OIG
OIG Annual Report
Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General
of the
OFFICE
OIG
INSPECTOR GENERAL
Independent Prison Oversight March 2024
2023 Annual Report
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STATE of CALIFORNIA
OIG OFFICE of the Amarik K. Singh, Inspector General
INSPECTOR GENERAL Neil Robertson, Chief Deputy Inspector General
Independent Prison Oversight
Regional Offices
Sacramento
Bakersfield
Rancho Cucamonga
March 12, 2024
The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California
Dear Governor and Legislative Leaders:
Enclosed please find our annual report summarizing the work that the Office of the
Inspector General completed in 2023. In 2023, we issued 16 public reports detailing our
oversight of the California Department of Corrections and Rehabilitation: eight reports
on medical inspection results, and one summary report for the medical inspections of
Cycle 6; two reports on our monitoring of the department’s internal investigations and
employee disciplinary process; one report on our monitoring of the department’s use of
force; one report on our monitoring of the department’s staff misconduct complaints
process, one audit report, one special review, and our 2022 annual report. In addition, we
introduced a new type of publication, case blocks. We published seven sets of these for
other operational units.
Respectfully submitted,
Amarik K. Singh
Inspector General
Gavin Newsom, Governor
10111 Old Placerville Road, Suite 110
Sacramento, California 95827
Telephone: (916) 288-4212
www.oig.ca.gov
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ii 2023 Annual Report
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Office of the Inspector General, State of California
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2023 Annual Report iii
Contents
Illustrations iv
Foreword v
Vision v
Mission v
Organizational Overview and Functions 1
Reports Published in 2023 5
Internal Investigations and Employee Discipline Monitoring 5
Use-of-Force Monitoring 8
Use-of-Force Statistics, 2022 8
Highlights of Our Use-of-Force Monitoring 9
Medical Inspection Reports: Cycles 6 and 7 12
Cycle 6 12
Cycle 7 12
Staff Misconduct Complaints Monitoring 14
Audit Reports and Special Reviews 19
Other OIG Operational Units: Status Updates 21
Complaint Intake 21
Prison Rape Elimination Act 24
Inmate Advisory Council (IAC) Meetings 24
Grievance and Staff Misconduct Processes 24
Institutional Culture 25
Positive Feedback From IACs 27
Whistleblower Retaliation Claims 28
Recommendations Made to the Department 29
Appendix: Publications Released in 2023 31
Office of the Inspector General, State of California
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iv 2023 Annual Report
Illustrations
Figures
1. The Office of the Inspector General Organizational Chart, 2023 3
2. Distribution of the Applications of Force in the 890 Use-of-Force
Incidents We Monitored 9
3. The Department’s Actions on Complaints Submitted
by Incarcerated People and Parolees 14
4. Total Number of Complaints the OIG Received Over the Past
Five Years, From 2019 Through 2023 22
5. Distribution of Allegations the OIG Received in 2023:
Percentages and Total Amounts 23
Tables
1. The OIG’s Medical Inspections for Cycles 6 & 7: Final Reports
Published in 2023 13
2. Ratings of the Centralized Screening Team (CST) Referrals 16
3. The OIG’s Ratings of Inquiries Conducted by the Department 16
4. Total Number of Complaints the OIG Received Over the
Past Five Years, From 2019 Through 2023 16
5. The OIG’s Ratings of Investigations Conducted by the Department’s
Office of Internal Affairs’ Allegation Investigation Unit 18
Exhibits
The OIG’s Mandate vi
1. The Office of the Inspector General’s Dashboard Module
of Recommendations 29
Office of the Inspector General, State of California
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2023 Annual Report v
Foreword
Vision
The California prison system, by its very nature, operates almost entirely
behind walls, both literal and figurative. The Office of the Inspector
General (the OIG) exists to provide a window through which the citizens
of the State can witness that system and be assured of its soundness. By
statutory mandate, our agency oversees and reports on several operations
of the California Department of Corrections and Rehabilitation (the
department). We act as the eyes and ears of the public, measuring the
department’s adherence to its own policies and, when appropriate,
recommending changes to improve its operations.
The OIG serves as an oversight agency known to provide outstanding
service to our stakeholders, our government, and the people of the State
of California. We do this through diligent monitoring, honest assessment,
and dedication to improving the correctional system of our State. Our
overriding concern is providing transparency to the correctional system
so that lessons learned may be adopted as best practices.
Mission
Although the OIG’s singular vision is to provide transparency, our
mission encompasses multiple areas, and our staff serve in numerous
roles providing oversight and transparency concerning distinct
aspects of the department’s operations, which include discipline
monitoring, complaint intake, warden vetting, medical inspections, the
California Rehabilitation Oversight Board (C-ROB), and a variety of
special assignments.
Therefore, to safeguard the integrity of the State’s correctional system,
we work to provide oversight and transparency through monitoring,
reporting, and recommending improvements on the policies and
practices of the department.
— Amarik K. Singh
Inspector General
Office of the Inspector General, State of California
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vi 2023 Annual Report
T
here is hereby
created
the independent
Office of the
Inspector General
which shall not be
a subdivision of
any other
governmental
entity.
— State of California
Penal Code section 6125
Office of the Inspector General, State of California
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2023 Annual Report 1
Organizational Overview
and Functions
The Office of the Inspector General (the OIG) is an independent agency
of the State of California. First established by State statute in 1994
to conduct investigations, review policy, and conduct management
review audits within California’s correctional system, California Penal
Code sections 2641 and 6125–6141 provide our agency’s statutory
authority in detail, outlining our establishment and operations.
The Governor appoints the Inspector General to a six-year term, subject
to California State Senate confirmation. The Governor appointed our
current Inspector General, Amarik K. Singh, on December 22, 2021; her
term will expire on August 25, 2028.
The OIG is organized into a headquarters operation, which encompasses
executive and administrative functions and is located in Sacramento, and
three regional offices: north, central, and south. The northern regional
office is located in Sacramento, co-located with our headquarters; the
central regional office is in Bakersfield; and the southern regional office
is in Rancho Cucamonga.
Our staff consist of a skilled team of professionals, including attorneys
with expertise in investigations, criminal law, and employment law, as
well as inspectors knowledgeable in correctional policy, operations,
and auditing.
The OIG also employs a cadre of medical professionals, including
physicians and nurses, in the Medical Inspection Unit. These
practitioners evaluate policy adherence and quality of care within the
prison system. Analysts, editors, and administrative staff within the OIG
contribute in various capacities, all of which are integral in achieving
our mission.
