April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks

Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight As of January 1, 2025, the Department of Adult Institutions discontinued its staff misconduct process relating to allegation inquiries conducted by locally designated investigators. If an allegation does not fall within the scope of the Allegation Decision Index, the department’s Centralized Screening Team will now route the allegation to the institution’s Office of Grievances for a routine review to be conducted by a supervisor or manager. From April 2025 through June 2025, the OIG closed 29 routine review cases its staff monitored retrospectively. The OIG rated the department’s overall performance inadequate in 23 cases, or 79 percent. The OIG rated the department’s overall performance improvement needed in three cases, or 10 percent. The OIG rated the department’s overall performance adequate in three cases, or 10 percent. Cases Monitored Retrospectively by the Office of the Inspector General From April 2025 Through June 2025 Adequate 3 (10%) Improvement Needed 3 (10%) N = 29 Cases 23 Inadequate (79%) Note: Amounts in percentages have been rounded and may not sum to 100%. Source: Office of the Inspector General Tracking and Reporting System. The OIG made the following noteworthy observations: 1. The fact gatherer properly gathered and reviewed all relevant documentary and other evidence in seven of the 29 monitored cases, or 24 percent. 2. The fact gatherer completed all necessary and relevant interviews in eight of the 29 monitored cases, or 28 percent. 3. The fact gatherer adequately documented all relevant facts, evidence, and supporting exhibits in the department’s confidential records system in four of the 29 monitored cases, or 14 percent. 4. The department issued a written decision letter no later than 60 calendar days after receipt of the grievance in 28 of the 29 monitored cases, or 97 percent. The summaries that follow present five notable routine review cases the OIG monitored retrospectively and closed during this period. Page 1 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight OIG Case Number Rating Assessment 25-02-09 Inadequate Case Summary On February 14, 2025, two officers allegedly refused to allow an incarcerated person to change his soiled incontinence supplies prior to being transported to an outside medical appointment, refused to allow the incarcerated person to take additional incontinence supplies, and refused to transport the incarcerated person to his appointment. Case Disposition The reviewing authority conducted a routine review and denied the incarcerated person’s grievance. The OIG did not concur because the routine review was inadequate and the reviewing authority should have requested additional fact gathering. Overall Routine Review Assessment The department’s performance was inadequate because the fact gatherer failed to obtain all relevant evidence. The fact gatherer failed to obtain the work schedule of the two officers to determine an accurate time frame for the alleged misconduct and failed to obtain the appointment and transportation schedule to confirm the incarcerated person’s medical appointment on the date of the alleged misconduct. The fact gatherer failed to interview the two officers and failed to interview any incarcerated person witnesses in cells adjacent to the incarcerated person who submitted the complaint. The fact gatherer failed to include any information regarding the one interview conducted and failed to provide any documentation regarding the evidence collected in the department’s confidential records system. In addition, the fact gatherer provided an incorrect citation to the restricted departmental operations manual in the controlling authority section of the decision. Because the fact gatherer failed to document any evidence collected during the review, the recommendation to deny the incarcerated person’s grievance was inappropriate. As a result, the reviewing authority did not have all the necessary information to make an informed decision regarding the alleged misconduct and should have required additional fact gathering. OIG Case Number Rating Assessment Inadequate 25-02-14 Case Summary Between January 4, 2025, and January 5, 2025, a lieutenant allegedly lied about what privileges an incarcerated person would lose after a rules violation report hearing. On February 27, 2025, the incarcerated person alleged that he never received a final copy of the rules violation report. Page 2 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight Case Disposition The reviewing authority conducted a routine review and denied the incarcerated person’s grievances. The OIG concurred with the reviewing authority’s determination regarding the allegation that the lieutenant lied about the privileges an incarcerated person would lose after a rules violation report hearing. The OIG did not concur with the reviewing authority’s determination regarding the allegation that the incarcerated person never received a final copy of the rules violation report because the routine review was inadequate and the reviewing authority should have requested additional fact gathering. Overall Routine Review Assessment The department’s performance was inadequate. The department failed to document in its confidential records system whether a check for prior sustained allegations of similar misconduct had been completed for the lieutenant. The grievance coordinator improperly assigned a second lieutenant to be the fact gatherer for the routine review, despite the highest-ranking employee accused of alleged staff misconduct was also a lieutenant. The fact gatherer conducted the interview of the lieutenant over the phone because the lieutenant had transferred to another prison, but the fact gatherer failed to document how the confidentiality of