OIG
OIG Annual Report
Robert A. Barton Office of the Inspector General
Inspector General
2016 ANNUAL REPORT
February 2017
Office of the Inspector General
20 16 ANNUAL REPORT
Robert A. Barton
Inspector General
Roy W. Wesley
Chief Deputy Inspector General
Shaun R. Spillane
Public Information Officer
February 2017
Table of Contents
FOREWORD i
OIG OUTREACH 1
Expert Assistance Provided to the California Health and Human Services Agency 3
ORGANIZATIONAL OVERVIEW 4
FUNCTIONS OF THE OFFICE OF THE INSPECTOR GENERAL 5
Statewide General Intake 5
CDCR Oversight Activities 6
Monitoring Activities 7
Medical Inspections 8
Warden/Superintendent Vetting 9
Blueprint Monitoring 10
California Rehabilitation Oversight Board 11
Special Reviews 11
CDCR CORRECTIVE ACTION PLAN UPDATE 12
Status of Recommendations Made to CDCR in 2016 12
Status of Recommendations Made to CDCR in 2015 12
APPENDIX: REPORTS RELEASED IN 2016 13
FOREWORD
OIG Mission
To safeguard the integrity of the State’s correctional system by providing oversight and
transparency through monitoring, reporting, and recommending improvements on policy and
practices of the California Department of Corrections and Rehabilitation.
OIG Vision
To transform the State’s correctional system into a model for inmate rehabilitation, employee
conduct, health care delivery, and transparency in correctional programs.
As I write this, I realize that it will be the last annual report of my current term as Inspector
General. This realization causes reflection not only on what the agency has done this last year,
but what we have done for the past five years. I would be remiss if I did not acknowledge the
hard work and dedication of my staff over that time, and the staff of the California Department of
Corrections and Rehabilitation (CDCR or the department) who have made great strides in
improving the correctional system in California for the benefit of all.
When I began my term in 2011, the Inspector General’s office was in turmoil and required a
complete reorganization and new focus on accomplishing its mission. There were massive
budget cuts, a change of statutory authority, new mandates, and a new Administration with a
bold vision for the future of the correctional system. A system was envisioned where offenders
could be rehabilitated, public safety could be protected upon their release, and future
victimization of citizens would be reduced. During this time recidivism has dropped from
67 percent to 44 percent, inclusive of those who have been re-incarcerated locally as a result of
AB 109. Severe overcrowding and the problems that go with it have greatly diminished. The
discipline system that ensures legitimacy within the system has improved. The rehabilitation
opportunities have multiplied, and staff and inmates alike are supporting a culture that values
positive change more than ever before.
The Office of the Inspector General (OIG) over this time has constantly grown and changed,
adding value to the system by providing transparent oversight and recommendations for
improvement in several different critical areas. Gains have been achieved by forging working
relationships with CDCR and policy makers emphasizing our shared goal of improving the
correctional system; a monumental task given the size and complexity of the California
Department of Corrections and Rehabilitation. There is still much more that can be done, but we
have also come a long way from the time when suspicion of corruption within the system was a
daily news item, and accusations of abuse were commonplace. One of the major benefits of an
independent oversight agency is the transparency it provides for everyone. Bad things can, and
do still happen within prisons, but the alleged layer of secrecy and cover-ups is much less
possible given the role of our agency and the unfettered access we have to the prisons.
The OIG role continues to expand as new challenges are identified. For example, the OIG has
consulted and provided expertise and personnel to assist the California Health and Human
Services Agency with the creation of its own internal affairs and discipline oversight program.
The OIG staff and I go to great lengths to educate the diverse stakeholders about our agency and
what it offers the correctional system. We are constantly in the prisons and meeting with people
2016 Annual Report Page i
Office of the Inspector General State of California
and organizations inside and outside of CDCR. The OIG complaint Intake process has become
more interactive, and we now report on those complaints that are referred out to our regional
staff in the field who can problem solve directly with wardens and key prison staff. This would
not be possible without the cooperation we have developed over the last several years. OIG
powers are generally limited to making recommendations, but when the department knows we
share its goals for improvement, and the focus is on solving problems rather than advertising
blame, there is more willingness to work together.
We have also increased our monitoring and reporting of Sexual Abuse in Detention Elimination
Act (SADEA) cases and encourage the department to continue its forward progress in this area.
Once again, when problems like prison rape are taken seriously, and inmates have an outlet for
their concerns, it builds legitimacy that encourages both the incarcerated, and their families, to
buy into a justice system they previously rejected.
The Office of the Inspector General has also grown in other ways. During my term, we have
established a contraband watch monitoring program that has seen the use of this procedure
diminish dramatically. The time people are kept on contraband watch has also drastically
reduced. This is a significant cost-savings, and eliminates many of the prior concerns about
potential abuses of the process, health risks to offenders, as well as the subsequent lawsuits they
engendered. The OIG use-of-force monitoring program has evolved and embraced technology
that allows us to monitor trends in a way that can serve as an early warning system for potential
areas of concern. The OIG shares this information with the department on a regular basis, and
the OIG has redoubled efforts to review a higher percentage of use-of-force incidents than ever
before. Officer training in this area is critical, as improper application of force can cause danger
to staff, needless injuries, abuse, complaints and lawsuits. It also may illustrate where bigger
problems exist.