Staff in our office perform a variety of oversight functions relative to the
department, including those listed below:
• Conduct medical inspections
• Carry out audits and authorized special reviews
• Staff the complaint hotline and intake unit
• Review, and when appropriate, investigate whistleblower
retaliation complaints
• Handle complaints filed directly with the OIG by incarcerated
persons, employees, and other stakeholders regarding
the department
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2 2023 Annual Report
• Conduct special reviews authorized by the Legislature or the
Governor’s Office
• As ombudsperson, monitor Sexual Abuse in Detention
Elimination Act (SADEA) / Prison Rape Elimination Act
(PREA) cases
• Coordinate and chair the California Rehabilitation Oversight
Board (C-ROB)
• Conduct warden and superintendent vettings
• Monitor the following:
◦ Internal investigations and litigation of employee
disciplinary actions
◦ Critical incidents, including deaths of incarcerated
persons, large-scale riots, hunger strikes, and
so forth
◦ Staff complaint grievances filed by incarcerated persons
◦ Adherence to the Blueprint plan for the future of
the department
◦ Uses of force
◦ Contraband surveillance watches
Office of the Inspector General, State of California
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2023 Annual Report 3
Figure 1. The Office of the Inspector General Organizational Chart, 2023
Executive
Team
Chief
C-ROB *
Counsel
Legal
Services
Unit
Discipline Field Intake Medical Staff Warden Information
A T u e d am its Mon U i n to it ring In M ve o s n U t i i n t g o i a t r t i i n o g n s Pro c U e n s i s t i ng Insp U e n c it tion M M i o sc n U o i n t n o it d ri u n c g t ( V H e e t a t d in qu g a r U te n r i s t ) Tech U n n o it logy Administration
Enga A g u e d m it e nts M D o is n c i i t p o l r in in e g U M se o - n o i f t - o F r o in rc g e Co In m ta p k la e int In M sp e e d c i t c io al n s In M ve o s T n t e i i g a to m a r t i i n o g n s V W e a tt r i d n e g n s D H e e s lp k B S u e U s r i v n n i i e c t e ss s
Centralized Project Human
R S e p v e ie ci w al s O ( f A fic d e m r A i o n O f is t t D h ra e t i D ve ay) M I o C n n c r i i i d t t i o c e r a n i l n t g M Sc o T r n e e i e t a o n m r in in g g M B o lu n e it p o r r i i n n t g Management Res U o n u i r t ces
Development
Local Publications
Inquiry Team
Team
Infrastructure
Training
Headquarters
Team
Security
* C-ROB is the abbreviation for the California Rehabilitation Oversight Board.
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4 2023 Annual Report
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Office of the Inspector General, State of California
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2023 Annual Report 5
Reports Published in 2023
Internal Investigations and Employee
Discipline Monitoring
The Discipline Monitoring Unit (DMU) attorneys are responsible for the
contemporaneous oversight of the department’s internal investigations
and employee disciplinary process. The California Penal Code requires
that the OIG publish its findings at least semiannually. We released two
discipline monitoring reports in 2023. The first report, released in June
2023, covered the July through December 2022 reporting period and the
second report, released in September 2023 covered the January through
June 2023 reporting period.
During these two periods, the Office of Internal Affairs addressed
and made decisions concerning 2,315 referrals for investigation or for
authorization to take disciplinary action without an investigation. Of
those 2,315 referrals, the Office of Internal Affairs approved 2,139 for
investigation or direct disciplinary action. Our staff monitored and
assessed the department’s more serious internal investigations of alleged
employee misconduct, such as cases involving alleged dishonesty, code of
silence, use of force, and criminal activity. During these two periods, we
monitored and closed 376 cases, which is an increase from the 248 cases
we had monitored and closed in the previous two periods.
Unlike in previous reporting periods, we categorized our assessment
across three separate indicators instead of six. Each of the three
indicators assessed the performance of three departmental entities
as follows:
1. Hiring authorities in discovering alleged employee
misconduct, in referring the allegations to the Office of
Internal Affairs, and in making findings concerning the
investigations and allegations;
2. The Office of Internal Affairs in processing and
analyzing referrals and investigating the allegations;
and
3. Department attorneys in providing legal advice to
the Office of Internal Affairs and in representing the
department in litigation regarding employee discipline.
These indicators are organized to reflect the performance of these
three groups in the department across all stages of the investigative and
disciplinary process from a case’s inception to its ultimate conclusion.
Indicator 1 is used to assess the hiring authority’s performance, which
is usually that of a warden. Indicator 2 is used to assess the Office of
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6 2023 Annual Report
Internal Affairs’ performance, for both the performance of its staff
during the Central Intake Panel meetings and the special agent’s
performance during the investigation. Indicator 3 is used to assess
the Employment Advocacy and Prosecution Team (EAPT) attorney’s
performance during the investigative and disciplinary phases.
Previously, the OIG assigned a rating of superior, satisfactory, or poor to
each applicable indicator, and an overall rating to each case. As of the
2023–1 reporting period, we have assigned a rating of sufficient, sufficient
with recommendations, or insufficient to each applicable indicator, and an
overall rating to each case.
In general, a sufficient rating means that the OIG did not identify any
significant deficiencies. A sufficient with recommendations rating means
that the OIG found significant deficiencies, but the deficiencies did not
appear to cause a negative outcome for either the department or the case
under review. An insufficient rating means that the OIG found significant
deficiencies that caused a negative outcome for either the department or
the case.
The OIG determines an overall rating for each case we monitor after
considering the ratings for each indicator. The overall rating of a case
is equal to the rating of the worst performance indicator. For example,
if any of the three performance indicators is rated insufficient, we rate
the entire case insufficient. Likewise, if the lowest-rated performance
indicator is sufficient with recommendations, we rate the entire case
sufficient with recommendations.
The OIG has also developed compliance- and performance-related
questions concerning each indicator. As with our new rating system,
these questions have been modified for the 2023-1 reporting period.
Our attorneys assigned to monitor each case answered these questions,
rated each of the three indicators for each case sufficient, sufficient with
recommendations, or insufficient using the same rating terminology. We
applied this new methodology in the second discipline monitoring report
of 2023, issued in September 2023, which covered the January through
June 2023 reporting period and thus began a new semiannual cycle. We
found the department’s performance was sufficient in 23 percent of cases,
sufficient with recommendations in 49 percent of the cases, and insufficient
in 28 percent of cases we monitored.
However, under our previous assessment criteria, we found that
during the July through December 2022 reporting period, each of the
three entities performed in a satisfactory manner for one performance
indicator, but a poor manner for the other. For example, hiring authorities
performed satisfactorily in discovering allegations of employee
misconduct and in referring those allegations to the Office of Internal
Affairs in 78 percent of cases we monitored, yet poorly in making
investigative and disciplinary findings in 34 percent of cases. The Office
of Internal Affairs performed satisfactorily in 78 percent of criminal
investigations and in 86 percent of administrative investigations we
monitored. Department attorneys performed satisfactorily in providing
Office of the Inspector General, State of California
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2023 Annual Report 7
legal advice to the department when the Office of Internal Affairs
processed employee misconduct referrals and conducted investigations
in 89 percent of cases. However, department attorneys performed
satisfactorily in providing legal representation during litigation in only
60 percent of cases we monitored.
The OIG also identified and made recommendations regarding the
disciplinary process. In our discipline monitoring report released in
June 2023, which covered the July through December 2022 reporting
period, we made the following two recommendations:
• The department should maintain and install holding cells at all
conservation camps so that incarcerated people are not kept in
vehicles and exposed to inclement weather when detained on
suspicion of violating prison rules. The installation and use of
such cells can also reduce the risk of escape and civil liability
when an incarcerated person cannot be transferred to other
suitable buildings or facilities.
