free time activities are provided but does not note the hour requirement. This is non-compliant. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Exercise. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of large muscle (RTSB) Manual Section 1306: Programs, activity each day. recreation and Exercise Youth are to be provided with the ☒ ☐ ☐ opportunity to participate in at least one hour of exercise. Documentation provided noted that youth receive an hour of exercise daily. The administrator/manager may suspend, for a period not Residential Treatment Services Bureau to exceed 24 hours, access to recreation and programs. (RTSB) Manual Section 1306: Programs, The administrator/manager shall document the reasons ☒ ☐ ☐ recreation and Exercise why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1004: Religious The facility administrator shall provide access to Services religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth ☒ ☐ ☐ Services are provided for both Catholic and shall be allowed to participate in an activity outside of Protestant religions. their room if he/she elects not to participate in religious programs. Religious programs shall provide for: (a) opportunity for religious services and practices; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (b) availability of clergy; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (c) availability of religious diets. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services 1373 WORK PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1003: Work Crews The facility administrator shall develop policies and procedures regarding the fair and consistent assignment • Transition Partnership Program of youth to work programs. Work assigned to a youth (TPP) shall be meaningful, constructive and related to • Work Ability Central vocational training or increasing a youth's sense of • Youth Bridges Program responsibility. Work programs shall not be imposed as a ☒ ☐ ☐ • Pacific Gateway Internship disciplinary measure. All programs are site-based employment services that can assist youth with gaining employment skills while in custody thus assisting them in transitioning home and back to the community with employment skills. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 62 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1374 VISITING Residential Treatment Services Bureau (RTSB) Manual Section 902: Visiting The facility administrator shall develop and implement Procedures, 903: Saturday and Sunday written policies and procedures for visiting, that include Visiting and 904: Special Visits provisions for special visits. Youth shall be allowed to receive visits by parents, guardians or persons standing Visiting logs provided for review. in loco parentis, and children of youth. Other family ☒ ☐ ☐ A sample of a letter that is sent to parents of members, such as grandparents and siblings, and youth detained in both the Juvenile Halls and supportive adults, may be allowed to visit with the the camps was provided for our review. The approval of the facility administrator or designee, and in letter was dated in September 2019 and conjunction with the youth’s case plan or in the best contained information that was not updated interest of the youth. to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to Residential Treatment Services Bureau the limitations necessary to maintain order and security. (RTSB) Manual Section 902: Visiting Visitation shall not be denied solely based on the visitor’s Procedures, 903: Saturday and Sunday criminal history. The staff shall determine in each case, Visiting and 904: Special Visits whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ Visitation occurs on Sundays from 1:00PM the safety of youth or staff in the facility. Any denial of to 4:00PM. visitation or limitation on visitations shall be communicated to the youth, person denied and facility Administration will always make exceptions administrator. for those that cannot make it on the weekend. Opportunity for visitation shall be a minimum of two Residential Treatment Services Bureau hours per week. Visits may be supervised, but (RTSB) Manual Section 902 and Visiting conversations shall not be monitored unless there is a Procedures, 903: Saturday and Sunday security or safety need. Visiting ☒ ☐ ☐ Youth have over 2 hours of visitation opportunity on the weekends and administration will make arrangements during the week for youth to have the same amount of time if needed. Provisions for special visits, in addition to the two-hour Residential Treatment Services Bureau minimum and/or outside of the regular visiting hours, (RTSB) Manual Section 902: Visiting shall be accommodated as necessary and within the Procedures, 903: Saturday and Sunday discretion of the facility administrator or designee. ☒ ☐ ☐ Visiting and 904: Special Visits 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 Residential Treatment Services Bureau alternative, but not as a replacement, to in-person (RTSB) Manual Section 902: Visiting visiting. ☒ ☐ ☐ Procedures 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1375 CORRESPONDENCE Residential Treatment Services Bureau (RTSB) Manual Section 510: Mail The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for correspondence Youth can write letters daily. Mail is also which provide that: distributed daily. (a) there is no limitation on the volume of mail that youth Residential Treatment Services Bureau may send or receive; ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (b) youth may send two letters per week postage free; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (c) youth may correspond confidentially with state and Residential Treatment Services Bureau federal courts, any member of the State Bar or holder (RTSB) Manual Section 510: Mail of 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 Residential Treatment Services Bureau in (c), may be read by staff only when there is (RTSB) Manual Section 510: Mail ☒ ☐ ☐ reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Residential Treatment Services Bureau (RTSB) Manual Section 509: Telephone The administrator of each juvenile facility shall develop ☒ ☐ ☐ Calls and implement written policies and procedures to provide youth with access to telephone communications. Youth may call home weekly. 1377 ACCESS TO LEGAL SERVICES Residential Treatment Services Bureau (RTSB) Manual Section 520: Access to The facility administrator shall develop written ☒ ☐ ☐ Legal Services 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 Residential Treatment Services Bureau attorneys and their authorized representatives; ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (b) provision for confidential consultation with Residential Treatment Services Bureau attorneys; and, ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (c) unlimited postage free, legal correspondence and Residential Treatment Services Bureau cost-free telephone access as appropriate. ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 64 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1390 DISCIPLINE Residential Treatment Services Bureau (RTSB) Manual Section 601: Discipline, The facility administrator shall develop and implement 602: Facility Rules and 603: Behavior written policies and procedures for the discipline of Management Program youth that shall promote acceptable behavior; including the use of positive behavior interventions and supports. ☒ ☐ ☐ Youth also receive a copy of the RTSB Discipline shall be imposed at the least restrictive level Orientation Handbook and the Behavior which promotes the desired behavior and Deprivation of Management Program Handbook at the following is not permitted: orientation. (a) bed and bedding; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (b) daily shower, access to drinking fountain, toilet and Residential Treatment Services Bureau ☒ ☐ ☐ personal hygiene items, and clean clothing; (RTSB) Manual Section 601: Discipline (c) full nutrition; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (d) contact with parent or attorney; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (e) exercise; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (f) medical services and counseling; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (g) religious services; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (h) clean and sanitary living conditions; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (i) the right to send and receive mail; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (j) education; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (k) rehabilitative programming. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline The facility administrator shall establish rules of conduct Residential Treatment Services Bureau and disciplinary penalties to guide the conduct of youth. (RTSB) Manual Section 604: Continuum of Such rules and penalties shall include both major Correction violations and minor violations, be stated simply and ☒ ☐ ☐ Information regarding the rules is provided affirmatively, and be made available to all youth. in the orientation and BMP handbooks that Provision shall be made to provide accessible are provided to the youth. information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS Residential Treatment Services Bureau (RTSB) Manual Section 604: Continuum of The facility administrator shall develop and implement ☒ ☐ ☐ Correction and 606: Due Process written policies and procedures for the administration of discipline which shall include, but not be limited to: 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 65 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) designation of personnel authorized to impose Residential Treatment Services Bureau discipline for violation of rules; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (b) prohibiting discipline to be delegated to any youth; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (c) definition of major and minor rule violations and Residential Treatment Services Bureau their consequences, and due process requirements; ☒ ☐ ☐ (RTSB) Manual Section 604: Continuum of Correction (d) trauma-informed approaches and positive behavior Residential Treatment Services Bureau interventions; ☒ ☐ ☐ (RTSB) Manual Section 602: Facility Rules and 604: Continuum of Correction (e) minor rule violations may be handled informally by Residential Treatment Services Bureau counseling, advising the youth of expected conduct (RTSB) Manual Section 604: Continuum of imposing a minor consequence. Discipline shall be Correction accompanied by written documentation and a ☐ ☒ ☐ policy of review and appeal to a supervisor; and, No documentation of minor rule violations provided separate than sanctions and appeals form with PIR’s (f) major rule violations and the discipline process Residential Treatment Services Bureau shall be documented and require the following: ☒ ☐ ☐ (RTSB) Manual Section 606: Due Process 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) written notice of violation prior to a hearing; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process There is no location/space for notice of violation on the current form. Policy is consistent with regulation requirements; documentation is not. Facility staff provided Sanctions and Appeals forms that are required for all PIR SCM packets. Technical assistance has previously been provided and discussed with Bureau Management regarding the sanctions and appeal form and the need to revise and change the form to ensure compliance. We were assured this would be revised/updated to be more consistent to address the regulation requirements. This issue was addressed with the Prior Bureau Chief and consultant staff and it was agreed a new form would be implemented for this next cycle. The form does not provide proof of notice of violation and the recommendations noted are not the actual sanctions being recommended ☐ ☒ ☐ or imposed. All sanctions must be noted and made a part of this process and Youth must have the option of a due process hearing on the actual consequences and sanctions they receive. We have confirmed agency staff have corrected policy and forms to correct this issue however, we are unable to determine implementation. This is currently non- compliant. We appreciate the efforts that have been made and look forward to reviewing documentation in the near future to review for compliance. We will continue to follow up with the agency to provide support and technical assistance as needed. Documentation provided from Campus Kilpatrick was completed on the same forms as previously used in past cycles. In addition, policy requires staff to document the major rule violation on the SIR which we did not find evidence of and policy states that all penalties are held in abeyance pending the outcome of the hearing. In some cases, it was not. 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 67 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) accommodations provided to youth with Residential Treatment Services Bureau disabilities, limited literacy, and English (RTSB) Manual Section 606: Due Process language learners; Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (3) hearing by a person who is not a party to the Residential Treatment Services Bureau incident; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK (4) opportunity for the youth to be heard, present Residential Treatment Services Bureau evidence and testimony; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (5) provision for youth to be assisted by staff in the Residential Treatment Services Bureau hearing process; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. . (6) provision for administrative review. Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (g) violations that result in a removal from camp or Residential Treatment Services Bureau commitment program, but not a return to court, will (RTSB) Manual Section 604: Continuum of ☒ ☐ ☐ follow the due process provisions in subsection (e) Correction above. f 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 68 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the facility. ☒ ☐ ☐ (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Vi Dependent or neglected minors who are defined under Section ☐ olati ☒ 300 of the Welfare and Institutions Code (WIC) are held only on 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 ☐Vi Delinquents (WIC 602)? (WIC 207[d]). ☐ olati ☒ on 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 ☐Vi from minors. ☐ olati ☒ on Adult inmates from an adult facility (e.g. inmate workers or ☐Vi “Scared Straight” programs) are not allowed in the facility in a ☒ olati ☐ manner that allows contact with minors. on 7232 Los Angeles Campus Kilpatrick PRO 18 20 - 2 - J453 JUV PRO-Eff. 01-01-2019 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 BSCC Code: 7232 FACILITY NAME: FACILITY TYPE: Campus Kilpatrick Juvenile Camp 4/98: 2001: 2003: 2009: 2014 APPLICABLE REGULATIONS (Check All That XX Apply): FIELD REPRESENTATIVE: Lisa Southwell DATE: June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS Reception/Intake Admission (JH; 1.1) 1230.1.1 Not Required for Camp Facilities X Contains a weapons locker as specified in these regulations Contains a secure room for the confinement of X minors pending admission to JH Provides access to a shower X Provides a secure vault or storage space for minor's X valuables Provides telephone access to minors X Provides staff access to hot and cold running water X Locked Holding Room (1.2) 1230.1.2 Not Required for Camp Facilities There are no locked holding rooms in the X Contains a minimum of 15 square feet of floor area facility. per minor Provides no less than 45 square feet of floor area X Contains seating to accommodate all minors as X specified in these regulations 98: Provides access to a toilet, wash basin and drinking fountain as specified in these regulations 03: Be equipped with a toilet, wash basin and X drinking fountain unless a procedure is in effect to provide access Maximizes staff visual supervision X 03: Outward swinging or lateral sliding door required X Natural Light (1.3) The facility provides excellent natural light in both the living and non-living areas. Visual access to natural light is provided in locked X sleeping rooms, single and double occupancy sleeping rooms, dormitories and dayrooms. 1 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS Corridors (1.4) There are no corridors in the living area. Corridors in living areas are at least eight feet wide. When doors are staggered or if rooms are located X only on one side, corridors may be at least six feet wide. Living Unit (JH; 1.5) 1230.1.5 Not Required for Camp Facilities JH living units do not exceed 30 minors and contain sleeping areas and plumbing fixtures, commensurate with the number of minors housed. X 12: living unit shall not be divided in a way that hinders direct access, supervision or immediate intervention or other action if needed. Locked Sleeping Rooms (1.6) There are no locked sleeping rooms in the facility. 98: Have a toilet, wash basin and drinking fountain unless a procedure is in effect to provide other X access to these fixtures 03: Toilet, wash basin and drinking fountain required in locked sleeping rooms Single Occupancy Sleeping Rooms (1.7) There are no single occupancy sleeping rooms in the facility. 98: Minimum of 63 square feet of floor area and a X clear ceiling height of eight feet 03: Minimum of 70 square feet of floor area and a clear ceiling height of eight feet 98: A door view panel is constructed of security glazing and is a maximum of 144 square inches. 01: View panel size changed to a minimum of 144 X inches. 03: Outward swinging or lateral sliding door required X Double Occupancy Sleeping Rooms (1.8) There are no double occupancy rooms in the facility. Minimum of 100 square feet floor area, a clear ceiling X height of eight feet, and a minimum width of seven feet 98: A door view panel is constructed of security glazing and is a maximum of 144 square inches. 01: View panel size changed to a minimum of 144 X inches 03: Outward swinging or lateral sliding door required X Dormitories (1.9) The space exceeds the requirement. In JHs and camps, there is a minimum of 50 square feet of floor area per minor, with a minimum dormitory X size of 200 square feet and a minimum clear ceiling height of eight feet. 2 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS In JHs and camps, dormitories are designed for no Each sleeping area is for 12 youth: 6 on each X fewer than four minors. side. 98: JH dormitories for detained minors are designed for no more than 15 minors (NA camps). 03: This subsection deleted, eliminating the 15-minor X limitation. (See below.) 98: JH dormitories for court commitments are designed for no more than 30 minors (NA Camps). 03: No JH dormitory can be designed for more than X 30 minors (regardless of whether it is for court commitments or other detained minors). Dayrooms (1.10) JH dayrooms contain 35 square feet of floor area per X minor. 98: Dayrooms in camps and SPJHs contain 30 square feet of floor area per minor. X 09: Camps and SPJHs were removed). All dayrooms provide access to toilets, wash basins, drinking fountains and showers. X Physical Activity and Recreation Spaces (NA SPJH; 1.11) 98: Facilities with a capacity of less than 41 minors have a minimum of 9,000 square feet dedicated X indoor-outdoor space. 01: Facilities with a capacity of 40 minors or less have a minimum of 9,000 square feet dedicated indoor-outdoor space. 98: Facilities with a capacity of 41 to 100 minors have a minimum of 9,000 square feet dedicated indoor-outdoor space, plus a field area. The field area contains a minimum of one acre with a X minimum dimension of 100 feet. 01: Facilities with a capacity of 41-274 minors have a minimum of 225 square feet of dedicated indoor- outdoor space per minor, up to 61,650 feet. 98: Facilities with a capacity over 100 minors have a The facility has ample space for the youth to minimum of 18,000 square feet dedicated indoor- participate in exercise and other recreational outdoor space, plus a field area. The field area activities. There are outdoor basketball contains a minimum of one acre with a minimum courts, a volleyball court, circuit workout area, dimension of 100 feet. pool, indoor, full sized gymnasium, baseball X 01: Facilities with a capacity of 275 or more minors field and each cottage has an exterior have 61,650 square feet dedicated indoor- outdoor area with a basketball hoop for small outdoor space, plus 145 square feet for each group or single activity with staff. minor beyond 274 (up to a maximum of 87,120 square feet). 98: At least one half of the dedicated indoor-outdoor space is a paved or "like" surface. X 01: Changed from one-half to one-quarter of the space 3 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS A portion of the dedicated physical activity and recreation space is out-of-doors and is equipped and X of a sufficient size to comply with Title 15, § 1371. 01: The required recreation area has no single X dimension less than 40 feet. Outdoor recreation area lighting allows for evening activities and provides security. X Academic Classrooms (NA SPJH; 1.12) **County has been noticed as to classroom limitations on the number of students as X Classrooms are designed for a maximum of 20 noted below. minors. There is a minimum of one classroom in each facility 2001: Dedicated classroom space is available for X every juvenile in the facility. The primary purpose for the academic classroom is for education. Each classroom contains a minimum of 160 square feet of floor space for the teacher's desk and work X area, and a minimum of 28 square feet floor space per minor. There is a communication system in each classroom that allows for immediate response to emergencies. X Safety Room (1.13) 1230.1.13 Not Required for Camp Facilities X Provides a minimum of 63 square feet of floor space and a minimum clear ceiling height of eight feet Limited to one minor X Padded as specified in these regulations X There are one or more vertical view panels constructed of security glazing. Panels provide a X view of the entire room and are no more than four inches wide and at least 24 inches long. Audio monitoring system as specified in these X regulations Access to a toilet, wash basin and drinking fountain is X provided. 03: Be equipped with a variable intensity security- type lighting fixture, with controls outside the X room 03: Any wall- or ceiling-mounted devices are designed to prohibit the occupant’s access. X Medical Examination Room (NA SPJH; 1.14) There is a minimum of one suitably equipped medical X examination room in every juvenile facility. The examination room provides the following: Space for routine and emergency examinations X that is used for no other purpose; Privacy for minors; X Lockable storage for medical supplies; X Not less than 144 square feet floor space with no X single dimension less than seven feet; 4 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS Hot and cold running water; and, X 01: Smooth, non-porous, washable surfaces. X Pharmaceutical Storage (1.15) There is lockable storage space for medical supplies X and pharmaceutical preparations as specified by Title 15 § 1438. Dining Areas (NA SPJH; 1.16) Youth will be fed in shifts in the dining commons as per the Operational Plan. There is a minimum of 15 square feet floor space and X sufficient tables and seating for each person being fed (including minors, staff and visitors). Dining areas do not contain toilets or showers in the same room, unless there is an appropriate visual X barrier. Visiting Space (1.17) Youth will visit in the commons as per the Operational Plan. X Visiting space is provided. Institutional Storage (1.18) There is a minimum of 80 cubic feet of storage space per minor for institutional clothing, bedding, supplies X and activity equipment, in one or more storage rooms. Personal Storage (1.19) Youth have lockers in the laundry room to store their personal items. Each minor has a minimum of nine cubic feet of X secure storage space for personal clothing and belongings. Safety Equipment Storage (1.20) There is a secure area for storing safety equipment, such as fire extinguishers, self-contained breathing X apparatus, wire and bar cutters, emergency lights, etc. Janitor Closet (1.21) There is at least one securely lockable janitorial X closet containing a mop sink and sufficient area for storing cleaning implements within the security area. 5 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS Audio Monitoring System (1.22) No locked sleeping areas. There is an audio monitoring system capable of actuation by the minor to alert staff in: safety rooms; locked holding rooms, locked sleeping rooms; single and double occupancy sleeping rooms and X dormitories of JHs and in locked sleeping rooms and single occupancy rooms of secure camps. 09:JH and locked sleeping rooms and single occupancy rooms of secure camps were removed Emergency Power (1.23) Generator provides 3 days of load shed capacity power. There is an emergency power source capable of providing minimal lighting in all living units, activity areas, corridors, stairs, and central control points, to X maintain fire and life safety, security, communications and alarm systems. The power source conforms to the requirements specified in Title 24, Part 3, Article 700, California Electrical Code (CCR). Confidential Interview Room (1.24) X Contain a minimum of 60 square feet of floor area and provide for confidential consultation with minors There is a minimum of one suitably furnished X interview room for each 30 minors in JHs. There is a minimum of one suitably furnished interview room in each camp. X Court Holding Room for Minors (1.26) 1230.1.26 Not Required for Camp Facilities X Contains a minimum of 10 square feet of floor area per minor Limited to no more than 16 minors X Provides 40 square feet of floor area and a minimum X clear ceiling height of eight feet Contains seating to accommodate all minors X Contains a toilet, wash basin and drinking fountain as X specified in these regulations Maximizes staffs' visual supervision of minors X Programs and Activity Area (1.27) Camp and ranch facilities shall include adequate X space for specific programs in addition to recreation and exercise area. Toilets/Urinals (2.1) Toilets are available on living units in a ratio of 1:6 in JH; 1:10 in camps; and, 1:8 in locked holding rooms. X One toilet and one urinal may be substituted for every 15 boys. Toilet areas provide modesty for the minors without mitigating staff’s ability to supervise. 6 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS Wash basins (2.2) Wash basins must provide hot and cold or tempered water and be available on living units in a ratio of 1:6 X in JH; 1:10 in camps; and, 1:8 in locked sleeping rooms. Drinking Fountains (2.3) Drinking fountains are accessible to minors and staff X in living areas and indoor-outdoor recreation areas. 01: The drinking fountain bubbler is activated by mechanical means and is at an angle that prevents waste water from flowing over the X bubbler. Showers (2.4) Showers provide tempered water and are available X on living units at a ratio of at least one shower or bathtub to every six minors. Shower areas provide for inmate privacy without mitigating staff's ability to supervise. X Beds (2.5) Beds are at least 30 inches wide and 76 long and are of a pan-bottom type or constructed of concrete. X 12: pan bottom was deleted 12: Solid bottom was added Beds are at least 12 inches of the floor and spaced no less than 36 inches apart. X 12: Bunk beds must be 33 inches vertically between the bottom 12: In secure facilities, bunks shall be securely X anchored and flushed against floor and/or wall. Lighting (2.6) There is at least 20 foot-candles (216 1x) of illumination at desk level in locked sleeping rooms, X single and double occupancy rooms, dormitories, dayrooms and activity areas. Night lighting in the above areas provides good visibility and is conducive to sleep. X Padding (2.7) 1230.2.7 Not Required for Camp Facilities Padding in safety rooms covers the floor, door and X walls to a clear height of eight feet. Benches or platforms are not placed on the floor of safety rooms. Padded rooms are equipped with a tamper-resistant fire sprinkler as approved by the State Fire Marshal X (SFM). 7 7232 Los Angeles Campus Kilpatrick 18-20 PHY TITLE 24 SECTION YES NO N/A COMMENTS The padding is approved by the SFM and is: non- porous; at least one-half inch thick; of a unitary or laminated construction; firmly bonded to all padded X surfaces; and, is without exposed seams. Seating (2.8) Seating is designed for the level of security. When bench seating is used, 18 inches of bench seating is X allowed for each person. Weapons Locker (2.9) Weapons lockers are located outside the security perimeter of the facility. (Personnel do not bring any X weapon into the security area.) 12: deleted perimeter and added area Lockers are equipped with individual compartments, each with their own locking device. X Assess for New Construction/Remodel or Repair: X Security Glazing (2.10) (Added in 2003) (Note to inspector: This will typically be assessed from specifications provided at plan review.) Security glazing complies with the minimum requirements of one of the following test standards: X American Society for Testing and Materials, ASTM F 1233-98, Class III glass; California Department of Corrections, CDC 860-94d, Class C glass; or, H. P. White Laboratory, Inc., HPW-TP-0500.02, Forced Entry Level III. Design Requirements (201(c)6) Design requirements as specified in Title 24, Part 1, 201(c) 6 are met. X (Note to inspector: See regulation for specific requirements. Note areas of non-compliance that are applicable to the facility type and construction date in the "comments" section.) ** Educational Facilities Classroom 20’ x 25’10” Classroom can hold up to 102 517 Sq. Feet 12 youth Classroom 20’ x 25’10” Classroom can hold up to 103 517 Sq. Feet 12 youth Classroom 20’ x 25’10” Classroom can hold up to 104 517 Sq. Feet 12 youth Classroom 17’10” x 25’ Classroom can hold up to 119 446 Sq. Feet 10 youth Classroom 19’9” x 24’10” Classroom can hold up to 120 490 Sq. Feet 12 youth Classroom 19’6” x 24’11” Classroom can hold up to 121 486 Sq. Feet 12 youth Classroom 19’6” x 24’11” Classroom can hold up to 8 7232 Los Angeles Campus Kilpatrick 18-20 PHY 122 486 Sq. Feet 12 youth Classroom 19’6” x 24’11” Classroom can hold up to 123 486 Sq. Feet 12 youth Classroom 17’ x 16’6” Classroom can hold up to 105 281 Sq. Feet 4 youth Classroom 17’ x 16’9” Classroom can hold up to 106 285 Sq. Feet 4 youth Culinary 30 x 50 Classroom can hold up to estimated** 20 youth 1500Sq. Feet Shop 49’ x 22’3” Classroom can hold up to 1090 Sq. Feet 20 youth Library 32’ X 25”10” If used as a classroom, 827 Sq. Feet can hold up to 20 youth 9 7232 Los Angeles Campus Kilpatrick 18-20 PHY JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION Board of State & Community Corrections Inspection BSCC Code: 7232 FACILITY: TYPE: RC: Campus Kilpatrick Camp 120 FIELD REPRESENTATIVE: DATE Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ROOMS EACH ROOM COMMENTS Cell Applicable # EACH CELL Total DIMENSIONS FIXTURES* Location Type Standards Cells # Beds RC RC (L x W x H) T U W F S Living Units Cottage 1 (RC 24) A-Side 1 Dorm N/A 6 6 6 15’7’’x 20’10’’ 2 1 3 1 3 325 Sq. Feet A-Side 2 Dorm N/A 6 6 6 17’7’’ x 19’ “” “” “” “” “” 334 Sq. Feet B-Side 1 Dorm N/A 6 6 6 17’8’’ x 20’ 2 1 3 1 3 353Sq. Feet B-Side 2 Dorm N/A 6 6 6 15’6” x 20’10” “” “” “” “” “” 323 Sq. Feet Dayroom -- 19’9’’ x 25’10” - - - - - A 510 Sq. Feet -- 19’9’’ x 25’10” - - - - - Dayroom 510 Sq. Feet B Quad 575 Sq. Feet *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. "+" indicates that capacity includes prorated air space from adjacent areas. 7232 Los Angeles Campus Kilpatrick 18 20 LASE - 1 - A360 LAS Adult-05.dot (8/05) ROOMS EACH ROOM COMMENTS Cell Applicable # EACH CELL Total DIMENSIONS FIXTURES* Location Type Standards Cells # Beds RC RC (L x W x H) T U W F S Cottage 2 (RC 24) A-Side 1 Dorm N/A 6 6 6 15’7’’x 20’10’’ 2 1 3 1 3 325 Sq. Feet A-Side 2 Dorm N/A 6 6 6 17’7’’ x 19’ “” “” “” “” “” 334 Sq. Feet B-Side 1 Dorm N/A 6 6 6 17’8’’ x 20’ 2 1 3 1 3 353Sq. Feet B-Side 2 Dorm N/A 6 6 6 15’6” x 20’10” “” “” “” “” “” 323 Sq. Feet Dayroom -- 19’9’’ x 25’10” - - - - - A 510 Sq. Feet -- 19’9’’ x 25’10” - - - - - Dayroom 510 Sq. Feet B Quad 575 Sq. Feet Cottage 3 (RC 24) A-Side 1 Dorm N/A 6 6 6 15’7’’x 20’10’’ 2 1 3 1 3 325 Sq. Feet A-Side 2 Dorm N/A 6 6 6 17’7’’ x 19’ “” “” “” “” “” 334 Sq. Feet B-Side 1 Dorm N/A 6 6 6 17’8’’ x 20’ 2 1 3 1 3 353Sq. Feet B-Side 2 Dorm N/A 6 6 6 15’6” x 20’10” “” “” “” “” “” 323 Sq. Feet Dayroom -- 19’9’’ x 25’10” - - - - - A 510 Sq. Feet *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. "+" indicates that capacity includes prorated air space from adjacent areas. 7232 Los Angeles Campus Kilpatrick 18 20 LASE - 2 - A360 LAS Adult-05.dot (8/05) ROOMS EACH ROOM COMMENTS Cell Applicable # EACH CELL Total DIMENSIONS FIXTURES* Location Type Standards Cells # Beds RC RC (L x W x H) T U W F S -- 19’9’’ x 25’10” - - - - - Dayroom 510 Sq. Feet B Quad 575 Sq. Feet Cottage 4 (RC 24) A-Side 1 Dorm N/A 6 6 6 15’7’’x 20’10’’ 2 1 3 1 3 325 Sq. Feet A-Side 2 Dorm N/A 6 6 6 17’7’’ x 19’ “” “” “” “” “” 334 Sq. Feet B-Side 1 Dorm N/A 6 6 6 17’8’’ x 20’ 2 1 3 1 3 353Sq. Feet B-Side 2 Dorm N/A 6 6 6 15’6” x 20’10” “” “” “” “” “” 323 Sq. Feet Dayroom -- 19’9’’ x 25’10” - - - - - A 510 Sq. Feet -- 19’9’’ x 25’10” - - - - - Dayroom 510 Sq. Feet B Quad 575 Sq. Feet Cottage 5 (RC 24) A-Side 1 Dorm N/A 6 6 6 15’7’’x 20’10’’ 2 1 3 1 3 325 Sq. Feet A-Side 2 Dorm N/A 6 6 6 17’7’’ x 19’ “” “” “” “” “” 334 Sq. Feet B-Side 1 Dorm N/A 6 6 6 17’8’’ x 20’ 2 1 3 1 3 353Sq. Feet B-Side 2 Dorm N/A 6 6 6 15’6” x 20’10” “” “” “” “” “” 323 Sq. Feet *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. "+" indicates that capacity includes prorated air space from adjacent areas. 7232 Los Angeles Campus Kilpatrick 18 20 LASE - 3 - A360 LAS Adult-05.dot (8/05) ROOMS EACH ROOM COMMENTS Cell Applicable # EACH CELL Total DIMENSIONS FIXTURES* Location Type Standards Cells # Beds RC RC (L x W x H) T U W F S Dayroom -- 19’9’’ x 25’10” - - - - - A 510 Sq. Feet -- 19’9’’ x 25’10” - - - - - Dayroom 510 Sq. Feet B Quad 575 Sq. Feet Opening LASE: Completed May 31, 2017- Letter sent June 27, 2017 2016-2018: No Change to RC-120 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** *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. "+" indicates that capacity includes prorated air space from adjacent areas. 7232 Los Angeles Campus Kilpatrick 18 20 LASE - 4 - A360 LAS Adult-05.dot (8/05) JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7234 FACILITY NAME: FACILITY TYPE: Dorothy Kirby Center Juvenile Camp PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, DPO II; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 Virtual Documentation Review TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND Residential Treatment Services Bureau EVALUATION OF BUILDING AND GROUNDS (RTSB) Manual Section -2001: Inspections On an annual basis, or as otherwise required by law, and Evaluation of Building and Grounds each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Residential Treatment Services Bureau the Board of Supervisors to approve building safety; (RTSB) Manual Section -2002: Types of Inspections and Evaluations 2018 inspections were verified to have occurred. ☐ ☒ ☐ 2019 The building inspection was completed by Tennyson D’Sena. The facility was inspected on August 7, 2019. Corrections are required. (B) Fire authority having jurisdiction, including a fire Residential Treatment Services Bureau clearance as required by Health and Safety Code (RTSB) Manual Section -2002: Types of Section 13146.1 (a) and (b); Inspections and Evaluations ☒ ☐ ☐ The fire inspection was completed by Los Angeles County Fire Department on 01/31/2020. 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. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Local health officer, inspection in accordance with Residential Treatment Services Bureau Health and Safety Code Section 101045; (RTSB) Manual Section -2002: Types of Inspections and Evaluations Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the Environmental Health (EH) inspections as ☐ ☒ ☐ noted below. 2018 Inspections were verified to have occurred. 2019 Inspections are noted as follows: Medical Mental Health: January 29-30 and February 19, 2019 Nutrition: February 12, 2019 Environmental Health: February 12, 2019 There are outstanding corrections necessary for the nutritional and the medical/mental health inspection. (D) County superintendent of schools on the adequacy Residential Treatment Services Bureau of educational services and facilities as required in (RTSB) Manual Section -2002: Types of Section 1370; Inspections and Evaluations Education for the is provided by the Los Angeles County Office of Education. ☒ ☐ ☐ 2019 The education program was evaluated by Susan Connolly, Executive Director of Student Services Placer County Office of Education on June 26, 2019. Ms. Connolly found the education program to comply with all regulatory requirements. (E) Juvenile court as required by Section 209 of the Residential Treatment Services Bureau Welfare and Institutions Code (RTSB) Manual Section -2002: Types of ☐ ☐ ☒ Inspections and Evaluations No documentation provided. Not required for Juvenile Camps. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (F) Juvenile Justice Commission as required by Section Residential Treatment Services Bureau 229 of the Welfare and Institutions Code or (RTSB) Manual Section -2002: Types of Probation Commission as required by Section 240 of ☐ ☒ ☐ Inspections and Evaluations the Welfare and Institutions Code. A report was not completed for the camp. This is non-compliant. 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is received from Chief Probation Officer Terri determined by receipt of the Chief Probation Officer’s McDonald certifying that appointments and qualifications of agency staff comply with all certification letter confirming that all elements of elements of regulation. regulation are met. (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: (1) recruit and hire employees who possess 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 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 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ accordance with Section 1031 et seq. of the Government Code. (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract employees of the facility, who may be present at the personnel, volunteers and other non- facility, shall have such clearance and qualifications employees participate in background checks and are approved through each facility for as may be required by law, and their presence at the ☒ ☐ ☐ entrance with the exception of LACOE who facility shall be subject to the approval and control of conducts their own criminal records review the facility manager. as required by the Probation Department. Probation maintains control as to who has access into the facility. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1321 STAFFING Residential Treatment Services Bureau (RTSB) Manual Section -206: Staffing Each juvenile facility shall: Random dates were selected throughout the cycle and staffing was viewed to ensure adequate personnel were present. Documentation provided included facility staffing rosters, cycle questionnaire, staffing breakdown documents from April 2019, employee org charts, new hire information from May 2020 and staffing and unit schedules and supervisor sign in sheets. Each cottage can house only up to 10 youth and documentation noted more than one staff were assigned to the cottages with very few discrepancies to address ratio requirements; however, we suggest that unit actual population is placed on schedules. We did not note any significant issues with program or facility operations being impacted by lack of staff. It appears the facility was staffed appropriately for the number of youth housed. a) have an adequate number of personnel sufficient to Residential Treatment Services Bureau carry out the overall facility operation and its (RTSB) Manual Section -206: Staffing programming, to provide for safety and security of ☒ ☐ ☐ youth and staff, and meet established standards and regulations; b) ensure that no required services shall be denied Residential Treatment Services Bureau because of insufficient numbers of staff on duty ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing absent exigent circumstances; c) have a sufficient number of supervisory level staff to Residential Treatment Services Bureau ensure adequate supervision of all staff members; (RTSB) Manual Section -206: Staffing Camp Dorothy Kirby Center has 15 ☒ ☐ ☐ supervisors assigned to the facility with a few current vacancies. The facility has an awake supervisor on duty throughout the late-night hours. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS d) have a clearly identified person on duty at all times Residential Treatment Services Bureau who is responsible for operations and activities and (RTSB) Manual Section -206: Staffing has completed the Juvenile Corrections Officer Core Course and PC 832 training; ☒ ☐ ☐ The facility director is responsible for the overall operations of the facility, but the supervisor is responsible for the daily operations of the facility. e) have at least one staff member present on each living Residential Treatment Services Bureau unit whenever there are youth in the living unit; (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ There is always a staff present in the dorm or where a youth is present. Youth are never left alone per consultant staff. f) have sufficient food service personnel relative to the Residential Treatment Services Bureau number and security of living units, including staff (RTSB) Manual Section -206: Staffing qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen The facility has a full dining hall. All youth supervision; direct food preparation and servings; ☒ ☐ ☐ eat their meals in the dining hall unless they conduct related training programs for culinary staff; refuse to leave the dorm. The dining hall is and maintain necessary records; or, a facility may staffed by facility cooks who plan and serve food that meets nutritional standards prepared prepare all meals. Cooks do not supervise by an outside source; youth. g) have sufficient administrative, clerical, recreational, Residential Treatment Services Bureau medical, dental, mental health, building (RTSB) Manual Section -206: Staffing maintenance, transportation, control room, facility ☒ ☐ ☐ security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Residential Treatment Services Bureau continuous wide-awake supervision of youth, (RTSB) Manual Section -206: Staffing subject to 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: (1) Juvenile Halls (minimum youth-staff ratio) Facility is not a Juvenile Hall. (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 Facility is not a Juvenile Hall. room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth in detention; 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff Facility is not a Juvenile Hall 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 Facility is not a Juvenile Hall ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other Facility is not a Juvenile Hall duties such as administration, supervision of ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile staff ratio) Hall ☐ ☐ ☒ (A) during hours that youth are awake, one wide-awake youth supervision staff member is on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room Facility is not a Special Purpose Juvenile for the purpose of sleeping, one wide-awake youth Hall ☐ ☐ ☒ supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff Facility is not a Special Purpose Juvenile members on duty at all times, regardless of the Hall ☐ ☐ ☒ 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 Facility is not a Special Purpose Juvenile who is the same gender as youth housed in the Hall ☐ ☐ ☒ facility. (E) personnel with primary responsibility for other Facility is not a Special Purpose Juvenile duties such as administration, supervision of Hall ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Residential Treatment Services Bureau (A) during the hours that youth are awake, one wide- (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ 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 Residential Treatment Services Bureau room for the purpose of sleeping, one wide-awake (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ youth supervision staff member on duty for each 30- youth present in the facility; 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff Residential Treatment Services Bureau members on duty at all times, regardless of the (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau who is the same gender as youth housed in the (RTSB) Manual Section -206: Staffing facility; ☒ ☐ ☐ There are always male and female staff on duty. (E) in addition to the minimum staff to youth ratio Residential Treatment Services Bureau required in (h)(3)(A)-(B), consideration shall be (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau duties such as administration, supervision of (RTSB) Manual Section -206: Staffing personnel, academic or trade instruction, clerical, ☒ ☐ ☐ Only youth supervision staff provide farm, forestry, kitchen or maintenance shall not be supervision of the youth. classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF Residential Treatment Services Bureau ORIENTATION AND TRAINING (RTSB) Manual -2104: Professional (a) Prior to assuming any responsibilities each youth Development and Training supervision staff member shall be properly oriented to their duties, including: All staff assigned to RTSB have completed Correctional Officer CORE training prior to reporting to the facility Upon assignment, each staff is paired with a onsite training officer who assists them in their orientation and training. Training transcripts were provided as verification of ☒ ☐ ☐ required training which includes CORE. These training transcripts documented the mandated trainings. Additionally, a training memo was received from Director Mike Varela providing information regarding the mandatory training that staff who supervise DKC youth participate in. We were unable to view individual training files as not on site. Compliance is based on policy. We will verify training documents when back on site. (1) youth supervision duties; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) scope of decisions they shall make; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (3) the identity of their supervisor; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) the identity of persons who are responsible to Residential Treatment Services Bureau them; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) persons to contact for decisions that are beyond Residential Treatment Services Bureau their responsibility; and ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (6) ethical responsibilities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (b) Prior to assuming any responsibility for the Residential Treatment Services Bureau supervision of youth, each youth supervision staff (RTSB) Manual -2104: Professional ☒ ☐ ☐ member shall receive a minimum of 40 hours of Development and Training facility-specific orientation, including: (1) individual and group supervision techniques; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) regulations and policies relating to discipline and Residential Treatment Services Bureau rights of youth pursuant to law and the ☒ ☐ ☐ (RTSB) Manual -2104: Professional provisions of this chapter; Development and Training (3) basic health, sanitation and safety measures; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) suicide prevention and response to suicide Residential Treatment Services Bureau attempts ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) policies regarding use of force, de-escalation Residential Treatment Services Bureau techniques, chemical agents, mechanical and (RTSB) Manual -2104: Professional physical restraints; Development and Training ☒ ☐ ☐ The facility does not use chemical agents in the camp setting. (6) review of policies and procedures referencing Residential Treatment Services Bureau trauma and trauma-informed approaches; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (7) procedures to follow in the event of Residential Treatment Services Bureau emergencies; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (8) routine security measures, including facility Residential Treatment Services Bureau perimeter and grounds; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (9) crisis intervention and mental health referrals to Residential Treatment Services Bureau mental health services; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (10) documentation; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (11) fire/life safety training Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (c) Prior to assuming sole supervision of youth, each Residential Treatment Services Bureau youth supervision staff member shall successfully (RTSB) Manual -2104: Professional complete the requirements of the Juvenile ☒ ☐ ☐ Development and Training Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer Residential Treatment Services Bureau youth supervision staff shall successfully complete (RTSB) Manual -2104: Professional ☒ ☐ ☐ training pursuant to Section 830 et seq. of the Penal Development and Training Code. 1323 FIRE AND LIFE SAFETY Residential Treatment Services Bureau (RTSB) Manual -2104: Professional Whenever there is a youth in a juvenile facility, there Development and Training shall be at least one wide awake person on duty at all ☒ ☐ ☐ times who meets the training standards established by the All staff are trained in fire and life safety in Board for general fire and life safety which relate CORE training. All Supervisors have been specifically to the facility. trained. There will always be a supervisor on duty. 1324 POLICY AND PROCEDURES MANUAL The agency manual is specific to RTSB and All facility administrators shall develop, publish, and camp operations and has been provided to the implement a manual of written policies and procedures BSCC for review. The manual was last that address, at a minimum, all regulations that are reviewed and updated in June 2020. applicable to the facility. Such a manual shall be made available to all employees, reviewed by all employees, The BSCC has reviewed the agency Policy and shall be administratively reviewed at a minimum and Procedure as provided to us specific to every two years, and updated, as necessary. Those regulations and has confirmed the policies records relating to the standards and requirements set and procedure exist as cited. There may be forth in these regulations shall be accessible to the Board cites noted in the comments that may not on request. match due to updates that were unable to be The manual shall include: reverified. ☒ ☐ ☐ Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. In all cases, copies of policies and directives were provided that were not from the current manual. Technical assistance provided and discussed that this should be rectified. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) table of organization, including channels of Residential Treatment Services Bureau communications and a description of job (RTSB) Manual Sections: classifications; • 101: Vision, Mission, and Core Values • 102: Role of the Camp System • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff • 207: Organizational Chart The manual has a table of contents. They agency channel of communication follows chain of command. (b) responsibility of the probation department, purpose Residential Treatment Services Bureau of programs, relationship to the juvenile court, the (RTSB) Manual Sections: Juvenile Justice/Delinquency Prevention • 101: Vision, Mission, and Core Commission or Probation Committee, probation Values staff, school personnel and other agencies that are • 102: Role of Camp System involved in juvenile facility programs; • 908: Medical Services • 909: Mental Health Services ☒ ☐ ☐ • 910: Educational Services • 1005: Community Based Organizations • 1006: Volunteers (c) responsibilities of all employees; Residential Treatment Services Bureau (RTSB) Manual Sections: • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff (d) initial orientation and training program for Residential Treatment Services Bureau employees; (RTSB) Manual -2104: Professional Development and Training ☒ ☐ ☐ See Section 1322 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) initial orientation, including safety and security Residential Treatment Services Bureau issues and anti-discrimination policies, for support (RTSB) Manual -2200: Non-Sworn staff, contract employees, school, mental/behavioral Personnel and Partner Agencies Handbook health and medical staff, program providers and ☐ ☐ UNK Unable to view employee training files as not volunteers; on site. Compliance is based on policy. We will verify training documents when back on site. (f) maintenance of record-keeping, statistics and Residential Treatment Services Bureau communication system to ensure: (RTSB) Manual 701: Case Planning and Procedures and 702-General Duties and Responsibilities RTSB maintains an extensive record- keeping system to record operations and to report on the youth in its care. Through these reports, the RTSB is able to document ☒ ☐ ☐ and retrieve accurate accounts of specific incidents or operations and to develop a database for statistical analysis. The assigned camp DPO is responsible for the casework functions while the youth is in the camp setting. The supervisor is responsible to ensure that all information is thoroughly documented within the Probation Case Management System. (1) efficient operation of the juvenile facility; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (2) legal and proper care of youth; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (3) maintenance of individual youth's records; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (4) supply of information to the juvenile court and Residential Treatment Services Bureau those authorized by the court or by the law; and, (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (5) release of information regarding youth. Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (g) ethical responsibilities; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-2130: Employee Honesty 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) trauma-informed approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-518: Trauma Informed Approaches (i) culturally responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-519: Culturally Responsive Approaches (j) gender responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-517: Promoting Dignity for Female Youth Housed in RTSB (k) a non-discrimination provision that provides that all Residential Treatment Services Bureau youth within the facility shall have fair and equal (RTSB) Manual-2110: Non-Discrimination access to all available services, placement, care, Policy treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group ☒ ☐ ☐ identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Residential Treatment Services Bureau chemical agents related security devices, and (RTSB) Manual-1922: Weapons and ☒ ☐ ☐ weapons and ammunition, where applicable; Ammunition (m) establishment of procedures for collection of Medi- Residential Treatment Services Bureau Cal eligibility information and enrollment of eligible ☒ ☐ ☐ (RTSB) Manual-706: Case Plan Activities youth; and, (n) establishment of a policy that prohibits all forms of Residential Treatment Services Bureau sexual abuse, sexual assault and sexual harassment. (RTSB) Manual-1600: Prison Rape The policy shall include an approach to preventing, Elimination Act detecting and responding to such conduct and any retaliation for reporting such conduct, as well as a ☒ ☐ ☐ Staff are trained in PREA within their first provision for reporting such conduct by youth, staff year of employment and every two years or a third party. thereafter. 1325 FIRE SAFETY PLAN Residential Treatment Services Bureau The facility administrator shall consult with the local fire (RTSB) Manual-1910: Fire Prevention and department having jurisdiction over the facility, or with ☒ ☐ ☐ Suppression the State Fire Marshal, in developing a plan for fire safety which shall include, but not be limited to: a) a fire prevention plan to be included as part of the Residential Treatment Services Bureau manual of policy and procedures; (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS b) monthly fire and life safety inspections by facility Residential Treatment Services Bureau staff with two- year retention of the inspection (RTSB) Manual-1910: Fire Prevention and record; Suppression ☒ ☐ ☐ Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. c) fire prevention inspections as required by Health Residential Treatment Services Bureau and Safety Code Section 13146.1(a) and (b); (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression See Section 1313 d) an evacuation plan; Residential Treatment Services Bureau (RTSB) Manual Sections: 1910: Fire Prevention and Suppression 1917: Emergency Evacuation ☒ ☐ ☐ Facility provided County of Los Angeles Building Emergency Plan, the DKC Emergency Manual and site evacuation maps for our review. e) documented fire drills not less than quarterly; Residential Treatment Services Bureau (RTSB) Manual-1910: Fire Prevention and Suppression Fire Drills are to be completed quarterly. Fire ☐ ☒ ☐ drills have not been completed as required. Documentation was provided for drills completed in July, August and October 2019 and January 2020 and included the full facility. f) a written plan for the emergency housing of youth in Residential Treatment Services Bureau the case of fire; and, (RTSB) Manual-1917: Emergency Evacuation ☒ ☐ ☐ Emergency housing will always be at one of the camps or the juvenile halls dependent on location of the fire and a safe route of travel. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS g) development of a fire suppression pre-plan In Residential Treatment Services Bureau cooperation with the local fire department. (RTSB) Manual-1910: Fire Prevention and Suppression The County of Los Angeles Building Emergency Plan was revised in 2019 and ☒ ☐ ☐ was provided for our review. The facility administrator consulted with Tony Polino from Los Angeles County Fire Department and the document was signed and stamped “reviewed” on 10-16-2019. A memo was also provided by Director Varella dated March 25, 2020. 1326 SECURITY REVIEW Residential Treatment Services Bureau (RTSB) Manual- 1312: Security Checks Each facility administrator shall develop policies and procedures to annually review, evaluate, and document ☒ ☐ ☐ Security review was completed on March 27, security of the facility. The review and evaluation shall 2020 by Assistant Director Cesar include internal and external security, including, but not Mayorquin. limited to, key control, equipment, and staff training. 1327 EMERGENCY PROCEDURES Facility provided and utilizes (in addition to the Bureau Policy Manual) the County of The facility administrator shall develop facility-specific Los Angeles Building Emergency Plan and policies and procedures for emergencies that shall the DKC Emergency Manual as they both include, but not be limited to: ☒ ☐ ☐ have emergency procedures in the documents We did not review for comparison and suggest that the agency review and compare to ensure there are no inconsistencies. (a) escape, disturbances, and the taking of hostages; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1907 Escapes 1909: Major Disturbances 1914: Hostages (b) civil disturbance, active shooter and terrorist attack; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1908: Outside Intruder 1915: Active Shooter 1916: Terrorist Attack (c) fire and natural disasters; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1910: Fire Prevention and Suppression 1913: Earthquake (d) periodic testing of emergency equipment; Residential Treatment Services Bureau (RTSB) Manual Sections: 1321: Testing of Emergency Equipment ☒ ☐ ☐ Internal Services Department conducts monthly and as needed testing in coordination with MSB. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) emergency evacuation of the facility; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections: 1917: Emergency Evacuation (f) a program to provide all youth supervision staff Residential Treatment Services Bureau with an annual review of emergency procedures. (RTSB) Manual Sections: 1903: Staff Roles and Responsibilities Memo provided stating that Supervisors and ☐ ☒ ☐ Movement and Control (RS) staff have completed the annual review but not all line staff have completed the review. This does not meet regulatory requirements. This is non-compliant. 1328 SAFETY CHECKS Residential Treatment Services Bureau (RTSB) Manual Sections: 1313: Safety The facility administrator shall develop and implement Checks and Section 1119 policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, We reviewed random safety checks from the at random or varied intervals during hours when youth documentation provided (September and are asleep or when youth are in their rooms, confined in November 2019) and found the majority of holding cells or confined to their bed in a dormitory. checks were completed consistent to Supervision is not replaced, but may be supplemented regulatory time expectations with minimal by, an audio/visual electronic surveillance system discrepancies. This section is compliant with designed to detect overt, aggressive or assaultive regulation. behavior and to summon aid in emergencies. All safety Technical assistance was provided regarding checks shall be documented with the actual time the documentation and legibility of safety check check is completed. ☒ ☐ ☐ forms as in some cases, what is written is illegible. We also noted that supervisors are not completing their regular audits of safety checks as required by policy except for the late-night shift which we found to be completed with the most consistency. A work instruction memo was provided to staff in November 2019; however, it is unknown if there has been any correction as a result. Technical assistance provided that operations and policy must be consistent and there should be follow up to ensure this occurs per policy. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Residential Treatment Services Bureau The facility administrator, in collaboration with the (RTSB) Manual Sections: 1201: Suicide healthcare and behavioral/mental health administrators, Prevention Plan shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. 1201: Suicide prevention Plan The plan shall consider the needs of youth experiencing past or current trauma. 1202 Enhanced and Specialized Supervision Requirements for Youths in Juvenile Suicide prevention responses shall be respectful and in Facilities the least invasive manner consistent with the level of suicide risk. ☒ ☐ ☐ 1203: Suicide Prevention Policy for Juvenile Facilities (Cross ref with directive 1186) The plan shall include the following elements: Policy was developed in collaboration with Juvenile Court Health Services (JCHS) and the Department of Mental Health (DMH). Documentation reviewed included incident reports, Initial Intake, Screening and Referral Questionnaire, Mental Health Referral, Enhanced Supervision Observation Form, Mental Health Recording Form- Green Sheet (a) Suicide prevention training as required in Residential Treatment Services Bureau Section 1322, Youth Supervision Staff (RTSB) Manual Sections: 1203: Suicide Orientation, and Training and the Juvenile Prevention Policy for Juvenile Facilities and Corrections Officer Core Course. 2104: Professional Development and ☒ ☐ ☐ Training. Staff are trained in CORE training and annual refresher training (b) Screening, Identification Assessment and Residential Treatment Services Bureau Precautionary Protocols (RTSB) Manual Sections:1202: Enhanced (1) All youth shall be screened for risk of and Specialized Supervision Requirements suicide at intake and as needed during of Youth in Juvenile Facilities and 1203: detention. Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ All youth are screened prior to entry by DMH who conduct a Juvenile Justice Child/Adolescent Assessment. A DPOII Clinician and DMH staff member interview youth at Juvenile Hall prior to arrival to the Camp. Once at camp all youth are screened again at intake with the Initial Intake, Screening and Referral Questionnaire. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) All youth supervision staff who perform Residential Treatment Services Bureau intake processes shall be trained in (RTSB) Manual Sections: 1203: Suicide screening youth for risk of suicide. Prevention Policy for Juvenile Facilities Staff complete the Initial Intake Screening ☒ ☐ ☐ Referral Questionnaire at admission. This form addresses suicide risk. Staff who complete intake/admissions are trained in completing them. Suicide update training is completed annually as part of the Enhanced Supervision Training. (3) All youth who have been identified during Residential Treatment Services Bureau the intake screening process to be at risk of (RTSB) Manual Section: 1203: Suicide suicide shall be referred to Prevention Policy for Juvenile Facilities behavioral/mental health staff for a suicide risk assessment. ☒ ☐ ☐ We did not find any youth to be suicidal at intake based on the documentation we reviewed; however, bureau staff stated that youth would be referred to DMH for follow up if they were. (4) Precautionary protocols shall be developed Residential Treatment Services Bureau to ensure the youth’s safety pending the (RTSB) Manual Sections:1202: Enhanced behavioral/mental health assessment. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ In most cases, mental health staff are on site and see the youth as soon as possible. If they are not on site, staff may also place the youth on level to ensure their safety. At risk youth may be placed on enhanced supervision levels, 1-4. (c) Referral process to behavioral/mental health Residential Treatment Services Bureau staff for assessment and/or services. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Policy requires all facility staff to complete a “Request for Mental Health Consultation” when appropriate. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Procedures for monitoring of youth identified Residential Treatment Services Bureau at risk for suicide. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Per policy, enhanced supervision Levels 1-4 determine the level of supervision a youth receives. Level 4 requires a constant supervision until a youth can be transported out to emergency hospitalization, Level 3 is a constant visual 1:1 supervision, Level 2; is 10-minute safety check and Level 1 is regular 15-minute safety checks. (e) Safety Interventions Residential Treatment Services Bureau (1) Procedures to address intervention (RTSB) Manual Sections:1202: Enhanced protocols for youth identified at risk for and Specialized Supervision Requirements suicide which may include, but are not ☒ ☐ ☐ of Youth in Juvenile Facilities limited to: A. Housing consideration Youth are placed on a SSP. Supervision and housing direction are included on the forms. B. Treatment strategies including Residential Treatment Services Bureau trauma-informed approaches (RTSB) Manual Section: 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. (2) Procedures to instruct youth supervision Residential Treatment Services Bureau staff how to respond to youth who exhibit (RTSB) Manual Sections:1202: Enhanced suicidal behaviors. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) Communication Residential Treatment Services Bureau (1) The intake process shall include (RTSB) Manual Section: 1203: Suicide communication with the arresting officer Prevention Policy for Juvenile Facilities and family guardians regarding the youth’s past or present suicidal ideations, behaviors Youth are transported directly from the or attempts. Juvenile Hall to the camp. Policy states that the intake officer shall contact the youth’s ☐ ☒ ☐ parent and/or guardians via telephone during the initial intake process to gather information regarding the youth’s past or present suicidal ideations, behaviors or attempts. There was no documentation provided to show that this contact was made. (2) Procedures for clear and current Residential Treatment Services Bureau information sharing about youth at risk for (RTSB) Manual Section: 1203: Suicide suicide with youth supervision, healthcare, Prevention Policy for Juvenile Facilities and behavioral/mental health staff. ☒ ☐ ☐ There are protocols in place for sharing of information between facility partners. A new alert log is created each day and provided to all staff and agencies coming into contact with the youth. (g) Debriefing of Critical Incidents Related to Residential Treatment Services Bureau Suicides or Attempts (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ (1) Process for administrative review of the Prevention Policy for Juvenile Facilities circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected Residential Treatment Services Bureau staff. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities (3) Process for a debriefing event with affected Residential Treatment Services Bureau youth. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Documentation Residential Treatment Services Bureau (1) Documentation processes shall be (RTSB) Manual Sections:1202: Enhanced developed to ensure compliance with this and Specialized Supervision Requirements regulation of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities Youth identified at risk for suicide shall not be denied Residential Treatment Services Bureau the opportunity to participate in facility programs, (RTSB) Manual Section: 1202: Enhanced services and activities which are available to other non- and Specialized Supervision Requirements suicidal youth, unless deemed necessary for the safety for Youths in Juvenile Facilities of the youth or security of the facility. Any deprivation of programs, services or activities for youth at risk of Reviewed all documentation provided. suicide shall be documented and approved by the Programming should be included on ES facility manager. ☒ ☐ ☐ logs. Technical assistance provided and discussed that staff could be including consistent documentation of all program’s youth participate in on the Enhanced Supervision Log. If youth do not participate, the reason why should be documented. 1340 REPORTING OF LEGAL ACTIONS Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each facility shall submit to the Board a letter of Statements, RTSB Management notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities ☒ ☐ ☐ The Camp Director is responsible to ensure responsible for juvenile facility operation. that all reporting is completed. No legal actions have been reported to the BSCC this cycle for this facility. 1341 DEATH AND SERIOUS ILLNESS OR Residential Treatment Services Bureau INJURY OF A YOUTH WHILE (RTSB) Manual Sections:1919: Deaths at DETAINED Camp Facilities (1) Death of a Youth. Policy was developed in collaboration with (a) The facility administrator, In cooperation with the Juvenile Court Health Services (JCHS) and health administrator and the behavioral/mental ☒ ☐ ☐ the Department of Mental Health (DMH), 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. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) The health administrator, In cooperation with the Residential Treatment Services Bureau facility administrator, shall develop written policies (RTSB) Manual Sections:1919: Deaths at and procedures to assure there is a medical and Camp Facilities operational review of every in-custody death of 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. (c) The administrator of the facility shall provide to the Residential Treatment Services Bureau Board a copy of the report submitted to the Attorney (RTSB) Manual Sections:1919: Deaths at General under Government Code Section 12525. A ☒ ☐ ☐ Camp Facilities 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 Residential Treatment Services Bureau the administrator, the Board may within 30 calendar (RTSB) Manual Sections:1919: Deaths at days inspect and evaluate the juvenile facility, jail, Camp Facilities 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 Residential Treatment Services Bureau (a) The facility administrator, In cooperation with the (RTSB) Manual Section 1920: Serious health administrator, shall develop written policies Illness or Injury of a Youth While Detained 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 Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each juvenile facility shall submit required population Statements, RTSB Management and profile survey reports to the Board within 10 working days after the end of each reporting period, in Both the Camp Director and Assistant ☒ ☐ ☐ a format to be provided by the Board. Director in all camps are responsible to ensure that all reporting is completed. All population reports were completed in a timely manner. 1343 JUVENILE FACILITY CAPACITY Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty When the number of youth detained in a living unit of a Statements, RTSB Management juvenile facility exceeds its rated capacity for more than fifteen (15) calendar days in a month, the facility ☒ ☐ ☐ The Camp Director is responsible to ensure administrator shall provide a crowding report to the that all reporting is completed. Board in a format provided by the Board. The facility has not exceeded their rated capacity this cycle. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 400: Camp written policies and procedures for admittance of youth Admissions and Section 502: Orientation that emphasize respectful and humane engagement with Process and Handbook youth and reflect that the admission process may be The Admission process for camp youth traumatic to youth who may have already experienced begins before the youth arrive on campus. trauma. Policies shall be trauma-informed, culturally ☒ ☐ ☐ Youth are assessed and screened at Camp relevant, and responsive to the language and literacy Headquarters and again by camp staff, needs of youth. In addition to the requirements of medical and mental health before the youth Sections 1324 and 1430 of these regulations: even arrive. Upon arrival, youth are admitted and oriented by camp staff. Documentation of admission/intake paperwork for 20 random youth was provided for our review. (a) the admittance process shall include: Residential Treatment Services Bureau (1) Access to two free phone calls within one hour (RTSB) Manual Sections:502: Orientation of admittance in accordance with the provisions Process and Handbook of Welfare and Institution Code Section 627; ☒ ☐ ☐ Youth are to be provided with a phone call at admission to notify their parent of their transfer to the camp. Youth were provided with their calls to let their parents know of their transfer. (2) Offer of a shower; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Documentation provided by facility staff that all youth were provided with the opportunity to shower. (3) Documented secure storage of personal Residential Treatment Services Bureau belongings; (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Youth are transported to camp in juvenile hall clothing with only their juvenile hall personals. All personal clothing and belongings are released to their parents or guardians from the juvenile hall. (4) Offer of food upon arrival; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Documentation provided by facility staff that all youth were provided with the opportunity to shower. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health Residential Treatment Services Bureau and safety issues, intellectual or developmental (RTSB) Manual Sections:402: Assessment disabilities; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (6) Screening for physical and developmental Residential Treatment Services Bureau disabilities in accordance with Sections 1329, (RTSB) Manual Sections:402: Assessment 1418, and 1430 of these regulations; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (7) Contact with Regional Center for the Youth that are Regional Center Clients Developmentally Disabled for youth that are would not likely be ordered to a camp ☐ ☐ ☒ suspected of or identified as having a commit. developmental disability, pursuant to Section 1418; and, (8) Procedures consistent with Section 1352.5. Residential Treatment Services Bureau (RTSB) Manual Sections:403: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (b) juvenile hall administrators shall establish written Not Applicable criteria for detention that considers the least ☐ ☐ ☒ restrictive environment. (c) juvenile camps and post-dispositional programs in Residential Treatment Services Bureau juvenile halls shall develop policies and procedures (RTSB) Manual Sections:502: Orientation that advise the youth of the estimated length of Process and Handbook stay, inform them of program guidelines and ☒ ☐ ☐ provide written screening criteria for inclusion and Estimated length of stay estimates were exclusion from the program. consistently completed and documentation provided in packets provided. (d) juvenile halls shall develop policies and procedures Not Applicable that advise any committed youth of the estimated ☐ ☐ ☒ length of his/her stay. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Residential Treatment Services Bureau ABUSE (RTSB) Manual Sections: 402: Assessment The facility administrator shall develop and implement and Classification and 503: Screening for the written policies and procedures to reduce the risk of Risk of Sexual Abuse sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of Policy is in place; however, documentation admission based on the following information: provided consists of PREA Risk questions ☐ ☒ ☐ on the intake screening assessment that are not consistent with regulation requirements. This section is non-compliant as the documentation process has not yet been implemented. Agency is in the process of finalizing and rolling out the new procedure. (a) Prior sexual victimization or abusiveness; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (b) Gender nonconforming appearance or manner; Residential Treatment Services Bureau or identification as lesbian, gay or bisexual, (RTSB) Manual Sections: 402: Assessment transgender, queer or intersex, and whether the ☐ ☒ ☐ and Classification and 503: Screening for the youth may, therefore, be vulnerable to sexual Risk of Sexual Abuse abuse; (c) Current charges and offense history; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (d) Age; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (e) Level of emotional and cognitive development; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (f) Physical size and stature; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (g) Mental illness or mental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (h) Intellectual or developmental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (i) Physical disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (j) The youth’s perception of vulnerability; and, Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (k) Any other specific information about the Residential Treatment Services Bureau individual youth that may indicate heightened (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ needs for supervision, additional safety and Classification and 503: Screening for the precautions, or separation from certain other Risk of Sexual Abuse youth. Staff shall ascertain this information through Residential Treatment Services Bureau conversations with the youth during the admittance (RTSB) Manual Sections:503: Screening for process, medical and behavioral health screenings; the Risk of Sexual Abuse ☐ ☒ ☐ during classification assessments; and by reviewing court records, case files, facility behavioral records, and Current procedure has not been other relevant documentation from the youth’s files. implemented. The facility administrator shall implement appropriate Residential Treatment Services Bureau controls on the dissemination of information within the (RTSB) Manual Sections:503: Screening for facility relative to responses received pursuant to this the Risk of Sexual Abuse ☐ ☒ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other It is unknown how the facility will ensure youth. documents are kept confidential. 1351 RELEASE PROCEDURES Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release The facility administrator shall develop and implement ☒ ☐ ☐ Procedures written policies and procedures for release of youth from custody which provide for: (a) verification of identity/release papers; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures (b) return of personal clothing and valuables; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures ☒ ☐ ☐ Compliance reviewed through Juvenile Hall Property Receipts. Parents/guardian bring clothing for youth to be released in on day of release. (c) notification to the youth's parents or guardian; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) notification to the facility health care provider in Residential Treatment Services Bureau accordance with Sections 1408 and 1437 of these (RTSB) Manual Sections:809: Release regulations, for coordination with outside agencies; Procedures and, ☒ ☐ ☐ Health care is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (e) notification of school staff; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Education is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (f) notification of facility mental health personnel. Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Mental Health is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. The facility administrator shall develop and implement Residential Treatment Services Bureau policies and procedures for post-disposition youth to (RTSB) Manual Section: 703: MDT Process coordinate the provision of transitional and reentry services including, but not limited to, medical and Each youth has a Transition MDT 45-60 behavioral health, education, probation supervision and days prior to release that addresses all community-based services. required services and other pertinent areas. All facility partners and the PO are present ☐ ☐ ☒ with the youth to discuss the plan. The youth’s parents or guardian are invited to participate and either attend in person or via a conference call. (Reference Regulation 1355) All Transition plans reviewed were completed in compliance with regulation requirements. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS The facility administrator shall develop and implement Residential Treatment Services Bureau written policies and procedures for the furlough of (RTSB) Manual Section: 1802: Private youth from custody. Appointments ☒ ☐ ☐ The agency has no formal furlough policy; however, will transport youth to private appointments for exigent circumstances such as funerals or hospital visits with a court order. 1352 CLASSIFICATION Residential Treatment Services Bureau (RTSB) Manual Sections:402: Assessment The facility administrator shall develop and implement and Classification Policy and Section 408: written policies and procedures on classification of Classification youth for the purpose of determining housing placement in the facility. ☒ ☐ ☐ Documentation provided by facility staff for youth classification. Cottage assignment is Such procedures shall: identified by the onsite classification supervisor. Youth who have specific supervision needs, staff initiate a SSP which provides additional supervision expectations. (a) provide for the safety of the youth, other youth, Residential Treatment Services Bureau facility staff, and the public by placing youth in the (RTSB) Manual Sections:402: Assessment appropriate, least restrictive housing and program and Classification Policy settings. Housing assignments shall consider the Youth are assessed by the Camp Assessment need for single, double or dormitory assignment or Unit (CAU) after being ordered to Camp by location within the dormitory; ☒ ☐ ☐ the court. The CAU determines which camp is the appropriate camp for the youth based on classification factors and camp programs. This decision is made based on several different factors and includes an interview and input from the youth. (b) consider facility populations and physical design of Residential Treatment Services Bureau the facility; (RTSB) Manual Sections:402: Assessment ☒ ☐ ☐ and Classification Policy See above (a) (c) provide that a youth shall be classified upon Residential Treatment Services Bureau admittance to the facility; classification factors (RTSB) Manual Sections:402: Assessment shall include, but not be limited to: age, maturity, and Classification Policy sophistication, emotional stability, program needs, legal status, public safety considerations, ☒ ☐ ☐ Youth are classified to cottage and location within the cottage upon arrival and entry to medical/mental health considerations, gender and the facility. gender identity of the youth; 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) provide for periodic classification reviews, Residential Treatment Services Bureau including provisions that consider the level of (RTSB) Manual Sections:402: Assessment supervision and the youth's behavior while in and Classification Policy custody; and, All youth who are placed on an SSP are ☒ ☐ ☐ reviewed within 30 days. All other youth are considered for review at the time of any incident, upon request, or as needed. If any change is to occur, an SSP is initiated. (e) provide that facility staff shall not separate youth Residential Treatment Services Bureau from the general population or assign youth to a (RTSB) Manual Sections:402: Assessment single occupancy room based solely on the youth's and Classification Policy actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, ☒ ☐ ☐ gender expression, mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, Residential Treatment Services Bureau bisexual, transgender, questioning or intersex (RTSB) Manual Sections:402: Assessment identification or status as an indicator of likelihood ☒ ☐ ☐ and Classification Policy of being sexually abusive. 1352.5 TRANSGENDER AND INTERSEX YOUTH. Residential Treatment Services Bureau (RTSB) Manual Sections: 403: Juvenile The facility administrator shall develop written policies ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Transgender, Questioning and Intersex treatment of transgender and intersex youth. The Youth in an Institutional Setting policies shall provide that: (a) Facility staff shall respect every youth’s gender Residential Treatment Services Bureau identity and shall refer to the youth by the youth’s (RTSB) Manual Sections: 403: Juvenile preferred name and gender pronoun, regardless of Supervision of Lesbian, Gay, Bisexual, the youth’s legal name. Facilities may prohibit the ☒ ☐ ☐ Transgender, Questioning and Intersex use of gang or slang names or names that otherwise Youth in an Institutional Setting 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 Residential Treatment Services Bureau themselves in a manner consistent with their gender (RTSB) Manual Sections: 403: Juvenile identity and shall provide youth with the ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, institution’s clothing and undergarments consistent Transgender, Questioning and Intersex with their gender identity. Youth in an Institutional Setting 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Facility staff shall house youth in the unit or room Residential Treatment Services Bureau that best meets their individual needs and promotes (RTSB) Manual Sections: 403: Juvenile their safety and well-being. Staff may not Supervision of Lesbian, Gay, Bisexual, automatically house youth according to their Transgender, Questioning and Intersex external anatomy and shall document the reasons Youth in an Institutional Setting 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 ☒ ☐ ☐ If a youth request to reside in another unit preferences, as well as any recommendations from other than the unit that coincides with the the youth’s health or behavioral health provider. youth’s biological sex, a medical referral is made, and an MDT is held. Pending a decision, the youth will be housed in the medical unit. (This process occurs before arrival at the camp due to lack of alternate housing.) (d) Facility administrators shall ensure that transgender Residential Treatment Services Bureau and intersex youth have access to medical and (RTSB) Manual Sections: 403: Juvenile behavioral health providers qualified to provide Supervision of Lesbian, Gay, Bisexual, care and treatment to transgender and intersex Transgender, Questioning and Intersex youth. Youth in an Institutional Setting ☒ ☐ ☐ Upon entry, youth are asked If they identify with LGBTQI and if so, they are referred to medical for continuation and coordination of gender affirming services. (e) Consistent with the facility’s reasonable and Residential Treatment Services Bureau necessary security considerations and physical (RTSB) Manual Sections: 403: Juvenile plant, facility staff shall make every effort to ensure ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, the safety and privacy of transgender and intersex Transgender, Questioning and Intersex youth when the youth are using the bathroom or Youth in an Institutional Setting shower, or dressing or undressing. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Facility staff shall not conduct physical searches of any Residential Treatment Services Bureau youth for the purpose of determining the youth’s (RTSB) Manual Sections: 403: Juvenile anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of Transgender, Questioning and Intersex the staff member who conducts any search of the youth. Youth in an Institutional Setting Policy notes that youth are provided with the option to choose the gender of the staff they wish to search them. Policy also notes that ☒ ☐ ☐ the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy alone. 1353 ORIENTATION Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation The facility administrator shall develop and implement Process and Handbook written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal At inspection we noted the orientation information shall be provided and supplemented with ☒ ☐ ☐ handbook was not updated to all current video orientation if feasible. Provision shall be made to regulatory requirements. This issue was provide accessible orientation information to all addressed and corrected, and the now current detained youth including those with disabilities, limited and updated handbook has been literacy, or English language learners. Orientation shall implemented. include information that addresses: (a) facility rules including contraband and searches and Residential Treatment Services Bureau disciplinary procedures; ☒ ☐ ☐ (RTSB) Manual Section: 502: Orientation Process and Handbook (b) facility’s system of positive behavior interventions Residential Treatment Services Bureau and supports, including behavior expectations, (RTSB) Manual Section: 502: Orientation incentives that youth will receive for complying Process and Handbook with facility rules, and consequences that may ☒ ☐ ☐ Youth are provided with a copy of the result when youth violate the rules of the facility; Behavior Management Program Handbook at orientation. This process is reviewed during orientation. (c) age appropriate information that explains the Residential Treatment Services Bureau facility’s policy prohibiting sexual abuse and sexual (RTSB) Manual Section: 1600: PREA ☒ ☐ ☐ harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) identification of key staff and their roles; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (e) the existence of the grievance procedure, the steps Residential Treatment Services Bureau that must be taken to use it, the youth’s right to be (RTSB) Manual Section: 502: Orientation free of retaliation for reporting a grievance, and the Process and Handbook ☒ ☐ ☐ name of the person or position designated to resolve the issue; (f) access to legal services and information on the court Residential Treatment Services Bureau process; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (g) access to routine and emergency health and mental Residential Treatment Services Bureau health care; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (h) access to education, religious services, and Residential Treatment Services Bureau recreational activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (i) housing assignments; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (j) opportunity for personal hygiene and daily showers Residential Treatment Services Bureau including the availability of personal care items (RTSB) Manual Section: 502: Orientation Process and Handbook ☒ ☐ ☐ (k) rules and access to correspondence, visits and Residential Treatment Services Bureau telephone use; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (l) availability of reading materials, programming, and Residential Treatment Services Bureau other activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (m) facility policies on the use of force, use of restraints, Residential Treatment Services Bureau chemical agents and room confinement; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (n) immigration legal services; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (o) emergencies including evacuation procedures; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation Process and Handbook ☒ ☐ ☐ (p) non-discrimination policy and the right to be free Residential Treatment Services Bureau from physical, verbal or sexual abuse and (RTSB) Manual Section: 502: Orientation harassment by other youth and staff; ☒ ☐ ☐ Process and Handbook (q) availability of services and programs in a language Residential Treatment Services Bureau other than English if appropriate; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (r) the process for requesting different housing, Residential Treatment Services Bureau education, programming and work assignments; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (s) a process for which parents/guardians receive Residential Treatment Services Bureau information regarding the youth’s stay in the (RTSB) Manual Section: 502: Orientation facility that at a minimum includes answers to Process and Handbook ☒ ☐ ☐ frequently asked questions and provides contact Orienting officer provides parent info and information for the facility, medical, school and provides contact info. mental health; and, (t) a process by which youth may request access to Residential Treatment Services Bureau Title 15 Minimum Standards for Juvenile Facilities. (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 1354 SEPARATION Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 514: Separation, written policies and procedures that address: 515: Room Confinement and Section 1400: ☒ ☐ ☐ The Healing Opportunities and Positive Engagement (HOPE) Center (a) separation of youth for reasons that include, but are Residential Treatment Services Bureau not be limited to, medical and mental health (RTSB) Manual Section: 514: Separation, conditions, assaultive behavior, disciplinary 515: Room Confinement and Section 1400: consequences and protective custody. ☐ ☒ ☐ The Healing Opportunities and Positive Engagement (HOPE) Center 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) consideration of positive youth development and Residential Treatment Services Bureau trauma-informed care. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation (c) separated youth shall not be denied normal Residential Treatment Services Bureau privileges available at the facility, except when (RTSB) Manual Section: 514: Separation necessary to accomplish the objective of separation. If a youth is not on active Room Confinement due to imminent safety or security, he or she should be considered as full program and be fully integrated into a full general population program and receive all programming and activities in the HOPE Center as appropriate or returned to the ☐ ☐ UNK dorm. We were unable to determine which youth present in the HOPE Center were eligible for programming as we were provided with no specific documentation to view. We are unable to make a determination of compliance at this time. We will review this further when we return on site (d) when the objective of the separation is discipline, Residential Treatment Services Bureau Title 15 Section 1390 shall apply. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation (e) when separation results in room confinement, the Residential Treatment Services Bureau separation shall occur in accordance with Welfare (RTSB) Manual Section: 514: Separation ☒ ☐ ☐ and Institutions Code Section 208.3 and Section1354.5 of these regulations. (f) policies and procedures shall ensure a daily review Residential Treatment Services Bureau of separated youth to determine if separation (RTSB) Manual Section: 514: Separation remains necessary. ☒ ☐ ☐ and Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354.5 ROOM CONFINEMENT Residential Treatment Services Bureau (RTSB) Manual Section: 515: Room (a) The facility administrator shall develop and Confinement and Section 1400: The Healing implement written policies and procedures Opportunities and Positive Engagement addressing the confinement of youth in their room (HOPE) Center that are consistent with Welfare and Institutions Code Section 208.3. The placement of a youth in The HOPE Center at Dorothy Kirby Center room confinement shall be accomplished in is used for Dorothy Kirby Center youth only. accordance with the following guidelines: The HOPE Center receives youth for a variety of reasons which include separation or cool down, decontamination, administrative holds, housing, mental health, and for safety and security purposes. Youth who are in need of Room Confinement, are also moved to the HOPE Center. With the implementation of the Room Confinement regulations and the ☐ ☒ ☐ implementation of specific requirements, the documentation received for review was problematic, as it does not consistently provide proof of compliant practices nor are, we able to determine which youth are held under room confinement expectations. In many cases, we were unable to determine if the youth was placed in a locked room therefore, we were unable to determine what requirements and documentation were necessary. Policy, procedure and documentation will need to be reviewed and updated to achieve compliance. Room confinement and separation policies should be revised concurrently to ensure consistency as well as to ensure compliance with all pieces of this regulation. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Room confinement shall not be used before Residential Treatment Services Bureau other, less restrictive, options have been (RTSB) Manual Section: 515: Room attempted and exhausted, unless attempting Confinement and Section 1400: The Healing those options poses a threat to the safety or Opportunities and Positive Engagement security of any youth or staff. (HOPE) Center 9 (greater than) 4-hour placements and 10 (less than) 4-hour HOPE Center Packets were provided for our review. ☒ ☐ ☐ We found that in many cases, staff make efforts to redirect and counsel youth to avoid Hope Center placements. Efforts are made to deescalate a youth’s behaviors and removing a youth to the HOPE Center is a last effort. (2) Room confinement shall not be used for the Residential Treatment Services Bureau purposes of punishment, coercion, (RTSB) Manual Section: 515: Room convenience, or retaliation by staff. Confinement and Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center In most of the documentation we viewed, the youth escalated the situation/circumstances and exhibited ☐ ☒ ☐ threatening, aggressive or assaultive behavior however: there were incidents we viewed in which the youth was moved to the HOPE Center for reasons such as failure to follow instructions, refusal to return to their cottage or due to mental health issues. We were unable to clearly determine in those circumstances if a youth was placed in a locked room, an unlocked room or in the day room based on the documentation provided. (3) Room confinement shall not be used to the Residential Treatment Services Bureau extent that it compromises the mental and (RTSB) Manual Section: 515: Room physical health of the youth. Confinement We found no incident of excessive room ☒ ☐ ☐ confinement in the documentation we viewed. Mental health referrals or consultations were included in the documentation reviewed. All youth were cleared by medical staff immediately following the incident. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) A youth may be held up to four hours in room Residential Treatment Services Bureau confinement. After the youth has been held in room (RTSB) Manual Section 1400: The Healing confinement for a period of four hours, staff shall Opportunities and Positive Engagement do one or more of the following: (HOPE) Center ☒ ☐ ☐ Documentation was provided for youth who were in the HOPE Center for less than 4 hours and youth who remained for longer than 4 hours. (1) Return the youth to general population. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☒ ☐ ☐ Opportunities and Positive Engagement (HOPE) Center (2) Consult with mental health or medical staff. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center Policy and procedure must be updated to include consultation with mental health or medical staff for youth who are held beyond 4 hours. Policy also requires that any youth ☐ ☒ ☐ placed on room confinement shall complete a Behavior Chain Analysis (BCA’s) and be assessed by DMH as part of the stabilization process however, documentation provided did not demonstrate compliance in this area. Currently, mental health staff respond and see youth as a result of the precipitating incident, but not due to the isolation. This is non-compliant. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 36 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Develop an individualized plan that includes Residential Treatment Services Bureau the goals and objectives to be met in order to (RTSB) Manual Section 1400: The Healing reintegrate the youth to general population. Opportunities and Positive Engagement (HOPE) Center Policy notes that youth shall not remain assigned to the HOPE Center for longer than 4 hours without the initiation of a formal Major Administrative Action Review reviewed by the facility Director or designee and must include an individualized plan that includes goals and objectives to be met to ☐ ☒ ☐ reintegrate the youth back to general population. They must be documented on the SSP. The SSP addresses supervision issues and does not include goals and objectives to reintegrate the youth to general population for this purpose. No documentation of any individualized plans that included goals and objectives to reintegrate the youth to general population was provided. This section is non-compliant. (4) If room confinement must be extended beyond Residential Treatment Services Bureau four hours, staff shall do each of the following: (RTSB) Manual Section 1400: The Healing ☒ ☐ ☐ Opportunities and Positive Engagement (HOPE) Center (A) Document the reasons for room Residential Treatment Services Bureau confinement and the basis for the (RTSB) Manual Section 1400: The Healing extension, the date and time the youth was Opportunities and Positive Engagement ☐ ☒ ☐ first placed in room confinement, and when (HOPE) Center he or she is eventually released from room confinement. No documentation provided for this section. (B) Develop an individualized plan that Residential Treatment Services Bureau includes the goals and objectives to be met (RTSB) Manual Section 1400: The Healing in order to integrate the youth to general Opportunities and Positive Engagement population. (HOPE) Center ☐ ☒ ☐ See above B(3) There were no individualized plans provided. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Obtain documented authorization by the Residential Treatment Services Bureau facility superintendent or his or her (RTSB) Manual Section 1400: The Healing designee every four hours thereafter. Opportunities and Positive Engagement (HOPE) Center Major Administrative Actions were signed ☒ ☐ ☐ off by the Director. We found that documentation was not signed every 4 hours once moved to SSP and MAA but we were unable to determine if the youth was still in room confinement. This must be addressed through policy. (5) This section is not intended to limit the use of Residential Treatment Services Bureau single-person rooms or cells for the housing of (RTSB) Manual Section: 515: Room youth in juvenile facilities and does not apply Confinement ☒ ☐ ☐ to normal sleeping hours. (6) This section does not apply to youth or wards Residential Treatment Services Bureau in court holding facilities or adult facilities. (RTSB) Manual Section: 515: Room ☒ ☐ ☐ Confinement (7) Nothing in this section shall be construed to Residential Treatment Services Bureau conflict with any law providing greater or (RTSB) Manual Section: 515: Room ☒ ☐ ☐ additional protections to youth. Confinement (8) This section does not apply during an Residential Treatment Services Bureau extraordinary emergency circumstance that (RTSB) Manual Section: 515: Room requires a significant departure from normal Confinement 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. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 38 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (9) This section does not apply when a youth is Residential Treatment Services Bureau placed in a locked cell or sleeping room to treat (RTSB) Manual Section: 515: Room and protect against the spread of a Confinement 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 Residential Treatment Services Bureau PLAN (RTSB) Manual Section 402: Assessment and Classification and 703: The MDT The facility administrator shall develop and implement Process written policies and procedures for assessment and case planning. The process of assessment begins upon a youth being ordered to a camp. A youth is ☒ ☐ ☐ assessed by the Camp Assessment Unit and by the facility upon arrival. The case plan is developed through a collaborative multi- disciplinary Team. Periodic review is completed by the assigned casework Probation Officer. The transition plan is completed by the collaborative multi- disciplinary team. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Assessment: Residential Treatment Services Bureau The assessment is based on information collected (RTSB) Manual Section 703: The MDT during the admission process with periodic review, Process which includes the youth's risk factors, needs and strengths including, but not limited to, The process of case planning begins with the identification of substance abuse history, assessment process. 10 Initial and educational, vocational, counseling, behavioral Transitional MDT packets were reviewed. health, consideration of known history of trauma, The Camp Assessment Unit completes all and family strengths and needs. assessments on the youth prior to transfer. The assessment summary was not provided for our review nor was it in the case notes; however, it is practice and is completed for all youth in RTSB per Bureau staff. At inspection, we were unable to determine ☐ ☐ UNK compliance in this area at this time without seeing the assessment, speaking to staff and youth. Prior to writing this report, we have been notified that the agency has updated their policy and has corrected their forms and documentation to be consistent with regulation and to provide a more clear and efficient process for the youth and their families. Staff training occurred in August 2020 and the new process was implemented in September 2020. We will follow up with this section to review for compliance upon our return to the facility. (b) Institutional Case Plan: Residential Treatment Services Bureau (1) A case plan shall be developed for each youth (RTSB) Manual Section 703: The MDT held for at least 30 days or more and created Process within 40 days of admission. The initial MDT acts as the youth’s case plan and provides direction as to what programs ☒ ☐ ☐ they will participate in. Some programs are automatic as they are court ordered. The MDT is targeted to be completed within the first 2 weeks of a youth’s arrival at camp. All MDT’s occurred within the time allotted by regulation. (2) The institutional plan shall include, but not be Residential Treatment Services Bureau limited to, written documentation that provides: ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (A) objectives and time frame for the resolution Residential Treatment Services Bureau of problems identified in the assessment; (RTSB) Manual Section 705: Ongoing Case Management Activities The MDT process and format provides the structure for the youth’s case plan. Objectives are based on the assessment. Those programs that are ordered and are camp required programs, the timelines are noted as part of the program i.e. 10 weeks substance abuse program or 16-week DBT Program. Technical Assistance regarding the ☒ ☐ ☐ structure of the process and making the plans more individualized in the coming cycle. With the change in regulation, the assessment drives the objectives and goals and the case plans are more individualized and not solely based on a court order or camp program. RTSB has enhanced their process. We will follow up with this section and determine compliance upon our return to the facility (B) a plan for meeting the objectives that Residential Treatment Services Bureau includes a description of program resources (RTSB) Manual Section 705: Ongoing Case needed and individuals responsible for Management Activities assuring that the plan is implemented; We found the current plan and timelines are embedded within the camp program expectations or court orders i.e. 10 weeks substance abuse program, individual counseling or family counseling weekly or 16-week DBT. ☐ ☐ UNK Discussed need to ensure these programs and other assessed needs are documented more consistently so the youth’s other needs are individual to the youth. We need more information to determine compliance. We will follow up with this section and determine compliance upon our return to the facility. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) periodic evaluation of progress towards meeting Residential Treatment Services Bureau the objectives, including periodic review and (RTSB) Manual Section 705: Ongoing Case discussion of the plan with the youth; Management Activities Periodic review is documented in case notes which were provided with each MDT- ☒ ☐ ☐ Caseplan. Assigned Camp Casework Probation Officers complete weekly case notes with their assigned youth. Documentation provided showed that youth were met with face to face in the spirit of meeting for casework purposes. (4) a transition plan, the contents of which shall be Residential Treatment Services Bureau subject to existing resources, shall be developed (RTSB) Manual Section 706: Case Plan for post dispositional youth in accordance with Activities- Pre- Release Section 1351; and, ☒ ☐ ☐ Transition MDT’s are completed for all youth and contain all areas required by regulation. (5) in as much as possible and if appropriate, the Residential Treatment Services Bureau plan, including the transition plan, shall be (RTSB) Manual Section 705: Ongoing Case developed with input from the family, Management Activities supportive adults, youth, and Regional Center ☒ ☐ ☐ The youth’s parent or guardian is invited to for the Developmentally Disabled. attend the MDT. The family is contacted by phone and by letter to attend. 1356 COUNSELING AND CASEWORK Residential Treatment Services Bureau SERVICES (RTSB) Manual Section 705: Ongoing Case Management Activities The facility administrator shall develop and implement written policies and procedures ensuring the availability Counseling, case management and casework of appropriate counseling and casework services for all ☒ ☐ ☐ activities are expected tasks of staff in youth. Policies and procedures shall ensure: RTSB. Supervisors at DKC complete weekly PCMS of their cottage staff casework contacts with the youth. This extra step enhances outcomes of staff meeting the expectations of caseload management. (a) youth will receive assistance with needs or concerns Residential Treatment Services Bureau that may arise; ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) youth will receive assistance in requesting contact Residential Treatment Services Bureau with parents, other supportive adults, attorney, (RTSB) Manual Section 705: Ongoing Case clergy, probation officer, or other public official; Management Activities ☒ ☐ ☐ and, (c) youth will be provided access to available resources Residential Treatment Services Bureau to meet the youth’s needs. ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 1357 USE OF FORCE Residential Treatment Services Bureau (RTSB) Manual Section 1701: Physical The facility administrator, In cooperation with the intervention Policy for Juvenile Facilities responsible physician, shall develop and implement and the Transportation Section written policies and procedures for the use of force, which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or Policy was developed with the Juvenile treatment. ☒ ☐ ☐ Court Health Services (JCHS) and includes (a) At a minimum, each facility shall develop policies the use of soft restraints. OC is not used in and procedures which: the camps. Documentation was provided from throughout the cycle. 10 Incidents were selected for review from July 2019, August 2019, November 2019, December 2019 and March 2020. (1) restricts the use of force to that which is deemed Residential Treatment Services Bureau reasonable and necessary, as defined in Section (RTSB) Manual Section 1704: Safe Crisis 1302 to ensure the safety and security of youth, Management and Physical Intervention staff, others and the facility. Procedures All documentation reviewed were fights, ☒ ☐ ☐ assaults by youth on other youth, assaults on staff by youth and interventions. All incidents viewed appeared appropriate and to be reasonable and necessary. Staff gave direction to stop and attempts were made to deescalate. (2) outline the force options available to staff Residential Treatment Services Bureau including both physical and non-physical (RTSB) Manual Section 1704: Safe Crisis options and define when those force options are Management and Physical Intervention appropriate. Procedures ☒ ☐ ☐ Non-Physical Options: De-escalation Techniques Physical Options: Authorized Levels of Physical Interventions 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) describe force options or techniques that are Residential Treatment Services Bureau expressly prohibited by the facility. (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ Management and Physical Intervention Procedures (4) describe the requirements of staff to report any Residential Treatment Services Bureau inappropriate use of force, and to take (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ affirmative action to immediately stop it. Management and Physical Intervention Procedures (5) define a standardized reporting format that Residential Treatment Services Bureau includes time period and procedure for (RTSB) Manual Section 1703: Safe Crisis documenting and reporting the use of force, Management-Physical Intervention Report including reporting requirements of Forms, 1704: Safe Crisis Management and management and line staff and procedures for Physical Intervention Procedures and 1706: reviewing and tracking use of force incidents by Safe Crisis Management Physical supervisory and or management staff, which Intervention Reports include procedures for debriefing a particular Every incident is reviewed by the duty incident with staff and/or youth for the purposes supervisor and again reviewed by the Safe of training as well as mitigating the effects of Crisis Management Supervisor whose trauma that may have been experienced by staff responsibility is to review for violation of and /or the youth involved. policy and procedures. This review also includes interviews with all youth involved and other witnesses as appropriate. We did not see any reference to debriefing of incidents however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further ☐ ☐ UNK into this issue when on site at the next inspection. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (6) Include an administrative review and a system Residential Treatment Services Bureau for investigating unreasonable use of force. (RTSB) Manual Section 1706: Safe Crisis Management Physical Intervention Reports Any incident that falls outside of agency policy is referred to the facility director for referral for an administrative review or referral to the Probation Departments Special Investigation Unit for further review. ☒ ☐ ☐ 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Residential Treatment Services Bureau procedures required after use of force incidents (RTSB) Manual Section 1704: Safe Crisis for medical, mental health staff and parents or Management and Physical Intervention legal guardians. Procedures and 1706: Safe Crisis Management Physical Intervention Reports We found that in all incident reports and in documentation reviewed we found that youth were medically cleared and were either seen by mental health or a mental health referral was submitted on the youth’s behalf for follow up. At inspection, we did not see any reference in the PIR as required by policy for a contact ☒ ☐ ☐ being made to the youth’s parent if the child was involved in a use of force incident. Technical assistance provided and additional documentation was subsequently requested for review. Staff and supervisors began to contact the youth’s parent as required however; this contact was documented in the facility case notes. Agency policy requires the contact to be documented in the incident report, thus additional training was provided to staff and was addressed. This issue was corrected, and we were provided with documentation of corrective action and proof of contact being made and documentation being completed. (8) describe the limitations of use of force on Residential Treatment Services Bureau pregnant youth in accordance with Penal Code (RTSB) Manual Section 1704: Safe Crisis Section 6030(f) and Welfare and Institutions Management and Physical Intervention ☒ ☐ ☐ Code Section 222. Procedures (b) Facilities that authorize chemical agents as a force Residential Treatment Services Bureau option shall include policies and procedures that: (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (1) identify who is approved to carry and/or utilize NA chemical agents in the facility and the type, size ☐ ☐ ☒ and the approved method of deployment for those chemical agents. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) mandate that chemical agents only be used when NA there is an imminent threat to the youth’s safety ☐ ☐ ☒ or the safety of others and only when de- escalation efforts have been unsuccessful or are not reasonably possible. (3) outline the facility’s approved methods and NA timelines for decontamination from chemical agents. This shall include that youth who have ☐ ☐ ☒ been exposed to chemical agents shall not be left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. (4) define the role, notification, and follow-up NA procedures required after use of force incidents ☐ ☐ ☒ involving chemical agents for medical, mental health staff and parents or legal guardians. (5) provide for the documentation of each incident NA of use of chemical agents, including the reasons for which it was used, efforts to de-escalate ☐ ☐ ☒ prior to use, youth and staff involved, the date, time and location of use, decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure Residential Treatment Services Bureau which require that agencies provide initial and (RTSB) Manual Section 1702: Training ☒ ☐ ☐ regular training in use of force and chemical agents when appropriate that address: (1) known medical and behavioral health Residential Treatment Services Bureau conditions that would contraindicate certain ☒ ☐ ☐ (RTSB) Manual Section 1702: Training types of force; (2) acceptable chemical agents and the methods of Residential Treatment Services Bureau application. (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (3) signs or symptoms that should result in Residential Treatment Services Bureau immediate referral to medical or behavioral ☒ ☐ ☐ (RTSB) Manual Section 1702: Training health. (4) instruction on the Constitutional Limitations of Residential Treatment Services Bureau ☒ ☐ ☐ Use of Force. (RTSB) Manual Section 1702: Training (5) physical training force options that may require Residential Treatment Services Bureau ☒ ☐ ☐ the use of perishable skills. (RTSB) Manual Section 1702: Training 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (6) timelines the facility uses to define regular Residential Treatment Services Bureau training. (RTSB) Manual Section 1702: Training ☒ ☐ ☐ Initial training occurs in CORE and regular training is held through annual refresher training. 1358 USE OF PHYSICAL RESTRAINTS Residential Treatment Services Bureau (RTSB) Manual Section 1705: Restraints The facility administrator, In cooperation with the responsible physician and mental health director, shall The policy was developed in cooperation with DMH and JCHS develop and implement written policies and procedures for the use of restraint devices. Restraint devices ☒ ☐ ☐ Documentation provided for incidents that include any devices which immobilize a youth's occurred in July 2019, August 2019, October extremities and/or prevent the youth from being 2019 and January 2020. ambulatory. Facility utilized and provided a copy of a restraint log for incidents. Physical restraints may be used only for those youth Residential Treatment Services Bureau who present an immediate danger to themselves or (RTSB) Manual Section 1705: Restraints others, who exhibit behavior which results in the destruction of property or reveals the intent to cause ☒ ☐ ☐ self-inflicted physical harm. Physical restraints should All incidents involved youth whose behavior be utilized only when it appears less restrictive was out of control and either escalated or was likely to escalate without restraints. alternatives would be ineffective in controlling the youth’s behavior. In no case shall restraints be used as punishment or Residential Treatment Services Bureau discipline, or as a substitute for treatment. The use of (RTSB) Manual Section 1705: Restraints restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through ☒ ☐ ☐ affixing of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Residential Treatment Services Bureau handcuffs, shackles or other restraint devices when used (RTSB) Manual Section 1705: Restraints to restrain youth for movement or transportation within ☒ ☐ ☐ the facility. Movement within the facility shall be governed by Section 1358.5, Use of Restraint Devices for Movement Within the Facility. Youth shall be placed in restraints only with the approval Residential Treatment Services Bureau of the facility manager or designee. The facility manager (RTSB) Manual Section 1705: Restraints may delegate authority to place a youth in restraints to a ☒ ☐ ☐ physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS A medical opinion on the safety of placement and Residential Treatment Services Bureau retention shall be secured as soon as possible, but no later (RTSB) Manual Section 1705: Restraints than two hours from the time of placement. The youth ☒ ☐ ☐ All youth were seen by the nurse shall be medically cleared for continued retention at least immediately following the incident. every three hours thereafter. A mental health consultation shall be secured as soon as Residential Treatment Services Bureau possible, but in no case longer than four hours from the (RTSB) Manual Section 1705: Restraints time of placement, to assess the need for mental health All youth were either seen by a mental health treatment. clinician to assist in their de-escalation, immediately following the incident or Mental Health was contacted or a referral was submitted. There were some that it is unknown if the youth was seen within 4 hours; however, not enough to be non- ☒ ☐ ☐ compliant. A referral was also submitted based on the precipitating incident. Technical assistance provided for these incidents, a MH consultation must occur within 4 hours and must be documented. For those that a referral was submitted, it is unknown if they youth are seen within 4 hours. This will need to be corrected. Continuous direct visual supervision shall be conducted Residential Treatment Services Bureau to ensure that the restraints are properly employed, and (RTSB) Manual Section 1705: Restraints to ensure the safety and well-being of the youth. Documentation was provided for all youth in Observations of the youth's behavior and any staff ☒ ☐ ☐ restraints. DKC utilizes a restraint log. There interventions shall be documented at least every 15 were a few 2-minute restraints that were left minutes, with actual time of the documentation recorded. blank; however, all other were completed correctly. In addition to the requirements above, policies and Residential Treatment Services Bureau procedures shall address: (RTSB) Manual Section 1705: Restraints (a) documentation of the circumstances leading to an Residential Treatment Services Bureau ☒ ☐ ☐ application of restraints. (RTSB) Manual Section 1705: Restraints (b) known medical conditions that would Residential Treatment Services Bureau contraindicate certain restraint devices and/or ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints techniques. (c) acceptable restraint devices. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (d) signs or symptoms which should result in Residential Treatment Services Bureau ☒ ☐ ☐ immediate medical/mental health referral. (RTSB) Manual Section 1705: Restraints 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) availability of cardiopulmonary resuscitation Residential Treatment Services Bureau ☒ ☐ ☐ equipment. (RTSB) Manual Section 1705: Restraints (f) protective housing of restrained youth. While in Residential Treatment Services Bureau restraint devices, all youth shall be housed alone or (RTSB) Manual Section 1705: Restraints in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (h) exercising of extremities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 1358.5 USE OF RESTRAINT DEVICES FOR Residential Treatment Services Bureau MOVEMENT AND TRANSPORTATION WITHIN (RTSB) Manual Section 1710: The Use of THE FACILITY. Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, In cooperation with the responsible physician and behavioral/mental health The policy was developed in cooperation director, shall develop and implement written policies with DMH and JCHS. and procedures for the use of restraint devices when the purpose is for movement or transportation within the Policy is in place but not yet trained and facility that shall include the following: implemented. The below areas are non- compliant. (a) identification of acceptable restraint devices, staff Residential Treatment Services Bureau approved to utilize restraint devices and the (RTSB) Manual Section 1710: The Use of required training. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility Handcuffs are authorized for regular use and flex cuffs in emergency situations. (b) the circumstances leading to the application of Residential Treatment Services Bureau restraints must be documented. (RTSB) Manual Section 1710: The Use of Mechanical Restraints for Movement and Transport Within the Facility ☐ ☒ ☐ No documentation was provided for our review. This section is non-compliant. (c) an individual assessment of the need to apply Residential Treatment Services Bureau restraints for movement or transportation that (RTSB) Manual Section 1710: The Use of includes consideration of less restrictive Mechanical Restraints for Movement and alternatives, consideration of a youth’s known ☐ ☒ ☐ Transport Within the Facility medical or mental health conditions, trauma No documentation was provided for our informed approaches, and a process for review. This section is non-compliant. documentation and supervisor review and approval. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) consideration of safety and security of the facility, Residential Treatment Services Bureau with a clearly defined expectation that restraint (RTSB) Manual Section 1710: The Use of devices shall not be used for the purposes of Mechanical Restraints for Movement and ☒ ☐ ☐ discipline or retaliation. Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Residential Treatment Services Bureau accordance with Penal Code Section6030(f) and (RTSB) Manual Section 1710: The Use of ☒ ☐ ☐ Welfare and Institutions Code Section 222. Mechanical Restraints for Movement and Transport Within the Facility 1359 SAFETY ROOM PROCEDURES There is no safety room in the camps. Does not apply. (a) The facility administrator, and where applicable, In 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. (b) The placement of a youth in the safety room shall be ☐ ☐ ☒ accomplished in accordance with the following: 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (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 Residential Treatment Services Bureau (RTSB) Manual Sections: The facility administrator shall develop and implement 1316: Searches in Detention Facilities written policies and procedures governing the search of 1317: Body Searches (Pat- Down, Strip, and youth, the facility, and visitors. Policies and procedures Body Cavity Searches) shall provide that: Cottage Inspections Sheets from September and November 2019 and January and April ☒ ☐ ☐ 2020 and K9 searches from February 2020 were provided for our review. Cottages are searched daily by staff and were also searched randomly by canine units. Good efforts by staff and managers to ensure the safety and security of the youth and the facility. (a) Searches shall be conducted to ensure the safety and Residential Treatment Services Bureau security of the facility, public, visitors, youth, and ☒ ☐ ☐ (RTSB) Manual Sections 1316: Searches in staff. Detention Facilities 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Searches shall be conducted in a manner that Residential Treatment Services Bureau preserves the privacy and dignity of the person (RTSB) Manual Sections 1316: Searches in being searched and shall not be conducted for ☒ ☐ ☐ Detention Facilities harassment or as a form of discipline or punishment. (c) Strip searches and visual or physical body cavity Residential Treatment Services Bureau searches shall comply with Penal Code Section (RTSB) Manual Sections: ☒ ☐ ☐ 4030. 1316: Searches in Detention Facilities 1317: Body Searches (Pat- Down, Strip, and Body Cavity Searches) (d) Physical body cavity searches shall only be Residential Treatment Services Bureau conducted by a medical professional. (RTSB) Manual Section 1317: Body ☒ ☐ ☐ Searches (Pat- Down, Strip, and Body Cavity Searches) (e) Any youth held after a detention hearing shall only Residential Treatment Services Bureau be strip searched with prior approval of a supervisor (RTSB) Manual Section 1317: Body when there is reasonable suspicion based on Searches (Pat- Down, Strip, and Body Cavity ☒ ☐ ☐ specific and articulable facts to believe that youth is Searches) concealing contraband. The reasonable suspicion All youth are post disposition. shall be documented. (f) Searches of transgender and intersex youth shall Residential Treatment Services Bureau comply with Section 1352.5. (RTSB) Manual Section 1303: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (g) Cross-gender pat-down searches and strip searches Residential Treatment Services Bureau are prohibited except in exigent circumstances or (RTSB) Manual Section 1317: Body ☒ ☐ ☐ when conducted by a medical professional. Such Searches (Pat- Down, Strip, and Body Cavity searches must be justified and documented in Searches) writing. 1361 GRIEVANCE PROCEDURE Residential Treatment Services Bureau (RTSB) Manual Section 508: Grievance The facility administrator shall develop and Procedures implement written policies and procedures whereby any youth may appeal and have resolved grievances Grievance samples were provided from relating to any condition of confinement, including March, July and October 2019 were but not limited to health care services, classification provided for our review. ☒ ☐ ☐ decisions, program participation, telephone, mail or Compliance noted through review of visiting procedures, food, clothing, bedding, documentation, from policy and through mistreatment, harassment or violations of the conversation with consultant staff. We were nondiscrimination policy. There shall be no time not onsite to view the process. limit on filing grievances. Policies and procedures shall include provisions whereby the facility manager ensures: 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) a grievance form and instructions for registering a Residential Treatment Services Bureau grievance, which includes provisions for the youth (RTSB) Manual Section 508: Grievance to have free access to the form; Procedures Per bureau consultant staff, grievance forms and the instructions are available in the ☒ ☐ ☐ dorms and in other areas around the facility. Youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same. We viewed documentation from this system also. (b) the youth shall have the option to confidentially file Residential Treatment Services Bureau the grievance or to deliver the form to any youth (RTSB) Manual Section 508: Grievance supervision staff working in the facility; Procedures Youth may submit to any staff member or submit the grievance in the confidential box or directly to the Supervisor. Youth may ☒ ☐ ☐ also submit grievances through the JIGS system. This is through LACOE laptops. Once the youth submits the grievance, it is addressed like any other paper grievance. The grievance officer checks their inbox by 10am each morning. (c) resolution of the grievance at the lowest appropriate Residential Treatment Services Bureau staff level; (RTSB) Manual Section 508: Grievance Procedures ☒ ☐ ☐ Youth may submit to any staff member, submit through the confidential box or directly to the Supervisor. (d) provision for a prompt review and initial response Residential Treatment Services Bureau to grievances within three (3) business days, (RTSB) Manual Section 508: Grievance grievances that relate to health and safety issues Procedures ☒ ☐ ☐ must be addressed immediately; All grievances were timely and met regulation expectations. (1) The youth may elect to be present to explain Residential Treatment Services Bureau his/her version of the grievance to a person not (RTSB) Manual Section 508: Grievance directly involved in the circumstances which ☒ ☐ ☐ Procedures led to the grievance. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Provision for a staff representative approved by Residential Treatment Services Bureau the facility administrator to assist the youth. (RTSB) Manual Section 508: Grievance ☒ ☐ ☐ Procedures (e) provision for a written response to the grievance Residential Treatment Services Bureau which includes the reasons for the decisions; ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures (f) a system which provides that any appeal of a Residential Treatment Services Bureau grievance shall be heard by a person not directly (RTSB) Manual Section 508: Grievance involved in the circumstances which led to the ☒ ☐ ☐ Procedures grievance; (g) resolution of the grievance must occur within ten Residential Treatment Services Bureau (10) business days unless circumstances dictate a (RTSB) Manual Section 508: Grievance ☒ ☐ ☐ longer time frame. The youth shall be notified of Procedures any delay; and, (h) the policy shall provide multiple internal and Residential Treatment Services Bureau external methods to report sexual abuse and sexual ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance harassment. Procedures Whether or not associated with a grievance, concerns of Residential Treatment Services Bureau parents, guardians, staff or other parties shall be (RTSB) Manual Section 508: Grievance ☒ ☐ ☐ addressed and documented in accordance with written Procedures policies and procedures within a specified timeframe. 1362 REPORTING OF INCIDENTS Residential Treatment Services Bureau (RTSB) Manual Section 1120: Reducing A written report of all incidents which result in physical Youth on Youth on Violence and 1919: harm, use of force, serious threat of physical harm, or Deaths at Camp Facilities death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the A variety of incident reports were provided staff and submitted to the facility manager by the end of for our review. All appeared to be submitted the shift, unless additional time is necessary and in a timely manner. authorized by the facility manager or designee. 1363 USE OF REASONABLE FORCE TO Residential Treatment Services Bureau COLLECT DNA SPECIMENS, SAMPLES, (RTSB) Manual Section 306: Live Scan and IMPRESSIONS DNA Collection and 1122: Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections DSB personnel are responsible for personnel including peace officers, may employ ☐ ☐ ☒ conducting all DNA Collection. The reasonable force to collect blood specimens, saliva remaining sections are all marked as NA. samples, and thumb 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. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) For the purpose of this section, the “use of Residential Treatment Services Bureau reasonable force” shall be defined as the force that (RTSB) Manual Section 306: Live Scan and an objective, trained and competent correctional DNA Collection and 1122: Juvenile employee, faced with similar facts and Collection of DNA Samples circumstances, would consider necessary and The Juvenile Halls are responsible for the reasonable to gain compliance with this section. collection of DNA samples for all detained ☐ ☐ ☒ and non- detained youth. Per policy, force will not be used to obtain DNA samples unless ordered by the court. If a youth refuses to cooperate, this information is provided to the court for further determination. (2) The use of reasonable force shall be preceded by Residential Treatment Services Bureau efforts to secure voluntary compliance. Efforts to (RTSB) Manual Section 306: Live Scan and secure voluntary compliance shall be documented DNA Collection and 1122: Juvenile ☐ ☐ ☒ and include an advisement of the legal obligation to Collection of DNA Samples provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Residential Treatment Services Bureau authorization of the supervising officer on duty. (RTSB) Manual Section 306: Live Scan and The authorization shall include information that DNA Collection and 1122: Juvenile ☐ ☐ ☒ reflects the fact that the offender was asked to Collection of DNA Samples provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Residential Treatment Services Bureau extraction, the extraction shall be videotaped. (RTSB) Manual Section 306: Live Scan and Video shall be directed at the cell extraction DNA Collection and 1122: Juvenile event. The videotape shall be retained by the Collection of DNA Samples ☐ ☐ ☒ agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County (a) School Programs Probation and Los Angeles County Office of The County Board of Education shall provide for the Education: Juvenile Courts and Community administration and operation of juvenile court Schools. schools in conjunction with the Chief Probation A Matrix was provided for our review from Officer, or designee pursuant to applicable State Sr. Director Dr. Jesus Coral that detailed all laws. The school and facility administrators shall areas of Section 1370. All policy areas for develop and implement written policy and this section are either noted in the LACOE procedures to ensure communication and Board Policy or are in the RTSB Policy. coordination between educators and probation staff. Culturally responsive and trauma-informed BSCC Field Representatives do not inspect approaches should be applied when providing the education program for compliance with instruction. Education staff should collaborate with Title 15. Title 15 requires the Superintendent of Schools to conduct this the facility administrator to use technology to review in conjunction with a qualified facilitate learning and ensure safe technology ☒ ☐ ☐ outside agency or individual. practices. The facility administrator shall request an annual review of each required element of the The education program was inspected by program by the Superintendent of Schools, and a Susan Connolly, Executive Director of report or review checklist on compliance, Student Services Placer County Office of deficiencies, and corrective action needed to achieve Education on June 26, 2019 compliance with this section. Such a review, when conducted, cannot be delegated to the principal or any other staff of any juvenile 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 facility administrator or designee shall review each item with the Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the BP 6011 Instruction, BP 0460 Philosophy, State Education Code and County Board of Goals, Objectives and Comprehensive Plans Education policies, all applicable federal education BP 005 Philosophy, Goals, Objectives and statutes and regulations and provide for an annual Comprehensive Plans Item 3,4,5 evaluation of the educational program offerings. As stated in the 2009 California Standards for the ☒ ☐ ☐ Teaching Profession, teachers shall establish and maintain learning 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. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. ☒ ☐ ☐ Staff 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Comprehensive Plans ☒ ☐ ☐ courses required for high school graduation. Item 3,4,5 (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California ☒ ☐ ☐ Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) ☒ ☐ ☐ and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of ☒ ☐ ☐ Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth AR-6179 Instruction BPP 5149 who do not demonstrate sufficient progress towards ☒ ☐ ☐ grade level standards. (6) The minimum school day shall be consistent with BP 6112 Instruction State Education Code Requirements for juvenile court 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 BP 6112 Instruction Partially address classification, housing, security status, disciplinary requirement; AR 5131 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 AR 5144 Students (1) Positive behavior management will be 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 BP 5021 Students CF 6020 ☒ ☐ ☐ decisions made by probation staff that may affect the educational programming of students. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 58 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension Code, expulsion/suspension from school shall be and Expulsion/Due Process (Students with imposed only when other means of correction fails Disabilities) 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 BP 5144 education staff will develop policies and procedures ☒ ☐ ☐ that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or ☒ ☐ ☐ 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 BP 6174 Instruction afforded an educational program that addresses their ☒ ☐ ☐ language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement ☒ ☐ ☐ (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction ☒ ☐ ☐ (B) Home Language Survey and the results of the State AR 6174 Instruction ☒ ☐ ☐ Test used for English language proficiency; (C) Needs and services of special populations as defined BP 6162.5 Instruction ☒ ☐ ☐ by the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. ☒ ☐ ☐ BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary BP 6162.5 Instruction ☒ ☐ ☐ education plan shall be developed for each youth within five school days. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with AR 5125 Students the State Education Code and request the youth's records from his/her prior school(s), including, but not 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 AR 5125 Students ☒ ☐ ☐ (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies ☒ ☐ ☐ 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever possible, collaborate with local post- ☒ ☐ ☐ secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Residential Treatment Services Bureau EXERCISE. (RTSB) Manual Section 1306: Programs, recreation and Exercise The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Residential Treatment Services Bureau programs, recreation, and exercise a minimum of three (RTSB) Manual Section 1306: Programs, hours a day during the week and five hours a day each recreation and Exercise Saturday, Sunday or other non-school days, of which Documentation provided does not one hour shall be an outdoor activity, weather permitting. ☐ ☒ ☐ demonstrate compliance in this area, times are not documented to confirm one hour of time for each required activity and we noted several incidents where required activities were not documented. This section is non- compliant. A youth’s participation in programs, recreation, and Residential Treatment Services Bureau exercise may be suspended only upon a written finding (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ by the administrator/manager or designee that a youth recreation and Exercise represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall Residential Treatment Services Bureau be posted in the living units. (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ recreation and Exercise There will be a written annual review of the programs, Residential Treatment Services Bureau recreation, and exercise by the responsible agency to (RTSB) Manual Section 1306: Programs, ensure content offered is current, consistent, and recreation and Exercise relevant to the population. Facility provided memo correspondence identifying the programs available to the youth of DKC in 2018, 2019 and 2020. At inspection, there were no individual reviews included by any of the providing Community Based Organizations. Technical assistance provided regarding the need for the responsible agency to provide a review. ☒ ☐ ☐ Additional documentation was provided from Probation noting the specific programs coming into the camp. Additional efforts were made to seek reviews from the CBO’s. The facility was able to get one review for The Unusual Suspects. Due to COVID, we understand the difficulties of getting documents for annual reviews. Please ensure that all reviews are available for the next onsite inspection for all programs and providers. Failure to do so will result in this area being marked non- compliant. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Programs. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of daily (RTSB) Manual Section 1306: Programs, programming to include, but not be limited to, recreation and Exercise trauma focused, cognitive, evidence-based, best Youth are to be provided with the practice interventions that are culturally relevant and opportunity to participate in at least one hour linguistically appropriate, or pro-social interventions of programming that is rehabilitational daily. and activities designed to reduce recidivism. These programs should be based on the youth’s individual Staff track school attendance, exercise, needs as required by Sections 1355 and 1356. Such counseling, and other programs and activities programs may be provided under the direction of the on a tracking form. There is a programming Chief Probation Officer or the County Office of schedule and a copy was provided for our Education and can be administered by county review. partners such as mental health agencies, community- Documentation provided was inconsistent based organizations, faith-based organizations or and did not show compliance with regulation Probation staff. expectations. Only DBT was noted as to Programs may include but are not limited to: have occurred. This section is non-compliant ☐ ☒ ☐ (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; (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 Residential Treatment Services Bureau opportunity for at least one hour of daily access to (RTSB) Manual Section 1306: Programs, unscheduled activities such as leisure reading, letter recreation and Exercise writing, and entertainment. Activities shall be Youth are to be provided with the supervised and include orientation and may include opportunity to participate in at least one hour coaching of youth. ☐ ☒ ☐ of recreation (Known as “Free Time” in your documentation) Documentation provided notes that free time activities are provided but does not note the hour requirement. This is non-compliant. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 62 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Exercise. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of large muscle (RTSB) Manual Section 1306: Programs, activity each day. recreation and Exercise Youth are to be provided with the ☒ ☐ ☐ opportunity to participate in at least one hour of exercise. Documentation provided noted that youth receive an hour of exercise daily. The administrator/manager may suspend, for a period not Residential Treatment Services Bureau to exceed 24 hours, access to recreation and programs. (RTSB) Manual Section 1306: Programs, The administrator/manager shall document the reasons ☒ ☐ ☐ recreation and Exercise why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1004: Religious The facility administrator shall provide access to Services religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth ☒ ☐ ☐ Services are provided for both Catholic and shall be allowed to participate in an activity outside of Protestant religions. their room if he/she elects not to participate in religious programs. Religious programs shall provide for: (a) opportunity for religious services and practices; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (b) availability of clergy; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (c) availability of religious diets. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1373 WORK PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1003: Work Crews The facility administrator shall develop policies and procedures regarding the fair and consistent assignment DKC has established a robust work program of youth to work programs. Work assigned to a youth for their youth. The programs are as follows: shall be meaningful, constructive and related to • Decennial Census Tracker vocational training or increasing a youth's sense of • Los Angeles County Countywide responsibility. Work programs shall not be imposed as a Youth Bridges Program disciplinary measure. ☒ ☐ ☐ • JVS SoCal (Jobs Vision Success) • The Targeted Local Hire Program • WLCAC Youth Source • Apprenticeship Readiness Program (ARP) • Youth at Work at Probation Camps/Halls Training These programs are available onsite. 