The OIG plays a role in the risk management of critical incidents within the prisons. OIG staff
respond 24 hours per day, 7 days per week to homicides, large scale riots, deadly force incidents,
and other critical incidents within CDCR. The OIG presence provides transparency for the
public and enhanced confidence that matters will be handled in a thorough and fair manner with
outcomes that are appropriate. This is another area where the OIG presence within the individual
prisons on a constant basis benefits the interaction and ability to get it right.
Perhaps one of the biggest evolutions within the OIG has been the ever more crucial role our
Medical Inspection Unit serves for the system. Over the last few years it has gone through a
metamorphosis. What started as a simple medical policy auditing function has now become a
full compliance and quality evaluation monitoring and reporting team, staffed by qualified
medical experts. This role is much more aligned with our statutory mandate. As a result, there is
now an attendant benefit to the state and inmates. The OIG reports are now utilized by the
department to make improvements to healthcare that benefit the inmates, and are considered by
the Federal Receiver and the Federal Court as one factor in determining the cessation of the long-
running Plata lawsuit. The main goal is ensuring adequate healthcare is provided. This in turn
also adds to the legitimacy of a prison system that is among the largest in the world.
Another duty the OIG takes very seriously, given the impact on the entire system, is the review
of qualifications and recommendations for warden and superintendent placements. In my term, I
have personally been involved in this process at every institution in the system and some more
than once. I have conducted over 60 such reviews and as a result have met many promising
2016 Annual Report Page ii
Office of the Inspector General State of California
executives who can help CDCR progress into the future. I can say without hesitation that as an
overall group, the current wardens are the most supportive of programming and public safety
since I started with the OIG in 2005.
The OIG in my term has created a unit dedicated to the assessment and oversight of
rehabilitation efforts within CDCR. This unit helps to fulfill not only the duties of the California
Rehabilitation Board (C-ROB) by conducting fieldwork to determine the status of programming,
but also assists in monitoring CDCR’s adherence to its rehabilitation goals as stated in its
strategic plans (the Blueprint and the follow up to the Blueprint). The OIG’s rehabilitation unit
continually travels to prisons and researches what is working in California and elsewhere. This
work goes into reports that are published on the current successes and challenges within the
system. They too make recommendations to CDCR staff regarding programming opportunities.
As demonstrated by the Department’s response to the OIG’s recommendations, our reporting on
all these efforts has had a meaningful impact. Since 2012, we have made 169 recommendations
in our Special Review, C-ROB, Semi-Annual, and Use-of-Force reports. This is in addition to
the specific recommendations given to individual prisons in our medical reports. Eighty-three of
those recommendations have been fully implemented, 17 substantially implemented, 32 partially
implemented, 10 still pending, and only 27 (16 percent) have not been implemented. All of the
OIG’s reports are available on the website, and this annual report explains OIG’s function in
more detail.
The credit of course for any of the gains achieved in California’s correctional system goes to the
hardworking and conscientious staff doing a very difficult job, very well, every day. It also goes
to an Administration and policymakers that value the possibility of human redemption and how
that approach benefits public safety for all of us in the long run. Finally, recognition should also
be given to dedicated volunteers and the many entities outside of the ‘system’ that also dedicate
countless hours to its improvement. The OIG’s existence and vigilance is now an integral part of
keeping the system on track, continuing to move in a positive direction, and ensuring that gains
already achieved are not lost.
Robert A. Barton
Inspector General
2016 Annual Report Page iii
Office of the Inspector General State of California
OIG OUTREACH
The Office of the Inspector General (OIG) constantly seeks opportunities to better assess and
recommend improvements within the California Department of Corrections and Rehabilitation
(CDCR or the department). This requires communication with departmental staff, the
institutions, and outside stakeholders. The OIG also educates these entities about the OIG
mission and solicits input from them. Finally, the OIG searches for ways to discover best
practices to recommend for the State’s correctional system. All of this requires constant outreach
by the agency.
The OIG provides public transparency for the state correctional system. One of the ways to have
an impact and become aware of issues within corrections is to have a personal presence within
the institutions. In addition to daily presence through OIG staff monitoring and providing
on-scene response to incidents, the Inspector General or Chief Deputy Inspector General visits
every adult institution and youth correctional facility at least once annually. In 2016, the
Inspector General conducted 35 institution visits and the Chief Deputy Inspector General
conducted 13 institution visits. The Inspector General and Chief Deputy Inspector General also
visited the two out-of-state correctional facilities that house California inmates—Tallahatchie
County Correctional Facility in Mississippi, and La Palma Correctional Center in Arizona. In
total, the Inspector General and Chief Deputy conducted 50 institution visits in 2016.
Above and beyond the staff who monitor systems within the prisons on a daily basis, OIG staff
are specifically tasked to assess the rehabilitation and education operations as part of a review for
the California Rehabilitation Oversight Board (C-ROB) and Blueprint monitoring function at
least twice per year.
