OIG
Use-of-Force Monitoring Report
Roy W. Wesley, Inspector General Bryan B. Beyer, Chief Deputy Inspector General
OFFICE of the
OIG
INSPECTOR GENERAL
Independent Prison Oversight June 2019
Monitoring the Use of Force
The California Department of Corrections
and Rehabilitation Continues to Perform Well
in Self-Assessing Its Use-of-Force Incidents, but
Has Shown Little Improvement in Its Overall
Compliance with Policies and Procedures
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For questions concerning the contents of this report,
please contact Shaun Spillane, Public Information Officer,
at 916-255-1131.
STATE of CALIFORNIA
OIG OFFICE of the Roy W. Wesley, Inspector General
INSPECTOR GENERAL Bryan B. Beyer, Chief Deputy Inspector General
Independent Prison Oversight
Regional Offices
Sacramento
Bakersfield
Rancho Cucamonga
June 24, 2019
Dear Governor and Legislative Leaders:
Enclosed is the Office of the Inspector General’s report titled The California Department of Corrections
and Rehabilitation Continues to Perform Well in Self-Assessing Its Use-of-Force Incidents, but Has Shown
Little Improvement in Its Overall Compliance with Policies and Procedures. It covers use-of-force incidents
we monitored for which the California Department of Corrections and Rehabilitation (the department)
completed a review between January 1, 2018, and December 31, 2018.
This report concludes that the department thoroughly reviewed incidents after its staff used force, which
is similar to our observation during our prior reporting period from July 1, 2017, through December 31, 2017.
However, the department’s overall compliance rate remains low, with the department finding only 55 percent
of incidents in full compliance with its policies and procedures. For most incidents, we concurred with the
department’s policy determinations and actions to address deviations. However, we did not agree with the
review committee’s decision for a small number of incidents.
We found the department demonstrated only minimal improvement concerning officers articulating the
presence of an imminent threat to justify the force they used, compared with findings published in our
previous report. Specifically, we found a disproportionate share of officers at contract facilities who did not
articulate an imminent threat to justify force. In addition, while the department showed some improvement
compared with the findings in our prior report—and the overall number is still relatively low—we found
further instances in which its staff members’ actions may have contributed to the need to use force.
We also found that, despite the department’s repeated efforts to reinforce policy requirements, sergeants
and lieutenants who conducted required video-recorded interviews of inmates who alleged unnecessary
or excessive force continued violating policy at a high rate. Examples of such violations include sergeants
and lieutenants completing untimely interviews, not recording inmate injuries, completing interviews in a
nonconfidential setting, or conducting interviews even though they were involved in the incident. The failure
to conduct proper interviews may hinder the department’s ability to appropriately and thoroughly address
an inmate’s allegation of misconduct. Finally, we noted the persistence of a low compliance rate during
controlled use-of-force incidents, a type of force staff used when the inmate did not pose an imminent threat
and was isolated to a confined area.
Respectfully submitted,
Roy W. Wesley
Inspector General
Gavin Newsom, Governor
10111 Old Placerville Road, Suite 110
Sacramento, California 95827
Telephone: (916) 255-1102
www.oig.ca.gov
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iv Monitoring the Use of Force
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Monitoring the Use of Force v
Contents
Summary 1
Introduction 5
Background 5
Scope and Methodology 15
Monitoring Results 17
Compared with Last Year, the Department Again Performed Well
in Self-Assessing Compliance with Its Use-of-Force Policy, yet Its
Compliance Rate Remained Low 17
Departmental Staff Showed Minimal Improvement in Articulating
an Imminent Threat to Justify the Force Used, and We Identified
Additional Incidents in Which Officers Contributed to the Need
to Use Force 23
Sergeants and Lieutenants Continued to Routinely Violate
Video-Recorded Interview Requirements 27
The Department’s Noncompliance Rate Involving Controlled
Use-of-Force Incidents Remained a Concern 30
Recommendations 33
Appendices 35
Appendix A: Detail of Use-of-Force Incidents 36
Appendix B: Detail of Policy Violations as Determined by the
Department, Grouped by OIG Category 38
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vi Monitoring the Use of Force
Illustrations
Figures
1. Distribution of Use-of-Force Incidents the OIG Monitored 10
2. Distribution of the Applications of Force in 6,426 Uses of Force 12
3. Use-of-Force Incidents, by Mission within the Division of Adult
Institutions and Other Departmental Entities 13
4. Flowchart Depicting the Division of Adult Institutions’
Use-of-Force Review Process 17
5. Departmental Compliance with Video-Recorded Interviews 28
6. Incidents of Controlled Uses of Force, by Institution or Facility 32
Tables
Definitions of Select Terms Used in This Report 6
1. Number of Use-of-Force Incidents by Departmental Entity 11
2. Number of Incidents a Review Committee Determined Were
In or Out of Policy Compliance 20
Box
OIG Categories of Departmental Policy Determinations 21
Office of the Inspector General, State of California
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Monitoring the Use of Force 1
Summary
Within its statutory mandate, the Office of the Inspector General (OIG)
monitors the California Department of Corrections and Rehabilitation’s
(the department) process for reviewing and evaluating uses of force
by departmental staff, and reports its findings. This report contains
our evaluation concerning the use-of-force incidents for which the
department completed reviews during the period from January 1, 2018,
through December 31, 2018.
Any departmental employee who uses force, or observes another
employee use force, is required to prepare a written report of the
incident before being relieved from duty at the end of the working
shift. These reports are then subjected to a multitiered review
process culminating with an executive review committee’s evaluation.
The OIG’s monitoring process included having its inspectors visit
every adult institution and juvenile facility, headquarters, and the
northern and southern parole regions to attend 1,294 of the
1,764 executive review committee meetings (a 73 percent attendance
rate), during which time, hiring authorities reviewed and evaluated
every use-of-force incident to assess compliance with departmental
policy and training.
As part of our oversight process for this 12-month period, our
inspectors reviewed and analyzed 6,426 use-of-force incidents. OIG
inspectors reviewed all written reports and documentation and,
where applicable, viewed all related video recordings of incidents
and interviews. We independently determined whether staff actions
were reasonable under the circumstances and in compliance with the
department’s policy and training. During the committee meetings,
our inspectors provided real-time feedback and recommendations to
review committee chairs.
Office of the Inspector General, State of California
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2 Monitoring the Use of Force
Use-of-Force Statistics for Incidents Monitored during the
Period from January 1, 2018, through December 31, 2018
• The OIG monitored 6,426 use-of-force incidents by attending
1,294 of the department’s 1,764 executive review committee
meetings (73 percent).
• Approximately 93 percent of the use-of-force incidents
(5,996 of 6,426) occurred at the state prisons and contract
facilities housing adult inmates, with the remainder involving
the juvenile facilities (359), parole regions (57), and the Office
of Correctional Safety (14).
• Approximately one-third of the incidents we reviewed
occurred at only five state prisons: Salinas Valley State Prison
(500), California State Prison, Sacramento (495), Kern Valley
State Prison (484), California State Prison, Los Angeles
County (421), and California State Prison, Corcoran (420).
• We monitored 6,426 incidents involving 19,527 “applications”
of force—for example, two baton strikes count as two
“applications” during a single incident. Chemical agents
accounted for 9,736 (50 percent) of total applications, while
physical strength and holds accounted for 5,995 (31 percent).
The remaining 19 percent of applications comprised force
options such as less-lethal projectiles, baton strikes, tasers,
and firearms.
Highlights
The department continued to perform well in reviewing incidents; however,
staff were fully compliant with departmental policies in only 55 percent of
the use-of-force incidents.
The department subjects its use-of-force incidents to several levels
of review, which culminate with an executive review committee
determining compliance with use-of-force policies and procedures.
As noted in our last report,1 this process has proven effective in
self-identifying instances of noncompliance. For example, while the
department found that 55 percent of the incidents during this period
fully met policy standards, it identified policy violations by its staff
in 45 percent (2,883 of 6,426) of the incidents that we monitored
during this one-year period. We agreed with the vast majority of the
department’s compliance determinations, yet we also identified some
¹ In this report, when we refer to our “last report,” this means our use-of-force
monitoring report we published in July 2018.