the interview was determined. The fact gatherer also failed to interview two officers identified by the incarcerated person as potential witnesses and should have reviewed additional documents such as employee attendance records and the incarcerated person testing schedules on the date of the alleged incident to ascertain any other potential incarcerated witnesses. The fact gatherer failed to address the allegation that the incarcerated person did not receive a final copy of the rules violation report. The fact gatherer failed to identify and interview the chief disciplinary officer who was responsible for providing the incarcerated person with a final copy of the rules violation report. As a result, the fact gatherer would have discovered that the chief disciplinary officer was also assigned as the reviewing authority for the review. The reviewing manager unreasonably delayed 15 days to submit a recommendation to the reviewing authority. The reviewing authority should have required additional fact gathering regarding the incarcerated person’s allegation that he never received a copy of his final rules violation report. OIG Case Number Rating Assessment 25-02-17 Inadequate Case Summary On March 20, 2025, a control booth officer allegedly refused to allow an incarcerated person out of his cell for an incontinence shower. Case Disposition The reviewing authority conducted a routine review and denied the incarcerated person’s grievance. The OIG did not concur because the routine review was inadequate and the reviewing authority should have requested additional fact gathering. Page 3 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight Overall Routine Review Assessment The department’s performance was inadequate. The fact gatherer failed to document whether he requested video surveillance evidence and include a copy of the request as a supporting exhibit, failed to document a summary of available video surveillance relevant to the allegation, failed to appropriately document the interviews conducted, failed to include in the recommended decision the appropriate departmental policy, and provided an incorrect citation of the department’s repealed local inquiry regulations in the controlling authority section of the decision. The fact gatherer failed to reference any of the evidence collected in the reasoning portion of the decision. As a result, the reviewing authority lacked sufficient information to make an informed decision regarding the alleged misconduct. The reviewing manager failed to document whether he performed a review of the recommended decision. Given the inadequate fact gathering and complete lack of evidentiary record by the fact gatherer, the manager and the reviewing authority should have required additional fact gathering. OIG Case Number Rating Assessment 25-02-25 Inadequate Case Summary On February 4, 2025, an officer allegedly refused to allow an incarcerated person out of his cell to attend a medical appointment and to take an incontinence shower. Case Disposition The reviewing authority conducted a routine review and denied the incarcerated person’s grievance. The OIG did not concur because the routine review was inadequate and the reviewing authority should have requested additional fact gathering. Overall Routine Review Assessment The department’s performance was inadequate. The department failed to document in its confidential records system whether a priors check was completed for the officer. The fact gatherer failed to conduct all necessary interviews of potential witnesses and the incarcerated person. The fact gatherer failed to document in the confidential records system whether he asked the officer about departmental policy regarding incontinence showers, how to identify whether an incarcerated person is incontinent, and how to determine if an incarcerated person has a scheduled medical appointment. The fact gatherer also failed to request video surveillance evidence relevant to the allegations. Despite the inadequate fact gathering, the reviewing authority nonetheless denied the incarcerated person’s grievance. The manager and the reviewing authority should have required additional fact gathering. Page 4 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight OIG Case Number Rating Assessment 25-02-27 Inadequate Case Summary On January 25, 2025, an officer allegedly refused to allow an incarcerated person to receive his daily medication. Case Disposition The reviewing authority conducted a routine review and denied the incarcerated person’s grievance. The OIG did not concur because the routine review was inadequate and the reviewing authority should have requested additional fact gathering. Overall Routine Review Assessment The department’s performance was inadequate. The department failed to document in its confidential records system whether a check for prior sustained allegations of similar misconduct had been completed for the officer. The fact gatherer failed to document in the confidential records system whether he requested, obtained, or reviewed any video surveillance evidence. The fact gatherer failed to document any review of the incarcerated person’s medical record and failed to identify the records of departmental policy and procedure applicable to the allegations and include or reference those records in the confidential records system or the written decision letter. The fact gatherer failed to interview the incarcerated person, failed to interview a staff witness who was allegedly ordered by the officer to stop the medication pass before the incarcerated person could receive his medication, and failed to identify and interview any other potential witnesses. Despite these deficiencies, the reviewing authority denied the incarcerated person’s grievance. The manager and the reviewing authority should have required additional fact gathering. Page 5 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight Appendix Assessment Indicator Questions The Assessment Indicator assessed the performance of the fact gatherer in conducting the routine review and the performance of the reviewing authority. In general, adequate means the OIG did not identify any significant deficiencies. An improvement needed rating means the OIG found significant deficiencies, but the deficiencies did not appear to cause a negative outcome for the department or for the routine review. An inadequate rating means the OIG found significant deficiencies that caused a negative outcome for the department or for the routine review. Assessment Indicator – Fact Gatherer 1. Did the OIG identify any bias by the fact gatherer during the routine review? 