OIG
August 2024 Local Inquiry Team Case Blocks
Amarik K. Singh
OIG OFFICE of the Inspector General
INSPECTOR GENERAL Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
During August 2024, the OIG’s Local Inquiry Team closed 26 monitored inquiries.
Of those 26 inquiries, the OIG monitored six inquiries contemporaneously and
monitored 20 inquiries retrospectively. The OIG rated the department’s overall
performance as poor in 16 inquiries, or 62 percent. The OIG rated the department’s
overall performance as satisfactory in 10 inquiries, or 38 percent.
26 Monitored Inquiries Closed by the Office of the Inspector General During August 2024
Retrospectively Reviewed Contemporaneously Monitored Overall
Performance Ratings Performance Ratings Performance Ratings
6 2
10
(30%) (33%)
(38%)
N = 20 N = 6 N = 26
16
14 4 (62%)
(70%) (67%)
Legend: Satisfactory Poor
Source: Office of the Inspector General Tracking and Reporting System.
The OIG made the following noteworthy observations:
• The locally designated investigator thoroughly and appropriately
conducted the inquiry in 11 of the 26 monitored cases, or 42 percent.
• The Office of Internal Affairs adequately reviewed the draft inquiry report
and appropriately determined whether the report was sufficient, complete,
and unbiased in 13 of the 26 monitored cases, or 50 percent.
• The hiring authority made a timely determination on the allegations, within
90 days of the complaint being received by the Centralized Screening
Team, in 15 of the 26 monitored cases, or 58 percent.
• Aside from exceeding statutory, regulatory, or policy timelines, the
department unreasonably delayed completing the inquiry in seven of the
26 monitored cases, or 27 percent.
• Of the 20 inquiries the OIG monitored retrospectively, the OIG rated the
department’s performance as poor in 14 inquiries, or 70 percent.
The summaries that follow present seven notable inquiries the OIG monitored and
closed during August 2024.
Page 1 of 9
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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Retrospective Reviews
OIG Case Number Rating Assessment
24-0086743-INQ Poor
Case Summary
On December 23, 2022, a sergeant allegedly instructed two officers to transport an
incarcerated person and his property to a second prison without inventorying the
property until they arrived at the second prison. When the second prison refused
to accept the property without a property inventory record from the first prison, the
transportation officers allegedly failed to return the incarcerated person’s property in
full to the first prison before prison staff inventoried and stored the property pending
the incarcerated person’s return.
Case Disposition
The hiring authority conducted an inquiry and sustained the allegation against the
sergeant. The hiring authority determined that corrective action was appropriate and
issued training to the sergeant. The OIG concurred.
Overall Inquiry Assessment
Overall, the department performed poorly. The hiring authority assigned the first
investigator to the inquiry on January 25, 2023, but the investigator failed to initiate
any work on the inquiry. The department delayed until May 17, 2024, to assign a
second investigator to the inquiry, 478 days after assigning the first investigator.
The investigator completed the first interview on May 23, 2024, 491 days after the
department received the complaint on January 18, 2023. Due to the unreasonable
delays, the department deleted the video-recorded evidence pursuant to its 90-day
video-retention policy before the inquiry began.
The investigator failed to follow departmental training and best practices regarding
the order for completing interviews by interviewing the sergeant who was the
subject of the inquiry before interviewing the incarcerated person who submitted the
complaint and did not provide justification in the inquiry report for this deviation. The
investigator failed to ask the incarcerated person all relevant questions during the
interview to discern what other personal property went missing during his transport.
The hiring authority reviewed the inquiry report and sustained the allegation against
the sergeant but initially did not impose a penalty. The hiring authority incorrectly
opined that he could not impose a penalty without identifying the officers at the
second prison who refused to accept the incarcerated person’s noninventoried
property. After the OIG inquired to the department regarding the hiring authority’s
rationale against issuing corrective action for a sustained allegation, the hiring
authority reassessed his decision. The hiring authority determined the officers’ identity
was irrelevant given that the sending prison never inventoried the property, and the
hiring authority identified the matter as a training issue. Overall, the department
untimely completed the inquiry on June 12, 2024, 511 days after the Centralized
Page 2 of 9
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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Retrospective Reviews (continued)
Screening Team received the complaint on January 18, 2023, 421 days beyond the
department’s goal, and 146 days beyond the deadline to impose disciplinary action
if warranted.