Office of the Inspector General, State of California
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Monitoring the Use of Force 3
instances of noncompliance that the department’s review committees
had not considered.
The department showed minimal improvement in articulating an imminent
threat to justify the force used, and we identified additional incidents
during which officers2 contributed to the need to use force.
The department’s policy for the use of immediate force requires that
officers provide justification by articulating in reports their reasoning
for using force, for example, in response to a threat against the life
of another or to prevent great bodily injury or escape. Despite this
requirement, we concluded that officers did not adequately articulate
an imminent threat in 95 of the 6,426 incidents (1.5 percent) we
monitored during this one-year period, leading us to question whether
the use of force was justified. This percentage is similar to that noted
in our last report covering our monitoring of use-of-force incidents,
which was 1.8 percent. However, we reiterate that while the number
of such instances is relatively small compared with the totality of all
use-of-force incidents during the period, the negative impact of any
such incident involving unnecessary force can be quite significant in
its potential to create tension between the inmate population and staff
members, and in exposing the department to legal liability.
The department continues to experience low compliance with its
procedures for video-recording interviews with inmates.
Departmental policy requires that staff conduct video-recorded
interviews with inmates who allege unnecessary or excessive force,
or who sustain serious or great bodily injury, possibly from the use of
force. The policy contains specific requirements, including that staff
record these interviews within 48 hours of discovery of the injury or
inmate allegation and that staff video-record any visible or alleged
injuries. We noted that the department’s compliance rate with its own
standards was only 51 percent during this one-year period. Despite
the department’s repeated attempts to provide additional training and
direction to its staff regarding the requirements, the compliance rate
remained low throughout this reporting period.
2 In this report, unless we specify an individual’s classification, when we refer to
“officers,” the term refers to various departmental peace officer classifications, such
as correctional officers, sergeants, lieutenants, youth correctional officers, parole
agents, and special agents. This list is not all-inclusive of all departmental peace officer
classifications.
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4 Monitoring the Use of Force
In controlled use-of-force incidents, the department’s compliance rate
slightly improved over our 2017 reporting period, but noncompliance
remained high, with at least one violation in 65 percent of incidents.
The department implements “controlled force” procedures when an
inmate’s presence or conduct poses a threat, yet the inmate is located
in an area that can be controlled or isolated. These procedures require
advance planning and organization by custody staff, and medical and
mental health staff. In addition, institutional staff must video-record
the incident.
Of the 100 controlled use-of-force incidents we monitored during our
one-year review period, the department’s executive review committees
found that staff violated one or more departmental policies specific to
controlled use-of-force policies in 65 incidents (65 out of 100). Most
of these violations occurred, not with the force itself, but rather, with
complying with the requirements that led up to the actual force. While
this showed progress, compared with the compliance rate noted in our
last report (a 75 percent noncompliance rate), there are opportunities
for improvement.
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Monitoring the Use of Force 5
Introduction
Background
Nearly 25 years ago, in the class-action lawsuit Madrid v. Gomez,
the federal court found, among other things, that officials with the
California Department of Corrections3 (the department) “permitted
and condoned a pattern of using excessive force, all in conscious
disregard of the serious harm that these practices inflict” in violation of
the Eighth Amendment of the United States Constitution.4
As a result of those findings, in 2007, the Office of the Inspector
General (OIG) began monitoring the department’s use-of-force internal
review process. In 2011, after significant improvements to reform
the department’s use-of-force review and disciplinary processes, the
federal court dismissed the case. The OIG, however, has continued
monitoring these processes. This report includes use-of-force incidents
that the department reviewed and we monitored from January 1, 2018,
through December 31, 2018, and presents our analysis and conclusions
of how well the department followed its own policies and training.
3 In 2005, the Department of Corrections was subsequently renamed the
Department of Corrections and Rehabilitation.
4 Madrid et al. v. Gomez et al., 889 F. Supp. 1146 (N.D. Cal. 1995), January 10, 1995.
Office of the Inspector General, State of California
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6 Monitoring the Use of Force
Use-of-Force Policy: Common Terms Defined
Throughout this report, we use a number of terms and concepts
specific to the use of force and allegations of excessive force. For
clarity, we present the department’s policy definitions5 for the
following terms:
Definitions of Select Terms Used in This Report
The force that an objective, trained, and competent correctional employee, faced
with similar facts and circumstances, would consider necessary and reasonable to
Reasonable force
subdue an attacker, overcome resistance, effect custody, or gain compliance with a
lawful order.
Unnecessary force The use of force when none is required or appropriate.
The use of more force than is objectively reasonable to accomplish a lawful
Excessive force
purpose.
The force used to respond without delay to a situation or circumstance that
Immediate use of force constitutes an imminent threat to institution/facility security or the safety of
persons.
Any situation or circumstance that jeopardizes the safety of persons or
compromises the security of the institution, requiring immediate action to stop
Imminent threat
the threat. Some examples include, but are not limited to, an attempt to escape,
ongoing physical harm, or active physical resistance.
The force used in an institutional or facility setting when an inmate’s presence or
conduct poses a threat to safety or security, and the inmate is located in an area
Controlled use of force
that can be controlled or isolated. These situations do not normally involve the
imminent threat to loss of life or imminent threat to institution security.
A serious impairment of physical condition, including, but not limited to the
following: (1) loss of consciousness; (2) concussion; (3) bone fracture;
Serious bodily injury
(4) protracted loss or impairment of function of any bodily member or organ;
(5) a wound requiring extensive suturing; and (6) serious disfigurement.
Great bodily injury Any bodily injury that creates a substantial risk of death.
Use-of-Force Options
Inmate behavior can be unpredictable, and at times, departmental staff
must use force to gain an inmate’s compliance to ensure the safety of
other inmates or staff. When determining the best course of action
to resolve a particular situation, staff must evaluate the totality of
5 Article 2, Use of Force, 51020.4 “Definitions,” California Department of Corrections and
Rehabilitation, Adult Institutions, Programs, and Parole Operations Manual. On the web at
https://www.cdcr.ca.gov/Regulations/Adult_Operations/docs/DOM/DOM%20
2019/2019-DOM.pdf (accessed 6-11-19). The publication is commonly referred to as
the DOM.
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Monitoring the Use of Force 7
the circumstances, including the inmate’s demeanor, mental health
status and medical concerns (if known), and the inmate’s ability
to understand and comply with orders. Departmental policy states
that staff should attempt to verbally persuade whenever possible,
to mitigate the need for force. When force becomes necessary, staff
must consider specific qualities for each force option when choosing
among options to deploy, including the range of effectiveness for the
force option, the level of potential injury, the threat level presented,
the distance between staff and inmate, the number of staff and inmates
involved, and the inmate’s ability to understand. Departmental policy
includes a number of force options, such as the following:
• Chemical agents
• Hand-held baton
• Physical strength and holds6
• Less-lethal weapons7
• Lethal weapons8
Levels of Use-of-Force Review: Adult Institutions
Institution Executive Review Committee : This is the primary level
of review for use-of-force incidents involving the Division of Adult
Institutions, including in-state and out-of-state contract facilities. For
each adult institution, an institution’s executive review committee
examines every use of force, except those involving deadly force. This
committee is chaired by the warden (or his or her designee, such as
a chief deputy warden). The committee also includes an institution’s
associate wardens, captains, and health care representatives.
Committees at each institution meet regularly, depending on the
volume of use-of-force incidents, to discuss the merits of the force
used, and to determine whether staff followed policies and procedures
when using force. Departmental policy generally requires the
committees to review each incident within 30 days of occurrence.
6 Refers to a staff member using any part of his or her body as force.
7 Less-lethal weapons are those not intended to cause death when used in a prescribed
manner; they include the following: 37 mm or 40 mm launchers used to fire rubber, foam,
or wooden projectiles, and electronic control devices.
8 Lethal weapons: A firearm is a lethal weapon because it is used to fire lethal projectiles.
A lethal weapon is any weapon that is likely to result in death. DOM, 51020.5.