2. Did the fact gatherer properly gather and review all relevant documentary and other evidence? 3. Did the fact gatherer complete all necessary and relevant interviews? 4. Did the fact gatherer obtain all relevant and necessary information through conducted interviews? 5. Did the fact gatherer thoroughly and appropriately conduct the routine review? 6. Did the fact gatherer properly document all relevant facts, evidence, and supporting exhibits in the department’s confidential records system? 7. Was the fact gathering adequate to enable the reviewing authority to make an appropriate finding regarding each allegation? 8. Based upon the evidence, did the fact gatherer provide an appropriate and supported recommended determination to the reviewing authority? 9. Did the fact gatherer unreasonably delay in completing the routine review? 10. Did a departmental manager review the draft decision and appropriately approve the decision or properly return it to the fact gatherer for additional fact gathering? Page 6 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight Appendix (continued) Assessment Indicator – Reviewing Authority 11. Did the reviewing authority ensure that any individual whose personal interaction with a claimant is part of the claim was excluded from participating in the process regarding that claim, including any interview of a claimant conducted as part of the process? 12. Was the reviewing authority who made the determination on the allegations at least one rank higher than the highest-ranking subject? 13. Did the reviewing authority review the draft decision and supporting evidence and appropriately determine whether the fact gathering was adequate to make a determination on each allegation? 14. Did the reviewing authority make an appropriate finding for each allegation? 15. Did the department issue a written decision no later than 60 calendar days after the grievance was received? 16. Did the Office Of Grievances send the written decision letter to the incarcerated person no later than 10 business days after its issuance? 17. If corrective action was ordered, did the reviewing authority timely take the corrective action? 18. Did the reviewing authority unreasonably delay in completing the routine review? Page 7 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Shaun Spillane Chief Deputy Inspector General April–June 2025 Staff Misconduct Monitoring Team Routine Review Case Blocks Independent Published in October 2025 Prison Oversight Table A–1. Routine Case Review Ratings From April 2025 Through June 2025 OIG Case No. Rating Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18 25-02-01 Inadequate No Yes No Yes No No No No No No Yes Yes No No Yes Yes N/A No 25-02-02 Inadequate No No No No No No No No No No Yes Yes No No Yes Yes N/A No 25-02-03 Inadequate No No No No No No No No Yes No Yes Yes No No No N/A N/A No 25-02-04 Inadequate Yes No No No No No No No No No Yes Yes No No Yes Yes N/A No Improvement 25-02-05 No Yes Yes Yes No No No Yes No No Yes Yes Yes Yes Yes Yes Yes No Needed 25-02-06 Inadequate No No No No No No No No No No Yes Yes No No Yes Yes N/A No 25-02-07 Inadequate No No No No No No No No Yes No Yes Yes No No Yes Yes N/A No Improvement 25-02-08 Needed No Yes Yes Yes No No No No Yes No Yes Yes Yes Yes Yes Yes N/A No 25-02-09 Inadequate No No No No No No No No Yes No Yes Yes No No Yes Yes N/A No 25-02-10 Inadequate No No No No No No No No Yes No Yes Yes No No Yes Yes N/A No Improvement 25-02-11 Needed No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A No 25-02-12 Adequate No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A No 25-02-13 Inadequate No No No No No Yes No No Yes No Yes Yes No No Yes No N/A No 25-02-14 Inadequate Yes No No Yes No No No No Yes No No Yes No No Yes Yes N/A No 25-02-15 Inadequate No No Yes No No No No Yes Yes No Yes Yes No No Yes Yes N/A No 25-02-16 Adequate No Yes No Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No 25-02-17 Inadequate No No No No Yes No No No Yes No Yes Yes No No Yes Yes N/A No 25-02-18 Inadequate No No No No No No No No Yes No Yes Yes No No Yes Yes N/A No 25-02-19 Inadequate No No No N/A No Yes No No Yes No Yes Yes No No Yes Yes N/A No 25-02-20 Inadequate No No No No N/A Yes Yes No Yes No Yes Yes No No Yes Yes N/A No 25-02-21 Inadequate No No No No No No No No Yes No Yes Yes No No Yes N/A N/A No 25-02-22 Inadequate No No Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A No 25-02-23 Inadequate No No Yes No No No No No Yes No Yes Yes No No Yes Yes N/A No 25-02-24 Inadequate No No No No N/A Yes No No Yes No Yes Yes No No Yes Yes N/A No 25-02-25 Inadequate No No No No Yes Yes No No Yes No Yes Yes No No Yes Yes N/A No 25-02-26 Adequate No Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes N/A No 25-02-27 Inadequate No No No No No Yes No No Yes No Yes Yes No No Yes Yes N/A No 25-02-28 Inadequate No No No No N/A Yes No No Yes No Yes Yes No No Yes Yes N/A No 25-02-29 Inadequate No No No No No Yes No No Yes No Yes Yes No No Yes Yes N/A No Source: Data analyzed by OIG staff. Page 8 of 8 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov