OIG
Annual Report
Amarik K. Singh, Inspector General Shaun Spillane, Chief Deputy Inspector General
of the
OFFICE
OIG
INSPECTOR GENERAL
Independent Prison Oversight March 2025
2024 Annual Report
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at 916-288-4233.
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STATE of CALIFORNIA
OIG OFFICE of the Amarik K. Singh, Inspector General
INSPECTOR GENERAL Shaun Spillane, Chief Deputy Inspector General
Independent Prison Oversight
Regional Offices
Sacramento
Bakersfield
Rancho Cucamonga
March 3, 2025
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 2024. In 2024, we issued 20 public reports detailing our
oversight of the California Department of Corrections and Rehabilitation: 10 reports on
medical inspection results; 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, two audit reports, one special review, one sentinel
case, one semiannual intake report, and our 2023 annual report. In addition, we released
40 case blocks 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 2024 Annual Report
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Office of the Inspector General, State of California
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2024 Annual Report iii
Contents
Illustrations iv
Foreword v
Vision v
Mission v
Organizational Overview and Functions 1
Reports Published in 2024 5
Internal Investigations and Employee Discipline Monitoring 5
Use-of-Force Monitoring 8
2023 Use-of-Force Statistics 8
2024 Use-of-Force Reporting 10
Medical Inspection Reports: Cycle 7 12
Staff Misconduct Monitoring 14
Oversight Areas Reported During
the 2023 Reporting Period 14
Audit Reports and Special Reviews 18
Audit of the California Department of Corrections
and Rehabilitation’s Release Date Calculations 18
Audit of the California Department of Corrections
and Rehabilitation’s Processes and Procedures for
Preventing, Detecting, and Responding to Escapes 19
Special Review: The Department Violated Its Regulations by
Redirecting Backlogged Allegations of Staff Misconduct
to Be Processed as Routine Grievances 21
Other OIG Operational Units: Status Updates 23
Complaint Intake 23
Prison Rape Elimination Act 25
Inmate Advisory Council (IAC) Meetings 26
Whistleblower Retaliation Claims 27
Recommendations Made to the Department 29
Appendix: Publications Released in 2024 31
Office of the Inspector General, State of California
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iv 2024 Annual Report
Illustrations
Figures
The OIG’s Mandate vi
1. The Office of the Inspector General Organizational Chart, 2024 3
2. Distribution of the Applications of Force in the 730 Use-of-
Force Incidents the OIG Monitored in 2023 9
3. Discrepancies in the Department’s Reporting of Incarcerated
Person Escapes in 2022 and 2023 21
4. Total Number of Complaints and Claims the OIG Received
in 2023 and 2024 23
5. Complaints Received by the OIG Hotline in 2024 24
6. Categories of Complaints the OIG Received in 2024 24
Tables
1. Rating Percentages for the Reporting Periods
July Through December 2023, and January Through June 2024 6
2. The OIG’s Medical Inspections for Cycle 7: Final Reports
Published in 2024 13
3. The OIG’s Staff Misconduct Monitoring Unit
Recommendations 17
Photographs
1. Five Makeshift Weapons Found in a Prison Cell 25
Exhibits
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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2024 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 2024 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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2024 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 2024 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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2024 Annual Report 3
Figure 1. The Office of the Inspector General Organizational Chart, 2024
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 2024 Annual Report
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Office of the Inspector General, State of California
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2024 Annual Report 5
Reports Published in 2024
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 2024. The first report, released in April
2024, covered the July through December 2023 reporting period and the
second report, released in October 2024 covered the January through
June 2024 reporting period.
During those two reporting periods, the Office of Internal Affairs
addressed and made decisions concerning 2,227 referrals for investigation
or for authorization to take disciplinary action without an investigation.
Of those 2,227 referrals, the Office of Internal Affairs approved 2,069
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 394 cases, which was an increase from the 376
cases we had monitored and closed during the previous two reporting
periods.
We categorized our assessment across three separate indicators and
used each of the three indicators to assess the performance of three
departmental entities as follows:
1. The performance of hiring authorities in discovering
alleged employee misconduct, in referring allegations
to the Office of Internal Affairs, and in making
findings concerning investigations, allegations, and
disciplinary determinations;
2. The performance of the Office of Internal Affairs
in processing and analyzing referrals, and in
investigating the allegations; and
3. The performance of department attorneys in providing
legal advice to the Office of Internal Affairs and to the
hiring authorities, and in representing the department
in litigation regarding employee discipline.
These indicators are organized to reflect the performance of the three
groups within the department across all stages of the investigative and
disciplinary process from a case’s inception to its ultimate conclusion.
Indicator 1 was used to assess the hiring authority’s performance,
usually a warden. Indicator 2 was used to assess the Office of Internal
Office of the Inspector General, State of California
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6 2024 Annual Report
Affairs’ performance, both at Central Intake Panel meetings and the
special agent’s performance during the investigation. Indicator 3 was
used to assess the Employment Advocacy and Prosecution Team (EAPT)
attorney’s performance during the investigative and disciplinary phases.
The OIG has developed compliance- and performance-related
questions that we use to assess each indicator. Our attorneys assigned
to monitor each case answered these questions and rated each of the
three indicators for each case using one of three ratings: sufficient,
sufficient with recommendations, or insufficient. The following provides
more detail about our rating terminology. 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. We
present our findings for the two reporting periods in Table 1 below.
Table 1. Rating Percentages for the Reporting Periods
July Through December 2023, and January Through June 2024
Rating Period
Rating July Through January Through
December 2023 June 2024
Sufficient 25% 16%
Sufficient With
45% 51%
Recommendations
Insufficient 30% 33%
Source: Office of the Inspector General Tracking and Reporting System.
The OIG also identified and made recommendations regarding the
disciplinary process. In our discipline monitoring report released in
April 2024, which covered the July through December 2023 reporting
period, we made the following recommendations:
• We recommended that Office of Internal Affairs’ special agents
refrain from asking leading questions, wait for a complete
response to a question before asking an interviewee another
question, and ask an interviewee all relevant questions before
disclosing information from an investigation.
• We also recommended that the department provide advice
on a newly enacted California law to guide employees on
expectations for off-duty cannabis use and to ensure that
employees were receiving proper cannabis testing.
Office of the Inspector General, State of California
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2024 Annual Report 7
• Finally, we recommended that department attorneys provide
the OIG with a draft of the prehearing settlement conference
statement for review before filing it with the State Personnel
Board, and allow sufficient time to review and provide feedback
to the department attorney.