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8 Monitoring the Use of Force
Department Executive Review Committee : This is a committee of staff
selected by—and that includes—the headquarters’ associate director
of the respective mission in which the force occurred. This committee
reviews incidents during which staff used deadly force, but wherein the
force did not meet the criteria for review by the Deadly Force Review
Board (e.g., warning shots), and incidents during which serious bodily
injury, great bodily injury, or death could have been caused by the
use of force by staff. It may also review incidents referred to it by an
institution executive review committee. To reduce the duplication of
work, this committee does not review incidents for which the Office
of Internal Affairs has completed an investigation. The department’s
policy allows this committee up to 60 days to complete its review.
Levels of Use-of-Force Review: Juvenile Facilities
Force Review Committee : For each of the juvenile facilities,9 a force
review committee examines every use of force. The review committee
is a multidisciplinary team at each facility tasked with evaluating use-
of-force incidents to identify effective and noneffective intervention
techniques with the goal of reducing the use of force. The committee
is chaired by the superintendent (or his or her designee, such as an
assistant superintendent or chief of security), and includes program
administrators, treatment team supervisors, a training officer, and
health care representatives. As with the adult committees, the juvenile
committees meet regularly to ensure each incident is reviewed within
30 days of occurrence, as required by policy.
Division Force Review Committee : The Division Force Review
Committee is a headquarters-based multidisciplinary team of
representatives whose members are designated by the director of
the Division of Juvenile Justice. This committee reviews a minimum
of 10 percent of all use-of-force incidents that the Force Review
Committee at each facility evaluates to provide another level of
review and ensure employees act in accordance with the department’s
policies, procedures, and training.
Level of Use-of-Force Review: Adult Parole Operations
Field Executive Review Committee : For the two parole regions, a
field executive review committee examines every use of force and is
9 The Division of Juvenile Justice has different use-of-force policies, procedures, and
training from those of the Division of Adult Institutions.
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Monitoring the Use of Force 9
chaired by the regional parole administrator (or his or her designee,
such as a chief deputy). Normally, the committee consists of the chair,
one other manager, a supervising training coordinator, and a use-of-
force coordinator. The department’s policy generally requires the
committees to review each incident within 30 days of occurrence.
Level of Use-of-Force Review: Deadly Force (Statewide)
Deadly Force Review Board : The Office of Internal Affairs conducts
criminal and administrative investigations into every use of deadly
force (except for certain types of warning shots inside an institution)
and every death or great bodily injury that could have been caused
by a staff member’s use of force, regardless of whether the incident
occurred in an institutional or community setting. The department’s
Deadly Force Review Board subsequently examines these incidents.
The board consists of at least four members, three of whom are law
enforcement experts outside the department and another high-ranking
official from the department. As part of its disciplinary monitoring
function, the OIG monitors the Office of Internal Affairs’ deadly force
investigations, as defined above, and subsequently monitors the board’s
reviews of these investigations. The OIG reports on its monitoring of
these deadly force incidents in a separate report semiannually.
Number of Use-of-Force Incidents and Type of Force Applied
We reviewed 6,426 use-of-force incidents for which the department
conducted a review between January 1, 2018, and December 31, 2018.
The majority of the incidents occurred at adult institutions, with
a smaller share occurring in juvenile facilities and within the
communities where offenders were on parole. We also reviewed a few
incidents of force applied by the department’s Office of Correctional
Safety, which, among other things, acts as a liaison with other law
enforcement entities and apprehends fugitives in the community
(Figure 1, next page).
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10 Monitoring the Use of Force
As part of the 6,426 use-of-force incidents that we monitored, staff
members used 19,527 “applications” of force, defined as separate force
actions. An application of force is a count of the number of times an
officer used a force option. For example, if an officer used his baton to
strike an inmate three times, this would count as three applications
of force.
Figure 1. Distribution of Use-of-Force Incidents the OIG Monitored
Division of Adult Parole Operations 57
(1%)
Department of Juvenile Justice
Office of Correctional Safety 14
(< 1%)
359
(6%)
N = 6,426
Incidents
5,996
(93%)
Division of Adult Institutions
Source: Office of the Inspector General’s Tracking and Reporting System for the period
January 1, 2018, through December 31, 2018.
Table 1 on the following page identifies the number of force incidents,
applications of force, and the number of staff and inmates involved.
The Division of Adult Institutions experienced most of the incidents,
accounting for nearly 93 percent of the incidents we monitored
(5,996 of 6,426).10
10 The total figure of 5,996 includes 5,830 incidents at all adult institutions,
46 incidents at in-state Contract Beds Unit facilities, and 120 incidents at out-of-state
Contract Beds Unit facilities.
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Monitoring the Use of Force 11
Table 1. Number of Use-of-Force Incidents by Departmental Entity
Number of:
Inmates,
Wards, or
Staff Who Parolees to
Use-of-Force Applications Applied Whom Force
Departmental Entity Incidents of Force Force * Was Applied *
Adult Institutions 5,830 17,539 13,656 10,721
Contract Beds Unit: In State 46 128 100 75
Contract Beds Unit: Out of State 120 468 220 322
Juvenile Facilities 359 1,214 733 1,150
Parole Regions 57 149 140 57
Office of Correctional Safety 14 29 25 14
Totals 6,426 19,527 14,874 12,339
* The OIG counted the name of each staff member and inmate every time they were involved with a use-
of-force incident. Therefore, we counted several staff members and inmates more than once. The word
wards also refers to youth.
Source: Office of the Inspector General’s Tracking and Reporting System for the period January 1, 2018,
through December 31, 2018.
When staff members encounter a situation in which an application
of force is necessary, they must quickly assess the situation, and
determine the most appropriate type of force for each situation to
resolve the incident. The most common force option staff members
used was chemical agents, which accounted for 50 percent of the
total applications of force, followed by physical strength and holds, at
31 percent. Staff members used other force options less frequently, such
as less-lethal projectiles, batons, a shield, nonconventional force, tasers,
and the Mini 14 rifle (Figure 2, next page).
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12 Monitoring the Use of Force
Figure 2. Distribution of the Applications of Force in 6,426 Uses of Force
9,736 N = 19,527 Applications of Force
(50%)
5,995
(31%)
2,396
(12%)
1,232
148
(6%) 20
(1%)
(< 1%)
Chemical Physical 37 / 40 mm Expandable Other † Mini 14
Agents * Strength Baton
and Holds
* Chemical agents include oleoresin capsicum (OC) (8,951), CN gas (487), pepperball launcher (251),
CS gas (32), and sting ball grenades (15).
† Other includes the use of a shield (77), nonconventional uses of force (50), and a taser (21).
Note: Percentages do not sum to 100 percent due to rounding.
Source: Office of the Inspector General’s Tracking and Reporting System for the period
January 1, 2018, through December 31, 2018.
Frequency of Force Incidents
On the following page, Figure 3 shows the distribution of the 6,426 use-
of-force incidents throughout the department’s institutional missions
and other departmental entities. Not surprisingly, the majority of
incidents occurred at the department’s adult institutions, which
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Monitoring the Use of Force 13
accounted for 93 percent of all incidents we monitored. Institutions
within the high security mission, which housed the most serious and
dangerous offenders, accounted for the highest percentage (50 percent)
of incidents. A closer look at the data revealed that within the high
security mission, five adult prisons—Salinas Valley State Prison (500),
California State Prison, Sacramento (495), Kern Valley State Prison
(484), California State Prison, Los Angeles County (421), and California
State Prison, Corcoran (420)—accounted for more than one-third of
the incidents.
Figure 3. Use-of-Force Incidents, by Mission within the Division
of Adult Institutions and Other Departmental Entities
3,198
(50%)
N = 6,426 Incidents
1,026
(16%) 889 883
(14%) (14%)
430
(7%)
High Reception Female Offender General Other
Security Centers Programs and Population Departmental
and Fire Services / Entities †
Camps Special Housing *
Division of Adult Institutions
* The mission encompassing the category of female offender programs and services /special
housing facilities includes contract facilities that are located both in and outside California.