• The department should implement new policies and procedures
for quickly dismissing employees who commit serious criminal
misconduct. This includes a policy or procedure promoting the
use of the unpaid administrative time-off statute.
In our discipline monitoring report released in September 2023, which
covered the January through June 2023 reporting period, we made the
following recommendation:
• The department should consider drafting disciplinary actions
that would allow an administrative law judge to consider
multiple theories. Doing so can help the department avoid
findings by the State Personnel Board that employees have not
received sufficient notice of alleged misconduct. This issue can
arise when an administrative law judge makes factual findings
that support misconduct, but that are different from what the
department alleged in the disciplinary action.
In addition to publishing the two discipline monitoring reports, we also
publish our findings regarding individual cases monthly on our public-
facing website. Visit www.oig.ca.gov, click on our Data Explorer tab,
and then select the section labeled Case Summaries to read our findings.
The OIG also monitors several types of critical incidents, including uses
of deadly force and unexpected deaths of incarcerated people such as
homicides, suicides, and deaths caused by an overdose of narcotics. Our
findings regarding the department’s performance in handling critical
incidents can also be found on our public-facing website.
Office of the Inspector General, State of California
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8 2023 Annual Report
Use-of-Force Monitoring
One way in which we fulfilled our oversight mandate was by monitoring
the department’s process for reviewing use-of-force incidents. Our
staff review use-of-force incident reports and related video footage,
when available, and attend committee meetings at institutional and
departmental levels. Following a review of the use-of-force incident
documentation, our inspectors attended executive review committee
meetings. During these meetings, they provided real-time feedback
and recommendations to the committees. To evaluate the effectiveness
of the department’s process of handling use-of-force incidents and its
compliance with policies and procedures, our staff reviewed various
rules and regulations relevant to the department’s use-of-force practices.
Because we did not personally observe use-of-force incidents, our
assessments relied on departmental staff’s written accounts of each
incident and recordings from fixed cameras or body-worn cameras, when
available. Our methodology consists of criteria that we use to identify
a sampling of use-of-force incidents that are at a higher risk of being
termed significant policy violations or staff misconduct.
In July 2023, we published the report titled Monitoring the Use-of-Force
Review Process of the California Department of Corrections and Rehabilitation.
This publication covered our monitoring of use-of-force incidents that
occurred on or after January 1, 2022, and for which the department
completed its review on or before December 31, 2022. During this period,
we monitored 890 use-of-force incidents that occurred at adult prisons
(812), juvenile facilities (47), within the communities where offenders
were on parole (17), and those involving the Office of Correctional Safety
(14), which acts as a liaison with other law enforcement entities and
apprehends fugitives in the community.
Use-of-Force Statistics, 2022
• We monitored 890 incidents that involved 2,646 applications of
force (Figure 2, on the next page).
• Chemical agents accounted for 1,165 of the total applications
(44 percent), while physical strength and holds accounted for
974 of the total applications (37 percent).
• The remaining force applications consisted of the use of such
options as less-lethal projectiles, baton strikes, tasers, and the
Mini-14 rifle.
Office of the Inspector General, State of California
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2023 Annual Report 9
Figure 2. Distribution of the Applications of Force in the 890 Use-of-Force
Incidents We Monitored
1,165
(44%)
N = 2,646
974
(37%) Applications
of Force
292
(11%)
162 50
(6%) (2%) 3
(< 1%)
Chemical Physical Less-Lethal Expandable Other † Mini-14
Agents * Strength Projectiles Baton
and Holds
* Chemical agents include oleoresin capsicum (OC), CN gas, and CS gas.
† Other includes the use of a shield, nonconventional uses of force, and a taser.
Note: Percentages may not sum to 100 percent due to rounding.
Source: The Office of the Inspector General Tracking and Reporting System.
Highlights of Our Use-of-Force Monitoring
While, overall, the department performed adequately in a majority of
the 890 incidents we monitored, we expect the department to perform
well in all aspects prior to, during, and following each incident, and to
proactively identify and address deficiencies once realized. Our July 2023
report provided our stakeholders with transparent assessments of
incidents and issues we identified that are of significant concern.
Our report highlighted six incidents of particular concern, including
incidents involving possible staff misconduct that the department failed
to address; a departmental staff member who failed to provide use-of-
Office of the Inspector General, State of California
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10 2023 Annual Report
force documentation and video recordings, which impeded our ability to
effectively monitor the use-of-force process; and an incident in which a
hiring authority refused to request video recordings from an outside law
enforcement agency that revealed a departmental agent had used and
observed force, but failed to report it.
During the reporting period, we identified 113 incidents in which the
involved officers had the opportunity to de-escalate the situation prior
to using force. In 44 of those incidents (39 percent), officers failed
to effectively communicate with the incarcerated person or did not
adequately attempt de-escalation strategies. In 2017, the department
implemented mandated training to improve staff communication skills
and further its commitment to resolving conflicts and crises at the lowest
level when an imminent threat is not present. Until 2020, the department
included this training in its required annual training program, but
due to the restrictions resulting from the novel coronavirus pandemic
(COVID-19), the department removed this portion of the training from
the mandatory training schedule. Consequently, we recommend the
department reinstate its de-escalation course as mandated training for all
custody staff.
During this period, we monitored 466 incidents that were captured on
video. While the department did not add fixed or body-worn cameras to
any new prisons in 2022, it planned to add body-worn cameras at four
prisons and fixed cameras at 11 prisons in 2023. We are encouraged by
some of the successes of video-recording implementation. Even so, we
indicate in our report our concerns that supervisors and managers did
not always evaluate an adequate amount of video recordings during the
review process to determine whether staff had fully complied with policy
and procedures.
The report provided an update related to two concerns and
recommendations made in our prior report that we issued in
August 2022. First, the department’s supervisors and managers
continued to perform poorly when reviewing use-of-force incidents, and
identifying policy and training violations. We identified 367 incidents
(41 percent) in which one or more reviewers failed to identify policy
violations. In our most recent report in 2023, we recommended that
the department evaluate its policy to ensure supervisors and managers
capture deviations. The department responded that the current policy
is sufficient to identify deviations and to hold reviewers accountable
when they do not identify any. Despite the department’s assurances,
we identified that hiring authorities provided corrective action to
supervisors and managers who failed to address the deficiencies in only
62 cases (17 percent).
Finally, we identified that the department has yet to implement a policy
to ensure that use-of-force incidents deferred during an initial executive
review committee meeting are returned to the committee in a timely
manner to resolve outstanding issues and close the use-of-force incident.
In our prior report issued in August 2022, we noted our concerns
Office of the Inspector General, State of California
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2023 Annual Report 11
regarding the lack of policy to return incidents to the committee for
closure, and we identified several incidents with extensive delays
between initial and final reviews. To address unreasonable delays, we
recommended that the department develop and implement a policy to
require prisons to return deferred incidents to the committee for closure
in a timely manner. Despite our recommendation, the department had
not implemented a new policy, and many incidents remained in deferred
status for several months after the department’s initial review.
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12 2023 Annual Report
Medical Inspection Reports: Cycles 6 and 7
Cycle 6
In 2023, the OIG completed its sixth cycle of medical inspections and
published eight reports for this unit. We published a report for each of
the following seven institutions: Chuckawalla Valley State Prison, Sierra
Conservation Center, California Institution for Men, San Quentin State
Prison, California City Correctional Facility, Ironwood State Prison,
California Health Care Facility, We also published a summary report
to conclude Cycle 6. Through those reports, the OIG made several
recommendations to the department to further improve the delivery of
medical care to its patients; these recommendations can be viewed on the
OIG’s dashboard at www.oig.ca.gov.
Cycle 7
In 2023, the OIG commenced its seventh cycle of medical inspections
and published one report for the following institution: California
State Prison, Los Angeles County. Through this report, the OIG made
several recommendations to the department to further improve the
delivery of medical care to its patients; these recommendations can
be viewed on the OIG’s dashboard at www.oig.ca.gov. In 2023, the
OIG also completed inspections of the following institutions: Valley
State Prison; Wasco State Prison; California State Prison, Solano;
California Rehabilitation Center; California State Prison, Corcoran;
California Medical Facility; North Kern State Prison; Richard J. Donovan
Correctional Facility; Salinas Valley State Prison; and Substance Abuse
Treatment Facility and State Prison, Corcoran. In 2024, we anticipate
publishing these Cycle 7 inspection reports and completing or beginning
our Cycle 7 inspection process for all remaining institutions.
Table 1 on the following page lists the institutions for which we
completed our Cycle 6 and Cycle 7 inspections and issued final reports
in 2023, the month each report was published, and our overall rating for
each institution.
Overall
Rating
Overall
Proficient Rating
Overall
Adequate Rating
Inadequate
Styling for the rating seals used in MIU reports as introduced for Cycle 6.
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2023 Annual Report 13
Table 1. The OIG’s Medical Inspections Adequate Inadequate
for Cycles 6 & 7: Final Reports Published
in 2023
Publication Overall
Institution Inspected Month Rating
Chuckawalla Valley State Prison January
Sierra Conservation Center March
California Institution for Men May
San Quentin State Prison June
California City Correctional Facility June
Ironwood State Prison July
California Health Care Facility September
California State Prison, Los Angeles County * December
* First published report for Cycle 7.
Source: The Office of the Inspector General medical inspection results.
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14 2023 Annual Report
Staff Misconduct Complaints Monitoring
Pursuant to Penal Code section 6126 (i), the OIG provided
contemporaneous oversight of the “department’s process for reviewing
and investigating inmate allegations of staff misconduct” and other
grievances. This responsibility included our monitoring of staff
misconduct complaint screening decisions made by the department’s
Centralized Screening Team, local inquiry cases completed by prison
investigators, and investigations conducted by the Office of Internal
Affairs’ Allegation Investigation Unit.
In January 2022, the department implemented emergency regulations
revising its statewide process for reviewing and processing incarcerated
people’s allegations of staff misconduct. The purpose of this new process
was to increase the department’s independence and fairness in reviewing
these complaints. On October 20, 2022, the department permanently
adopted these regulations.
With the new staff misconduct complaint process, as of January 1, 2022,
each prison’s grievance office began to forward allegations of staff
misconduct to a new unit, the Centralized Screening Team within the
Office of Internal Affairs. Beginning May 31, 2022, the Centralized
Screening Team reviewed each complaint submitted by incarcerated
people and parolees, and assigned staff misconduct allegations one of
three categories: 1) routine issue; 2) local inquiry; or 3) investigation.
Allegations of staff misconduct were either formally investigated by the
new Office of Internal Affairs’ Allegation Investigation Unit or returned
to the prisons for locally designated investigators to conduct inquiries
into the allegations. If the Centralized Screening Team determined
that a complaint did not constitute allegations of staff misconduct, the
Centralized Screening Team returned the complaint to either the prison
or a regional parole office to handle as a routine complaint.
Figure 3. The Department’s Actions on Complaints Submitted by
Incarcerated People and Parolees
Allegations Referred
for Local Inquiry
9,122 (5.6%)
N = 164,042
Complaints
Allegations Referred
for Investigation
10,589 (6.5%)
Complaints Returned to
the Prison as Routine
144,331 (88%)
Note: Numbers may not sum to 100 percent due to rounding.
Source: The California Department of Corrections and Rehabilitation’s Offender Grievance
Tracking System.
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2023 Annual Report 15
From January 1, 2022, through December 31, 2022, according to
department figures, the Centralized Screening Team received a
total of 164,042 complaints from incarcerated people or parolees. In
total, it routed 144,331 (88.0 percent) of those allegations as routine
issues, 9,122 allegations (5.6 percent) to prisons for a local inquiry,
and 10,589 (6.5 percent) to the Office of Internal Affairs for inquiry
or investigation.
On May 24, 2023, we published a report concerning our office’s
monitoring from May 31, 2022, through December 31, 2022, of the
department’s handling of the screening decisions made by the
department’s Centralized Screening Team, local inquiry cases completed
by prison investigators, and investigations conducted by the Office
of Internal Affairs’ Allegation Investigation Unit. In addition, for the
period from January 1, 2022, through October 26, 2022, we reported
on our monitoring of the inquiry cases completed by the Office of
Internal Affairs’ Allegation Inquiry Management Section pursuant to
the department’s prior regulatory framework. Finally, we presented our
concerns regarding the department’s limited retention period for body-
worn cameras and video-surveillance recordings.
For each of the cases we monitored, we assessed the performance of
departmental staff and provided an overall rating. We assessed the
overall screening work of the Centralized Screening Team, the inquiry
work of locally designated and Allegation Inquiry Management Section
investigators, the investigation work of the Office of Internal Affairs’
Allegation Investigation Unit, department attorneys, and hiring
authorities to which we assigned the ratings superior, satisfactory, or
poor. We used this rating system to evaluate and assess the department’s
overall performance in five main areas:
• Whether the Centralized Screening Team appropriately
screened and referred allegations of employee misconduct and
other related complaints;
• Whether the department appropriately conducted inquiries into
allegations of employee misconduct;
• Whether the Office of Internal Affairs’ Allegation Investigation
Unit appropriately conducted investigations;
• Whether the department attorney or employee relations officer
properly performed during the investigation, the disciplinary
process, and the litigation process; and
• Whether the hiring authority properly determined findings
concerning alleged employee misconduct, and properly
processed the employee disciplinary case.
Office of the Inspector General, State of California
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16 2023 Annual Report
Beginning July 1, 2022, through December 31, 2022, the
Table 2. Ratings of the
Centralized Screening Team OIG monitored and closed 1,067 grievances which included
(CST) Referrals 1,682 complaints that the Centralized Screening Team
Number of received. We found that the department’s Centralized
Ratings CST Decisions
Screening Team conducted satisfactory screening decisions
Superior 1 in 1,008 of the 1,067 grievances (94 percent) we monitored.
Satisfactory 1,008 In 58 complaints (five percent), the Centralized Screening
Team’s performance was poor. In one case, we issued the
Poor 58
department a superior rating.