OIG Case Number Rating Assessment
24-0085115-INQ Poor
Case Summary
On January 7, 2024, an officer allegedly refused to alert medical staff that an
incarcerated person’s bandage was leaking discharge, refused to provide the
incarcerated person with her name and badge number, and refused to activate her
body-worn camera all out of discrimination based on the incarcerated person’s
transgender status.
Case Disposition
The hiring authority conducted an inquiry and found insufficient evidence to sustain
the allegations. The OIG concurred.
Overall Inquiry Assessment
Overall, the department performed poorly. The investigator failed to address and
investigate the allegations that the officer who was the subject of the inquiry refused
to provide her name and badge number to the incarcerated person and discriminated
against the incarcerated person based on the incarcerated person’s transgender
identity. The investigator also failed to interview medical staff who were potential
witnesses to the incident and failed to obtain medical documentation related to the
incarcerated person’s wound care to support or refute whether the officer notified
medical staff about the leaking bandage.
In addition, the investigator failed to provide a detailed summary in the inquiry report
of the video-recorded evidence, such as the relevant time stamps or the verbal
exchange between the incarcerated person and the officer. Instead, the investigator
improperly documented conclusions that the incarcerated person was not receptive
and behaved rudely, which is a determination for the hiring authority to make. The
investigator failed to identify, reference, and include in the inquiry report the records
of departmental policy and procedure applicable to the allegations. Finally, the
investigator unreasonably delayed the inquiry 71 days because the investigator
submitted a draft inquiry report to the Office of Internal Affairs manager three times
for review before the manager deemed the report adequate. The Office of Internal
Affairs manager and the hiring authority ultimately failed to identify the investigator’s
omissions in the inquiry report and instead approved the report as adequate.
Page 3 of 9
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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Retrospective Reviews (continued)
Overall, the department untimely completed the inquiry on June 17, 2024, 159 days
after the Centralized Screening Team received the complaint on January 10, 2024, and
69 days beyond the department’s goal.
OIG Case Number Rating Assessment
24-0088720-INQ Poor
Case Summary
On March 7, 2024, an officer allegedly referred to a male incarcerated person as the
spouse of a second male incarcerated person. The officer also allegedly asked to
view the first incarcerated person’s tattoo in front of other incarcerated people and
officers which caused the incarcerated person to feel uncomfortable. The second male
incarcerated person also made a similar allegation about the officer referring to the
first incarcerated person as a spouse in a separate complaint.
Case Disposition
The hiring authority conducted an inquiry into the first grievance and found insufficient
evidence to sustain the allegations. The OIG did not concur with the hiring authority’s
finding that there was insufficient evidence to sustain the allegation that the officer
referred to the first incarcerated person as the spouse of the second incarcerated
person. Contrary to the hiring authority’s findings after the first inquiry, the hiring
authority sustained the allegation against the officer after the inquiry into the second
incarcerated person’s complaint and provided the officer training.
Overall Inquiry Assessment
Overall, the department performed poorly. The Centralized Screening Team received
separate written complaints from two incarcerated people who alleged an officer
acted discourteously when she referred to one incarcerated person as the spouse of
the other. Despite the identical allegation against the same officer, the department
wasted resources by opening two separate inquiries and assigning each inquiry to
two separate investigators. Consequently, the investigators interviewed the same
individuals during each inquiry and collected conflicting evidence. The investigator
assigned to the first inquiry failed to identify, reference, and include in the inquiry
report the records of departmental policy and procedure applicable to the allegation.
The investigator also failed to request or obtain any potentially relevant video-
recorded evidence for lack of a specific time frame for the incident even though the
incarcerated person who submitted the complaint provided the date and reasonable
time frame for the misconduct. Due to the investigator’s decision to not request video-
recorded evidence, the department deleted the recordings pursuant to its 90-day
video-retention policy. The investigator also made a self-contradictory statement in
the inquiry report that video recordings did not show the alleged incident despite the
investigator’s failure to obtain the video footage. The investigator interviewed the
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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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Retrospective Reviews (continued)
incarcerated person who submitted the complaint, two incarcerated person witnesses,
an officer witness, and the officer who was the subject of the inquiry but failed to
document if he provided a confidentiality admonishment during the interviews. The
Office of Internal Affairs manager initially found the investigator’s draft inquiry report
insufficient and directed the investigator to obtain the video-recorded evidence.