† Other Departmental Entities includes the Division of Adult Parole Operations (57), the
Division of Juvenile Justice (359), and the Office of Correctional Safety (14).
Note: Percentages do not sum to 100 percent due to rounding.
Source: Office of the Inspector General’s Tracking and Reporting System for the period
January 1, 2018, through December 31, 2018.
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14 Monitoring the Use of Force
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Monitoring the Use of Force 15
Scope and Methodology
In this report, the OIG presents its evaluation of the use-of-force
incidents we monitored and for which the department completed a
review between January 1, 2018, through December 31, 2018. To evaluate
the effectiveness of the department’s process of handling use-of-force
incidents and its compliance with policies and procedures, our staff
carefully reviewed various regulations and rules relevant to use-of-
force practices. We also reviewed the department’s use-of-force policy
and related training modules, and other applicable operational policies.
To further understand the department’s procedures, we also observed
use-of-force training at some institutions.
To determine whether institutions properly assessed use-of-force
compliance, OIG inspectors visited every adult and juvenile institution
as well as the northern and southern parole regions, and attended
1,246 of the 1,715 review committee meetings (73 percent) held during
this period.11 Our inspectors reviewed and analyzed 6,426 separate
incidents concerning the use of force.12 For each of these incidents,
our inspectors reviewed all written reports and documentation and,
when applicable, viewed all video recordings of both related incidents
and interviews. We then independently determined whether staff
actions before, during, and after the use of force were reasonable
under the circumstances and within the bounds of departmental policy
and training procedures. Finally, although OIG inspectors served as
nonvoting attendees at review committee meetings, they provided real-
time feedback and recommendations on compliance-related matters to
committee chairs, when necessary.
Inmates alleged unreasonable force in 660 of the 6,426 incidents we
monitored, approximately 10 percent. Departmental policy triggers
specific procedures upon receipt of an allegation, including the
requirement for staff to video-record an interview with the inmate. Our
review process includes analyzing the department’s compliance with
its video-recording requirements.
11 These numbers represent the number of meetings attended and held at the
department’s 35 adult institutions, two parole regions, and three juvenile facilities. A
committee in the department’s headquarters office reviews use-of-force incidents from
all in-state and out-of-state contract facilities.
12 If the department reviews the same incident at the institutional level and the
headquarters level, we count that as one separate incident.
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16 Monitoring the Use of Force
To determine whether the department executive review committees
(for adult institutions) and the department force review committees
(for juvenile facilities) properly assessed force incidents, inspectors
attended 48 of the 49 meetings (98 percent) held at the department’s
headquarters level that the committees notified us were scheduled to
take place during the 12-month period.13
13 The OIG attended 1,294 of the 1,764 total meetings held at the institutional level and
the headquarters level combined.
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Monitoring the Use of Force 17
Monitoring Results
Compared with Last Year, the Department Again
Performed Well in Self-Assessing Compliance
with Its Use-of-Force Policy, yet Its Compliance
Rate Remained Low
The department’s use-of-force policy requires staff to complete a
thorough, multistep process to review and evaluate all uses of force.
The review process involves a minimum of five levels of supervisory
and managerial review and, on those occasions when staff use deadly
force or cause serious injuries, another review at the department’s
executive level. This review process may involve more than a dozen
individuals for every incident. The department generally requires that
the review process be concluded within 30 days of the incident, given
the critical nature of these issues and the severity of the potential
negative outcomes. Figure 4 below presents a general illustration of the
steps the Division of Adult Institutions takes in its review process.
Figure 4. Flowchart Depicting the Division of Adult Institutions’ Use-of-Force
Review Process
Staff Who Used Force
Prepares a written report (Form 837) and describes the force used or observed
1st-Line Supervisor (Sergeant)
Collects 837s, medical evaluationss, and video recordings;
reviews package; requests clarification
2nd-Line Supervisor (Lieutenant)
Reviews package; requests clarification;
prepares summary (Form 837-A)
1st Manager (Captain)
Clarification Reviews package; requests clarification; concludes
whether force was within policy
2nd Manager (Associate Warden)
Reviews package; requests clarification;
concludes whether force was within policy
Institution Executive Review Committee
(Committee + Warden or Designee, Chair)
Reviews package; requests clarification; finally
concludes whether force was within policy
Source: The Office of the Inspector General’s analysis of the California Department of Corrections and
Rehabilitation’s review process.
Office of the Inspector General, State of California
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18 Monitoring the Use of Force
The review process for the Division of Adult Institutions begins
following any use of force. Departmental policy requires that staff who
use or observe force submit a written report before being relieved
from duty at the end of the working shift. In general, reports should
include a description of the inmate’s actions and the staff member’s
perception of the threat that led to the use of force, a description of the
specific force used or observed, and a description of the inmate’s level
of resistance. The policy also requires that medical personnel evaluate
and assess the extent of any injuries sustained during the event and
thoroughly document their medical evaluation.
The incident response supervisor (typically, a first-line supervisor,
such as a sergeant) is responsible for collecting all the reports from
staff who may have used or observed force. During this first level of
review, the supervisor determines whether the reports contain the
necessary information, then forwards the reports—including any
medical assessments—to the next level of review.
At the second level of review, the incident commander (typically,
a second-level supervisor, such as a lieutenant) must review
all the reports for quality, accuracy, and content. The incident
commander may ask staff to submit additional information if he or
she determines the initial staff reports were unclear or incomplete in
their descriptions. The incident commander is also responsible for
providing an overall summary of the incident based on all reports
submitted by staff and then analyzing their actions taken during the
use of force to determine whether such actions complied with policy
and training. The incident commander then moves the incident
package along to the next reviewer.
At the third and fourth levels of review, managers who are at the
captain and associate warden levels, respectively, review the incident
package for content and sufficiency, and may request that staff clarify
their individual reports, if needed. Each of these reviewers, in turn,
independently determines compliance with both policy and training,
and moves the reports along to the next level of review.
The fifth level of review occurs at the institution executive review
committee meeting, which is chaired by the warden or chief deputy
warden, or superintendent or assistant superintendent. Typically,
institutions hold these meetings once every week. Other institutional
managers also attend these meetings, in addition to a health care
representative, and under certain circumstances, a mental health
practitioner. The institution executive review committee reviews every
reported use of force to determine whether each application of force
was reasonable under the circumstances and whether staff complied
with departmental policies and training. This committee also reviews
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Monitoring the Use of Force 19
every allegation of unreasonable or unnecessary force, which may arise
either directly in connection with use-of-force incidents or via inmates
reporting on a separate basis.
During these meetings, if the institution executive review committee
determines that staff reports remain unclear—even after the four
previous levels of review—its members may request additional
clarification from respective staff or conduct an internal fact-finding
inquiry and re-review the incident at a subsequent meeting. Ultimately,
the institution executive review committee chair determines whether
the force used and the staff’s actions were within policy.
If the chair determines staff actions were out of policy, he or she
may order corrective action, which could include training, a letter
of instruction, or counseling. For more serious policy violations (or
repeated violations), the chair may refer the matter to the department’s
Office of Internal Affairs for an investigation or authorization to
impose disciplinary action14 directly.
The Department’s Self-Assessment of Compliance with Its Use-
of-Force Policy
Between January 1, 2018, and December 31, 2018, the OIG reviewed and
analyzed 6,426 staff-reported use-of-force incidents. These incidents
predominantly occurred in a prison setting, but some occurred in the
juvenile facilities or in a community setting.
Overall, the department determined that its staff completely followed
policy in only 3,543 out of 6,426 incidents (55 percent) that we
monitored during this period, as depicted in Table 2 on the next page.
The OIG predominantly agreed with the review committees’ decisions
in these incidents. However, in our opinion, some type of policy
violation was present for 276 of the incidents for which the department
concluded its staff followed policy.