The Office of the Inspector General staff make presentations to the CDCR Office of Internal
Affairs academy regarding the role and function of the OIG. OIG also presents to correctional
officer candidates in the Galt academy, and at CDCR leadership conferences. Additional
presentations on the OIG’s role and function were provided to various entities when requested,
such as the Division of Adult Parole Operations, Life Support Alliance, the American Civil
Liberties Union (ACLU), Statewide Inmate Family Council, etc.
The OIG continues to liaise with senior management at the department. The Inspector General
meets monthly with the Secretary of CDCR, the Director of Rehabilitative Programs, and the
Director of Adult Institutions. The Inspector General also meets regularly with representatives
from the Legislature and Governor’s office. The Chief Deputy Inspector General holds monthly
meetings with the Director of Adult Institutions, the Director of Adult Parole Operations, the
Chief Counsel for the Office of Legal Affairs, and the Director of Internal Oversight and
Research. These meetings allow for high-level discussions of issues and problems and their
timely resolution. In addition, the Assistant Chief Deputy Inspector General has monthly
meetings with the Chief Counsel for the Employment Advocacy and Prosecution Team, the OIA
Chief of Field Operations, the Deputy Director for the Office of Internal Affairs, the regional
Assistant Chief Counsels for the Employment Advocacy and Prosecution Team, and regional
Special Agents in Charge for the Office of Internal Affairs. These meetings delve into more
day-to-day operational issues and have been extremely helpful in resolving issues at the field
2016 Annual Report Page 1
Office of the Inspector General State of California
level. The Inspector General and OIG staff also attend noteworthy events throughout the State to
maintain contact with the department and the public in order to educate and establish working
relationships with stakeholders.
The Inspector General personally:
• Attended and presented at the annual National Association for Civilian Oversight of Law
Enforcement (NACOLE) conference
• Attended CDCR’s Medal of Valor Ceremony hosted by the California Correctional
Supervisors Organization
• Attended the 23rd annual community service awards dinner for the Asian Peace Officers
Association, Inc.
• Contributed to an article for the California Schools quarterly publication “Breaking the
Silence”
• Attended the Anti-Recidivism Coalition’s screenwriting workshop world premiere of “They
Call Us Monsters” at the Los Angeles film festival
• Presented at the Mountain Oaks Adult Education Center Commencement Ceremony
• Spoke at the Golden Hills Adult School training event at Avenal State Prison
• Presented at the Office of Correctional Education’s central region staff development
conference
• Spoke at the Children of Incarcerated Parents conference presented by Friends Outside of
Los Angeles County
• Attended the California Prison Industry inmate graduation at the Folsom Women’s Facility
• Attended and presented at CDCR’s Warden’s meeting in Galt
• Attended and presented at the Division of Adult Parole’s Administrative Professional’s
Development Training in Fresno
Children of Incarcerated Parents Folsom Women’s Facility Graduation
Conference Ceremony
Staff of the OIG from the C-ROB, Publications, and Rehabilitation unit:
• Observed 45 inmate leisure time rehabilitative program groups at 35 institutions
• Participated in the Reentry Solutions training conference
• Participated in CDCR’s Internet Protocol Television Integration Content Selection
Committee
• Participated in the Prison University Project Training Conference
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Office of the Inspector General State of California
• Coordinated an agency-wide book drive collecting over 1,500 books for CDCR libraries and
a local women and children’s shelter
• Attended briefings on crime trends and prison capacity challenges held at the Public Policy
Institute of California in Sacramento
• Attended Lifer Awareness Group, an inmate-led activity group, graduation at California
Men’s Colony
• Participated in University of California, San Diego (UCSD) Cross-Training for custody staff
and contracted treatment providers
• Participated in the 2016 California Coalition on Sexual Offending training conference
Other staff of the OIG:
• Presented and attended quarterly Prison Crimes Council meetings with CDCR
• Coordinated an agency-wide toy and clothing drive for Saint John’s women’s shelter for at-
risk women with children
• Participated in an annual OIG All-Staff meeting that included CDCR speakers and other
stakeholders
Expert Assistance Provided to the California Health and Human Services
Agency
Pursuant to consultations with the Governor’s office, the legislature, and the California Health
and Human Services Agency (CHHS), the OIG has continued to provide expert assistance in the
creation of a discipline oversight and monitoring program for the California Department of
Developmental Services and the Department of State Hospitals. The OIG has provided two
highly experienced monitors on a contractual basis to help develop a robust internal affairs
program, an independent monitoring program for the handling of discipline cases and a
transparent public reporting process. The OIG is committed to providing ongoing assistance to
CHHS.
2016 Annual Report Page 3
Office of the Inspector General State of California
ORGANIZATIONAL OVERVIEW
The OIG is organized into three regions: North, Central, and South. The North Region is
co-located with executive and administrative operations in Sacramento (Rancho Cordova),
the Central Region is in Bakersfield, and the South Region is in Rancho Cucamonga.