In our discipline monitoring report released in October 2024, which
covered the January through June 2024 reporting period, we made the
following recommendations:
• We recommended that the department establish policies
or guidelines requiring department attorneys to contact
stakeholders to ensure that investigative and disciplinary
findings conferences would be completed within the time
frames set by policy and without undue delay.
• We also recommended that the department extend its body-
worn-camera video retention policy to secure important
evidence.
In addition to publishing the two discipline monitoring reports, each
month, we also publish our findings regarding individual cases 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 2024 Annual Report
Use-of-Force Monitoring
In August 2024, we published the report titled Monitoring the Use-of-Force
Review Process of California Department of Corrections and Rehabilitation.
This report addressed 730 use-of-force incidents that occurred within
the California Department of Corrections and Rehabilitation (the
department), and for which the department closed its reviews between
January 1, 2023, and December 31, 2023. This report also highlighted
14 use-of-force incidents of significance that identified possible
staff misconduct.
2023 Use-of-Force Statistics
• We monitored 730 incidents that involved 2,649 applications of
force (Figure 2, next page).
• Physical strength and holds accounted for 1,165 of the total
applications (44 percent), while chemical agents accounted for
991 of the total applications (37 percent).
• The remaining use-of-force applications consisted of
other options such as less-lethal projectiles, baton strikes,
nonconventional uses of force, shields, the Mini-14 rifle,
and tasers.
Figure 2 on the next page shows the distribution of the use-of-force
applications we monitored during 2023.
In our annual use-of-force report issued the year before, in July 2023,
we noted several incidents in which officers did not use de-escalation
techniques before a use-of-force incident occurred. Officers’ failures to
de-escalate these situations often led to the unnecessary use of force. The
July 2023 report also identified incidents in which officers used physical
force instead of initiating a controlled use of force, even though no
imminent threat justified the use of physical force. In our recent August
2024 report, we again highlighted incidents in which officers should have
attempted de-escalation techniques before resorting to physical force.
Before 2020, the department’s officer training curriculum included
standalone de-escalation modules. However, the department abandoned
these training modules during the COVID-19 pandemic. In response
to our recommendation to reinstate its de-escalation training, the
department advised our office that the current training curriculum was
adequate and that no additional training would be provided. At the time
of our August 2024 report, we continued to emphasize the importance
of communication and de-escalation training, and reasserted our
recommendation to reinstate it.
Another important issue highlighted in our August 2024 report
involved the department’s use of body-worn cameras and audio-video
surveillance systems, which had recently been implemented at many
Office of the Inspector General, State of California
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2024 Annual Report 9
Figure 2. Distribution of the Applications of Force in the 730 Use-of-Force Incidents the OIG
Monitored in 2023
N = 2,649
Applications of Force
Physical Strength
1,165 (44%)
and Holds
Chemical Agents * 991 (37%)
40 mm Round 231 (9%)
Expandable Baton 217 (8%)
Nonconventional
16 (< 1%)
Uses of Force
Shield 10 (< 1%)
Mini-14 Rifle 10 (< 1%)
Taser 9 (< 1%)
0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200
* Chemical agents include oleoresin capsicum (OC), chloroacetophenone (CN) gas, and 2-chlorobenzalmalononitrile (CS) gas.
Note: Percentages may not sum to 100 percent due to rounding.
Source: The Office of the Inspector General Tracking and Reporting System.
of the department’s prisons. Body-worn cameras and fixed audio-video
surveillance systems were not available at all prisons at the time this
report was published; however, the department advised its plan was to
continue installing them at additional prisons each year. In our July 2023
report, we noted supervisors and managers often failed to review and
evaluate an adequate number of video recordings during their review
process to determine whether staff had fully complied with policies and
procedures. Again, in our July 2023 use-of-force report, we noted that
access to an appropriate number of video recordings would have assisted
departmental reviewers in determining whether staff had attempted
to communicate with the incarcerated person to resolve the situation
without using force.
In our August 2024 report, our inspectors found several additional
issues involving body-worn cameras. In several incidents, officers failed
to activate body-worn cameras while in the presence of incarcerated
people, thereby precluding incidents from being captured on video, and
subsequently, officers drafted reports that contradicted video-recorded
evidence. The department also refused to hold supervisors and managers
Office of the Inspector General, State of California
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10 2024 Annual Report
accountable for failing to identify potential staff misconduct in their
review of use-of-force incidents.
The department’s policies require staff to consider using controlled
force when no imminent threat is present. We attended a departmentally
mandated remedial training session that was provided to in-service
training representatives from each prison, at which time we learned
training personnel emphasized that the department’s operations manual
only authorized staff to use immediate force if an imminent threat
was present. Although the department has provided custody staff with
remedial training, we continue to catalogue and review incidents in
which officers used immediate force instead of controlled force when no
imminent threat was present. No wardens, associate wardens, or captains
attended this remedial training session. Because people from these
classifications ultimately decide whether each use of force complied with
departmental policy, their attendance at these trainings was critical.
2024 Use-of-Force Reporting
In 2024, the OIG began reporting use-of-force incidents at regular
intervals throughout the year, through a format we call case blocks. This
change in our reporting structure allowed our staff to more frequently
highlight significant use-of-force incidents as our inspectors closed
them out, as opposed to waiting to release that information in an annual
report. This new, accelerated reporting schedule has allowed us more
flexibility to report the outcome of our efforts. Doing so is especially
useful for cases we may have closed months before we would have
released that information in an annual report. Producing case block
publications provide our stakeholders and the public with cogent, timely
reports that show how the department is handling use-of-force incidents
at prisons.
From January 1, 2024, through December 31, 2024, our inspectors
monitored 427 use-of-force incidents at all 33 prisons, the Division of
Adult Parole Operations, and the Office of Correctional Safety. Of the
427 incidents we monitored in 2024, we considered the 33 incidents we
reported on in our case blocks to be of the highest significance.
Overall, the most significant issue we identified was that officers and
medical staff failed to report or timely report the use of force they
had used or witnessed. This concern occurred in 16 of the significant
incidents we published; we recommended the hiring authority refer
these incidents for investigation. However, hiring authorities agreed
to refer only three of these incidents for an investigation for failure to
report the force used or witnessed. Failure to report force—either used
or witnessed—has been an ongoing issue for the department, one our
staff have raised in our two most recently published use-of-force reports.