Total 1,067
Note: In this reporting period, we From January 1, 2022, through December 31, 2022, the OIG
monitored and rated 1,067 of the
department’s CST referrals. monitored and closed 41 staff misconduct inquiry cases:
Source: The Office of the 19 staff misconduct inquiry cases completed by Office of
Inspector General Tracking and
Internal Affairs’ Allegation Inquiry Management Section
Reporting System.
investigators and
22 staff misconduct Table 3. The OIG’s Ratings of Inquiries
inquiry cases completed by locally Conducted by the Department
designated (prison) investigators. In Number of Number of
these cases, we assessed the work of Ratings Local Inquiries AIMS Inquiries
investigators and that of the Superior 0 0
wardens who made decisions Satisfactory 8 10
regarding the inquiry cases. Of the
Poor 14 9
19 inquiry cases completed by the
Note: In this reporting period, we monitored and rated a
Office of Internal Affairs’
total of 41 of the inquiries that the department conducted.
Allegation Inquiry Management
Source: The Office of the Inspector General Tracking and
Section, we assessed the work of Reporting System.
departmental staff as poor in nine
cases (47 percent) and satisfactory in 10 cases (53 percent). In addition, of
the 22 local inquiry cases monitored, we rated the work of departmental
staff poor in 14 cases (64 percent) and satisfactory in eight cases
(36 percent). We did not assign any inquiry cases a superior rating.
Table 4. The OIG’s Ratings of Investigations Conducted by the
Department’s Office of Internal Affairs’ Allegation Investigation Unit
OIA-AIU * Department Hiring
Ratings Investigations Attorneys Authorities
Superior 0 0 0
Satisfactory 3 4 5
Poor 7 6 5
* OIA-AIU is the abbreviation for the Office of Internal Affairs’ Allegation
Investigation Unit.
Note: In this reporting period, we monitored and rated 10 of the investigations
that the department conducted.
Source: The Office of the Inspector General Tracking and Reporting System.
Office of the Inspector General, State of California
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2023 Annual Report 17
From May 31, 2022, through December 31, 2022, the OIG monitored
and closed 10 staff misconduct investigation cases completed by the
Office of Internal Affairs’ Allegation Investigation Unit. In these cases,
we also assessed the work of the wardens who made findings and
decisions regarding the investigation cases and the performance of
department attorneys assigned to the cases. We found the performance
of departmental staff poor in seven of the 10 investigation cases the
OIG monitored and satisfactory in three of the cases. In addition, we
determined the performance of department attorneys in these cases
was poor in six of 10 cases and satisfactory in four of the cases, and the
wardens’ performance was poor in five of 10 cases and satisfactory in five
of the cases. We did not assign any cases a superior rating.
Our monitoring of the department’s six prisons equipped with audio-
video surveillance systems (AVSS) and body-worn cameras (BWC)
revealed that investigators failed to collect video recordings during
several local inquiries and investigations. Such failure to obtain
recordings is problematic for the adequacy and integrity of inquiries
and investigations to substantiate or refute allegations of staff
misconduct, and for the department’s compliance with court-ordered
remedial measures.
In reviewing inquiries and investigations for which investigators did
not obtain BWC and AVSS recordings because the recordings had
already been purged, it became apparent that the department’s current
90-day retention period for video evidence was not sufficient. Although
allegations of staff misconduct made by an incarcerated person require
that video evidence be retained beyond 90 days, unless an investigator
submitted a specific request to review video recordings within the 90-day
retention period, aside from any other triggering events, the department
automatically deleted the video evidence after 90 days.
In our monitored cases, the OIG identified that departmental staff were
not always able to preserve the recorded data as potential evidence
in an inquiry or investigation because of delays in the department’s
processes of assigning and starting inquiries and investigations, in its
staff requesting pertinent video recordings, and in the processing of
video requests by investigation services unit staff. In other instances,
the alleged incident took place months before the complaint was filed,
and the retention period had lapsed. All these issues were contributing
factors to the department’s choosing to delete video evidence. However,
given that delays like these inevitably occur, the department’s 90-day
retention period unnecessarily results in the destruction of critical video-
and audio-recorded evidence, incomplete inquiries and investigations,
and potentially erroneous hiring authority decisions regarding
staff misconduct.
For each section of the department’s staff misconduct investigation and
review process that we monitored in 2022, we provided the department
with our findings and recommendations, as outlined in Table 5 on the
next page.
Office of the Inspector General, State of California
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18 2023 Annual Report
Table 5. The OIG’s Findings and Recommendations
Findings Recommendations
Centralized Screening Team Decisions
The department suffers from deficiencies The OIG recommends that the department resolve
with its electronic tracking system and has issues preventing a direct entry into the electronic
failed to reclassify allegations based on its tracking system and ensure that allegations it agrees to
agreement to the OIG’s recommendations. are reclassified.
The department failed to adequately train The OIG recommends that the department provide
screening staff on how to interview incarcer- meaningful training to the Centralized Screening Team
ated people. analysts in how to conduct clarifying interviews.
Local Inquiry Cases
Investigators failed to use effective interview-
The OIG recommends that locally designated investiga-
ing techniques when conducting interviews
tors audio record all interviews.
by not audio recording each interview.
Inadequate planning resulted in investigators’ The OIG recommends that locally designated investiga-
failure to complete all relevant interviews, to tors submit an inquiry case plan to an Office of Internal
gather and review all relevant documentary Affairs’ Allegation Investigation Unit manager or the
evidence, and to prepare complete inqui- investigator’s manager, prior to conducting interviews,
ry reports. to encourage thoroughly completed inquiries.
Investigation Cases
The OIG recommends that the department eliminate
video quick-close reports as an option in staff
misconduct investigations as they are contrary to
regulations which require thorough investigations, are
In some cases, hiring authorities inappropri-
inconsistent with how local prison investigators conduct
ately determined investigations were suffi-
inquiries into staff misconduct, provide a conclusion
cient and made disciplinary findings in cases
regarding the staff misconduct allegation that usurps
where no interviews were conducted at all.
or undermines the hiring authority’s role as the one to
determine if there is or is not staff misconduct, and have
led to poor recommendations by department attorneys,
and poor decisions by hiring authorities.
Body-Worn Camera and Video Surveillance Recordings
The OIG recommends that the department revise its
Departmental policy requiring a
policy to prevent the deletion of video evidence after
90-day retention period for preservation
90 days for inquiries and investigations. One key change
of video may not be long enough to allow
is to increase the minimum video retention and storage
investigators to request, review, and
policy to one year for all allegations of staff misconduct
preserve all relevant video evidence for staff
the Centralized Screening Team refers for an inquiry
complaint inquiries and investigations.
and investigation.
Source: The Office of the Inspector General.
Office of the Inspector General, State of California
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2023 Annual Report 19
Audit Reports and Special Reviews
The OIG’s Audit Unit published one audit report and one special review
in 2023. In our audit report titled Audit of the Department of Corrections
and Rehabilitation’s Controlled Substances Contraband Interdiction Efforts,
we determined that the department underutilized canines and electronic
drug detection devices at multiple prisons. We found that the canines
were not always available at their assigned prisons to conduct searches,
and even if they were, the department did not regularly use them to
search prison grounds. Similarly, the department did not use electronic
drug detection devices to screen for drugs at most prisons despite the
devices’ proven effectiveness.