California Penal Code Sections 2641 and 6125 et seq. provide the statutory authority for the
OIG’s establishment and operations. The OIG staff is a skilled team of professionals,
including attorneys with expertise in internal affairs investigations, criminal law, and
employment law, as well as inspectors knowledgeable in correctional policy, operations, and
investigations.
The OIG also has a cadre of medical professionals in the Medical Inspection Unit. These
practitioners evaluate policy adherence and quality of care within the prison system. There
are also analysts and various support staff within the OIG, all of whom are integral in
achieving the OIG mission.
OIG Organizational Chart
Inspector
General
C-ROB, Chief Deputy Blueprint,
Chief Intake and
Administration Publications, Inspector Vetting,
Counsel Investigations
Rehabilitation General SLAA
Human
Medical Discipline Information
R esources
Inspection Monitoring Technology
Unit Unit
Business
Services
Assistant Chief
Deputy
Inspector
General
North Central South Special
Region Region Region Assignments
Team
2016 Annual Report Page 4
Office of the Inspector General State of California
FUNCTIONS OF THE In non-urgent matters, staff directly contact
institutional personnel to remedy issues that
OFFICE OF THE may be addressed informally, such as failure
to accept an appeal, failure to schedule a
INSPECTOR GENERAL
classification hearing, or failure to schedule
medical appointments. The Intake Unit
California Penal Code Section 6125
focuses OIG staff resources on the most
establishes the Office of the Inspector
serious complaints by using a matrix of
General as an independent agency and
common prison issues that receive priority
provides for the Inspector General to be
attention. Lack of access to grievance
appointed to a six-year term by the
processes or health care, serious due process
Governor, subject to Senate confirmation.
violations, unnecessary extended stays in
Robert A. Barton was appointed on August
segregation units, sexual abuse, serious staff
29, 2011, and his term will expire in 2017.
misconduct, and inappropriate uses of force
are among the higher priority issues in the
California Penal Code Sections 2641 and
matrix. However, if a trend of lesser policy
6125 et seq. set forth the functions of the
violations is identified, the Intake Unit
Office of the Inspector General.
makes efforts to remedy any potential
systemic issues. In most instances, the
Statewide General Intake
Intake Unit encourages complainants to
utilize CDCR’s grievance processes to
The OIG maintains a statewide intake
resolve their issues before contacting the
process to receive communications from any
OIG; therefore, lack of access to the
individual regarding allegations of improper
grievance process or unjustified rejection of
activity within CDCR. Any complaints of
appeals by CDCR staff often receive the
misconduct are brought to the department’s
most attention from Intake Unit staff.
attention.
When Intake Unit staff finds potential
The OIG Intake Unit logs, reviews,
misconduct or policy violations after
analyzes, and responds to every non-
reviewing complaints and corresponding
duplicative complaint it receives. Intake
CDCR documents, those cases are presented
Unit staff screen all complaints within 24
at a meeting every two weeks with the
hours of receipt to identify potential safety
Inspector General for consideration of
concerns. During 2016, Intake Unit staff
referral to OIG regional field staff. In the
contacted institutions 38 times indicating
field, OIG staff make recommendations to
potential safety concerns based on letters
CDCR administrators to remedy identified
and messages left on the toll-free public
issues, usually resulting in simple, informal
phone line, calls received on the main OIG
fixes, such as the training of staff, the
telephone number, and complaints submitted
initiation of inquiries, or use-of-force
electronically. These complaints expressed
reviews to determine whether misconduct
potentially unsafe conditions, such as enemy
may have occurred. If CDCR initiates a
concerns, threatening behavior, or other
formal investigation, OIG regional staff
indicators that there may be a safety or
monitors the case in accordance with the
security risk for staff or inmates. Intake Unit
OIG’s normal discipline monitoring
staff request CDCR provide a status of the
activities and reports the findings in the
situation to ensure the department rectifies
Semi-Annual Report.
any safety concerns and provides
appropriate intervention to mental health
Complaints alleging theft, fraud, or waste of
inmate patients.
State resources concerning CDCR are also
2016 Annual Report Page 5
Office of the Inspector General State of California
presented to the Inspector General for CDCR Oversight Activities
consideration of referral to the California
State Auditor.
Retaliation Claims
In 2016, the OIG’s Intake Unit received
California Penal Code sections 6128 and
2,851 general complaints submitted by
6129 authorize the OIG to receive and
inmates, parolees, families, CDCR
review complaints of retaliation levied
employees, and advocacy groups, including
against members of CDCR management by
32 complaints the Office of the Governor
CDCR employees. The OIG’s Legal
assigned the OIG to review. Intake Unit staff
Services Unit analyzes the allegations of
conducted additional research into matters
each complaint to determine whether the
or requested clarifying documentation from
complaint states a prima facie case of
CDCR institutions for 1,409 of these
retaliation. If the complaint meets this initial
complaints.