1374 VISITING Residential Treatment Services Bureau (RTSB) Manual Section 902: Visiting The facility administrator shall develop and implement Procedures, 903: Saturday and Sunday written policies and procedures for visiting, that include Visiting and 904: Special Visits provisions for special visits. Youth shall be allowed to receive visits by parents, guardians or persons standing Visiting logs provided for review. Technical in loco parentis, and children of youth. Other family assistance provided to update how members, such as grandparents and siblings, and attendance is captured to ensure a more supportive adults, may be allowed to visit with the ☒ ☐ ☐ current update. approval of the facility administrator or designee, and in A sample of a letter that is sent to parents of conjunction with the youth’s case plan or in the best youth detained in both the Juvenile Halls and interest of the youth. the camps was provided for our review. The letter was dated in September 2019 and contained information that was not updated to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to Residential Treatment Services Bureau the limitations necessary to maintain order and security. (RTSB) Manual Section 902: Visiting Visitation shall not be denied solely based on the visitor’s Procedures, 903: Saturday and Sunday criminal history. The staff shall determine in each case, Visiting and 904: Special Visits whether the visitor’s criminal history represents a risk to Visitation occurs on Sundays from 1:00PM the safety of youth or staff in the facility. Any denial of to 4:00PM. visitation or limitation on visitations shall be ☒ ☐ ☐ communicated to the youth, person denied and facility Administration will always make exceptions administrator. for those that cannot make it on the weekend. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 64 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Opportunity for visitation shall be a minimum of two Residential Treatment Services Bureau hours per week. Visits may be supervised, but (RTSB) Manual Section 902 and Visiting conversations shall not be monitored unless there is a Procedures, 903: Saturday and Sunday security or safety need. Visiting ☒ ☐ ☐ Youth have over 2 hours of visitation opportunity on the weekends and administration will make arrangements during the week for youth to have the same amount of time if needed. Provisions for special visits, in addition to the two-hour Residential Treatment Services Bureau minimum and/or outside of the regular visiting hours, (RTSB) Manual Section 902: Visiting shall be accommodated as necessary and within the Procedures, 903: Saturday and Sunday discretion of the facility administrator or designee. ☒ ☐ ☐ Visiting and 904: Special Visits 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 Residential Treatment Services Bureau alternative, but not as a replacement, to in-person (RTSB) Manual Section 902: Visiting visiting. ☒ ☐ ☐ Procedures 1375 CORRESPONDENCE Residential Treatment Services Bureau (RTSB) Manual Section 510: Mail The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for correspondence Youth can write letters daily. Mail is also which provide that: distributed daily. (a) there is no limitation on the volume of mail that youth Residential Treatment Services Bureau may send or receive; ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (b) youth may send two letters per week postage free; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (c) youth may correspond confidentially with state and Residential Treatment Services Bureau federal courts, any member of the State Bar or holder (RTSB) Manual Section 510: Mail of 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 Residential Treatment Services Bureau in (c), may be read by staff only when there is (RTSB) Manual Section 510: Mail ☒ ☐ ☐ reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Residential Treatment Services Bureau (RTSB) Manual Section 509: Telephone The administrator of each juvenile facility shall develop ☒ ☐ ☐ Calls and implement written policies and procedures to provide youth with access to telephone communications. Youth may call home weekly. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 65 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1377 ACCESS TO LEGAL SERVICES Residential Treatment Services Bureau (RTSB) Manual Section 520: Access to The facility administrator shall develop written ☒ ☐ ☐ Legal Services 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 Residential Treatment Services Bureau attorneys and their authorized representatives; ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (b) provision for confidential consultation with Residential Treatment Services Bureau attorneys; and, ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (c) unlimited postage free, legal correspondence and Residential Treatment Services Bureau cost-free telephone access as appropriate. ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 1390 DISCIPLINE Residential Treatment Services Bureau (RTSB) Manual Section 601: Discipline, The facility administrator shall develop and implement 602: Facility Rules and 603: Behavior written policies and procedures for the discipline of Management Program youth that shall promote acceptable behavior; including ☒ ☐ ☐ the use of positive behavior interventions and supports. Youth also receive a copy of the RTSB Discipline shall be imposed at the least restrictive level Orientation Handbook and the Behavior which promotes the desired behavior and Deprivation of Management Program Handbook at the following is not permitted: orientation. (a) bed and bedding; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (b) daily shower, access to drinking fountain, toilet and Residential Treatment Services Bureau ☒ ☐ ☐ personal hygiene items, and clean clothing; (RTSB) Manual Section 601: Discipline (c) full nutrition; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (d) contact with parent or attorney; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (e) exercise; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (f) medical services and counseling; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (g) religious services; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (h) clean and sanitary living conditions; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (i) the right to send and receive mail; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (j) education; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (k) rehabilitative programming. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS The facility administrator shall establish rules of conduct Residential Treatment Services Bureau and disciplinary penalties to guide the conduct of youth. (RTSB) Manual Section 604: Continuum of Such rules and penalties shall include both major Correction violations and minor violations, be stated simply and ☒ ☐ ☐ Information regarding the rules is provided affirmatively, and be made available to all youth. in the orientation and BMP handbooks that Provision shall be made to provide accessible are provided to the youth. information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for the administration of discipline which shall include, but not be limited to: (a) designation of personnel authorized to impose Residential Treatment Services Bureau discipline for violation of rules; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (b) prohibiting discipline to be delegated to any youth; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (c) definition of major and minor rule violations and Residential Treatment Services Bureau their consequences, and due process requirements; ☒ ☐ ☐ (RTSB) Manual Section 604: Continuum of Correction (d) trauma-informed approaches and positive behavior Residential Treatment Services Bureau interventions; ☒ ☐ ☐ (RTSB) Manual Section 602: Facility Rules and 604: Continuum of Correction (e) minor rule violations may be handled informally by Residential Treatment Services Bureau counseling, advising the youth of expected conduct (RTSB) Manual Section 604: Continuum of imposing a minor consequence. Discipline shall be Correction accompanied by written documentation and a ☒ ☐ ☐ policy of review and appeal to a supervisor; and, Random sampling of sanction documentation for minor rule violations provided for our review. Will review larger sampling when back on site. (f) major rule violations and the discipline process Residential Treatment Services Bureau shall be documented and require the following: ☒ ☐ ☐ (RTSB) Manual Section 606: Due Process 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 67 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) written notice of violation prior to a hearing; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process There is no location/space for notice of violation on the current form. Policy is consistent with regulation requirements; documentation is not. Facility staff provided Sanctions and Appeals forms that are required for all PIR SCM packets. Technical assistance has previously been provided and discussed with Bureau Management regarding the sanctions and appeal form and the need to revise and change the form to ensure compliance. We were assured this would be revised/updated to be more consistent to address the regulation requirements. This issue was addressed with the Prior Bureau Chief and consultant staff and it was agreed a new form would be implemented for this next cycle. The form does not provide proof of notice of ☐ ☒ ☐ violation and the recommendations noted are not the actual sanctions being recommended or imposed. All sanctions must be noted and made a part of this process and Youth must have the option of a due process hearing on the actual consequences and sanctions they receive. We have confirmed agency staff have corrected policy and forms to correct this issue however, we are unable to determine implementation. This is currently non- compliant. We appreciate the efforts that have been made and look forward to reviewing documentation in the near future to review for compliance. We will continue to follow up with the agency to provide support and technical assistance as needed. Documentation provided from DKC was completed on the same forms as previously provided. In addition, policy requires staff to document the major rule violation on the SIR. We did not find evidence of this. (2) accommodations provided to youth with Residential Treatment Services Bureau disabilities, limited literacy, and English (RTSB) Manual Section 606: Due Process language learners; ☐ ☐ UNK Unable to confirm any hearing practice as there were not hearings documented. 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 68 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) hearing by a person who is not a party to the Residential Treatment Services Bureau incident; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK Unable to confirm any hearing practice as there were not hearings documented. (4) opportunity for the youth to be heard, present Residential Treatment Services Bureau evidence and testimony; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK Unable to confirm any hearing practice as there were not hearings documented. (5) provision for youth to be assisted by staff in the Residential Treatment Services Bureau hearing process; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK Unable to confirm any hearing practice as there were not hearings documented. (6) provision for administrative review. Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☐ ☐ UNK Unable to confirm any hearing practice as there were not hearings documented. (g) violations that result in a removal from camp or Residential Treatment Services Bureau commitment program, but not a return to court, will (RTSB) Manual Section 604: Continuum of ☒ ☐ ☐ follow the due process provisions in subsection (e) Correction above. f 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 69 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the ☒ ☐ ☐ facility. (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Vi Dependent or neglected minors who are defined under ☐ olati ☒ Section 300 of the Welfare and Institutions Code (WIC) are on 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 ☐Vi Juvenile Delinquents (WIC 602)? (WIC 207[d]). ☐ olati ☒ on 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 ☐Vi from minors. ☐ olati ☒ on Adult inmates from an adult facility (e.g. inmate workers or ☐Vi “Scared Straight” programs) are not allowed in the facility ☒ olati ☐ in a manner that allows contact with minors. on 7234 Los Angeles Camp Dorothy Kirby Center 18 20 PRO - 70 - J453 JUV PRO-Eff. 01-01-2019 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections Applicable Title 24 Regulations: Pre-1998* BSCC Code: 7234 FACILITY NAME: FACILITY TYPE: Dorothy Kirby Center Camp CONSTRUCTION/REMODEL DATE(S): 1960 IDENTIFY FACILITY PHYSICAL PLANT MODIFICATIONS SINCE 1992: FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018 2020 Virtual Inspection: Camp Scott youth have been relocated to DKC and are being housed in Amethyst and Jade cottages. We have not confirmed the physical plant information and have provided last year’s evaluation for information only. TITLE 24 SECTION YES NO N/A COMMENTS RECEPTION AREA (JH) Applies only to Juvenile Halls. ✓ Holding Rooms: Contain 15 square feet per minor; Have sufficient seating to accommodate the rated ✓ capacity based on floor space; Provide access to water closets and wash basins at a ✓ ratio of a 1:8; and Provide access to drinking fountain. ✓ Provide access to telephone. ✓ Provide access to private room(s) for interviews. ✓ MEDICAL EXAM SPACE (JH & CAMP) Space or room(s) afford privacy, are equipped to carry out ✓ routine examinations and emergency care and have sufficient locked storage space for medical supplies. LIVING UNITS (JH AND SPJH) Applies only to Juvenile Halls and Special Purpose Juvenile Halls. ✓ Living units are designed to accommodate no more than 30 minors and contain: Showers at a ratio of 1:6; ✓ Washbasins at a ratio of 1:6; ✓ Water closets at a ratio of 1:6 or water closet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain by minors and staff. ✓ Doors of each sleeping room have a view panel (maximum of 144 square inches of shatter-proof glass or plastic ✓ materials) that allows the visual supervision of all parts of the room. Hallways in the detention living units are at least eight feet wide. If rooms are located on only one side, or if room ✓ doors are staggered, hallways are at least six feet wide. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 1 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SINGLE ROOMS (JH, SPJH & CAMP) Contain a minimum of 500 cubic feet of air space and 63 ✓ cubic feet of floor space. DOUBLE ROOMS (JH, SPJH & CAMP) ✓ Contain a minimum of 800 cubic feet of airspace and 100 square feet of floor space. DORMITORY SLEEPING AREAS (JH & CAMP) ✓ Contain a minimum of 400 cubic feet of airspace and 50 square feet of floor space per minor. LOCKED SLEEPING ROOMS (JH, SPJH & CAMP) There are 3 locked sleeping rooms located in the Intensive Care Unit (ICU). Contain an individual or combination drinking fountain, ✓ wash basin and toilet, unless a communication system or procedure is in effect to give minor immediate access to these fixtures. PLUMBING FIXTURES (CAMP) The following plumbing fixtures are adjacent to each ✓ sleeping area: Shower or bathtub at a ratio of 1:6; Washbasins at a ratio of 1:10; ✓ Access to toilets at a ratio of 1:10 or toilet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain. ✓ BEDS AND MATTRESSES (JH, SPJH & CAMP) Beds and mattresses are: ✓ A least 30 inches wide and 76 inches long; Spaced at least 36 inches apart and at least 12 inches off ✓ the floor; and, Mattresses are made of a fire retardant material. ✓ INTERVIEW ROOMS (JH, SPJH & CAMP) ✓ There is one interview room for each detention unit in juvenile halls and special purpose juvenile halls. There is a private room suitably equipped for conferences ✓ and interviews in each camp. LIGHTING (JH, SPJH & CAMP) There are at least 50 foot candles of illumination at desk ✓ level and, at night, there is a maximum illumination of two foot candles at bed level in individual and multiple occupancy rooms. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 2 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS ACADEMIC CLASSROOM (JH & CAMP) Each classroom contains a minimum of 160 square feet with a teacher's desk and work area, and a minimum of 28 square ✓ feet per student. Classrooms should be designed for no more than 15 students. 98: Designed for no more than 20 students DINING SPACE (JH & CAMP) ✓ There is a minimum of 15 square feet of space for each person being fed at any given time. PHYSICAL ACTIVITY SPACE (JH & CAMP) (See 2001 regulations for revised calculations.) There is indoor space consisting of at least 30 square feet of ✓ clear space for each minor, which may be included in a day room, a recreational building, or a multipurpose space (gymnasium). There is outdoor and/or multipurpose (gymnasium) space consisting of: ✓ No less than the equivalent of 90' X 100' outdoor and /or multipurpose space (gymnasium) for a facility with a capacity of 40 or less. No less than the equivalent of 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with a capacity of more than ✓ 40, and a juvenile hall with a capacity between 41 to 100 minors. No less than the equivalent of two 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with a capacity of more ✓ than 40 and a juvenile hall with a capacity in excess of 101 minors. Lighting is adequate for security and evening recreational ✓ activities in camps. STORAGE SPACE (JH, SPJH & CAMP) ✓ Each minor is provided 9 cubic feet of secure storage space for personal clothing and belongings. Camps shall have adequate space (12 square feet of floor area is recommended) for bulk and activity storage ✓ equipment. MULTIPURPOSE SPACE OR ROOM (SPJH) Applies only to Special Purpose Juvenile Halls. There is a multipurpose space or room that provides space ✓ for reception, dining, recreation, exercise and/or education. This room contains a minimum of: 30 square feet of clear floor space per minor in the ✓ room; 10 feet by 20 feet floor dimensions; and, ✓ 1600 cubic feet of air space with a minimum ceiling ✓ height of eight feet. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 3 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SPECIAL PURPOSE JH EXEMPTIONS SPJHs are exempt from the following Pre-1998 Title 15 regulations: Section 4272(b) Medical exam rooms Section 4272(m) Academic classrooms ✓ Section 4272(n) Dining space Section 4272(o) Physical activities space *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 4 - J455 PHY Pre-98.dot (03/01) JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION Board of State and Community Corrections Inspection BSCC Code: 7234 FACILITY: TYPE: RC: Dorothy Kirby Center Camp 80 FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. Updated RC to include the loss of 20 beds account for 20 beds for Camp Scott. Provided for information only** ROOMS EACH ROOM Unit Room Applicable # Each Room Total Size (L x W x H) or FIXTURES* COMMENTS Designation Type Standards Rooms # Beds RC RC Square/Cubic Feet T U W F S Amber Pre-98 Dayroom 1 = 642 1 Restroom 1 2 3 3 Single 10 1 1 10 7’5” x 11’7” = 87 Emerald Pre-98 Dayroom 1 = 642 1 Restroom 2 3 3 Single 10 1 1 10 7’5” X 11’7” = 87 Garnet Pre-98 Dayroom 1 = 642 1 Restroom 1 2 3 3 . Single 10 1 1 10 7’5” x 11’7” = 87 Turquoise Pre-98 Dayroom 1 = 642 1 Restroom 1 2 3 3 Single 10 1 1 10 7’5” x 11’7” = 87 Aqua Pre-98 Dayroom 1 51’ x 30’ = 1,530 (No. Hall) Restroom 1 1 2 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. 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 1 - J460 LAS JUV-05.dot (8/05) ROOMS EACH ROOM Unit Room Applicable # Each Room Total Size (L x W x H) or FIXTURES* COMMENTS Designation Type Standards Rooms # Beds RC RC Square/Cubic Feet T U W F S Single 5 1 1 5 7’8” x 11’8” = 89 (So. Hall) Restroom 1 1 2 1 1 Single 5 1 1 5 7’8” x 11’8” = 89 Amethyst Pre-98 (Removed from DKC RC Count) To SCOTT RC Dayroom 1 = 642 1 Restroom 2 3 3 Single 10 1 1 10 7’7” x 11’7” = 88 Jade Pre-98 (Removed from DKC RC Count) To SCOTT RC Dayroom 1 = 642 1 Restroom 1 2 3 3 Single 10 1 1 10 7’7” x 11’7” = 88 Topaz Pre-98 Dayroom 1 = 642 1 Restroom 2 3 3 Single 10 1 1 10 7’5” x 11’7” = 87 Sapphire Pre-98 Dayroom 1 1 1 10 = 642 1 Restroom 1 2 2 Single 7’5” x 11’7” = 87 ICU Pre-98 Single 9’9-3/4” x 11-1/2” Dry rooms. There were no permanent beds in 3 0 0 0 =89 these rooms. Restroom 1 1 1 1 Diamond Pre-98 Single 1 24’ x 42’ = 1,008 1 1 Restroom 1 2 2 Single 10 1 1 10 9’7” x 7’6” = 72 *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. 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 2 - J460 LAS JUV-05.dot (8/05) ROOMS EACH ROOM Unit Room Applicable # Each Room Total Size (L x W x H) or FIXTURES* COMMENTS Designation Type Standards Rooms # Beds RC RC Square/Cubic Feet T U W F S HISTORICAL NOTES: Site includes 6 classrooms. Each unit has an attached patio. 2010-12: Changes made to the LASE during the 2011 inspection: Sapphire: Fixtures removed to allow installation of ADA compliant toilet (1 where there had been 2), showers (2 where there had been 3) and washbasins (2 where there had been 3). ICU: It was noted that there was only one shower where previously 2 were listed. Diamond: Fixtures removed to allow installation of ADA compliant toilet (1 where there had been 2) and washbasins (2 where there had been 3). 2012-14: Aqua, Amethyst and Topaz were vacant on the day of the inspection. 2014-2016 Inspection Cycle Notes: RC stands at 100 however the facility has removed beds to provide for programing space, mental health staff offices etc. Changes have occurred in a way beds can be re installed in a matter of a few days. 2016-2018 Inspection Cycle Notes: No change to RC 2016 2018 Inspection Cycle Notes: **2018-2020 Inspection Cycle Notes: Inspection completed virtually. Updated RC to include the loss of 20 beds account for 20 beds for Camp Scott. Provided for information only** *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. 7234 LA Camp Dorothy Kirby Center 18-20 PHY - 3 - J460 LAS JUV-05.dot (8/05) JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7255 FACILITY NAME: FACILITY TYPE: Joseph Paige Juvenile Camp PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, Deputy Probation Officer 2; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell, Manual Reviewed-June 26, 2020 Virtual Documentation Review TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND Residential Treatment Services Bureau EVALUATION OF BUILDING AND GROUNDS (RTSB) Manual Section -2001: Inspections On an annual basis, or as otherwise required by law, and Evaluation of Building and Grounds each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Residential Treatment Services Bureau the Board of Supervisors to approve building safety; (RTSB) Manual Section -2002: Types of Inspections and Evaluations 2018 inspections were verified to have ☐ ☒ ☐ occurred. The 2019 inspection results are as follows. 2019 The facility was inspected on August 13, 2019. Corrections are required. (B) Fire authority having jurisdiction, including a fire Residential Treatment Services Bureau clearance as required by Health and Safety Code (RTSB) Manual Section -2002: Types of Section 13146.1 (a) and (b); Inspections and Evaluations ☒ ☐ ☐ The fire inspection was completed by Inspector Kaulback of Los Angeles County Fire Department, Whittier Office, Schools and Institutions Unit on December 10, 2019. Fire Clearance was granted. 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. 7255 Los Angeles Camp Paige 18-20 PRO - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Local health officer, inspection in accordance with Residential Treatment Services Bureau Health and Safety Code Section 101045; (RTSB) Manual Section -2002: Types of Inspections and Evaluations Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the Environmental Health (EH) inspections as noted below. ☐ ☒ ☐ 2018 Inspections were verified to have occurred. The 2019 Inspection is noted as follows: Environmental Health: February 5, 2019: No corrections required. Nutritional Health: February 5, 2019 Medical/Mental Health: January 29-30 and February 5, 2019 Corrections are required for both the Nutrition and Medical/Mental Health Inspections. (D) County superintendent of schools on the adequacy Residential Treatment Services Bureau of educational services and facilities as required in (RTSB) Manual Section -2002: Types of Section 1370; Inspections and Evaluations Education for the is provided by the Los Angeles County Office of Education. ☒ ☐ ☐ 2019 The education program was evaluated by Bruce E. Petersen, Executive Director, San Diego County Office of Education on June 3, 2019. Mr. Petersen found the educational program to be compliant with all regulations. (E) Juvenile court as required by Section 209 of the Residential Treatment Services Bureau Welfare and Institutions Code (RTSB) Manual Section -2002: Types of ☐ ☐ ☒ Inspections and Evaluations No documentation provided. Not required for Juvenile Camps. 7255 Los Angeles Camp Paige 18-20 PRO - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (F) Juvenile Justice Commission as required by Section Residential Treatment Services Bureau 229 of the Welfare and Institutions Code or (RTSB) Manual Section -2002: Types of Probation Commission as required by Section 240 of Inspections and Evaluations the Welfare and Institutions Code. An inspection was completed September ☒ ☐ ☐ 24, 2019, November 4, 2019 and 12,23, 2019 by Commissioner Herbon. Commission Herbon addressed concerns with the facility administration. These concerns were formally responded to by the Probation Department. 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is received from Chief Probation Officer Terri determined by receipt of the Chief Probation Officer’s McDonald certifying that appointments and qualifications of agency staff comply with all certification letter confirming that all elements of elements of regulation. regulation are met. (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: (1) recruit and hire employees who possess 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 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 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ accordance with Section 1031 et seq. of the Government Code. (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract employees of the facility, who may be present at the personnel, volunteers and other non- facility, shall have such clearance and qualifications employees participate in background checks and are approved through each facility for as may be required by law, and their presence at the ☒ ☐ ☐ entrance except for LACOE, who conducts facility shall be subject to the approval and control of their own criminal records review as the facility manager. required by the Probation Department. Probation maintains control as to who has access into the facility. 7255 Los Angeles Camp Paige 18-20 PRO - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1321 STAFFING Residential Treatment Services Bureau (RTSB) Manual Section -206: Staffing Each juvenile facility shall: Random dates throughout the cycle were requested for review throughout the cycle to determine adequacy of staffing levels. Facility administrators completed the Master Cycle Questionnaire as requested. Facility population ranged from a high of 60 youth and a low of 40 through 2019. Facility staffing ranged from 10 to 13 staff during awake hours and no less than 5 during sleeping hours. Off duty staff sleep on site and are available for emergencies. There were 7 SDPO’s with 2 vacancies, 26 DPOII’s with 2 vacancies, 33 DPO I’s with 1 vacancy and 9 GSN’s. Additional documentation was provided of the camp master staff roster, an education staff roster and a facility maintenance staff roster. a) have an adequate number of personnel sufficient to Residential Treatment Services Bureau carry out the overall facility operation and its (RTSB) Manual Section -206: Staffing programming, to provide for safety and security of ☒ ☐ ☐ youth and staff, and meet established standards and See above comment. regulations; b) ensure that no required services shall be denied Residential Treatment Services Bureau because of insufficient numbers of staff on duty (RTSB) Manual Section -206: Staffing absent exigent circumstances; ☒ ☐ ☐ See above comment. c) have a sufficient number of supervisory level staff to Residential Treatment Services Bureau ensure adequate supervision of all staff members; (RTSB) Manual Section -206: Staffing At the time of inspection, Camp Paige had 7 ☒ ☐ ☐ supervisor positions assigned to the facility and 2 vacancies. When a SDPO is unavailable a DPOII is assigned as an acting Supervisor. We will continue to monitor this when back on site. 7255 Los Angeles Camp Paige 18-20 PRO - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS d) have a clearly identified person on duty at all times Residential Treatment Services Bureau who is responsible for operations and activities and (RTSB) Manual Section -206: Staffing has completed the Juvenile Corrections Officer Core Course and PC 832 training. ☒ ☐ ☐ The facility director is responsible for the overall operations of the facility, but the supervisor is responsible for the daily operations of the facility. e) have at least one staff member present on each living Residential Treatment Services Bureau unit whenever there are youth in the living unit; (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ There is always a staff present in the dorm or where a youth is present. Youth are never left alone per consultant staff. f) have sufficient food service personnel relative to the Residential Treatment Services Bureau number and security of living units, including staff (RTSB) Manual Section -206: Staffing qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen The facility has a full dining hall. All youth supervision; direct food preparation and servings; ☒ ☐ ☐ eat their meals in the dining hall unless they conduct related training programs for culinary staff; refuse to leave the dorm. The dining hall is and maintain necessary records; or, a facility may staffed by facility cooks who plan and serve food that meets nutritional standards prepared prepare all meals. Cooks do not supervise by an outside source; youth. g) have sufficient administrative, clerical, recreational, Residential Treatment Services Bureau medical, dental, mental health, building (RTSB) Manual Section -206: Staffing maintenance, transportation, control room, facility ☒ ☐ ☐ security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Residential Treatment Services Bureau continuous wide-awake supervision of youth, (RTSB) Manual Section -206: Staffing subject to 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: (1) Juvenile Halls (minimum youth-staff ratio) Facility is not a Juvenile Hall. (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 Facility is not a Juvenile Hall. room for the purpose of sleeping, one wide-awake ☐ ☐ ☒ youth supervision staff member on duty for each 30 youth in detention; 7255 Los Angeles Camp Paige 18-20 PRO - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff Facility is not a Juvenile Hall 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 Facility is not a Juvenile Hall ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other Facility is not a Juvenile Hall duties such as administration, supervision of ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile staff ratio) Hall ☐ ☐ ☒ (A) during hours that youth are awake, one wide-awake youth supervision staff member is on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room Facility is not a Special Purpose Juvenile for the purpose of sleeping, one wide-awake youth ☐ ☐ ☒ Hall supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff Facility is not a Special Purpose Juvenile members on duty at all times, regardless of the Hall ☐ ☐ ☒ 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 Facility is not a Special Purpose Juvenile who is the same gender as youth housed in the Hall ☐ ☐ ☒ facility. (E) personnel with primary responsibility for other Facility is not a Special Purpose Juvenile duties such as administration, supervision of Hall ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Residential Treatment Services Bureau (A) during the hours that youth are awake, one wide- ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau room for the purpose of sleeping, one wide-awake ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing youth supervision staff member on duty for each 30- youth present in the facility; 7255 Los Angeles Camp Paige 18-20 PRO - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) at least two wide-awake youth supervision staff Residential Treatment Services Bureau members on duty at all times, regardless of the (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau who is the same gender as youth housed in the (RTSB) Manual Section -206: Staffing facility; ☒ ☐ ☐ There are always male and female staff on duty. (E) in addition to the minimum staff to youth ratio Residential Treatment Services Bureau required in (h)(3)(A)-(B), consideration shall be (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau duties such as administration, supervision of (RTSB) Manual Section -206: Staffing personnel, academic or trade instruction, clerical, ☒ ☐ ☐ Only youth supervision staff provide farm, forestry, kitchen or maintenance shall not be supervision of the youth. classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF Residential Treatment Services Bureau ORIENTATION AND TRAINING (RTSB) Manual -2104: Professional (a) Prior to assuming any responsibilities each youth Development and Training supervision staff member shall be properly oriented to their duties, including: All staff assigned to RTSB have completed Correctional Officer CORE training prior to reporting to the facility. Upon assignment, each staff is paired with a onsite training officer who assists them in ☒ ☐ ☐ their orientation and training. Training transcripts were provided as verification of required training which includes CORE. These training transcripts documented the mandated trainings We were unable to view individual training files for the specific location training as we were not on site due to COVID 19. Compliance is based on policy. We will verify training documents when back on site. (1) youth supervision duties; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7255 Los Angeles Camp Paige 18-20 PRO - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) scope of decisions they shall make; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (3) the identity of their supervisor; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) the identity of persons who are responsible to Residential Treatment Services Bureau them; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) persons to contact for decisions that are beyond Residential Treatment Services Bureau their responsibility; and ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (6) ethical responsibilities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (b) Prior to assuming any responsibility for the Residential Treatment Services Bureau supervision of youth, each youth supervision staff (RTSB) Manual -2104: Professional ☒ ☐ ☐ member shall receive a minimum of 40 hours of Development and Training facility-specific orientation, including: (1) individual and group supervision techniques; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) regulations and policies relating to discipline and Residential Treatment Services Bureau rights of youth pursuant to law and the ☒ ☐ ☐ (RTSB) Manual -2104: Professional provisions of this chapter; Development and Training (3) basic health, sanitation and safety measures; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) suicide prevention and response to suicide Residential Treatment Services Bureau attempts ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) policies regarding use of force, de-escalation Residential Treatment Services Bureau techniques, chemical agents, mechanical and (RTSB) Manual -2104: Professional physical restraints; Development and Training ☒ ☐ ☐ The facility does not use chemical agents in the camp setting. (6) review of policies and procedures referencing Residential Treatment Services Bureau trauma and trauma-informed approaches; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (7) procedures to follow in the event of Residential Treatment Services Bureau emergencies; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (8) routine security measures, including facility Residential Treatment Services Bureau perimeter and grounds; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7255 Los Angeles Camp Paige 18-20 PRO - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (9) crisis intervention and mental health referrals to Residential Treatment Services Bureau mental health services; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (10) documentation; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (11) fire/life safety training Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (c) Prior to assuming sole supervision of youth, each Residential Treatment Services Bureau youth supervision staff member shall successfully (RTSB) Manual -2104: Professional complete the requirements of the Juvenile ☒ ☐ ☐ Development and Training Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer Residential Treatment Services Bureau youth supervision staff shall successfully complete (RTSB) Manual -2104: Professional ☒ ☐ ☐ training pursuant to Section 830 et seq. of the Penal Development and Training Code. 1323 FIRE AND LIFE SAFETY Residential Treatment Services Bureau (RTSB) Manual -2104: Professional Whenever there is a youth in a juvenile facility, there Development and Training shall be at least one wide awake person on duty at all ☒ ☐ ☐ times who meets the training standards established by the All staff are trained in fire and life safety in Board for general fire and life safety which relate CORE training. All Supervisors have been specifically to the facility. trained. There will always be a supervisor or an acting supervisor on duty. 7255 Los Angeles Camp Paige 18-20 PRO - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1324 POLICY AND PROCEDURES MANUAL The agency manual is specific to RTSB and All facility administrators shall develop, publish, and camp operations and has been provided to the implement a manual of written policies and procedures BSCC for review. The manual was last that address, at a minimum, all regulations that are reviewed and updated in June 2020. applicable to the facility. Such a manual shall be made available to all employees, reviewed by all employees, The BSCC has reviewed the agency Policy and shall be administratively reviewed at a minimum and Procedure as provided to us specific to every two years, and updated, as necessary. Those regulations and has confirmed the policies records relating to the standards and requirements set and procedure exist as cited. There may be forth in these regulations shall be accessible to the Board cites noted in the comments that may not on request. match due to updates that were unable to be The manual shall include: reverified. ☒ ☐ ☐ Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. In all cases, copies of policies and directives were provided that were not from the current manual. Technical assistance provided and discussed that this should be rectified. (a) table of organization, including channels of Residential Treatment Services Bureau communications and a description of job (RTSB) Manual Sections: classifications; • 101: Vision, Mission, and Core Values • 102: Role of the Camp System • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff • 207: Organizational Chart The manual has a table of contents. The agency’s channel of communication follows chain of command. 7255 Los Angeles Camp Paige 18-20 PRO - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) responsibility of the probation department, purpose Residential Treatment Services Bureau of programs, relationship to the juvenile court, the (RTSB) Manual Sections: Juvenile Justice/Delinquency Prevention • 101: Vision, Mission, and Core Commission or Probation Committee, probation Values staff, school personnel and other agencies that are • 102: Role of Camp System involved in juvenile facility programs; ☒ ☐ ☐ • 908: Medical Services • 909: Mental Health Services • 910: Educational Services • 1005: Community Based Organizations • 1006: Volunteers (c) responsibilities of all employees; Residential Treatment Services Bureau (RTSB) Manual Sections: • 202: RTSB Administrative Structure 203: Duty Statements, RTSB ☒ ☐ ☐ Management • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff (d) initial orientation and training program for Residential Treatment Services Bureau employees; (RTSB) Manual -2104: Professional Development and Training ☒ ☐ ☐ See Section 1322 (e) initial orientation, including safety and security Residential Treatment Services Bureau issues and anti-discrimination policies, for support (RTSB) Manual -2200: Non-Sworn staff, contract employees, school, mental/behavioral Personnel and Partner Agencies Handbook health and medical staff, program providers and ☐ ☐ UNK Unable to view employee training files as not volunteers; on site. Compliance is based on policy. We will verify training documents when back on site. 7255 Los Angeles Camp Paige 18-20 PRO - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) maintenance of record-keeping, statistics and Residential Treatment Services Bureau communication system to ensure: (RTSB) Manual 701: Case Planning and Procedures and 702-General Duties and Responsibilities RTSB maintains an extensive record- keeping system (PCMS) to record operations and to report on the youth in its’ care. Through these reports, the RTSB is able to document and retrieve accurate ☒ ☐ ☐ accounts of specific incidents or operations and to develop a database for statistical analysis. The assigned camp DPO is responsible for the casework functions while the youth is in the camp setting. The supervisor is responsible to ensure that all information is thoroughly documented within the Probation Case Management System. (1) efficient operation of the juvenile facility; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (2) legal and proper care of youth; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (3) maintenance of individual youth's records; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (4) supply of information to the juvenile court and Residential Treatment Services Bureau those authorized by the court or by the law; and, (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (5) release of information regarding youth. Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (g) ethical responsibilities; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-2130: Employee Honesty (h) trauma-informed approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-518: Trauma Informed Approaches (i) culturally responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-519: Culturally Responsive Approaches 7255 Los Angeles Camp Paige 18-20 PRO - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (j) gender responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-517: Promoting Dignity for Female Youth Housed in RTSB (k) a non-discrimination provision that provides that all Residential Treatment Services Bureau youth within the facility shall have fair and equal (RTSB) Manual-2110: Non-Discrimination access to all available services, placement, care, Policy treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group ☒ ☐ ☐ identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Residential Treatment Services Bureau chemical agents related security devices, and (RTSB) Manual-1922: Weapons and ☒ ☐ ☐ weapons and ammunition, where applicable; Ammunition (m) establishment of procedures for collection of Medi- Residential Treatment Services Bureau Cal eligibility information and enrollment of eligible ☒ ☐ ☐ (RTSB) Manual-706: Case Plan Activities youth; and, (n) establishment of a policy that prohibits all forms of Residential Treatment Services Bureau sexual abuse, sexual assault and sexual harassment. (RTSB) Manual-1600: Prison Rape The policy shall include an approach to preventing, Elimination Act detecting and responding to such conduct and any retaliation for reporting such conduct, as well as a ☒ ☐ ☐ Staff are trained in PREA within their first provision for reporting such conduct by youth, staff year of employment and every two years or a third party. thereafter. 1325 FIRE SAFETY PLAN Residential Treatment Services Bureau The facility administrator shall consult with the local fire (RTSB) Manual-1910: Fire Prevention and department having jurisdiction over the facility, or with ☒ ☐ ☐ Suppression and 1917: Emergency the State Fire Marshal, in developing a plan for fire safety Evacuation which shall include, but not be limited to: a) a fire prevention plan to be included as part of the Residential Treatment Services Bureau manual of policy and procedures; (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression b) monthly fire and life safety inspections by facility Residential Treatment Services Bureau staff with two- year retention of the inspection (RTSB) Manual-1910: Fire Prevention and record; Suppression ☒ ☐ ☐ Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. 7255 Los Angeles Camp Paige 18-20 PRO - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS c) fire prevention inspections as required by Health Residential Treatment Services Bureau and Safety Code Section 13146.1(a) and (b); (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression See Section 1313 d) an evacuation plan; Residential Treatment Services Bureau (RTSB) Manual Sections: 1910: Fire Prevention and Suppression 1917: Emergency Evacuation ☒ ☐ ☐ Facility provided County of Los Angeles Building Emergency Plan with site evacuation maps for our review. e) documented fire drills not less than quarterly; Residential Treatment Services Bureau (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression All fire drills were completed as required. f) a written plan for the emergency housing of youth in Residential Treatment Services Bureau the case of fire; and, (RTSB) Manual-1917: Emergency Evacuation ☒ ☐ ☐ Emergency housing will always be at one of the camps or juvenile halls dependent on location of the fire and a safe route of travel. g) development of a fire suppression pre-plan In Residential Treatment Services Bureau cooperation with the local fire department. (RTSB) Manual-1910: Fire Prevention and Suppression ☒ ☐ ☐ The County of Los Angeles Building Emergency Plan for Camp Paige was signed by LACO Fire Department inspectors Daniel Garcia on November 23, 2019 and by Eric Arrellano on June 2, 2020. 1326 SECURITY REVIEW Residential Treatment Services Bureau (RTSB) Manual- 1312: Security Checks Each facility administrator shall develop policies and procedures to annually review, evaluate, and document ☒ ☐ ☐ Security review was completed July 18, 2019 security of the facility. The review and evaluation shall by Director Jose Jimenez include internal and external security, including, but not limited to, key control, equipment, and staff training. 1327 EMERGENCY PROCEDURES Facility provided and utilizes (in addition to the Bureau Policy Manual), the County of The facility administrator shall develop facility-specific Los Angeles Building Emergency Plan. Both policies and procedures for emergencies that shall documents have emergency procedures include, but not be limited to: ☒ ☐ ☐ regarding the facilities. We did not review the documents for comparison and suggest that the agency review and compare to ensure there are no inconsistencies. 7255 Los Angeles Camp Paige 18-20 PRO - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) escape, disturbances, and the taking of hostages; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1907 Escapes 1909: Major Disturbances 1914: Hostages (b) civil disturbance, active shooter and terrorist attack; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1908: Outside Intruder 1915: Active Shooter 1916: Terrorist Attack (c) fire and natural disasters; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1910: Fire Prevention and Suppression 1913: Earthquake (d) periodic testing of emergency equipment; Residential Treatment Services Bureau (RTSB) Manual Sections: 1321: Testing of Emergency Equipment ☒ ☐ ☐ Internal Services Department (ISD) conducts monthly and as needed testing in coordination with MSB. (e) emergency evacuation of the facility; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections: 1917: Emergency Evacuation (f) a program to provide all youth supervision staff Residential Treatment Services Bureau with an annual review of emergency procedures. (RTSB) Manual Sections: 1903: Staff Roles and Responsibilities ☐ ☒ ☐ Documentation provided of intention to train staff; however, no final proof of practice received. This is non-compliant. 7255 Los Angeles Camp Paige 18-20 PRO - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1328 SAFETY CHECKS Residential Treatment Services Bureau (RTSB) Manual Sections: 1313: Safety The facility administrator shall develop and implement Checks and Section 1119 policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, Documentation of Safety Checks were at random or varied intervals during hours when youth provided for September and November 2019. are asleep or when youth are in their rooms, confined in We reviewed random checks from the holding cells or confined to their bed in a dormitory. documentation provided and found that Supervision is not replaced, but may be supplemented overall, checks were completed within 15 by, an audio/visual electronic surveillance system minutes with minimal discrepancies. There designed to detect overt, aggressive or assaultive were some instances of nonrandom and non- behavior and to summon aid in emergencies. All safety varied checks; however, facility checks shall be documented with the actual time the administration addressed the issue through a check is completed. corrective action and work instruction memo prior to inspection. Technical assistance provided regarding enhancing supervision through the use of less time between checks. ☒ ☐ ☐ Policy also requires supervisors to regularly audit safety check logs by making unannounced inspections at least once a shift of the Safety Check Sheets in the buildings under their supervision. Supervisors are to ensure compliance and to assure that staff are completing the checks according to policy. Supervisors are to document their name, date, time of the audit under the last check. Facility managers corrected this issue also through their own review and provided a work instruction memo. We reviewed subsequent checks and noted improvement in both areas. We will be sure to review these issues to ensure continued compliance in the future. 7255 Los Angeles Camp Paige 18-20 PRO - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Residential Treatment Services Bureau The facility administrator, in collaboration with the (RTSB) Manual Sections: 1201: Suicide healthcare and behavioral/mental health administrators, Prevention Plan shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. 1201: Suicide prevention Plan 1202 Enhanced and Specialized Supervision The plan shall consider the needs of youth experiencing Requirements for Youths in Juvenile past or current trauma. Facilities Suicide prevention responses shall be respectful and in 1203: Suicide Prevention Policy for Juvenile the least invasive manner consistent with the level of Facilities (Cross ref with directive 1186) suicide risk. ☒ ☐ ☐ Policy was developed in collaboration with The plan shall include the following elements: Juvenile Court Health Services (JCHS) and the Department of Mental Health (DMH). A memo was provided by the Facility Director that there have been no Suicide attempts in 2018 or 2019. There was no documentation provided for our review. Compliance is based on policy and admission/intake documents. We will follow up when on site to ensure interpretation is consistent for the future. (a) Suicide prevention training as required in Residential Treatment Services Bureau Section 1322, Youth Supervision Staff (RTSB) Manual Sections: 1203: Suicide Orientation, and Training and the Juvenile Prevention Policy for Juvenile Facilities and Corrections Officer Core Course. 2104: Professional Development and ☒ ☐ ☐ Training. Staff are trained in CORE training and annual refresher training. 7255 Los Angeles Camp Paige 18-20 PRO - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Screening, Identification Assessment and Residential Treatment Services Bureau Precautionary Protocols (RTSB) Manual Sections:1202: Enhanced (1) All youth shall be screened for risk of and Specialized Supervision Requirements suicide at intake and as needed during of Youth in Juvenile Facilities and 1203: detention. Suicide Prevention Policy for Juvenile Facilities All youth are screened prior to entry by DMH who conduct a Juvenile Justice Child/Adolescent Assessment. A DPOII ☒ ☐ ☐ Clinician and DMH staff member interview youth at Juvenile Hall prior to arrival to the Camp. Once at camp all youth are screened again at intake with the Initial Intake, Screening and Referral Questionnaire. DMH work with youth throughout their stay, assessing them for risk and will adjust their supervision level as needed. All youth files we reviewed had screenings completed at intake/admission. (2) All youth supervision staff who perform Residential Treatment Services Bureau intake processes shall be trained in (RTSB) Manual Sections: 1203: Suicide screening youth for risk of suicide. Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Staff who complete intake/admissions are trained in completing them. Suicide update training is completed annually as part of the Enhanced Supervision Training. (3) All youth who have been identified during Residential Treatment Services Bureau the intake screening process to be at risk of (RTSB) Manual Section: 1203: Suicide suicide shall be referred to Prevention Policy for Juvenile Facilities behavioral/mental health staff for a suicide risk assessment. ☒ ☐ ☐ We did not find any youth to be suicidal at intake based on the documentation we reviewed; however, bureau staff stated that youth would be referred to DMH for follow up. (4) Precautionary protocols shall be developed Residential Treatment Services Bureau to ensure the youth’s safety pending the (RTSB) Manual Sections:1202: Enhanced behavioral/mental health assessment. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities 7255 Los Angeles Camp Paige 18-20 PRO - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Referral process to behavioral/mental health Residential Treatment Services Bureau staff for assessment and/or services. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Policy requires all facility staff to complete a “Request for Mental Health Consultation” when appropriate. This would occur at any time throughout detention. (d) Procedures for monitoring of youth identified Residential Treatment Services Bureau at risk for suicide. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Per policy, enhanced supervision Levels 1-4 determine the level of supervision a youth receives. Level 4 requires a constant supervision until a youth can be transported out to emergency hospitalization, Level 3 is a constant visual 1:1 supervision, Level 2; is 10-minute safety check and Level 1 is regular 15-minute safety checks. (e) Safety Interventions Residential Treatment Services Bureau (1) Procedures to address intervention (RTSB) Manual Sections:1202: Enhanced protocols for youth identified at risk for and Specialized Supervision Requirements suicide which may include, but are not ☒ ☐ ☐ of Youth in Juvenile Facilities limited to: A. Housing consideration Youth are placed on a Specialized Supervision Plan-SSP. Supervision and housing direction are included on the forms. B. Treatment strategies including Residential Treatment Services Bureau trauma-informed approaches (RTSB) Manual Section: 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Mental health staff would provide direction to staff on the Mental Health Recording Form- Green Sheet. 7255 Los Angeles Camp Paige 18-20 PRO - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Procedures to instruct youth supervision Residential Treatment Services Bureau staff how to respond to youth who exhibit (RTSB) Manual Sections:1202: Enhanced suicidal behaviors. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. (f) Communication Residential Treatment Services Bureau (1) The intake process shall include (RTSB) Manual Section: 1203: Suicide communication with the arresting officer Prevention Policy for Juvenile Facilities and family guardians regarding the youth’s past or present suicidal ideations, behaviors Youth are transported directly from the or attempts. Juvenile Hall to the camp. Policy states that the intake officer shall contact the youth’s parents and/or guardians via telephone during the initial intake process to gather ☒ ☐ ☐ information regarding the youth’s past or present suicidal ideations, behaviors or attempts. Interagency communication and communication with parents, guardians and other caregivers share information regarding potential suicidal or self-harming activities. Documentation reviewed noted that youth’s parents were contacted regarding suicide history. (2) Procedures for clear and current Residential Treatment Services Bureau information sharing about youth at risk for (RTSB) Manual Section: 1203: Suicide suicide with youth supervision, healthcare, ☒ ☐ ☐ Prevention Policy for Juvenile Facilities and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Residential Treatment Services Bureau Suicides or Attempts (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ (1) Process for administrative review of the Prevention Policy for Juvenile Facilities circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected Residential Treatment Services Bureau staff. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities (3) Process for a debriefing event with affected Residential Treatment Services Bureau youth. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities 7255 Los Angeles Camp Paige 18-20 PRO - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Documentation Residential Treatment Services Bureau (1) Documentation processes shall be (RTSB) Manual Sections:1202: Enhanced developed to ensure compliance with this and Specialized Supervision Requirements regulation of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities Youth identified at risk for suicide shall not be denied Residential Treatment Services Bureau the opportunity to participate in facility programs, (RTSB) Manual Section: 1202: Enhanced services and activities which are available to other non- and Specialized Supervision Requirements suicidal youth, unless deemed necessary for the safety ☒ ☐ ☐ for Youths in Juvenile Facilities of the youth or security of the facility. Any deprivation of programs, services or activities for youth at risk of suicide shall be documented and approved by the facility manager. 1340 REPORTING OF LEGAL ACTIONS Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each facility shall submit to the Board a letter of Statements, RTSB Management notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities ☒ ☐ ☐ The Camp Director is responsible to ensure responsible for juvenile facility operation. that all reporting is completed. No legal actions have been reported to the BSCC this cycle. 1341 DEATH AND SERIOUS ILLNESS OR Residential Treatment Services Bureau INJURY OF A YOUTH WHILE (RTSB) Manual Sections:1919: Deaths at DETAINED Camp Facilities (1) Death of a Youth. Policy was developed in collaboration with (a) The facility administrator, In cooperation with the Juvenile Court Health Services (JCHS) and health administrator and the behavioral/mental ☒ ☐ ☐ the Department of Mental Health (DMH), 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 Residential Treatment Services Bureau facility administrator, shall develop written policies (RTSB) Manual Sections:1919: Deaths at and procedures to assure there is a medical and Camp Facilities operational review of every in-custody death of 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. 7255 Los Angeles Camp Paige 18-20 PRO - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) The administrator of the facility shall provide to the Residential Treatment Services Bureau Board a copy of the report submitted to the Attorney (RTSB) Manual Sections:1919: Deaths at General under Government Code Section 12525. A ☒ ☐ ☐ Camp Facilities 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 Residential Treatment Services Bureau the administrator, the Board may within 30 calendar (RTSB) Manual Sections:1919: Deaths at days inspect and evaluate the juvenile facility, jail, Camp Facilities 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 Residential Treatment Services Bureau (a) The facility administrator, In cooperation with the (RTSB) Manual Section 1920: Serious health administrator, shall develop written policies Illness or Injury of a Youth While Detained 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 Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each juvenile facility shall submit required population Statements, RTSB Management and profile survey reports to the Board within 10 working days after the end of each reporting period, in ☒ ☐ ☐ The Camp Director is responsible to ensure a format to be provided by the Board. that all reporting is completed. All population reports were completed in a timely manner. 1343 JUVENILE FACILITY CAPACITY Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty When the number of youth detained in a living unit of a Statements, RTSB Management juvenile facility exceeds its rated capacity for more than fifteen (15) calendar days in a month, the facility ☒ ☐ ☐ The Camp Director is responsible to ensure administrator shall provide a crowding report to the that all reporting is completed. Board in a format provided by the Board. Facility has not exceeded their rated capacity this cycle. 7255 Los Angeles Camp Paige 18-20 PRO - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 400: Camp written policies and procedures for admittance of youth Admissions and Section 502: Orientation that emphasize respectful and humane engagement with Process and Handbook youth and reflect that the admission process may be The Admission process for camp youth traumatic to youth who may have already experienced begins before youth arrive on campus. trauma. Policies shall be trauma-informed, culturally ☒ ☐ ☐ Youth are assessed and screened at Camp relevant, and responsive to the language and literacy Headquarters and again by camp staff, needs of youth. In addition to the requirements of medical and mental health before the youth Sections 1324 and 1430 of these regulations: even arrive. Upon arrival, youth are admitted and oriented by camp staff. Documentation of admission/intake paperwork for 20 random youth was provided for our review. (a) the admittance process shall include: Residential Treatment Services Bureau (1) Access to two free phone calls within one hour (RTSB) Manual Sections:502: Orientation of admittance in accordance with the provisions Process and Handbook of Welfare and Institution Code Section 627; By policy, youth are to be provided with a ☒ ☐ ☐ phone call to notify their parent or guardian that they have been transferred to the Camp. All files noted phone calls were made to the parent/guardian of the youth. (2) Offer of a shower; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ All youth were offered a shower upon arrival. (3) Documented secure storage of personal Residential Treatment Services Bureau belongings; (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Youth are transported to camp in juvenile hall clothing with only their juvenile hall personals. All personal clothing and belongings are released to their parents or guardians from the juvenile hall. (4) Offer of food upon arrival; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ All youth were offered food upon arrival to the camp. 7255 Los Angeles Camp Paige 18-20 PRO - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health Residential Treatment Services Bureau and safety issues, intellectual or developmental (RTSB) Manual Sections:402: Assessment disabilities; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (6) Screening for physical and developmental Residential Treatment Services Bureau disabilities in accordance with Sections 1329, (RTSB) Manual Sections:402: Assessment 1418, and 1430 of these regulations; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (7) Contact with Regional Center for the Youth that are Regional Center Clients Developmentally Disabled for youth that are would not likely be ordered to a camp ☒ ☐ ☐ suspected of or identified as having a commit. developmental disability, pursuant to Section 1418; and, (8) Procedures consistent with Section 1352.5. Residential Treatment Services Bureau (RTSB) Manual Sections:403: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (b) juvenile hall administrators shall establish written Not Applicable criteria for detention that considers the least ☒ ☐ ☐ restrictive environment. (c) juvenile camps and post-dispositional programs in Residential Treatment Services Bureau juvenile halls shall develop policies and procedures (RTSB) Manual Sections:502: Orientation that advise the youth of the estimated length of Process and Handbook stay, inform them of program guidelines and ☒ ☐ ☐ provide written screening criteria for inclusion and Estimated length of stay estimates were exclusion from the program. consistently completed and documentation provided in packets provided. (d) juvenile halls shall develop policies and procedures Not Applicable that advise any committed youth of the estimated ☐ ☐ ☒ length of his/her stay. 7255 Los Angeles Camp Paige 18-20 PRO - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Residential Treatment Services Bureau ABUSE (RTSB) Manual Sections: 402: Assessment The facility administrator shall develop and implement and Classification and 503: Screening for the written policies and procedures to reduce the risk of Risk of Sexual Abuse sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of Policy is in place; however, documentation admission based on the following information: provided consists of PREA Risk questions on the intake screening assessment that are ☐ ☒ ☐ not consistent with regulation requirements. Technical assistance will be provided as requested. No proof of practice provided. This section is non-compliant as the documentation process has not yet been implemented. Agency is in the process of finalizing and rolling out the new procedure. (a) Prior sexual victimization or abusiveness; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (b) Gender nonconforming appearance or manner; Residential Treatment Services Bureau or identification as lesbian, gay or bisexual, (RTSB) Manual Sections: 402: Assessment transgender, queer or intersex, and whether the ☐ ☒ ☐ and Classification and 503: Screening for the youth may, therefore, be vulnerable to sexual Risk of Sexual Abuse abuse; (c) Current charges and offense history; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (d) Age; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (e) Level of emotional and cognitive development; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (f) Physical size and stature; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (g) Mental illness or mental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse 7255 Los Angeles Camp Paige 18-20 PRO - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Intellectual or developmental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (i) Physical disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (j) The youth’s perception of vulnerability; and, Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (k) Any other specific information about the Residential Treatment Services Bureau individual youth that may indicate heightened (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ needs for supervision, additional safety and Classification and 503: Screening for the precautions, or separation from certain other Risk of Sexual Abuse youth. Staff shall ascertain this information through Residential Treatment Services Bureau conversations with the youth during the admittance (RTSB) Manual Sections:503: Screening for process, medical and behavioral health screenings; the Risk of Sexual Abuse ☐ ☒ ☐ during classification assessments; and by reviewing court records, case files, facility behavioral records, and Current procedure has not been other relevant documentation from the youth’s files. implemented. The facility administrator shall implement appropriate Residential Treatment Services Bureau controls on the dissemination of information within the (RTSB) Manual Sections:503: Screening for facility relative to responses received pursuant to this the Risk of Sexual Abuse ☐ ☒ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other It is unknown how the facility will ensure youth. documents are kept confidential. 1351 RELEASE PROCEDURES Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release The facility administrator shall develop and implement ☒ ☐ ☐ Procedures written policies and procedures for release of youth from custody which provide for: (a) verification of identity/release papers; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures (b) return of personal clothing and valuables; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures ☒ ☐ ☐ Compliance reviewed through Juvenile Hall property receipts viewed. Parents/guardian bring clothing for youth to be released in on day of release. (c) notification to the youth's parents or guardian; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process 7255 Los Angeles Camp Paige 18-20 PRO - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) notification to the facility health care provider in Residential Treatment Services Bureau accordance with Sections 1408 and 1437 of these (RTSB) Manual Sections:809: Release regulations, for coordination with outside agencies; Procedures and, ☒ ☐ ☐ Health care is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (e) notification of school staff; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Education is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (f) notification of facility mental health personnel. Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Mental Health is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. The facility administrator shall develop and implement Residential Treatment Services Bureau policies and procedures for post-disposition youth to (RTSB) Manual Section: 703: MDT Process coordinate the provision of transitional and reentry services including, but not limited to, medical and Each youth has a Transition MDT 45-60 behavioral health, education, probation supervision and days prior to release that addresses all community-based services. required services and other pertinent areas. ☒ ☐ ☐ All facility partners and the PO are present with the youth to discuss the plan. The youth’s parents are invited to participate and either attend in person or via a conference call. (Reference Regulation 1355) Eight transition plans were reviewed and met all regulatory requirements. The facility administrator shall develop and implement Residential Treatment Services Bureau written policies and procedures for the furlough of (RTSB) Manual Section: 1802: Private youth from custody. Appointments ☒ ☐ ☐ The agency has no formal furlough policy; however, staff will transport youth to private appointments for exigent circumstances such as funerals or hospital visits with a court order. 7255 Los Angeles Camp Paige 18-20 PRO - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1352 CLASSIFICATION Residential Treatment Services Bureau (RTSB) Manual Sections:402: Assessment The facility administrator shall develop and implement and Classification Policy and Section 408: written policies and procedures on classification of Classification youth for the purpose of determining housing placement in the facility. ☒ ☐ ☐ Documentation provided for our review for 20 youth. All classifications were Such procedures shall: completed, some had Specialized Supervision Plans (SSP’s) attached for additional instruction for supervision or housing needs. (a) provide for the safety of the youth, other youth, Residential Treatment Services Bureau facility staff, and the public by placing youth in the (RTSB) Manual Sections:402: Assessment appropriate, least restrictive housing and program and Classification Policy settings. Housing assignments shall consider the Youth are assessed by the Camp Assessment need for single, double or dormitory assignment or Unit (CAU) after being ordered to camp by location within the dormitory; ☒ ☐ ☐ the court. The CAU determines which camp is the appropriate camp for the youth based on classification factors and camp population. This decision is made based on several different factors and includes an interview and input from the youth. (b) consider facility populations and physical design of Residential Treatment Services Bureau the facility; (RTSB) Manual Sections:402: Assessment and Classification Policy ☒ ☐ ☐ Youth are classified to a camp based on classification factors and then assigned to a location within the dorm. (c) provide that a youth shall be classified upon Residential Treatment Services Bureau admittance to the facility; classification factors (RTSB) Manual Sections:402: Assessment shall include, but not be limited to: age, maturity, and Classification Policy sophistication, emotional stability, program needs, ☒ ☐ ☐ Youth are classified to a camp based on legal status, public safety considerations, classification factors. medical/mental health considerations, gender and gender identity of the youth; (d) provide for periodic classification reviews, Residential Treatment Services Bureau including provisions that consider the level of (RTSB) Manual Sections:402: Assessment supervision and the youth's behavior while in and Classification Policy custody; and, All youth who are placed on an SSP are ☒ ☐ ☐ reviewed within 30 days. All other youth are considered for review at the time of any incident, upon request, or as needed. If any change is to occur, an SSP is initiated. 7255 Los Angeles Camp Paige 18-20 PRO - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provide that facility staff shall not separate youth Residential Treatment Services Bureau from the general population or assign youth to a (RTSB) Manual Sections:402: Assessment single occupancy room based solely on the youth's and Classification Policy actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, ☒ ☐ ☐ gender expression, mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, Residential Treatment Services Bureau bisexual, transgender, questioning or intersex (RTSB) Manual Sections:402: Assessment ☒ ☐ ☐ identification or status as an indicator of likelihood and Classification Policy of being sexually abusive. 