Prompt departmental reporting is essential to accurately document
use-of-force incidents, especially considering those reports can serve
as evidence in potential cases that may be opened for uses of force.
Office of the Inspector General, State of California
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2024 Annual Report 11
Departmental policy requires all staff who use or witness force to write a
report on the same day the incident occurred, detailing the type of force.
Our inspectors also identified eight incidents in which departmental
staff allegedly used excessive or unnecessary force. Departmental policy
prohibits excessive and unnecessary force because such actions can
contribute to injuries to both incarcerated people and prison staff. Our
inspectors recommended that the department refer these eight incidents
for investigation. However, departmental management agreed to refer
only four of those incidents for investigation and declined to refer the
remaining four incidents. In one case, officers used unnecessary physical
force against an incarcerated person when no imminent threat was
present. In this case, an incarcerated person in restraints was on the
ground. Officers picked him up, and dragged and forced him to walk
across a prison yard. On reviewing video footage of the incident, OIG
inspectors identified the unnecessary use-of-force and also noted that
the officers did not report their use of force. Our staff recommended that
the hiring authority refer the officers for investigation, and the hiring
authority agreed.
Another additional area of concern our inspectors identified was custody
staff’s failure to perform their duties in accordance with policy. In five
of the significant incidents we published, staff failed to perform their
duties, which contributed to the need for custody staff to use force. In
one incident, our inspectors identified a control booth officer failed to
secure housing unit doors, which allowed unauthorized incarcerated
people to enter the housing unit and attack another incarcerated person
using an inmate-manufactured weapon. The group of incarcerated
people inflicted such significant injuries on their victim that he was
transported to an outside hospital for additional care. The prison
hiring authority initially recommended that the officer receive training;
however, we recommended that the hiring authority refer the matter for
investigation. Our inspector identified the officer’s actions led to this
significant assault. If the officer had followed policy and ensured the
housing unit was secure, the prison would likely have avoided this use-
of-force incident. The hiring authority ultimately agreed with the OIG
and referred the control booth officer who failed to secure the housing
unit door for investigation.
Beginning in 2025, the OIG will no longer issue an annual use-of-
force report. Our office will adjust how we monitor and report on
the department’s handling of use-of-force incidents. This adjustment
is designed to effectively align with recent changes concerning how
departmental staff review use-of-force incidents. While we intend to
continue periodically reporting significant incidents in our published
case blocks, this year, our office will incorporate use-of-force incident
monitoring activities into our staff misconduct reports, which are
scheduled to be published semiannually.
Office of the Inspector General, State of California
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12 2024 Annual Report
Medical Inspection Reports: Cycle 7
In 2024, the OIG continued its seventh cycle of medical inspections and
Case Review published a total of 10 institutional medical inspection reports. In 2023,
Overall Rating
the OIG published one report for California State Prison, Los Angeles
Profi cient
County, and at the beginning of 2024, the OIG published the second
Cycle 7 report for Valley State Prison. However, following the publication
of this report, the OIG retroactively amended the format of our reporting
to bifurcate the overall institution ratings into individual ratings for the
case review and compliance components of each report for greater clarity
Case Review
Overall Rating regarding our findings. Consequently, the OIG amended and republished
Adequate the two reports for California State Prison, Los Angeles County, and
Valley State Prison.
In addition, using this new format, the OIG published eight more
reports for the following institutions: Wasco State Prison; California
Case Review State Prison, Solano; California Rehabilitation Center; California
Overall Rating
State Prison, Corcoran; California Medical Facility; North Kern State
Inadequate
Prison; Richard J. Donovan Correctional Facility; and Substance Abuse
Treatment Facility and State Prison, Corcoran. Table 2 on the next page
lists the institutions for which we completed our Cycle 7 inspections and
issued our final reports in 2024, the month each report was published,
and our overall individual component ratings for each institution.
Through these 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
Compliance
Overall Rating at www.oig.ca.gov.
Profi cient
In 2024, the OIG also completed all inspections of the following
14 additional institutions: Salinas Valley State Prison; California
Correctional Institution; Avenal State Prison; Kern Valley State Prison;
Central California Women’s Facility; Correctional Training Facility;
Compliance Centinela State Prison; Folsom State Prison; High Desert State Prison;
Overall Rating California Institution for Women; California Men’s Colony; Pelican
Adequate
Bay State Prison; Calipatria State Prison; and California State Prison,
Sacramento. In 2025, we anticipate publishing these Cycle 7 inspection
reports, completing our Cycle 7 inspections for all seven remaining
institutions, and beginning our Cycle 8 inspection process.
Compliance
Table 1 on the following page lists the institutions for which we
Overall Rating
completed our Cycle 7 inspections and issued final reports in 2024, the
Inadequate
month each report was published, and our case review and compliance
ratings for each institution.
Styling for the bifurcated rating
seals used in MIU reports as
introduced for Cycle 7.
Office of the Inspector General, State of California
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2024 Annual Report 13
Adequate Inadequate
Table 2. The OIG’s Medical Inspections for Cycle 7:
Final Reports Published in 2024
Publication Overall Rating
Institution Inspected Month Case Review Compliance
California State Prison, Los Angeles County June
Valley State Prison June
Wasco State Prison June
California State Prison, Solano June
California State Prison, Corcoran August
California Medical Facility August
California Rehabilitation Center September
North Kern State Prison November
Richard J. Donovan Correctional Facility December
Substance Abuse Treatment Facility
December
and State Prison, Corcoran
Source: The Office of the Inspector General medical inspection results.
Office of the Inspector General, State of California
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14 2024 Annual Report
Staff Misconduct Monitoring
Pursuant to California Penal Code section 6126 (i), the Inspector General
“shall provide contemporaneous oversight of grievances that fall
within the department’s process for reviewing and investigating inmate
allegations of staff misconduct and other specialty grievances, examining
compliance with regulations, department policy, and best practices.”1 In
this report, we use the terms grievances and complaints synonymously.
The law requires that we issue reports annually. This section covers
the OIG’s monitoring and assessment of the department’s handling of
its staff misconduct complaint process from January 1, 2023, through
December 31, 2023.