legal threshold, the OIG initiates an
investigation into the allegations and
The OIG’s Intake Unit received 321
determines whether retaliation occurred. If
complaints alleging inappropriate
the OIG determines a CDCR employee was
healthcare, lack of access to healthcare, or
subjected to unlawful retaliation, the OIG
both. OIG Intake or medical staff conducted
provides a report of its findings to CDCR
additional analysis of these medical, dental,
along with a recommendation for
and mental health complaints. The OIG
appropriate corrective action.
referred 7 of the 321 complaints to CDCR’s
Division of Correctional Health Care
At the beginning of 2016, there were two
Services or CDCR (institutions with
complaints and one investigation pending
delegated authority for medical operations)
from 2015. The OIG concluded the
for remedy where the OIG determined
investigation and completed its review of
potential violations of medical policies or
those two complaints, neither of which
procedures occurred.
stated a prima facie case of retaliation. In
2016, the OIG received nine new retaliation
Field Inquiries
complaints. The Legal Services Unit
completed analyses of seven complaints and
Since its inception, the OIG has provided a
determined none stated a prima facie case of
process by which inmates, CDCR staff, and
retaliation. Two complaints are still pending.
the public can report misconduct. The OIG
examines complaints received and assigns
Sexual Abuse in Detention
staff to conduct field inquiries regarding the
Elimination Act Ombudsperson
complaints at the institutions. In 2016, the
OIG referred 70 field inquiries to the OIG’s Claims (also referred to as Prison
regional operations teams to bring the Rape Elimination Act claims)
matters to the attention of the specific
institutions and to monitor departmental California Penal Code Section 2641 directs
response at the local level. The results of the OIG to act as the ombudsperson for
CDCR’s response to OIG’s inquiries are complaints related to sexual abuse in
included in the OIG’s Semi-Annual report. detention. The OIG is tasked with reviewing
OIG’s inquiries are limited to finding out if allegations of mishandled sexual abuse
the hiring authority is aware of the problem, investigations within correctional
and to recommend appropriate action. OIG institutions, maintaining the confidentiality
staff do not conduct investigative activities. of sexual abuse victims, and ensuring
2016 Annual Report Page 6
Office of the Inspector General State of California
impartial resolution of inmate and ward CDCR’s internal affairs investigations and
sexual abuse complaints. employee discipline process. The OIG also
oversees CDCR’s response to critical
CDCR notified the OIG of 396 sexual abuse incidents within the institutions and
allegations during 2016, including 252 with monitors the department’s contraband
a staff member as the alleged perpetrator, surveillance watch process and use-of-force
and 144 with an inmate as the alleged reviews.
perpetrator. The OIG monitors CDCR’s
handling of all sexual abuse allegations and Internal Affairs and Employee
all subsequent investigations of alleged staff Discipline Monitoring
involvement.
The OIG’s monitoring of CDCR’s internal
In order to fulfill the independent role of affairs and employee discipline cases
SADEA ombudsperson, the OIG supplies includes the OIA allegation intake process,
informational posters to all the adult the investigative phase by CDCR’s Office of
institutions, Division of Juvenile Justice Internal Affairs, the decision-making
(DJJ) facilities, and parole offices explaining process by the hiring authorities, and the
how to report SADEA allegations. As a handling of the matter by the CDCR
result, the OIG SADEA Ombudsperson Employment Advocacy and Prosecution
received and reviewed 167 complaints Team attorneys (referred to as “vertical
directly from inmates, family members, and advocates”). Monitoring includes all case
third parties. Most, but not all, of these activity, up to and including State Personnel
allegations were also included in the Board proceedings, if necessary. The
allegation notifications from CDCR listed Semi-Annual Reports document the
above. department’s adherence to its operating rules
and procedures as well as the quality of the
Seventeen of those contacts requested investigation and legal representation
general SADEA information which was regarding employee discipline. In 2016, the
provided, and 13 complaints alleged OIG opened 679 employee discipline cases
inadequate investigation by CDCR. Twenty- for monitoring. California Penal Code
seven of the complaints were referred to the Section 6133(b)(1) mandates the OIG
OIG regional offices to follow up and make publish a Semi-Annual Report of its
recommendations for resolution. oversight of CDCR.
The complainant first notified the OIG of 16 Closed discipline cases are reported in
allegations of sexual abuse or sexual Volume I of the OIG’s Semi-Annual Report:
harassment which the OIG referred directly www.oig.ca.gov/pages/reports.php
to CDCR to conduct an initial investigation
or inquiry. This third-party reporting process
Critical Incident Monitoring
increases transparency and provides another
reporting method for inmates who are
The OIG maintains regional on-call staff
concerned with reporting the alleged abuse
who can respond on site 24-hours-per-day to
or harassment directly to CDCR staff.
critical incidents reported to the OIG from
any of the State’s correctional institutions.
Monitoring Activities
In 2016, the OIG monitored 204 critical
incidents.
The OIG’s Discipline Monitoring Unit
provides contemporaneous oversight of
2016 Annual Report Page 7
Office of the Inspector General State of California
The OIG monitors a critical incident and any and length of contraband surveillance watch
subsequent investigation with special is a positive trend.
emphasis on determining what led up to the
incident, whether it was handled
Contraband surveillance watch reports are
appropriately, and what, if any, action
found in Volume II of the OIG’s Semi-Annual
should be taken afterward. If the facts
Report, at: www.oig.ca.gov/pages/reports.php
appear to show neglect or misconduct, OIG
staff will recommend, and subsequently
monitor, any investigation. The OIG may Use-of-Force Monitoring
recommend policy changes to prevent future
occurrences and conform to best practices. The OIG continues to monitor the
In some instances, the OIG has identified department’s use-of-force review process.
systemic issues and made recommendations The OIG attended 1,512 Executive Review
statewide or at a specific institution. Committee meetings and reviewed 6,434 of
the 7,349 use of force incidents. The OIG
Critical incident case summaries are reported in developed a new use-of-force monitoring
Volume II of the OIG’s Semi-Annual Report, tool to allow more in-depth analysis of each
available at: www.oig.ca.gov/pages/reports.php
use-of-force incident, and allow collection
of data identifying those officers who use
Contraband Surveillance Watch force most often and those inmates against
whom force is used most often. The new
The OIG monitors the department’s tool will also allow identification of “hot
contraband surveillance watch process to spots” where force is used within a prison.
ensure it is conducted within departmental The new tool was deployed on January 1,
policy and not used for punitive purposes. 2016. The data collected is shared with the
department each month. The OIG also
Department staff notify the OIG any time an participates as a non-voting member of the
inmate is placed on contraband surveillance CDCR Deadly Force Review Board.
watch. The OIG reviews all relevant data
regarding the use of contraband surveillance
watch. Additionally, whenever the Use-of-Force monitoring reports are found in
department keeps an inmate on contraband Volume II of the OIG’s Semi-Annual Report,
surveillance watch longer than 72 hours, the at: www.oig.ca.gov/pages/reports.php
OIG goes on scene to inspect the inmate’s
condition, and ensures the department is
following its policies. This on-scene process Medical Inspections
continues every 72 hours until the
department removes the inmate from Pursuant to Penal Code Section 6126(f) the
contraband surveillance watch. The OIG OIG conducts an objective, clinically
immediately discusses serious breaches of appropriate, and metric-oriented medical
policy with institution managers. inspection program to review delivery of
In 2016, the OIG was notified of 238 medical care at each of the adult institutions
contraband surveillance watch cases, 70 in California.
fewer than in 2015. Of the 238 notifications
in 2016, the OIG monitored 72 cases that During 2016, the OIG completed the
extended beyond 72 hours, as compared to fieldwork for the remaining 26 Cycle 4
101 cases extending beyond 72 hours in medical inspections. Related to those
2015. The continued decrease in the need inspections, the OIG issued 18 final public
reports. As of December 31, 2016, the OIG
2016 Annual Report Page 8
Office of the Inspector General State of California
had also issued five draft reports to external CAL September 2016 Adequate
stakeholders. The following nine institutions COR November 2016 Inadequate
received delegations back to the department
SVSP November 2016 Inadequate
from the Receiver in 2016:
HDSP December 2016 Adequate
• Folsom State Prison CMC December 2016 Adequate
• Correctional Training Facility
• Chuckawalla Valley State Prison
Medical Inspection reports are available on the
• California Correctional Institution
OIG’s website at:
• Pelican Bay State Prison
www.oig.ca.gov/pages/reports.php
• California State Prison, Centinela
• Sierra Conservation Center
Warden/Superintendent Vetting
• California Institution for Men
• Avenal State Prison
Penal Code Section 6126.6 requires that the
The Cycle 4 medical inspection includes
OIG evaluate the qualifications of every
qualitative reviews and compliance testing
candidate whom the Governor nominates for
conducted by teams staffed with OIG
appointment as a warden or a youth
clinicians and registered nurses, who used
correctional facility superintendent, and
16 quality indicators of health care to assess
report the recommendation in confidence to
each institution. The OIG plans to complete
the Governor within 90 days of the request
the Cycle 5 inspections over a period of
to evaluate the candidate. Candidates have
approximately 12 months. In December
typically been acting wardens for at least
2016, the OIG issued three job start letters
three months before the OIG process begins.
for Cycle 5 medical inspections to Valley
The OIG is keenly aware of the need for
State Prison, California Medical Facility,
stability in management and, therefore,
and Ironwood State Prison in preparation for
strives to complete its part of the vetting
starting fieldwork for these institutions in
process as expeditiously as possible.
2017.
The OIG uses a three-phase vetting process
OIG Cycle 4 Medical Inspections Final
with an internal completion goal of 60 days.
Reports Issued During 2016
This year, eleven vettings were completed
Institution with an average completion time of 61 days.
Issue Date Rating
Inspected In addition to conducting a background
CCI January 2016 Adequate investigation of the candidate and surveying
designated stakeholders, the first phase
CEN February 2016 Adequate
consists of a site visit conducted by a team
PBSP February 2016 Adequate
of inspectors, who provide the OIG with an
VSP February 2016 Inadequate
overview of the institution’s operations.
SCC March 2016 Adequate
During the second phase, the Inspector
WSP April 2016 Inadequate General personally consults with outside
CIM April 2016 Adequate stakeholders, conducts a management
review, and tours the facility with the
MCSP May 2016 Inadequate
candidate. In the final phase, the Inspector
ISP May 2016 Inadequate
General reviews all of the information
SQ July 2016 Adequate
gathered during the vetting process and
ASP August 2016 Adequate
evaluates the candidate’s suitability for the
CIW September 2016 Adequate position of warden or superintendent after a
CMF September 2016 Inadequate one-on-one interview. The Inspector
2016 Annual Report Page 9
Office of the Inspector General State of California
General then submits a confidential • Establish and adhere to the new prison
recommendation to the Governor. gang management system.
Given the high rate of turnover due to The department continued to show progress
retirement within CDCR management, the in implementing the goals of the Blueprint
OIG anticipates a continued demand for in 2016. Two of the reforms contained in the
warden vetting in 2017. initial Blueprint, standardized staffing and
the inmate classification score system have
As of December 31, 2016, the following been completed. Also, many of the housing
adult and youth institutions were without plans outlined in the Blueprint have been
permanent wardens or superintendents: completed, or are nearing completion, and
the department is housing inmates at
California City Correctional Facility
Blueprint-prescribed levels.
California Correctional Center
California Correctional Institution
As a result of the settlement agreement
Central California Women’s Facility
reached in January 2016 for Todd Ashker, et
California Institution for Women
al., v. Governor of the State of California, et
California Training Facility
al, the department agreed to change its
California State Prison, Sacramento
policies and practices for placing, housing,
Wasco State Prison
managing, and retaining inmates who have
N.A. Chaderjian Youth Correctional
been validated as prison gang members and
Facility and O.H. Close Youth
associates, as well as the conditions in each
Correctional Facility and,
of its four Security Housing Unit (SHU)
Ventura Youth Correctional Facility
institutions. The department also expedited
its review of inmates in the Step-Down
Blueprint Monitoring
Program (SDP) to determine eligibility for
release from the SHU and transfer to a
In 2012, the Legislature passed and the general population facility.
Governor signed legislation mandating the
OIG periodically review delivery of the In January 2016, the department issued An
reforms identified in The Future of Update to the Future of California
California Corrections: A Blueprint to Save Corrections, which provides a summary of
Billions of Dollars, End Federal Court the goals identified and progress made since
Oversight and Improve the Prison System the initial Blueprint, as well as the
(the Blueprint). department’s future vision for rehabilitative
programming and safety and security. The
The OIG monitored the department’s
OIG will monitor the department’s
progress implementing five key goals:
remaining goals from the initial Blueprint
• Establish and adhere to the standardized including rehabilitative programming and
staffing model at each institution; SHU inmate status.
• Establish and adhere to the new inmate
classification score system;
Blueprint monitoring reports are available on
• Implement and adhere to the
the OIG’s website at:
comprehensive housing plan;
www.oig.ca.gov/pages/reports.php
• Increase the percentage of inmates
served in rehabilitative programs to 70
percent of the target population prior to
the inmate’s release; and
2016 Annual Report Page 10
Office of the Inspector General State of California
California Rehabilitation Oversight Special Reviews
Board
A special review process is codified in Penal
The Public Safety and Offender Code Section 6126. Upon request of the
Rehabilitation Services Act of 2007 (AB Governor, the Speaker of the Assembly, or
900) established the 11-member California the Senate Rules Committee, the OIG will
Rehabilitation Oversight Board (C-ROB) conduct a review of CDCR policies,
Chaired by the Inspector General. California practices, or procedures set forth in the
Rehabilitation Oversight Board meetings are review request. Upon completion of the
conducted three times per year to examine review, the OIG reports its findings and
CDCR’s various mental health, substance recommendations to the authorizing entity
abuse, education, and employment programs and publishes a public report. In 2016, no
for inmates and parolees. The C-ROB report special reviews were requested.
is published annually, on September 15.
In 2016, C-ROB staff, in collaboration with Special Reviews are available on the OIG’s
the OIG’s Blueprint monitoring team, website at:
www.oig.ca.gov/pages/reports.php
visited all 35 adult institutions to observe
rehabilitation programs and identify
successes and challenges in programming.
C-ROB staff review a broad range of
rehabilitative programs, services, and
activity groups, including substance use
treatment, academic education programs,
career technical education programs, and
volunteer rehabilitative programming.
Institution site visits revealed many positive
changes occurring within the department,
especially its efforts to expand reentry
centers and substance abuse treatment
programs to all 35 adult institutions. The
department successfully increased the health
benefit approval process for pre-release
benefits, an important rehabilitative need.
The department has also developed a
comprehensive case management plan, and
has addressed three of the four
recommendations from the 2015 C-ROB
report. The 2016 C-ROB report provides
five additional recommendations.