1352.5 TRANSGENDER AND INTERSEX YOUTH. Residential Treatment Services Bureau (RTSB) Manual Sections: 403: Juvenile The facility administrator shall develop written policies ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Transgender, Questioning and Intersex treatment of transgender and intersex youth. The Youth in an Institutional Setting policies shall provide that: (a) Facility staff shall respect every youth’s gender Residential Treatment Services Bureau identity and shall refer to the youth by the youth’s (RTSB) Manual Sections: 403: Juvenile preferred name and gender pronoun, regardless of Supervision of Lesbian, Gay, Bisexual, the youth’s legal name. Facilities may prohibit the ☒ ☐ ☐ Transgender, Questioning and Intersex use of gang or slang names or names that otherwise Youth in an Institutional Setting 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 Residential Treatment Services Bureau themselves in a manner consistent with their gender (RTSB) Manual Sections: 403: Juvenile identity and shall provide youth with the ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, institution’s clothing and undergarments consistent Transgender, Questioning and Intersex with their gender identity. Youth in an Institutional Setting (c) Facility staff shall house youth in the unit or room Residential Treatment Services Bureau that best meets their individual needs, and promotes (RTSB) Manual Sections: 403: Juvenile their safety and well-being. Staff may not Supervision of Lesbian, Gay, Bisexual, automatically house youth according to their Transgender, Questioning and Intersex external anatomy, and shall document the reasons Youth in an Institutional Setting for any decision to house youth in a unit that does If a youth request to reside in another unit not match their gender identity. In making a ☒ ☐ ☐ other than the unit that coincides with the housing decision, staff shall consider the youth’s youth’s biological sex, a medical referral is preferences, as well as any recommendations from made, and an MDT is held. Pending a the youth’s health or behavioral health provider. decision, the youth will be housed in the medical unit. (This process occurs before arrival at the camp due to lack of alternate housing.) 7255 Los Angeles Camp Paige 18-20 PRO - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Facility administrators shall ensure that transgender Residential Treatment Services Bureau and intersex youth have access to medical and (RTSB) Manual Sections: 403: Juvenile behavioral health providers qualified to provide Supervision of Lesbian, Gay, Bisexual, care and treatment to transgender and intersex Transgender, Questioning and Intersex youth. Youth in an Institutional Setting ☒ ☐ ☐ Upon entry, youth are asked If they identify with LGBTQI and if so, they are referred to medical for continuation and coordination of gender affirming services. (e) Consistent with the facility’s reasonable and Residential Treatment Services Bureau necessary security considerations and physical (RTSB) Manual Sections: 403: Juvenile plant, facility staff shall make every effort to ensure ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, the safety and privacy of transgender and intersex Transgender, Questioning and Intersex youth when the youth are using the bathroom or Youth in an Institutional Setting shower, or dressing or undressing. Facility staff shall not conduct physical searches of any Residential Treatment Services Bureau youth for the purpose of determining the youth’s (RTSB) Manual Sections: 403: Juvenile anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of Transgender, Questioning and Intersex the staff member who conducts any search of the youth. Youth in an Institutional Setting Policy notes that youth are provided with the option to choose the gender of the staff they wish to search them. Policy also notes that ☒ ☐ ☐ the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy alone. 7255 Los Angeles Camp Paige 18-20 PRO - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1353 ORIENTATION Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation The facility administrator shall develop and implement Process and Handbook written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal Documentation was provided for 20 youth information shall be provided and supplemented with and all orientations were found to be video orientation if feasible. Provision shall be made to completed timely and consistent with provide accessible orientation information to all regulation. ☒ ☐ ☐ detained youth including those with disabilities, limited We noted at inspection that the RTSB literacy, or English language learners. Orientation shall orientation handbook was not updated to all include information that addresses: current regulatory requirements. This issue was quickly addressed and corrected, and the updated handbook has since been implemented and contains all areas of required regulation. (a) facility rules including contraband and searches and Residential Treatment Services Bureau disciplinary procedures; ☒ ☐ ☐ (RTSB) Manual Section: 502: Orientation Process and Handbook (b) facility’s system of positive behavior interventions Residential Treatment Services Bureau and supports, including behavior expectations, (RTSB) Manual Section: 502: Orientation incentives that youth will receive for complying Process and Handbook with facility rules, and consequences that may ☒ ☐ ☐ Youth are provided with a copy of the result when youth violate the rules of the facility; Behavior Management Program Handbook at orientation. This process is reviewed during orientation. (c) age appropriate information that explains the Residential Treatment Services Bureau facility’s policy prohibiting sexual abuse and sexual (RTSB) Manual Section: 1600: PREA ☒ ☐ ☐ harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (e) the existence of the grievance procedure, the steps Residential Treatment Services Bureau that must be taken to use it, the youth’s right to be (RTSB) Manual Section: 502: Orientation free of retaliation for reporting a grievance, and the Process and Handbook ☒ ☐ ☐ name of the person or position designated to resolve the issue; (f) access to legal services and information on the court Residential Treatment Services Bureau process; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (g) access to routine and emergency health and mental Residential Treatment Services Bureau health care; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7255 Los Angeles Camp Paige 18-20 PRO - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) access to education, religious services, and Residential Treatment Services Bureau recreational activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (i) housing assignments; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (j) opportunity for personal hygiene and daily showers Residential Treatment Services Bureau including the availability of personal care items (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (k) rules and access to correspondence, visits and Residential Treatment Services Bureau telephone use; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (l) availability of reading materials, programming, and Residential Treatment Services Bureau other activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (m) facility policies on the use of force, use of restraints, Residential Treatment Services Bureau chemical agents and room confinement; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (n) immigration legal services; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (o) emergencies including evacuation procedures; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (p) non-discrimination policy and the right to be free Residential Treatment Services Bureau from physical, verbal or sexual abuse and (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ harassment by other youth and staff; Process and Handbook (q) availability of services and programs in a language Residential Treatment Services Bureau other than English if appropriate; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (r) the process for requesting different housing, Residential Treatment Services Bureau education, programming and work assignments; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (s) a process for which parents/guardians receive Residential Treatment Services Bureau information regarding the youth’s stay in the (RTSB) Manual Section: 502: Orientation facility that at a minimum includes answers to Process and Handbook frequently asked questions and provides contact A parent handbook is available for parents information for the facility, medical, school and ☒ ☐ ☐ and can be accessed online or a copy may be mental health; and, received at any facility. The Orienting officer also provides the youth’s parent with information during the initial contact. 7255 Los Angeles Camp Paige 18-20 PRO - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (t) a process by which youth may request access to Residential Treatment Services Bureau Title 15 Minimum Standards for Juvenile Facilities. (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 1354 SEPARATION Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 514: Separation, written policies and procedures that address: 515: Room Confinement and Section 1400: ☒ ☐ ☐ The Healing Opportunities and Positive Engagement (HOPE) Center (a) separation of youth for reasons that include, but are Residential Treatment Services Bureau not be limited to, medical and mental health (RTSB) Manual Section: 514: Separation, conditions, assaultive behavior, disciplinary 515: Room Confinement and Section 1400: consequences and protective custody. The Healing Opportunities and Positive Engagement (HOPE) Center Agency HOPE Centers are operationally utilized for youth who require separation for a variety of purposes including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation to provide time for the youth to deescalate and adjust their behavior to return to the program. Current policies are not clear and although collectively, policy and procedure outline regulation requirements, operationally, do not meet requirements. Separation policy must be updated concurrently with Room Confinement policy to ensure consistency ☐ ☒ ☐ and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Agency policy requires due process for any separation. Currently, due process only occurs as a result of the incident which precipitated the separation. While not non- compliant with regulation, this is inconsistent with agency policy. Camp Paige does not have a HOPE Center but if camp youth need to be separated for any reason, they are transported to Camp Rockey for separation or room confinement. All paperwork and documentation occur at that camp. Technical assistance provided that this information should also be included in the agency policy/procedure. 7255 Los Angeles Camp Paige 18-20 PRO - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) consideration of positive youth development and Residential Treatment Services Bureau trauma-informed care. (RTSB) Manual Section: 514: Separation Camp Paige does not have a HOPE Center. Youth who require separation are transported to Camp Rockey which has a HOPE Center. 2 samples of a Specialization Supervision Plan (SSP) in which the youth were transported to the Camp Rockey HOPE ☒ ☐ ☐ Center for housing were provided for our review but did not include the incident report or any other information about what occurred once they were there. Efforts were made to provide enhanced supervision; however, no documentation of full program or otherwise were provided for our review with this camps documentation. (c) separated youth shall not be denied normal Residential Treatment Services Bureau privileges available at the facility, except when (RTSB) Manual Section: 514: Separation necessary to accomplish the objective of separation. ☐ ☐ ☒ Documentation is maintained at the receiving camp. (d) when the objective of the separation is discipline, Residential Treatment Services Bureau Title 15 Section 1390 shall apply. ☐ ☐ ☒ (RTSB) Manual Section: 514: Separation (e) when separation results in room confinement, the Residential Treatment Services Bureau separation shall occur in accordance with Welfare (RTSB) Manual Section: 514: Separation and Institutions Code Section 208.3 and ☐ ☐ ☒ Documentation is maintained at the receiving Section1354.5 of these regulations. camp (f) policies and procedures shall ensure a daily review Residential Treatment Services Bureau of separated youth to determine if separation (RTSB) Manual Section: 514: Separation remains necessary. ☐ ☐ ☒ Documentation is maintained at the receiving camp 7255 Los Angeles Camp Paige 18-20 PRO - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354.5 ROOM CONFINEMENT Residential Treatment Services Bureau (RTSB) Manual Section: 515: Room (a) The facility administrator shall develop and Confinement and Section 1400: The Healing implement written policies and procedures Opportunities and Positive Engagement addressing the confinement of youth in their room (HOPE) Center that are consistent with Welfare and Institutions Code Section 208.3. The placement of a youth in There are areas of policy that need to be room confinement shall be accomplished in revised and updated. Camp Paige does not accordance with the following guidelines: have a HOPE Center and there is no Room Confinement that occurs at the camp; however, youth from Camp Paige will be transported to the HOPE Center at Camp Rockey as needed for separation and room ☐ ☐ ☒ confinement needs. All documentation and expectations of the regulations are addressed by Camp Rockey. See Camp Rockey for more information. Policy, procedure and documentation will need to be reviewed and updated to achieve compliance for the bureau. Room confinement and separation policies should be revised concurrently to ensure consistency as well as to ensure compliance with all pieces of this regulation. (1) Room confinement shall not be used before Residential Treatment Services Bureau other, less restrictive, options have been (RTSB) Manual Section: 515: Room attempted and exhausted, unless attempting ☐ ☐ ☒ Confinement and Section 1400: The Healing those options poses a threat to the safety or Opportunities and Positive Engagement security of any youth or staff. (HOPE) Center (2) Room confinement shall not be used for the Residential Treatment Services Bureau purposes of punishment, coercion, (RTSB) Manual Section: 515: Room convenience, or retaliation by staff. Confinement and Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (3) Room confinement shall not be used to the Residential Treatment Services Bureau extent that it compromises the mental and ☐ ☐ ☒ (RTSB) Manual Section: 515: Room physical health of the youth. Confinement (b) A youth may be held up to four hours in room Residential Treatment Services Bureau confinement. After the youth has been held in room (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ confinement for a period of four hours, staff shall Opportunities and Positive Engagement do one or more of the following: (HOPE) Center (1) Return the youth to general population. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center 7255 Los Angeles Camp Paige 18-20 PRO - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Consult with mental health or medical staff. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (3) Develop an individualized plan that includes Residential Treatment Services Bureau the goals and objectives to be met in order to (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ reintegrate the youth to general population. Opportunities and Positive Engagement (HOPE) Center (4) If room confinement must be extended beyond Residential Treatment Services Bureau four hours, staff shall do each of the following: (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ Opportunities and Positive Engagement (HOPE) Center (A) Document the reasons for room Residential Treatment Services Bureau confinement and the basis for the (RTSB) Manual Section 1400: The Healing extension, the date and time the youth was Opportunities and Positive Engagement ☐ ☐ ☒ first placed in room confinement, and when (HOPE) Center he or she is eventually released from room confinement. (B) Develop an individualized plan that Residential Treatment Services Bureau includes the goals and objectives to be met (RTSB) Manual Section 1400: The Healing in order to integrate the youth to general Opportunities and Positive Engagement ☐ ☐ ☒ population. (HOPE) Center . (C) Obtain documented authorization by the Residential Treatment Services Bureau facility superintendent or his or her (RTSB) Manual Section 1400: The Healing ☐ ☐ ☒ designee every four hours thereafter. Opportunities and Positive Engagement (HOPE) Center (5) This section is not intended to limit the use of Residential Treatment Services Bureau single-person rooms or cells for the housing of (RTSB) Manual Section: 515: Room ☐ ☐ ☒ youth in juvenile facilities and does not apply Confinement to normal sleeping hours. (6) This section does not apply to youth or wards Residential Treatment Services Bureau in court holding facilities or adult facilities. (RTSB) Manual Section: 515: Room ☐ ☐ ☒ Confinement (7) Nothing in this section shall be construed to Residential Treatment Services Bureau conflict with any law providing greater or (RTSB) Manual Section: 515: Room ☐ ☐ ☒ additional protections to youth. Confinement 7255 Los Angeles Camp Paige 18-20 PRO - 36 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (8) This section does not apply during an Residential Treatment Services Bureau extraordinary emergency circumstance that (RTSB) Manual Section: 515: Room requires a significant departure from normal Confinement 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 Residential Treatment Services Bureau placed in a locked cell or sleeping room to treat (RTSB) Manual Section: 515: Room and protect against the spread of a Confinement 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 Residential Treatment Services Bureau PLAN (RTSB) Manual Section 402: Assessment and Classification and 703: The MDT The facility administrator shall develop and implement Process written policies and procedures for assessment and case planning. The process of assessment begins upon a youth being ordered to a camp. A youth is assessed by the Camp Assessment Unit and by the facility upon arrival. The case plan is completed at the initial MTD and is developed through a collaborative multi- ☒ ☐ ☐ disciplinary team made up of staff representation from Probation, Department of Mental Health, Education, Health Care, Social Services as appropriate and any others as necessary based on the youth or family needs. A transition MDT is also completed as the youth gets closer to release. MDT’s are completed as needed throughout detention as the need arises. Periodic review is completed by the assigned casework Probation Officer. The transition plan is completed by the collaborative multi- disciplinary team. 7255 Los Angeles Camp Paige 18-20 PRO - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Assessment: Residential Treatment Services Bureau (RTSB) Manual Section 703: The MDT The assessment is based on information collected Process during the admission process with periodic review, which includes the youth's risk factors, needs and The process of case planning begins with the strengths including, but not limited to, identification of assessment process. 13 Initial and 8 substance abuse history, educational, vocational, Transitional MDT packets were reviewed. counseling, behavioral health, consideration of known The Camp Assessment Unit completes all history of trauma, and family strengths and needs. assessments on the youth prior to transfer. The assessment summary was not provided for our review in the case notes; however, it is practice and completed for all youth for RTSB per Bureau staff. At inspection, we were unable to determine ☐ ☐ UNK compliance in this area at this time without seeing the assessment, speaking to staff and youth. Prior to writing this report, we have been notified that the agency has updated their policy and has corrected their forms and documentation to be consistent with regulation and to provide a more clear and efficient process for the youth and their families. Staff training occurred in August 2020 and the new process was implemented in September 2020. We will follow up with this section to review for compliance upon our return to the facility. (b) Institutional Case Plan: Residential Treatment Services Bureau (1) A case plan shall be developed for each youth (RTSB) Manual Section 703: The MDT held for at least 30 days or more and created Process within 40 days of admission. We reviewed 16 Initial and 8 Transitional MDT packets. ☒ ☐ ☐ The initial MDT acts as the youth’s case plan and provides direction as to what programs they will participate in. Most programs are automatic as they are court ordered. The MDT is targeted to be completed within the first 2 weeks of a youth’s arrival at camp. All MDT’s occurred within the time allotted by regulation. (2) The institutional plan shall include, but not be Residential Treatment Services Bureau limited to, written documentation that provides: ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7255 Los Angeles Camp Paige 18-20 PRO - 38 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (A) objectives and time frame for the resolution Residential Treatment Services Bureau of problems identified in the assessment; (RTSB) Manual Section 705: Ongoing Case Management Activities The MDT process and format provides the structure for the youth’s case plan. Objectives are based on the assessment. We do not have enough information at this time to make a final decision on compliance. ☒ ☐ UNK With the change in regulation, the assessment drives the objectives and goals and the case plans are more individualized and not solely based on a court order or camp program. RTSB has enhanced their process. We will follow up with this section and determine compliance upon our return to the facility. (B) a plan for meeting the objectives that Residential Treatment Services Bureau includes a description of program resources (RTSB) Manual Section 705: Ongoing Case needed and individuals responsible for Management Activities assuring that the plan is implemented; We found the current plan and timelines are embedded within the camp program expectations or court orders i.e. 10 weeks substance abuse program, individual counseling or family counseling weekly or 16-week DBT. ☐ ☐ UNK Technical assistance provided and discussed to ensure these programs and other assessed needs are documented more consistently so the youth’s other needs are individual to the youth. We need more information to determine compliance. We will follow up with this section and determine compliance upon our return to the facility. (3) periodic evaluation of progress towards meeting Residential Treatment Services Bureau the objectives, including periodic review and (RTSB) Manual Section 705: Ongoing Case discussion of the plan with the youth; Management Activities ☒ ☐ ☐ Officers noted “met with youth” in their documentation thus it was clear these discussions were held with the youth face to face. 7255 Los Angeles Camp Paige 18-20 PRO - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) a transition plan, the contents of which shall be Residential Treatment Services Bureau subject to existing resources, shall be developed (RTSB) Manual Section 706: Case Plan for post dispositional youth in accordance with Activities- Pre- Release Section 1351; and, ☒ ☐ ☐ Transition MDT’s are completed for all youth and contain all areas required by regulation. (5) in as much as possible and if appropriate, the Residential Treatment Services Bureau plan, including the transition plan, shall be (RTSB) Manual Section 705: Ongoing Case developed with input from the family, Management Activities supportive adults, youth, and Regional Center ☒ ☐ ☐ The youth’s parent or guardian is invited to for the Developmentally Disabled. attend the MDT. The family is contacted by phone and by letter to attend. 1356 COUNSELING AND CASEWORK Residential Treatment Services Bureau SERVICES (RTSB) Manual Section 705: Ongoing Case Management Activities The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: (a) youth will receive assistance with needs or concerns Residential Treatment Services Bureau that may arise; ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities (b) youth will receive assistance in requesting contact Residential Treatment Services Bureau with parents, other supportive adults, attorney, (RTSB) Manual Section 705: Ongoing Case clergy, probation officer, or other public official; Management Activities ☒ ☐ ☐ and, (c) youth will be provided access to available resources Residential Treatment Services Bureau to meet the youth’s needs. ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 1357 USE OF FORCE Residential Treatment Services Bureau (RTSB) Manual Section 1701: Physical The facility administrator, In cooperation with the intervention Policy for Juvenile Facilities responsible physician, shall develop and implement and the Transportation Section written policies and procedures for the use of force, which may include chemical agents. Force shall never Policy was developed with the Juvenile be applied as punishment, discipline, retaliation or ☒ ☐ ☐ Court Health Services (JCHS) and includes treatment. the use of soft restraints. OC is not used in the camps. (a) At a minimum, each facility shall develop policies and procedures which: Documentation was provided from throughout the cycle. 12 incidents were selected for review. 7255 Los Angeles Camp Paige 18-20 PRO - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) restricts the use of force to that which is deemed Residential Treatment Services Bureau reasonable and necessary, as defined in Section (RTSB) Manual Section 1704: Safe Crisis 1302 to ensure the safety and security of youth, Management and Physical Intervention staff, others and the facility. Procedures All documentation reviewed were appropriate. Documentation noted staff gave ☒ ☐ ☐ direction to stop and attempts were made to deescalate the situations before force was used. All incidents reviewed appeared appropriate and to be reasonable and necessary for the safety of staff and youth. (2) outline the force options available to staff Residential Treatment Services Bureau including both physical and non-physical (RTSB) Manual Section 1704: Safe Crisis options and define when those force options are Management and Physical Intervention appropriate. Procedures ☒ ☐ ☐ Non-Physical Options: De-escalation Techniques Physical Options: Authorized Levels of Physical Interventions (3) describe force options or techniques that are Residential Treatment Services Bureau expressly prohibited by the facility. (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ Management and Physical Intervention Procedures (4) describe the requirements of staff to report any Residential Treatment Services Bureau inappropriate use of force, and to take (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ affirmative action to immediately stop it. Management and Physical Intervention Procedures 7255 Los Angeles Camp Paige 18-20 PRO - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) define a standardized reporting format that Residential Treatment Services Bureau includes time period and procedure for (RTSB) Manual Section 1703: Safe Crisis documenting and reporting the use of force, Management-Physical Intervention Report including reporting requirements of Forms, 1704: Safe Crisis Management and management and line staff and procedures for Physical Intervention Procedures and 1706: reviewing and tracking use of force incidents by Safe Crisis Management Physical supervisory and or management staff, which Intervention Reports include procedures for debriefing a particular Facilities keep a use of force log. Incident incident with staff and/or youth for the purposes reports are completed before going off shift. of training as well as mitigating the effects of trauma that may have been experienced by staff ☐ ☐ UNK Every incident is reviewed by the duty and /or the youth involved. supervisor and again reviewed by the Safe Crisis Management reviewing supervisor and signed off by the facility Manager. We did not see any reference to debriefing of incidents however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further into this issue when on site at the next inspection. (6) Include an administrative review and a system Residential Treatment Services Bureau for investigating unreasonable use of force. (RTSB) Manual Section 1706: Safe Crisis Management Physical Intervention Reports Any incident that falls outside of agency ☒ ☐ ☐ policy is referred to the facility director for referral for an administrative review or referral to the Probation Departments Special Investigation Unit for further review. 7255 Los Angeles Camp Paige 18-20 PRO - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Residential Treatment Services Bureau procedures required after use of force incidents (RTSB) Manual Section 1704: Safe Crisis for medical, mental health staff and parents or Management and Physical Intervention legal guardians. Procedures and 1706: Safe Crisis Management Physical Intervention Reports We found that in all incident reports and in documentation reviewed we found that youth were medically cleared and were either seen by mental health or a mental health referral was submitted on the youth’s behalf for follow up. At inspection, we did not see any reference ☒ ☐ ☐ in the PIR as required by policy for a contact being made to the youth’s parent if the child was involved in a use of force incident. Technical assistance provided and additional documentation was subsequently requested for review. Staff and supervisors began to contact the youth’s parent as required however; this contact was documented in the facility case notes. Agency policy requires the contact to be documented in the incident report, thus additional training was provided to staff and was addressed. This issue was corrected. (8) describe the limitations of use of force on Residential Treatment Services Bureau pregnant youth in accordance with Penal Code (RTSB) Manual Section 1704: Safe Crisis Section 6030(f) and Welfare and Institutions Management and Physical Intervention ☒ ☐ ☐ Code Section 222. Procedures (b) Facilities that authorize chemical agents as a force Residential Treatment Services Bureau option shall include policies and procedures that: (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (1) identify who is approved to carry and/or utilize NA chemical agents in the facility and the type, size ☐ ☐ ☒ and the approved method of deployment for those chemical agents. (2) mandate that chemical agents only be used when NA there is an imminent threat to the youth’s safety ☐ ☐ ☒ or the safety of others and only when de- escalation efforts have been unsuccessful or are not reasonably possible. 7255 Los Angeles Camp Paige 18-20 PRO - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) outline the facility’s approved methods and NA timelines for decontamination from chemical agents. This shall include that youth who have ☐ ☐ ☒ been exposed to chemical agents shall not be left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. (4) define the role, notification, and follow-up NA procedures required after use of force incidents ☐ ☐ ☒ involving chemical agents for medical, mental health staff and parents or legal guardians. (5) provide for the documentation of each incident NA of use of chemical agents, including the reasons for which it was used, efforts to de-escalate ☐ ☐ ☒ prior to use, youth and staff involved, the date, time and location of use, decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure Residential Treatment Services Bureau which require that agencies provide initial and ☒ ☐ ☐ (RTSB) Manual Section 1702: Training regular training in use of force and chemical agents when appropriate that address: (1) known medical and behavioral health Residential Treatment Services Bureau conditions that would contraindicate certain ☒ ☐ ☐ (RTSB) Manual Section 1702: Training types of force; (2) acceptable chemical agents and the methods of Residential Treatment Services Bureau application. (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (3) signs or symptoms that should result in Residential Treatment Services Bureau immediate referral to medical or behavioral ☒ ☐ ☐ (RTSB) Manual Section 1702: Training health. (4) instruction on the Constitutional Limitations of Residential Treatment Services Bureau ☒ ☐ ☐ Use of Force. (RTSB) Manual Section 1702: Training (5) physical training force options that may require Residential Treatment Services Bureau ☒ ☐ ☐ the use of perishable skills. (RTSB) Manual Section 1702: Training (6) timelines the facility uses to define regular Residential Treatment Services Bureau training. (RTSB) Manual Section 1702: Training ☒ ☐ ☐ Initial training occurs in CORE and regular training is held through annual refresher training. 7255 Los Angeles Camp Paige 18-20 PRO - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358 USE OF PHYSICAL RESTRAINTS Residential Treatment Services Bureau (RTSB) Manual Section 1705: Restraints The facility administrator, In cooperation with the responsible physician and mental health director, shall The policy was developed in cooperation with DMH and JCHS develop and implement written policies and procedures for the use of restraint devices. Restraint devices Facility did not provide any documentation include any devices which immobilize a youth's of Use of Physical Restraints. extremities and/or prevent the youth from being There were no incidents or documentation of ambulatory. ☒ ☐ ☐ physical restraints provided for our review for this section. Facility provided a memo noting there were no incidents of physical restraint due to youth exhibiting any self-harming behavior or exhibiting any behavior resulting in property damage. All other compliance is noted through policy only. Physical restraints may be used only for those youth Residential Treatment Services Bureau who present an immediate danger to themselves or (RTSB) Manual Section 1705: Restraints 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 Residential Treatment Services Bureau discipline, or as a substitute for treatment. The use of (RTSB) Manual Section 1705: Restraints restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through ☒ ☐ ☐ affixing of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Residential Treatment Services Bureau handcuffs, shackles or other restraint devices when used (RTSB) Manual Section 1705: Restraints to restrain youth for movement or transportation within ☒ ☐ ☐ the facility. Movement within the facility shall be governed by Section 1358.5, Use of Restraint Devices for Movement Within the Facility. Youth shall be placed in restraints only with the approval Residential Treatment Services Bureau of the facility manager or designee. The facility manager (RTSB) Manual Section 1705: Restraints may delegate authority to place a youth in restraints to a ☒ ☐ ☐ physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. 7255 Los Angeles Camp Paige 18-20 PRO - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS A medical opinion on the safety of placement and Residential Treatment Services Bureau retention shall be secured as soon as possible, but no later (RTSB) Manual Section 1705: Restraints ☒ ☐ ☐ 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 Residential Treatment Services Bureau possible, but in no case longer than four hours from the (RTSB) Manual Section 1705: Restraints ☒ ☐ ☐ time of placement, to assess the need for mental health treatment. Continuous direct visual supervision shall be conducted Residential Treatment Services Bureau to ensure that the restraints are properly employed, and (RTSB) Manual Section 1705: Restraints to ensure the safety and well-being of the youth. ☒ ☐ ☐ Observations of the youth's behavior and any staff interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. In addition to the requirements above, policies and Residential Treatment Services Bureau procedures shall address: (RTSB) Manual Section 1705: Restraints (a) documentation of the circumstances leading to an Residential Treatment Services Bureau ☒ ☐ ☐ application of restraints. (RTSB) Manual Section 1705: Restraints (b) known medical conditions that would Residential Treatment Services Bureau contraindicate certain restraint devices and/or ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints techniques. (c) acceptable restraint devices. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (d) signs or symptoms which should result in Residential Treatment Services Bureau ☒ ☐ ☐ immediate medical/mental health referral. (RTSB) Manual Section 1705: Restraints (e) availability of cardiopulmonary resuscitation Residential Treatment Services Bureau ☒ ☐ ☐ equipment. (RTSB) Manual Section 1705: Restraints (f) protective housing of restrained youth. While in Residential Treatment Services Bureau restraint devices, all youth shall be housed alone or (RTSB) Manual Section 1705: Restraints in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (h) exercising of extremities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 7255 Los Angeles Camp Paige 18-20 PRO - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358.5 USE OF RESTRAINT DEVICES FOR Residential Treatment Services Bureau MOVEMENT AND TRANSPORTATION WITHIN (RTSB) Manual Section 1709: The Use of THE FACILITY. Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, In cooperation with the responsible physician and behavioral/mental health The policy was developed in cooperation director, shall develop and implement written policies with DMH and JCHS. and procedures for the use of restraint devices when the purpose is for movement or transportation within the Policy is in place but not yet trained and facility that shall include the following: implemented. The below areas are non- compliant. (a) identification of acceptable restraint devices, staff Residential Treatment Services Bureau approved to utilize restraint devices and the (RTSB) Manual Section 1709: The Use of required training. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility Handcuffs are authorized for regular use and flex cuffs in emergency situations. (b) the circumstances leading to the application of Residential Treatment Services Bureau restraints must be documented. (RTSB) Manual Section 1709: The Use of Mechanical Restraints for Movement and ☐ ☒ ☐ Transport Within the Facility No documentation was provided for our review. This section is non-compliant. (c) an individual assessment of the need to apply Residential Treatment Services Bureau restraints for movement or transportation that (RTSB) Manual Section 1709: The Use of includes consideration of less restrictive Mechanical Restraints for Movement and alternatives, consideration of a youth’s known ☐ ☒ ☐ Transport Within the Facility medical or mental health conditions, trauma No documentation was provided for our informed approaches, and a process for review. This section is non-compliant. documentation and supervisor review and approval. (d) consideration of safety and security of the facility, Residential Treatment Services Bureau with a clearly defined expectation that restraint (RTSB) Manual Section 1710: The Use of devices shall not be used for the purposes of Mechanical Restraints for Movement and ☒ ☐ ☐ discipline or retaliation. Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Residential Treatment Services Bureau accordance with Penal Code Section6030(f) and (RTSB) Manual Section 1709: The Use of Welfare and Institutions Code Section 222. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility 7255 Los Angeles Camp Paige 18-20 PRO - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1359 SAFETY ROOM PROCEDURES There is no safety room in the camps. Does not apply. (a) The facility administrator, and where applicable, In 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. (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. 7255 Los Angeles Camp Paige 18-20 PRO - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (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 Residential Treatment Services Bureau (RTSB) Manual Sections: The facility administrator shall develop and implement 1316: Searches in Detention Facilities written policies and procedures governing the search of 1317: Body Searches (Pat- Down, Strip, and youth, the facility, and visitors. Policies and procedures Body Cavity Searches) shall provide that: Various samples of search documents from 2019 and 2020 were provided for our review. These included dorm inspections, strip ☒ ☐ ☐ search log and authorizations, K-9 inspections, A Facility Entrance Report-, Inspection for Contraband and a Living Quarters Inspection were provided for our review. Staff efforts resulted in the confiscation of contraband. Good efforts by staff and managers to ensure the safety and security of the youth and the facility. (a) Searches shall be conducted to ensure the safety and Residential Treatment Services Bureau security of the facility, public, visitors, youth, and (RTSB) Manual Sections 1316: Searches in staff. ☒ ☐ ☐ Detention Facilities (b) Searches shall be conducted in a manner that Residential Treatment Services Bureau preserves the privacy and dignity of the person (RTSB) Manual Sections 1316: Searches in being searched and shall not be conducted for ☒ ☐ ☐ Detention Facilities harassment or as a form of discipline or punishment. 7255 Los Angeles Camp Paige 18-20 PRO - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Strip searches and visual or physical body cavity Residential Treatment Services Bureau searches shall comply with Penal Code Section (RTSB) Manual Sections: ☒ ☐ ☐ 4030. 1316: Searches in Detention Facilities 1317: Body Searches (Pat- Down, Strip, and Body Cavity Searches) (d) Physical body cavity searches shall only be Residential Treatment Services Bureau conducted by a medical professional. (RTSB) Manual Section 1317: Body ☒ ☐ ☐ Searches (Pat- Down, Strip, and Body Cavity Searches) (e) Any youth held after a detention hearing shall only Residential Treatment Services Bureau be strip searched with prior approval of a supervisor (RTSB) Manual Section 1317: Body when there is reasonable suspicion based on Searches (Pat- Down, Strip, and Body Cavity ☒ ☐ ☐ specific and articulable facts to believe that youth is Searches) concealing contraband. The reasonable suspicion All youth are post disposition. shall be documented. (f) Searches of transgender and intersex youth shall Residential Treatment Services Bureau comply with Section 1352.5. (RTSB) Manual Section 1303: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (g) Cross-gender pat-down searches and strip searches Residential Treatment Services Bureau are prohibited except in exigent circumstances or (RTSB) Manual Section 1317: Body ☒ ☐ ☐ when conducted by a medical professional. Such Searches (Pat- Down, Strip, and Body Cavity searches must be justified and documented in Searches) writing. 1361 GRIEVANCE PROCEDURE Residential Treatment Services Bureau (RTSB) Manual Section 508: Grievance The facility administrator shall develop and Procedures implement written policies and procedures whereby any youth may appeal and have resolved grievances There were no grievances for the months relating to any condition of confinement, including requested. The grievance log was provided but not limited to health care services, classification for review and there was only one grievance decisions, program participation, telephone, mail or in July 2019. The grievance was regarding ☒ ☐ ☐ visiting procedures, food, clothing, bedding, the dorm air conditioning and that it wasn’t mistreatment, harassment or violations of the working. This issue was addressed timely nondiscrimination policy. There shall be no time and in compliance with regulation. limit on filing grievances. Policies and procedures Compliance noted through review of shall include provisions whereby the facility documentation, from policy and through manager ensures: conversation with consultant staff. We were not onsite to view the full grievance process. 7255 Los Angeles Camp Paige 18-20 PRO - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) a grievance form and instructions for registering a Residential Treatment Services Bureau grievance, which includes provisions for the youth (RTSB) Manual Section 508: Grievance to have free access to the form; Procedures Per bureau consultant staff, grievance forms ☒ ☐ ☐ and the instructions are available in the dorms and in other areas around the facility. Youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same. (b) the youth shall have the option to confidentially file Residential Treatment Services Bureau the grievance or to deliver the form to any youth (RTSB) Manual Section 508: Grievance supervision staff working in the facility; Procedures Per bureau consultant staff, youth may submit to any staff member or submit the ☒ ☐ ☐ grievance in the confidential box or directly to the Supervisor. Youth may also submit grievances through the JIGS system. This is through LACOE laptops. Once the youth submits the grievance, it is addressed like any other paper grievance per staff we spoke with. (c) resolution of the grievance at the lowest appropriate Residential Treatment Services Bureau staff level; (RTSB) Manual Section 508: Grievance Procedures ☒ ☐ ☐ Per policy, youth may submit to any staff member, submit through the confidential box or directly to the Supervisor. The grievance was addressed by a DPO I. (d) provision for a prompt review and initial response Residential Treatment Services Bureau to grievances within three (3) business days, (RTSB) Manual Section 508: Grievance grievances that relate to health and safety issues ☒ ☐ ☐ Procedures must be addressed immediately; The grievance was addressed within 2 days. (1) The youth may elect to be present to explain Residential Treatment Services Bureau his/her version of the grievance to a person not (RTSB) Manual Section 508: Grievance directly involved in the circumstances which Procedures led to the grievance. ☒ ☐ ☐ The youth’s grievance was upheld and the officer contacted MSB regarding the AC not working properly. (2) Provision for a staff representative approved by Residential Treatment Services Bureau the facility administrator to assist the youth. ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures 7255 Los Angeles Camp Paige 18-20 PRO - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provision for a written response to the grievance Residential Treatment Services Bureau which includes the reasons for the decisions; ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures (f) a system which provides that any appeal of a Residential Treatment Services Bureau grievance shall be heard by a person not directly (RTSB) Manual Section 508: Grievance involved in the circumstances which led to the ☒ ☐ ☐ Procedures grievance; There were no parent complaints to view. (g) resolution of the grievance must occur within ten Residential Treatment Services Bureau (10) business days unless circumstances dictate a ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance longer time frame. The youth shall be notified of Procedures any delay; and, (h) the policy shall provide multiple internal and Residential Treatment Services Bureau external methods to report sexual abuse and sexual ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance harassment. Procedures Whether or not associated with a grievance, concerns of Residential Treatment Services Bureau parents, guardians, staff or other parties shall be (RTSB) Manual Section 508: Grievance addressed and documented in accordance with written ☒ ☐ ☐ Procedures policies and procedures within a specified timeframe. There was no documentation to view. 1362 REPORTING OF INCIDENTS Residential Treatment Services Bureau (RTSB) Manual Section 1120: Reducing A written report of all incidents which result in physical Youth on Youth on Violence and 1919: harm, use of force, serious threat of physical harm, or Deaths at Camp Facilities death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the Multiple incident reports for additional staff and submitted to the facility manager by the end of incidents were received for review. All the shift, unless additional time is necessary and incident reports were submitted timely as authorized by the facility manager or designee. required. 1363 USE OF REASONABLE FORCE TO Residential Treatment Services Bureau COLLECT DNA SPECIMENS, SAMPLES, (RTSB) Manual Section 306: Live Scan and IMPRESSIONS DNA Collection and 1122: Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections RTSB does not collect DNA samples. If a personnel including peace officers, may employ ☐ ☐ ☒ sample is needed, youth are transported back reasonable force to collect blood specimens, saliva to the JH’s. DSB personnel are responsible samples, and thumb or palm print impressions from for conducting all DNA Collection. The individuals who are required to provide such remaining sections are all marked as NA. samples, specimens or impressions pursuant to Penal Code Section 296 and who refuse following written or oral request. 7255 Los Angeles Camp Paige 18-20 PRO - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) For the purpose of this section, the “use of Residential Treatment Services Bureau reasonable force” shall be defined as the force that (RTSB) Manual Section 306: Live Scan and an objective, trained and competent correctional DNA Collection and 1122: Juvenile employee, faced with similar facts and Collection of DNA Samples circumstances, would consider necessary and The Juvenile Halls are responsible for the reasonable to gain compliance with this section. collection of DNA samples for all detained ☐ ☐ ☒ and non- detained youth. Per policy, force will not be used to obtain DNA samples unless ordered by the court. If a youth refuses to cooperate, this information is provided to the court for further determination. (2) The use of reasonable force shall be preceded by Residential Treatment Services Bureau efforts to secure voluntary compliance. Efforts to (RTSB) Manual Section 306: Live Scan and secure voluntary compliance shall be documented DNA Collection and 1122: Juvenile ☐ ☐ ☒ and include an advisement of the legal obligation to Collection of DNA Samples provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Residential Treatment Services Bureau authorization of the supervising officer on duty. (RTSB) Manual Section 306: Live Scan and The authorization shall include information that DNA Collection and 1122: Juvenile ☐ ☐ ☒ reflects the fact that the offender was asked to Collection of DNA Samples provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Residential Treatment Services Bureau extraction, the extraction shall be videotaped. (RTSB) Manual Section 306: Live Scan and Video shall be directed at the cell extraction DNA Collection and 1122: Juvenile event. The videotape shall be retained by the Collection of DNA Samples ☐ ☐ ☒ agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7255 Los Angeles Camp Paige 18-20 PRO - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County (a) School Programs Probation and Los Angeles County Office of The County Board of Education shall provide for the Education: Juvenile Courts and Community administration and operation of juvenile court Schools. schools in conjunction with the Chief Probation A Matrix was provided for our review from Officer, or designee pursuant to applicable State Sr. Director Dr. Jesus Coral that detailed all laws. The school and facility administrators shall areas of Section 1370. All policy areas for develop and implement written policy and this section are either noted in the LACOE procedures to ensure communication and Board Policy or are in the RTSB Policy. coordination between educators and probation staff. Culturally responsive and trauma-informed The education program was evaluated by approaches should be applied when providing Bruce E. Petersen, Executive Director, San instruction. Education staff should collaborate with Diego County Office of Education on June 3, the facility administrator to use technology to 2019. Mr. Petersen found the educational facilitate learning and ensure safe technology ☒ ☐ ☐ program to be compliant with all regulations. practices. The facility administrator shall request an BSCC Field Representatives do not inspect annual review of each required element of the the education program for compliance with program by the Superintendent of Schools, and a Title 15. Title 15 requires the report or review checklist on compliance, Superintendent of Schools to conduct this deficiencies, and corrective action needed to achieve review in conjunction with a qualified compliance with this section. Such a review, when outside agency or individual. conducted, cannot be delegated to the principal or any other staff of any juvenile 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 facility administrator or designee shall review each item with the Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the BP 6011 Instruction, BP 0460 Philosophy, State Education Code and County Board of Goals, Objectives and Comprehensive Plans Education policies, all applicable federal education BP 005 Philosophy, Goals, Objectives and statutes and regulations and provide for an annual Comprehensive Plans Item 3,4,5 evaluation of the educational program offerings. As stated in the 2009 California Standards for the ☒ ☐ ☐ Teaching Profession, teachers shall establish and maintain learning 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. 7255 Los Angeles Camp Paige 18-20 PRO - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. ☒ ☐ ☐ Staff 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Comprehensive Plans ☒ ☐ ☐ courses required for high school graduation. Item 3,4,5 (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California ☒ ☐ ☐ Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) ☒ ☐ ☐ and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of ☒ ☐ ☐ Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth AR-6179 Instruction BPP 5149 who do not demonstrate sufficient progress towards ☒ ☐ ☐ grade level standards. (6) The minimum school day shall be consistent with BP 6112 Instruction State Education Code Requirements for juvenile court 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 BP 6112 Instruction Partially address classification, housing, security status, disciplinary requirement; AR 5131 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 AR 5144 Students (1) Positive behavior management will be 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 BP 5021 Students CF 6020 ☒ ☐ ☐ decisions made by probation staff that may affect the educational programming of students. 7255 Los Angeles Camp Paige 18-20 PRO - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension Code, expulsion/suspension from school shall be and Expulsion/Due Process (Students with imposed only when other means of correction fails Disabilities) 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 BP 5144 education staff will develop policies and procedures ☒ ☐ ☐ that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or ☒ ☐ ☐ 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 BP 6174 Instruction afforded an educational program that addresses their ☒ ☐ ☐ language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement ☒ ☐ ☐ (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction ☒ ☐ ☐ (B) Home Language Survey and the results of the State AR 6174 Instruction ☒ ☐ ☐ Test used for English language proficiency; (C) Needs and services of special populations as defined BP 6162.5 Instruction ☒ ☐ ☐ by the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. ☒ ☐ ☐ BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary BP 6162.5 Instruction ☒ ☐ ☐ education plan shall be developed for each youth within five school days. 7255 Los Angeles Camp Paige 18-20 PRO - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with AR 5125 Students the State Education Code and request the youth's records from his/her prior school(s), including, but not 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 AR 5125 Students ☒ ☐ ☐ (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies ☒ ☐ ☐ 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever possible, collaborate with local post- ☒ ☐ ☐ secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Residential Treatment Services Bureau EXERCISE. (RTSB) Manual Section 1306: Programs, recreation and Exercise The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7255 Los Angeles Camp Paige 18-20 PRO - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Residential Treatment Services Bureau programs, recreation, and exercise a minimum of three (RTSB) Manual Section 1306: Programs, hours a day during the week and five hours a day each recreation and Exercise Saturday, Sunday or other non-school days, of which Based on documentation provided, we are one hour shall be an outdoor activity, weather unable to determine if the Camp is providing permitting. ☐ ☒ ☐ the opportunity for programs, recreation and exercise a minimum of 3 hours during the week and 5 hours on weekends and other non-school days, one hour of which shall be out doors weather permitting. This section is non-compliant. A youth’s participation in programs, recreation, and Residential Treatment Services Bureau exercise may be suspended only upon a written finding (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ by the administrator/manager or designee that a youth recreation and Exercise represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall Residential Treatment Services Bureau be posted in the living units. (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ recreation and Exercise 7255 Los Angeles Camp Paige 18-20 PRO - 58 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS There will be a written annual review of the programs, Residential Treatment Services Bureau recreation, and exercise by the responsible agency to (RTSB) Manual Section 1306: Programs, ensure content offered is current, consistent, and recreation and Exercise relevant to the population. Facility administration provided documentation noting programs offered at the facility in coordination with DMH, LACOE and by Probation. DMH provides: • Individual and Family Treatment • De-escalation and Crisis Intervention • Adaptive Dialectical Behavioral Therapy (DBT) • Substance Abuse Groups • Seeking Safety Group • Psychiatric Care as appropriate • Aftercare Planning as appropriate Probation Education Services provides: • Post-Secondary College Courses in coordination with local colleges • Work Programs • Transitional Partnership Programs ☒ ☐ ☐ • Voter Registration • Selective Services information • R.I.S.E. Curriculum Community Based Organizations provide: • Arts for Incarcerated Youth Network The facility provided additional documentation of programs that come into the facility, however, did not have letters to review. • Religious Services • AA • Operation Read • LA Dads • Youth Council • Alma Family Services • Student Council Technical Assistance: Due to COVID, we understand the difficulties of getting documents for annual reviews. Please ensure that all reviews are available for the next onsite inspection for all programs and providers. 7255 Los Angeles Camp Paige 18-20 PRO - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Programs. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of daily (RTSB) Manual Section 1306: Programs, programming to include, but not be limited to, recreation and Exercise trauma focused, cognitive, evidence-based, best Youth are to be provided with the practice interventions that are culturally relevant and opportunity to participate in at least one hour linguistically appropriate, or pro-social interventions of programming that is rehabilitational daily. and activities designed to reduce recidivism. These A dorm calendar was provided but programs should be based on the youth’s individual documentation provided did not show needs as required by Sections 1355 and 1356. Such compliance with regulation expectations programs may be provided under the direction of the (program and time) or that the program Chief Probation Officer or the County Office of occurred. This section is non-compliant 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: ☐ ☒ ☐ (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; (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 Residential Treatment Services Bureau opportunity for at least one hour of daily access to (RTSB) Manual Section 1306: Programs, unscheduled activities such as leisure reading, letter recreation and Exercise writing, and entertainment. Activities shall be Youth are to be provided with the supervised and include orientation and may include opportunity to participate in at least one hour coaching of youth. ☐ ☒ ☐ of recreation (Known as “Free Time” in your documentation) Documentation provided notes that free time activities are provided but does not note the hour requirement. This is non-compliant. 7255 Los Angeles Camp Paige 18-20 PRO - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Exercise. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of large muscle (RTSB) Manual Section 1306: Programs, activity each day. recreation and Exercise Youth are to be provided with the ☒ ☐ ☐ opportunity to participate in at least one hour of exercise. Documentation provided noted that youth receive an hour of exercise daily. The administrator/manager may suspend, for a period not Residential Treatment Services Bureau to exceed 24 hours, access to recreation and programs. (RTSB) Manual Section 1306: Programs, The administrator/manager shall document the reasons ☒ ☐ ☐ recreation and Exercise why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1004: Religious The facility administrator shall provide access to Services religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth ☒ ☐ ☐ Services are provided for both Catholic and shall be allowed to participate in an activity outside of Protestant religions. their room if he/she elects not to participate in religious programs. Religious programs shall provide for: (a) opportunity for religious services and practices; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (b) availability of clergy; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (c) availability of religious diets. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services 1373 WORK PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1003: Work Crews The facility administrator shall develop policies and procedures regarding the fair and consistent assignment • Transition Partnership Program of youth to work programs. Work assigned to a youth (TPP) ☒ ☐ ☐ shall be meaningful, constructive and related to • AJCC vocational training or increasing a youth's sense of Youth have access to 2 work programs at the responsibility. Work programs shall not be imposed as a Camp. Youth are paid and receive training disciplinary measure. through Education staff. Paychecks are provided upon release. 7255 Los Angeles Camp Paige 18-20 PRO - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1374 VISITING Residential Treatment Services Bureau (RTSB) Manual Section 902: Visiting The facility administrator shall develop and implement Procedures, 903: Saturday and Sunday written policies and procedures for visiting, that include Visiting and 904: Special Visits provisions for special visits. Youth shall be allowed to receive visits by parents, guardians or persons standing Documentation provided for September, in loco parentis, and children of youth. Other family November and December 2019. members, such as grandparents and siblings, and ☒ ☐ ☐ A sample of a letter that is sent to parents of supportive adults, may be allowed to visit with the youth detained in both the Juvenile Halls and approval of the facility administrator or designee, and in the camps was provided for our review. The conjunction with the youth’s case plan or in the best letter was dated in September 2019 and interest of the youth. contained information that was not updated to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to Residential Treatment Services Bureau the limitations necessary to maintain order and security. (RTSB) Manual Section 902: Visiting Visitation shall not be denied solely based on the visitor’s Procedures, 903: Saturday and Sunday criminal history. The staff shall determine in each case, Visiting and 904: Special Visits whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ Visitation occurs on Sundays from 1:00PM the safety of youth or staff in the facility. Any denial of to 4:00PM. visitation or limitation on visitations shall be communicated to the youth, person denied and facility Administration will always make exceptions administrator. for those that cannot make it on the weekend. Opportunity for visitation shall be a minimum of two Residential Treatment Services Bureau hours per week. Visits may be supervised, but (RTSB) Manual Section 902 and Visiting conversations shall not be monitored unless there is a Procedures, 903: Saturday and Sunday security or safety need. Visiting ☒ ☐ ☐ Youth have over 2 hours of visitation opportunity on the weekends and administration will make arrangements during the week for youth to have the same amount of time if needed. Provisions for special visits, in addition to the two-hour Residential Treatment Services Bureau minimum and/or outside of the regular visiting hours, (RTSB) Manual Section 902: Visiting shall be accommodated as necessary and within the Procedures, 903: Saturday and Sunday discretion of the facility administrator or designee. ☒ ☐ ☐ Visiting and 904: Special Visits 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 Residential Treatment Services Bureau alternative, but not as a replacement, to in-person (RTSB) Manual Section 902: Visiting visiting. ☒ ☐ ☐ Procedures 7255 Los Angeles Camp Paige 18-20 PRO - 62 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1375 CORRESPONDENCE Residential Treatment Services Bureau (RTSB) Manual Section 510: Mail The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for correspondence Youth can write letters daily. Mail is also which provide that: distributed daily. (a) there is no limitation on the volume of mail that youth Residential Treatment Services Bureau may send or receive; ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (b) youth may send two letters per week postage free; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (c) youth may correspond confidentially with state and Residential Treatment Services Bureau federal courts, any member of the State Bar or holder (RTSB) Manual Section 510: Mail of 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 Residential Treatment Services Bureau in (c), may be read by staff only when there is (RTSB) Manual Section 510: Mail ☒ ☐ ☐ reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Residential Treatment Services Bureau (RTSB) Manual Section 509: Telephone The administrator of each juvenile facility shall develop ☒ ☐ ☐ Calls and implement written policies and procedures to provide youth with access to telephone communications. Youth may call home weekly. 1377 ACCESS TO LEGAL SERVICES Residential Treatment Services Bureau (RTSB) Manual Section 520: Access to The facility administrator shall develop written ☒ ☐ ☐ Legal Services 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 Residential Treatment Services Bureau attorneys and their authorized representatives; ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (b) provision for confidential consultation with Residential Treatment Services Bureau attorneys; and, ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (c) unlimited postage free, legal correspondence and Residential Treatment Services Bureau cost-free telephone access as appropriate. ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 1390 DISCIPLINE Residential Treatment Services Bureau (RTSB) Manual Section 601: Discipline, The facility administrator shall develop and implement 602: Facility Rules and 603: Behavior written policies and procedures for the discipline of Management Program youth that shall promote acceptable behavior; including ☒ ☐ ☐ the use of positive behavior interventions and supports. Discipline shall be imposed at the least restrictive level which promotes the desired behavior and Deprivation of the following is not permitted: 7255 Los Angeles Camp Paige 18-20 PRO - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) bed and bedding; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (b) daily shower, access to drinking fountain, toilet and Residential Treatment Services Bureau ☒ ☐ ☐ personal hygiene items, and clean clothing; (RTSB) Manual Section 601: Discipline (c) full nutrition; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (d) contact with parent or attorney; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (e) exercise; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (f) medical services and counseling; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (g) religious services; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (h) clean and sanitary living conditions; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (i) the right to send and receive mail; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (j) education; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (k) rehabilitative programming. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline The facility administrator shall establish rules of conduct Residential Treatment Services Bureau and disciplinary penalties to guide the conduct of youth. (RTSB) Manual Section 604: Continuum of Such rules and penalties shall include both major Correction violations and minor violations, be stated simply and ☒ ☐ ☐ Information regarding the rules is provided affirmatively, and be made available to all youth. in the orientation and BMP handbooks that Provision shall be made to provide accessible are provided to the youth at orientation. information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS Residential Treatment Services Bureau (RTSB) Manual Section 604: Continuum of The facility administrator shall develop and implement ☒ ☐ ☐ Correction and 606: Due Process written policies and procedures for the administration of discipline which shall include, but not be limited to: (a) designation of personnel authorized to impose Residential Treatment Services Bureau discipline for violation of rules; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (b) prohibiting discipline to be delegated to any youth; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (c) definition of major and minor rule violations and Residential Treatment Services Bureau their consequences, and due process requirements; ☒ ☐ ☐ (RTSB) Manual Section 604: Continuum of Correction (d) trauma-informed approaches and positive behavior Residential Treatment Services Bureau interventions; ☒ ☐ ☐ (RTSB) Manual Section 602: Facility Rules and 604: Continuum of Correction 7255 Los Angeles Camp Paige 18-20 PRO - 64 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) minor rule violations may be handled informally by Residential Treatment Services Bureau counseling, advising the youth of expected conduct (RTSB) Manual Section 604: Continuum of imposing a minor consequence. Discipline shall be Correction accompanied by written documentation and a ☐ ☒ ☐ policy of review and appeal to a supervisor; and, No documentation of minor rule violations provided separate than sanctions and appeals form with PIR’s (f) major rule violations and the discipline process Residential Treatment Services Bureau shall be documented and require the following: ☒ ☐ ☐ (RTSB) Manual Section 606: Due Process 7255 Los Angeles Camp Paige 18-20 PRO - 65 - J453 JUV PRO-Eff. 01-01-2019 (1) written notice of violation prior to a hearing; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process There is no location/space for notice of violation on the current form. Policy is consistent with regulation requirements; documentation is not. Facility staff provided Sanctions and Appeals forms that are required for all PIR SCM packets. Technical assistance has previously been provided and discussed with Bureau Management regarding the sanctions and appeal form and the need to revise and change the form to ensure compliance. We were assured this would be revised/updated to be more consistent to address the regulation requirements. This issue was addressed with the Prior Bureau Chief and consultant staff and it was agreed a new form would be implemented for this next cycle. The form does not provide proof of notice of violation and the recommendations noted are not the actual sanctions being recommended or imposed. All sanctions must be noted and ☐ ☒ ☐ made a part of this process and Youth must have the option of a due process hearing on the actual consequences and sanctions they receive. We have confirmed agency staff have corrected policy and forms to correct this issue however, we are unable to determine implementation. This is currently non- compliant. We appreciate the efforts that have been made and look forward to reviewing documentation in the near future to review for compliance. We will continue to follow up with the agency to provide support and technical assistance as needed. Documentation provided from Camp Paige as well as other camps was completed on the same forms as previously used in past cycles. Due process is being conducted on removals to the HOPE Center, DMH referrals and in some cases, on no action at all. In addition, policy requires staff to document the major rule violation on the incident report which we did not find evidence of and policy states that all penalties are held in abeyance pending the outcome of the hearing. 7255 Los Angeles Camp Paige 18-20 PRO - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) accommodations provided to youth with Residential Treatment Services Bureau disabilities, limited literacy, and English (RTSB) Manual Section 606: Due Process language learners; Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (3) hearing by a person who is not a party to the Residential Treatment Services Bureau incident; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK (4) opportunity for the youth to be heard, present Residential Treatment Services Bureau evidence and testimony; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (5) provision for youth to be assisted by staff in the Residential Treatment Services Bureau hearing process; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. . (6) provision for administrative review. Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (g) violations that result in a removal from camp or Residential Treatment Services Bureau commitment program, but not a return to court, will (RTSB) Manual Section 604: Continuum of ☒ ☐ ☐ follow the due process provisions in subsection (e) Correction above. f 7255 Los Angeles Camp Paige 18-20 PRO - 67 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the facility. ☒ ☐ ☐ (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Viol Dependent or neglected minors who are defined under Section ☐ ☐ ation 300 of the Welfare and Institutions 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 ☐Viol ☐ ☒ Delinquents (WIC 602)? (WIC 207[d]). ation 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 ☐Viol ☐ ☒ from minors. ation Adult inmates from an adult facility (e.g. inmate workers or ☐Viol “Scared Straight” programs) are not allowed in the facility in a ☐ ☒ ation manner that allows contact with minors. 