Oversight Areas Reported During the 2023 Reporting Period
From January 1, 2023, through December 31, 2023, the department
reported receiving 183,051 complaints from incarcerated people, parolees,
and third-party individuals or entities.2 The department reported that it
made the following screening decisions for the complaints it received
in 2023:3
• 158,162 complaints routed and returned to prisons as
routine issues4
• 12,520 complaints of staff misconduct routed to prisons for a
local inquiry
• 11,149 complaints of staff misconduct routed to the Office
of Internal Affairs’ Allegation Investigation Unit for
an investigation
We assessed the overall screening decisions of the department’s
Centralized Screening Team; the inquiry work of locally designated
investigators; and the investigations conducted by the Office of
Internal Affairs and the employee disciplinary process handled by
hiring authorities and department attorneys. We utilized an assessment
1. Any person can submit a complaint of staff misconduct when they believe departmen-
tal staff have engaged in behavior that resulted in a violation of law, policy, regulation, or
procedure, or an ethical or professional standard. Incarcerated people and parolees can file
a CDCR Form 602-1, a CDCR Form 602-HC, Health Care grievance, or a CDCR Form 1824,
Reasonable Accommodation Request. Third parties can submit a Citizen’s Complaint
in writing. The California Code of Regulations (CCR), Title 15, sections 3486(a)(1), 3486(b),
and 3417.
2. Due to the department’s phased roll out of the staff misconduct process, 6,237 com-
plaints bypassed the Centralized Screening Team. Effective November 30, 2023, all staff
misconduct complaints are routed through the Centralized Screening Team.
3. The Centralized Screening Team rerouted 1,220 complaints to hiring authorities because
those complaints did not involve an incarcerated person or parolee. Per CCR, Title 15, sec-
tion 3486.1 (b), “allegations of staff misconduct not involving an inmate or parolee” shall not
be referred to the Centralized Screening Team. If a complaint is received by the Centralized
Screening Team that does not contain allegations involving misconduct toward an inmate
or parolee, the Centralized Screening Team shall refer the complaint to the hiring authority
for disposition.
4. Refers to any complaint received by the Centralized Screening Team that is not identi-
fied as an allegation of staff misconduct.
Office of the Inspector General, State of California
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2024 Annual Report 15
tool that consisted of five overarching questions each with a series of
subquestions and provided an overall rating of superior, satisfactory, or
poor to each complaint monitored.
The OIG analyzed each screening decision of the Centralized Screening
Team to assess how the department processed each allegation included
in a complaint. A complaint may contain one or more allegations of
staff misconduct.
Between January 1, 2023, and December 31, 2023, the Centralized
Screening Team received and screened 176,814 complaints. Of those
complaints, the OIG reviewed and monitored 6,953 complaints. We
assessed whether the Centralized Screening Team appropriately
identified and referred allegations of staff misconduct to the appropriate
entity within the department. In 2023, we concluded the following:
• The Centralized Screening Team conducted satisfactory
screening decisions in 6,248 of the 6,953 complaints, or
90 percent.
• The Centralized Screening Team made poor screening decisions
in 701 of the 6,953 complaints, or 10 percent.
• The Centralized Screening Team performed in a superior
manner when making screening decisions in four of the
6,953 complaints.
The OIG randomly selected the department’s local inquiries for
monitoring. Local inquiries are conducted by locally designated
investigators who are based in the prison or parole office where the
complaint originated and who gather evidence and facts in the form of a
confidential allegation inquiry report.
Between January 1, 2023, and December 31, 2023, the department
conducted 7,903 local inquiries. Of those local inquiries, the OIG
monitored 113 inquiry cases. We assessed whether the performance of
locally designated investigators and the wardens who made decisions
regarding the inquiry cases was sufficient, complete, and unbiased.
Overall, the department performed poorly in conducting staff
misconduct inquiry cases.
• The department performed poorly in 77 of the 113, or 68 percent,
of the inquiry cases.
• The department performed satisfactorily in 36 of the 113, or 32
percent, of the inquiry cases.
• In no inquiry cases did the department perform in a superior
manner when conducting inquiries.
The OIG monitored the department’s most significant staff misconduct
investigations, such as those involving allegations that staff members
were dishonest, used unreasonable force, retaliated against others, or
Office of the Inspector General, State of California
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16 2024 Annual Report
engaged in sexual misconduct. We monitored cases from the start of
investigations until the conclusion of the cases. If an investigation led to
discipline of an employee, then our attorneys continued to monitor the
employee discipline process until its conclusion.
Between January 1, 2023, and December 31, 2023, the department
completed 7,124 investigations. Of those investigations, the OIG
monitored 121 staff misconduct investigations and the employee
disciplinary process for those cases. The OIG evaluated the performance
of Office of Internal Affairs investigators, department attorneys, and the
wardens who made decisions regarding the investigation cases. Overall,
the department performed poorly in conducting staff misconduct
investigations and the disciplinary process.
• The department performed poorly in 77 of the 121, or 64 percent,
of the investigation cases.
• The department performed satisfactorily in 44 of the 121, or
36 percent, of the investigation cases.
• The department did not perform in a superior manner in any
investigation cases.
For each section of the department’s staff misconduct investigation and
review process that we monitored in 2023, we provided the department
with our recommendations, as outlined in the table on the next page.
Office of the Inspector General, State of California
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2024 Annual Report 17
Table 3. The OIG’s Staff Misconduct Monitoring Unit Recommendations
Centralized Screening Team Decisions
• The department should clarify departmental policy in writing to require screeners to ask the complainant
questions during a clarification interview to obtain sufficient information to ultimately make an informed
screening decision about the allegation.
• The OIG recommends that the department focus more quality-control attention on claims initially identified as
routine matters. We also recommend the department establish clear policy requiring medical subject matter
experts review only claims related to medical treatment, and custody subject matter experts review claims
related to custody and correctional issues, such as use of force, even when the person alleged to have committed
misconduct is a medical employee.
• The OIG recommends that the department require locally designated investigators to complete a conflict-of-
interest review and acknowledge that they do not have an actual or potential conflict of interest before an inquiry
begins. The OIG recommends the department adopt its already-existing conflict-of-interest form, used by the
Office of Internal Affairs.
Local Inquiry Cases
• The OIG renews the recommendation made in our 2022 annual report that locally designated investigators audio-
record all interviews.*
• The OIG recommends that the department amend its policy to permit investigators the independence and
authority to identify, obtain, and review all video-recorded evidence that they have determined to be potentially
relevant to their inquiry.
• Hiring authorities should receive training on how to conduct thorough reviews of allegation inquiry reports and
on departmental policy to ensure that they make proper staff misconduct determinations.