14 Disciplinary action is also referred to as “adverse” action.
Office of the Inspector General, State of California
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20 Monitoring the Use of Force
Table 2. Number of Incidents a Review Committee Determined Were In or
Out of Policy Compliance
Number of Percentage of Number of
Incidents: Incidents: Incidents:
In Which the
OIG Did Not
Concur with
Deemed In With at Least Deemed In With at Least Committees’
Policy by One Policy Policy by One Policy In-Policy
Category Committee Violation Committee Violation Decision
Actual Force 6,247 179 97% 3% 41
Apart from Force 4,207 2,219 65% 35% 204
Nonuse of Force 5,331 1,095 83% 17% 58
Overall * 3,543 2,883 55% 45% 276
* The values in the row labeled Overall represent unique incidents. Several of the values in the three categories
overlap; therefore, to account for unique incidents, we counted each incident only once.
Source: Office of the Inspector General’s Tracking and Reporting System for the period January 1, 2018, through
December 31, 2018.
When evaluating force in relation to departmental policy, the OIG
groups decisions into three primary categories: (1) actual force,
referring to the force itself; (2) apart from the actual force, referring
to requirements encompassed within the use-of-force policy, but not
the force itself; and (3) nonuse of force, referring to actions covered
under departmental policy, unrelated to the use-of-force policy or
use-of-force training (see box, following page). These categories help
provide some measure of context to overall compliance rates. Many of
the incidents had more than one policy violation within a particular
category, and some incidents had policy violations in more than one
category. For additional detail, see Appendix B.
The department concluded that staff followed policy with the actual
force requirements in 6,247 of the incidents, 97 percent. The OIG
mostly agreed with the department’s review committees’ decisions,
but determined 41 of the 6,247 incidents had at least one policy
violation relevant to this category not addressed by the committee,
fewer than 1 percent.
Regarding the apart from the actual force policy requirement, the
department determined that it followed policy in only 4,207 of the
incidents. This represents a 65 percent compliance rate, and, by far, it
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Monitoring the Use of Force 21
was the lowest compliance rate of the OIG’s three categories. Again,
the OIG agreed with most of these determinations, but determined
204, or nearly 5 percent, of the 4,207 incidents reflected at least
one policy violation relevant to this category that the committee
failed to address. The number of disagreements was higher in this
category than any other and represented a significant increase over
the prior year when we disagreed with only about 2 percent of the
department’s conclusions.
Finally, the department determined that it followed policy with the
nonuse-of-force requirements in 5,331 of the incidents, or 83 percent.
The OIG mostly agreed, but concluded 58 of those incidents reflected
at least one policy violation relevant to this category that the
committee failed to address.
While the department’s determination of compliance was essentially
the same as the rate noted in our last report, during this period,
we disagreed with the department’s decisions more often. In our
prior report, we disagreed with the department’s decisions in about
2 percent of the incidents in which the department found no policy
violations. In this report, that percentage of disagreements increased to
about 8 percent of the incidents (276 of 3,543 incidents).
The OIG groups policy determinations into three primary categories:
Actual force Refers to the force itself
Refers to the department’s policies and training
encompassed within the use-of-force policy, excluding
the force itself. Common examples of this include the
Apart from the
completion of medical assessments and assessment
actual force
forms, the timely completion of forms following an
incident, requirements concerning video-recording
interviews, and various protocols leading up to a
controlled use of force
Refers to actions covered by departmental policy,
Nonuse of force
unrelated to the use of force
Source: Office of the Inspector General.
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22 Monitoring the Use of Force
Overwhelmingly, the Department Provided Training to Remedy
Policy Violations; but in a Few Instances, It Took a Higher Level
of Corrective or Adverse Action
The department identified policy violations in 2,883 of the
6,426 incidents, a rate of 45 percent. It required training for the
staff involved for at least 2,747 of the 2,883 out-of-policy incidents,
or 95 percent. Furthermore, the department took other corrective
action by counseling staff in 163 of the 2,883 out-of-policy incidents
(6 percent). Finally, the department imposed disciplinary action for
staff misconduct in 35 of the 2,883 incidents (about 1 percent).15 The
OIG monitors and reports on the investigations the Office of Internal
Affairs conducts, including any resulting disciplinary determinations,
in a separate public report semiannually.
The Department Still Has Not Implemented a Reliable
Statewide Use-of-Force Tracking System to Identify Trends and
Monitor Corrective Action
In our last report, we noted that the department began tracking its use-
of-force data in a statewide system called the Incident Report Tracking
SharePoint (the tracking system).
The department designed the tracking system to include all reported
use-of-force incidents at each institution and to display force incident-
related information concerning individual staff members and inmates,
the type of force used, the results of the use of force, and corrective
action taken (if applicable). According to the department, the tracking
system was supposed to provide staff with the ability to identify trends,
create reports, and provide real-time data to its users.
Shortly after implementing the tracking system, however, the
department determined the system was not reliable. The department
notified our office that a replacement tracking system is scheduled to
be implemented in August 2019. We will continue to monitor progress
made toward it and report on its status in future reports.
15 When allegations of serious misconduct arise, the institution executive review
committee can defer a case and refer it to the Office of Internal Affairs for investigation.
As of December 31, 2018, there were 31 cases that had been deferred by the committee for
referral to the Office of Internal Affairs, which were pending a final outcome.
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Monitoring the Use of Force 23
Departmental Staff Showed Minimal
Improvement in Articulating an Imminent
Threat to Justify the Force Used, and We
Identified Additional Incidents in Which Officers
Contributed to the Need to Use Force
The department allows officers to use immediate force when an
imminent threat jeopardizes the safety of persons or compromises the
security of the institution. Its policy further requires that officers clearly
articulate in their use-of-force reports the threat that necessitated their
actions. Despite this requirement, officers did not adequately articulate
an imminent threat in 95 of the 6,426 incidents (1.5 percent), leading us
to question whether the force was necessary. Although this is a very
low percentage in relative terms, and represents a slight improvement
since we issued our last report (1.8 percent), any instance of
unnecessary force could represent a critical issue for staff, inmates, and
the department. When officers engage in unnecessary force, doing so
can increase tension between staff and inmates, and may also expose
the department to legal liability.
Some Officers Did Not Articulate a Threat to Justify
the Force Used
The department self-identified unnecessary force in 50 of these
95 incidents and took action to address the violations, ranging
from training to formal discipline. The OIG identified an additional
44 incidents in which we believed the officer(s) did not adequately
justify the need for force. In 7 of the 44 incidents, the review
committee agreed with our position and concluded the force was out
of policy. In the remaining 37 cases, the committee disagreed with our
assertion and found no violation related to the force used.16 The OIG
recognizes the difficulty of making split-second decisions during these
types of incidents; it is much easier to second-guess staff members’
actions after the fact. Yet these events serve as a reminder of how
dangerous it can be to work in a prison setting, how quickly situations
can escalate, and how important it is for staff to remain vigilant and
aware at all times.
In one case, an inmate refused to leave a medical clinic, but ultimately
complied with an officer’s orders. Once outside the clinic, the yard
camera captured footage of the incident. The inmate continued
16 In one additional incident, a sergeant’s force was unintentional. Although not justified,
the OIG agreed with the committee’s decision to take no action against the sergeant.
Office of the Inspector General, State of California
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24 Monitoring the Use of Force
to request medication and to see a doctor. The inmate refused the
officer’s orders to submit to handcuffs, but did not appear physically
aggressive. Several officers responded to the scene and surrounded
the inmate, while the initial officer continued to engage in a dialogue
with the inmate. The footage showed an additional officer running to
the scene, past the other officers, grabbing the inmate from behind,
and physically forcing him to the ground. Other officers then joined
in with physical force to place handcuffs on the inmate. We suggested,
based on both the video recording and the officers’ reports, there had
been no imminent threat to the safety of persons or the security of
the institution that would justify the officer grabbing the inmate and
forcing him to the ground. The warden disagreed with our position
that the force was unnecessary and determined the officers’ actions
were in policy.
In another case, an officer deployed pepper-spray against two fighting
inmates. One inmate complied with orders to “get down,” on the
ground. The officer and a sergeant approached the other inmate, who
was standing against a wall, rubbing his eyes from the pepper spray
exposure. The officer and the sergeant physically forced the inmate
face-down to the ground, “to gain compliance of [a] direct order.” We
believed the reports did not articulate an imminent threat necessitating
the use of physical force. Furthermore, the officer articulated that he
used immediate force solely to gain compliance with a lawful order—
a violation of departmental policy. The warden referred the incident
to the department’s executive review committee. The department
executives agreed with our position and determined the officers did
not articulate an imminent threat to justify the immediate force.
The committee ordered training for the officer, the sergeant, and the
managers at the institution who reviewed the incident.
In a third case, an officer observed an inmate running from another
officer on an exercise yard and refusing orders to get down. The officer
stated that he drew his pepper spray and “in an attempt to keep [the
inmate] from dumping the contraband he had into a dorm and to effect
custody on him, I gave a 1-second burst of my [pepper spray] to his
facial area.” Departmental policy does not permit the use of force to
prevent the destruction of contraband. The warden determined there
was no imminent threat to the safety of persons or the security of the
institution and imposed formal discipline on the officer.
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Monitoring the Use of Force 25
The Department’s Contract Facilities Experienced a High
Percentage of Incidents in Which Officers Did Not Articulate
a Threat to Justify the Force
We noted a disproportionately high number of incidents for the
department’s contract facilities during which officers did not articulate
an imminent threat to justify the force. The use-of-force incidents
at contract facilities accounted for fewer than 3 percent of the total
number throughout the department. However, incidents at contract
facilities accounted for 29 percent of incidents during which officers
did not articulate a threat to necessitate such force. In all instances,
the committee chair took appropriate action, ranging from training
to formal discipline, but the number of incidents is clear cause for
concern. To ensure officers at contract facilities understand the
department’s policy regarding immediate force, we recommend
the department provide training to staff at the contract facilities
concerning the department’s use-of-force policies, and specifically
regarding immediate-force requirements.
In a Few Instances, Officers May Have Contributed to the Need
for Using Force
The actions of officers in 64 of the 6,426 incidents (1 percent)
unnecessarily contributed to the need to use force. Although this is a
very low percentage of occurrences, and is the same percentage noted
in our last report, it is important to reiterate the seriousness of the
conduct. While we recognize that results from these actions could not
have been easily foreseen, the department should examine these types
of events so that it can train staff to better recognize warning signs
before dangerous situations materialize. Even though these officers
may not have intended to use force at the time of their initial actions,
their actions nevertheless contributed to the outcomes. The review
committees identified most of these instances and took actions ranging
from training to disciplinary action.
In one incident, for example, a control booth officer released an inmate
from his cell to take a shower, without providing an escort, in violation
of the institution’s modified procedures for that day, which required an
escort for any inmate released from his cell. As the inmate returned to
his cell, investigative services unit officers entered the unit and ordered
the inmate to stop. The inmate entered his open cell and reached for
his waistband. The officers followed the inmate, and one of the officers
grabbed the inmate’s wrist and shoulder. The inmate pulled away from
the officer and flushed an object in the toilet. The officer wrote in his
report that he “was able to pull [the inmate] away from the toilet in
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26 Monitoring the Use of Force
[an] attempt to stop him from flushing more contraband” and used
further physical force to place the inmate in a prone position. The
warden determined the control booth officer negligently allowed the
inmate to exit his cell without an escort, and there was no imminent
threat to the safety of persons or the security of the institution to
justify the officer’s use of physical force to prevent the inmate from
flushing contraband. The warden imposed formal discipline on the
control booth officer and the officer who used physical force.
In another case, a control booth officer released two inmates from their
cells without the direction and presence of officers in the dayroom.
One inmate stabbed the other inmate with a sharpened piece of metal.
The control booth officer fired six less-lethal rounds to stop the attack.
The victim sustained multiple stab wounds, including a punctured
lung. The other inmate sustained minor injuries from the force used.
The warden concluded that the control booth officer inappropriately
released the inmates from their cells and imposed formal discipline.
In a third incident, a handcuffed inmate in a holding cell spat on
a nearby officer who was monitoring the inmate. Two sergeants
responded and instructed another officer to enter the cell and place
a spit mask on the inmate. As the officer opened the holding cell
door, the inmate kicked the officer, resulting in the officer and two
sergeants using physical force to place the inmate on the ground. The
inmate continued to resist the efforts of the sergeants and the officer
and kicked at one of them. One of the sergeants struck the inmate
four times on his leg to stop the kicking and control the inmate. One
officer and the inmate sustained minor injuries during the incident. We
suggested that the sergeants should have recognized that opening the
cell door may have unnecessarily jeopardized the safety of the officer
and sergeants. We further suggested—as did the associate warden
who reviewed the incident—that the officer could have continued
to monitor the inmate from a safe distance. The hiring authority
disagreed with our position and determined that staff members’
actions were appropriate.
Office of the Inspector General, State of California
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Monitoring the Use of Force 27
Sergeants and Lieutenants Continued to
Routinely Violate Video-Recorded Interview
Requirements
The department requires staff to video-record an interview with an
inmate who alleges unnecessary or excessive force or who sustains
serious or great bodily injury possibly due to the use of force. The
department’s policy requires staff to conduct the interview as soon
as possible, but no later than 48 hours from the date of discovery of
the injury or allegation. The policy further requires that any visible
or alleged injuries be documented on the recording and specifies that
the interviews be conducted only by custodial supervisors—such as
sergeants or lieutenants—who did not themselves use or observe the
force during the incident. The policy also requires that supervisors not
inhibit or discourage the inmate from providing relevant information.
Figure 5, on the next page, displays the number of interviews the
review committees found to be in compliance and out of compliance
with video-recording policies, along with displaying the types of
violations. The department’s review committees found that staff
actions in only 343 of the 675 video-recorded interviews we monitored
fully complied with policy. This represents a compliance rate of only
51 percent. The review committees found at least one instance of
noncompliance in each of the remaining 332 interviews.
Similar to our last report, the most common violation resulted from
interviews that staff did not perform promptly. Staff failed to timely
interview inmates in 161 of the 675 video-recorded interviews assessed
by the OIG. The number of days beyond the required 48 hours ranged
from one day to 252 days. There are several reasons for the 48-hour
requirement, perhaps most importantly, to capture potential visual
evidence of the inmate’s alleged injuries. In all the interviews reviewed,
we identified 70 instances during which the interviewer failed to
capture the inmate’s alleged injuries on camera, even when conducting
a timely interview. Timely and properly documenting evidence may
obviously support an inmate’s claim, but a lack of visible injuries
may refute an inmate’s allegation. For instance, an inmate’s allegation
that officers punched and kicked him in the face could be seen as less
credible if no visible injuries were promptly and properly documented.
In addition, without gathering prompt and proper documentation,
the department is left susceptible to allegations of a cover-up and
ultimately impairs the department’s ability to take prompt action.
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28 Monitoring the Use of Force
Figure 5. Departmental Compliance with Video-Recorded Interviews
N = 675
0 100 200 300 400 500 600 700
Overall Video Compliance* 343 332
Was the video completed
514 161
within 48 hours?
CDCR Form 7219 completed
641 34
before interview?
Interviewer and cameraman
656 19
introduction prior to video?
Interview conducted by staff
646 29
uninvolved in the incident?
Inmate refusal to interview
156 7 512
captured on video?
Reasonable attempt to capture
injuries on video? 529 70 76
Video stopped to capture
previously unidentified injuries? 61 48 566
Interviewer openly
conducted the interview? 665 10
Interview conducted
643 32
free of distractions?
Interview completed
638 37
in confidential setting?
In Compliance Out of Compliance Not Applicable
* Overall Video Compliance encompasses total compliance for all questions. We found at least one deficiency in 332 of the 675 videos
we reviewed, a compliance rate of 51 percent.
Source: Office of the Inspector General’s Tracking and Reporting System for the period January 1, 2018, through December 31, 2018.
Office of the Inspector General, State of California
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Monitoring the Use of Force 29
The OIG has presented this concern in past reports, but the low
compliance rate persists, with an additional 6 percent drop in the
compliance rate, compared with the figure of 57 percent from our last
report. In March 2017, after we published the low video-recording
compliance rate of 61 percent for the July-through-December-2016
period, the department directed that additional training be given to all
custodial supervisors and managers concerning its video-recording
requirements. However, the timing of this training did not help the
department achieve an improved compliance rate for the next six-
month period. Specifically, during the period covering January through
June 2017, the compliance rate continued to drop, falling another three
percentage points, to 58 percent. In our last report, we concluded that
the department complied with policy in 57 percent of the required
interviews. To improve the compliance rate, the OIG recommended
that the department reevaluate the training it provides regarding
the correct procedures to follow when conducting video-recorded
interviews. In January 2019, in response to our recommendation, the
department reiterated its video-recording requirements to all wardens
and required that certified use-of-force instructors train all supervisors
and managers regarding these requirements. We will continue to
monitor the department’s compliance in this area and report the results
in future reports.
Office of the Inspector General, State of California
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30 Monitoring the Use of Force
The Department’s Noncompliance Rate
Involving Controlled Use-of-Force Incidents
Remained a Concern
The department defines the controlled use of force as “the force used
in an institutional or facility setting when an inmate’s presence or
conduct poses a threat to safety or security, and the inmate is located
in an area that can be controlled or isolated. These situations do
not normally involve the imminent threat to loss of life or imminent
threat to institution security.”17 A controlled use of force involves
advance planning, staffing, and organization; it also requires both the
authorization and the presence of a first- or second-level manager (or
an administrator-of-the-day during nonbusiness hours), and a video-
recording of the incident.
The following depiction presents a typical example of when an
institution might authorize a controlled use of force: an inmate
refuses to exit his or her cell after being told he or she is transferring
to another institution. Policy allows officers to use controlled force
to remove the inmate from a cell to facilitate a transfer. Officers may
also use controlled force when staff must administer medications,
provide medical treatment, or complete mandated testing.
Compared with immediate uses of force, controlled uses of force occur
very infrequently.
During this reporting period, the OIG monitored 100 controlled
use-of-force incidents.18 Figure 6 (page 32) displays the incidents of
controlled uses of force, by institution. More than 87 percent of these
incidents involved an inmate who, at the time of the incident, was
participating in the department’s mental health services delivery
system. The department’s review committees found staff violated
policy in 65 of the 100 incidents, a 35 percent compliance rate. The
review committees found 64 of the 65 incidents out of compliance with
elements “apart from the actual force” and also found seven incidents
among the 65 out of compliance during the actual application of force.
The OIG agreed with the committee findings in all but three incidents.
In those three incidents, the review committees determined actions
in compliance “apart from the actual force,” but we identified at least
one area of noncompliance with which the committee did not agree.
The OIG independently identified “apart from the actual force” policy
violations in 20 incidents and “actual force” policy violations in two
incidents.
17 Article 2, Use of Force, 51020.4 “Definitions,” DOM.
18 Some incidents involved more than one inmate. In the 100 controlled use-of-force
incidents, 111 inmates were involved.
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Monitoring the Use of Force 31
We persuaded the review committees that the department should
provide training to its staff for both types of violations.
During the reporting period of July 1, 2017, to December 31, 2017, the
department’s noncompliance rate concerning its controlled use-of-
force incidents was 75 percent. In response, we recommended that
the department “reevaluate its training curriculum, provide additional
training to staff, and select for participation in controlled use-of-force
incidents only those who have completed additional training.” The
department rejected our recommendation, stating:
The current lesson plan was reviewed and deemed adequate. The
infrequent amount of controlled UOF [use-of-force] incidents can be
attributed to the outstanding job staff are doing using communication and
de-escalation techniques. Select group training will not be implemented.
While the department has shown slight improvement in its
compliance rate—35 percent compliance versus the previous
25 percent—in the OIG’s opinion, there is room for more improvement
(Figure 6, next page).
Office of the Inspector General, State of California
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32 Monitoring the Use of Force
Figure 6. Incidents of Controlled Uses of Force, by Institution or Facility
11
N = 100
In Policy Out of Policy
10
10
13
7
5
2
5
4 4
3 1 1 1
2 2 2 2 2 2
1 1 1 1 1 1 1 1 1 1 1
SAC SVSP CHCF COR LAC CMC CMF KVSP MCSP PVSP RJD SATF SQ CCWF CIW CVSP DVI HDSP NKSP PBSP VYCF NACYCF
Division of Division of
Adult Institutions Juvenile Justice
Source: Office of the Inspector General’s Tracking and Reporting System for the period January 1, 2018, through December 31, 2018.
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Monitoring the Use of Force 33
Recommendations
We recommend that the department pursue the following actions:
Ensure that the department validates the data collected
in the new tracking system for accuracy and evaluates
the data for monitoring use-of-force trends.
For the 2017 reporting period, we made several
recommendations to the department based on its
implementation of a statewide tracking system. Our
recommendations included identifying beneficial
use-of-force management reports, analyzing the data
the system would produce for trends, monitoring
staff who frequently use force or violate policy, and
tracking the corrective or adverse actions hiring
authorities imposed. While the department was
generally responsive to our recommendations, the
tracking system will not be implemented until
August 2019. We look forward to the new tracking
system’s deployment and recommend that the
department continuously analyze the information to
ensure it meets management’s needs.
Ensure that managers hold supervisors accountable for
deficiencies in the video-recorded interview process.
The OIG previously recommended that the
department reevaluate the training it provides
regarding the correct procedures to follow
when conducting video-recorded interviews. In
January 2019, in response to our recommendation,
the department reiterated its video-recording
requirements to all wardens and required that
certified use-of-force instructors train all supervisors
and managers regarding the requirements. The
department’s compliance has not improved since we
reported the deficiencies in 2017, yet the department
determined its training curriculum to be adequate.
Therefore, we recommend the department’s managers
hold supervisors accountable by imposing progressive
discipline on those who violate the requirements.
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34 Monitoring the Use of Force
Ensure that managers hold staff accountable for
violations of policy related to controlled use-of-force
incidents.
Due to the low compliance rate with controlled
use-of-force requirements, we recommended in our
prior report that the department evaluate its training
curriculum, provide additional training to staff, and
consider utilizing only a select group of trained staff
to participate in these incidents. The department
rejected our recommendation and determined that
its current training was adequate. We recommend
that the department impose progressive discipline
on staff who violate policy while supervising and/or
participating in controlled use-of-force incidents.
Require all staff at contract facilities to attend use-
of-force training to ensure compliance with the
department’s use-of-force policy.
The staff at the department’s contract facilities
used force without articulating an imminent threat
to necessitate that force at a disproportionate rate
when compared with officers at the department’s
institutions. To increase compliance with the use
of immediate force at the contract facilities, we
recommend the department provide training to staff
at the contract facilities concerning the department’s
use-of-force policies, and specifically regarding
immediate-force requirements.
Office of the Inspector General, State of California
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Monitoring the Use of Force 35
Appendices
Office of the Inspector General, State of California
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36 Monitoring the Use of Force
Appendix A: Detail of Use-of-Force Incidents
Number of:
Inmates,
Wards, or
Parolees
Staff Who to Whom
Use-of-Force Applications Applied Force Was
Prison or Departmental Entity Incidents of Force Force * Applied *
Adult Institutions 5,830 17,539 13,656 10,721
Avenal State Prison 48 119 91 126
California City Correctional Facility 26 79 55 54
Calipatria State Prison 146 426 305 351
California Correctional Center 75 173 142 160
California Correctional Institution 323 885 737 703
Central California Women’s Facility 262 760 631 395
Centinela State Prison 86 200 146 196
California Health Care Facility 203 721 619 224
California Institution for Men 39 73 54 61
California Institution for Women 105 230 203 146
California Men’s Colony 107 297 242 148
California Medical Facility 90 305 271 111
California State Prison, Corcoran 420 1053 869 690
California Rehabilitation Center 47 153 95 99
Correctional Training Facility 26 82 60 61
Chuckawalla Valley State Prison 20 45 38 49
Deuel Vocational Institution 109 283 231 217
Folsom State Prison 63 251 167 118
High Desert State Prison 267 1017 724 587
Ironwood State Prison 38 119 92 80
Kern Valley State Prison 484 1360 1064 930
California State Prison, Los Angeles County 421 1371 1108 728
Mule Creek State Prison 300 996 726 489
North Kern State Prison 130 284 216 230
Pelican Bay State Prison 72 430 288 221
Pleasant Valley State Prison 128 435 335 345
Richard J. Donovan Correctional Facility 156 313 275 222
California State Prison, Sacramento 495 1613 1279 791
California Substance Abuse Treatment Facility 190 541 383 327
Sierra Conservation Center 50 136 93 111
Continued on next page.
