Audit of the Department of Corrections and Rehabilitation’s Processes and Procedures for Preventing, Detecting, and Responding to Escapes

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General of the OFFICE OIG INSPECTOR GENERAL Independent Prison Oversight November 2024 Audit of the California Department of Corrections and Rehabilitation’s Processes and Procedures for Preventing, Detecting, and Responding to Escapes AUD № 23–02 Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-288-4233. Connect with us on social media STATE of CALIFORNIA OIG OFFICE of the Amarik K. Singh, Inspector General INSPECTOR GENERAL Neil Robertson, Chief Deputy Inspector General Independent Prison Oversight Regional Offices Sacramento Bakersfield Rancho Cucamonga November 21, 2024 Mr. Jeffrey Macomber Secretary California Department of Corrections and Rehabilitation 1515 S Street Sacramento, California Dear Mr. Macomber: Enclosed is the Office of the Inspector General’s (the OIG) report titled Audit of the Department of Corrections and Rehabilitation’s Processes and Procedures for Preventing, Detecting, and Responding to Escapes. California Penal Code section 6126, subdivisions (b) and (c) authorize the OIG to initiate audits of the California Department of Corrections and Rehabilitation’s (the department) policies, practices, and procedures. We issue this public copy of the report to omit certain information to protect the safety and security of the department’s prisons and facilities. In this audit, we reviewed the department’s classification process to screen incarcerated people for escape risk 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. Lastly, 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. We found the department’s count procedures were effective in detecting missing incarcerated people and initiating emergency counts to confirm escapes. Moreover, departmental staff 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 several instances, prisons or conservation camps did not follow all the required escape pursuit activities. In addition, 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. Gavin Newsom, Governor 10111 Old Placerville Road, Suite 110 Sacramento, California 95827 Telephone: (916) 288-4212 www.oig.ca.gov Mr. Jeffrey Macomber, Secretary November 21, 2024 Incarcerated Person Escapes Page 2 In addition, 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 that the recommendations for corrective actions were not fully implemented in three of the six cases. Addressing deficiencies that managers found to have contributed to the escape is critical to preventing future incidents. Finally, we found inconsistencies between the escape data the department had publicly reported and the data it provided for this audit, in part because there is no central location or source where escapes and attempted escapes are 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. Following publication, we request that the department provide its status on implementing our recommendations at intervals of 60 days, six months, and one year from the date of the audit. Respectfully submitted, Amarik K. Singh Inspector General Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | iii Contents Illustrations iv Introduction 1 Background 1 Methods Used to Deter and Prevent Escapes 2 Responding to Escapes 3 Escape Statistics 4 Results 7 The Department Could Improve Its Policies and Procedures to Ensure That Established Protocols are Followed to Prevent, Promptly Detect, and Respond to Escapes 7 After-Action Reports Were Not Written After All Escapes as Required by Departmental Guidelines and Policy 9 Recommendations 11 The Department Does Not Always Adequately Oversee Facilities’ Responses to Escapes to Identify and Correct Security Weaknesses 12 Recommendation 14 The Department Does Not Have a Central Source of Data for Tracking and Monitoring Escapes 15 Recommendation 16 Appendix 17 Scope and Methodology 17 Assessment of Data Reliability 20 The Department’s Comments to Our Audit Report 21 Office of the Inspector General, State of California Return to Contents iv | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 Illustrations Figures 1. Discrepancies in the Department’s Reporting of Incarcerated Person Escapes in 2022 and 2023 16 Tables Definitions v 1. Five-Year Escape Data: Total Escapes Compared With Total Population 4 2. Five-Year Escape Data by Facility Type 5 3. Summary of The Required Sequence of Escape Pursuit Activities and Noncompliance Rates 8 A–1. Audit Objectives and Methodology 18 Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | v Definitions Term Definition Administrative or irregular placement conditions to house an incarcerated Administrative Determinant person in a facility with a security level which is not consistent with the incarcerated person’s placement score. Custody of the department means the incarcerated person is in the physical custody of the department. Incarcerated people are considered out of the department’s custody when they attend court proceedings, Custody are housed in a county or federal facility, escape and do not return to departmental custody, are in a nondepartmental mental health facility, and are in a medical facility under nondepartmental supervision. When an incarcerated person without lawful authority, removes or attempts to remove himself or herself from official confinement; an Escape incarcerated person is in official confinement from the time the person is booked into any custodial facility or jail until the person is released or placed on parole. Refers to any reliable information or incarcerated person self-admission to an escape, attempted escape, walkaway, or plan to escape. Available Escape History information describing the circumstances of the escape or attempted escape shall be evaluated in determining the incarcerated person’s level of risk to correctional safety and security. Any prison, community-access facility, community correctional facility, Facility camp, or other subfacility of a prison under the department’s jurisdiction. As applied to escape or attempted escape, force refers to incarcerated Force people’s use of physical contact or threat of physical harm against a person while enabling or attempting an escape. Generally, a location staffed by the appropriate departmental personnel Incident Command Post for the purpose of responding to an escape or other incident. The nationally recognized approach to the command, control, and Incident Command System coordination of emergency responses. Includes, but is not limited to camps, minimum-support facilities, restitution centers, community prisoner mother programs, community Minimum-Custody Program correctional reentry centers, community correctional facilities, drug treatment facilities, and the Folsom transitional treatment facility. A facility without a security perimeter, which includes minimum-support Nonsecure Facility facilities, camps, and community correctional centers. A departmental institution or correctional facility with a secure perimeter Secure Facility that is designed to confine incarcerated people on facility property and prevent escapes. Any unbroken physical barrier or combination of physical barriers that Security Perimeter restricts incarcerated person movement to a contained area without being processed through a door, gate, or sallyport. Walkaway To leave a nonsecure setting without permission and fail to return. Source: Title 15, California Code of Regulations, sections 3000 and 3375.2, and departmental policy. Office of the Inspector General, State of California Return to Contents vi | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 1 Introduction California Penal Code section 6126(b) authorizes the Office of the Inspector General (the OIG) to conduct an audit of the California Department of Corrections and Rehabilitation’s (the department’s) policies, practices, and procedures. In this audit we evaluated the department’s policies and processes for preventing, detecting, and immediately responding to escapes. We reviewed escapes that occurred from January 1, 2022, through December 31, 2023, from minimum-support facilities and conservation camps—the only locations with reported escapes during the audit period. Our audit did not include a review of escapes or attempted escapes from community reentry programs. We reviewed the department’s classification process to screen incarcerated people for escape risk. We also observed the physical security layouts and protocols for incarcerated-person counts at two minimum-support facilities and two conservation camps. Moreover, we reviewed documentation regarding selected escapes, as well as the escape pursuit plans that facilities initiated to apprehend escapees. Lastly, we assessed both the security recommendations made by managers at facilities and the corrective action taken to address the escapes. Background One of the department’s primary objectives is to protect the public by maintaining physical custody of incarcerated people. Incarcerated people are generally not considered to be in the department’s physical custody when they attend court proceedings, when they are housed in a county or federal facility, when they are housed in a nondepartmental mental health facility, when they are housed in a medical facility that is not under departmental supervision, or when they escape. Incarcerated people are guilty of escape if, without lawful authority, they remove or attempt to remove themselves from official confinement. Prisons and other departmental facilities such as conservation camps and community correctional centers are designated as either secure or nonsecure. Secure facilities generally have multiple physical barriers and checkpoints, such as sallyports and gates, which confine incarcerated people and restrict their movement within the facilities. Conversely, nonsecure facilities generally do not restrict movement and include fewer physical barriers. For example, although minimum-support facilities are located on prison grounds, they are considered nonsecure facilities because they are outside the prison’s secured perimeter and are generally surrounded by a single, nonelectric fence. Other nonsecure facilities include community Office of the Inspector General, State of California Return to Contents 2 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 correctional centers and conservation camps, commonly known as fire camps. The department jointly operates conservation camps with either the California Department of Forestry and Fire Protection or the Los Angeles County Fire Department. When incarcerated people are taken into departmental custody, they undergo a classification process to establish where they will be housed. The department’s Classifications Services Unit first reviews the incarcerated person’s criminal and escape history to determine a placement score. Staff then use the placement score, in conjunction with escape history and other case factors (administrative determinants), to house the person in either a secure or nonsecure facility. Generally, incarcerated people who have a history of certain sex offenses or certain other violent offenses, or who have been sentenced to life terms or have longer than eight years remaining on their sentence, are ineligible for placement in nonsecure facilities. Moreover, incarcerated people are permanently excluded from placement in nonsecure facilities if they have a history of escapes or attempted escapes from a secure facility, have been convicted of an escape or attempted escape in which they used force, or have verbalized an intent to escape. The department also temporarily restricts incarcerated people from being housed in nonsecure facilities for 10 years if they have a history of walkaways1 without using force. Because they are considered to have a low security risk, incarcerated people housed in minimum-support facilities and conservation camps are eligible for desirable work or program assignments located either on or off prison grounds. For example, people incarcerated at conservation camps are trained to fight wildfires or respond to other emergencies in the communities in which their camps are located. Incarcerated people also enjoy more liberties and freedom of movement in nonsecure settings. According to the department, the fact that incarcerated people have more freedom in settings with minimal or no fencing explains why most escapes occur from nonsecure facilities. However, only individuals determined to be low security risk are housed in nonsecure facilities. Furthermore, the robust rehabilitative benefits available to people incarcerated in nonsecure settings mitigate the risk of escape. Methods Used to Deter and Prevent Escapes Departmental regulations include measures that may deter and prevent escapes including conducting physical counts to track and account for incarcerated people. Every day, custody staff are required to conduct at least four formal physical counts of incarcerated people housed 1. For the purposes of this report, the term escape is used synonymously with walkaway. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 3 within prisons’ secured perimeters, minimum-support facilities, and conservation camps. At least one physical count must be a standing count during which incarcerated people either stand at their cell doors or sit on their bunks until officers complete the count. On an hourly basis, custody and camp staff who supervise incarcerated workers are also required to conduct informal counts—a physical count and identification of incarcerated people at their work assignments. Moreover, officers must conduct emergency counts to determine whether an escape occurred within 30 minutes of discovering that an incarcerated person is missing. For these counts, generally all incarcerated people must return to their cells for identification. The department’s Design and Construction Standards: Design Criteria Guidelines (design guidelines) also help deter and prevent escapes by requiring security fences and walls, based on the security level of the facility. Additional security measures such as coil barbed wire or electrification are also required based on a facility’s security level. In general, fences are not required at conservation camps. Although the design guidelines do not require razor wire or barbed wire, most prisons that currently operate minimum-support facilities include fencing with razor or barbed wire. The remaining three facilities are surrounded by fences that meet departmental guidelines. In contrast, most conservation camps do not have physical fences. Despite the department’s methods of preventing and deterring escapes, incarcerated people can escape from nonsecure facilities relatively easily because they have few or no physical barriers around their perimeters. However, escapes from these facilities are rare because incarcerated people do not want to risk losing the relative freedom and access to rehabilitative programming offered in those settings. According to the department, most escapees are motivated by family emergencies or troubled romantic relationships. Therefore, if departmental staff learn that an incarcerated person is experiencing personal problems, the individual may be moved into a secure facility. The department may also consider allowing incarcerated people in minimum-security settings to visit with family outside their facilities to prevent and deter escapes. Responding to Escapes In addition to procedures for detecting and preventing escapes, each prison and conservation camp is required to have an escape pursuit plan that must be updated annually. As we discuss in greater detail later in this report, escape pursuit plans are initiated by prisons and conservation camps when an incarcerated person is discovered missing. First, staff must initiate emergency count procedures to identify the escapee and confirm that an escape occurred. Staff must also establish an incident command post and notify the department’s Office of Correctional Safety Special Services Unit, which will assume control of the escape pursuit Office of the Inspector General, State of California Return to Contents 4 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 and coordinate with outside law enforcement agencies to apprehend the escapee. After every escape, staff must prepare an after-action report summarizing the incident and detailing a time line of key events that occurred both before and after the escape. After-action reports also identify deficiencies that contributed to the escape and recommend specific actions to correct the deficiencies. Escape Statistics Overall, relatively few incarcerated people have escaped from departmental prisons or conservation camps. As illustrated in Table 1, the number of escapes that occurred in the last five years is less than one percent of the total prison and camp population. Table 1. Five-Year Escape Data: Total Escapes Compared With Total Population Total Prison* and Escapes as a Total Year Camp Percentage of Escapes Population Total Population 2019 12 117,393 0.010% 2020 8 92,116 0.009% 2021 6 96,472 0.006% 2022 12 92,606 0.013% 2023 13 † 92,897 0.013% * Prison population includes incarcerated people housed in minimum-support facilities. † Includes four escapes from conservation camps that were not included on the department’s escape logs. Source: The department’s Monthly Report of Population as of December 31 of each year; the department’s Office of Correctional Safety escape logs. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 5 Table 2 provides a further breakdown of escapes from prisons, minimum- support facilities, and conservation camps. In total, from 2019 through 2023, one incarcerated person escaped from a secure prison facility, while 50 incarcerated people escaped from either a minimum-support facility or a conservation camp. Table 2. Five-Year Escape Data by Facility Type Minimum- Minimum- Prisons as a Support Camps as a Support Camps – Prisons – Percentage Facilities as Percentage Year Facilities – Minimum Secure of Total a Percentage of Total Minimum Custody Escapes of Total Escapes Custody Escapes 2019 0 3 9 0 25% 75% 2020 0 1 7 0 13% 88% 2021 1 0 5 17% 0 71% 2022 0 1 11 0 8% 92% 2023 0 2 11* 0 15% 85% Five-Year 1 7 43 Total * Includes four escapes from conservation camps that were not included on the department’s escape logs. Source: The department’s Office of Correctional Safety escape logs and after-action reports. Finally, incarcerated people who successfully escape from departmental facilities are recaptured in most cases. According to the department, only 12 escapees in the last 25 years remain at large. Although the number of escapes is relatively 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 one escape can be severe and tragic, resulting in injury and harm to prison staff and the public. Office of the Inspector General, State of California Return to Contents 6 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 7 Results The Department Could Improve Its Policies and Procedures to Ensure That Established Protocols are Followed to Prevent, Promptly Detect, and Respond to Escapes We found that departmental staff generally followed required procedures to physically count and maintain custody of people incarcerated in minimum-support facilities and conservation camps. In our review of 12 of 25 escapes that occurred from January 1, 2022, through December 31, 2023, we found that count procedures were effective in detecting missing incarcerated people and initiating emergency counts to confirm escapes. Moreover, departmental staff 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. Staff generally initiated escape pursuit plans immediately after an incarcerated person was discovered to be missing. Although each facility’s plan may be unique, departmental policy requires staff to follow a set of procedures when pursuing escapees. For example, incident commanders—the individuals responsible for directing pursuit activities—must first notify the command post, management at the facility from which the escape occurred, and departmental management of the escape. We found that incident commanders generally made the required notifications to the command post and facility management. Furthermore, facilities coordinated with departmental staff to ensure that escape warrants and bulletins were prepared, local residents were notified of the escape, and the Office of Correctional Safety was notified of the escape to conduct an investigation and apprehend the escapee. However, we also found that in several instances, 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. Table 3 on the next page lists the required sequence of escape pursuit activities and the number of instances in which prisons or conservation camps did not follow departmental policies and procedures. Office of the Inspector General, State of California Return to Contents 8 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 Table 3. Summary of the Required Sequence of Escape Pursuit Activities and Noncompliance Rates Number of Times Policies or Percentage of Required Chronological Sequence of Escape Pursuit Activities Procedures Were Noncompliance Not Followed in 12 Escapes Tested Report incident to command post 0 0 Contact institution head or administrative officer of the day 0 0 Contact the department’s Division of Adult Institutions’ 2 17% administrative officer of the day Contact appropriate associate director 2 17% Assign central case records manager to coordinate with 0 0 warrants unit Assign extra central control staff * 11 92% Retrieve incarcerated person’s record files, visiting card and file, 8 67% and mail card Ensure that staff are assigned to fixed and mobile patrols 1 8% Contact Office of Correctional Safety 0 0 Notify neighboring prisons 3 25% Notify the Division of Adult Parole Operations 10 83% Ensure that State and departmental vehicles are accounted for 4 33% Ensure that escape bulletin is prepared for immediate 1 8% distribution Ensure that local residents are notified 2 17% Ensure that any victim listed in the incarcerated person’s files 11 92% is notified Ensure that off-duty staff are called in, as necessary 2 17% * According to a departmental administrator, conservation camp staff may not have extra staff to assign to respond to escapes even though it is required by departmental policy. Source: The OIG’s review of documentation for 12 selected escapes. Because there was no evidence that prisons and conservation camps followed departmental procedures when responding to the 12 escapes we reviewed, we could not adequately assess whether policies were followed or instead should be revised to better prevent and respond to escapes. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 9 After-Action Reports Are Not Written After All Escapes as Required by Departmental Guidelines and Policy The department’s after-action report guidelines and policy require managers to complete after-action reports after escapes. However, departmental staff provided us with vague and contradictory explanations regarding the circumstances under which after-action reports are required after an escape. During our review, departmental managers stated that after-action reports had not been completed for seven escapes. Even though the department later provided after-action reports in three of the seven cases we had selected for substantive testing, the department’s explanations as to why the reports were missing and when they were required to be submitted are contrary to departmental guidelines and policy. According to the department’s after-action report guidelines, an after- action report must be prepared when an incident command post2 or emergency operations center is initiated, and it must summarize the time line of the escape. It also documents field-level response activities, the actions taken by the incident command post, the execution of the escape pursuit plan, the involved departments or agencies, and the recovery activities taken by field operations teams. Lastly, the report summarizes deficiencies managers found to have contributed to the escapes and includes recommendations to correct the deficiencies. Although the department’s after-action report guidelines require managers to prepare after-action reports, departmental managers initially told us that reports had not been required or written for seven escapes. When we made numerous requests for clarification as to why the reports were not prepared, a departmental manager stated that departmental policy does not require after-action reports for all escapes, and that policy supersedes the guidelines that require after- action reports: . . . an AAR [after-action report] is requested when an Incident Command System (ICS) is activated for emergency operations. For these instances an Incident Command Post (ICP) was activated but not an ICS.3 However, both departmental executives and prison managers confirmed that after-action reports are written in response to all escapes. In an attempt to garner more clarification, we requested an explanation of how an incident command system differs from an incident command post. We also requested clarification of what circumstances necessitate the activation of an incident command system. 2. Generally, an incident command post is a location staffed by the appropriate departmental personnel for the purpose of responding to an escape or other incident. 3. An incident command system is a nationally recognized approach to commanding, controlling, and coordinating emergency responses. Office of the Inspector General, State of California Return to Contents 10 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 In a subsequent response, the departmental manager stated the following: The ICS [incident command system] would automatically be activated once the ICP [incident command post] is established. The departmental manager added that the incident command system is “organically activated” once an incident command post is established. This happens after departmental staff activate the escape pursuit plan upon notification of an escape: At this point in time the ICP [incident command post] is established, and the ICS [incident command system] is organically activated. Finally, the chief of the Office of Correctional Safety confirmed that departmental policy requires staff to complete after-action reports after an incident command post is activated. We are, therefore, puzzled as to why after-action reports were not completed after all escapes and why a departmental manager would say they are not required after all escapes. The department’s communication regarding whether after-action reports had been completed for the three cases we tested, whether executive staff had reviewed the after-action reports for those cases, and the date on which one of the after-action reports had been completed was also confusing and inconsistent. We requested that the department provide us with after-action reports for three escapes we had selected for substantive testing. After informing us multiple times that those reports did not exist, the department ultimately provided the reports 49 days after we had initially requested them. However, none of the three reports documented that they had been submitted to departmental executives for review or approval, and the department could not confirm whether management had reviewed them. Furthermore, the department could not provide the date on which one of the three after-action reports had been prepared. Because after-action reports document deficiencies managers find that contribute to an escape and recommend corrective actions to address those deficiencies, they are critical to preventing future escapes. If staff do not comply with existing policy to complete after action reports, the department cannot effectively monitor staff’s compliance with procedures to prevent and respond to escapes, provide guidance, or revise polices to address escape risks and improve operations. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 11 Recommendations • The department should ensure that after-action reports are prepared after all escapes in compliance with departmental guidelines and policy. • The department should require staff to document the staff member who prepared each after-action report and the date each report was prepared. • The department should require designated managers to document that they reviewed and approved the after- action reports. Office of the Inspector General, State of California Return to Contents 12 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 The Department Does Not Always Adequately Oversee Facilities’ Responses to Escapes to Identify and Correct Security Weaknesses We found that the department did not always require that deficiencies identified during escapes be corrected. As discussed earlier, staff are required to complete an after-action report that includes a corrective action plan anytime an incident command post or emergency operations center is initiated. In those reports, managers recommended specific actions to correct deficiencies related to six of the 12 escapes we reviewed. However, we found that the managers’ recommendations were not followed in three of the six cases. For example, in one instance, the incident commander’s contact information was missing from an initial press release issued after an escape. Because the incident commander’s contact information was missing from the press release, the incident commander did not receive timely information regarding a sighting of the escapee, and law enforcement units were not immediately dispatched. According to the department, staff who were responsible for issuing the incomplete press release received training, but the department neither provided proof of training nor training memoranda to support the statement. After another escape, a manager recommended corrective action to address deficiencies identified in staff reports, in communication among staff, and in the monitoring of a conservation camp’s telephone system. We made three separate attempts to obtain documentation regarding this escape but could not verify whether the after-action report had been prepared immediately after the escape. In addition, although the department provided a participation sheet as evidence that staff had attended training after the escape, it did not include any information about the training topic, the individuals who attended, or the date the training was provided. Therefore, we found no evidence that staff at the conservation camp had carried out the corrective action recommended in the after-action report. Finally, a manager from a conservation camp jointly operated with the California Department of Forestry and Fire Protection (CAL FIRE) recommended corrective action after identifying errors in reports, deficiencies in the inventory of vehicles used at the camp, and delayed telematics reporting from a stolen CAL FIRE vehicle used in an escape. In this third incident, a custody officer failed to complete the required incarcerated person counts at a conservation camp, and a CAL FIRE staff member failed to account for the escapee during seven hours of his work shift. Custody staff mistakenly counted another incarcerated person with the same last name as the escapee twice during the required Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 13 evening mealtime count. Consequently, the escapee was gone for at least 10 hours before he was identified as missing. Although the conservation camp did respond to this incident by conducting additional staff training on incarcerated person count procedures, it is concerning that staff had not followed the required count procedures to both promptly detect and respond to the escape. The incarcerated person also stole a CAL FIRE vehicle to facilitate his escape, but staff did not discover that the vehicle was missing during the initial search for the escapee. Moreover, although CAL FIRE had equipped the vehicle with a telematics monitoring system, the global positioning system (GPS) tracking feature had been disabled. Therefore, a departmental investigator had to request CAL FIRE personnel to contact CAL FIRE’s fleet management section to enable GPS location tracking on the vehicle. Had the GPS tracking been enabled, investigators could have obtained the vehicle tracking information sooner to track the incarcerated person’s movement. The conservation camp took corrective action after the escape by requiring that staff attend additional training and by implementing measures to control the inventory of vehicles; however, it did not address the inability to promptly access telematics reporting from the CAL FIRE vehicle. Although we acknowledge that CAL FIRE is responsible for enabling telematics on its vehicles, the department should have proposed a plan to communicate with CAL FIRE to ensure that the issue does not happen again. When we asked why this deficiency was not addressed, the department stated the following: CDCR has zero access or any point of contact for CAL FIRE telematics after hours. This is a CAL FIRE issue and will need to [sic] handled at a higher level to streamline this process between CDCR and CAL FIRE. It cannot be handled at the local level and camps have no control over this issue. Because conservation camps are jointly operated by the department and CAL FIRE, other CAL FIRE vehicles could be commandeered during escapes if this problem is not addressed. Therefore, the department should have immediately communicated with CAL FIRE to facilitate the exchange of vital telematics data after the escape, and it should have consulted with CAL FIRE to ensure that the GPS tracking system is always enabled for all its vehicles used at conservation camps. Nevertheless, based on the department’s response, nothing has been done in the two years since the escape occurred to develop a system for departmental staff to ensure that GPS is enabled on all vehicles so that telematics information is accessible. Because the department failed to address this known weakness, its ability to promptly track escapees continues to be impaired. Office of the Inspector General, State of California Return to Contents 14 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 Recommendation • The department should clarify or, if necessary, develop and implement policies and procedures to ensure that corrective action is taken to address all issues identified in after-action reports written in response to escapes. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 15 The Department Does Not Have a Central Source of Data for Tracking and Monitoring Escapes We found inconsistencies between the escape data the department had publicly reported and the data it provided for this audit, in part because there is no central database where escapes and attempted escapes are tracked and monitored. According to departmental management, all escape data is tracked in its Strategic Offender Management System (SOMS), one of its electronic databases. The department, therefore, pulls data from SOMS to publicly report escape statistics. However, the escape data provided to us during this audit came from the Office of Correctional Safety’s (OCS) escape logs, a manual tracking system that is maintained outside of SOMS. When a prison or conservation camp requests assistance from OCS to respond to an escape, and OCS staff are deployed, a special agent in that office generates a case number and manually logs the incident in its records. If OCS is not contacted or OCS staff are not deployed, the escape is not documented on its escape logs. Despite our requests for all documentation of all escapes from prisons and conservation camps from 2022 and 2023, the department only provided OCS escape logs, and not information from SOMS. In its response to our request, the department stated the following: Please note, the Office of Research consulted with the Office of Correctional Safety (OCS) relative to the data request, and believe that the spreadsheet maintained by OCS provides the most accurate account of all escapes, attempted escapes, and walkaways. Because the department did not provide the information we had requested from SOMS, we were unable to reconcile the two data sources to verify that the escape statistics the department had publicly reported were accurate. However, we reconciled the department’s 2022 and 2023 OCS escape logs to the after-action reports the department had provided and identified four escapes in 2023 that had not been included in OCS escape logs. Figure 1 on the next page shows the discrepancy between the number of escapes the department publicly reported and the department’s Office of Correctional Safety escape logs. Office of the Inspector General, State of California Return to Contents 16 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 Figure 1. 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. Without consistent and accurate sources of information and procedures to report and track escapes, the department’s publicly reported escape statistics may be inaccurate, and the department’s ability to effectively respond to and monitor escapes is reduced. Recommendation • The department should develop a central tracking system to collect and report all escapes and attempted escapes. The tracking protocols should include reporting all incidents—not only those for which OCS is notified or OCS staff are deployed. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 17 Appendix Scope and Methodology California Penal Code section 6126(b) and (c) authorizes the Office of the Inspector General (the OIG) to initiate audits of the California Department of Corrections and Rehabilitation’s (the department’s) policies, practices, and procedures. This audit focuses on the department’s operational processes for preventing, detecting, and responding to incarcerated person escapes. The audit does not include a review of escape incidents from community reentry programs. The table on the following page presents the objectives of our audit and the methods we used to fulfill them. We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions according to our audit objectives. We believe that the evidence we obtained provides a reasonable basis for our findings and conclusions. Office of the Inspector General, State of California Return to Contents 18 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 A–1. Audit Objectives and the Methods Used to Fulfill Them Audit Objectives Method 1. Determine whether the A. We reviewed relevant laws, rules, regulations, policies, and procedures department has adequate related to the department’s incarcerated person escape operations. controls in place to prevent, promptly detect, and respond to B. We interviewed departmental staff to understand requirements for incarcerated person escapes prisons, minimum-support facilities, and fire camps related to: • Screening of incarcerated people for escape risk for housing placement; • Routine daily incarcerated person counts and accounting for incarcerated person movement; • Physical security of both facilities’ boundaries and housing units; • Immediate escape response procedures when an incarcerated person is found to be missing or to have escaped. C. We selected a combination of targeted and random sample of 12 out of 25 (48 percent) escape incidents that occurred from January 1, 2022, through December 31, 2023, for substantive testing. The sample included: • All three escape incidents that occurred at prisons’ minimum- support facilities; • All four escape incidents from conservation camps in which the escapee walked away while on fire duty or other work assignment; • Five randomly selected escape incidents from conservation camps. D. We reviewed and analyzed after-action reports, incident reports, and other supporting documentation for the selected sample to determine whether prison, camp, and departmental staff: • Performed the required daily counts to promptly detect the missing incarcerated person; • Promptly responded when the incarcerated person was found missing; • Took actions according to the escape pursuit plan to find the missing incarcerated person; • Took actions to understand how the incarcerated person escaped; • Made reasonable efforts to identify and correct the security weaknesses that allowed the escape; • Placed the administrative determinant code for escape in the incarcerated person’s case file to prevent placement in a minimum-custody program. (Continued on next page.) Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 19 A–1. Audit Objectives and the Methods Used to Fulfill Them (continued) Audit Objectives Method E. We conducted on-site observations and inquiries at two minimum-support facilities and two conservation camps where escapes occurred from January 1, 2022, through December 31, 2023. • We interviewed staff on count procedures, accounting for movement of incarcerated people and physical security of housing areas. • We observed staff conduct incarcerated person counts. • We physically observed housing units and their surrounding areas to understand the physical security controls in place to prevent escapes. The site visits included Folsom State Prison (minimum-support facility), North Kern State Prison (minimum-support facility), Delta Conservation Camp, and Acton Conservation Camp. F. We requested escape statistics for the period from January 1, 2022, through December 31, 2023, and the source of those statistics, and performed audit procedures to test the reliability of the data. The source of the escape statistics comes from the Office of Correctional Safety’s escape logs. • We reconciled the escape log data to after-action reports provided to us for the audit period. • We reconciled the escape log data to the department’s COMPSTAT reports published on the department’s website. • We verified the accuracy of escape information on the escape logs by comparing it to supporting documentation for the 12 incidents we selected for testing as part of our audit. 2. Determine whether the A. We reviewed and analyzed after-action reports, incident reports, and department identifies and corrects other supporting documentation for the selected sample above to security weaknesses after every identify issues and security weaknesses pertaining to the escape. incarcerated person escape incident and promptly revises its B. We reviewed corrective action plans and supporting documentation to policies and procedures to reduce determine whether departmental staff took reasonable action to: risk of future escapes • Identify the method of escape; • Identify security weaknesses that allowed the incarcerated person to escape; • Implement corrective action. Source: Compiled by OIG auditing staff. Office of the Inspector General, State of California Return to Contents 20 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 Assessment of Data Reliability The U.S. Government Accountability Office, whose standards our office follows in performing and preparing audits, requires us to assess the sufficiency and appropriateness of computer-processed information that we use to support our findings, conclusions, or recommendations. In performing this audit, we determined that information system controls were not significant to the audit objectives. We did not rely on the department’s computer-processed information to substantiate our analysis or conclusions and, therefore, did not perform transactional testing of computer data. However, we did perform audit procedures to test the reliability of data the department provided to us regarding the escape statistics presented in this report. We found inconsistencies between the department’s tracking of escapes in its Office of Correctional Safety (OCS) escape logs and the data it reported publicly. Specifically, the 2022 OCS escape log reported two incidents fewer than the number of incidents the department publicly reported for the same 12-month period. A variance of two escapes represents 17 percent of the total escapes reported in the 2022 escape log. In addition, we identified four escapes for which after-action reports were written, but the escapes were not documented on the 2023 OCS escape log. Office of the Inspector General, State of California Return to Contents OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 | 21 The Department’s Comments to Our Audit Report The department received a draft of this report prior to publication and was given the opportunity to comment. The department did not provide comments to the report but stated it would provide a detailed response in its Corrective Action Plan on the implementation of our audit recommendations. Office of the Inspector General, State of California Return to Contents 22 | OIG Report AUD № 23–02, Incarcerated Person Escapes, November 2024 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Return to Contents Audit of the California Department of Corrections and Rehabilitation’s Processes and Procedures for Preventing, Detecting, and Responding to Escapes Audit Report № 23–02 OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA November 2024 OIG