• The OIG recommends that the department implement a policy requiring locally designated investigators and
hiring authorities to complete the local inquiry process within 90 days of the date the Centralized Screening Team
receives an allegation.
• The OIG recommends that the department develop, implement, and maintain a policy and process to require
meaningful communication with the OIG during the course of each local inquiry to enable the OIG to perform
its statutorily required monitoring activities. The OIG also recommends that the department hold employees
accountable for failing to communicate with the OIG.
Investigation Cases
• The OIG recommends that the department require all members of an Office of Internal Affairs investigation team,
including managers, to complete conflict-of-interest forms and recuse themselves from working on investigations
in which they have a conflict of interest with—or bias for or against—any of the subjects or witnesses of an
investigation.
• The OIG recommends that the department eliminate the use of summarized investigation reports which allow
investigators to close staff misconduct investigations without conducting any interviews.
• The OIG recommends that the department expand its video-recording retention policy by increasing the
minimum retention time for all recordings to one year to ensure that relevant video-recorded evidence is
available for staff misconduct investigations.
• The OIG recommends that investigators determine the independent recollection of a witness before presenting
him or her with video evidence.
• The OIG recommends that, during recorded interviews, Office of Internal Affairs investigators properly document
which video file and which portion of the video file—including a time stamp—the investigator presents to the
subject or witness during an interview.
• The OIG recommends that the Office of Internal Affairs conduct interviews in confidential settings. The OIG
recommends that the Office of Internal Affairs investigators order subjects and witnesses to maintain the
confidentiality of investigations while investigations are pending.
• The OIG recommends that the department issue a specific policy concerning the time frame in which a hiring
authority, such as warden, must conduct an investigative and disciplinary findings conference after receipt of an
Office of Internal Affairs investigation report.
• The OIG recommends that the department require its investigators, department attorneys, and wardens, or staff
designated by a warden, to enter and maintain accurate information in its staff misconduct database. Moreover,
the OIG recommends that the department establish a clear policy as to which departmental personnel are
responsible for updating and maintaining specific information in the database to ensure that the records are
timely and accurate.
* Monitoring the Staff Misconduct Investigation and Review Process of the California Department of Corrections and
Rehabilitation: 2022 Annual Report.
Source: The Office of the Inspector General.
Office of the Inspector General, State of California
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18 2024 Annual Report
Audit Reports and Special Reviews
California Penal Code section 6126, subdivisions (b) and (c), authorize
the OIG to initiate audits of departmental policies, practices, and
procedures. In 2024, the OIG’s Audits Unit issued two audit reports
regarding the department’s operational practices concerning release date
calculations and how the department prevents, detects, and responds to
escapes. In addition, the unit conducted a special review regarding the
department’s redirection of backlogged allegations of staff misconduct to
be processed as routine grievances, consequently violating regulations.
Audit of the California Department of Corrections and
Rehabilitation’s Release Date Calculations
On August 15, 2024, the OIG issued an audit report evaluating the
department’s process for ensuring the accuracy of sentencing-term
release dates and determining whether the department correctly applied
time credits—those earned, forfeited, and restored—in its calculation
of release dates, in accordance with applicable laws, regulations,
and guidelines.
During our audit, we examined the accuracy and consistency of prison
release date calculations for incarcerated people with determinate
sentences and evaluated the department’s processes and procedures
related to those calculations.
The results of our audit showed that since 2004, the department has
released approximately 2,300 incarcerated individuals either early or
late, which has led to litigation against the department. According to our
review of incarcerated people released between July 1, 2022, and June 30,
2023, four cases contained calculation errors that could have led to early
or late releases had the errors been overlooked. Furthermore, we found
the department mistakenly released an incarcerated person without
requiring a court-ordered parole period.
While calculation errors leading to early or late releases are a recurring
problem, the causes of the errors vary. Extremely complex and frequently
changing sentencing laws are a significant factor in inaccurate release
date calculations. Other factors include a multitude of different credit-
earning rates and the corresponding misapplication of credits in
calculations, errors in court documents, inadequate training materials,
high staff vacancy rates in case records departments, and a lack of
supervisory review of initial release date calculations. Moreover, when
erroneous release date calculations result in early or late releases,
analysts who make such errors do not always receive training to improve
their skills.
Finally, we concluded that the department’s policies and procedures
regarding release date calculations had not been updated since 1993, and
training regarding how to perform release date calculations had not been
standardized or centralized.
Office of the Inspector General, State of California
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2024 Annual Report 19
In summary, we recommended that the department analyze current
sentencing laws, and also identify specific areas in which sentencing
laws should be clarified and work with stakeholders to clarify those
areas to reduce calculation errors. In addition, we recommended the
department work with county courts to obtain access to electronically
available legal documents that courts are required to provide. We also
recommended that department require managers and supervisors review
release date calculations completed after incarcerated people transfer to
their first mainline prison, ensure release date calculations are completed
accurately, and review release date calculations after triggering events
at predetermined intervals. We also recommended that the department
evaluate the classification specifications and job duties of staff in case
records areas to determine how those descriptions can be revised to
attract and retain a greater number of highly qualified staff. Finally,
we recommended that the department update staff training for release
date calculations.
Audit of the California Department of Corrections and
Rehabilitation’s Processes and Procedures for Preventing,
Detecting, and Responding to Escapes
On November 21, 2024, the OIG issued a report titled Audit of the
California Department of Corrections and Rehabilitation’s Processes and
Procedures for Preventing, Detecting, and Responding to Escapes. Our office
released two versions reporting the results of our audit: a confidential
version addressed to the Secretary of the department, and a public
version omitting select information contained in the confidential report.
We issued these two versions of the report to protect the safety and
security of the department’s prisons and facilities.
In this audit, we reviewed the department’s classification process used
to screen incarcerated people for being at risk of escape and observed
physical security layouts and protocols for incarcerated-people counts.
We reviewed documentation on select escapes that occurred between
January 1, 2022, and December 31, 2023, from minimum-support
facilities and conservation camps—the only locations with reported
escapes during the audit period. Last, we assessed both the security
recommendations made by managers at affected facilities and the
corrective action taken to address the escapes. The audit did not include
a review of escapes or attempted escapes from community reentry
programs.
Overall, few incarcerated people (less than one percent of the population)
have escaped from departmental prisons or conservation camps. The
number of escapes that occurred in the last five years is less than
one percent of the total prison and camp population. Although the
number of escapes is low, the department must take every precaution to
prevent them to protect the safety and security of prisons, prison staff,
incarcerated people, and the public. The risks and consequences of just
Office of the Inspector General, State of California
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20 2024 Annual Report
one escape can be severe and tragic, resulting in injury and harm to
prison staff or to the public.
We reviewed 12 escapes during our audit period and found the
department’s count procedures were effective in detecting missing
incarcerated people and initiating emergency counts to confirm escapes.
Moreover, departmental staff effectively conducted the required searches
of housing and yard areas after escapes were suspected. However, staff
did not always follow departmental policy and procedures when carrying
out the escape pursuit plan.
In addition, we identified several instances in which prisons or
conservation camps did not follow all required escape pursuit activities.
For example, incident commanders failed to notify designated
departmental units of escapes, assign additional central control staff
to pursue the escapee, retrieve and review escapees’ records, or notify
escapees’ documented victims.
We also found that staff did not prepare after-action reports after all
escapes as required by departmental policy and guidelines. After-action
reports summarize the incident, provide a time line of key events that
occurred both before and after the escape, identify deficiencies that
contributed to the escape, and recommend corrective action to address
the deficiencies.
Even when after-action reports were completed, the department did not
always require deficiencies identified during escapes to be corrected.
Managers recommended specific actions to correct deficiencies
related to six of the 12 escapes we reviewed. However, we found the
recommendations for corrective actions were not fully implemented in
three of the six cases. Examples of deficiencies the department did not
address were issuing a press release with incorrect information, failing
to provide staff training, and not communicating with the California
Department of Forestry and Fire Protection—which jointly operates the
conservation camps with the department—to correct delayed telematics
reporting on a stolen vehicle. Addressing deficiencies that managers
found to have contributed to the escape is critical to prevent future
incidents.
Finally, we found inconsistencies between the escape data the
department had publicly reported and the data it provided for our audit,
in part because there was no central location or source in which escapes
and attempted escapes were tracked and monitored. Without a consistent
and accurate source of information to report and track escapes, the
department’s publicly reported escape statistics may be inaccurate. In
addition, the department’s ability to effectively respond to and monitor
escapes is reduced. Figure 3 on the next page shows the discrepancy in
the number of escapes the department publicly reported and the number
of escapes documented in the department’s Office of Correctional Safety
escape logs.
Office of the Inspector General, State of California
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2024 Annual Report 21
Figure 3. Discrepancies in the Department’s Reporting of Incarcerated Person Escapes in 2022 and 2023
14
14% discrepancy 13
(2 escapes)
12
31% discrepancy
(4 escapes)
9
2022 2023
Reported OCS Reported OCS
Publicly Escape Logs Publicly Escape Logs
Note: OCS stands for the Office of Correctional Safety.
Source: Departmental COMPSTAT reports and OCS escape logs for the period from January 1, 2022, through December 31, 2023.
We recommended that the department ensure after-action reports be
prepared after all escapes, document the name of the staff member
who prepared each after-action report and the date each report was
prepared, and require that managers document their review of after-
action reports. We also recommended that the department implement
policies and procedures to ensure corrective action is taken to address
issues identified in after-action reports. Finally, we recommended that
the department develop a central tracking system to collect and report all
escapes and attempted escapes.
Special Review: The Department Violated Its Regulations by
Redirecting Backlogged Allegations of Staff Misconduct to Be
Processed as Routine Grievances
On January 29, 2024, we issued a special review to shed light on
one particularly problematic decision the department made when
determining how to address a backlog of staff misconduct complaints it
had amassed under its prior process for handling incarcerated people’s
allegations of staff misconduct. We found the department’s decision
violated both the department’s regulations and its policy for screening
Office of the Inspector General, State of California
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22 2024 Annual Report
and investigating grievances received from incarcerated people who
alleged staff misconduct.
Our office monitors the department’s process for reviewing and
investigating incarcerated people’s allegations of staff misconduct.
We issue annual reports that assess several facets of the department’s
overall statewide staff misconduct process. We became aware of the
department’s decision to address the staff misconduct complaint backlog
during our monitoring of the department’s handling of staff misconduct
allegations. At that time, we received a departmental memorandum
outlining a directive to convert backlogged grievances containing
allegations of staff misconduct into “routine grievances” and redirect
them to be handled by prison grievance offices. After receiving this
memorandum, we reviewed a backlog of staff misconduct allegations the
department had received from February 24, 2022, through February 27,
2023, which the department closed pursuant to this directive. From this
backlog of 595 cases, we performed detailed analyses of 22 grievances for
which the statutes of limitation had expired before the grievances were
redirected and 71 grievances that prison staff closed after the grievances
were redirected.
Our review found the department’s decision to redirect those grievances
to its prisons circumvented control measures that had been implemented
to prevent prison authorities from making potentially biased decisions
when responding to allegations of staff misconduct. The redirection
resulted in a wasteful duplication of efforts and misallocation of
resources because departmental staff had already determined the
grievances contained allegations of misconduct and had referred the
grievances for allegation inquires or investigations. The department
also allowed the statute of limitations for taking disciplinary action to
expire in many grievances, and prison staff who reviewed the grievances
did not always adequately address or investigate complaints that its
Centralized Screening Team had already determined included allegations
of staff misconduct.
Office of the Inspector General, State of California
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2024 Annual Report 23
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 Intake Processing Unit (Intake) receives
complaints from incarcerated people, supervised people,5 their families,
departmental employees, advocacy groups, and other complainants.
Complaints are submitted via letter, toll-free phone call, State-issued
tablet, or our website. We strive to screen all complaints within one
business day of receipt to identify potential safety concerns, serious
medical or mental health concerns, or reports of sexual abuse.
In 2024, we received 6,591 complaints, a 26 percent increase from
2023. A complaint may contain one or more claims submitted for our
review. From the nearly 6,600 complaints we received, we processed
10,428 claims (see Figure 4, below), which was an average of 869 monthly
claims. This is a 27 percent increase from the 8,227 claims we processed
in 2023.
Figure 4. Total Number of Complaints and Claims the OIG Received
in 2023 and 2024
12,000
10,000 10,428 *
8,000
8,227
6,000
6,591 *
5,225
4,000
2,000
0
Complaints Claims
* Subsequent to publication of the 2024 Annual Report, errors were identified in
the chart above. On May 7, 2025, the year 2024 total complaints were revised from
6,582 to 6,591 and total claims from 11,076 to 10,428 due to removal of duplicate
allegations that were identified. The correct amounts are now reflected herein.