We also observed the search process at pedestrian entrances, as well as
searches conducted of incarcerated people during work shift changes,
after visiting, and during cell searches, and found them lacking. The
searches we observed were not always thorough and were unlikely to
discover concealed drugs.
Finally, we reviewed investigations conducted by prison investigative
services’ units to determine the sources of drugs discovered on prison
grounds and found that the department had minimal policies and
procedures in place for investigating the source of drug discoveries.
Furthermore, the investigations we reviewed were generally of poor
quality and rarely identified the source of the drugs.
In response to our findings, we made many recommendations. Regarding
searches, we recommended that the department develop and implement
procedures to effectively use canines to search individuals entering
prisons, as well as prison grounds. We also recommended that the
department develop policies and procedures to better search staff and
their belongings, including using canines. We further recommended
that the department clarify methods to search incarcerated people
coming from and going to job assignments and use electronic drug
detection devices during the searches. Finally, we recommended that the
department ensure staff consistently complete and document required
cell searches and implement training to reinforce skills and expectations
for conducting effective cell searches.
In regard to investigations of the sources of drug discoveries, we
recommended that the department establish clear policies, procedures,
and guidance for investigating discoveries, and develop and conduct
specific training for prison investigators. We also recommended the
department establish policies and procedures for properly documenting
drug discoveries and improving the quality of its data.
In addition to the audit, the Audit Unit published one special review
titled Special Review: The California Department of Corrections and
Rehabilitation’s Implementation of the Transgender Respect, Agency, and
Dignity Act (the Act). During our review, we found that the department’s
Office of the Inspector General, State of California
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20 2023 Annual Report
still-evolving process to evaluate transfer requests under the Act has
resulted in significant delays and that the vast majority of applicants had
not been evaluated for suitability to transfer.
In addition, we found that many incarcerated people at women’s prisons
expressed safety and privacy concerns living with transferees under the
Act. The Act has created tension and a perception of inequity between
transferees and those incarcerated people at women’s prisons who did
not wish to house with transferees in the same cell or dormitory because
of safety concerns. The perceived inequity was in part caused by the fact
that transferees’ perception of health and safety when accepting housing
assignments must be given serious consideration under the Act, but the
same is not always true for nontransferees.
Finally, we found that the department properly investigated or responded
to all allegations of consensual sexual misconduct or assault between
transferees and other incarcerated people. Although consensual sexual
relationships between transferees and nontransferees was reportedly
commonplace, none of the cases we reviewed included alleged rape or
attempted rape.
In summary, we recommended that the department develop specific
criteria for both evaluating and completing evaluations for transfer
requests. On a closely related note, we also recommended that the
department develop a plan for reducing its backlog of transfer requests,
train staff, and better communicate with those requesting transfers.
Finally, we recommended that the department document when and why a
transferee requests a bed change and give a copy of the documentation to
the requesting transferee.
Office of the Inspector General, State of California
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2023 Annual Report 21
Complaint Intake
The OIG maintains a statewide complaint intake process that provides a
point of contact regarding allegations of improper activity that take place
within the department. Our Complaint Intake Processing Unit (Intake)
receives complaints from incarcerated people, parolees, their families,
departmental employees, advocacy groups, and other complainants.
Complaints are submitted via letter, toll-free phone call, institutional
tablets, or our website. We strive to screen all complaints within one
business day of receipt to identify potential safety concerns, medical or
mental health concerns, or reports of sexual abuse.
In 2023, we received 8,227 complaints (Figure 4, next page). This was
a 157 percent increase from the 3,200 complaints received in 2022. We
can attribute this increase to several factors, including the department’s
distribution of tablets for incarcerated persons from August 2021
through September 2023 (with 19 prisons becoming operational with
tablets in 2023); our distribution of new OIG posters statewide with
a new confidential speed dial feature for phones; and our Intake staff
having made 10 visits to institutions where we could interact directly
with advisory councils for incarcerated persons (i.e., Inmate Advisory
Council (IAC); each prison has multiple IACs, typically one for each
facility, with three to five per prison).
Our Intake staff assign a unique identification number for complaints
received that we use to document and maintain records for in our
case activity database. In 2023, we reviewed and closed 6,699 of the
8,227 complaints received. In addition, some incarcerated people
often submit numerous complaints which typically include duplicate
allegations previously reviewed and closed by Intake staff. In 2023, we
completed our review of 1,246 duplicative complaint issues received from
22 complainants. In 2024, our staff will continue working to resolve the
remaining 282 complaints (three percent) pending from 2023.
In November 2023, Intake published its initial Impact Case Blocks to
highlight select intake complaints. This select group led to a positive
change or an impact as raised by the complainant. When Intake staff
review a complaint, this may result in our office requesting that the
Office of Internal Affairs consider opening an investigation into an
allegation of staff misconduct or that our Staff Misconduct Monitoring
Unit (SMMU) begin monitoring inquiries or investigations for an
allegation. One of the complaints highlighted in the case blocks involved
a parolee never having been compensated for lost and damaged property.
Intake staff located documentation supporting this claim, contacted
departmental staff about the delayed payment, and received notification
when the parolee received compensation; Intake’s Impact Case Blocks may
be found on our website.
Approximately 81 percent of the complaints we received in 2023 were
submitted by incarcerated people across the State, while 15 percent
Office of the Inspector General, State of California
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22 2023 Annual Report
Figure 4. Total Number of Complaints the OIG Received Over
the Past Five Years, From 2019 Through 2023
9,000
8,000
8,227
7,000
6,000
5,000
4,000
4,144 4,200
3,505
3,000
3,200
2,000
1,000
0
2019 2020 2021 2022 2023
Source: The Office of the Inspector General Tracking and Reporting System.
were submitted by citizens. The OIG received the remaining complaints
from departmental employees, anonymous people, parolees, or other
individuals. We received about 50 percent of the complaints through
voicemail (via phone and tablet), more than 38 percent by mail, 12 percent
from our website, and the remainder in person.
In response to these complaints, our staff often conducted inquiries
into the allegations by accessing information from various departmental
databases, reviewing the department’s policies and procedures, or
requesting relevant documentation from the prisons. However, we
frequently received complaints that lacked the details needed to clearly
identify and research the allegation. After our review or inquiry into
complaints, we advised complainants about how they could more fully
address their concerns with the department or recommended that
they provide us with more details. We provided a written response
or contacted the complainant by phone for complaints that required
a response.
The most frequent types of allegations we received in 2023 pertained
to such issues as staff misconduct; prison conditions, policies, or
operations; the appeals and grievance process; the Prison Rape
Elimination Act (known as PREA); or health care concerns. A complaint
can frequently contain multiple allegations of improper activity
occurring within the department. Figure 5 on the next page shows the
distribution of the top five complaint allegation categories we received.
Office of the Inspector General, State of California
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2023 Annual Report 23
Figure 5. Distribution of Allegations the OIG Received in 2023: Percentages and Total Amounts
Reporting Categories
and Total Allegations
(N = 9,197)
3,081 Prison Conditions
(33%) and Operations
2,728 Staff Misconduct
(30%)
971 PREA Allegations
(11%) or Investigations
660 Medical, Dental, or
(7%) Mental Health Care
Grievance / Appeals
655
(7%) Process
Undetermined
524 476 102 No Jurisdiction
(6%) (5%) (1%)
Legal
Definitions
Prison Conditions and Operations to a decision that has a material adverse effect on an
incarcerated person’s physical or mental well-being.
Complaints that involve concerns with prison conditions,
such as incorrect release date calculations, missing Undetermined
property, access to rehabilitative programs, or the
Complaints that do not identify a specific concern,
visiting process.
allegation, or request, such as incarcerated people
Staff Misconduct and Grievance / Appeals Process requesting to be interviewed or making general
statements about their incarceration.
Complaints that involve concerns with processing
of grievances and appeals and allegations of staff No OIG Jurisdiction
misconduct by departmental staff.
Allegations that fall outside OIG jurisdiction, such as
Prison Rape Elimination Act (PREA)
complaints involving county jails, federal prisons, or local
Allegations that an incarcerated person was subjected law enforcement.
to sexual harassment or misconduct by incarcerated
persons or staff, or made PREA complaints that were not Legal
handled appropriately. Requests for various types of legal assistance, including
access to public records, and allegations of retaliation by
Medical, Dental, or Mental Health
departmental staff.
Complaints that involve concerns with access to
medical, dental, or mental health services or objection Source: Definitions and data generated by the Office of the Inspector General.
Office of the Inspector General, State of California
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24 2023 Annual Report
Prison Rape Elimination Act
In 2023, we received 864 complaints involving alleged sexual misconduct
or assault, known as PREA allegations, from incarcerated people,
family members, and other third parties. In accordance with federal
PREA standards, we forwarded these allegations of sexual abuse
and sexual harassment to both the respective hiring authority and
PREA compliance manager, allowing the person who reported the
allegation to remain anonymous if requested.
In 2023, the department also notified our Intake staff of 589 PREA
allegations involving alleged sexual abuse and sexual harassment
incidents. The reports included, in part, allegations of nonconsensual
sexual acts, abusive sexual acts, sexual harassment, and sexual
misconduct. The department tracks and reports statistics on these
alleged incidents annually on its website, and posts PREA audit reports
of the prisons.
Inmate Advisory Council (IAC) Meetings
As part of our complaint intake duties, we actively work to gain
knowledge of local and departmentwide issues through attending
periodic meetings with inmate advisory councils (IACs) at institutions
throughout the State.
During 2023, our intake staff met with IACs at 10 institutions to educate
council members about the OIG’s mission and to solicit input. While
most council representatives were aware of our office, there was a
lack of understanding of our functions and how we elevate and notify
the department about concerns that are brought to our attention.
Accordingly, in all our meetings, we provided an overview of the OIG,
addressed confidentiality concerns, and explained how to contact us. Our
staff also provided how we may be able to assist incarcerated people with
specific issues.
The council representatives discussed many concerns and issues that
they felt were not being adequately addressed at the institution. The
most common issues raised involved the grievance and staff misconduct
processes and institutional culture. We also received positive feedback
from several IACs regarding their institution or interactions with
departmental staff.
Grievance and Staff Misconduct Processes
Generally, the primary issues of concern that many of the
IAC representatives identified concerned the department’s handling
of grievances (presented on CDCR Form 602-1) and allegations of staff
misconduct. The councils expressed concern regarding how long it can
take for the grievance process to be resolved, grievance issues that are
Office of the Inspector General, State of California
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2023 Annual Report 25
never addressed, and a perceived lack of transparency and accountability
throughout the process.
At one institution, some incarcerated people who had filed grievances
did not always receive an acknowledgment from the Office of Grievances
for having done so. Without having received a grievance log number, an
incarcerated person cannot track whether the grievance was received
or learn about the status of a grievance decision. In another instance,
an IAC representative mentioned receiving a response from the Office
of Grievances after the department’s 60-day deadline had passed;
however, the date identified on the response letter showed the Office of
Grievances had responded timely. Furthermore, the Office of Appeals’
second-level review, at times, allows time constraints to expire without
conducting any review; thus, the grievance issue is never addressed. In
addition, IAC representatives at several institutions stated that they
preferred the hard-copy request form that the department used in the
past, which provided a receipt. Incarcerated people could use the form
to document that a request had been filed and reviewed by staff and a
supervisor, prior to submitting a grievance form.
IAC members also noted that they believed the grievance process is not
confidential, and some incarcerated people are subject to retaliation
for filing grievances. One IAC member cited a situation wherein he
had submitted a grievance in the grievance lockbox and was confronted
the next day by the officer identified in the complaint. There was a
perception that the facility captain’s office technician, who was typically
tasked with retrieving grievance forms from lockboxes, was subsequently
sharing grievance information with custody staff. Another IAC member
alleged having submitted a staff complaint and then, was interviewed.
During the investigative interview conducted via video conference, the
investigator instructed custody staff to leave the confidential interview
room, but custody staff remained in the room without the investigator’s
knowledge. Thus, the IAC member declined to be interviewed as he
feared retaliation. Intake staff referred this concern to our office’s
SMMU, whose staff subsequently monitored the department’s
investigation for this case that included a reinterview of the incarcerated
person in a confidential setting.
Institutional Culture
The IACs at most institutions expressed concerns that incarcerated
people were not treated with dignity and respect by some departmental
staff. IAC representatives discussed the perception of a generally
negative culture, an attitude that was perceived among some staff and
directed toward incarcerated people. The IACs cited retaliatory practices
when members or other incarcerated people filed grievances, negative
outcomes when they were sent to the restricted housing unit (RHU), and
discourteous treatment directed toward incarcerated people and visitors.
Office of the Inspector General, State of California
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26 2023 Annual Report
IAC members shared several examples of these concerns. For example,
after an incarcerated person submitted a staff misconduct grievance
against an officer, IAC members stated that some of them were subject
to unannounced cell searches, loss of programs, or transfer to another
institution. This created fear among the incarcerated population and
concern over whether it would be worthwhile to file a grievance.
In November 2023, the department implemented emergency regulations
that applied to its RHU. The regulations included reforms limiting these
units’ use to incarcerated people who have engaged in violence in prison
or have expressed serious safety or security concerns. IAC members
shared ongoing concerns when they were placed in restricted housing.
One example described the following scenario: When an incarcerated
person was sent to the RHU, custody staff allowed the persons’ cellmate
to “pack [up]” the belongings of the person sent to the RHU. This has
created problems when cellmates do not have a good relationship, and
property is found to have gone missing when they return from the RHU.
Another example: After reporting a PREA violation, an alleged victim of
sexual misconduct or harassment would be placed in the RHU. Then, for
reporting misconduct, the victim’s property would become permanently
“lost” in retaliation—directly or indirectly—as a further punishment
meted out by custody staff. One IAC member stated that whenever an
incarcerated person was sent to the RHU, a designated officer should be
required to account for, pack, and secure that person’s property.