7255 Los Angeles Camp Paige 18-20 PRO - 68 - J453 JUV PRO-Eff. 01-01-2019 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections Applicable Title 24 Regulations: Pre-1998* BSCC Code: 7255 FACILITY NAME: FACILITY TYPE: Joseph Paige Camp CONSTRUCTION/REMODEL DATE(S): 1960 IDENTIFY FACILITY PHYSICAL PLANT MODIFICATIONS SINCE 1992: FIELD REPRESENTATIVE: DATE Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS RECEPTION AREA (JH) This applies only to Juvenile Halls. ✓ Holding Rooms: Contain 15 square feet per minor; Have sufficient seating to accommodate the rated ✓ capacity based on floor space; Provide access to water closets and wash basins ✓ at a ratio of a 1:8; and Provide access to drinking fountain. ✓ Provide access to telephone. ✓ Provide access to private room(s) for interviews. ✓ MEDICAL EXAM SPACE (JH & CAMP) Space or room(s) afford privacy, are equipped to carry ✓ out routine examinations and emergency care and have sufficient locked storage space for medical supplies. LIVING UNITS (JH AND SPJH) This applies only to Juvenile Halls and Special Purpose Juvenile Halls. ✓ Living units are designed to accommodate no more than 30 minors and contain: Showers at a ratio of 1:6; ✓ Washbasins at a ratio of 1:6; ✓ Water closets at a ratio of 1:6 or water closet and ✓ one urinal for every 15 boys; and, Access to a drinking fountain by minors and staff. ✓ Doors of each sleeping room have a view panel (maximum of 144 square inches of shatter-proof glass ✓ or plastic materials) that allows the visual supervision of all parts of the room. Hallways in the detention living units are at least eight feet wide. If rooms are located on only one side, or if ✓ room doors are staggered, hallways are at least six feet wide. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7255 Los Angeles Camp Paige18-20 PHY - 1 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SINGLE ROOMS (JH, SPJH & CAMP) Contain a minimum of 500 cubic feet of air space and ✓ 63 cubic feet of floor space. DOUBLE ROOMS (JH, SPJH & CAMP) ✓ Contain a minimum of 800 cubic feet of airspace and 100 square feet of floor space. DORMITORY SLEEPING AREAS (JH & CAMP) ✓ Contain a minimum of 400 cubic feet of airspace and 50 square feet of floor space per minor. LOCKED SLEEPING ROOMS (JH, SPJH & CAMP) Contain an individual or combination drinking fountain, ✓ wash basin and toilet, unless a communication system or procedure is in effect to give minor immediate access to these fixtures. PLUMBING FIXTURES (CAMP) The following plumbing fixtures are adjacent to each ✓ sleeping area: Shower or bathtub at a ratio of 1:6; Washbasins at a ratio of 1:10; ✓ Access to toilets at a ratio of 1:10 or toilet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain. ✓ BEDS AND MATTRESSES (JH, SPJH & CAMP) Beds and mattresses are: ✓ A least 30 inches wide and 76 inches long; Spaced at least 36 inches apart and at least 12 ✓ inches off the floor; and, Mattresses are made of a fire-retardant material. ✓ INTERVIEW ROOMS (JH, SPJH & CAMP) ✓ There is one interview room for each detention unit in juvenile halls and special purpose juvenile halls. There is a private room suitably equipped for ✓ conferences and interviews in each camp. LIGHTING (JH, SPJH & CAMP) There are at least 50-foot candles of illumination at ✓ desk level and, at night, there is a maximum illumination of two foot candles at bed level in individual and multiple occupancy rooms. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7255 Los Angeles Camp Paige18-20 PHY - 2 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS ACADEMIC CLASSROOM (JH & CAMP) Educational classrooms are shared with minors from Camp Afflerbaugh. Each classroom contains a minimum of 160 square feet with a teacher's desk and work area, and a ✓ minimum of 28 square feet per student. Classrooms should be designed for no more than 15 students. 98: Designed for no more than 20 students DINING SPACE (JH & CAMP) ✓ There is a minimum of 15 square feet of space for each person being fed at any given time. PHYSICAL ACTIVITY SPACE (JH & CAMP) (See 2001 regulations for revised calculations.) There is indoor space consisting of at least 30 square ✓ feet of clear space for each minor, which may be included in a day room, a recreational building, or a multipurpose space (gymnasium). There is outdoor and/or multipurpose (gymnasium) space consisting of: ✓ No less than the equivalent of 90' X 100' outdoor and /or multipurpose space (gymnasium) for a facility with a capacity of 40 or less. No less than the equivalent of 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ ✓ a capacity of more than 40, and a juvenile hall with a capacity between 41 to 100 minors. No less than the equivalent of two 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40 and a juvenile hall with a capacity in excess of 101 minors. Lighting is adequate for security and evening ✓ recreational activities in camps. STORAGE SPACE (JH, SPJH & CAMP) ✓ Each minor is provided 9 cubic feet of secure storage space for personal clothing and belongings. Camps shall have adequate space (12 square feet of floor area is recommended) for bulk and activity ✓ storage equipment. MULTIPURPOSE SPACE OR ROOM (SPJH) There is a multipurpose space or room that provides space for reception, dining, recreation, exercise and/or ✓ education. This room contains a minimum of: 30 square feet of clear floor space per minor in the ✓ room; 10 feet by 20 feet floor dimensions; and, ✓ 1600 cubic feet of air space with a minimum ✓ ceiling height of eight feet. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7255 Los Angeles Camp Paige18-20 PHY - 3 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SPECIAL PURPOSE JH EXEMPTIONS SPJHs are exempt from the following Pre-1998 Title 15 regulations: ✓ Section 4272(b) Medical exam rooms Section 4272(m) Academic classrooms Section 4272(n) Dining space Section 4272(o) Physical activities space *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7255 Los Angeles Camp Paige18-20 PHY - 4 - J455 PHY Pre-98.dot (03/01) JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION BOARD OF STATE AND COMMUNITY CORRECTIONS INSPECTION BSCC Code: 7255 FACILITY: TYPE: RC: Joseph Paige Camp 116 FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ALL DIMENSIONS BASED ON CYA DATA UNLESS OTHERWISE DESIGNATED. ROOMS EACH ROOM Unit Room Applicable # Each Room Total Size (L x W x H) FIXTURES* COMMENTS or Designa- Type Standards Room # RC RC Square/Cubic T U W F S tion s Beds Feet Dormitory Dorm Pre-98 1 127 116 116 160’ x 39’ = 6,058 2 Dayroom Pre-98 1 40’ x 19’ = 760 Restroo Pre-98 1 9 1 2 1 m 2 4 7 Historical Notes Camp Paige and Camp Afflerbaugh share the same school area. 2011: At the time of the 2010-12 inspection, minors from Camp Paige were housed at neighboring Camp Afflerbaugh due to a fire that occurred in the laundry room. The laundry room area was under re-construction at the time of our visit. 2013: Two of the toilets were inoperable at the time of the inspection. 2014-2016 Inspection Cycle Notes: RC stands at 116 however the facility has removed beds to provide for programing space, mental health staff offices etc. Changes have occurred in a way beds can be re installed in a matter of a few days. 2016-2018 Inspection Cycle Notes: No Change to RC 2018-2020: **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** *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. 7255 LA Camp Paige LASE - 1 - J460 LAS JUV-05.dot(8\05) JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7261 FACILITY NAME: FACILITY TYPE: Glenn Rockey Juvenile Camp PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, Deputy Probation Officer 2; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell, Manual Reviewed-June 26, 2020 Virtual Documentation Review TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND Residential Treatment Services Bureau EVALUATION OF BUILDING AND GROUNDS (RTSB) Manual Section -2001: Inspections On an annual basis, or as otherwise required by law, and Evaluation of Building and Grounds each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Residential Treatment Services Bureau the Board of Supervisors to approve building safety; (RTSB) Manual Section -2002: Types of Inspections and Evaluations 2018 inspections were verified to have ☐ ☒ ☐ occurred. 2019 The facility was inspected on August 15, 2019. Corrections are required. (B) Fire authority having jurisdiction, including a fire Residential Treatment Services Bureau clearance as required by Health and Safety Code (RTSB) Manual Section -2002: Types of Section 13146.1 (a) and (b); Inspections and Evaluations ☒ ☐ ☐ The fire inspection was completed by Inspector Kaulback of Los Angeles County Fire Department, Whittier Office, Schools and Institutions Unit on May 1, 2019. Fire Clearance was granted. 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. 7261 Los Angeles Camp Rockey 18-20 PRO - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Local health officer, inspection in accordance with Residential Treatment Services Bureau Health and Safety Code Section 101045; (RTSB) Manual Section -2002: Types of Inspections and Evaluations Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the Environmental Health (EH) inspections as noted below. ☒ ☐ ☐ 2018 Inspections were verified to have occurred. The 2019 and 2020 Inspections are noted as follows: Environmental Health: January 22, 2019 and January 7, 2020: No corrections required. Nutritional Health: January 22, 2019 and January 6, 2020: Corrections made Medical/Mental Health: January 22, 29 and 30, 2019. No corrections necessary. (D) County superintendent of schools on the adequacy Residential Treatment Services Bureau of educational services and facilities as required in (RTSB) Manual Section -2002: Types of Section 1370; Inspections and Evaluations Education for the is provided by the Los Angeles County Office of Education. ☒ ☐ ☐ 2019 The education program was evaluated by Bruce E. Petersen, Executive Director, San Diego County Office of Education on June 3, 2019. Mr. Petersen found the educational program to be compliant with all regulations. (E) Juvenile court as required by Section 209 of the Residential Treatment Services Bureau Welfare and Institutions Code (RTSB) Manual Section -2002: Types of ☐ ☐ ☒ Inspections and Evaluations No documentation provided. Not required for Juvenile Camps. 7261 Los Angeles Camp Rockey 18-20 PRO - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (F) Juvenile Justice Commission as required by Section Residential Treatment Services Bureau 229 of the Welfare and Institutions Code or (RTSB) Manual Section -2002: Types of Probation Commission as required by Section 240 of Inspections and Evaluations the Welfare and Institutions Code. ☒ ☐ ☐ An inspection was completed November 11, 2019 by Commissioner Carter. Commission Carter addressed concerns with the facility administration. These concerns were formally responded to. 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is received from Chief Probation Officer Terri determined by receipt of the Chief Probation Officer’s McDonald certifying that appointments and qualifications of agency staff comply with all certification letter confirming that all elements of elements of regulation. regulation are met. (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: (1) recruit and hire employees who possess 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 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 pursuant to Section 6035 of the Penal Code; and (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ accordance with Section 1031 et seq. of the Government Code. (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract employees of the facility, who may be present at the personnel, volunteers and other non- facility, shall have such clearance and qualifications employees participate in background checks and are approved through each facility for as may be required by law, and their presence at the ☒ ☐ ☐ entrance except for LACOE, who conducts facility shall be subject to the approval and control of their own criminal records review as the facility manager. required by the Probation Department. Probation maintains control as to who has access into the facility. 7261 Los Angeles Camp Rockey 18-20 PRO - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1321 STAFFING Residential Treatment Services Bureau (RTSB) Manual Section -206: Staffing Each juvenile facility shall: Random dates and documentation were requested throughout the cycle to determine adequacy of staffing levels. Facility schedules and staffing lists from July 2019 and January 2020 were provided for our review. Facility administrators completed the Master Cycle Questionnaire as requested. Facility population ranged from a high of 60 youth and a low of 36 through 2019. Facility staffing ranged from 10 to 17 staff during awake hours and no less than 6 during sleeping hours. We noted one shift with 4 which appeared to be an anomaly. Off duty staff sleep on site and are available for emergencies. Facility work schedules were provided which noted population in the dorm, staffing levels, and supervisors on duty for the AM and PM shift. Additional documentation provided included a facility organization chart, a facility maintenance and other services roster, an administrative staff roster, a LACOE roster and a facility staff roster of sworn staff. There were 9 SDPO’s with 2 vacancies, 29 DPOII’s with 2 vacancies, 43 DPO I’s with 3 vacancies and 13 GSN’s. We noted staffing was listed as an area of concern in the Juvenile Justice report. We did see that there was a lot of overtime used to cover shifts. We did not see staffing as an area of concern noted in other areas of documentation we viewed. a) have an adequate number of personnel sufficient to Residential Treatment Services Bureau carry out the overall facility operation and its (RTSB) Manual Section -206: Staffing programming, to provide for safety and security of ☒ ☐ ☐ youth and staff, and meet established standards and See above comment. regulations; b) ensure that no required services shall be denied Residential Treatment Services Bureau because of insufficient numbers of staff on duty (RTSB) Manual Section -206: Staffing absent exigent circumstances; ☒ ☐ ☐ See above comment. 7261 Los Angeles Camp Rockey 18-20 PRO - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS c) have a sufficient number of supervisory level staff to Residential Treatment Services Bureau ensure adequate supervision of all staff members; (RTSB) Manual Section -206: Staffing At the time of inspection, Camp Rockey had ☒ ☐ ☐ 9 supervisors assigned to the facility and 2 vacancies. When a SDPO is unavailable a DPOII is assigned as an acting Supervisor. We will continue to monitor this when back on site. d) have a clearly identified person on duty at all times Residential Treatment Services Bureau who is responsible for operations and activities and (RTSB) Manual Section -206: Staffing has completed the Juvenile Corrections Officer Core Course and PC 832 training; ☒ ☐ ☐ The facility director is responsible for the overall operations of the facility, but the supervisor is responsible for the daily operations of the facility. e) have at least one staff member present on each living Residential Treatment Services Bureau unit whenever there are youth in the living unit; (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ There is always a staff present in the dorm or where a youth is present. Youth are never left alone per consultant staff. f) have sufficient food service personnel relative to the Residential Treatment Services Bureau number and security of living units, including staff (RTSB) Manual Section -206: Staffing qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen The facility has a full dining hall. All youth supervision; direct food preparation and servings; ☒ ☐ ☐ eat their meals in the dining hall unless they conduct related training programs for culinary staff; refuse to leave the dorm. The dining hall is and maintain necessary records; or, a facility may staffed by facility cooks who plan and serve food that meets nutritional standards prepared prepare all meals. Cooks do not supervise by an outside source; youth. g) have sufficient administrative, clerical, recreational, Residential Treatment Services Bureau medical, dental, mental health, building (RTSB) Manual Section -206: Staffing maintenance, transportation, control room, facility ☒ ☐ ☐ security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Residential Treatment Services Bureau continuous wide-awake supervision of youth, (RTSB) Manual Section -206: Staffing subject to 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: 7261 Los Angeles Camp Rockey 18-20 PRO - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Juvenile Halls (minimum youth-staff ratio) Facility is not a Juvenile Hall. (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 Facility is not a Juvenile Hall. 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 Facility is not a Juvenile Hall 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 Facility is not a Juvenile Hall ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other Facility is not a Juvenile Hall duties such as administration, supervision of ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile staff ratio) Hall ☐ ☐ ☒ (A) during hours that youth are awake, one wide-awake youth supervision staff member is on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room Facility is not a Special Purpose Juvenile for the purpose of sleeping, one wide-awake youth ☐ ☐ ☒ Hall supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff Facility is not a Special Purpose Juvenile members on duty at all times, regardless of the Hall ☐ ☐ ☒ 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 Facility is not a Special Purpose Juvenile who is the same gender as youth housed in the Hall ☐ ☐ ☒ facility. (E) personnel with primary responsibility for other Facility is not a Special Purpose Juvenile duties such as administration, supervision of Hall ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Residential Treatment Services Bureau (A) during the hours that youth are awake, one wide- ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing awake youth supervision staff member on duty for each 15 youth in the camp population; 7261 Los Angeles Camp Rockey 18-20 PRO - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (B) during the hours that youth are confined to their Residential Treatment Services Bureau room for the purpose of sleeping, one wide-awake ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing youth supervision staff member on duty for each 30- youth present in the facility; (C) at least two wide-awake youth supervision staff Residential Treatment Services Bureau members on duty at all times, regardless of the (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau who is the same gender as youth housed in the (RTSB) Manual Section -206: Staffing facility; ☒ ☐ ☐ There are always male and female staff on duty. (E) in addition to the minimum staff to youth ratio Residential Treatment Services Bureau required in (h)(3)(A)-(B), consideration shall be (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau duties such as administration, supervision of (RTSB) Manual Section -206: Staffing personnel, academic or trade instruction, clerical, ☒ ☐ ☐ Only youth supervision staff provide farm, forestry, kitchen or maintenance shall not be supervision of the youth. classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF Residential Treatment Services Bureau ORIENTATION AND TRAINING (RTSB) Manual -2104: Professional (a) Prior to assuming any responsibilities each youth Development and Training supervision staff member shall be properly oriented to their duties, including: All staff assigned to RTSB have completed Correctional Officer CORE training prior to reporting to the facility. Upon assignment, each staff is paired with a onsite training officer who assists them in ☒ ☐ ☐ their orientation and training. Training transcripts were provided as verification of required training which includes CORE. These training transcripts documented the mandated trainings We were unable to view individual training files for the specific location training as we were not on site due to COVID 19. Compliance is based on policy. We will verify training documents when back on site. 7261 Los Angeles Camp Rockey 18-20 PRO - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) youth supervision duties; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) scope of decisions they shall make; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (3) the identity of their supervisor; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) the identity of persons who are responsible to Residential Treatment Services Bureau them; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) persons to contact for decisions that are beyond Residential Treatment Services Bureau their responsibility; and ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (6) ethical responsibilities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (b) Prior to assuming any responsibility for the Residential Treatment Services Bureau supervision of youth, each youth supervision staff (RTSB) Manual -2104: Professional ☒ ☐ ☐ member shall receive a minimum of 40 hours of Development and Training facility-specific orientation, including: (1) individual and group supervision techniques; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) regulations and policies relating to discipline and Residential Treatment Services Bureau rights of youth pursuant to law and the ☒ ☐ ☐ (RTSB) Manual -2104: Professional provisions of this chapter; Development and Training (3) basic health, sanitation and safety measures; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) suicide prevention and response to suicide Residential Treatment Services Bureau attempts ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) policies regarding use of force, de-escalation Residential Treatment Services Bureau techniques, chemical agents, mechanical and (RTSB) Manual -2104: Professional physical restraints; Development and Training ☒ ☐ ☐ The facility does not use chemical agents in the camp setting. (6) review of policies and procedures referencing Residential Treatment Services Bureau trauma and trauma-informed approaches; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (7) procedures to follow in the event of Residential Treatment Services Bureau emergencies; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (8) routine security measures, including facility Residential Treatment Services Bureau perimeter and grounds; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7261 Los Angeles Camp Rockey 18-20 PRO - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (9) crisis intervention and mental health referrals to Residential Treatment Services Bureau mental health services; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (10) documentation; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (11) fire/life safety training Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (c) Prior to assuming sole supervision of youth, each Residential Treatment Services Bureau youth supervision staff member shall successfully (RTSB) Manual -2104: Professional complete the requirements of the Juvenile ☒ ☐ ☐ Development and Training Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer Residential Treatment Services Bureau youth supervision staff shall successfully complete (RTSB) Manual -2104: Professional ☒ ☐ ☐ training pursuant to Section 830 et seq. of the Penal Development and Training Code. 1323 FIRE AND LIFE SAFETY Residential Treatment Services Bureau (RTSB) Manual -2104: Professional Whenever there is a youth in a juvenile facility, there Development and Training shall be at least one wide awake person on duty at all ☒ ☐ ☐ times who meets the training standards established by the All staff are trained in fire and life safety in Board for general fire and life safety which relate CORE training. All Supervisors have been specifically to the facility. trained. There will always be a supervisor or an acting supervisor on duty. 7261 Los Angeles Camp Rockey 18-20 PRO - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1324 POLICY AND PROCEDURES MANUAL The agency manual is specific to RTSB and All facility administrators shall develop, publish, and camp operations and has been provided to the implement a manual of written policies and procedures BSCC for review. The manual was last that address, at a minimum, all regulations that are reviewed and updated in June 2020. applicable to the facility. Such a manual shall be made available to all employees, reviewed by all employees, The BSCC has reviewed the agency Policy and shall be administratively reviewed at a minimum and Procedure as provided to us specific to every two years, and updated, as necessary. Those regulations and has confirmed the policies records relating to the standards and requirements set and procedure exist as cited. There may be forth in these regulations shall be accessible to the Board cites noted in the comments that may not on request. match due to updates that were unable to be The manual shall include: reverified. ☒ ☐ ☐ Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. In all cases, copies of policies and directives were provided that were not from the current manual. Technical assistance provided and discussed that this should be rectified. (a) table of organization, including channels of Residential Treatment Services Bureau communications and a description of job (RTSB) Manual Sections: classifications; • 101: Vision, Mission, and Core Values • 102: Role of the Camp System • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff • 207: Organizational Chart The manual has a table of contents. The agency’s channel of communication follows chain of command. 7261 Los Angeles Camp Rockey 18-20 PRO - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) responsibility of the probation department, purpose Residential Treatment Services Bureau of programs, relationship to the juvenile court, the (RTSB) Manual Sections: Juvenile Justice/Delinquency Prevention • 101: Vision, Mission, and Core Commission or Probation Committee, probation Values staff, school personnel and other agencies that are • 102: Role of Camp System involved in juvenile facility programs; ☒ ☐ ☐ • 908: Medical Services • 909: Mental Health Services • 910: Educational Services • 1005: Community Based Organizations • 1006: Volunteers (c) responsibilities of all employees; Residential Treatment Services Bureau (RTSB) Manual Sections: • 202: RTSB Administrative Structure 203: Duty Statements, RTSB ☒ ☐ ☐ Management • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff (d) initial orientation and training program for Residential Treatment Services Bureau employees; (RTSB) Manual -2104: Professional Development and Training ☒ ☐ ☐ See Section 1322 (e) initial orientation, including safety and security Residential Treatment Services Bureau issues and anti-discrimination policies, for support (RTSB) Manual -2200: Non-Sworn staff, contract employees, school, mental/behavioral Personnel and Partner Agencies Handbook health and medical staff, program providers and ☐ ☐ UNK Unable to view employee training files as not volunteers; on site. Compliance is based on policy. We will verify training documents when back on site. 7261 Los Angeles Camp Rockey 18-20 PRO - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) maintenance of record-keeping, statistics and Residential Treatment Services Bureau communication system to ensure: (RTSB) Manual 701: Case Planning and Procedures and 702-General Duties and Responsibilities RTSB maintains an extensive record- keeping system (PCMS) to record operations and to report on the youth in its’ care. Through these reports, the RTSB is able to document and retrieve accurate ☒ ☐ ☐ accounts of specific incidents or operations and to develop a database for statistical analysis. The assigned camp DPO is responsible for the casework functions while the youth is in the camp setting. The supervisor is responsible to ensure that all information is thoroughly documented within the Probation Case Management System. (1) efficient operation of the juvenile facility; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (2) legal and proper care of youth; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (3) maintenance of individual youth's records; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (4) supply of information to the juvenile court and Residential Treatment Services Bureau those authorized by the court or by the law; and, (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (5) release of information regarding youth. Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (g) ethical responsibilities; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-2130: Employee Honesty (h) trauma-informed approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-518: Trauma Informed Approaches (i) culturally responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-519: Culturally Responsive Approaches 7261 Los Angeles Camp Rockey 18-20 PRO - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (j) gender responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-517: Promoting Dignity for Female Youth Housed in RTSB (k) a non-discrimination provision that provides that all Residential Treatment Services Bureau youth within the facility shall have fair and equal (RTSB) Manual-2110: Non-Discrimination access to all available services, placement, care, Policy treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group ☒ ☐ ☐ identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Residential Treatment Services Bureau chemical agents related security devices, and (RTSB) Manual-1922: Weapons and ☒ ☐ ☐ weapons and ammunition, where applicable; Ammunition (m) establishment of procedures for collection of Medi- Residential Treatment Services Bureau Cal eligibility information and enrollment of eligible ☒ ☐ ☐ (RTSB) Manual-706: Case Plan Activities youth; and, (n) establishment of a policy that prohibits all forms of Residential Treatment Services Bureau sexual abuse, sexual assault and sexual harassment. (RTSB) Manual-1600: Prison Rape The policy shall include an approach to preventing, Elimination Act detecting and responding to such conduct and any retaliation for reporting such conduct, as well as a ☒ ☐ ☐ Staff are trained in PREA within their first provision for reporting such conduct by youth, staff year of employment and every two years or a third party. thereafter. 1325 FIRE SAFETY PLAN Residential Treatment Services Bureau The facility administrator shall consult with the local fire (RTSB) Manual-1910: Fire Prevention and department having jurisdiction over the facility, or with ☒ ☐ ☐ Suppression and 1917: Emergency the State Fire Marshal, in developing a plan for fire safety Evacuation which shall include, but not be limited to: a) a fire prevention plan to be included as part of the Residential Treatment Services Bureau manual of policy and procedures; (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression b) monthly fire and life safety inspections by facility Residential Treatment Services Bureau staff with two- year retention of the inspection (RTSB) Manual-1910: Fire Prevention and record; Suppression ☒ ☐ ☐ Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. 7261 Los Angeles Camp Rockey 18-20 PRO - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS c) fire prevention inspections as required by Health Residential Treatment Services Bureau and Safety Code Section 13146.1(a) and (b); (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression See Section 1313 d) an evacuation plan; Residential Treatment Services Bureau (RTSB) Manual Sections: 1910: Fire Prevention and Suppression 1917: Emergency Evacuation ☒ ☐ ☐ Facility provided County of Los Angeles Building Emergency Plan with site evacuation maps for our review e) documented fire drills not less than quarterly; Residential Treatment Services Bureau (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression All drills completed. f) a written plan for the emergency housing of youth in Residential Treatment Services Bureau the case of fire; and, (RTSB) Manual-1917: Emergency Evacuation ☒ ☐ ☐ Emergency housing will always be at one of the camps or juvenile halls dependent on location of the fire and a safe route of travel. g) development of a fire suppression pre-plan In Residential Treatment Services Bureau cooperation with the local fire department. (RTSB) Manual-1910: Fire Prevention and Suppression (The County of Los Angeles Building ☒ ☐ ☐ Emergency Plan for Camp Paige was signed by LACO Fire Department Ruelas. 1326 SECURITY REVIEW Residential Treatment Services Bureau (RTSB) Manual- 1312: Security Checks Each facility administrator shall develop policies and procedures to annually review, evaluate, and document Security review was completed by Director security of the facility. The review and evaluation shall Kenyaata Watkins on May 6, 2020. include internal and external security, including, but not limited to, key control, equipment, and staff training. A security review is required annually. ☒ ☐ ☐ Bureau notified that if annual reviews are not completed and provided in the future, this section will be marked as non-compliant; however, as facility administrator is new, technical assistance was provided for correction. 7261 Los Angeles Camp Rockey 18-20 PRO - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1327 EMERGENCY PROCEDURES Facility provided and utilizes (in addition to the Bureau Policy Manual), the County of The facility administrator shall develop facility-specific Los Angeles Building Emergency Plan. policies and procedures for emergencies that shall include, but not be limited to: ☒ ☐ ☐ Both documents have emergency procedures regarding the facilities. We did not review the documents for comparison and suggest that the agency review and compare to ensure there are no inconsistencies. (a) escape, disturbances, and the taking of hostages; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1907 Escapes 1909: Major Disturbances 1914: Hostages (b) civil disturbance, active shooter and terrorist attack; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1908: Outside Intruder 1915: Active Shooter 1916: Terrorist Attack (c) fire and natural disasters; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1910: Fire Prevention and Suppression 1913: Earthquake (d) periodic testing of emergency equipment; Residential Treatment Services Bureau (RTSB) Manual Sections: 1321: Testing of Emergency Equipment ☒ ☐ ☐ Internal Services Department (ISD) conducts monthly and as needed testing in coordination with MSB. (e) emergency evacuation of the facility; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections: 1917: Emergency Evacuation (f) a program to provide all youth supervision staff Residential Treatment Services Bureau with an annual review of emergency procedures. (RTSB) Manual Sections: 1903: Staff Roles and Responsibilities ☒ ☐ ☐ Memo provided that all staff were trained in emergency procedures each year. Technical assistance provided that the name of the course should be noted, saved and recalled upon request in the future. 7261 Los Angeles Camp Rockey 18-20 PRO - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1328 SAFETY CHECKS Residential Treatment Services Bureau (RTSB) Manual Sections: 1313: Safety The facility administrator shall develop and implement Checks and Section 1119 policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, Documentation of Safety Checks were at random or varied intervals during hours when youth provided for September and November 2019. are asleep or when youth are in their rooms, confined in We reviewed random checks from the holding cells or confined to their bed in a dormitory. documentation provided and found that Supervision is not replaced, but may be supplemented overall, checks were completed within 15 by, an audio/visual electronic surveillance system minutes with minimal discrepancies. There designed to detect overt, aggressive or assaultive were some instances of nonrandom and non- behavior and to summon aid in emergencies. All safety varied checks; however, facility checks shall be documented with the actual time the administration addressed the issue through a check is completed. corrective action and work instruction memo prior to inspection. Technical assistance provided regarding enhancing supervision through the use of less time between checks. ☒ ☐ ☐ Policy also requires supervisors to regularly audit safety check logs by making unannounced inspections at least once a shift of the Safety Check Sheets in the buildings under their supervision. Supervisors are to ensure compliance and to assure that staff are completing the checks according to policy. Supervisors are to document their name, date, time of the audit under the last check. Facility managers corrected this issue also through their own review and provided a work instruction memo. We reviewed subsequent checks and noted improvement in both areas. We will be sure to review these issues to ensure continued compliance in the future. 7261 Los Angeles Camp Rockey 18-20 PRO - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Residential Treatment Services Bureau The facility administrator, in collaboration with the (RTSB) Manual Sections: 1201: Suicide healthcare and behavioral/mental health administrators, Prevention Plan shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. 1201: Suicide prevention Plan 1202 Enhanced and Specialized Supervision The plan shall consider the needs of youth experiencing Requirements for Youths in Juvenile past or current trauma. Facilities Suicide prevention responses shall be respectful and in 1203: Suicide Prevention Policy for Juvenile the least invasive manner consistent with the level of Facilities (Cross ref with directive 1186) suicide risk. ☒ ☐ ☐ Policy was developed in collaboration with The plan shall include the following elements: Juvenile Court Health Services (JCHS) and the Department of Mental Health (DMH). No documentation was received for review in this section. Facility administrators verified there were no incidents of suicide attempts or behavior to review. Compliance is based on policy and admission/intake documents. We will follow up when on site to ensure interpretation is consistent for the future. (a) Suicide prevention training as required in Residential Treatment Services Bureau Section 1322, Youth Supervision Staff (RTSB) Manual Sections: 1203: Suicide Orientation, and Training and the Juvenile Prevention Policy for Juvenile Facilities and Corrections Officer Core Course. 2104: Professional Development and ☒ ☐ ☐ Training. Staff are trained in CORE training and annual refresher training. 7261 Los Angeles Camp Rockey 18-20 PRO - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Screening, Identification Assessment and Residential Treatment Services Bureau Precautionary Protocols (RTSB) Manual Sections:1202: Enhanced (1) All youth shall be screened for risk of and Specialized Supervision Requirements suicide at intake and as needed during of Youth in Juvenile Facilities and 1203: detention. Suicide Prevention Policy for Juvenile Facilities All youth are screened prior to entry by DMH who conduct a Juvenile Justice Child/Adolescent Assessment. A DPOII ☒ ☐ ☐ Clinician and DMH staff member interview youth at Juvenile Hall prior to arrival to the Camp. Once at camp all youth are screened again at intake with the Initial Intake, Screening and Referral Questionnaire. DMH work with youth throughout their stay, assessing them for risk and will adjust their supervision level as needed. All files reviewed had screenings completed at intake/admission. (2) All youth supervision staff who perform Residential Treatment Services Bureau intake processes shall be trained in (RTSB) Manual Sections: 1203: Suicide screening youth for risk of suicide. Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Staff who complete intake/admissions are trained in completing them. Suicide update training is completed annually as part of the Enhanced Supervision Training. (3) All youth who have been identified during Residential Treatment Services Bureau the intake screening process to be at risk of (RTSB) Manual Section: 1203: Suicide suicide shall be referred to Prevention Policy for Juvenile Facilities behavioral/mental health staff for a suicide risk assessment. ☒ ☐ ☐ We did not find any youth to be suicidal at intake based on the documentation we reviewed; however, bureau staff stated that youth would be referred to DMH for follow up. (4) Precautionary protocols shall be developed Residential Treatment Services Bureau to ensure the youth’s safety pending the (RTSB) Manual Sections:1202: Enhanced behavioral/mental health assessment. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities 7261 Los Angeles Camp Rockey 18-20 PRO - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Referral process to behavioral/mental health Residential Treatment Services Bureau staff for assessment and/or services. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Policy requires all facility staff to complete a “Request for Mental Health Consultation” when appropriate. This would occur at any time throughout detention. (d) Procedures for monitoring of youth identified Residential Treatment Services Bureau at risk for suicide. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Per policy, enhanced supervision Levels 1-4 determine the level of supervision a youth receives. Level 4 requires a constant supervision until a youth can be transported out to emergency hospitalization, Level 3 is a constant visual 1:1 supervision, Level 2; is 10-minute safety check and Level 1 is regular 15-minute safety checks. (e) Safety Interventions Residential Treatment Services Bureau (1) Procedures to address intervention (RTSB) Manual Sections:1202: Enhanced protocols for youth identified at risk for and Specialized Supervision Requirements suicide which may include, but are not ☒ ☐ ☐ of Youth in Juvenile Facilities limited to: A. Housing consideration Youth are placed on a Specialized Supervision Plan-SSP. Supervision and housing direction are included on the forms. B. Treatment strategies including Residential Treatment Services Bureau trauma-informed approaches (RTSB) Manual Section: 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Mental health staff would provide direction to staff on the Mental Health Recording Form- Green Sheet. 7261 Los Angeles Camp Rockey 18-20 PRO - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) Procedures to instruct youth supervision Residential Treatment Services Bureau staff how to respond to youth who exhibit (RTSB) Manual Sections:1202: Enhanced suicidal behaviors. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. (f) Communication Residential Treatment Services Bureau (1) The intake process shall include (RTSB) Manual Section: 1203: Suicide communication with the arresting officer Prevention Policy for Juvenile Facilities and family guardians regarding the youth’s past or present suicidal ideations, behaviors Youth are transported directly from the or attempts. Juvenile Hall to the camp. Policy states that the intake officer shall contact the youth’s parents and/or guardians via telephone ☒ ☐ ☐ during the initial intake process to gather information regarding the youth’s past or present suicidal ideations, behaviors or attempts. Documentation reviewed noted that youth’s parents were contacted regarding suicide history. (2) Procedures for clear and current Residential Treatment Services Bureau information sharing about youth at risk for (RTSB) Manual Section: 1203: Suicide suicide with youth supervision, healthcare, ☒ ☐ ☐ Prevention Policy for Juvenile Facilities and behavioral/mental health staff. (g) Debriefing of Critical Incidents Related to Residential Treatment Services Bureau Suicides or Attempts (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ (1) Process for administrative review of the Prevention Policy for Juvenile Facilities circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected Residential Treatment Services Bureau staff. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities (3) Process for a debriefing event with affected Residential Treatment Services Bureau youth. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities 7261 Los Angeles Camp Rockey 18-20 PRO - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Documentation Residential Treatment Services Bureau (1) Documentation processes shall be (RTSB) Manual Sections:1202: Enhanced developed to ensure compliance with this and Specialized Supervision Requirements regulation of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities Youth identified at risk for suicide shall not be denied Residential Treatment Services Bureau the opportunity to participate in facility programs, (RTSB) Manual Section: 1202: Enhanced services and activities which are available to other non- and Specialized Supervision Requirements suicidal youth, unless deemed necessary for the safety ☒ ☐ ☐ for Youths in Juvenile Facilities of the youth or security of the facility. Any deprivation of programs, services or activities for youth at risk of suicide shall be documented and approved by the facility manager. 1340 REPORTING OF LEGAL ACTIONS Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each facility shall submit to the Board a letter of Statements, RTSB Management notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities ☒ ☐ ☐ The Camp Director is responsible to ensure responsible for juvenile facility operation. that all reporting is completed. No legal actions have been reported to the BSCC this cycle for this facility. 1341 DEATH AND SERIOUS ILLNESS OR Residential Treatment Services Bureau INJURY OF A YOUTH WHILE (RTSB) Manual Sections:1919: Deaths at DETAINED Camp Facilities (1) Death of a Youth. Policy was developed in collaboration with (a) The facility administrator, In cooperation with the Juvenile Court Health Services (JCHS) and health administrator and the behavioral/mental ☒ ☐ ☐ the Department of Mental Health (DMH), 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 Residential Treatment Services Bureau facility administrator, shall develop written policies (RTSB) Manual Sections:1919: Deaths at and procedures to assure there is a medical and Camp Facilities operational review of every in-custody death of 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. 7261 Los Angeles Camp Rockey 18-20 PRO - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) The administrator of the facility shall provide to the Residential Treatment Services Bureau Board a copy of the report submitted to the Attorney (RTSB) Manual Sections:1919: Deaths at General under Government Code Section 12525. A ☒ ☐ ☐ Camp Facilities 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 Residential Treatment Services Bureau the administrator, the Board may within 30 calendar (RTSB) Manual Sections:1919: Deaths at days inspect and evaluate the juvenile facility, jail, Camp Facilities 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 Residential Treatment Services Bureau (a) The facility administrator, In cooperation with the (RTSB) Manual Section 1920: Serious health administrator, shall develop written policies Illness or Injury of a Youth While Detained 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 Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each juvenile facility shall submit required population Statements, RTSB Management and profile survey reports to the Board within 10 working days after the end of each reporting period, in ☒ ☐ ☐ The Camp Director is responsible to ensure a format to be provided by the Board. that all reporting is completed. All population reports were completed in a timely manner. 1343 JUVENILE FACILITY CAPACITY Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty When the number of youth detained in a living unit of a Statements, RTSB Management juvenile facility exceeds its rated capacity for more than fifteen (15) calendar days in a month, the facility ☒ ☐ ☐ The Camp Director is responsible to ensure administrator shall provide a crowding report to the that all reporting is completed. Board in a format provided by the Board. The facility has not exceeded their rated capacity this cycle. 7261 Los Angeles Camp Rockey 18-20 PRO - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 400: Camp written policies and procedures for admittance of youth Admissions and Section 502: Orientation that emphasize respectful and humane engagement with Process and Handbook youth and reflect that the admission process may be The Admission process for camp youth traumatic to youth who may have already experienced begins before youth arrive on campus. trauma. Policies shall be trauma-informed, culturally ☒ ☐ ☐ Youth are assessed and screened at Camp relevant, and responsive to the language and literacy Headquarters and again by camp staff, needs of youth. In addition to the requirements of medical and mental health before the youth Sections 1324 and 1430 of these regulations: even arrive. Upon arrival, youth are admitted and oriented by camp staff. Documentation of admission/intake paperwork for 20 random youth was provided for our review. (a) the admittance process shall include: Residential Treatment Services Bureau (1) Access to two free phone calls within one hour (RTSB) Manual Sections:502: Orientation of admittance in accordance with the provisions Process and Handbook of Welfare and Institution Code Section 627; By policy, youth are to be provided with a ☒ ☐ ☐ phone call to notify their parent or guardian that they have been transferred to the Camp. All files noted phone calls were made to the parent/guardian of the youth. (2) Offer of a shower; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ All youth were offered a shower upon arrival. (3) Documented secure storage of personal Residential Treatment Services Bureau belongings; (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Youth are transported to camp in juvenile hall clothing with only their juvenile hall personals. All personal clothing and belongings are released to their parents or guardians from the juvenile hall. (4) Offer of food upon arrival; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ All youth were offered food upon arrival to the camp. 7261 Los Angeles Camp Rockey 18-20 PRO - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health Residential Treatment Services Bureau and safety issues, intellectual or developmental (RTSB) Manual Sections:402: Assessment disabilities; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (6) Screening for physical and developmental Residential Treatment Services Bureau disabilities in accordance with Sections 1329, (RTSB) Manual Sections:402: Assessment 1418, and 1430 of these regulations; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (7) Contact with Regional Center for the Youth that are Regional Center Clients Developmentally Disabled for youth that are would not likely be ordered to a camp ☒ ☐ ☐ suspected of or identified as having a commit. developmental disability, pursuant to Section 1418; and, (8) Procedures consistent with Section 1352.5. Residential Treatment Services Bureau (RTSB) Manual Sections:403: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (b) juvenile hall administrators shall establish written Not Applicable criteria for detention that considers the least ☒ ☐ ☐ restrictive environment. (c) juvenile camps and post-dispositional programs in Residential Treatment Services Bureau juvenile halls shall develop policies and procedures (RTSB) Manual Sections:502: Orientation that advise the youth of the estimated length of Process and Handbook stay, inform them of program guidelines and ☒ ☐ ☐ provide written screening criteria for inclusion and Estimated length of stay estimates were exclusion from the program. consistently completed and documentation provided in packets provided. (d) juvenile halls shall develop policies and procedures Not Applicable that advise any committed youth of the estimated ☐ ☐ ☒ length of his/her stay. 7261 Los Angeles Camp Rockey 18-20 PRO - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Residential Treatment Services Bureau ABUSE (RTSB) Manual Sections: 402: Assessment The facility administrator shall develop and implement and Classification and 503: Screening for the written policies and procedures to reduce the risk of Risk of Sexual Abuse sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of Policy is in place; however, documentation admission based on the following information: provided consists of PREA Risk questions on the intake screening assessment that are ☐ ☒ ☐ not consistent with regulation requirements. Technical assistance will be provided as requested. No proof of practice provided. This section is non-compliant as the documentation process has not yet been implemented. Agency is in the process of finalizing and rolling out the new procedure. (a) Prior sexual victimization or abusiveness; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (b) Gender nonconforming appearance or manner; Residential Treatment Services Bureau or identification as lesbian, gay or bisexual, (RTSB) Manual Sections: 402: Assessment transgender, queer or intersex, and whether the ☐ ☒ ☐ and Classification and 503: Screening for the youth may, therefore, be vulnerable to sexual Risk of Sexual Abuse abuse; (c) Current charges and offense history; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (d) Age; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (e) Level of emotional and cognitive development; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (f) Physical size and stature; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (g) Mental illness or mental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse 7261 Los Angeles Camp Rockey 18-20 PRO - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Intellectual or developmental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (i) Physical disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (j) The youth’s perception of vulnerability; and, Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (k) Any other specific information about the Residential Treatment Services Bureau individual youth that may indicate heightened (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ needs for supervision, additional safety and Classification and 503: Screening for the precautions, or separation from certain other Risk of Sexual Abuse youth. Staff shall ascertain this information through Residential Treatment Services Bureau conversations with the youth during the admittance (RTSB) Manual Sections:503: Screening for process, medical and behavioral health screenings; the Risk of Sexual Abuse ☐ ☒ ☐ during classification assessments; and by reviewing court records, case files, facility behavioral records, and Current procedure has not been other relevant documentation from the youth’s files. implemented. The facility administrator shall implement appropriate Residential Treatment Services Bureau controls on the dissemination of information within the (RTSB) Manual Sections:503: Screening for facility relative to responses received pursuant to this the Risk of Sexual Abuse ☐ ☒ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other It is unknown how the facility will ensure youth. documents are kept confidential. 1351 RELEASE PROCEDURES Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release The facility administrator shall develop and implement ☒ ☐ ☐ Procedures written policies and procedures for release of youth from custody which provide for: (a) verification of identity/release papers; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures (b) return of personal clothing and valuables; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures ☒ ☐ ☐ Compliance reviewed through Juvenile Hall property receipts viewed. Parents/guardian bring clothing for youth to be released in on day of release. (c) notification to the youth's parents or guardian; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process 7261 Los Angeles Camp Rockey 18-20 PRO - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) notification to the facility health care provider in Residential Treatment Services Bureau accordance with Sections 1408 and 1437 of these (RTSB) Manual Sections:809: Release regulations, for coordination with outside agencies; Procedures and, ☒ ☐ ☐ Health care is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (e) notification of school staff; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Education is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (f) notification of facility mental health personnel. Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Mental Health is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. The facility administrator shall develop and implement Residential Treatment Services Bureau policies and procedures for post-disposition youth to (RTSB) Manual Section: 703: MDT Process coordinate the provision of transitional and reentry services including, but not limited to, medical and Each youth has a Transition MDT 45-60 behavioral health, education, probation supervision and days prior to release that addresses all community-based services. required services and other pertinent areas. All facility partners and the PO are present ☒ ☐ ☐ with the youth to discuss the plan. The youth’s parents or guardian are invited to participate and either attend in person or via a conference call. (Reference Regulation 1355) Eight transition plans were reviewed and met all regulatory requirements. The facility administrator shall develop and implement Residential Treatment Services Bureau written policies and procedures for the furlough of (RTSB) Manual Section: 1802: Private youth from custody. Appointments ☒ ☐ ☐ The agency has no formal furlough policy; however, staff will transport youth to private appointments for exigent circumstances such as funerals or hospital visits with a court order. 7261 Los Angeles Camp Rockey 18-20 PRO - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1352 CLASSIFICATION Residential Treatment Services Bureau (RTSB) Manual Sections:402: Assessment The facility administrator shall develop and implement and Classification Policy and Section 408: written policies and procedures on classification of Classification youth for the purpose of determining housing placement in the facility. 20 classifications, most with SSP’s attached ☒ ☐ ☐ were provided for our review. Many of the Such procedures shall: youth were identified as gang involved and had mental health issues. A policy update training directive was also provided for our review providing instruction and update for staff. (a) provide for the safety of the youth, other youth, Residential Treatment Services Bureau facility staff, and the public by placing youth in the (RTSB) Manual Sections:402: Assessment appropriate, least restrictive housing and program and Classification Policy settings. Housing assignments shall consider the Youth are assessed by the Camp Assessment need for single, double or dormitory assignment or Unit (CAU) after being ordered to camp by location within the dormitory; ☒ ☐ ☐ the court. The CAU determines which camp is the appropriate camp for the youth based on classification factors and camp population. This decision is made based on several different factors and includes an interview and input from the youth. (b) consider facility populations and physical design of Residential Treatment Services Bureau the facility; (RTSB) Manual Sections:402: Assessment and Classification Policy ☒ ☐ ☐ Youth are classified to a camp based on classification factors and then assigned to a location within the dorm. (c) provide that a youth shall be classified upon Residential Treatment Services Bureau admittance to the facility; classification factors (RTSB) Manual Sections:402: Assessment shall include, but not be limited to: age, maturity, and Classification Policy sophistication, emotional stability, program needs, ☒ ☐ ☐ Youth are classified to a camp based on legal status, public safety considerations, classification factors. medical/mental health considerations, gender and gender identity of the youth; (d) provide for periodic classification reviews, Residential Treatment Services Bureau including provisions that consider the level of (RTSB) Manual Sections:402: Assessment supervision and the youth's behavior while in and Classification Policy custody; and, All youth who are placed on an SSP are ☒ ☐ ☐ reviewed within 30 days. All other youth are considered for review at the time of any incident, upon request, or as needed. If any change is to occur, an SSP is initiated. 7261 Los Angeles Camp Rockey 18-20 PRO - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provide that facility staff shall not separate youth Residential Treatment Services Bureau from the general population or assign youth to a (RTSB) Manual Sections:402: Assessment single occupancy room based solely on the youth's and Classification Policy actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, ☒ ☐ ☐ gender expression, mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, Residential Treatment Services Bureau bisexual, transgender, questioning or intersex (RTSB) Manual Sections:402: Assessment ☒ ☐ ☐ identification or status as an indicator of likelihood and Classification Policy of being sexually abusive. 1352.5 TRANSGENDER AND INTERSEX YOUTH. Residential Treatment Services Bureau (RTSB) Manual Sections: 403: Juvenile The facility administrator shall develop written policies ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Transgender, Questioning and Intersex treatment of transgender and intersex youth. The Youth in an Institutional Setting policies shall provide that: (a) Facility staff shall respect every youth’s gender Residential Treatment Services Bureau identity and shall refer to the youth by the youth’s (RTSB) Manual Sections: 403: Juvenile preferred name and gender pronoun, regardless of Supervision of Lesbian, Gay, Bisexual, the youth’s legal name. Facilities may prohibit the ☒ ☐ ☐ Transgender, Questioning and Intersex use of gang or slang names or names that otherwise Youth in an Institutional Setting 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 Residential Treatment Services Bureau themselves in a manner consistent with their gender (RTSB) Manual Sections: 403: Juvenile identity and shall provide youth with the ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, institution’s clothing and undergarments consistent Transgender, Questioning and Intersex with their gender identity. Youth in an Institutional Setting (c) Facility staff shall house youth in the unit or room Residential Treatment Services Bureau that best meets their individual needs and promotes (RTSB) Manual Sections: 403: Juvenile their safety and well-being. Staff may not Supervision of Lesbian, Gay, Bisexual, automatically house youth according to their Transgender, Questioning and Intersex external anatomy and shall document the reasons Youth in an Institutional Setting for any decision to house youth in a unit that does If a youth request to reside in another unit not match their gender identity. In making a ☒ ☐ ☐ other than the unit that coincides with the housing decision, staff shall consider the youth’s youth’s biological sex, a medical referral is preferences, as well as any recommendations from made, and an MDT is held. Pending a the youth’s health or behavioral health provider. decision, the youth will be housed in the medical unit. (This process occurs before arrival at the camp due to lack of alternate housing.) 7261 Los Angeles Camp Rockey 18-20 PRO - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Facility administrators shall ensure that transgender Residential Treatment Services Bureau and intersex youth have access to medical and (RTSB) Manual Sections: 403: Juvenile behavioral health providers qualified to provide Supervision of Lesbian, Gay, Bisexual, care and treatment to transgender and intersex Transgender, Questioning and Intersex youth. Youth in an Institutional Setting ☒ ☐ ☐ Upon entry, youth are asked If they identify with LGBTQI and if so, they are referred to medical for continuation and coordination of gender affirming services. (e) Consistent with the facility’s reasonable and Residential Treatment Services Bureau necessary security considerations and physical (RTSB) Manual Sections: 403: Juvenile plant, facility staff shall make every effort to ensure ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, the safety and privacy of transgender and intersex Transgender, Questioning and Intersex youth when the youth are using the bathroom or Youth in an Institutional Setting shower, or dressing or undressing. Facility staff shall not conduct physical searches of any Residential Treatment Services Bureau youth for the purpose of determining the youth’s (RTSB) Manual Sections: 403: Juvenile anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of Transgender, Questioning and Intersex the staff member who conducts any search of the youth. Youth in an Institutional Setting Policy notes that youth are provided with the option to choose the gender of the staff they wish to search them. Policy also notes that ☒ ☐ ☐ the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy alone. 7261 Los Angeles Camp Rockey 18-20 PRO - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1353 ORIENTATION Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation The facility administrator shall develop and implement Process and Handbook written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal We were provided with a log of all information shall be provided and supplemented with orientations that occurred between July 2019 video orientation if feasible. Provision shall be made to and March 2020. 20 orientation packets were provide accessible orientation information to all provided for our review. We found that the detained youth including those with disabilities, limited majority were timely and consistent with ☒ ☐ ☐ literacy, or English language learners. Orientation shall regulation. include information that addresses: We noted at inspection that the RTSB orientation handbook was not updated to all current regulatory requirements. This issue was quickly addressed and corrected, and the updated handbook has since been implemented and contains all areas of required regulation. (a) facility rules including contraband and searches and Residential Treatment Services Bureau disciplinary procedures; ☒ ☐ ☐ (RTSB) Manual Section: 502: Orientation Process and Handbook (b) facility’s system of positive behavior interventions Residential Treatment Services Bureau and supports, including behavior expectations, (RTSB) Manual Section: 502: Orientation incentives that youth will receive for complying Process and Handbook with facility rules, and consequences that may ☒ ☐ ☐ Youth are provided with a copy of the result when youth violate the rules of the facility; Behavior Management Program Handbook at orientation. This process is reviewed during orientation. (c) age appropriate information that explains the Residential Treatment Services Bureau facility’s policy prohibiting sexual abuse and sexual (RTSB) Manual Section: 1600: PREA ☒ ☐ ☐ harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (e) the existence of the grievance procedure, the steps Residential Treatment Services Bureau that must be taken to use it, the youth’s right to be (RTSB) Manual Section: 502: Orientation free of retaliation for reporting a grievance, and the Process and Handbook ☒ ☐ ☐ name of the person or position designated to resolve the issue; (f) access to legal services and information on the court Residential Treatment Services Bureau process; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7261 Los Angeles Camp Rockey 18-20 PRO - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (g) access to routine and emergency health and mental Residential Treatment Services Bureau health care; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (h) access to education, religious services, and Residential Treatment Services Bureau recreational activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (i) housing assignments; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (j) opportunity for personal hygiene and daily showers Residential Treatment Services Bureau including the availability of personal care items (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (k) rules and access to correspondence, visits and Residential Treatment Services Bureau telephone use; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (l) availability of reading materials, programming, and Residential Treatment Services Bureau other activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (m) facility policies on the use of force, use of restraints, Residential Treatment Services Bureau chemical agents and room confinement; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (n) immigration legal services; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (o) emergencies including evacuation procedures; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (p) non-discrimination policy and the right to be free Residential Treatment Services Bureau from physical, verbal or sexual abuse and (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ harassment by other youth and staff; Process and Handbook (q) availability of services and programs in a language Residential Treatment Services Bureau other than English if appropriate; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (r) the process for requesting different housing, Residential Treatment Services Bureau education, programming and work assignments; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7261 Los Angeles Camp Rockey 18-20 PRO - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (s) a process for which parents/guardians receive Residential Treatment Services Bureau information regarding the youth’s stay in the (RTSB) Manual Section: 502: Orientation facility that at a minimum includes answers to Process and Handbook frequently asked questions and provides contact A parent handbook is available for parents information for the facility, medical, school and ☒ ☐ ☐ and can be accessed online or a copy may be mental health; and, received at any facility. The Orienting officer also provides the youth’s parent with information during the initial contact. (t) a process by which youth may request access to Residential Treatment Services Bureau Title 15 Minimum Standards for Juvenile Facilities. (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 1354 Separation Residential Treatment Services Bureau (RTSB) Manual Section: 514: Separation, The facility administrator shall develop and implement 515: Room Confinement and Section 1400: ☒ ☐ ☐ written policies and procedures that address: The Healing Opportunities and Positive Engagement (HOPE) Center 7261 Los Angeles Camp Rockey 18-20 PRO - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) separation of youth for reasons that include, but are Residential Treatment Services Bureau not be limited to, medical and mental health (RTSB) Manual Section: 514: Separation, conditions, assaultive behavior, disciplinary 515: Room Confinement and Section 1400: consequences and protective custody. The Healing Opportunities and Positive Engagement (HOPE) Center Agency HOPE Centers are operationally utilized for youth who require separation for a variety of purposes including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation to provide time for the youth to deescalate and adjust their behavior to return to the program. Current policies are not clear and although ☐ ☒ ☐ collectively, policy and procedure outline regulation requirements, operationally, do not meet requirements. Separation policy must be updated concurrently with Room Confinement policy to ensure consistency and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Agency policy requires due process for any separation. Currently, due process only occurs as a result of the incident which precipitated the separation. While not non- compliant with regulation, this is inconsistent with agency policy. (b) consideration of positive youth development and Residential Treatment Services Bureau trauma-informed care. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation 7261 Los Angeles Camp Rockey 18-20 PRO - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) separated youth shall not be denied normal Residential Treatment Services Bureau privileges available at the facility, except when (RTSB) Manual Section: 514: Separation necessary to accomplish the objective of separation. If a youth is not on active room confinement due to imminent safety or security, he or she should be considered as full program and be fully integrated into a full general population program and receive all programming and activities in the HOPE Center as appropriate or returned to the dorm. We were unable to determine which youth present in the HOPE Center were present for what type of separation or if they should be eligible for programming. Documentation consisted of an alert log ☐ ☐ UNK provided for December 6, 2019. 1 SSP and classification/assessment dated 11/18/19 was provided for one youth housed in the HOPE Center due to youth’s negative behavior over the past 30 days. No documentation provided for our review of programming. Documentation was reviewed from Camp Paige and Afflerbaugh in which youth were transported to Camp Rockey. It is unknown as to if the youth participated in programming as no additional documentation was provided for review. We are unable to make a determination of compliance at this time. We will review this further when we return on site. (d) when the objective of the separation is discipline, Residential Treatment Services Bureau Title 15 Section 1390 shall apply. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation (e) when separation results in room confinement, the Residential Treatment Services Bureau separation shall occur in accordance with Welfare (RTSB) Manual Section: 514: Separation ☒ ☐ ☐ and Institutions Code Section 208.3 and Section1354.5 of these regulations. (f) policies and procedures shall ensure a daily review Residential Treatment Services Bureau of separated youth to determine if separation (RTSB) Manual Section: 514: Separation remains necessary. and Section 1400: The Healing Opportunities ☒ ☐ ☐ and Positive Engagement (HOPE) Center 7261 Los Angeles Camp Rockey 18-20 PRO - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354.5 ROOM CONFINEMENT Residential Treatment Services Bureau (RTSB) Manual Section: 515: Room (a) The facility administrator shall develop and Confinement and Section 1400: The Healing implement written policies and procedures Opportunities and Positive Engagement addressing the confinement of youth in their room (HOPE) Center that are consistent with Welfare and Institutions Code Section 208.3. The placement of a youth in Agency HOPE Centers are operationally room confinement shall be accomplished in utilized for youth who require separation for accordance with the following guidelines: a variety of purposes including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation to provide time for the youth to deescalate and adjust their behavior to return to the program. Camp Rockey houses youth in the HOPE Center for room confinement and for other separation purposes for the camp and for surrounding camps as well. All documentation and expectations of the regulations are addressed by Camp Rockey. ☐ ☒ ☐ Current policies are not clear and although collectively, policy and procedure outline regulation requirements, operationally, do not meet requirements. Separation policy must be updated concurrently with Room Confinement policy to ensure consistency and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Agency policy requires due process for any separation. Currently, due process only occurs as a result of the incident which precipitated the separation. While not non- compliant with regulation, this is inconsistent with agency policy. 