Source: The Office of the Inspector General Tracking and Reporting System.
Of the 6,591 complaints received in 2024, 55 percent were received
via our OIG hotline/voicemail line (phone and tablet); 28 percent were
received by mail; and 17 percent were received through email, our
website, and in person. Our office’s hotline received an average of
300 complaints monthly in 2024, for a total of 3,597 complaints (see
Figure 5, next page).
5. Supervised person is a term the department uses to refer to various categories of
individuals paroled from the State’s prison system.
Office of the Inspector General, State of California
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24 2024 Annual Report
Figure 5. Complaints Received by the OIG Hotline in 2024
400
N = 3,597
350
351
300 320 325
311 310
299
290
250 277 284 276 272 282
200
150
100
50
0
Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sept. Oct. Nov. Dec.
Source: The Office of the Inspector General Tracking and Reporting System.
Approximately 75 percent of the complaints we received in 2024 were
submitted by incarcerated people or supervised people, while 25 percent
were submitted by others, such as private citizens, departmental
employees, and advocacy groups. The most common types of claims we
received in 2024 pertained to prison conditions, policies, or operations;
allegations of staff misconduct; the Prison Rape Elimination Act (PREA);
and safety concerns. Complaints frequently included multiple claims
of improper activity occurring within the department. Below, Figure 6
shows the distribution of claim categories we received.
Figure 6. Categories of Complaints the OIG Received in 2024
CDCR Conditions,
Policies,or Operations 3,334
Allegations of Staff
2,902
Misconduct
Prison Rape
851
Elimination Act
Safety 797
Concerns
N = 10,428 *
Miscellaneous 790
Medical, Dental, or
785
Mental Health Care
Appeals/Grievance
700
Process
No OIG Jurisdiction 269
0 500 1,000 1,500 2,000 2,500 3,000 3,500
* Subsequent to publication of the 2024 Annual Report, errors were identified in the chart above. On May 7, 2025, the
year 2024 total claims were revised from 11,076 to 10,428 due to removal of duplicate allegations that were identified. The
correct amounts are now reflected herein.
Source: The Office of the Inspector General Tracking and Reporting System.
Office of the Inspector General, State of California
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2024 Annual Report 25
Our Intake staff create a unique identification number for each
complaint received to document our case activity. In 2024, we reviewed
and closed 6,450 of the 6,591 complaints received, a completion rate of
98 percent. Some incarcerated people submitted numerous complaints
with duplicative claims, which our Intake staff had previously reviewed
and closed. In 2024, we completed our review of 1,163 duplicative
complaints received from 42 complainants. In 2025, our staff will
continue working to resolve the remaining 132 complaints (2 percent)
pending from 2024.
In response to these complaints, our staff often conducted inquiries by
accessing information from various departmental databases, reviewing
the department’s policies and procedures, and requesting relevant
documentation from the department. However, many complaints lacked
the details needed to clearly identify and properly research the claims.
After our review or inquiry into such complaints, we usually advised
complainants about how they could address their concerns with the
department or recommended that they provide us with more details.
Typically, the OIG provides a written response to complainants outlining
this information or technical assistance to resolve the complaint issue.
OIG Intake staff prepare impact case blocks throughout the year, which
are published on a regular basis. The case blocks showcase select
complaints that our Intake staff received; these complaints may have
resulted in a positive change or impact or highlight an area of concern.
The initial work Intake staff undertake can lead to the OIG requesting
the Office of Internal Affairs to open an investigation into an allegation
of staff misconduct or result in the OIG’s Staff Misconduct Monitoring
Unit commencing to monitor inquiries or investigations.
In one example, an anonymous complainant
provided Intake staff with last names and
locations of several incarcerated people who
allegedly possessed weapons and intended
to kill an officer. We immediately notified
the warden of the safety concern, and
within 45 minutes, seven weapons ranging
from 3-¾ inches to 7 inches in length were
confiscated from two cells. Pictured here is a
photograph of five of the makeshift weapons
found in one of the cells. In 2024, our office
published 24 Intake impact case blocks;
they can be accessed at www.oig.ca.gov/
publications/.
Prison Rape Elimination Act
In accordance with U.S. Federal Prison Rape Photo 1. Five makeshift weapons
Elimination Act (PREA) standards, the OIG found in Cell № 1 (photographed by
departmental staff on 7-29-24).
Office of the Inspector General, State of California
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26 2024 Annual Report
forwards allegations of sexual abuse or sexual harassment, commonly
referred to as PREA allegations, to the hiring authority and to the PREA
compliance manager. Allegations may be received from incarcerated
people, supervised people, family members, and other third parties.
Following a notification, typically, the department reviews the
allegations and will interview the involved parties. The expectation
is that the department will evaluate the information and initiate an
investigation if necessary. If alleged victims are dissatisfied with how
the PREA investigation was handled, they can file a complaint with our
office after they have exhausted all administrative remedies.
In 2024, the OIG received 910 complaints designated as involving
a PREA allegation. The OIG sent 538 PREA notifications alleging
sexual abuse or sexual harassment to the appropriate parties for
processing. When multiple PREA allegations were received within
a short period of time, they were sent as a single notification. In
addition, some complaints did not meet PREA reporting criteria, such
as those not involving an incarcerated person and disputing how an
investigation was handled, or those disagreeing with the results of a
completed investigation.
Inmate Advisory Council (IAC) Meetings
As part of our complaint intake duties, we actively work to gain
knowledge of local and departmentwide issues through participating in
periodic meetings with inmate advisory councils (IACs) at institutions
throughout the State.
During 2024, the OIG’s Intake staff met with departmental
IAC representatives at 21 institutions to educate them about the
OIG’s mission as well as to solicit input.6 While most council
representatives were aware of our office, we learned representatives
lacked an understanding of our functions and how our staff elevate and
notify the department of concerns brought to our attention. Accordingly,
during all our meetings, OIG staff provided an overview of the OIG,
addressed confidentiality concerns, and explained how to contact this
office. Council representatives discussed concerns and issues they felt
were not adequately being addressed at the institutional level and shared
some positive feedback. Our staff also provided information about how
we may be able to assist them with specific issues.
In July 2024, Intake published its initial semiannual report, which
summarized our meetings with the IACs. Find it, along with all future
such reports, at www.oig.ca.gov/publications/.
6. Between October 2023 and November 2024, Intake staff visited all institutions that were
not scheduled for closure that year.
Office of the Inspector General, State of California
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2024 Annual Report 27
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 reported
improper governmental activity or refused to obey an illegal order (blew
the whistle)—and that the complainant was thereafter subjected to
an adverse employment action due to having blown 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 2024, the OIG received 20 retaliation complaints. We completed
analyses of 19 complaints and determined that none stated the legally
required elements of a whistleblower retaliation claim. We also
completed analyses of the complaint pending from 2023, which did not
state 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 2024.
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28 2024 Annual Report
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Office of the Inspector General, State of California
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2024 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
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30 2024 Annual Report
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Office of the Inspector General, State of California
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2024 Annual Report 31
Appendix: Publications Released
in 2024
Annual and Semiannual Reports
• 2023 Annual Report: A Summary of Publications (March 12, 2024)
• 13th Blueprint Monitoring Report: The OIG’s Monitoring of the
Delivery of the Reforms Identified by the Department of Corrections
and Rehabilitation in Its Report Titled The Future of California
Corrections: A Blueprint to Save Billions of Dollars, End
Federal Court Oversight, and Improved the Prison System and
Its Update (March 11, 2024)
• Monitoring Internal Investigations and the Employee Disciplinary
Process of the California Department of Corrections and
Rehabilitation: Semiannual Report, July–December 2023
(April 16, 2024)
• The Office of the Inspector General Monitoring in 2023 of the
California Department of Corrections and Rehabilitation’s Staff
Misconduct Complaint Screening, Inquiry, Investigation, and
Employee Disciplinary Processes: 2023 Annual Report and Fact
Sheet (April 25, 2024)
• Intake Processing Unit: Semiannual Report, January–June 2024
(July 22, 2024)
• 2023 Monitoring the Use-of-Force Review Process of the California
Department of Corrections and Rehabilitation (August 22, 2024)
• Monitoring Internal Investigations and the Employee
Disciplinary Process of the California Department of Corrections
and Rehabilitation: Semiannual Report, January–June 2024
(October 30, 2024)
Periodical Reports
Sentinel Cases
• The Department Entered Into a Settlement Agreement Allowing
a Correctional Administrator to Return to Work Despite Strong
Evidence the Administrator Engaged in Serious Misconduct,
Including Sexual Harassment, Racism, and Intimidation Sentinel
Case No. 24–01 (October 17, 2024)
Office of the Inspector General, State of California
Return to Contents
32 2024 Annual Report
Medical Inspection Reports: Cycle 7 Results
• California State Prison, Los Angeles County (June 14, 2024)
• Valley State Prison (June 14, 2024)
• Wasco State Prison (June 21, 2024)
• California State Prison, Solano (June 21, 2024)
• California State Prison, Corcoran (August 7, 2024)
• California Medical Facility (August 19, 2024)
• California Rehabilitation Center (September 9, 2024)
• North Kern State Prison (November 27, 2024)
• Richard J. Donovan Correctional Facility (December 4, 2024)
• Substance Abuse Treatment Facility and State Prison at
Corcoran (December 9, 2024)
Audit Reports and Special Reviews
• Special Review: The Department Violated Its Regulations by
Redirecting Backlogged Allegations of Staff Misconduct to Be
Processed as Routine Grievances (January 29, 2024)
• Audit of the California Department of Corrections and
Rehabilitation’s Release Date Calculations, Audit Report № 23-01
(Report and Fact Sheet) (August 15, 2024)
• Audit of the Department of Corrections and Rehabilitation’s
Processes and Procedures for Preventing, Detecting, and Responding
to Escapes, Audit Report № 23-02 (Report and Fact Sheet)
(November 21, 2024)
Field Team Case Blocks
Centralized Screening Monitoring Team
• December 2023 Case Blocks (February 7, 2024)
• January 2024 Case Blocks (March 26, 2024)
• February 2024 Case Blocks (April 5, 2024)
• March 2024 Case Blocks (May 14, 2024)
• April 2024 Case Blocks (June 3, 2024)
• May 2024 Case Blocks (July 17, 2024)
Office of the Inspector General, State of California
Return to Contents
2024 Annual Report 33
• June 2024 Case Blocks (August 19, 2024)
• July 2024 Case Blocks (September 3, 2024)
• August 2024 Case Blocks (October 7, 2024)
• September 2024 Case Blocks (November 18, 2024)
• October 2024 Case Blocks (December 16, 2024)
Local Inquiry Team
• November 2023 Case Blocks (January 10, 2024)
• October 2023–November 2023 Retrospective Reviews
(January 16, 2024)
• December 2023 Retrospective Reviews (February 5, 2024)
• December 2023 Case Blocks (February 5, 2024)
• January 2024 Case Blocks (February 26, 2024)
• January 2024 Retrospective Reviews (February 26, 2024)
• February 2024 Retrospective Reviews (April 16, 2024)
• February 2024 Case Blocks (April 16, 2024)
• March 2024 Case Blocks (May 6, 2024)
• March 2024 Retrospective Reviews (May 6, 2024)
• April 2024 Case Blocks (June 10, 2024)
• April 2024 Retrospective Reviews (June 10, 2024)
• May 2024 Case Blocks (July 23, 2024)
• June 2024 Case Blocks (August 19, 2024)
• July 2024 Case Blocks (September 3, 2024)
• August 2024 Case Blocks (October 7, 2024)
• September 2024 Case Blocks (November 5, 2024)
Intake Processing Unit
• March 2024 Impact Case Blocks (March 25, 2024)
• May 2024 Impact Case Blocks (July 22, 2024)
• August 2024 Impact Case Blocks (October 21, 2024)
Office of the Inspector General, State of California
Return to Contents
34 2024 Annual Report
Use-of-Force Team
• February 2024 Case Blocks (March 28, 2024)
• February–March 2024 Case Blocks (April 23, 2024)
• March–April 2024 Case Blocks (May 21, 2024)
• April 2024 Case Blocks (June 5, 2024)
• May 2024 Case Blocks (July 23, 2024)
• June 2024 Case Blocks (August 26, 2024)
• July 2024 Case Blocks (September 23, 2024)
• August 2024 Case Blocks (October 16, 2024)
• September–December 2024 Case Blocks (December 30, 2024)
Office of the Inspector General, State of California
Return to Contents
2024
Annual Report
A Summary of Publications
OFFICE of the INSPECTOR GENERAL
Amarik K. Singh
Inspector General
Shaun Spillane
Chief Deputy Inspector General
STATE of CALIFORNIA
March 2025
OIG