Moreover, one main way for incarcerated people to connect with their
family and friends was through regular in-person visitation. Several IACs
highlighted concerns that their members or other incarcerated people
had faced in 2023. These included the following concerns:
• Visitors were processed slowly, which sometimes took
several hours.
• Incarcerated people were called for visiting at the exact time
of “pill call,” which reduced the time available for incarcerated
people to enjoy the visit.
• Some family-visiting units were unavailable because they were
being used instead for storage space, thus limiting the units
available for overnight visits.
• Visiting staff assignments were ever-changing and included
inexperienced staff, which resulted in an inconsistent
application of policy, such as the judgmental enforcement of
whether visitors’ attire was considered “very tight, form-fitting”
and thus not allowed.
Another example alleged that a visiting officer intentionally separated
children by placing them in the children’s play area of the visiting room,
far away from their parents, so the incarcerated parents could not easily
watch their children. IAC members strongly believed that this type of
Office of the Inspector General, State of California
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2023 Annual Report 27
treatment served as a sign of general disrespect directed toward visitors
and their family members, which created a negative cultural atmosphere
in the prisons.
Positive Feedback From IACs
Typically, IACs meet quarterly with the warden and monthly with
members of the warden’s management team, including a facility captain
and other supervisors. We asked IACs what was going well at their
institution, and they shared the following types of information with us:
• Members think highly of the warden, and it is the best
administration they have seen at the institution.
• The warden is working with staff and incarcerated people to
improve relationships and communication.
• The warden is a proponent of the California Model and
resolves issues.
IAC representatives also made positive comments about both staff and
available resources, including the following observations:
• There are more good staff who treat incarcerated people like
humans beings and work to create a good culture.
• There is better communication with staff, and issues regarding
packages and property get resolved without grievances.
• A sergeant was instrumental in recently assisting with a suicidal
incarcerated person; the sergeant was able to speak with [the
person] and properly dealt with the stressful situation.
• There are more programming opportunities than in the past.
The outside programming is positive, and tablets provide
additional course offerings.
• Tablets have allowed incarcerated people to get back in touch
with family to whom they had not spoken in years.
Office of the Inspector General, State of California
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28 2023 Annual Report
Whistleblower Retaliation Claims
In addition to receiving complaints as described in the preceding
sections, our statutory authority directs us to receive and review
complaints of whistleblower retaliation that departmental employees
levy against members of departmental management. The OIG analyzes
each complaint to determine whether it presents the legally required
elements of a claim of whistleblower retaliation—that the complainant
blew the whistle (reported improper governmental activity or refused to
obey an illegal order)—and that the complainant was thereafter subjected
to an adverse employment action because he or she blew the whistle. If
the complaint meets this initial legal threshold, our staff investigate the
allegations to determine whether whistleblower retaliation occurred.
If the OIG determines that the department’s management subjected
a departmental employee to unlawful retaliation, our office reports
its findings to the department along with a recommendation for
appropriate action.
Due to public misperception regarding what constitutes whistleblower
retaliation, few complaints present the legally required elements to
state an actionable claim of whistleblower retaliation. To counteract
this misunderstanding, we engage with complainants to educate them
regarding the elements of a whistleblower retaliation claim, invite
complainants to supplement their complaints with any necessary
information, and correspond with complainants to clarify any questions
we have regarding the information they submitted.
In 2023, the OIG received 22 retaliation complaints. We completed
analyses of 21 complaints and determined that none stated the legally
required elements of a whistleblower retaliation claim. We are still in
the process of reviewing the materials pertaining to one complaint we
received in late 2023.
Office of the Inspector General, State of California
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2023 Annual Report 29
Recommendations Made to
the Department
In 2023, the OIG published 16 formal reports, some of which contained
recommendations. These recommendations promote greater
transparency, process improvements, increased accountability, and
higher adherence to policies and constitutional standards. Details
concerning the vast number of recommendations made to the
department are available on our dashboards, which can be accessed
at our website.
If viewing this report on our website, clicking on the image below
will take the reader to the main interactive dashboard web page.
Choose from among several filter options to select a specific group of
recommendations: publication year, service (authorized/special review;
employee discipline monitoring, and use-of-force monitoring), general
topic, associated entity, report title, and report number. A separate
dashboard is also available on our site that lists the medical inspection
report recommendations we have made to both California Correctional
Health Care Services and the department.
Exhibit 1. The Office of the Inspector General’s Dashboard Module of Recommendations
Office of the Inspector General, State of California
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30 2023 Annual Report
(This page left blank for reproduction purposes.)
Office of the Inspector General, State of California
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2023 Annual Report 31
Appendix: Publications Released
in 2023
Annual and Semiannual Reports
• 2022 Annual Report: A Summary of Reports (February 21, 2023)
• Monitoring the Staff Misconduct Investigation and Review Process
of the California Department of Corrections and Rehabilitation,
2022 Annual Report (May 24, 2023)
• Monitoring Internal Investigations and the Employee Disciplinary
Process of the California Department of Corrections and
Rehabilitation, July – December 2022 (June 19, 2023)
• Monitoring the Use-of-Force Review Process of the California
Department of Corrections and Rehabilitation (July 3, 2023)
• Monitoring Internal Investigations and the Employee Disciplinary
Process of the California Department of Corrections and
Rehabilitation, January – June 2023 (September 29, 2023)
Medical Inspection Reports: Cycle 6 Results
• Chuckawalla Valley State Prison (January 30, 2023)
• Sierra Conservation Center (March 10, 2023)
• California Institution for Men (May 5, 2023)
• San Quentin State Prison (June 27, 2023)
• California City Correctional Facility (June 29, 2023)
• Ironwood State Prison (July 12, 2023)
• California Health Care Facility (September 27, 2023)
• Cycle 6 Medical Inspection Summary Report
(November 6, 2023)
Office of the Inspector General, State of California
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32 2023 Annual Report
Medical Inspection Reports: Cycle 7 Results
• California State Prison, Los Angeles County
(December 4, 2023)
Audit Reports and Special Reviews
• Audit of the Department of Corrections and Rehabilitation’s
Controlled Substances Contraband Interdiction Efforts,
Audit Report № 21-01 (January 11, 2023)
• Special Review: The California Department of Corrections and
Rehabilitation’s Implementation of the Transgender Respect, Agency,
and Dignity Act (August 31, 2023)
Field Team Case Blocks
• August 2023 Centralized Screening Monitoring Team Case Blocks
(October 9, 2023)
• September 2023 Centralized Screening Monitoring Team Case Blocks
(November 1, 2023)
• October 2023 Intake Unit Impact Case Blocks
(November 21, 2023)
• January Through September 2023 Local Inquiry Team Case Blocks
(November 27, 2023)
• October 2023 Local Inquiry Team Case Blocks
(December 4, 2023)
• October 2023 Centralized Screening Monitoring Team Case Blocks
(December 11, 2023)
• November 2023 Centralized Screening Monitoring Team Case Blocks
(December 20, 2023)
Office of the Inspector General, State of California
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2023
Annual Report
A Summary of Publications
OFFICE of the INSPECTOR GENERAL
Amarik K. Singh
Inspector General
Neil Robertson
Chief Deputy Inspector General
STATE of CALIFORNIA
March 2024
OIG