7261 Los Angeles Camp Rockey 18-20 PRO - 36 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Room confinement shall not be used before Residential Treatment Services Bureau other, less restrictive, options have been (RTSB) Manual Section: 515: Room attempted and exhausted, unless attempting Confinement those options poses a threat to the safety or security of any youth or staff. 20 Hope Center Packets were provided for our review. Packets included incident reports and HOPE Center documentation. We reviewed 12 packets at random and found 11 youth were involved in mutual fights and 1 youth was inciting a dorm disturbance. ☐ ☒ ☐ Each youth was taken to the HOPE Center and placed in a locked room as evidenced by the safety check documentation provided. It is unknown what efforts were made if any, prior to the youth being placed in room confinement as the incident reports did not provide this information. This section is non- compliant. (2) Room confinement shall not be used for the Residential Treatment Services Bureau purposes of punishment, coercion, (RTSB) Manual Section: 515: Room convenience, or retaliation by staff. Confinement Incident reports and other documentation provided does not clearly document the reason the youth requires isolation to minimize the threat to the safety or security of youth or staff once separated from the incident. ☐ ☒ ☐ We noted in half of the documents reviewed; the youth were not secured during escort to the HOPE Center. IF youth do not need to be handcuffed for movement/transport to the HOPE Center then why do they need to be in a locked room upon arrival?? This section is non-compliant. 7261 Los Angeles Camp Rockey 18-20 PRO - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Room confinement shall not be used to the Residential Treatment Services Bureau extent that it compromises the mental and (RTSB) Manual Section: 515: Room physical health of the youth. Confinement Policy requires that all youth placed in room confinement are to be assessed by a clinician from the Department of Mental Health. We noted that youth are generally seen as a result ☒ ☐ ☐ of the mental health referral that was submitted for the precipitating incident and not as a result of the room confinement. All youth were cleared by medical staff immediately following the incident. Technical assistance provided to clarify the intent of this in policy and in operation as the consultation does not address the isolation. (b) A youth may be held up to four hours in room Residential Treatment Services Bureau confinement. After the youth has been held in room (RTSB) Manual Section 1400: The Healing confinement for a period of four hours, staff shall ☒ ☐ ☐ Opportunities and Positive Engagement do one or more of the following: (HOPE) Center (1) Return the youth to general population. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center ☐ ☒ ☐ We found that in many cases, documentation and case notes were inconsistent. (2) Consult with mental health or medical staff. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center Policy and procedure must be updated to ☐ ☒ ☐ include consultation with mental health or medical staff for youth who are held beyond 4 hours. Currently, mental health staff respond and see youth as a result of the precipitating incident, but not due to the isolation. This is non-compliant. 7261 Los Angeles Camp Rockey 18-20 PRO - 38 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Develop an individualized plan that includes Residential Treatment Services Bureau the goals and objectives to be met in order to (RTSB) Manual Section 1400: The Healing reintegrate the youth to general population. Opportunities and Positive Engagement (HOPE) Center Policy notes that youth shall not remain assigned to the HOPE Center for longer than 4 hours without the initiation of a formal Major Administrative Action Review reviewed by the facility Director or designee and must include an individualized plan that includes goals and objectives to be met to ☐ ☒ ☐ reintegrate the youth back to general population. They must be documented on the SSP. The SSP addresses supervision issues and does not include goals and objectives to reintegrate the youth to general population for this purpose. No documentation of any individualized plan that included goals and objectives to reintegrate the youth to general population was provided. This section is non-compliant. (4) If room confinement must be extended beyond Residential Treatment Services Bureau four hours, staff shall do each of the following: (RTSB) Manual Section 1400: The Healing ☐ ☐ ☐ Opportunities and Positive Engagement (HOPE) Center (A) Document the reasons for room Residential Treatment Services Bureau confinement and the basis for the (RTSB) Manual Section 1400: The Healing extension, the date and time the youth was Opportunities and Positive Engagement first placed in room confinement, and when (HOPE) Center he or she is eventually released from room ☐ ☒ ☐ confinement. It is unknown if any of the youth were extended beyond four hours. (B) Develop an individualized plan that Residential Treatment Services Bureau includes the goals and objectives to be met (RTSB) Manual Section 1400: The Healing in order to integrate the youth to general Opportunities and Positive Engagement population. (HOPE) Center ☐ ☒ ☐ See above B(3) There were no individualized plans provided. 7261 Los Angeles Camp Rockey 18-20 PRO - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Obtain documented authorization by the Residential Treatment Services Bureau facility superintendent or his or her (RTSB) Manual Section 1400: The Healing designee every four hours thereafter. Opportunities and Positive Engagement (HOPE) Center Youth that were extended were placed on ☒ ☐ ☐ SSP by the Duty Supervisor. We are unable to determine if the Director was present during business hours. Technical assistance provided that in the future the Director should initial any documents signed for him/her in their absence. (5) This section is not intended to limit the use of Residential Treatment Services Bureau single-person rooms or cells for the housing of (RTSB) Manual Section: 515: Room youth in juvenile facilities and does not apply Confinement ☒ ☐ ☐ to normal sleeping hours. (6) This section does not apply to youth or wards Residential Treatment Services Bureau in court holding facilities or adult facilities. (RTSB) Manual Section: 515: Room ☒ ☐ ☐ Confinement (7) Nothing in this section shall be construed to Residential Treatment Services Bureau conflict with any law providing greater or (RTSB) Manual Section: 515: Room ☒ ☐ ☐ additional protections to youth. Confinement (8) This section does not apply during an Residential Treatment Services Bureau extraordinary emergency circumstance that (RTSB) Manual Section: 515: Room requires a significant departure from normal Confinement 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. 7261 Los Angeles Camp Rockey 18-20 PRO - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (9) This section does not apply when a youth is Residential Treatment Services Bureau placed in a locked cell or sleeping room to treat (RTSB) Manual Section: 515: Room and protect against the spread of a Confinement 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 Residential Treatment Services Bureau PLAN (RTSB) Manual Section 402: Assessment and Classification and 703: The MDT The facility administrator shall develop and implement Process written policies and procedures for assessment and case planning. The process of assessment begins upon a youth being ordered to a camp. A youth is assessed by the Camp Assessment Unit and by the facility upon arrival. The case plan is completed at the initial MTD and is developed through a collaborative multi- ☒ ☐ ☐ disciplinary team made up of staff representation from Probation, Department of Mental Health, Education, Health Care, Social Services as appropriate and any others as necessary based on the youth or family needs. A transition MDT is also completed as the youth gets closer to release. MDT’s are completed as needed throughout detention as the need arises. Periodic review is completed by the assigned casework Probation Officer. The transition plan is completed by the collaborative multi- disciplinary team. 7261 Los Angeles Camp Rockey 18-20 PRO - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Assessment: Residential Treatment Services Bureau (RTSB) Manual Section 703: The MDT The assessment is based on information collected Process during the admission process with periodic review, which includes the youth's risk factors, needs and The process of case planning begins with the strengths including, but not limited to, identification of assessment process. 13 Initial and 10 substance abuse history, educational, vocational, Transitional MDT packets were reviewed. counseling, behavioral health, consideration of known The Camp Assessment Unit completes all history of trauma, and family strengths and needs. assessments on the youth prior to transfer. The assessment summary was not provided for our review in the case notes; however, it is practice and completed for all youth for RTSB per Bureau staff. At inspection, we are unable to determine ☐ ☐ UNK compliance in this area at this time without seeing the assessment, speaking to staff and youth. Prior to writing this report, we have been notified that the agency has updated their policy and has corrected their forms and documentation to be consistent with regulation and to provide a more clear and efficient process for the youth and their families. Staff training occurred in August 2020 and the new process was implemented in September 2020. We will follow up with this section to review for compliance upon our return to the facility. (b) Institutional Case Plan: Residential Treatment Services Bureau (1) A case plan shall be developed for each youth (RTSB) Manual Section 703: The MDT held for at least 30 days or more and created Process within 40 days of admission. We reviewed 14 Initial and 10 Transitional MDT packets. ☒ ☐ ☐ The initial MDT acts as the youth’s case plan and provides direction as to what programs they will participate in. Most programs are automatic as they are court ordered. The MDT is targeted to be completed within the first 2 weeks of a youth’s arrival at camp. All MDT’s occurred within the time allotted by regulation. (2) The institutional plan shall include, but not be Residential Treatment Services Bureau limited to, written documentation that provides: ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7261 Los Angeles Camp Rockey 18-20 PRO - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (A) objectives and time frame for the resolution Residential Treatment Services Bureau of problems identified in the assessment; (RTSB) Manual Section 705: Ongoing Case Management Activities The MDT process and format provides the structure for the youth’s case plan. Objectives are based on the assessment. Those programs that are ordered and are camp required programs, the timelines are noted as part of the program i.e. 10 weeks substance abuse program or 16-week DBT Program. Technical Assistance regarding the ☒ ☐ ☐ structure of the process and making the plans more individualized in the coming cycle. With the change in regulation, the assessment drives the objectives and goals and the case plans are more individualized and not solely based on a court order or camp program. RTSB has enhanced their process. We will follow up with this section and determine compliance upon our return to the facility. (B) a plan for meeting the objectives that Residential Treatment Services Bureau includes a description of program resources (RTSB) Manual Section 705: Ongoing Case needed and individuals responsible for Management Activities assuring that the plan is implemented; We found the current plan and timelines are embedded within the camp program expectations or court orders i.e. 10 weeks substance abuse program, individual counseling or family counseling weekly or 16-week DBT. ☐ ☐ UNK Discussed need to ensure these programs and other assessed needs are documented more consistently so the youth’s needs are individual to the youth. We need more information to determine compliance. We will follow up with this section and determine compliance upon our return to the facility. 7261 Los Angeles Camp Rockey 18-20 PRO - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) periodic evaluation of progress towards meeting Residential Treatment Services Bureau the objectives, including periodic review and (RTSB) Manual Section 705: Ongoing Case discussion of the plan with the youth; Management Activities ☒ ☐ ☐ Documentation provided of periodic review with youth. (4) a transition plan, the contents of which shall be Residential Treatment Services Bureau subject to existing resources, shall be developed (RTSB) Manual Section 706: Case Plan for post dispositional youth in accordance with Activities- Pre- Release Section 1351; and, ☒ ☐ ☐ Transition MDT’s were provided for youth who completed their programs. These contained all areas required by regulation. (5) in as much as possible and if appropriate, the Residential Treatment Services Bureau plan, including the transition plan, shall be (RTSB) Manual Section 705: Ongoing Case developed with input from the family, Management Activities supportive adults, youth, and Regional Center ☒ ☐ ☐ The youth’s parent or guardian is invited to for the Developmentally Disabled. attend the MDT. The family is contacted by phone and by letter to attend. 1356 COUNSELING AND CASEWORK Residential Treatment Services Bureau SERVICES (RTSB) Manual Section 705: Ongoing Case Management Activities The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: (a) youth will receive assistance with needs or concerns Residential Treatment Services Bureau that may arise; ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities (b) youth will receive assistance in requesting contact Residential Treatment Services Bureau with parents, other supportive adults, attorney, (RTSB) Manual Section 705: Ongoing Case clergy, probation officer, or other public official; Management Activities ☒ ☐ ☐ and, (c) youth will be provided access to available resources Residential Treatment Services Bureau to meet the youth’s needs. ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7261 Los Angeles Camp Rockey 18-20 PRO - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1357 USE OF FORCE Residential Treatment Services Bureau (RTSB) Manual Section 1701: Physical The facility administrator, In cooperation with the intervention Policy for Juvenile Facilities responsible physician, shall develop and implement and the Transportation Section written policies and procedures for the use of force, which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or treatment. ☒ ☐ ☐ Policy was developed with the Juvenile Court Health Services (JCHS) and includes (a) At a minimum, each facility shall develop policies the use of soft restraints. OC is not used in and procedures which: the camps. Documentation was provided from throughout the cycle. 10 incidents were selected for review. (1) restricts the use of force to that which is deemed Residential Treatment Services Bureau reasonable and necessary, as defined in Section (RTSB) Manual Section 1704: Safe Crisis 1302 to ensure the safety and security of youth, Management and Physical Intervention staff, others and the facility. Procedures Documentation noted staff gave direction to ☒ ☐ ☐ stop and attempts were made to deescalate the situations before force was used. Force used was minimal. All incidents reviewed appeared appropriate and to be reasonable and necessary for the safety of staff and youth. (2) outline the force options available to staff Residential Treatment Services Bureau including both physical and non-physical (RTSB) Manual Section 1704: Safe Crisis options and define when those force options are Management and Physical Intervention appropriate. Procedures ☒ ☐ ☐ Non-Physical Options: De-escalation Techniques Physical Options: Authorized Levels of Physical Interventions (3) describe force options or techniques that are Residential Treatment Services Bureau expressly prohibited by the facility. (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ Management and Physical Intervention Procedures (4) describe the requirements of staff to report any Residential Treatment Services Bureau inappropriate use of force, and to take (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ affirmative action to immediately stop it. Management and Physical Intervention Procedures 7261 Los Angeles Camp Rockey 18-20 PRO - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) define a standardized reporting format that Residential Treatment Services Bureau includes time period and procedure for (RTSB) Manual Section 1703: Safe Crisis documenting and reporting the use of force, Management-Physical Intervention Report including reporting requirements of Forms, 1704: Safe Crisis Management and management and line staff and procedures for Physical Intervention Procedures and 1706: reviewing and tracking use of force incidents by Safe Crisis Management Physical supervisory and or management staff, which Intervention Reports include procedures for debriefing a particular Facilities keep a use of force log. Incident incident with staff and/or youth for the purposes reports are completed before going off shift. of training as well as mitigating the effects of trauma that may have been experienced by staff ☐ ☐ UNK Every incident is reviewed by the duty and /or the youth involved. supervisor and again reviewed by the Safe Crisis Management reviewing supervisor and signed off by the facility Manager. We did not see any reference to debriefing of incidents however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further into this issue when on site at the next inspection. (6) Include an administrative review and a system Residential Treatment Services Bureau for investigating unreasonable use of force. (RTSB) Manual Section 1706: Safe Crisis Management Physical Intervention Reports Any incident that falls outside of agency ☒ ☐ ☐ policy is referred to the facility director for referral for an administrative review or referral to the Probation Departments Special Investigation Unit for further review. 7261 Los Angeles Camp Rockey 18-20 PRO - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Residential Treatment Services Bureau procedures required after use of force incidents (RTSB) Manual Section 1704: Safe Crisis for medical, mental health staff and parents or Management and Physical Intervention legal guardians. Procedures and 1706: Safe Crisis Management Physical Intervention Reports We found that in all incident reports and in documentation reviewed we found that youth were medically cleared and were either seen by mental health or a mental health referral ☒ ☐ ☐ was submitted on the youth’s behalf for follow up. At inspection, we did not see any reference in the PIR as required by policy for a contact being made to the youth’s parent if the child was involved in a use of force incident. Technical assistance was provided and after further review, we found the issue was corrected. (8) describe the limitations of use of force on Residential Treatment Services Bureau pregnant youth in accordance with Penal Code (RTSB) Manual Section 1704: Safe Crisis Section 6030(f) and Welfare and Institutions Management and Physical Intervention ☒ ☐ ☐ Code Section 222. Procedures (b) Facilities that authorize chemical agents as a force Residential Treatment Services Bureau option shall include policies and procedures that: (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (1) identify who is approved to carry and/or utilize NA chemical agents in the facility and the type, size ☐ ☐ ☒ and the approved method of deployment for those chemical agents. (2) mandate that chemical agents only be used when NA there is an imminent threat to the youth’s safety ☐ ☐ ☒ or the safety of others and only when de- escalation efforts have been unsuccessful or are not reasonably possible. (3) outline the facility’s approved methods and NA timelines for decontamination from chemical agents. This shall include that youth who have ☐ ☐ ☒ been exposed to chemical agents shall not be left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. 7261 Los Angeles Camp Rockey 18-20 PRO - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) define the role, notification, and follow-up NA procedures required after use of force incidents ☐ ☐ ☒ involving chemical agents for medical, mental health staff and parents or legal guardians. (5) provide for the documentation of each incident NA of use of chemical agents, including the reasons for which it was used, efforts to de-escalate ☐ ☐ ☒ prior to use, youth and staff involved, the date, time and location of use, decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure Residential Treatment Services Bureau which require that agencies provide initial and ☒ ☐ ☐ (RTSB) Manual Section 1702: Training regular training in use of force and chemical agents when appropriate that address: (1) known medical and behavioral health Residential Treatment Services Bureau conditions that would contraindicate certain ☒ ☐ ☐ (RTSB) Manual Section 1702: Training types of force; (2) acceptable chemical agents and the methods of Residential Treatment Services Bureau application. (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (3) signs or symptoms that should result in Residential Treatment Services Bureau immediate referral to medical or behavioral ☒ ☐ ☐ (RTSB) Manual Section 1702: Training health. (4) instruction on the Constitutional Limitations of Residential Treatment Services Bureau ☒ ☐ ☐ Use of Force. (RTSB) Manual Section 1702: Training (5) physical training force options that may require Residential Treatment Services Bureau ☒ ☐ ☐ the use of perishable skills. (RTSB) Manual Section 1702: Training (6) timelines the facility uses to define regular Residential Treatment Services Bureau training. (RTSB) Manual Section 1702: Training ☒ ☐ ☐ Initial training occurs in CORE and regular training is held through annual refresher training. 1358 USE OF PHYSICAL RESTRAINTS Residential Treatment Services Bureau (RTSB) Manual Section 1705: Restraints The facility administrator, in cooperation with the responsible physician and mental health director, shall The policy was developed in cooperation develop and implement written policies and procedures ☒ ☐ ☐ with DMH and JCHS for the use of restraint devices. Restraint devices include any devices which immobilize a youth's extremities and/or prevent the youth from being ambulatory. 7261 Los Angeles Camp Rockey 18-20 PRO - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Physical restraints may be used only for those youth Residential Treatment Services Bureau who present an immediate danger to themselves or (RTSB) Manual Section 1705: Restraints others, who exhibit behavior which results in the Facility provided documentation for 3 destruction of property or reveals the intent to cause incidents of physical restraints but only 1 had self-inflicted physical harm. Physical restraints should an incident report. be utilized only when it appears less restrictive In this incident, staff used restraints to secure alternatives would be ineffective in controlling the the youth for a use of force incident and as youth’s behavior. part of that incident and once the youth was restrained, the youth banged his head on the ground. Staff took all precautions and protected the youth by placing their hands and a shirt under the youth’s head. No additional restraints were utilized, and the youth immediately stopped. Documentation provided for the other 2 ☐ ☐ UNK incidents did not provide information if restraints were used in the incidents or if restraints were necessary or justified. Documentation consisted only of the SSP’s that were not consistent with mental health behaviors. We are unable to determine if these incidents are in fact use of restraints for this section. We cannot determine compliance as it is unknown if there were more incidents of Use of Restraints pursuant to this section or if there were no other incidents that occurred in the two-year cycle. We will follow up with the facility when back on site. All remaining compliance is based on policy only. In no case shall restraints be used as punishment or Residential Treatment Services Bureau discipline, or as a substitute for treatment. The use of (RTSB) Manual Section 1705: Restraints restraint devices that attach a youth to a wall, floor or Compliance based on policy alone. other fixture, including a restraint chair, or through ☒ ☐ ☐ affixing of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Residential Treatment Services Bureau handcuffs, shackles or other restraint devices when used (RTSB) Manual Section 1705: Restraints 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. 7261 Los Angeles Camp Rockey 18-20 PRO - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Youth shall be placed in restraints only with the approval Residential Treatment Services Bureau of the facility manager or designee. The facility manager (RTSB) Manual Section 1705: Restraints may delegate authority to place a youth in restraints to a ☒ ☐ ☐ physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. A medical opinion on the safety of placement and Residential Treatment Services Bureau retention shall be secured as soon as possible, but no later (RTSB) Manual Section 1705: Restraints ☒ ☐ ☐ 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 Residential Treatment Services Bureau possible, but in no case longer than four hours from the (RTSB) Manual Section 1705: Restraints ☒ ☐ ☐ time of placement, to assess the need for mental health treatment. Continuous direct visual supervision shall be conducted Residential Treatment Services Bureau to ensure that the restraints are properly employed, and (RTSB) Manual Section 1705: Restraints to ensure the safety and well-being of the youth. ☒ ☐ ☐ Observations of the youth's behavior and any staff interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. In addition to the requirements above, policies and Residential Treatment Services Bureau procedures shall address: (RTSB) Manual Section 1705: Restraints (a) documentation of the circumstances leading to an Residential Treatment Services Bureau ☒ ☐ ☐ application of restraints. (RTSB) Manual Section 1705: Restraints (b) known medical conditions that would Residential Treatment Services Bureau contraindicate certain restraint devices and/or ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints techniques. (c) acceptable restraint devices. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (d) signs or symptoms which should result in Residential Treatment Services Bureau ☒ ☐ ☐ immediate medical/mental health referral. (RTSB) Manual Section 1705: Restraints (e) availability of cardiopulmonary resuscitation Residential Treatment Services Bureau ☒ ☐ ☐ equipment. (RTSB) Manual Section 1705: Restraints (f) protective housing of restrained youth. While in Residential Treatment Services Bureau restraint devices, all youth shall be housed alone or (RTSB) Manual Section 1705: Restraints in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (h) exercising of extremities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 7261 Los Angeles Camp Rockey 18-20 PRO - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358.5 USE OF RESTRAINT DEVICES FOR Residential Treatment Services Bureau MOVEMENT AND TRANSPORTATION WITHIN (RTSB) Manual Section 1709: The Use of THE FACILITY. Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, In cooperation with the responsible physician and behavioral/mental health The policy was developed in cooperation director, shall develop and implement written policies with DMH and JCHS. and procedures for the use of restraint devices when the purpose is for movement or transportation within the Policy is in place but not yet trained and facility that shall include the following: implemented. The below areas are non- compliant. (a) identification of acceptable restraint devices, staff Residential Treatment Services Bureau approved to utilize restraint devices and the (RTSB) Manual Section 1709: The Use of required training. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility Handcuffs are authorized for regular use and flex cuffs in emergency situations. (b) the circumstances leading to the application of Residential Treatment Services Bureau restraints must be documented. (RTSB) Manual Section 1709: The Use of Mechanical Restraints for Movement and Transport Within the Facility ☐ ☒ ☐ No documentation was provided for our review. This section is non-compliant. (c) an individual assessment of the need to apply Residential Treatment Services Bureau restraints for movement or transportation that (RTSB) Manual Section 1709: The Use of includes consideration of less restrictive Mechanical Restraints for Movement and alternatives, consideration of a youth’s known ☐ ☒ ☐ Transport Within the Facility medical or mental health conditions, trauma No documentation was provided for our informed approaches, and a process for review. This section is non-compliant. documentation and supervisor review and approval. (d) consideration of safety and security of the facility, Residential Treatment Services Bureau with a clearly defined expectation that restraint (RTSB) Manual Section 1710: The Use of devices shall not be used for the purposes of Mechanical Restraints for Movement and ☒ ☐ ☐ discipline or retaliation. Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Residential Treatment Services Bureau accordance with Penal Code Section6030(f) and (RTSB) Manual Section 1709: The Use of Welfare and Institutions Code Section 222. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility 7261 Los Angeles Camp Rockey 18-20 PRO - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1359 SAFETY ROOM PROCEDURES There is no safety room in the camps. Does not apply. (a) The facility administrator, and where applicable, In 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. (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. 7261 Los Angeles Camp Rockey 18-20 PRO - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (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 Residential Treatment Services Bureau (RTSB) Manual Sections: The facility administrator shall develop and implement 1316: Searches in Detention Facilities written policies and procedures governing the search of 1317: Body Searches (Pat- Down, Strip, and youth, the facility, and visitors. Policies and procedures Body Cavity Searches) shall provide that: Various samples of search documents from 2019 and 2020 were provided for our review. These included K-9 inspections, staff living ☒ ☐ ☐ quarter’s inspections, dorm inspections, strip search log and authorizations and Facility Entrance Report-Inspection for Contraband were provided for our review. These search efforts resulted in the confiscation of contraband. Good efforts by staff and managers to ensure the safety and security of the youth and the facility. (a) Searches shall be conducted to ensure the safety and Residential Treatment Services Bureau security of the facility, public, visitors, youth, and (RTSB) Manual Sections 1316: Searches in staff. ☒ ☐ ☐ Detention Facilities (b) Searches shall be conducted in a manner that Residential Treatment Services Bureau preserves the privacy and dignity of the person (RTSB) Manual Sections 1316: Searches in being searched and shall not be conducted for ☒ ☐ ☐ Detention Facilities harassment or as a form of discipline or punishment. (c) Strip searches and visual or physical body cavity Residential Treatment Services Bureau searches shall comply with Penal Code Section (RTSB) Manual Sections: ☒ ☐ ☐ 4030. 1316: Searches in Detention Facilities 1317: Body Searches (Pat- Down, Strip, and Body Cavity Searches) 7261 Los Angeles Camp Rockey 18-20 PRO - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Physical body cavity searches shall only be Residential Treatment Services Bureau conducted by a medical professional. (RTSB) Manual Section 1317: Body ☒ ☐ ☐ Searches (Pat- Down, Strip, and Body Cavity Searches) (e) Any youth held after a detention hearing shall only Residential Treatment Services Bureau be strip searched with prior approval of a supervisor (RTSB) Manual Section 1317: Body when there is reasonable suspicion based on Searches (Pat- Down, Strip, and Body Cavity ☒ ☐ ☐ specific and articulable facts to believe that youth is Searches) concealing contraband. The reasonable suspicion All youth are post disposition. shall be documented. (f) Searches of transgender and intersex youth shall Residential Treatment Services Bureau comply with Section 1352.5. (RTSB) Manual Section 1303: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (g) Cross-gender pat-down searches and strip searches Residential Treatment Services Bureau are prohibited except in exigent circumstances or (RTSB) Manual Section 1317: Body ☒ ☐ ☐ when conducted by a medical professional. Such Searches (Pat- Down, Strip, and Body Cavity searches must be justified and documented in Searches) writing. 1361 GRIEVANCE PROCEDURE Residential Treatment Services Bureau (RTSB) Manual Section 508: Grievance The facility administrator shall develop and Procedures implement written policies and procedures whereby any youth may appeal and have resolved grievances There were no grievances for the months relating to any condition of confinement, including requested. The grievance log was provided but not limited to health care services, classification and there were only 12 grievances in total. decisions, program participation, telephone, mail or Additional grievances were reviewed and ☒ ☐ ☐ visiting procedures, food, clothing, bedding, were addressed in compliance with mistreatment, harassment or violations of the regulation with the exception of one. See nondiscrimination policy. There shall be no time below comments. limit on filing grievances. Policies and procedures Compliance noted through review of shall include provisions whereby the facility documentation, from policy and through manager ensures: conversation with consultant staff. We were not onsite to view the full process. (a) a grievance form and instructions for registering a Residential Treatment Services Bureau grievance, which includes provisions for the youth (RTSB) Manual Section 508: Grievance to have free access to the form; Procedures Per bureau consultant staff, grievance forms ☒ ☐ ☐ and the instructions are available in the dorms and in other areas around the facility. Youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same. 7261 Los Angeles Camp Rockey 18-20 PRO - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) the youth shall have the option to confidentially file Residential Treatment Services Bureau the grievance or to deliver the form to any youth (RTSB) Manual Section 508: Grievance supervision staff working in the facility; Procedures Per bureau consultant staff, youth may submit to any staff member or submit the ☒ ☐ ☐ grievance in the confidential box or directly to the Supervisor. Youth may also submit grievances through the JIGS system. This is through LACOE laptops. Once the youth submits the grievance, it is addressed like any other paper grievance per staff we spoke with. (c) resolution of the grievance at the lowest appropriate Residential Treatment Services Bureau staff level; (RTSB) Manual Section 508: Grievance Procedures ☒ ☐ ☐ Per policy, youth may submit to any staff member, submit through the confidential box or directly to the Supervisor. The grievance was addressed by a DPO I. (d) provision for a prompt review and initial response Residential Treatment Services Bureau to grievances within three (3) business days, (RTSB) Manual Section 508: Grievance grievances that relate to health and safety issues Procedures must be addressed immediately; Grievances reviewed were reviewed timely ☒ ☐ ☐ except for one which was from the JIGS system. (LACOE System) This grievance was written in September 2019 and was not addressed until February 2020. This is excessive and will need to be addressed. (1) The youth may elect to be present to explain Residential Treatment Services Bureau his/her version of the grievance to a person not (RTSB) Manual Section 508: Grievance directly involved in the circumstances which ☒ ☐ ☐ Procedures led to the grievance. The youth did not wish to have a hearing. (2) Provision for a staff representative approved by Residential Treatment Services Bureau the facility administrator to assist the youth. ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures (e) provision for a written response to the grievance Residential Treatment Services Bureau which includes the reasons for the decisions; ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance Procedures (f) a system which provides that any appeal of a Residential Treatment Services Bureau grievance shall be heard by a person not directly (RTSB) Manual Section 508: Grievance involved in the circumstances which led to the ☒ ☐ ☐ Procedures grievance; 7261 Los Angeles Camp Rockey 18-20 PRO - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (g) resolution of the grievance must occur within ten Residential Treatment Services Bureau (10) business days unless circumstances dictate a ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance longer time frame. The youth shall be notified of Procedures any delay; and, (h) the policy shall provide multiple internal and Residential Treatment Services Bureau external methods to report sexual abuse and sexual ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance harassment. Procedures Whether or not associated with a grievance, concerns of Residential Treatment Services Bureau parents, guardians, staff or other parties shall be (RTSB) Manual Section 508: Grievance addressed and documented in accordance with written ☒ ☐ ☐ Procedures policies and procedures within a specified timeframe. There was no documentation to view. 1362 REPORTING OF INCIDENTS Residential Treatment Services Bureau (RTSB) Manual Section 1120: Reducing A written report of all incidents which result in physical Youth on Youth on Violence and 1919: harm, use of force, serious threat of physical harm, or Deaths at Camp Facilities death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the Multiple incident reports for additional staff and submitted to the facility manager by the end of incidents were received for review. All the shift, unless additional time is necessary and incident reports were submitted timely as authorized by the facility manager or designee. required. 1363 USE OF REASONABLE FORCE TO Residential Treatment Services Bureau COLLECT DNA SPECIMENS, SAMPLES, (RTSB) Manual Section 306: Live Scan and IMPRESSIONS DNA Collection and 1122: Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections RTSB does not collect DNA samples. If a personnel including peace officers, may employ ☐ ☐ ☒ sample is needed, youth are transported back reasonable force to collect blood specimens, saliva to the JH’s. DSB personnel are responsible samples, and thumb or palm print impressions from for conducting all DNA Collection. The individuals who are required to provide such remaining sections are all marked as NA. 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 Residential Treatment Services Bureau reasonable force” shall be defined as the force that (RTSB) Manual Section 306: Live Scan and an objective, trained and competent correctional DNA Collection and 1122: Juvenile employee, faced with similar facts and Collection of DNA Samples circumstances, would consider necessary and The Juvenile Halls are responsible for the reasonable to gain compliance with this section. collection of DNA samples for all detained ☐ ☐ ☒ and non- detained youth. Per policy, force will not be used to obtain DNA samples unless ordered by the court. If a youth refuses to cooperate, this information is provided to the court for further determination. 7261 Los Angeles Camp Rockey 18-20 PRO - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) The use of reasonable force shall be preceded by Residential Treatment Services Bureau efforts to secure voluntary compliance. Efforts to (RTSB) Manual Section 306: Live Scan and secure voluntary compliance shall be documented DNA Collection and 1122: Juvenile ☐ ☐ ☒ and include an advisement of the legal obligation to Collection of DNA Samples provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Residential Treatment Services Bureau authorization of the supervising officer on duty. (RTSB) Manual Section 306: Live Scan and The authorization shall include information that DNA Collection and 1122: Juvenile ☐ ☐ ☒ reflects the fact that the offender was asked to Collection of DNA Samples provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Residential Treatment Services Bureau extraction, the extraction shall be videotaped. (RTSB) Manual Section 306: Live Scan and Video shall be directed at the cell extraction DNA Collection and 1122: Juvenile event. The videotape shall be retained by the Collection of DNA Samples ☐ ☐ ☒ agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7261 Los Angeles Camp Rockey 18-20 PRO - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County (a) School Programs Probation and Los Angeles County Office of The County Board of Education shall provide for the Education: Juvenile Courts and Community administration and operation of juvenile court Schools. schools in conjunction with the Chief Probation A Matrix was provided for our review from Officer, or designee pursuant to applicable State Sr. Director Dr. Jesus Coral that detailed all laws. The school and facility administrators shall areas of Section 1370. All policy areas for develop and implement written policy and this section are either noted in the LACOE procedures to ensure communication and Board Policy or are in the RTSB Policy. coordination between educators and probation staff. Culturally responsive and trauma-informed The education program was evaluated by approaches should be applied when providing Bruce E. Petersen, Executive Director, San instruction. Education staff should collaborate with Diego County Office of Education on June 3, the facility administrator to use technology to 2019. Mr. Petersen found the educational facilitate learning and ensure safe technology ☒ ☐ ☐ program to be compliant with all regulations. practices. The facility administrator shall request an BSCC Field Representatives do not inspect annual review of each required element of the the education program for compliance with program by the Superintendent of Schools, and a Title 15. Title 15 requires the report or review checklist on compliance, Superintendent of Schools to conduct this deficiencies, and corrective action needed to achieve review in conjunction with a qualified compliance with this section. Such a review, when outside agency or individual. conducted, cannot be delegated to the principal or any other staff of any juvenile 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 facility administrator or designee shall review each item with the Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the BP 6011 Instruction, BP 0460 Philosophy, State Education Code and County Board of Goals, Objectives and Comprehensive Plans Education policies, all applicable federal education BP 005 Philosophy, Goals, Objectives and statutes and regulations and provide for an annual Comprehensive Plans Item 3,4,5 evaluation of the educational program offerings. As stated in the 2009 California Standards for the ☒ ☐ ☐ Teaching Profession, teachers shall establish and maintain learning 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. 7261 Los Angeles Camp Rockey 18-20 PRO - 58 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. ☒ ☐ ☐ Staff 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Comprehensive Plans ☒ ☐ ☐ courses required for high school graduation. Item 3,4,5 (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California ☒ ☐ ☐ Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) ☒ ☐ ☐ and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of ☒ ☐ ☐ Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth AR-6179 Instruction BPP 5149 who do not demonstrate sufficient progress towards ☒ ☐ ☐ grade level standards. (6) The minimum school day shall be consistent with BP 6112 Instruction State Education Code Requirements for juvenile court 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 BP 6112 Instruction Partially address classification, housing, security status, disciplinary requirement: AR 5131 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 AR 5144 Students (1) Positive behavior management will be 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 BP 5021 Students CF 6020 ☒ ☐ ☐ decisions made by probation staff that may affect the educational programming of students. 7261 Los Angeles Camp Rockey 18-20 PRO - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension Code, expulsion/suspension from school shall be and Expulsion/Due Process (Students with imposed only when other means of correction fails Disabilities) 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 BP 5144 education staff will develop policies and procedures ☒ ☐ ☐ that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or ☒ ☐ ☐ 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 BP 6174 Instruction afforded an educational program that addresses their ☒ ☐ ☐ language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement. ☒ ☐ ☐ (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction ☒ ☐ ☐ (B) Home Language Survey and the results of the State AR 6174 Instruction ☒ ☐ ☐ Test used for English language proficiency; (C) Needs and services of special populations as defined BP 6162.5 Instruction ☒ ☐ ☐ by the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. ☒ ☐ ☐ BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary BP 6162.5 Instruction ☒ ☐ ☐ education plan shall be developed for each youth within five school days. 7261 Los Angeles Camp Rockey 18-20 PRO - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with AR 5125 Students the State Education Code and request the youth's records from his/her prior school(s), including, but not 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 AR 5125 Students ☒ ☐ ☐ (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies ☒ ☐ ☐ 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever possible, collaborate with local post- ☒ ☐ ☐ secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Residential Treatment Services Bureau EXERCISE. (RTSB) Manual Section 1306: Programs, recreation and Exercise The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7261 Los Angeles Camp Rockey 18-20 PRO - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Residential Treatment Services Bureau programs, recreation, and exercise a minimum of three (RTSB) Manual Section 1306: Programs, hours a day during the week and five hours a day each recreation and Exercise Saturday, Sunday or other non-school days, of which Based on documentation provided, we are one hour shall be an outdoor activity, weather unable to determine if the camp is providing permitting. ☐ ☒ ☐ the opportunity for programs, recreation and exercise a minimum of 3 hours during the week and 5 hours on weekends and other non-school days, one hour of which shall be out doors weather permitting. This section is non-compliant. A youth’s participation in programs, recreation, and Residential Treatment Services Bureau exercise may be suspended only upon a written finding (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ by the administrator/manager or designee that a youth recreation and Exercise represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall Residential Treatment Services Bureau be posted in the living units. (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ recreation and Exercise 7261 Los Angeles Camp Rockey 18-20 PRO - 62 - J453 JUV PRO-Eff. 01-01-2019 There will be a written annual review of the programs, Residential Treatment Services Bureau recreation, and exercise by the responsible agency to (RTSB) Manual Section 1306: Programs, ensure content offered is current, consistent, and recreation and Exercise relevant to the population. Facility administration provided documentation review from the following Community Based Organizations • Arts for Incarcerated Youth Network Facility administration provided letters from DMH and LACOE regarding the programs offered. Programming is extensive and the listing specific and appropriate to the needs of the youth. Los Angeles County Department of Mental Health provides: • Anger Management • De-escalation/Crisis Intervention Services • Dialectical Behavior Therapy • Empowerment Group • Family Therapy • Individual Therapy • Operation Read • Psychiatric Services ☒ ☐ ☐ • Seeking Safety • Substance Abuse • Success for Life Group • Transition to Placement Group Los Angeles County Office of Education provides: • Achieve 300 • APEX Credit Recovery • Book Club • Career Zone • College Courses • Culinary Arts Program • Extended Learning Opportunity • Freedom School Summer Literacy • L.A. DADs • OSHA • Special Education (Day Classes) • Tutoring • Work Program • Outdoor Recreation • R.I.S.E. Other Community Based Organizations provide: • Religious Services • Bold Ink Writers 7261 Los Angeles Camp Rockey 18-20 PRO - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS • Pet Prescriptions Technical Assistance: Due to COVID, we understand the difficulties of getting documents for annual reviews. Please ensure that all reviews are available for the next onsite inspection for all programs and providers. (a) Programs. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of daily (RTSB) Manual Section 1306: Programs, programming to include, but not be limited to, recreation and Exercise trauma focused, cognitive, evidence-based, best Youth are to be provided with the practice interventions that are culturally relevant and opportunity to participate in at least one hour linguistically appropriate, or pro-social interventions of programming that is rehabilitative daily. A and activities designed to reduce recidivism. These dorm calendar was provided but programs should be based on the youth’s individual documentation provided did not show needs as required by Sections 1355 and 1356. Such compliance with regulation expectations programs may be provided under the direction of the (program and time) or that the program Chief Probation Officer or the County Office of occurred. This section is non-compliant 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: ☐ ☒ ☐ (1) Cognitive Behavior Interventions (2) Management of Stress and Trauma (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 7261 Los Angeles Camp Rockey 18-20 PRO - 64 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Recreation. All youth shall be provided the Residential Treatment Services Bureau opportunity for at least one hour of daily access to (RTSB) Manual Section 1306: Programs, unscheduled activities such as leisure reading, letter recreation and Exercise writing, and entertainment. Activities shall be Youth are to be provided with the supervised and include orientation and may include opportunity to participate in at least one hour coaching of youth. ☐ ☒ ☐ of recreation (Known as “Free Time” in your documentation) Documentation provided notes that free time activities are provided but does not note the hour requirement. This is non-compliant. (c) Exercise. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of large muscle (RTSB) Manual Section 1306: Programs, activity each day. recreation and Exercise Youth are to be provided with the ☒ ☐ ☐ opportunity to participate in at least one hour of exercise. Documentation provided noted that youth receive an hour of exercise daily. The administrator/manager may suspend, for a period not Residential Treatment Services Bureau to exceed 24 hours, access to recreation and programs. (RTSB) Manual Section 1306: Programs, The administrator/manager shall document the reasons ☒ ☐ ☐ recreation and Exercise why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1004: Religious The facility administrator shall provide access to Services religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth ☒ ☐ ☐ Services are provided for both Catholic and shall be allowed to participate in an activity outside of Protestant religions. their room if he/she elects not to participate in religious programs. Religious programs shall provide for: (a) opportunity for religious services and practices; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (b) availability of clergy; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (c) availability of religious diets. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services 7261 Los Angeles Camp Rockey 18-20 PRO - 65 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1373 WORK PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1003: Work Crews The facility administrator shall develop policies and procedures regarding the fair and consistent assignment Youth participate in the Workforce of youth to work programs. Work assigned to a youth ☒ ☐ ☐ Development and Aging Community shall be meaningful, constructive and related to program. This is paid work that youth may apply for and are selected to participate in. vocational training or increasing a youth's sense of Paychecks are held until release. responsibility. Work programs shall not be imposed as a disciplinary measure. 1374 VISITING Residential Treatment Services Bureau (RTSB) Manual Section 902: Visiting The facility administrator shall develop and implement Procedures, 903: Saturday and Sunday written policies and procedures for visiting, that include Visiting and 904: Special Visits provisions for special visits. Youth shall be allowed to receive visits by parents, guardians or persons standing Documentation provided for July 2019, in loco parentis, and children of youth. Other family January and February 2020. members, such as grandparents and siblings, and ☒ ☐ ☐ A sample of a letter that is sent to parents of supportive adults, may be allowed to visit with the youth detained in both the Juvenile Halls and approval of the facility administrator or designee, and in the camps was provided for our review. The conjunction with the youth’s case plan or in the best letter was dated in September 2019 and interest of the youth. contained information that was not updated to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to Residential Treatment Services Bureau the limitations necessary to maintain order and security. (RTSB) Manual Section 902: Visiting Visitation shall not be denied solely based on the visitor’s Procedures, 903: Saturday and Sunday criminal history. The staff shall determine in each case, Visiting and 904: Special Visits whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ Visitation occurs on Sundays from 1:00PM the safety of youth or staff in the facility. Any denial of to 4:00PM. visitation or limitation on visitations shall be communicated to the youth, person denied and facility Administration will always make exceptions administrator. for those that cannot make it on the weekend. Opportunity for visitation shall be a minimum of two Residential Treatment Services Bureau hours per week. Visits may be supervised, but (RTSB) Manual Section 902 and Visiting conversations shall not be monitored unless there is a Procedures, 903: Saturday and Sunday security or safety need. Visiting ☒ ☐ ☐ Youth have over 2 hours of visitation opportunity on the weekends and administration will make arrangements during the week for youth to have the same amount of time if needed. 7261 Los Angeles Camp Rockey 18-20 PRO - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Provisions for special visits, in addition to the two-hour Residential Treatment Services Bureau minimum and/or outside of the regular visiting hours, (RTSB) Manual Section 902: Visiting shall be accommodated as necessary and within the Procedures, 903: Saturday and Sunday discretion of the facility administrator or designee. ☒ ☐ ☐ Visiting and 904: Special Visits 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 Residential Treatment Services Bureau alternative, but not as a replacement, to in-person (RTSB) Manual Section 902: Visiting visiting. ☒ ☐ ☐ Procedures 1375 CORRESPONDENCE Residential Treatment Services Bureau (RTSB) Manual Section 510: Mail The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for correspondence Youth can write letters daily. Mail is also which provide that: distributed daily. (a) there is no limitation on the volume of mail that youth Residential Treatment Services Bureau may send or receive; ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (b) youth may send two letters per week postage free; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (c) youth may correspond confidentially with state and Residential Treatment Services Bureau federal courts, any member of the State Bar or holder (RTSB) Manual Section 510: Mail of 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 Residential Treatment Services Bureau in (c), may be read by staff only when there is (RTSB) Manual Section 510: Mail ☒ ☐ ☐ reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Residential Treatment Services Bureau (RTSB) Manual Section 509: Telephone The administrator of each juvenile facility shall develop ☒ ☐ ☐ Calls and implement written policies and procedures to provide youth with access to telephone communications. Youth may call home weekly. 1377 ACCESS TO LEGAL SERVICES Residential Treatment Services Bureau (RTSB) Manual Section 520: Access to The facility administrator shall develop written ☒ ☐ ☐ Legal Services 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 Residential Treatment Services Bureau attorneys and their authorized representatives; ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 7261 Los Angeles Camp Rockey 18-20 PRO - 67 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) provision for confidential consultation with Residential Treatment Services Bureau attorneys; and, ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (c) unlimited postage free, legal correspondence and Residential Treatment Services Bureau cost-free telephone access as appropriate. ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 1390 DISCIPLINE Residential Treatment Services Bureau (RTSB) Manual Section 601: Discipline, The facility administrator shall develop and implement 602: Facility Rules and 603: Behavior written policies and procedures for the discipline of Management Program youth that shall promote acceptable behavior; including ☒ ☐ ☐ the use of positive behavior interventions and supports. Discipline shall be imposed at the least restrictive level which promotes the desired behavior and Deprivation of the following is not permitted: (a) bed and bedding; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (b) daily shower, access to drinking fountain, toilet and Residential Treatment Services Bureau ☒ ☐ ☐ personal hygiene items, and clean clothing; (RTSB) Manual Section 601: Discipline (c) full nutrition; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (d) contact with parent or attorney; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (e) exercise; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (f) medical services and counseling; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (g) religious services; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (h) clean and sanitary living conditions; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (i) the right to send and receive mail; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (j) education; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (k) rehabilitative programming. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline The facility administrator shall establish rules of conduct Residential Treatment Services Bureau and disciplinary penalties to guide the conduct of youth. (RTSB) Manual Section 604: Continuum of Such rules and penalties shall include both major Correction violations and minor violations, be stated simply and ☒ ☐ ☐ Information regarding the rules is provided affirmatively, and be made available to all youth. in the orientation and BMP handbooks that Provision shall be made to provide accessible are provided to the youth at orientation. information to youth with disabilities, limited English proficiency, or limited literacy. 7261 Los Angeles Camp Rockey 18-20 PRO - 68 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1391 DISCIPLINE PROCESS Residential Treatment Services Bureau (RTSB) Manual Section 604: Continuum of The facility administrator shall develop and implement ☒ ☐ ☐ Correction and 606: Due Process written policies and procedures for the administration of discipline which shall include, but not be limited to: (a) designation of personnel authorized to impose Residential Treatment Services Bureau discipline for violation of rules; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (b) prohibiting discipline to be delegated to any youth; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (c) definition of major and minor rule violations and Residential Treatment Services Bureau their consequences, and due process requirements; ☒ ☐ ☐ (RTSB) Manual Section 604: Continuum of Correction (d) trauma-informed approaches and positive behavior Residential Treatment Services Bureau interventions; ☒ ☐ ☐ (RTSB) Manual Section 602: Facility Rules and 604: Continuum of Correction (e) minor rule violations may be handled informally by Residential Treatment Services Bureau counseling, advising the youth of expected conduct (RTSB) Manual Section 604: Continuum of imposing a minor consequence. Discipline shall be Correction accompanied by written documentation and a ☒ ☐ ☐ policy of review and appeal to a supervisor; and, No documentation of minor rule violations provided separate than sanctions and appeals form with PIR’s (f) major rule violations and the discipline process Residential Treatment Services Bureau shall be documented and require the following: ☐ ☐ ☒ (RTSB) Manual Section 606: Due Process 7261 Los Angeles Camp Rockey 18-20 PRO - 69 - J453 JUV PRO-Eff. 01-01-2019 (1) written notice of violation prior to a hearing; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process There is no location/space for notice of violation on the current form. Policy is consistent with regulation requirements; documentation is not. Facility staff provided Sanctions and Appeals forms that are required for all PIR SCM packets. Technical assistance has previously been provided and discussed with Bureau Management regarding the sanctions and appeal form and the need to revise and change the form to ensure compliance. We were assured this would be revised/updated to be more consistent to address the regulation requirements. This issue was addressed with the Prior Bureau Chief and consultant staff and it was agreed a new form would be implemented for this next cycle. The form does not provide proof of notice of violation and the recommendations noted are not the actual sanctions being recommended or imposed. All sanctions must be noted and ☐ ☒ ☐ made a part of this process and Youth must have the option of a due process hearing on the actual consequences and sanctions they receive. We have confirmed agency staff have corrected policy and forms to correct this issue however, we are unable to determine implementation. This is currently non- compliant. We appreciate the efforts that have been made and look forward to reviewing documentation in the near future to review for compliance. We will continue to follow up with the agency to provide support and technical assistance as needed. Documentation provided from Camp Rockey as well as other camps was completed on the same forms as previously used in past years. Due process is being conducted on removals to the HOPE Center, DMH referrals and in some cases, on no action at all. In addition, policy requires staff to document the major rule violation on the incident report which we did not find evidence of and policy states that all penalties are held in abeyance pending the outcome of the hearing. 7261 Los Angeles Camp Rockey 18-20 PRO - 70 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) accommodations provided to youth with Residential Treatment Services Bureau disabilities, limited literacy, and English (RTSB) Manual Section 606: Due Process language learners; ☐ ☐ UNK Unable to confirm hearing practices as not on site to view or to interview staff or youth. (3) hearing by a person who is not a party to the Residential Treatment Services Bureau incident; (RTSB) Manual Section 606: Due Process ☐ ☐ UNK Unable to confirm hearing practices as not on site to view or to interview staff or youth. (4) opportunity for the youth to be heard, present Residential Treatment Services Bureau evidence and testimony; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (5) provision for youth to be assisted by staff in the Residential Treatment Services Bureau hearing process; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. . (6) provision for administrative review. Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (g) violations that result in a removal from camp or Residential Treatment Services Bureau commitment program, but not a return to court, will (RTSB) Manual Section 604: Continuum of ☒ ☐ ☐ follow the due process provisions in subsection (e) Correction above. f 7261 Los Angeles Camp Rockey 18-20 PRO - 71 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the ☒ ☐ ☐ facility. (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Viola Dependent or neglected minors who are defined under ☒ ☐ tion Section 300 of the Welfare and Institutions 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 ☐Viola ☐ ☒ Delinquents (WIC 602)? (WIC 207[d]). tion 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 ☐Viola ☐ ☒ from minors. tion Adult inmates from an adult facility (e.g. inmate workers or ☐Viola “Scared Straight” programs) are not allowed in the facility in ☐ ☒ tion a manner that allows contact with minors. 7261 Los Angeles Camp Rockey 18-20 PRO - 72 - J453 JUV PRO-Eff. 01-01-2019 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections Applicable Title 24 Regulations: Pre-1998* BSCC Code: 7261 FACILITY NAME: FACILITY TYPE: Glenn Rockey Camp CONSTRUCTION/REMODEL DATE(S): 1981 IDENTIFY FACILITY PHYSICAL PLANT MODIFICATIONS SINCE 1992: 1978 FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the Physical Plant per administration. Provided for information only** TITLE 24 SECTION YES NO N/A COMMENTS RECEPTION AREA (JH) This applies only to Juvenile Halls. ✓ Holding Rooms: Contain 15 square feet per minor; Have sufficient seating to accommodate the rated ✓ capacity based on floor space; Provide access to water closets and wash basins ✓ at a ratio of a 1:8; and Provide access to drinking fountain. ✓ Provide access to telephone. ✓ Provide access to private room(s) for interviews. ✓ MEDICAL EXAM SPACE (JH & CAMP) Space or room(s) afford privacy, are equipped to carry ✓ out routine examinations and emergency care and have sufficient locked storage space for medical supplies. LIVING UNITS (JH AND SPJH) This applies only to Juvenile Halls and Special Purpose Juvenile Halls. ✓ Living units are designed to accommodate no more than 30 minors and contain: Showers at a ratio of 1:6; ✓ Washbasins at a ratio of 1:6; ✓ Water closets at a ratio of 1:6 or water closet and ✓ one urinal for every 15 boys; and, Access to a drinking fountain by minors and staff. ✓ Doors of each sleeping room have a view panel (maximum of 144 square inches of shatter-proof glass ✓ or plastic materials) that allows the visual supervision of all parts of the room. Hallways in the detention living units are at least eight feet wide. If rooms are located on only one side, or if ✓ room doors are staggered, hallways are at least six feet wide. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7261 Los Angeles Camp Rockey 18-20 PHY - 1 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SINGLE ROOMS (JH, SPJH & CAMP) The Special Handling Unit contains 20 single rooms. Contain a minimum of 500 cubic feet of air space and ✓ 63 cubic feet of floor space. DOUBLE ROOMS (JH, SPJH & CAMP) There are no double rooms in this camp. ✓ Contain a minimum of 800 cubic feet of airspace and 100 square feet of floor space. DORMITORY SLEEPING AREAS (JH & CAMP) ✓ Contain a minimum of 400 cubic feet of airspace and 50 square feet of floor space per minor. LOCKED SLEEPING ROOMS (JH, SPJH & CAMP) The SHU rooms are not equipped with these fixtures, but youth have access to such Contain an individual or combination drinking fountain, facilities. ✓ wash basin and toilet, unless a communication system or procedure is in effect to give minor immediate access to these fixtures. PLUMBING FIXTURES (CAMP) The following plumbing fixtures are adjacent to each ✓ sleeping area: Shower or bathtub at a ratio of 1:6; Washbasins at a ratio of 1:10; ✓ Access to toilets at a ratio of 1:10 or toilet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain. ✓ BEDS AND MATTRESSES (JH, SPJH & CAMP) Beds and mattresses are: ✓ A least 30 inches wide and 76 inches long; Spaced at least 36 inches apart and at least 12 ✓ inches off the floor; and, Mattresses are made of a fire retardant material. ✓ INTERVIEW ROOMS (JH, SPJH & CAMP) ✓ There is one interview room for each detention unit in juvenile halls and special purpose juvenile halls. There is a private room suitably equipped for ✓ conferences and interviews in each camp. LIGHTING (JH, SPJH & CAMP) There are at least 50 foot candles of illumination at ✓ desk level and, at night, there is a maximum illumination of two foot candles at bed level in individual and multiple occupancy rooms. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7261 Los Angeles Camp Rockey 18-20 PHY - 2 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS ACADEMIC CLASSROOM (JH & CAMP) Each classroom contains a minimum of 160 square feet with a teacher's desk and work area, and a ✓ minimum of 28 square feet per student. Classrooms should be designed for no more than 15 students. 98: Designed for no more than 20 students DINING SPACE (JH & CAMP) ✓ There is a minimum of 15 square feet of space for each person being fed at any given time. PHYSICAL ACTIVITY SPACE (JH & CAMP) (See 2001 regulations for revised calculations.) There is indoor space consisting of at least 30 square ✓ feet of clear space for each minor, which may be included in a day room, a recreational building, or a multipurpose space (gymnasium). There is outdoor and/or multipurpose (gymnasium) space consisting of: ✓ No less than the equivalent of 90' X 100' outdoor and /or multipurpose space (gymnasium) for a facility with a capacity of 40 or less. No less than the equivalent of 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40, and a juvenile hall with a capacity between 41 to 100 minors. No less than the equivalent of two 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with ✓ a capacity of more than 40 and a juvenile hall with a capacity in excess of 101 minors. Lighting is adequate for security and evening ✓ recreational activities in camps. STORAGE SPACE (JH, SPJH & CAMP) ✓ Each minor is provided 9 cubic feet of secure storage space for personal clothing and belongings. Camps shall have adequate space (12 square feet of floor area is recommended) for bulk and activity ✓ storage equipment. MULTIPURPOSE SPACE OR ROOM (SPJH) This applies only to Special Purpose Juvenile Halls. There is a multipurpose space or room that provides space for reception, dining, recreation, exercise and/or ✓ education. This room contains a minimum of: 30 square feet of clear floor space per minor in the ✓ room; 10 feet by 20 feet floor dimensions; and, ✓ 1600 cubic feet of air space with a minimum ✓ ceiling height of eight feet. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7261 Los Angeles Camp Rockey 18-20 PHY - 3 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SPECIAL PURPOSE JH EXEMPTIONS SPJHs are exempt from the following Pre-1998 Title 15 regulations: ✓ Section 4272(b) Medical exam rooms Section 4272(m) Academic classrooms Section 4272(n) Dining space Section 4272(o) Physical activities space *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7261 Los Angeles Camp Rockey 18-20 PHY - 4 - J455 PHY Pre-98.dot (03/01) JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION BOARD OF STATE AND COMMUNITY CORRECTIONS INSPECTION BSCC Code: 7261 FACILITY: TYPE: RC: Glenn Rockey Camp 125 FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ALL DIMENSIONS BASED ON CYA DATA UNLESS OTHERWISE DESIGNATED. ROOMS EACH ROOM Unit Room Applicable # Each Room Total Size (L x W x H) FIXTURES* COMMENTS or Designation Type Standards Room # RC RC Square/Cubic T U W F S s Beds Feet Dormitory Dorm Pre-98 1 125 105 105 160’ x 39’ = 6,058 2 Day Pre-98 1 40’ x 19’ =760 room Rest Pre-98 1 7 8 2 1 Three “bird bath” wash basins w/ 8 spigots each. 4 5 room HOPE Day Pre-98 2* 30’ x 26.5’ = 780 1 room Rest Pre-98 1 2 1 2 3 room Single Pre-98 10 1 1 10 8’ x 12’ = 96 All dry rooms. Rest Pre-98 1 2 1 2 3 room Single Pre-98 10 1 1 10 8’ x 12’ = 96 All dry rooms. Historical Notes: NOTES: The SHU has two separate bathroom areas and two dayroom areas. * Per agreement with the CYA, one of the two dayroom areas in the SHU was allowed to be designated as a classroom. 2011: At the time of the 2010-12 inspection, the SHU dayroom referred to above was used as program, rather than classroom space. 2013: The restroom to the left of the control area has been posted as off limits to youth. *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. 7261 LA Camp Rockey LASE - 1 - Juv LAS.dot;CSA 460(1/6/97) 2014-2016 Inspection Cycle Notes: RC stands at 125 however the facility has removed beds to provide for programing space, mental health staff offices etc. Changes have occurred in a way beds can be re installed in a matter of a few days. 2016-2018 Inspection Cycle Notes: No Changes to RC **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** *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. 7261 LA Camp Rockey LASE - 2 - Juv LAS.dot;CSA 460(1/6/97) JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS Board of State and Community Corrections PROCEDURES CHECKLIST1 BSCC Code: 7267 FACILITY NAME: FACILITY TYPE: Joseph Scott Juvenile Camp PERSON(S) INTERVIEWED: Jose Villar, Director; Lizet Barboza, DPO II; Neena Boelter, Program Analyst FIELD REPRESENTATIVE: DATE: Lisa Southwell Manual Reviewed-June 26, 2020 Virtual Documentation Review TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1313 COUNTY INSPECTION AND Residential Treatment Services Bureau EVALUATION OF BUILDING AND GROUNDS (RTSB) Manual Section -2001: Inspections On an annual basis, or as otherwise required by law, and Evaluation of Building and Grounds each juvenile facility administrator shall obtain a documented inspection and evaluation from the following: (A) County building inspection by agency designated by Residential Treatment Services Bureau the Board of Supervisors to approve building safety; (RTSB) Manual Section -2002: Types of Inspections and Evaluations 2018 inspections were verified to have occurred. 2019 ☐ ☒ ☐ The building inspection was completed by Tennyson D’Sena Facility was inspected on August 20, 2019. Corrections are required. Youth were moved from Camp Scott to Dorothy Kirby Center on May 9, 2020. 