Office of the Inspector General, State of California
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Monitoring the Use of Force 37
Appendix A: Detail of Use-of-Force Incidents (continued)
Number of:
Inmates,
Wards, or
Parolees
Staff Who to Whom
Use-of-Force Applications Applied Force Was
Prison or Departmental Entity Incidents of Force Force * Applied *
California State Prison, Solano 67 184 138 127
San Quentin State Prison 134 381 267 220
Salinas Valley State Prison 500 1649 1314 992
Valley State Prison 24 61 52 30
Wasco State Prison 179 514 346 382
Contract Beds: Community Correctional
46 128 100 75
Facilities (In State)
Central Valley Modified Community
3 3 3 4
Correctional Facility
Delano Modified Community Correctional
18 44 38 24
Facility
Desert View Modified Community
1 7 1 1
Correctional Facility
Golden State Modified Community
1 2 2 2
Correctional Facility
McFarland Female Community Reentry
3 6 5 5
Facility
Shafter Modified Community Correctional
17 58 45 34
Facility
Taft Modified Community Correctional Facility 3 8 6 5
Contract Beds: Out of State 120 468 220 322
Tallahatchie County Correctional Facility 42 127 64 100
La Palma Correctional Center 78 341 156 222
Juvenile Facilities 359 1214 733 1150
N.A. Chaderjian Youth Correctional Facility 165 651 365 477
O.H. Close Youth Correctional Facility 118 283 179 389
Pine Grove Youth Conservation Camp 1 1 1 1
Ventura Youth Correctional Facility 75 279 188 283
Parole Regions 57 149 140 57
Parole Region North 19 42 40 19
Parole Region South 38 107 100 38
Office of Correctional Safety 14 29 25 14
Grand Totals 6,426 19,527 14,874 12,339
* The OIG counted the name of each staff member and inmate every time they were involved with a use-of-force incident. Therefore,
we counted several of the staff and inmates more than once. The word wards also refers to youth.
Source: Office of the Inspector General’s Tracking and Reporting System for the period January 1, 2018, through December 31, 2018.
Office of the Inspector General, State of California
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38 Monitoring the Use of Force
Appendix B: Detail of Policy Violations as Determined by
the Department, Grouped by OIG Category
Out of Policy:
Number Number
of of Number
Incidents: Apart Incidents: of
Number Apart from Use Actual Actual Incidents:
of from Use of Force Use of Use of Nonuse of Nonuse of
Prison or Departmental Entity Incidents of Force (%) Force Force (%) Force Force (%)
Adult Institutions 5,830 1,878 32% 109 2% 1,012 17%
Avenal State Prison 48 10 21% 0 0% 7 15%
California City Correctional Facility 26 21 81% 2 8% 12 46%
Calipatria State Prison 146 24 16% 10 7% 23 16%
California Correctional Center 75 20 27% 1 1% 15 20%
California Correctional Institution 323 69 21% 1 0% 53 16%
Central California Women’s Facility 262 132 50% 15 6% 90 34%
Centinela State Prison 86 13 15% 1 1% 5 6%
California Health Care Facility 203 114 56% 6 3% 23 11%
California Institution for Men 39 15 38% 0 0% 11 28%
California Institution for Women 105 38 36% 4 4% 31 30%
California Men’s Colony 107 75 70% 2 2% 23 21%
California Medical Facility 90 45 50% 1 1% 9 10%
California State Prison, Corcoran 420 159 38% 0 0% 103 25%
California Rehabilitation Center 47 11 23% 0 0% 5 11%
Correctional Training Facility 26 14 54% 3 12% 4 15%
Chuckawalla Valley State Prison 20 2 10% 0 0% 2 10%
Deuel Vocational Institution 109 28 26% 0 0% 24 22%
Folsom State Prison 63 16 25% 0 0% 8 13%
High Desert State Prison 267 32 12% 4 1% 34 13%
Ironwood State Prison 38 4 11% 3 8% 4 11%
Kern Valley State Prison 484 148 31% 4 1% 51 11%
California State Prison, Los Angeles County 421 70 17% 4 1% 50 12%
Mule Creek State Prison 300 121 40% 11 4% 34 11%
North Kern State Prison 130 39 30% 2 2% 25 19%
Pelican Bay State Prison 72 23 32% 1 1% 15 21%
Pleasant Valley State Prison 128 20 16% 2 2% 24 19%
Richard J. Donovan Correctional Facility 156 28 18% 2 1% 27 17%
California State Prison, Sacramento 495 143 29% 15 3% 95 19%
California Substance Abuse Treatment
190 86 45% 2 1% 60 32%
Facility
Sierra Conservation Center 50 22 44% 1 2% 17 34%
Continued on next page.
Office of the Inspector General, State of California
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Monitoring the Use of Force 39
Appendix B: Detail of Policy Violations (continued)
Out of Policy:
Number Number
of of Number
Incidents: Apart Incidents: of
Number Apart from Use Actual Actual Incidents:
of from Use of Force Use of Use of Nonuse of Nonuse of
Prison or Departmental Entity Incidents of Force (%) Force Force (%) Force Force (%)
California State Prison, Solano 67 32 48% 0 0% 2 3%
San Quentin State Prison 134 60 45% 2 1% 23 17%
Salinas Valley State Prison 500 193 39% 9 2% 74 15%
Valley State Prison 24 6 25% 1 4% 5 21%
Wasco State Prison 179 45 25% 0 0% 24 13%
Contract Beds: Community Correctional
46 31 67% 15 33% 8 17%
Facilities (In State)
Central Valley Modified Community
3 2 67% 1 33% 1 33%
Correctional Facility
Delano Modified Community Correctional
18 11 61% 8 44% 1 6%
Facility
Desert View Modified Community
1 1 100% 0 0% 0 0%
Correctional Facility
Golden State Modified Community
1 1 100% 0 0% 0 0%
Correctional Facility
McFarland Female Community Reentry
3 2 67% 0 0% 2 67%
Facility
Shafter Modified Community Correctional
17 12 71% 4 24% 1 6%
Facility
Taft Modified Community Correctional
3 2 67% 2 67% 3 100%
Facility
Contract Beds: Out of State 120 87 73% 45 38% 42 35%
Tallahatchie County Correctional Facility 42 33 79% 18 43% 14 33%
La Palma Correctional Center 78 54 69% 27 35% 28 36%
Juvenile Facilities 359 213 59% 9 3% 22 6%
N.A. Chaderjian Youth Correctional Facility 165 101 61% 6 4% 8 5%
O.H. Close Youth Correctional Facility 118 75 64% 1 1% 5 4%
Pine Grove Youth Conservation Camp 1 1 100% 0 0% 0 0%
Ventura Youth Correctional Facility 75 36 48% 2 3% 9 12%
Parole Regions 57 10 18% 1 2% 11 19%
Parole Region North 19 5 26% 0 0% 3 16%
Parole Region South 38 5 13% 1 3% 8 21%
Office of Correctional Safety 14 0 0% 0 0% 0 0%
Grand Totals 6,426 2,219 35% 179 3% 1,095 17%
Source: Office of the Inspector General’s Tracking and Reporting System for the period January 1, 2018, through December 31, 2018.
Office of the Inspector General, State of California
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40 Monitoring the Use of Force
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Office of the Inspector General, State of California
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Monitoring
the Use of Force
OFFICE of the INSPECTOR GENERAL
Roy W. Wesley
Inspector General
Bryan B. Beyer
Chief Deputy Inspector General
STATE of CALIFORNIA
June 2019
OIG