California Rehabilitation Oversight Board
reports are available on the OIG’s website at:
http://www.oig.ca.gov/pages/c-rob.php
2016 Annual Report Page 11
Office of the Inspector General State of California
CDCR CORRECTIVE ACTION PLAN UPDATE
In 2016, the OIG published 25 formal reports containing 15 recommendations. The
recommendations in these reports promote greater transparency, taxpayer savings, process
improvements, increased accountability, and higher adherence to policies and constitutional
standards.
Status of Recommendations Made to CDCR in 2016
The OIG made six recommendations to CDCR in the March 2016 Semi-Annual Report, and four
more recommendations in the September 2016 Semi-Annual Report. The department has fully or
substantially implemented one of the ten Semi-Annual Report recommendations and partially
implemented two of the recommendations. Six of the recommendations have not been
implemented, and the remaining one is currently being reviewed.
There were also five recommendations made in the California Rehabilitation Oversight Board
(C-ROB) September 2016 annual report. C-ROB is an independent board, and, unlike the OIG,
does not have authority to request specific responses to recommendations; however, the
department has fully or substantially implemented one of the five C-ROB report
recommendations and partially implemented one of the recommendations. One of the
recommendations has not been implemented and the remaining two are being reviewed.
Status of Recommendations Made to CDCR in 2015
The OIG made eight recommendations to CDCR in the March 2015 Semi-Annual Report, and
five more recommendations in the September 2015 Semi-Annual Report. The department has
fully or substantially implemented six of the thirteen Semi-Annual Report recommendations and
partially implemented four of the recommendations. Two of the recommendations have not been
implemented, and the one remaining recommendation is currently being reviewed.
The OIG made 45 recommendations to the department in the December 2015 Special Review:
High Desert State Prison Susanville, CA. The department has fully or substantially implemented
33 of the 45 recommendations and partially implemented three of the recommendations. Eight of
the recommendations have not been implemented, and the one remaining recommendation is
currently being reviewed.
There were also four recommendations made in the September 2015 C-ROB report. The
department has fully or substantially implemented each of the four recommendations from the
report.
The Medical Inspection Reports also contain institution-specific recommendations that are
provided to the Receiver and the department, but due to the authority of the Receiver to
implement corrections, the department does not submit a corrective action plan for the
recommendations in the MIU reports.
2016 Annual Report Page 12
Office of the Inspector General State of California
APPENDIX: REPORTS RELEASED IN 2016
Annual Report
2015 OIG Annual Report (January 2016)
Semi-Annual Reports
OIG Semi-Annual Report July–December 2015 Volume I (June 1, 2016)
OIG Semi-Annual Report July–December 2015 Volume II (June 1, 2016)
OIG Semi-Annual Report January–June 2016 Volume I (September 28, 2016)
OIG Semi-Annual Report January–June 2016 Volume II (September 28, 2016)
Medical Inspection Reports
California Correctional Institution Medical Inspection Results Cycle 4 (January 11, 2016)
Pelican Bay State Prison Medical Inspection Results Cycle 4 (February 10, 2016)
Valley State Prison Medical Inspection Results Cycle 4 (February 22, 2016)
California State Prison, Centinela Medical Inspection Results Cycle 4 (February 26, 2016)
Sierra Conservation Center Medical Inspection Results Cycle 4 (March 16, 2016)
California Institution for Men Medical Inspection Results Cycle 4 (April 15, 2016)
Wasco State Prison Medical Inspection Results Cycle 4 (April 15, 2016)
Mule Creek State Prison Medical Inspection Results Cycle 4 (May 18, 2016)
Ironwood State Prison Medical Inspection Results Cycle 4 (May 25, 2016)
San Quentin State Prison Medical Inspection Results Cycle 4 (July 13, 2016)
Avenal State Prison Medical Inspection Results Cycle 4 (August 3, 2016)
California Institution for Women Medical Inspection Results Cycle 4 (September 12, 2016)
California Medical Facility Medical Inspection Results Cycle 4 (September 19, 2016)
Calipatria State Prison Medical Inspection Results Cycle 4 (September 19, 2016)
Salinas Valley State Prison Medical Inspection Results Cycle 4 (November 1, 2016)
California State Prison, Corcoran Medical Inspection Results Cycle 4 (November 16, 2016)
High Desert State Prison Medical Inspection Results Cycle 4 (December 6, 2016)
California Men’s Colony Medical Inspection Results Cycle 4 (December 30, 2016)
2016 Annual Report Page 13
Office of the Inspector General State of California
California Rehabilitation Oversight Board (C-ROB) Report
C-ROB September 15, 2016 Annual Report (September 15, 2016)
Blueprint Monitoring Reports
Seventh Report on CDCR’s Progress Implementing its Future of California Corrections
Blueprint (March 23, 2016)
All Reports are available on the OIG’s website at:
www.oig.ca.gov/pages/reports.php
2016 Annual Report Page 14
Office of the Inspector General State of California
2016 ANNUAL REPORT
OFFICE OF THE INSPECTOR GENERAL
Robert A. Barton
INSPECTOR GENERAL
Roy W. Wesley
CHIEF DEPUTY INSPECTOR GENERAL
STATE OF CALIFORNIA
February 2017