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. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 1 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (B) Fire authority having jurisdiction, including a fire Residential Treatment Services Bureau clearance as required by Health and Safety Code (RTSB) Manual Section -2002: Types of Section 13146.1 (a) and (b); Inspections and Evaluations Fire inspection completed on August 29, 2019 and June 8, 2020. The fire clearance was withheld in 2019 due to pending corrections of deficiencies. The inspection completed in 2020 indicated “Prisoners no ☐ ☒ ☐ longer detained at this facility” and noted corrections were required. If the camp will continue to be used in the future, this issue is non-compliant and must be addressed through corrective action. If the camp will be closed permanently, never to reopen, this section will not need to be corrected as part of the corrective action process. (C) Local health officer, inspection in accordance with Residential Treatment Services Bureau Health and Safety Code Section 101045; (RTSB) Manual Section -2002: Types of Inspections and Evaluations Los Angeles County Department of Public Health conducts all local health inspections. Tia Mao, RN, BSN, MSHCM, PHN, Medical/Mental Health Evaluator conducted the Medical/Mental Health (MMH) inspections, David Kornoff, EHS III conducted the Nutrition (N) inspections and Jangbir Singh, REHS conducted the ☐ ☒ ☐ Environmental Health (EH) inspections as noted below. 2018 Inspections were verified to have occurred. 2019 Inspections are noted as follows: Medical Mental Health: January 29-30 and February 6, 2019 Nutrition: February 6, 2019 Environmental Health: February 6, 2019 There are outstanding corrections necessary for the medical/mental health inspection. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 2 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (D) County superintendent of schools on the adequacy Residential Treatment Services Bureau of educational services and facilities as required in (RTSB) Manual Section -2002: Types of Section 1370; Inspections and Evaluations Education for the is provided by the Los Angeles County Office of Education. ☒ ☐ ☐ 2019 The education program was evaluated by Kim Herrera and Karen Loucks, Principals from Taft California found the education program to comply with all regulatory requirements. (E) Juvenile court as required by Section 209 of the Residential Treatment Services Bureau Welfare and Institutions Code (RTSB) Manual Section -2002: Types of ☐ ☐ ☒ Inspections and Evaluations No documentation provided. Not required for Juvenile Camps. (F) Juvenile Justice Commission as required by Section Residential Treatment Services Bureau 229 of the Welfare and Institutions Code or (RTSB) Manual Section -2002: Types of Probation Commission as required by Section 240 of ☐ ☒ ☐ Inspections and Evaluations the Welfare and Institutions Code. A report was not completed for the camp. This is non-compliant. 1320 APPOINTMENT AND QUALIFICATIONS A letter, dated September 28, 2019, was BSCC Note: Compliance with this section is received from Chief Probation Officer Terri determined by receipt of the Chief Probation Officer’s McDonald certifying that appointments and qualifications of agency staff comply with all certification letter confirming that all elements of elements of regulation. regulation are met. (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: (1) recruit and hire employees who possess 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 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 pursuant to Section 6035 of the Penal Code; and 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 3 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) conduct a criminal records review, on each new employee, and psychological examination in ☒ ☐ ☐ accordance with Section 1031 et seq. of the Government Code. (c) Contract personnel, volunteers, and other non- Per facility administrators, all contract employees of the facility, who may be present at the personnel, volunteers and other non- facility, shall have such clearance and qualifications employees participate in background checks and are approved through each facility for as may be required by law, and their presence at the ☒ ☐ ☐ entrance with the exception of LACOE who facility shall be subject to the approval and control of conducts their own criminal records review the facility manager. as required by the Probation Department. Probation maintains control as to who has access into the facility. 1321 STAFFING Residential Treatment Services Bureau (RTSB) Manual Section -206: Staffing Each juvenile facility shall: Random dates were requested throughout the cycle and facility schedules and staffing lists were provided for our review to determine adequacy of staffing levels. Documentation was provided from August 2019 and January 2020 for our review. Documentation provided included facility staff rosters of sworn staff and collaborative partner staff. Dorm schedules were also provided which noted population in the dorm, staffing levels, supervisors on duty and identified the shift leader. It appears the facility was staffed appropriately for the number of youth housed. a) have an adequate number of personnel sufficient to Residential Treatment Services Bureau carry out the overall facility operation and its (RTSB) Manual Section -206: Staffing programming, to provide for safety and security of ☒ ☐ ☐ youth and staff, and meet established standards and regulations; b) ensure that no required services shall be denied Residential Treatment Services Bureau because of insufficient numbers of staff on duty ☒ ☐ ☐ (RTSB) Manual Section -206: Staffing absent exigent circumstances; 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 4 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS c) have a sufficient number of supervisory level staff to Residential Treatment Services Bureau ensure adequate supervision of all staff members; (RTSB) Manual Section -206: Staffing At the time of inspection, Camp Scott had 7 ☒ ☐ ☐ supervisors assigned to the facility with one vacancy. The facility has an awake supervisor on duty throughout the late-night hours. d) have a clearly identified person on duty at all times Residential Treatment Services Bureau who is responsible for operations and activities and (RTSB) Manual Section -206: Staffing has completed the Juvenile Corrections Officer Core Course and PC 832 training; The facility director is responsible for the ☒ ☐ ☐ overall operations of the facility, but the supervisor is responsible for the daily operations of the facility. Camp Scott also identifies a Shift Leader for each shift. e) have at least one staff member present on each living Residential Treatment Services Bureau unit whenever there are youth in the living unit; (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ There is always a staff present in the dorm or where a youth is present. Youth are never left alone per consultant staff. f) have sufficient food service personnel relative to the Residential Treatment Services Bureau number and security of living units, including staff (RTSB) Manual Section -206: Staffing qualified and available to: plan menus meeting nutritional requirements of youth; provide kitchen The facility has a full dining hall. All youth supervision; direct food preparation and servings; ☒ ☐ ☐ eat their meals in the dining hall unless they conduct related training programs for culinary staff; refuse to leave the dorm. The dining hall is and maintain necessary records; or, a facility may staffed by facility cooks who plan and serve food that meets nutritional standards prepared prepare all meals. Cooks do not supervise by an outside source; youth. g) have sufficient administrative, clerical, recreational, Residential Treatment Services Bureau medical, dental, mental health, building (RTSB) Manual Section -206: Staffing maintenance, transportation, control room, facility ☒ ☐ ☐ security and other support staff for the efficient management of the facility, and to ensure that youth supervision staff shall not be diverted from supervising youth; and, h) assign sufficient youth supervision staff to provide Residential Treatment Services Bureau continuous wide-awake supervision of youth, (RTSB) Manual Section -206: Staffing subject to 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: 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 5 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Juvenile Halls (minimum youth-staff ratio) Facility is not a Juvenile Hall. (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 Facility is not a Juvenile Hall. 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 Facility is not a Juvenile Hall 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 Facility is not a Juvenile Hall ☐ ☐ ☒ who is the same gender as youth housed in the facility. (E) personnel with primary responsibility for other Facility is not a Juvenile Hall duties such as administration, supervision of ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (2) Special Purpose Juvenile Halls (minimum youth- Facility is not a Special Purpose Juvenile staff ratio) Hall ☐ ☐ ☒ (A) during hours that youth are awake, one wide-awake youth supervision staff member is on duty for each 10 youth in detention; (B) during the hours that youth are confined to their room Facility is not a Special Purpose Juvenile for the purpose of sleeping, one wide-awake youth Hall ☐ ☐ ☒ supervision staff member on duty for each 30 youth in detention; (C) at least two wide-awake youth supervision staff Facility is not a Special Purpose Juvenile members on duty at all times, regardless of the Hall ☐ ☐ ☒ 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 Facility is not a Special Purpose Juvenile who is the same gender as youth housed in the Hall ☐ ☐ ☒ facility. (E) personnel with primary responsibility for other Facility is not a Special Purpose Juvenile duties such as administration, supervision of Hall ☐ ☐ ☒ personnel, academic or trade instruction, clerical, kitchen or maintenance shall not be classified as youth supervision staff positions. (3) Camps (minimum youth -staff ratio) Residential Treatment Services Bureau (A) during the hours that youth are awake, one wide- (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ awake youth supervision staff member on duty for each 15 youth in the camp population; 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 6 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (B) during the hours that youth are confined to their Residential Treatment Services Bureau room for the purpose of sleeping, one wide-awake (RTSB) Manual Section -206: Staffing ☒ ☐ ☐ youth supervision staff member on duty for each 30- youth present in the facility; (C) at least two wide-awake youth supervision staff Residential Treatment Services Bureau members on duty at all times, regardless of the (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau who is the same gender as youth housed in the (RTSB) Manual Section -206: Staffing facility; ☒ ☐ ☐ There are always male and female staff on duty. (E) in addition to the minimum staff to youth ratio Residential Treatment Services Bureau required in (h)(3)(A)-(B), consideration shall be (RTSB) Manual Section -206: Staffing 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 Residential Treatment Services Bureau duties such as administration, supervision of (RTSB) Manual Section -206: Staffing personnel, academic or trade instruction, clerical, ☒ ☐ ☐ Only youth supervision staff provide farm, forestry, kitchen or maintenance shall not be supervision of the youth. classified as youth supervision staff positions. 1322 YOUTH SUPERVISION STAFF Residential Treatment Services Bureau ORIENTATION AND TRAINING (RTSB) Manual -2104: Professional (a) Prior to assuming any responsibilities each youth Development and Training (policy is supervision staff member shall be properly oriented compliant) to their duties, including: All staff assigned to RTSB have completed Correctional Officer CORE training prior to reporting to the facility. Upon assignment, each staff is paired with a ☒ ☐ ☐ onsite training officer who assists them in their orientation and training. Training transcripts were provided as verification of required training which includes CORE. These training transcripts documented the mandated trainings. We were unable to view individual training files for the specific location training as we were not on site. Compliance is based on policy alone. We will verify training documents when back on site. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 7 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) youth supervision duties; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) scope of decisions they shall make; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (3) the identity of their supervisor; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) the identity of persons who are responsible to Residential Treatment Services Bureau them; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) persons to contact for decisions that are beyond Residential Treatment Services Bureau their responsibility; and ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (6) ethical responsibilities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (b) Prior to assuming any responsibility for the Residential Treatment Services Bureau supervision of youth, each youth supervision staff (RTSB) Manual -2104: Professional ☒ ☐ ☐ member shall receive a minimum of 40 hours of Development and Training facility-specific orientation, including: (1) individual and group supervision techniques; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (2) regulations and policies relating to discipline and Residential Treatment Services Bureau rights of youth pursuant to law and the ☒ ☐ ☐ (RTSB) Manual -2104: Professional provisions of this chapter; Development and Training (3) basic health, sanitation and safety measures; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (4) suicide prevention and response to suicide Residential Treatment Services Bureau attempts ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (5) policies regarding use of force, de-escalation Residential Treatment Services Bureau techniques, chemical agents, mechanical and (RTSB) Manual -2104: Professional physical restraints; Development and Training ☒ ☐ ☐ The facility does not use chemical agents in the camp setting. (6) review of policies and procedures referencing Residential Treatment Services Bureau trauma and trauma-informed approaches; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (7) procedures to follow in the event of Residential Treatment Services Bureau emergencies; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (8) routine security measures, including facility Residential Treatment Services Bureau perimeter and grounds; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 8 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (9) crisis intervention and mental health referrals to Residential Treatment Services Bureau mental health services; ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (10) documentation; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (11) fire/life safety training Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual -2104: Professional Development and Training (c) Prior to assuming sole supervision of youth, each Residential Treatment Services Bureau youth supervision staff member shall successfully (RTSB) Manual -2104: Professional complete the requirements of the Juvenile ☒ ☐ ☐ Development and Training Corrections Officer Core Course pursuant to Penal Code Section 6035. (d) Prior to exercising the powers of a peace officer Residential Treatment Services Bureau youth supervision staff shall successfully complete (RTSB) Manual -2104: Professional ☒ ☐ ☐ training pursuant to Section 830 et seq. of the Penal Development and Training Code. 1323 FIRE AND LIFE SAFETY Residential Treatment Services Bureau (RTSB) Manual -2104: Professional Whenever there is a youth in a juvenile facility, there Development and Training shall be at least one wide awake person on duty at all ☒ ☐ ☐ times who meets the training standards established by the All staff are trained in fire and life safety in Board for general fire and life safety which relate CORE training. All Supervisors have been specifically to the facility. trained. There will always be a supervisor on duty. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 9 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1324 POLICY AND PROCEDURES MANUAL The agency manual is specific to RTSB and All facility administrators shall develop, publish, and camp operations and has been provided to the implement a manual of written policies and procedures BSCC for review. The manual was last that address, at a minimum, all regulations that are reviewed and updated in June 2020. applicable to the facility. Such a manual shall be made available to all employees, reviewed by all employees, The BSCC has reviewed the agency Policy and shall be administratively reviewed at a minimum and Procedure as provided to us specific to every two years, and updated, as necessary. Those regulations and has confirmed the policies records relating to the standards and requirements set and procedure exist as cited. There may be forth in these regulations shall be accessible to the Board cites noted in the comments that may not on request. match due to updates that were unable to be The manual shall include: reverified. ☒ ☐ ☐ Staff access the policy manual via the local intranet known as “Prob. Net”. Staff review specific sections of the policy manual while in CORE training but not the full manual. There is no formalized process or review to determine or ensure that staff have read and understand the manual in its entirety. In all cases, copies of policies and directives were provided that were not from the current manual. Technical assistance provided and discussed that this should be rectified. (a) table of organization, including channels of Residential Treatment Services Bureau communications and a description of job (RTSB) Manual Sections: classifications; • 101: Vision, Mission, and Core Values • 102: Role of the Camp System • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff • 207: Organizational Chart The manual has a table of contents. They agency channel of communication follows chain of command. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 10 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) responsibility of the probation department, purpose Residential Treatment Services Bureau of programs, relationship to the juvenile court, the (RTSB) Manual Sections: Juvenile Justice/Delinquency Prevention • 101: Vision, Mission, and Core Commission or Probation Committee, probation Values staff, school personnel and other agencies that are • 102: Role of Camp System involved in juvenile facility programs; • 908: Medical Services • 909: Mental Health Services ☒ ☐ ☐ • 910: Educational Services • 1005: Community Based Organizations • 1006: Volunteers (c) responsibilities of all employees; Residential Treatment Services Bureau (RTSB) Manual Sections: • 202: RTSB Administrative Structure 203: Duty Statements, RTSB Management ☒ ☐ ☐ • 204: Duty Statements, Deputized Staff • 205: Duty Statements, Camp Support Staff (d) initial orientation and training program for Residential Treatment Services Bureau employees; (RTSB) Manual -2104: Professional Development and Training ☒ ☐ ☐ See Section 1322 (e) initial orientation, including safety and security Residential Treatment Services Bureau issues and anti-discrimination policies, for support (RTSB) Manual -2200: Non-Sworn staff, contract employees, school, mental/behavioral Personnel and Partner Agencies Handbook health and medical staff, program providers and ☐ ☐ UNK Unable to view employee training files as not volunteers; on site. Compliance is based on policy. We will verify training documents when back on site. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 11 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) maintenance of record-keeping, statistics and Residential Treatment Services Bureau communication system to ensure: (RTSB) Manual 701: Case Planning and Procedures and 702-General Duties and Responsibilities RTSB maintains an extensive record- keeping system to record operations and to report on the youth in its care. Through these reports, the RTSB is able to document ☒ ☐ ☐ and retrieve accurate accounts of specific incidents or operations and to develop a database for statistical analysis. The assigned camp DPO is responsible for the casework functions while the youth is in the camp setting. The supervisor is responsible to ensure that all information is thoroughly documented within the Probation Case Management System. (1) efficient operation of the juvenile facility; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (2) legal and proper care of youth; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (3) maintenance of individual youth's records; Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (4) supply of information to the juvenile court and Residential Treatment Services Bureau those authorized by the court or by the law; and, (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (5) release of information regarding youth. Residential Treatment Services Bureau (RTSB) Manual 701: Case Planning and ☒ ☐ ☐ Procedures and 702-General Duties and Responsibilities (g) ethical responsibilities; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-2130: Employee Honesty (h) trauma-informed approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-518: Trauma Informed Approaches (i) culturally responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-519: Culturally Responsive Approaches 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 12 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (j) gender responsive approaches; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual-517: Promoting Dignity for Female Youth Housed in RTSB (k) a non-discrimination provision that provides that all Residential Treatment Services Bureau youth within the facility shall have fair and equal (RTSB) Manual-2110: Non-Discrimination access to all available services, placement, care, Policy treatment, and benefits, and provides that no person shall be subject to discrimination or harassment on the basis of actual or perceived race, ethnic group ☒ ☐ ☐ identification, ancestry, national origin, immigration status, color, religion, gender, sexual orientation, gender identity, gender expression, mental or physical disability, or HIV status, including restrictive housing or classification decisions based solely on any of the above mentioned categories; (l) storage and maintenance requirements for any Residential Treatment Services Bureau chemical agents related security devices, and (RTSB) Manual-1922: Weapons and ☒ ☐ ☐ weapons and ammunition, where applicable; Ammunition (m) establishment of procedures for collection of Medi- Residential Treatment Services Bureau Cal eligibility information and enrollment of eligible ☒ ☐ ☐ (RTSB) Manual-706: Case Plan Activities youth; and, (n) establishment of a policy that prohibits all forms of Residential Treatment Services Bureau sexual abuse, sexual assault and sexual harassment. (RTSB) Manual-1600: Prison Rape The policy shall include an approach to preventing, Elimination Act detecting and responding to such conduct and any retaliation for reporting such conduct, as well as a ☒ ☐ ☐ Staff are trained in PREA within their first provision for reporting such conduct by youth, staff year of employment and every two years or a third party. thereafter. 1325 FIRE SAFETY PLAN Residential Treatment Services Bureau The facility administrator shall consult with the local fire (RTSB) Manual-1910: Fire Prevention and department having jurisdiction over the facility, or with ☒ ☐ ☐ Suppression the State Fire Marshal, in developing a plan for fire safety which shall include, but not be limited to: a) a fire prevention plan to be included as part of the Residential Treatment Services Bureau manual of policy and procedures; (RTSB) Manual-1910: Fire Prevention and ☒ ☐ ☐ Suppression b) monthly fire and life safety inspections by facility Residential Treatment Services Bureau staff with two- year retention of the inspection (RTSB) Manual-1910: Fire Prevention and record; Suppression ☒ ☐ ☐ Physical Plant Maintenance Inspections are completed monthly by Management Services Bureau (MSB) staff. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 13 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS c) fire prevention inspections as required by Health Residential Treatment Services Bureau and Safety Code Section 13146.1(a) and (b); (RTSB) Manual-1910: Fire Prevention and ☐ ☒ ☐ Suppression See Section 1313 d) an evacuation plan; Residential Treatment Services Bureau (RTSB) Manual Sections: 1910: Fire Prevention and Suppression 1917: Emergency Evacuation ☒ ☐ ☐ Facility provided County of Los Angeles Building Emergency Plan, and site evacuation maps for our review. e) documented fire drills not less than quarterly; Residential Treatment Services Bureau (RTSB) Manual-1910: Fire Prevention and Suppression ☒ ☐ ☐ All fire drills were completed except for one. Staff will ensure that all drills are completed in the future. f) a written plan for the emergency housing of youth in Residential Treatment Services Bureau the case of fire; and, (RTSB) Manual-1917: Emergency Evacuation ☒ ☐ ☐ Emergency housing will always be at one of the camps or juvenile halls dependent on location of the fire and a safe route of travel. g) development of a fire suppression pre-plan In Residential Treatment Services Bureau cooperation with the local fire department. (RTSB) Manual-1910: Fire Prevention and Suppression The County of Los Angeles Building ☒ ☐ ☐ Emergency Plan for Camp Joseph Scott was signed by Fire Inspector D. Narsworthy on October 12, 2019. The 2020 document was signed off by Robert Shick at Fire Station 108, Santa Clarita CA 91390. 1326 SECURITY REVIEW Residential Treatment Services Bureau (RTSB) Manual- 1312: Security Checks Each facility administrator shall develop policies and procedures to annually review, evaluate, and document Security review was completed May 6, 2019 security of the facility. The review and evaluation shall ☒ ☐ ☐ by Sharmane Franklin, Director of Camp include internal and external security, including, but not Joseph Scott. The review was provided to the limited to, key control, equipment, and staff training. Senior director and included pictures of the issues. 1327 EMERGENCY PROCEDURES The facility administrator shall develop facility-specific ☐ ☐ ☒ policies and procedures for emergencies that shall include, but not be limited to: 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 14 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) escape, disturbances, and the taking of hostages; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1907 Escapes 1909: Major Disturbances 1914: Hostages (b) civil disturbance, active shooter and terrorist attack; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1908: Outside Intruder 1915: Active Shooter 1916: Terrorist Attack (c) fire and natural disasters; Residential Treatment Services Bureau (RTSB) Manual Sections: ☒ ☐ ☐ 1910: Fire Prevention and Suppression 1913: Earthquake (d) periodic testing of emergency equipment; Residential Treatment Services Bureau (RTSB) Manual Sections: 1321: Testing of Emergency Equipment ☒ ☐ ☐ Internal Services Department (ISD) conducts monthly and as needed testing in coordination with MSB. (e) emergency evacuation of the facility; and Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections: 1917: Emergency Evacuation (f) a program to provide all youth supervision staff Residential Treatment Services Bureau with an annual review of emergency procedures. (RTSB) Manual Sections: 1903: Staff Roles and Responsibilities ☒ ☐ ☐ All staff completed emergency procedure training. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 15 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1328 SAFETY CHECKS Residential Treatment Services Bureau (RTSB) Manual Sections: 1313: Safety The facility administrator shall develop and implement Checks and Section 1119 policy and procedures that provide for direct visual observation of youth at a minimum of every 15 minutes, We reviewed random safety checks from the at random or varied intervals during hours when youth documentation provided (September and are asleep or when youth are in their rooms, confined in November 2019) and found the majority of holding cells or confined to their bed in a dormitory. checks are completed consistent to Supervision is not replaced, but may be supplemented regulatory time expectations with minimal by, an audio/visual electronic surveillance system discrepancies. This section is compliant with designed to detect overt, aggressive or assaultive regulation. behavior and to summon aid in emergencies. All safety checks shall be documented with the actual time the Policy also requires supervisors to regularly check is completed. audit safety check logs by making unannounced inspections at least once a shift of the Safety Check Sheets in the buildings under their supervision. Supervisors are to ensure compliance and to assure that staff ☒ ☐ ☐ are completing the checks according to policy. Supervisors are to document their name, date, time of the audit under the last check. We noted that supervisors are not completing their regular audits of safety checks as required by policy except for the late-night shift which we found to be completed with the most consistency. A work instruction memo was provided to staff in March 2020 to address the issue of supervisor oversight and other concerns of facility managers not related to regulation. Additional documentation was provided that noted some improvement was made. Technical assistance provided that operations and policy must be consistent and there should be follow up and training in this area as well. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 16 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1329 SUICIDE PREVENTION PLAN Residential Treatment Services Bureau The facility administrator, in collaboration with the (RTSB) Manual Sections: 1201: Suicide healthcare and behavioral/mental health administrators, Prevention Plan shall plan and implement written policies and procedures which delineate a Suicide Prevention Plan. 1201: Suicide prevention Plan 1202 Enhanced and Specialized Supervision The plan shall consider the needs of youth experiencing Requirements for Youths in Juvenile past or current trauma. Facilities Suicide prevention responses shall be respectful and in 1203: Suicide Prevention Policy for Juvenile the least invasive manner consistent with the level of Facilities (Cross ref with directive 1186) suicide risk. Policy was developed in collaboration with The plan shall include the following elements: Juvenile Court Health Services (JCHS) and ☒ ☐ ☐ the Department of Mental Health (DMH). Documentation provided consisted of policies, procedures and directives for suicide prevention, enhanced and specialized supervision, assessment and classification and an alert log sample. There were no samples of incident reports for suicide threat, behavior or attempts or risk of suicide provided. Compliance in subsequent areas are based on policy and admission/intake documents. We will follow up when on site to ensure continued compliance in the future. (a) Suicide prevention training as required in Residential Treatment Services Bureau Section 1322, Youth Supervision Staff (RTSB) Manual Sections: 1203: Suicide Orientation, and Training and the Juvenile Prevention Policy for Juvenile Facilities and Corrections Officer Core Course. 2104: Professional Development and ☒ ☐ ☐ Training. Staff are trained in CORE training and annual refresher training 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 17 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) Screening, Identification Assessment and Residential Treatment Services Bureau Precautionary Protocols (RTSB) Manual Sections:1202: Enhanced (1) All youth shall be screened for risk of and Specialized Supervision Requirements suicide at intake and as needed during of Youth in Juvenile Facilities and 1203: detention. Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ All youth are screened prior to entry by DMH who conduct a Juvenile Justice Child/Adolescent Assessment. A DPOII Clinician and DMH staff member interview youth at Juvenile Hall prior to arrival to the Camp. Once at camp all youth are screened again at intake with the Initial Intake, Screening and Referral Questionnaire. (2) All youth supervision staff who perform Residential Treatment Services Bureau intake processes shall be trained in (RTSB) Manual Sections: 1203: Suicide screening youth for risk of suicide. Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Staff who complete intake/admissions are trained in completing them. Suicide update training is completed annually as part of the Enhanced Supervision Training. (3) All youth who have been identified during Residential Treatment Services Bureau the intake screening process to be at risk of (RTSB) Manual Section: 1203: Suicide suicide shall be referred to Prevention Policy for Juvenile Facilities behavioral/mental health staff for a suicide risk assessment. ☒ ☐ ☐ We did not find any youth to be suicidal at intake based on the documentation we reviewed; however, bureau staff stated that youth would be referred to DMH for follow up. (4) Precautionary protocols shall be developed Residential Treatment Services Bureau to ensure the youth’s safety pending the (RTSB) Manual Sections:1202: Enhanced behavioral/mental health assessment. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ In most cases, mental health staff are on site and see the youth as soon as possible. If they are not on site, staff may also place the youth on level to ensure their safety. At risk youth may be placed on Enhanced Supervision levels, 1-4. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 18 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Referral process to behavioral/mental health Residential Treatment Services Bureau staff for assessment and/or services. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Policy requires all facility staff to complete a “Request for Mental Health Consultation” when appropriate. (d) Procedures for monitoring of youth identified Residential Treatment Services Bureau at risk for suicide. (RTSB) Manual Sections:1202: Enhanced and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Per policy, enhanced supervision Levels 1-4 determine the level of supervision a youth receives. Level 4 requires a constant supervision until a youth can be transported out to emergency hospitalization, Level 3 is a constant visual 1:1 supervision, Level 2; is 10-minute safety check and Level 1 is regular 15-minute safety checks. (e) Safety Interventions Residential Treatment Services Bureau (1) Procedures to address intervention (RTSB) Manual Sections:1202: Enhanced protocols for youth identified at risk for and Specialized Supervision Requirements suicide which may include, but are not ☒ ☐ ☐ of Youth in Juvenile Facilities limited to: A. Housing consideration Youth are placed on a SSP. Supervision and housing direction are included on the forms. B. Treatment strategies including Residential Treatment Services Bureau trauma-informed approaches (RTSB) Manual Section: 1203: Suicide Prevention Policy for Juvenile Facilities ☒ ☐ ☐ Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. (2) Procedures to instruct youth supervision Residential Treatment Services Bureau staff how to respond to youth who exhibit (RTSB) Manual Sections:1202: Enhanced suicidal behaviors. and Specialized Supervision Requirements of Youth in Juvenile Facilities and 1203: Suicide Prevention Policy for Juvenile ☒ ☐ ☐ Facilities Mental health staff provide direction to staff on the Mental Health Recording Form- Green Sheet. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 19 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (f) Communication Residential Treatment Services Bureau (1) The intake process shall include (RTSB) Manual Section: 1203: Suicide communication with the arresting officer Prevention Policy for Juvenile Facilities and family guardians regarding the youth’s past or present suicidal ideations, behaviors Youth are transported directly from the or attempts. Juvenile Hall to the camp. Policy states that the intake officer shall contact the youth’s ☐ ☒ ☐ parent and/or guardians via telephone during the initial intake process to gather information regarding the youth’s past or present suicidal ideations, behaviors or attempts. There was no documentation provided to show that this contact was made. (2) Procedures for clear and current Residential Treatment Services Bureau information sharing about youth at risk for (RTSB) Manual Section: 1203: Suicide suicide with youth supervision, healthcare, Prevention Policy for Juvenile Facilities and behavioral/mental health staff. ☒ ☐ ☐ There are protocols in place for sharing of information between facility partners. A new alert log is created each day and provided to all staff and agencies coming into contact with the youth. (g) Debriefing of Critical Incidents Related to Residential Treatment Services Bureau Suicides or Attempts (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ (1) Process for administrative review of the Prevention Policy for Juvenile Facilities circumstances and responses proceeding, during and after the critical incident. (2) Process for a debriefing event with affected Residential Treatment Services Bureau staff. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities (3) Process for a debriefing event with affected Residential Treatment Services Bureau youth. (RTSB) Manual Section: 1203: Suicide ☒ ☐ ☐ Prevention Policy for Juvenile Facilities 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 20 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) Documentation Residential Treatment Services Bureau (1) Documentation processes shall be (RTSB) Manual Sections:1202: Enhanced developed to ensure compliance with this and Specialized Supervision Requirements regulation of Youth in Juvenile Facilities and 1203: ☒ ☐ ☐ Suicide Prevention Policy for Juvenile Facilities Youth identified at risk for suicide shall not be denied Residential Treatment Services Bureau the opportunity to participate in facility programs, (RTSB) Manual Section: 1202: Enhanced services and activities which are available to other non- and Specialized Supervision Requirements suicidal youth, unless deemed necessary for the safety for Youths in Juvenile Facilities of the youth or security of the facility. Any deprivation of programs, services or activities for youth at risk of ☒ ☐ ☐ Technical assistance provided and discussed suicide shall be documented and approved by the that staff should be including consistent facility manager. documentation of all program’s youth participate in on the Enhanced Supervision Log. If youth do not participate, the reason why should be documented. 1340 REPORTING OF LEGAL ACTIONS Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each facility shall submit to the Board a letter of Statements, RTSB Management notification on each legal action, pertaining to conditions of confinement, filed against persons or legal entities ☒ ☐ ☐ The Camp Director is responsible to ensure responsible for juvenile facility operation. that all reporting is completed. No legal actions have been reported to the BSCC this cycle for this facility. 1341 DEATH AND SERIOUS ILLNESS OR Residential Treatment Services Bureau INJURY OF A YOUTH WHILE (RTSB) Manual Sections:1919: Deaths at DETAINED Camp Facilities (1) Death of a Youth. Policy was developed in collaboration with (a) The facility administrator, In cooperation with the Juvenile Court Health Services (JCHS) and health administrator and the behavioral/mental ☒ ☐ ☐ the Department of Mental Health (DMH), 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 Residential Treatment Services Bureau facility administrator, shall develop written policies (RTSB) Manual Sections:1919: Deaths at and procedures to assure there is a medical and Camp Facilities operational review of every in-custody death of 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. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 21 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) The administrator of the facility shall provide to the Residential Treatment Services Bureau Board a copy of the report submitted to the Attorney (RTSB) Manual Sections:1919: Deaths at General under Government Code Section 12525. A ☒ ☐ ☐ Camp Facilities 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 Residential Treatment Services Bureau the administrator, the Board may within 30 calendar (RTSB) Manual Sections:1919: Deaths at days inspect and evaluate the juvenile facility, jail, Camp Facilities 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 Residential Treatment Services Bureau (a) The facility administrator, In cooperation with the (RTSB) Manual Section 1920: Serious health administrator, shall develop written policies Illness or Injury of a Youth While Detained 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 Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty Each juvenile facility shall submit required population Statements, RTSB Management and profile survey reports to the Board within 10 working days after the end of each reporting period, in ☒ ☐ ☐ The Camp Director is responsible to ensure a format to be provided by the Board. that all reporting is completed. All population reports were completed in a timely manner. 1343 JUVENILE FACILITY CAPACITY Residential Treatment Services Bureau (RTSB) Manual Sections:203: Duty When the number of youth detained in a living unit of a Statements, RTSB Management juvenile facility exceeds its rated capacity for more than fifteen (15) calendar days in a month, the facility ☒ ☐ ☐ The Camp Director is responsible to ensure administrator shall provide a crowding report to the that all reporting is completed. Board in a format provided by the Board. The facility has not exceeded their rated capacity this cycle. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 22 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350 ADMITTANCE PROCEDURES Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 400: Camp written policies and procedures for admittance of youth Admissions and Section 502: Orientation that emphasize respectful and humane engagement with Process and Handbook youth and reflect that the admission process may be The Admission process for camp youth traumatic to youth who may have already experienced begins before the youth arrive on campus. trauma. Policies shall be trauma-informed, culturally ☒ ☐ ☐ Youth are assessed and screened at Camp relevant, and responsive to the language and literacy Headquarters and again by camp staff, needs of youth. In addition to the requirements of medical and mental health before the youth Sections 1324 and 1430 of these regulations: even arrive. Upon arrival, youth are admitted and oriented by camp staff. Documentation of admission/intake paperwork for 20 random youth was provided for our review. (a) the admittance process shall include: Residential Treatment Services Bureau (1) Access to two free phone calls within one hour (RTSB) Manual Sections:502: Orientation of admittance in accordance with the provisions Process and Handbook of Welfare and Institution Code Section 627; Youth are to be provided with a phone call to ☒ ☐ ☐ notify their parent or guardian that they have been transferred to the Camp. Youth were provided with a phone call to notify their parent or guardian of their transfer. (2) Offer of a shower; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Documentation provided noted that all youth were provided with the opportunity to shower. (3) Documented secure storage of personal Residential Treatment Services Bureau belongings; (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Youth are transported to camp in juvenile hall clothing with only their juvenile hall personals. All personal clothing and belongings are released to their parents or guardians from the juvenile hall. (4) Offer of food upon arrival; Residential Treatment Services Bureau (RTSB) Manual Sections:502: Orientation Process and Handbook ☒ ☐ ☐ Documentation provided noted that all youth were provided with the opportunity to eat upon arrival. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 23 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (5) Screening for physical and behavioral health Residential Treatment Services Bureau and safety issues, intellectual or developmental (RTSB) Manual Sections:402: Assessment disabilities; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (6) Screening for physical and developmental Residential Treatment Services Bureau disabilities in accordance with Sections 1329, (RTSB) Manual Sections:402: Assessment 1418, and 1430 of these regulations; and Classification ☒ ☐ ☐ Per policy, this review is conducted prior to admission and staff review the youth’s paper and electronic files. (7) Contact with Regional Center for the Youth that are Regional Center Clients Developmentally Disabled for youth that are would not likely be ordered to a camp ☐ ☐ ☒ suspected of or identified as having a commit. developmental disability, pursuant to Section 1418; and, (8) Procedures consistent with Section 1352.5. Residential Treatment Services Bureau (RTSB) Manual Sections:403: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (b) juvenile hall administrators shall establish written Not Applicable criteria for detention that considers the least ☒ ☐ ☐ restrictive environment. (c) juvenile camps and post-dispositional programs in Residential Treatment Services Bureau juvenile halls shall develop policies and procedures (RTSB) Manual Sections:502: Orientation that advise the youth of the estimated length of Process and Handbook stay, inform them of program guidelines and ☒ ☐ ☐ provide written screening criteria for inclusion and Estimated length of stay estimates were exclusion from the program. consistently completed and documentation provided in packets provided. (d) juvenile halls shall develop policies and procedures Not Applicable that advise any committed youth of the estimated ☐ ☐ ☒ length of his/her stay. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 24 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1350.5. SCREENING FOR THE RISK OF SEXUAL Residential Treatment Services Bureau ABUSE (RTSB) Manual Sections: 402: Assessment The facility administrator shall develop and implement and Classification and 503: Screening for the written policies and procedures to reduce the risk of Risk of Sexual Abuse sexual abuse by or upon youth. The policy shall require facility staff to assess each youth within 72 hours of Policy is in place; however, documentation admission based on the following information: provided consists of PREA Risk questions ☐ ☒ ☐ on the intake screening assessment that are not consistent with regulation requirements. This section is non-compliant as the documentation process has not yet been implemented. Agency is in the process of finalizing and rolling out the new procedure. (a) Prior sexual victimization or abusiveness; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (b) Gender nonconforming appearance or manner; Residential Treatment Services Bureau or identification as lesbian, gay or bisexual, (RTSB) Manual Sections: 402: Assessment transgender, queer or intersex, and whether the ☐ ☒ ☐ and Classification and 503: Screening for the youth may, therefore, be vulnerable to sexual Risk of Sexual Abuse abuse; (c) Current charges and offense history; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (d) Age; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (e) Level of emotional and cognitive development; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (f) Physical size and stature; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (g) Mental illness or mental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (h) Intellectual or developmental disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 25 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (i) Physical disabilities; Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (j) The youth’s perception of vulnerability; and, Residential Treatment Services Bureau (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ and Classification and 503: Screening for the Risk of Sexual Abuse (k) Any other specific information about the Residential Treatment Services Bureau individual youth that may indicate heightened (RTSB) Manual Sections: 402: Assessment ☐ ☒ ☐ needs for supervision, additional safety and Classification and 503: Screening for the precautions, or separation from certain other Risk of Sexual Abuse youth. Staff shall ascertain this information through Residential Treatment Services Bureau conversations with the youth during the admittance (RTSB) Manual Sections:503: Screening for process, medical and behavioral health screenings; the Risk of Sexual Abuse ☐ ☒ ☐ during classification assessments; and by reviewing court records, case files, facility behavioral records, and Current procedure has not been other relevant documentation from the youth’s files. implemented. The facility administrator shall implement appropriate Residential Treatment Services Bureau controls on the dissemination of information within the (RTSB) Manual Sections:503: Screening for facility relative to responses received pursuant to this the Risk of Sexual Abuse ☐ ☒ ☐ assessment in order to ensure that sensitive information is not exploited to the youth’s detriment by staff or other It is unknown how the facility will ensure youth. documents are kept confidential. 1351 RELEASE PROCEDURES Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release The facility administrator shall develop and implement ☒ ☐ ☐ Procedures written policies and procedures for release of youth from custody which provide for: (a) verification of identity/release papers; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures (b) return of personal clothing and valuables; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures ☒ ☐ ☐ Compliance reviewed through Juvenile Hall Property Receipts. Parents/guardian bring clothing for youth to be released in on day of release. (c) notification to the youth's parents or guardian; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 26 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) notification to the facility health care provider in Residential Treatment Services Bureau accordance with Sections 1408 and 1437 of these (RTSB) Manual Sections:809: Release regulations, for coordination with outside agencies; Procedures and, ☒ ☐ ☐ Health care is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (e) notification of school staff; Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Education is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. (f) notification of facility mental health personnel. Residential Treatment Services Bureau (RTSB) Manual Sections:809: Release Procedures and 703: MDT Process ☒ ☐ ☐ Mental Health is included as a partner in the Transition MDT process. Partners are notified of release in advance through the MDT process and at the time of release. The facility administrator shall develop and implement Residential Treatment Services Bureau policies and procedures for post-disposition youth to (RTSB) Manual Section: 703: MDT Process coordinate the provision of transitional and reentry services including, but not limited to, medical and Each youth has a Transition MDT 45-60 behavioral health, education, probation supervision and days prior to release that addresses all community-based services. required services and other pertinent areas. All facility partners and the PO are present ☒ ☐ ☐ with the youth to discuss the plan. The youth’s parents or guardian are invited to participate and either attend in person or via a conference call. (Reference Regulation 1355) Transition plans were compliant with regulation requirements. The facility administrator shall develop and implement Residential Treatment Services Bureau written policies and procedures for the furlough of (RTSB) Manual Section: 1802: Private youth from custody. Appointments ☒ ☐ ☐ The agency has no formal furlough policy; however, will transport youth to private appointments for exigent circumstances such as funerals or hospital visits with a court order. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 27 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1352 CLASSIFICATION Residential Treatment Services Bureau (RTSB) Manual Sections:402: Assessment The facility administrator shall develop and implement and Classification Policy and Section 408: written policies and procedures on classification of Classification youth for the purpose of determining housing placement in the facility. Documentation provided for our review for ☒ ☐ ☐ 20 youth. Youth who have specific Such procedures shall: supervision needs, staff initiate a SSP which provides additional supervision expectations. Most classification forms had additional notes included that were specific to the youth’s needs. (a) provide for the safety of the youth, other youth, Residential Treatment Services Bureau facility staff, and the public by placing youth in the (RTSB) Manual Sections:402: Assessment appropriate, least restrictive housing and program and Classification Policy settings. Housing assignments shall consider the Youth are assessed by the Camp Assessment need for single, double or dormitory assignment or Unit (CAU) after being ordered to Camp by location within the dormitory; ☒ ☐ ☐ the court. The CAU determines which camp is the appropriate camp for the youth based on classification factors and camp programs. This decision is made based on several different factors and includes an interview and input from the youth. (b) consider facility populations and physical design of Residential Treatment Services Bureau the facility; (RTSB) Manual Sections:402: Assessment and Classification Policy ☒ ☐ ☐ Youth are classified to a camp based on classification factors and then assigned to a location within the dorm. (c) provide that a youth shall be classified upon Residential Treatment Services Bureau admittance to the facility; classification factors (RTSB) Manual Sections:402: Assessment shall include, but not be limited to: age, maturity, and Classification Policy sophistication, emotional stability, program needs, ☒ ☐ ☐ Youth are classified to a camp based on legal status, public safety considerations, classification factors. medical/mental health considerations, gender and gender identity of the youth; (d) provide for periodic classification reviews, Residential Treatment Services Bureau including provisions that consider the level of (RTSB) Manual Sections:402: Assessment supervision and the youth's behavior while in and Classification Policy custody; and, All youth who are placed on an SSP are ☒ ☐ ☐ reviewed within 30 days. All other youth are considered for review at the time of any incident, upon request, or as needed. If any change is to occur, an SSP is initiated. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 28 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) provide that facility staff shall not separate youth Residential Treatment Services Bureau from the general population or assign youth to a (RTSB) Manual Sections:402: Assessment single occupancy room based solely on the youth's and Classification Policy actual or perceived race, ethnic group identification, ancestry, national origin, color, religion, gender, sexual orientation, gender identity, ☒ ☐ ☐ gender expression, mental or physical disability, or HIV status. This section does not prohibit staff from placing youth in a single occupancy room at the youth's specific request or in accordance with Title 15 regulations regarding separation. (f) facility staff shall not consider lesbian, gay, Residential Treatment Services Bureau bisexual, transgender, questioning or intersex (RTSB) Manual Sections:402: Assessment identification or status as an indicator of likelihood ☒ ☐ ☐ and Classification Policy of being sexually abusive. 1352.5 TRANSGENDER AND INTERSEX YOUTH. Residential Treatment Services Bureau (RTSB) Manual Sections: 403: Juvenile The facility administrator shall develop written policies ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, and procedures ensuring respectful and equitable Transgender, Questioning and Intersex treatment of transgender and intersex youth. The Youth in an Institutional Setting policies shall provide that: (a) Facility staff shall respect every youth’s gender Residential Treatment Services Bureau identity and shall refer to the youth by the youth’s (RTSB) Manual Sections: 403: Juvenile preferred name and gender pronoun, regardless of Supervision of Lesbian, Gay, Bisexual, the youth’s legal name. Facilities may prohibit the ☒ ☐ ☐ Transgender, Questioning and Intersex use of gang or slang names or names that otherwise Youth in an Institutional Setting 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 Residential Treatment Services Bureau themselves in a manner consistent with their gender (RTSB) Manual Sections: 403: Juvenile identity and shall provide youth with the ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, institution’s clothing and undergarments consistent Transgender, Questioning and Intersex with their gender identity. Youth in an Institutional Setting (c) Facility staff shall house youth in the unit or room Residential Treatment Services Bureau that best meets their individual needs and promotes (RTSB) Manual Sections: 403: Juvenile their safety and well-being. Staff may not Supervision of Lesbian, Gay, Bisexual, automatically house youth according to their Transgender, Questioning and Intersex external anatomy and shall document the reasons Youth in an Institutional Setting for any decision to house youth in a unit that does If a youth request to reside in another unit not match their gender identity. In making a ☒ ☐ ☐ other than the unit that coincides with the housing decision, staff shall consider the youth’s youth’s biological sex, a medical referral is preferences, as well as any recommendations from made, and an MDT is held. Pending a the youth’s health or behavioral health provider. decision, the youth will be housed in the medical unit. (This process occurs before arrival at the camp due to lack of alternate housing.) 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 29 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Facility administrators shall ensure that transgender Residential Treatment Services Bureau and intersex youth have access to medical and (RTSB) Manual Sections: 403: Juvenile behavioral health providers qualified to provide Supervision of Lesbian, Gay, Bisexual, care and treatment to transgender and intersex Transgender, Questioning and Intersex youth. Youth in an Institutional Setting ☒ ☐ ☐ Upon entry, youth are asked If they identify with LGBTQI and if so, they are referred to medical for continuation and coordination of gender affirming services. (e) Consistent with the facility’s reasonable and Residential Treatment Services Bureau necessary security considerations and physical (RTSB) Manual Sections: 403: Juvenile plant, facility staff shall make every effort to ensure ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, the safety and privacy of transgender and intersex Transgender, Questioning and Intersex youth when the youth are using the bathroom or Youth in an Institutional Setting shower, or dressing or undressing. Facility staff shall not conduct physical searches of any Residential Treatment Services Bureau youth for the purpose of determining the youth’s (RTSB) Manual Sections: 403: Juvenile anatomical sex. Whenever feasible, the facility shall Supervision of Lesbian, Gay, Bisexual, respect the youth’s preference regarding the gender of Transgender, Questioning and Intersex the staff member who conducts any search of the youth. Youth in an Institutional Setting Policy notes that youth are provided with the option to choose the gender of the staff they wish to search them. Policy also notes that the duty supervisor will make the determination and approve this on a case by case basis. It was noted by administrative staff that operationally, this does occur; however, there was no documentation provided from the facilities to review for ☒ ☐ ☐ compliance. Technical assistance provided that a process will need to be developed and implemented. Compliance is based on policy alone. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 30 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1353 ORIENTATION Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation The facility administrator shall develop and implement Process and Handbook written policies and procedures to orient a youth prior to placement in a living area. Both written and verbal At inspection we noted the orientation information shall be provided and supplemented with handbook was not updated to all current video orientation if feasible. Provision shall be made to regulatory requirements. This issue was ☒ ☐ ☐ provide accessible orientation information to all addressed and corrected, and the now current detained youth including those with disabilities, limited and updated handbook has been literacy, or English language learners. Orientation shall implemented. include information that addresses: Documentation provided for our review for 20 youth. All orientations were found to be completed timely. (a) facility rules including contraband and searches and Residential Treatment Services Bureau disciplinary procedures; ☒ ☐ ☐ (RTSB) Manual Section: 502: Orientation Process and Handbook (b) facility’s system of positive behavior interventions Residential Treatment Services Bureau and supports, including behavior expectations, (RTSB) Manual Section: 502: Orientation incentives that youth will receive for complying Process and Handbook with facility rules, and consequences that may ☒ ☐ ☐ Youth are provided with a copy of the result when youth violate the rules of the facility; Behavior Management Program Handbook at orientation. This process is reviewed during orientation. (c) age appropriate information that explains the Residential Treatment Services Bureau facility’s policy prohibiting sexual abuse and sexual (RTSB) Manual Section: 1600: PREA ☒ ☐ ☐ harassment and how to report incidents or suspicions of sexual abuse or sexual harassment; (d) identification of key staff and their roles; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (e) the existence of the grievance procedure, the steps Residential Treatment Services Bureau that must be taken to use it, the youth’s right to be (RTSB) Manual Section: 502: Orientation free of retaliation for reporting a grievance, and the Process and Handbook ☒ ☐ ☐ name of the person or position designated to resolve the issue; (f) access to legal services and information on the court Residential Treatment Services Bureau process; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (g) access to routine and emergency health and mental Residential Treatment Services Bureau health care; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 31 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (h) access to education, religious services, and Residential Treatment Services Bureau recreational activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (i) housing assignments; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (j) opportunity for personal hygiene and daily showers Residential Treatment Services Bureau including the availability of personal care items (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (k) rules and access to correspondence, visits and Residential Treatment Services Bureau telephone use; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (l) availability of reading materials, programming, and Residential Treatment Services Bureau other activities; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (m) facility policies on the use of force, use of restraints, Residential Treatment Services Bureau chemical agents and room confinement; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (n) immigration legal services; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (o) emergencies including evacuation procedures; Residential Treatment Services Bureau (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (p) non-discrimination policy and the right to be free Residential Treatment Services Bureau from physical, verbal or sexual abuse and (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ harassment by other youth and staff; Process and Handbook (q) availability of services and programs in a language Residential Treatment Services Bureau other than English if appropriate; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (r) the process for requesting different housing, Residential Treatment Services Bureau education, programming and work assignments; (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook (s) a process for which parents/guardians receive Residential Treatment Services Bureau information regarding the youth’s stay in the (RTSB) Manual Section: 502: Orientation facility that at a minimum includes answers to Process and Handbook ☒ ☐ ☐ frequently asked questions and provides contact Orienting officer provides parent info and information for the facility, medical, school and provides contact info. mental health; and, (t) a process by which youth may request access to Residential Treatment Services Bureau Title 15 Minimum Standards for Juvenile Facilities. (RTSB) Manual Section: 502: Orientation ☒ ☐ ☐ Process and Handbook 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 32 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354 SEPARATION Residential Treatment Services Bureau The facility administrator shall develop and implement (RTSB) Manual Section: 514: Separation, written policies and procedures that address: 515: Room Confinement and Section 1400: ☒ ☐ ☐ The Healing Opportunities and Positive Engagement (HOPE) Center (a) separation of youth for reasons that include, but are Residential Treatment Services Bureau not be limited to, medical and mental health (RTSB) Manual Section: 514: Separation conditions, assaultive behavior, disciplinary Agency HOPE Centers are operationally consequences and protective custody. utilized for youth who require separation for a variety of purposes including medical/mental health, temporary housing, protective custody, room confinement and disciplinary separation to provide time for the youth to deescalate and adjust their behavior to return to the program. Current policies are not clear and although collectively, policy and procedure outline regulation requirements, operationally, do ☐ ☒ ☐ not meet requirements. Separation policy must be updated concurrently with Room Confinement policy to ensure consistency and compliance with both regulations and should also clearly reflect all types of separations with documentation processes to show proof of practice. Agency policy requires due process for any separation. Currently, due process only occurs as a result of the incident which precipitated the separation. While not non- compliant with regulation, this is inconsistent with agency policy. (b) consideration of positive youth development and Residential Treatment Services Bureau trauma-informed care. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 33 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) separated youth shall not be denied normal Residential Treatment Services Bureau privileges available at the facility, except when (RTSB) Manual Section: 514: Separation necessary to accomplish the objective of separation. If a youth is not on active Room Confinement due to imminent safety or security, he or she should be considered as full program and be fully integrated into a full general population program and receive all programming and activities in the HOPE Center as appropriate or returned to the dorm. ☐ ☐ UNK Facility staff provided one Specialization Supervision Plan (SSP) for a youth that was involved in 7 documented violent incidents whose behavior has been deemed a threat to the safety and security of the youth in the dorm but not documentation of programming. We are unable to make a determination of compliance at this time. We will review this further when we return on site (d) when the objective of the separation is discipline, Residential Treatment Services Bureau Title 15 Section 1390 shall apply. ☒ ☐ ☐ (RTSB) Manual Section: 514: Separation (e) when separation results in room confinement, the Residential Treatment Services Bureau separation shall occur in accordance with Welfare (RTSB) Manual Section: 514: Separation ☒ ☐ ☐ and Institutions Code Section 208.3 and Section1354.5 of these regulations. (f) policies and procedures shall ensure a daily review Residential Treatment Services Bureau of separated youth to determine if separation (RTSB) Manual Section: 514: Separation remains necessary. ☐ ☐ ☒ and Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 34 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1354.5 ROOM CONFINEMENT Residential Treatment Services Bureau (RTSB) Manual Section: 515: Room (a) The facility administrator shall develop and Confinement and Section 1400: The Healing implement written policies and procedures Opportunities and Positive Engagement addressing the confinement of youth in their room (HOPE) Center that are consistent with Welfare and Institutions Code Section 208.3. The placement of a youth in The HOPE Center at Camp Scott is used for room confinement shall be accomplished in Camp Scott youth only. The HOPE Center accordance with the following guidelines: receives youth for a variety of reasons which include separation or cool down, decontamination, administrative holds, housing, mental health, and for safety and security purposes. Youth who are in need of Room Confinement, are also moved to the HOPE Center. With the implementation of the Room Confinement regulations and the ☐ ☒ ☐ implementation of specific requirements, the documentation received for review was problematic, as it does not consistently provide proof of compliant practices nor are, we able to determine which youth are held under room confinement expectations. In many cases, we were unable to determine if the youth was placed in a locked room therefore, we were unable to determine what requirements and documentation were necessary. Policy, procedure and documentation will need to be reviewed and updated to achieve compliance. Room confinement and separation policies should be revised concurrently to ensure consistency as well as to ensure compliance with all pieces of this regulation. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 35 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) Room confinement shall not be used before Residential Treatment Services Bureau other, less restrictive, options have been (RTSB) Manual Section: 515: Room attempted and exhausted, unless attempting Confinement and Section 1400: The Healing those options poses a threat to the safety or Opportunities and Positive Engagement security of any youth or staff. (HOPE) Center 20 Hope Center Packets were provided for our review. Most of the 15 we selected for random review, there was no SIR/PIR to provide a complete picture to note the incident and circumstances that precipitated the youth being moved to the Hope Center. ☐ ☒ ☐ We were unable to determine if the youth belonged in room confinement or if any other options were attempted or could be attempted. What information we found was assembled through pieces and parts of the documentation that was available on the Mental Health Referral, Behavior Chain Analysis, Major Administrative Action or the Classification Document. It is unknown what efforts were made if any, prior to the youth being admitted to the Hope Center. This section is non-compliant. (2) Room confinement shall not be used for the Residential Treatment Services Bureau purposes of punishment, coercion, (RTSB) Manual Section: 515: Room convenience, or retaliation by staff. Confinement and Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center ☐ ☒ ☐ There were few SIR/PIR’s provided in order to make a determination if the room confinement was appropriate based on regulatory requirements and does not clearly document the reason the youth requires isolation to minimize the threat to the safety and security of youth or staff once separated from the incident. (3) Room confinement shall not be used to the Residential Treatment Services Bureau extent that it compromises the mental and (RTSB) Manual Section: 515: Room physical health of the youth. Confinement ☒ ☐ ☐ Mental health referrals or consultations were included in the documentation reviewed. All youth were cleared by medical staff immediately following the incident. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 36 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) A youth may be held up to four hours in room Residential Treatment Services Bureau confinement. After the youth has been held in room (RTSB) Manual Section 1400: The Healing confinement for a period of four hours, staff shall Opportunities and Positive Engagement ☒ ☐ ☐ do one or more of the following: (HOPE) Center (1) Return the youth to general population. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing ☒ ☐ ☐ Opportunities and Positive Engagement (HOPE) Center (2) Consult with mental health or medical staff. Residential Treatment Services Bureau (RTSB) Manual Section 1400: The Healing Opportunities and Positive Engagement (HOPE) Center Policy and procedure must be updated to include consultation with mental health or medical staff for youth who are held beyond 4 hours. Policy also requires that any youth ☐ ☒ ☐ placed on room confinement shall complete a Behavior Chain Analysis (BCA’s) and be assessed by DMH as part of the stabilization process however, documentation provided did not demonstrate compliance in this area. Currently, mental health staff respond and see youth as a result of the precipitating incident, but not due to the isolation. This is non-compliant. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 37 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Develop an individualized plan that includes Residential Treatment Services Bureau the goals and objectives to be met in order to (RTSB) Manual Section 1400: The Healing reintegrate the youth to general population. Opportunities and Positive Engagement (HOPE) Center Policy notes that youth shall not remain assigned to the HOPE Center for longer than 4 hours without the initiation of a formal Major Administrative Action Review reviewed by the facility Director or designee and must include an individualized plan that includes goals and objectives to be met to ☐ ☒ ☐ reintegrate the youth back to general population. They must be documented on the SSP. The SSP addresses supervision issues and does not include goals and objectives to reintegrate the youth to general population for this purpose. No documentation of any individualized plans that included goals and objectives to reintegrate the youth to general population was provided. This section is non-compliant. (4) If room confinement must be extended beyond Residential Treatment Services Bureau four hours, staff shall do each of the following: (RTSB) Manual Section 1400: The Healing Opportunities and Positive Engagement ☐ ☒ ☐ (HOPE) Center It is unknown if any of the youth were extended beyond four hours. (A) Document the reasons for room Residential Treatment Services Bureau confinement and the basis for the (RTSB) Manual Section 1400: The Healing extension, the date and time the youth was Opportunities and Positive Engagement ☐ ☒ ☐ first placed in room confinement, and when (HOPE) Center he or she is eventually released from room confinement. No documentation provided for this section. (B) Develop an individualized plan that Residential Treatment Services Bureau includes the goals and objectives to be met (RTSB) Manual Section 1400: The Healing in order to integrate the youth to general Opportunities and Positive Engagement population. (HOPE) Center ☐ ☒ ☐ See above B(3) There were no individualized plans provided. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 38 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (C) Obtain documented authorization by the Residential Treatment Services Bureau facility superintendent or his or her (RTSB) Manual Section 1400: The Healing designee every four hours thereafter. Opportunities and Positive Engagement ☐ ☒ ☐ (HOPE) Center Unknown. (5) This section is not intended to limit the use of Residential Treatment Services Bureau single-person rooms or cells for the housing of (RTSB) Manual Section: 515: Room ☒ ☐ ☐ youth in juvenile facilities and does not apply Confinement to normal sleeping hours. (6) This section does not apply to youth or wards Residential Treatment Services Bureau in court holding facilities or adult facilities. (RTSB) Manual Section: 515: Room ☒ ☐ ☐ Confinement (7) Nothing in this section shall be construed to Residential Treatment Services Bureau conflict with any law providing greater or (RTSB) Manual Section: 515: Room ☒ ☐ ☐ additional protections to youth. Confinement (8) This section does not apply during an Residential Treatment Services Bureau extraordinary emergency circumstance that (RTSB) Manual Section: 515: Room requires a significant departure from normal Confinement 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 Residential Treatment Services Bureau placed in a locked cell or sleeping room to treat (RTSB) Manual Section: 515: Room and protect against the spread of a Confinement 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. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 39 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1355 INSTITUTIONAL ASSESSMENT AND Residential Treatment Services Bureau PLAN (RTSB) Manual Section 402: Assessment and Classification and 703: The MDT The facility administrator shall develop and implement Process written policies and procedures for assessment and case planning. The process of assessment begins upon a youth being ordered to a camp. A youth is assessed by the Camp Assessment Unit and by the facility upon arrival. The case plan is completed at the initial MTD and is developed through a collaborative multi- ☒ ☐ ☐ disciplinary Team made up of staff representation from Probation, Department of Mental Health, Education, Health Care, Social Services as appropriate and any others as necessary based on the youth or family needs. A transition MDT is also completed as the youth gets closer to release. MDT’s are completed as needed throughout detention as the need arises. Periodic review is completed by the assigned casework Probation Officer. The transition plan is completed by the collaborative multi- disciplinary team. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 40 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Assessment: Residential Treatment Services Bureau The assessment is based on information collected (RTSB) Manual Section 703: The MDT during the admission process with periodic review, Process which includes the youth's risk factors, needs and strengths including, but not limited to, The process of case planning begins with the identification of substance abuse history, assessment process. 10 Initial and educational, vocational, counseling, behavioral Transitional MDT packets were reviewed. health, consideration of known history of trauma, The Camp Assessment Unit completes all and family strengths and needs. assessments on the youth prior to transfer. The assessment summary was not provided for our review nor was it in the case notes; however, it is practice and is completed for all youth in RTSB per Bureau staff. At inspection, we were unable to determine ☐ ☐ UNK compliance in this area at this time without seeing the assessment, speaking to staff and youth. Prior to writing this report, we have been notified that the agency has updated their policy and has corrected their forms and documentation to be consistent with regulation and to provide a more clear and efficient process for the youth and their families. Staff training occurred in August 2020 and the new process was implemented in September 2020. We will follow up with this section to review for compliance upon our return to the facility. (b) Institutional Case Plan: Residential Treatment Services Bureau (1) A case plan shall be developed for each youth (RTSB) Manual Section 703: The MDT held for at least 30 days or more and created Process within 40 days of admission. The initial MDT acts as the youth’s case plan and provides direction as to what programs ☒ ☐ ☐ they will participate in. Some programs are automatic as they are court ordered. The MDT is targeted to be completed within the first 2 weeks of a youth’s arrival at camp. All MDT’s occurred within the time allotted by regulation. (2) The institutional plan shall include, but not be Residential Treatment Services Bureau limited to, written documentation that provides: ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 41 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (A) objectives and time frame for the resolution Residential Treatment Services Bureau of problems identified in the assessment; (RTSB) Manual Section 705: Ongoing Case Management Activities The MDT process and format provides the structure for the youth’s case plan. Objectives are based on the assessment. Those programs that are ordered and are camp required programs, the timelines are noted as part of the program i.e. 10 weeks substance abuse program or 16-week DBT ☒ ☐ ☐ Program. Technical Assistance regarding the structure of the process and making the plans more individualized in the coming cycle. With the change in regulation, the assessment drives the objectives and goals and the case plans are more individualized and not solely based on a court order or camp program. RTSB has enhanced their process. We will follow up with this section and determine compliance upon our return to the facility (B) a plan for meeting the objectives that Residential Treatment Services Bureau includes a description of program resources (RTSB) Manual Section 705: Ongoing Case needed and individuals responsible for Management Activities assuring that the plan is implemented; We found the current plan and timelines are embedded within the camp program expectations or court orders i.e. 10 weeks substance abuse program, individual counseling or family counseling weekly or 16-week DBT. ☐ ☐ UNK Discussed need to ensure these programs and other assessed needs are documented more consistently so the youth’s other needs are individual to the youth. We need more information to determine compliance. We will follow up with this section and determine compliance upon our return to the facility. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 42 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) periodic evaluation of progress towards meeting Residential Treatment Services Bureau the objectives, including periodic review and (RTSB) Manual Section 705: Ongoing Case discussion of the plan with the youth; Management Activities Regulation requires periodic review and discussion with the youth of their progress towards meeting their objectives. Periodic review is completed weekly by the assigned camp casework officer who completes the ☐ ☒ ☐ casework notes in the electronic database (PCMS). These notes were provided with each MDT-Case plan. Based on the collective set of case notes, we were unable to determine if these reviews were completed with the youth as written or if discussed at a later time or at all. This is non-compliant. (4) a transition plan, the contents of which shall be Residential Treatment Services Bureau subject to existing resources, shall be developed (RTSB) Manual Section 706: Case Plan for post dispositional youth in accordance with Activities- Pre- Release Section 1351; and, ☒ ☐ ☐ Transition MDT’s are completed for all youth and contain all areas required by regulation. (5) in as much as possible and if appropriate, the Residential Treatment Services Bureau plan, including the transition plan, shall be (RTSB) Manual Section 705: Ongoing Case developed with input from the family, Management Activities supportive adults, youth, and Regional Center ☒ ☐ ☐ The youth’s parent or guardian is invited to for the Developmentally Disabled. attend the MDT. The family is contacted by phone and by letter to attend. 1356 COUNSELING AND CASEWORK Residential Treatment Services Bureau SERVICES (RTSB) Manual Section 705: Ongoing Case Management Activities The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures ensuring the availability of appropriate counseling and casework services for all youth. Policies and procedures shall ensure: (a) youth will receive assistance with needs or concerns Residential Treatment Services Bureau that may arise; ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 43 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (b) youth will receive assistance in requesting contact Residential Treatment Services Bureau with parents, other supportive adults, attorney, (RTSB) Manual Section 705: Ongoing Case clergy, probation officer, or other public official; Management Activities ☒ ☐ ☐ and, (c) youth will be provided access to available resources Residential Treatment Services Bureau to meet the youth’s needs. ☒ ☐ ☐ (RTSB) Manual Section 705: Ongoing Case Management Activities 1357 USE OF FORCE Residential Treatment Services Bureau (RTSB) Manual Section 1701: Physical The facility administrator, In cooperation with the intervention Policy for Juvenile Facilities responsible physician, shall develop and implement and the Transportation Section written policies and procedures for the use of force, which may include chemical agents. Force shall never be applied as punishment, discipline, retaliation or Policy was developed with the Juvenile treatment. ☒ ☐ ☐ Court Health Services (JCHS) and includes (a) At a minimum, each facility shall develop policies the use of soft restraints. OC is not used in and procedures which: the camps. Documentation was provided from throughout the cycle. 10 Incidents were selected for review from July 2019, August 2019, September 2019, and March 2020. (1) restricts the use of force to that which is deemed Residential Treatment Services Bureau reasonable and necessary, as defined in Section (RTSB) Manual Section 1704: Safe Crisis 1302 to ensure the safety and security of youth, Management and Physical Intervention staff, others and the facility. Procedures All documentation reviewed were near fights/fights, gang fights, assaults on staff ☒ ☐ ☐ and one disruptive youth who threatened to break a window and did by throwing rocks at it until it broke. All incidents viewed appeared appropriate and to be reasonable and necessary. Staff gave direction to stop and attempts were made to deescalate. (2) outline the force options available to staff Residential Treatment Services Bureau including both physical and non-physical (RTSB) Manual Section 1704: Safe Crisis options and define when those force options are Management and Physical Intervention appropriate. Procedures ☒ ☐ ☐ Non-Physical Options: De-escalation Techniques Physical Options: Authorized Levels of Physical Interventions 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 44 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) describe force options or techniques that are Residential Treatment Services Bureau expressly prohibited by the facility. (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ Management and Physical Intervention Procedures (4) describe the requirements of staff to report any Residential Treatment Services Bureau inappropriate use of force, and to take (RTSB) Manual Section 1704: Safe Crisis ☒ ☐ ☐ affirmative action to immediately stop it. Management and Physical Intervention Procedures (5) define a standardized reporting format that Residential Treatment Services Bureau includes time period and procedure for (RTSB) Manual Section 1703: Safe Crisis documenting and reporting the use of force, Management-Physical Intervention Report including reporting requirements of Forms, 1704: Safe Crisis Management and management and line staff and procedures for Physical Intervention Procedures and 1706: reviewing and tracking use of force incidents by Safe Crisis Management Physical supervisory and or management staff, which Intervention Reports include procedures for debriefing a particular Facilities keep a use of force log. Incident incident with staff and/or youth for the purposes reports are completed before going off shift. of training as well as mitigating the effects of trauma that may have been experienced by staff ☐ ☐ UNK Every incident is reviewed by the duty and /or the youth involved. supervisor and again reviewed by the Safe Crisis Management reviewing supervisor and signed off by the facility Manager. We did not see any reference to debriefing of incidents however, as we are not on site, we are unable to confirm if this is occurring in other facility processes. We will look further into this issue when on site at the next inspection. (6) Include an administrative review and a system Residential Treatment Services Bureau for investigating unreasonable use of force. (RTSB) Manual Section 1706: Safe Crisis Management Physical Intervention Reports Any incident that falls outside of agency ☒ ☐ ☐ policy is referred to the facility director for referral for an administrative review or referral to the Probation Departments Special Investigation Unit for further review. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 45 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (7) define the role, notification, and follow-up Residential Treatment Services Bureau procedures required after use of force incidents (RTSB) Manual Section 1704: Safe Crisis for medical, mental health staff and parents or Management and Physical Intervention legal guardians. Procedures and 1706: Safe Crisis Management Physical Intervention Reports We found that in all incident reports and in documentation reviewed we found that youth were medically cleared and were either seen by mental health or a mental health referral was submitted on the youth’s behalf for ☒ ☐ ☐ follow up. At inspection, we did not see any reference in the PIR as required by policy for a contact being made to the youth’s parent if the child was involved in a use of force incident. Technical assistance provided and additional documentation was subsequently requested for review. This issue was corrected, and we were provided with documentation of corrective action and proof of contact being made and documentation being completed. (8) describe the limitations of use of force on Residential Treatment Services Bureau pregnant youth in accordance with Penal Code (RTSB) Manual Section 1704: Safe Crisis Section 6030(f) and Welfare and Institutions Management and Physical Intervention ☒ ☐ ☐ Code Section 222. Procedures (b) Facilities that authorize chemical agents as a force Residential Treatment Services Bureau option shall include policies and procedures that: (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (1) identify who is approved to carry and/or utilize NA chemical agents in the facility and the type, size ☐ ☐ ☒ and the approved method of deployment for those chemical agents. (2) mandate that chemical agents only be used when NA there is an imminent threat to the youth’s safety ☐ ☐ ☒ or the safety of others and only when de- escalation efforts have been unsuccessful or are not reasonably possible. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 46 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) outline the facility’s approved methods and NA timelines for decontamination from chemical agents. This shall include that youth who have ☐ ☐ ☒ been exposed to chemical agents shall not be left unattended until that youth is fully decontaminated or is no longer suffering the effects of the chemical agent. (4) define the role, notification, and follow-up NA procedures required after use of force incidents ☐ ☐ ☒ involving chemical agents for medical, mental health staff and parents or legal guardians. (5) provide for the documentation of each incident NA of use of chemical agents, including the reasons for which it was used, efforts to de-escalate ☐ ☐ ☒ prior to use, youth and staff involved, the date, time and location of use, decontamination procedures applied and identification of any injuries sustained as a result of such use. (c) Facilities shall develop policies and procedure Residential Treatment Services Bureau which require that agencies provide initial and (RTSB) Manual Section 1702: Training ☒ ☐ ☐ regular training in use of force and chemical agents when appropriate that address: (1) known medical and behavioral health Residential Treatment Services Bureau conditions that would contraindicate certain ☒ ☐ ☐ (RTSB) Manual Section 1702: Training types of force; (2) acceptable chemical agents and the methods of Residential Treatment Services Bureau application. (RTSB) Manual Section 1704: Safe Crisis Management and Physical Intervention ☐ ☐ ☒ Procedures OC is not used in any of the RTSB facilities. (3) signs or symptoms that should result in Residential Treatment Services Bureau immediate referral to medical or behavioral ☒ ☐ ☐ (RTSB) Manual Section 1702: Training health. (4) instruction on the Constitutional Limitations of Residential Treatment Services Bureau ☒ ☐ ☐ Use of Force. (RTSB) Manual Section 1702: Training (5) physical training force options that may require Residential Treatment Services Bureau ☒ ☐ ☐ the use of perishable skills. (RTSB) Manual Section 1702: Training (6) timelines the facility uses to define regular Residential Treatment Services Bureau training. (RTSB) Manual Section 1702: Training ☒ ☐ ☐ Initial training occurs in CORE and regular training is held through annual refresher training. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 47 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358 USE OF PHYSICAL RESTRAINTS Residential Treatment Services Bureau (RTSB) Manual Section 1705: Restraints The facility administrator, In cooperation with the responsible physician and mental health director, shall The policy was developed in cooperation with DMH and JCHS develop and implement written policies and procedures ☒ ☐ ☐ for the use of restraint devices. Restraint devices There was one incident provided. include any devices which immobilize a youth's Documentation did not include use of extremities and/or prevent the youth from being restraint log; however, the supervisor wrote a ambulatory. very detailed account of the incident that included all areas of regulation. Physical restraints may be used only for those youth Residential Treatment Services Bureau who present an immediate danger to themselves or (RTSB) Manual Section 1705: Restraints others, who exhibit behavior which results in the Documentation was requested for all use of destruction of property or reveals the intent to cause ☒ ☐ ☐ restraints that occurred since July 2019. One self-inflicted physical harm. Physical restraints should incident was provided. 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 Residential Treatment Services Bureau discipline, or as a substitute for treatment. The use of (RTSB) Manual Section 1705: Restraints restraint devices that attach a youth to a wall, floor or other fixture, including a restraint chair, or through ☒ ☐ ☐ affixing of hands and feet together behind the back (hogtying) is prohibited. The use of restraints on pregnant youth is limited in accordance with Penal Code Section 6030(f) and Welfare and Institutions Code Section 222. The provisions of this section do not apply to the use of Residential Treatment Services Bureau handcuffs, shackles or other restraint devices when used (RTSB) Manual Section 1705: Restraints to restrain youth for movement or transportation within ☒ ☐ ☐ the facility. Movement within the facility shall be governed by Section 1358.5, Use of Restraint Devices for Movement Within the Facility. Youth shall be placed in restraints only with the approval Residential Treatment Services Bureau of the facility manager or designee. The facility manager (RTSB) Manual Section 1705: Restraints may delegate authority to place a youth in restraints to a ☒ ☐ ☐ Supervisor was present during incident. physician. Reasons for continued retention in restraints shall be reviewed and documented at a minimum of every hour. A medical opinion on the safety of placement and Residential Treatment Services Bureau retention shall be secured as soon as possible, but no later (RTSB) Manual Section 1705: Restraints than two hours from the time of placement. The youth ☒ ☐ ☐ Youth was seen by the nurse immediately shall be medically cleared for continued retention at least following incident and at the conclusion of every three hours thereafter. the incident. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 48 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS A mental health consultation shall be secured as soon as Residential Treatment Services Bureau possible, but in no case longer than four hours from the (RTSB) Manual Section 1705: Restraints time of placement, to assess the need for mental health ☒ ☐ ☐ Youth was counselled by a DMH Dr. who treatment. was on site at the time of the incident. Continuous direct visual supervision shall be conducted Residential Treatment Services Bureau to ensure that the restraints are properly employed, and (RTSB) Manual Section 1705: Restraints to ensure the safety and well-being of the youth. ☒ ☐ ☐ Direct visual supervision was provided. Observations of the youth's behavior and any staff interventions shall be documented at least every 15 minutes, with actual time of the documentation recorded. In addition to the requirements above, policies and Residential Treatment Services Bureau procedures shall address: (RTSB) Manual Section 1705: Restraints (a) documentation of the circumstances leading to an Residential Treatment Services Bureau ☒ ☐ ☐ application of restraints. (RTSB) Manual Section 1705: Restraints (b) known medical conditions that would Residential Treatment Services Bureau contraindicate certain restraint devices and/or ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints techniques. (c) acceptable restraint devices. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (d) signs or symptoms which should result in Residential Treatment Services Bureau ☒ ☐ ☐ immediate medical/mental health referral. (RTSB) Manual Section 1705: Restraints (e) availability of cardiopulmonary resuscitation Residential Treatment Services Bureau ☒ ☐ ☐ equipment. (RTSB) Manual Section 1705: Restraints (f) protective housing of restrained youth. While in Residential Treatment Services Bureau restraint devices, all youth shall be housed alone or (RTSB) Manual Section 1705: Restraints in a specified housing area for restrained youth ☒ ☐ ☐ which makes provision to protect the youth from abuse. (g) provision for hydration and sanitation needs. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints (h) exercising of extremities. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1705: Restraints 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 49 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1358.5 USE OF RESTRAINT DEVICES FOR Residential Treatment Services Bureau MOVEMENT AND TRANSPORTATION WITHIN (RTSB) Manual Section 1709: The Use of THE FACILITY. Mechanical Restraints for Movement and Transport Within the Facility The Facility Administrator, In cooperation with the responsible physician and behavioral/mental health The policy was developed in cooperation director, shall develop and implement written policies with DMH and JCHS. and procedures for the use of restraint devices when the purpose is for movement or transportation within the Policy is in place but not yet trained and facility that shall include the following: implemented. The below areas are non- compliant. (a) identification of acceptable restraint devices, staff Residential Treatment Services Bureau approved to utilize restraint devices and the (RTSB) Manual Section 1709: The Use of required training. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility Handcuffs are authorized for regular use and flex cuffs in emergency situations. (b) the circumstances leading to the application of Residential Treatment Services Bureau restraints must be documented. (RTSB) Manual Section 1709: The Use of Mechanical Restraints for Movement and Transport Within the Facility ☐ ☒ ☐ No documentation was provided for our review. This section is non-compliant. (c) an individual assessment of the need to apply Residential Treatment Services Bureau restraints for movement or transportation that (RTSB) Manual Section 1709: The Use of includes consideration of less restrictive Mechanical Restraints for Movement and alternatives, consideration of a youth’s known ☐ ☒ ☐ Transport Within the Facility medical or mental health conditions, trauma No documentation was provided for our informed approaches, and a process for review. This section is non-compliant. documentation and supervisor review and approval. (d) consideration of safety and security of the facility, Residential Treatment Services Bureau with a clearly defined expectation that restraint (RTSB) Manual Section 1710: The Use of devices shall not be used for the purposes of Mechanical Restraints for Movement and ☒ ☐ ☐ discipline or retaliation. Transport Within the Facility (e) the use of restraints on pregnant youth is limited in Residential Treatment Services Bureau accordance with Penal Code Section6030(f) and (RTSB) Manual Section 1709: The Use of Welfare and Institutions Code Section 222. Mechanical Restraints for Movement and ☒ ☐ ☐ Transport Within the Facility 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 50 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1359 SAFETY ROOM PROCEDURES There is no safety room in the camps. Does not apply. (a) The facility administrator, and where applicable, In 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. (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. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 51 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (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 Residential Treatment Services Bureau (RTSB) Manual Sections: The facility administrator shall develop and implement 1316: Searches in Detention Facilities written policies and procedures governing the search of 1317: Body Searches (Pat- Down, Strip, and youth, the facility, and visitors. Policies and procedures Body Cavity Searches) shall provide that: July, September, October, November and December 2019 Facility Inspection Logs were provided for our review. Additional ☒ ☐ ☐ documentation included individual Facility Entrance Area Reports, Staff Quarter Reports, Dorm Reports and Facility Grounds search results. There was no instance of contraband found. Good efforts by staff and managers to ensure the safety and security of the youth and the facility. (a) Searches shall be conducted to ensure the safety and Residential Treatment Services Bureau security of the facility, public, visitors, youth, and ☒ ☐ ☐ (RTSB) Manual Sections 1316: Searches in staff. Detention Facilities (b) Searches shall be conducted in a manner that Residential Treatment Services Bureau preserves the privacy and dignity of the person (RTSB) Manual Sections 1316: Searches in being searched and shall not be conducted for ☒ ☐ ☐ Detention Facilities harassment or as a form of discipline or punishment. (c) Strip searches and visual or physical body cavity Residential Treatment Services Bureau searches shall comply with Penal Code Section (RTSB) Manual Sections: ☒ ☐ ☐ 4030. 1316: Searches in Detention Facilities 1317: Body Searches (Pat- Down, Strip, and Body Cavity Searches) 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 52 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) Physical body cavity searches shall only be Residential Treatment Services Bureau conducted by a medical professional. (RTSB) Manual Section 1317: Body ☒ ☐ ☐ Searches (Pat- Down, Strip, and Body Cavity Searches) (e) Any youth held after a detention hearing shall only Residential Treatment Services Bureau be strip searched with prior approval of a supervisor (RTSB) Manual Section 1317: Body when there is reasonable suspicion based on Searches (Pat- Down, Strip, and Body Cavity ☒ ☐ ☐ specific and articulable facts to believe that youth is Searches) concealing contraband. The reasonable suspicion All youth are post disposition. shall be documented. (f) Searches of transgender and intersex youth shall Residential Treatment Services Bureau comply with Section 1352.5. (RTSB) Manual Section 1303: Juvenile ☒ ☐ ☐ Supervision of Lesbian, Gay, Bisexual, Transgender, Questioning and Intersex Youth in an Institutional Setting (g) Cross-gender pat-down searches and strip searches Residential Treatment Services Bureau are prohibited except in exigent circumstances or (RTSB) Manual Section 1317: Body ☒ ☐ ☐ when conducted by a medical professional. Such Searches (Pat- Down, Strip, and Body Cavity searches must be justified and documented in Searches) writing. 1361 GRIEVANCE PROCEDURE Residential Treatment Services Bureau (RTSB) Manual Section 508: Grievance The facility administrator shall develop and Procedures implement written policies and procedures whereby any youth may appeal and have resolved grievances Grievance samples were provided from July relating to any condition of confinement, including and October 2019 for our review. We noted but not limited to health care services, classification a significant amount of anonymous decisions, program participation, telephone, mail or ☒ ☐ ☐ grievances submitted. visiting procedures, food, clothing, bedding, Compliance noted through review of mistreatment, harassment or violations of the documentation, from policy and through nondiscrimination policy. There shall be no time conversation with consultant staff. We were limit on filing grievances. Policies and procedures not onsite to view the process. shall include provisions whereby the facility manager ensures: 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 53 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) a grievance form and instructions for registering a Residential Treatment Services Bureau grievance, which includes provisions for the youth (RTSB) Manual Section 508: Grievance to have free access to the form; Procedures Per bureau consultant staff, grievance forms and the instructions are available in the dorms and in other areas around the facility. Youth may also complete a grievance electronically through their LACOE laptops. It is said that the process is the same. The only documentation provided was documentation from the JIGS system. There were no paper grievances provided. The ☒ ☐ ☐ grievance log noted there was “glitch” due to the change over from hard copies to computerized forms. The agency was notified previously that having an electronic process only would be non-compliant as youth must have free access at all times. LACOE computers are only available during school hours. Staff were asked to confirm that paper copies are available at all hours and we were told they were. We were unable to confirm if the grievances were available during the time the samples were collected from however, we have verified since that time that hard paper copies are available. (b) the youth shall have the option to confidentially file Residential Treatment Services Bureau the grievance or to deliver the form to any youth (RTSB) Manual Section 508: Grievance supervision staff working in the facility; Procedures Per bureau consultant staff, youth may submit to any staff member or submit the ☒ ☐ ☐ grievance in the confidential box or directly to the Supervisor. Youth may also submit grievances through the JIGS system. This is through LACOE laptops. Once the youth submits the grievance, it is addressed like any other paper grievance. (c) resolution of the grievance at the lowest appropriate Residential Treatment Services Bureau staff level; (RTSB) Manual Section 508: Grievance Procedures ☒ ☐ ☐ Per policy, youth may submit to any staff member, submit through the confidential box or directly to the Supervisor. In the documentation reviewed, we noted that all grievances were addressed by a supervisor. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 54 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (d) provision for a prompt review and initial response Residential Treatment Services Bureau to grievances within three (3) business days, (RTSB) Manual Section 508: Grievance grievances that relate to health and safety issues Procedures must be addressed immediately; There were 16 grievances in total provided for our review. All but 2 grievances provided were submitted in October 2019 but were not responded to until December 2019 due to a glitch in the electronic JIGS system. 5 grievances were confinement related issues; however, 9 were regarding very serious ☐ ☒ ☐ safety allegations involving staff that required immediate attention at the time of the grievance. We are unaware if the youth had the option to report their grievances on the paper copies. Upon receipt of the grievances, they were referred appropriately to administration for follow up and investigation. This section is non-compliant due to time the grievance was written and responded to. (1) The youth may elect to be present to explain Residential Treatment Services Bureau his/her version of the grievance to a person not (RTSB) Manual Section 508: Grievance directly involved in the circumstances which Procedures ☐ ☒ ☐ led to the grievance. The youth were not afforded a hearing. (2) Provision for a staff representative approved by Residential Treatment Services Bureau the facility administrator to assist the youth. (RTSB) Manual Section 508: Grievance ☐ ☒ ☐ Procedures The youth were not afforded a hearing. (e) provision for a written response to the grievance Residential Treatment Services Bureau which includes the reasons for the decisions; (RTSB) Manual Section 508: Grievance ☐ ☒ ☐ Procedures The youth were not afforded a hearing. (f) a system which provides that any appeal of a Residential Treatment Services Bureau grievance shall be heard by a person not directly (RTSB) Manual Section 508: Grievance involved in the circumstances which led to the ☐ ☒ ☐ Procedures grievance; The youth were not afforded a hearing. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 55 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (g) resolution of the grievance must occur within ten Residential Treatment Services Bureau (10) business days unless circumstances dictate a (RTSB) Manual Section 508: Grievance longer time frame. The youth shall be notified of Procedures any delay; and, ☐ ☒ ☐ The grievances were not addressed until over a month later. It is unknown at this time what the outcome will be. (h) the policy shall provide multiple internal and Residential Treatment Services Bureau external methods to report sexual abuse and sexual ☒ ☐ ☐ (RTSB) Manual Section 508: Grievance harassment. Procedures Whether or not associated with a grievance, concerns of Residential Treatment Services Bureau parents, guardians, staff or other parties shall be (RTSB) Manual Section 508: Grievance addressed and documented in accordance with written ☒ ☐ ☐ Procedures policies and procedures within a specified timeframe. There was no documentation to view. 1362 REPORTING OF INCIDENTS Residential Treatment Services Bureau (RTSB) Manual Section 1120: Reducing A written report of all incidents which result in physical Youth on Youth on Violence and 1919: harm, use of force, serious threat of physical harm, or Deaths at Camp Facilities death of an employee, youth or other person(s) shall be ☒ ☐ ☐ maintained. Such written record shall be prepared by the A variety of incident reports were provided staff and submitted to the facility manager by the end of for our review. All appeared to be submitted the shift, unless additional time is necessary and in a timely manner. authorized by the facility manager or designee. 1363 USE OF REASONABLE FORCE TO Residential Treatment Services Bureau COLLECT DNA SPECIMENS, SAMPLES, (RTSB) Manual Section 306: Live Scan and IMPRESSIONS DNA Collection and 1122: Juvenile Collection of DNA Samples (a) Pursuant to Penal Code Section 298.1 authorized law enforcement, custodial, or corrections DSB personnel are responsible for personnel including peace officers, may employ ☐ ☐ ☒ conducting all DNA Collection. The reasonable force to collect blood specimens, saliva remaining sections are all marked as NA. samples, and thumb 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. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 56 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (1) For the purpose of this section, the “use of Residential Treatment Services Bureau reasonable force” shall be defined as the force that (RTSB) Manual Section 306: Live Scan and an objective, trained and competent correctional DNA Collection and 1122: Juvenile employee, faced with similar facts and Collection of DNA Samples circumstances, would consider necessary and The Juvenile Halls are responsible for the reasonable to gain compliance with this section. collection of DNA samples for all detained ☐ ☐ ☒ and non- detained youth. Per policy, force will not be used to obtain DNA samples unless ordered by the court. If a youth refuses to cooperate, this information is provided to the court for further determination. (2) The use of reasonable force shall be preceded by Residential Treatment Services Bureau efforts to secure voluntary compliance. Efforts to (RTSB) Manual Section 306: Live Scan and secure voluntary compliance shall be documented DNA Collection and 1122: Juvenile ☐ ☐ ☒ and include an advisement of the legal obligation to Collection of DNA Samples provide the requisite specimen, sample or impression and the consequences of refusal. (b) The force shall not be used without the prior written Residential Treatment Services Bureau authorization of the supervising officer on duty. (RTSB) Manual Section 306: Live Scan and The authorization shall include information that DNA Collection and 1122: Juvenile ☐ ☐ ☒ reflects the fact that the offender was asked to Collection of DNA Samples provide the requisite specimen, sample, or impression and refused. (1) If the use of reasonable force includes a cell Residential Treatment Services Bureau extraction, the extraction shall be videotaped. (RTSB) Manual Section 306: Live Scan and Video shall be directed at the cell extraction DNA Collection and 1122: Juvenile event. The videotape shall be retained by the Collection of DNA Samples ☐ ☐ ☒ agency for the length of time required by statute. Notwithstanding the use of the video as evidence in a court proceeding, the tape shall be retained administratively. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 57 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1370 EDUCATION PROGRAM Education is provided through a collaboration between Los Angeles County (a) School Programs Probation and Los Angeles County Office of The County Board of Education shall provide for the Education: Juvenile Courts and Community administration and operation of juvenile court Schools. schools in conjunction with the Chief Probation A Matrix was provided for our review from Officer, or designee pursuant to applicable State Sr. Director Dr. Jesus Coral that detailed all laws. The school and facility administrators shall areas of Section 1370. All policy areas for develop and implement written policy and this section are either noted in the LACOE procedures to ensure communication and Board Policy or are in the RTSB Policy. coordination between educators and probation staff. Culturally responsive and trauma-informed BSCC Field Representatives do not inspect approaches should be applied when providing the education program for compliance with instruction. Education staff should collaborate with Title 15. Title 15 requires the Superintendent of Schools to conduct this the facility administrator to use technology to review in conjunction with a qualified facilitate learning and ensure safe technology ☒ ☐ ☐ outside agency or individual. practices. The facility administrator shall request an annual review of each required element of the The education program was evaluated by program by the Superintendent of Schools, and a Kim Herrera and Karen Loucks, Principals report or review checklist on compliance, from Taft California found the education deficiencies, and corrective action needed to achieve program to comply with all regulatory compliance with this section. Such a review, when requirements. conducted, cannot be delegated to the principal or any other staff of any juvenile 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 facility administrator or designee shall review each item with the Superintendent of Schools and shall take whatever corrective action is necessary to address each deficiency and to fully protect the educational interests of all youth in the facility. (b) Required Elements BP 6011 Instruction The facility school program shall comply with the BP 6011 Instruction, BP 0460 Philosophy, State Education Code and County Board of Goals, Objectives and Comprehensive Plans Education policies, all applicable federal education BP 005 Philosophy, Goals, Objectives and statutes and regulations and provide for an annual Comprehensive Plans Item 3,4,5 evaluation of the educational program offerings. As stated in the 2009 California Standards for the ☒ ☐ ☐ Teaching Profession, teachers shall establish and maintain learning 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. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 58 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS All youth shall be treated equally, and the education BP 5145.3 Students program shall be free from discriminatory action. ☒ ☐ ☐ Staff 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 BP 005 Philosophy, Goals, Objectives and Education Code and include, but not be limited to, Comprehensive Plans ☒ ☐ ☐ courses required for high school graduation. Item 3,4,5 (2) Information and preparation for the High School AR-6146.2 Equivalency Test as approved by the California ☒ ☐ ☐ Department of Education shall be made available to eligible youth. (3) Youth shall be informed of post-secondary education AR-6143 Instruction Item 9 (Grades 7-12) ☒ ☐ ☐ and vocational opportunities. (4) Administration of the High School Equivalency Tests AR6146-2 Instruction Ed Code 51420 as approved by the California Department of ☒ ☐ ☐ Education, shall be made available when possible. (5) Supplemental instruction shall be afforded to youth AR-6179 Instruction BPP 5149 who do not demonstrate sufficient progress towards ☒ ☐ ☐ grade level standards. (6) The minimum school day shall be consistent with BP 6112 Instruction State Education Code Requirements for juvenile court 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 BP 6112 Instruction Partially address classification, housing, security status, disciplinary requirement; AR 5131 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 AR 5144 Students (1) Positive behavior management will be 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 BP 5021 Students CF 6020 ☒ ☐ ☐ decisions made by probation staff that may affect the educational programming of students. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 59 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (3) Except as otherwise provided by the State Education BP 5144.1 Students; 5144.2 - Suspension Code, expulsion/suspension from school shall be and Expulsion/Due Process (Students with imposed only when other means of correction fails Disabilities) 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 BP 5144 education staff will develop policies and procedures ☒ ☐ ☐ that address the rights of any student who has continuing difficulty completing a school day. (d) Provisions for Special Populations BP 0430 Philosophy, Goals, Objectives and Comprehensive Plans (1) State and federal laws and regulations shall be observed for all individuals with disabilities or ☒ ☐ ☐ 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 BP 6174 Instruction afforded an educational program that addresses their ☒ ☐ ☐ language needs pursuant to all applicable state and federal laws and regulations governing programs for EL students. (e) Educational Screening and Admission BP 6162.5 Instruction Partially answers requirement ☒ ☐ ☐ (1) Youth shall be interviewed after admittance and a record maintained that documents a youth's educational history, including but not limited to: (A) School progress/school history; BP 6162.5 Instruction ☒ ☐ ☐ (B) Home Language Survey and the results of the State AR 6174 Instruction ☒ ☐ ☐ Test used for English language proficiency; (C) Needs and services of special populations as defined BP 6162.5 Instruction ☒ ☐ ☐ by the State Education Code, including but not limited to, students with special needs. (D) Discipline problems. ☒ ☐ ☐ BP 5131 Students (2) Youth will be immediately enrolled in school. BP 6162.5 Instruction Educational staff shall conduct an assessment to ☒ ☐ ☐ determine the youth's general academic functioning levels to enable placement in core curriculum courses. (3) After admission to the facility, a preliminary BP 6162.5 Instruction ☒ ☐ ☐ education plan shall be developed for each youth within five school days. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 60 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (4) Upon enrollment, education staff shall comply with AR 5125 Students the State Education Code and request the youth's records from his/her prior school(s), including, but not 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 AR 5125 Students ☒ ☐ ☐ (1) The complete facility educational record of the youth shall be forwarded to the next educational placement in accordance with the State Education Code. (2) The County Superintendent of Schools shall provide BP 5121 Students appropriate credit (full or partial) for course work ☒ ☐ ☐ completed while in juvenile court school in accordance with the State Education Code. (g) Transition and Re-Entry Planning AR 6159 Instruction (1) The Superintendent of Schools and the Chief Probation Officer or designee, shall develop policies ☒ ☐ ☐ 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 BP 6143 Instruction and BP 6163.4 Student Use of Technology (1) The school and facility administrator should, whenever possible, collaborate with local post- ☒ ☐ ☐ secondary education providers to facilitate access to educational and vocational opportunities for youth that considers the use of technology to implement these programs. 1371 PROGRAMS, RECREATION, AND Residential Treatment Services Bureau EXERCISE. (RTSB) Manual Section 1306: Programs, recreation and Exercise The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for programs, recreation, and exercise for all youth. The intent is to minimize the amount of time youth are in their rooms or their bed area. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 61 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS Juvenile facilities shall provide the opportunity for Residential Treatment Services Bureau programs, recreation, and exercise a minimum of three (RTSB) Manual Section 1306: Programs, hours a day during the week and five hours a day each recreation and Exercise Saturday, Sunday or other non-school days, of which Documentation provided noting Camp Scott one hour shall be an outdoor activity, weather offers a plethora of age and gender permitting. appropriate programming for the young ladies of the facility; however, the time spent ☐ ☒ ☐ in these programs or activities is not documented to confirm the minimum one hour has been completed. We noted several incidents where required activities (programs and recreation (free time) were not documented at all. This section is non- compliant. A youth’s participation in programs, recreation, and Residential Treatment Services Bureau exercise may be suspended only upon a written finding (RTSB) Manual Section 1306: Programs, ☒ ☐ ☐ by the administrator/manager or designee that a youth recreation and Exercise represents a threat to the safety and security of the facility. Such program, recreation, and exercise schedule shall Residential Treatment Services Bureau be posted in the living units. ☒ ☐ ☐ (RTSB) Manual Section 1306: Programs, recreation and Exercise 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 62 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS There will be a written annual review of the programs, Residential Treatment Services Bureau recreation, and exercise by the responsible agency to (RTSB) Manual Section 1306: Programs, ensure content offered is current, consistent, and recreation and Exercise relevant to the population. Facility administration provided a detailed memo with a complete listing and description of all programs offered at the facility in coordination with, LACOE and by Probation staff noting that the programs were appropriate for the youth. Los Angeles County Department of Mental Health provides: • Dialectical Behavior Therapy • Family Therapy • Individual Therapy • Life Skills • Parenting Classes • Seeking Safety ☒ ☐ ☐ • Mindfulness Substance Abuse Program materials and handouts were provided along with letters from the following programs were provided for our review: • The Spirit Awakening Foundation • Arts for Incarcerated Youth Network • Million Little • Anti-Recidivism Coalition • Pawsitive Steps Academy • Urban Strategies • The Swan Within Technical Assistance: Due to COVID, we understand the difficulties of getting documents for annual reviews. Please ensure that all reviews are available for the next onsite inspection for all programs and providers. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 63 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) Programs. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of daily (RTSB) Manual Section 1306: Programs, programming to include, but not be limited to, recreation and Exercise trauma focused, cognitive, evidence-based, best Youth are to be provided with the practice interventions that are culturally relevant and opportunity to participate in at least one hour linguistically appropriate, or pro-social interventions of programming that is rehabilitational daily. and activities designed to reduce recidivism. These programs should be based on the youth’s individual Documentation provided did not show needs as required by Sections 1355 and 1356. Such compliance with regulation expectations programs may be provided under the direction of the (program and time). This section is non- Chief Probation Officer or the County Office of compliant 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: ☐ ☒ ☐ (1) Cognitive Behavior Interventions; (2) Management of Stress and Trauma; (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 Residential Treatment Services Bureau opportunity for at least one hour of daily access to (RTSB) Manual Section 1306: Programs, unscheduled activities such as leisure reading, letter recreation and Exercise writing, and entertainment. Activities shall be Youth are to be provided with the supervised and include orientation and may include opportunity to participate in at least one hour coaching of youth. ☐ ☒ ☐ of recreation (Known as “Free Time” in your documentation) Documentation provided notes that free time activities are provided but does not note the hour requirement. This is non-compliant. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 64 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (c) Exercise. All youth shall be provided with the Residential Treatment Services Bureau opportunity for at least one hour of large muscle (RTSB) Manual Section 1306: Programs, activity each day. recreation and Exercise Youth are to be provided with the ☒ ☐ ☐ opportunity to participate in at least one hour of exercise. Documentation provided noted that youth receive an hour of exercise daily. The administrator/manager may suspend, for a period not Residential Treatment Services Bureau to exceed 24 hours, access to recreation and programs. (RTSB) Manual Section 1306: Programs, The administrator/manager shall document the reasons ☒ ☐ ☐ recreation and Exercise why suspension of recreation and programs occurs. 1372 RELIGIOUS PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1004: Religious The facility administrator shall provide access to Services religious services and/or religious counseling at least once each week. Attendance shall be voluntary. A youth ☒ ☐ ☐ Services are provided for both Catholic and shall be allowed to participate in an activity outside of Protestant religions. their room if he/she elects not to participate in religious programs. Religious programs shall provide for: (a) opportunity for religious services and practices; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (b) availability of clergy; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services (c) availability of religious diets. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 1004: Religious Services 1373 WORK PROGRAM Residential Treatment Services Bureau (RTSB) Manual Section 1003: Work Crews The facility administrator shall develop policies and procedures regarding the fair and consistent assignment Camp Scott has established a robust work of youth to work programs. Work assigned to a youth program for their youth. The programs are shall be meaningful, constructive and related to as follows: vocational training or increasing a youth's sense of ☒ ☐ ☐ • Workability Central Transition responsibility. Work programs shall not be imposed as a Partnership Program disciplinary measure. • Jobs for Youth These programs are available onsite. The facility has developed job specifications and an application process 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 65 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1374 VISITING Residential Treatment Services Bureau (RTSB) Manual Section 902: Visiting The facility administrator shall develop and implement Procedures, 903: Saturday and Sunday written policies and procedures for visiting, that include Visiting and 904: Special Visits provisions for special visits. Youth shall be allowed to receive visits by parents, guardians or persons standing Visiting logs provided for review. Technical in loco parentis, and children of youth. Other family assistance provided to update how members, such as grandparents and siblings, and attendance is captured to ensure a more supportive adults, may be allowed to visit with the ☒ ☐ ☐ current update. approval of the facility administrator or designee, and in A sample of a letter that is sent to parents of conjunction with the youth’s case plan or in the best youth detained in both the Juvenile Halls and interest of the youth. the camps was provided for our review. The letter was dated in September 2019 and contained information that was not updated to current regulations. This has been corrected. All visits shall occur at reasonable times, subject only to Residential Treatment Services Bureau the limitations necessary to maintain order and security. (RTSB) Manual Section 902: Visiting Visitation shall not be denied solely based on the visitor’s Procedures, 903: Saturday and Sunday criminal history. The staff shall determine in each case, Visiting and 904: Special Visits whether the visitor’s criminal history represents a risk to ☒ ☐ ☐ Visitation occurs on Sundays from 1:00PM the safety of youth or staff in the facility. Any denial of to 4:00PM. visitation or limitation on visitations shall be communicated to the youth, person denied and facility Administration will always make exceptions administrator. for those that cannot make it on the weekend. Opportunity for visitation shall be a minimum of two Residential Treatment Services Bureau hours per week. Visits may be supervised, but (RTSB) Manual Section 902 and Visiting conversations shall not be monitored unless there is a Procedures, 903: Saturday and Sunday security or safety need. Visiting ☒ ☐ ☐ Youth have over 2 hours of visitation opportunity on the weekends and administration will make arrangements during the week for youth to have the same amount of time if needed. Provisions for special visits, in addition to the two-hour Residential Treatment Services Bureau minimum and/or outside of the regular visiting hours, (RTSB) Manual Section 902: Visiting shall be accommodated as necessary and within the Procedures, 903: Saturday and Sunday discretion of the facility administrator or designee. ☒ ☐ ☐ Visiting and 904: Special Visits 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 Residential Treatment Services Bureau alternative, but not as a replacement, to in-person (RTSB) Manual Section 902: Visiting visiting. ☒ ☐ ☐ Procedures 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 66 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS 1375 CORRESPONDENCE Residential Treatment Services Bureau (RTSB) Manual Section 510: Mail The facility administrator shall develop and implement ☒ ☐ ☐ written policies and procedures for correspondence Youth can write letters daily. Mail is also which provide that: distributed daily. (a) there is no limitation on the volume of mail that youth Residential Treatment Services Bureau may send or receive; ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (b) youth may send two letters per week postage free; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 510: Mail (c) youth may correspond confidentially with state and Residential Treatment Services Bureau federal courts, any member of the State Bar or holder (RTSB) Manual Section 510: Mail of 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 Residential Treatment Services Bureau in (c), may be read by staff only when there is (RTSB) Manual Section 510: Mail ☒ ☐ ☐ reasonable cause to believe facility safety and security, public safety, or youth safety is jeopardized. 1376 TELEPHONE ACCESS Residential Treatment Services Bureau (RTSB) Manual Section 509: Telephone The administrator of each juvenile facility shall develop ☒ ☐ ☐ Calls and implement written policies and procedures to provide youth with access to telephone communications. Youth may call home weekly. 1377 ACCESS TO LEGAL SERVICES Residential Treatment Services Bureau (RTSB) Manual Section 520: Access to The facility administrator shall develop written ☒ ☐ ☐ Legal Services 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 Residential Treatment Services Bureau attorneys and their authorized representatives; ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (b) provision for confidential consultation with Residential Treatment Services Bureau attorneys; and, ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services (c) unlimited postage free, legal correspondence and Residential Treatment Services Bureau cost-free telephone access as appropriate. ☒ ☐ ☐ (RTSB) Manual Section 520: Access to Legal Services 1390 DISCIPLINE Residential Treatment Services Bureau (RTSB) Manual Section 601: Discipline, The facility administrator shall develop and implement 602: Facility Rules and 603: Behavior written policies and procedures for the discipline of Management Program youth that shall promote acceptable behavior; including ☒ ☐ ☐ the use of positive behavior interventions and supports. Youth also receive a copy of the RTSB Discipline shall be imposed at the least restrictive level Orientation Handbook and the Behavior which promotes the desired behavior and Deprivation of Management Program Handbook at the following is not permitted: orientation. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 67 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (a) bed and bedding; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (b) daily shower, access to drinking fountain, toilet and Residential Treatment Services Bureau ☒ ☐ ☐ personal hygiene items, and clean clothing; (RTSB) Manual Section 601: Discipline (c) full nutrition; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (d) contact with parent or attorney; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (e) exercise; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (f) medical services and counseling; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (g) religious services; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (h) clean and sanitary living conditions; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (i) the right to send and receive mail; Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (j) education; and, Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline (k) rehabilitative programming. Residential Treatment Services Bureau ☒ ☐ ☐ (RTSB) Manual Section 601: Discipline The facility administrator shall establish rules of conduct Residential Treatment Services Bureau and disciplinary penalties to guide the conduct of youth. (RTSB) Manual Section 604: Continuum of Such rules and penalties shall include both major Correction violations and minor violations, be stated simply and ☒ ☐ ☐ Information regarding the rules is provided affirmatively, and be made available to all youth. in the orientation and BMP handbooks that Provision shall be made to provide accessible are provided to the youth. information to youth with disabilities, limited English proficiency, or limited literacy. 1391 DISCIPLINE PROCESS Residential Treatment Services Bureau (RTSB) Manual Section 604: Continuum of The facility administrator shall develop and implement ☒ ☐ ☐ Correction and 606: Due Process written policies and procedures for the administration of discipline which shall include, but not be limited to: (a) designation of personnel authorized to impose Residential Treatment Services Bureau discipline for violation of rules; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (b) prohibiting discipline to be delegated to any youth; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ (c) definition of major and minor rule violations and Residential Treatment Services Bureau their consequences, and due process requirements; ☒ ☐ ☐ (RTSB) Manual Section 604: Continuum of Correction (d) trauma-informed approaches and positive behavior Residential Treatment Services Bureau interventions; ☒ ☐ ☐ (RTSB) Manual Section 602: Facility Rules and 604: Continuum of Correction 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 68 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (e) minor rule violations may be handled informally by Residential Treatment Services Bureau counseling, advising the youth of expected conduct (RTSB) Manual Section 604: Continuum of imposing a minor consequence. Discipline shall be Correction accompanied by written documentation and a ☐ ☒ ☐ policy of review and appeal to a supervisor; and, No documentation of minor rule violations provided separate than sanctions and appeals form with PIR’s (f) major rule violations and the discipline process Residential Treatment Services Bureau shall be documented and require the following: ☒ ☐ ☐ (RTSB) Manual Section 606: Due Process 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 69 - J453 JUV PRO-Eff. 01-01-2019 (1) written notice of violation prior to a hearing; Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process There is no location/space for notice of violation on the current form. Policy is consistent with regulation requirements; documentation is not. Facility staff provided Sanctions and Appeals forms that are required for all PIR SCM packets. Technical assistance has previously been provided and discussed with Bureau Management regarding the sanctions and appeal form and the need to revise and change the form to ensure compliance. We were assured this would be revised/updated to be more consistent to address the regulation requirements. This issue was addressed with the Prior Bureau Chief and consultant staff and it was agreed a new form would be implemented for this next cycle. The form does not provide proof of notice of violation and the recommendations noted are not the actual sanctions being recommended or imposed. All sanctions must be noted and ☐ ☒ ☐ made a part of this process and Youth must have the option of a due process hearing on the actual consequences and sanctions they receive. We have confirmed agency staff have corrected policy and forms to correct this issue however, we are unable to determine implementation. This is currently non- compliant. We appreciate the efforts that have been made and look forward to reviewing documentation in the near future to review for compliance. We will continue to follow up with the agency to provide support and technical assistance as needed. Documentation provided from Camp Scott was completed on the same forms as previously used in past cycles. In addition, policy requires staff to document the major rule violation on the SIR which we did not find evidence of and policy states that all penalties are held in abeyance pending the outcome of the hearing. 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 70 - J453 JUV PRO-Eff. 01-01-2019 TITLE 15 SECTION YES NO N/A P/P REFERENCE - COMMENTS (2) accommodations provided to youth with Residential Treatment Services Bureau disabilities, limited literacy, and English (RTSB) Manual Section 606: Due Process language learners; Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (3) hearing by a person who is not a party to the Residential Treatment Services Bureau incident; (RTSB) Manual Section 606: Due Process ☒ ☐ ☐ Reviewed and compared staff to ensure staff were not involved in the incident. (4) opportunity for the youth to be heard, present Residential Treatment Services Bureau evidence and testimony; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (5) provision for youth to be assisted by staff in the Residential Treatment Services Bureau hearing process; (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. . (6) provision for administrative review. Residential Treatment Services Bureau (RTSB) Manual Section 606: Due Process Unable to confirm hearing practices as not ☐ ☐ UNK on site to view or to interview staff or youth. (g) violations that result in a removal from camp or Residential Treatment Services Bureau commitment program, but not a return to court, will (RTSB) Manual Section 604: Continuum of ☒ ☐ ☐ follow the due process provisions in subsection (e) Correction above. f 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 71 - J453 JUV PRO-Eff. 01-01-2019 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 Allocation Eligibility Form are being provided at the facility. ☒ ☐ ☐ (Refer to the JPCF Program Agreement, Attachment B) 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 ☐Vi Dependent or neglected minors who are defined under Section ☐ olati ☒ 300 of the Welfare and Institutions Code (WIC) are held only on 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 ☐Vi Delinquents (WIC 602)? (WIC 207[d]). ☐ olati ☒ on 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 ☐Vi from minors. ☐ olati ☒ on Adult inmates from an adult facility (e.g. inmate workers or ☐Vi “Scared Straight” programs) are not allowed in the facility in a ☒ olati ☐ manner that allows contact with minors. on 7267 Los Angeles Camp Joseph Scott 18 20 PRO - 72 - J453 JUV PRO-Eff. 01-01-2019 JUVENILE HALLS, SPECIAL PURPOSE JUVENILE HALLS AND CAMPS PHYSICAL PLANT EVALUATION Board of State and Community Corrections Applicable Title 24 Regulations: Pre-1998* BSCC Code: 7267 FACILITY NAME: FACILITY TYPE: Joseph Scott Camp CONSTRUCTION/REMODEL DATE(S): 1960 IDENTIFY FACILITY PHYSICAL PLANT MODIFICATIONS SINCE 1992: FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018 2020 Virtual Inspection: Camp Scott youth have been relocated to DKC and are being housed in Amethyst and Jade cottages. We have not confirmed the physical plant information and have provided last year’s evaluation for information only. TITLE 24 SECTION YES NO N/A COMMENTS RECEPTION AREA (JH) Applies only to Juvenile Halls. ✓ Holding Rooms: Contain 15 square feet per minor; Have sufficient seating to accommodate the rated ✓ capacity based on floor space; Provide access to water closets and wash basins at a ✓ ratio of a 1:8; and Provide access to drinking fountain. ✓ Provide access to telephone. ✓ Provide access to private room(s) for interviews. ✓ MEDICAL EXAM SPACE (JH & CAMP) Space or room(s) afford privacy, are equipped to carry out ✓ routine examinations and emergency care and have sufficient locked storage space for medical supplies. LIVING UNITS (JH AND SPJH) Applies only to Juvenile Halls and Special Purpose Juvenile Halls. ✓ Living units are designed to accommodate no more than 30 minors and contain: Showers at a ratio of 1:6; ✓ Washbasins at a ratio of 1:6; ✓ Water closets at a ratio of 1:6 or water closet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain by minors and staff. ✓ Doors of each sleeping room have a view panel (maximum of 144 square inches of shatter-proof glass or plastic ✓ materials) that allows the visual supervision of all parts of the room. Hallways in the detention living units are at least eight feet wide. If rooms are located on only one side, or if room ✓ doors are staggered, hallways are at least six feet wide. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7267 LA Camp Scott at Camp Dorothy Kirby Center 18-20 PHY - 1 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SINGLE ROOMS (JH, SPJH & CAMP) Contain a minimum of 500 cubic feet of air space and 63 ✓ cubic feet of floor space. DOUBLE ROOMS (JH, SPJH & CAMP) ✓ Contain a minimum of 800 cubic feet of airspace and 100 square feet of floor space. DORMITORY SLEEPING AREAS (JH & CAMP) ✓ Contain a minimum of 400 cubic feet of airspace and 50 square feet of floor space per minor. LOCKED SLEEPING ROOMS (JH, SPJH & CAMP) There are 3 locked sleeping rooms located in the Intensive Care Unit (ICU). Contain an individual or combination drinking fountain, ✓ wash basin and toilet, unless a communication system or procedure is in effect to give minor immediate access to these fixtures. PLUMBING FIXTURES (CAMP) The following plumbing fixtures are adjacent to each ✓ sleeping area: Shower or bathtub at a ratio of 1:6; Washbasins at a ratio of 1:10; ✓ Access to toilets at a ratio of 1:10 or toilet and one ✓ urinal for every 15 boys; and, Access to a drinking fountain. ✓ BEDS AND MATTRESSES (JH, SPJH & CAMP) Beds and mattresses are: ✓ A least 30 inches wide and 76 inches long; Spaced at least 36 inches apart and at least 12 inches off ✓ the floor; and, Mattresses are made of a fire retardant material. ✓ INTERVIEW ROOMS (JH, SPJH & CAMP) ✓ There is one interview room for each detention unit in juvenile halls and special purpose juvenile halls. There is a private room suitably equipped for conferences ✓ and interviews in each camp. LIGHTING (JH, SPJH & CAMP) There are at least 50 foot candles of illumination at desk ✓ level and, at night, there is a maximum illumination of two foot candles at bed level in individual and multiple occupancy rooms. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7267 LA Camp Scott at Camp Dorothy Kirby Center 18-20 PHY - 2 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS ACADEMIC CLASSROOM (JH & CAMP) Each classroom contains a minimum of 160 square feet with a teacher's desk and work area, and a minimum of 28 square ✓ feet per student. Classrooms should be designed for no more than 15 students. 98: Designed for no more than 20 students DINING SPACE (JH & CAMP) ✓ There is a minimum of 15 square feet of space for each person being fed at any given time. PHYSICAL ACTIVITY SPACE (JH & CAMP) (See 2001 regulations for revised calculations.) There is indoor space consisting of at least 30 square feet of ✓ clear space for each minor, which may be included in a day room, a recreational building, or a multipurpose space (gymnasium). There is outdoor and/or multipurpose (gymnasium) space consisting of: ✓ No less than the equivalent of 90' X 100' outdoor and /or multipurpose space (gymnasium) for a facility with a capacity of 40 or less. No less than the equivalent of 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with a capacity of more than ✓ 40, and a juvenile hall with a capacity between 41 to 100 minors. No less than the equivalent of two 90' X 100' hardtop area and 260 X 260' field area and/or multipurpose space (gymnasium) for a camp with a capacity of more ✓ than 40 and a juvenile hall with a capacity in excess of 101 minors. Lighting is adequate for security and evening recreational ✓ activities in camps. STORAGE SPACE (JH, SPJH & CAMP) ✓ Each minor is provided 9 cubic feet of secure storage space for personal clothing and belongings. Camps shall have adequate space (12 square feet of floor area is recommended) for bulk and activity storage ✓ equipment. MULTIPURPOSE SPACE OR ROOM (SPJH) Applies only to Special Purpose Juvenile Halls. There is a multipurpose space or room that provides space ✓ for reception, dining, recreation, exercise and/or education. This room contains a minimum of: 30 square feet of clear floor space per minor in the ✓ room; 10 feet by 20 feet floor dimensions; and, ✓ 1600 cubic feet of air space with a minimum ceiling ✓ height of eight feet. *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7267 LA Camp Scott at Camp Dorothy Kirby Center 18-20 PHY - 3 - J455 PHY Pre-98.dot (03/01) TITLE 24 SECTION YES NO N/A COMMENTS SPECIAL PURPOSE JH EXEMPTIONS SPJHs are exempt from the following Pre-1998 Title 15 regulations: Section 4272(b) Medical exam rooms Section 4272(m) Academic classrooms ✓ Section 4272(n) Dining space Section 4272(o) Physical activities space *Regulations on this checklist are from the Pre-1998 Title 15 Sections 4272/4315.3(Juvenile Halls & Special Purpose Juvenile Halls) and 4323 (Camps & Ranches). 7267 LA Camp Scott at Camp Dorothy Kirby Center 18-20 PHY - 4 - J455 PHY Pre-98.dot (03/01) JUVENILE HALLS, SPECIAL PURPOSE HALLS AND CAMPS LIVING AREA SPACE EVALUATION Board of State and Community Corrections Inspection BSCC Code: 7234 FACILITY: TYPE: RC: Joseph Scott Camp 20 FIELD REPRESENTATIVE: DATE: Lisa Southwell June 26, 2020 **2018-2020 Inspection Cycle Notes: Inspection completed virtually. No changes to the LASE per administration. Provided for information only** ROOMS EACH ROOM Unit Room Applicable # Each Room Total Size (L x W x H) or FIXTURES* COMMENTS Designation Type Standards Rooms # Beds RC RC Square/Cubic Feet T U W F S Amethyst Pre-98 Camp Scott utilizes these 2 housing units only. RC 20. Dayroom 1 = 642 1 Restroom 2 3 3 Single 10 1 1 10 7’7” x 11’7” = 88 Jade Pre-98 Dayroom 1 = 642 1 Restroom 1 2 3 3 Single 10 1 1 10 7’7” x 11’7” = 88 HISTORICAL NOTES: Site includes 6 classrooms. Each unit has an attached patio. 2016 2018 Inspection Cycle Notes: **2018 2020 Virtual Inspection: Provided for information only. 20 beds moved from DKC (Jade and Amethyst) to Scott at DKC. Count -RC at 20 *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. 7234 Los Angeles Camp Scott at Camp Dorothy Kirby Center 18 20 LASE- 1 - J460 LAS JUV-05.dot (8/05)