However, the manager unreasonably delayed 20 days to review the inquiry report
resulting in the department’s deletion of the video footage pursuant to its 90-day
video-retention policy prior to returning the report to the investigator. The hiring
authority reviewed both inquiries and sustained the allegation against the officer in
one inquiry but did not sustain the allegation in the corresponding inquiry.
The hiring authority failed to identify the duplicate inquiries and the varying evidence
each inquiry unveiled, such as the officer’s conflicting statements to investigators.
Overall, the department untimely completed the inquiry on July 1, 2024, 112 days
after the Centralized Screening Team received the complaint on March 11, 2024, and
22 days beyond the department’s goal.
OIG Case Number Rating Assessment
24-0087899-INQ Poor
Case Summary
On April 7, 2024, an officer allegedly yelled expletives toward incarcerated people
while holding a less-lethal weapon. Also, the officer and two additional unknown
officers allegedly yelled with regularity at incarcerated people in the housing unit and
created a hostile environment which could be harmful to incarcerated persons with
mental health issues.
Case Disposition
The hiring authority conducted an inquiry and sustained the allegation against the
officer. The hiring authority determined that corrective action was appropriate and
issued training to the officer. The OIG concurred.
Overall Inquiry Assessment
Overall, the department performed poorly. The investigator failed to investigate
the allegation that two additional officers constantly yelled at incarcerated people
and created a hostile environment in a housing unit. Thus, the investigator made no
attempts to identify and interview the two officers as subjects of the inquiry. The
investigator also failed to ask all relevant questions during the interviews such as
to ask witnesses if they could identify the two officers who yelled with regularity
in the housing unit and if those officers’ actions created a hostile environment for
the incarcerated population. The investigator also failed to identify, reference, and
Page 5 of 9
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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Retrospective Reviews (continued)
include in the inquiry report the records of departmental policy and procedure
applicable to the allegations. The Office of Internal Affairs manager failed to identify
the investigator’s omissions in the inquiry report and instead approved the report
as adequate.
OIG Case Number Rating Assessment
24-0086273-INQ Poor
Case Summary
On May 12, 2024, an officer allegedly failed to reclaim handcuffs from an incarcerated
person after the incarcerated person refused to return the handcuffs and instead
left the incarcerated person unsupervised in his cell for up to two hours while the
incarcerated person remained in possession of the handcuffs.
Case Disposition
The hiring authority conducted an inquiry and found insufficient evidence to sustain
the allegations. The OIG did not concur with the hiring authority’s determination that
the inquiry was adequate to make a finding.
Overall Inquiry Assessment
Overall, the department performed poorly. The investigator failed to ask the officer
who was the subject of the inquiry questions about what specific actions he took to
retrieve the handcuffs from the incarcerated person who submitted the complaint.
The investigator failed to ask the sergeant who was a witness questions to explore
the incarcerated person’s reported habit of taking handcuffs from officers and what
steps supervisors and officers took to prevent the incarcerated person’s behavior
from continuing. The investigator should have obtained a statement of this nature
to provide the hiring authority more evidence about the officer’s actions, reasoning,
and compliance with departmental policies and procedures. During the inquiry, the
investigator obtained information related to the allegation that the incarcerated
person remained unsupervised while in possession of handcuffs which implicated
the sergeant as a subject of the inquiry; however, the investigator failed to properly
identify and treat the sergeant as a subject. As a result, the investigator failed to
investigate any potential misconduct attributable to the sergeant. The investigator
also failed to identify, reference, and include in the inquiry report the records of
departmental policy and procedure applicable to the officer’s alleged misconduct.
The Office of Internal Affairs manager and the hiring authority failed to identify
the investigator’s omissions in the inquiry report and instead approved the report
as adequate.
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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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Contemporaneously Monitored
OIG Case Number Rating Assessment
24-0080094-INQ Poor
Case Summary
On April 4, 2024, a nurse and a psychiatric technician allegedly refused to provide
an incarcerated person with his court-ordered medication or mandatory backup
medication. The nurse also allegedly failed to contact the prescribing clinician to
determine if the medicine should be forcefully administered. When the incarcerated
person engaged in self-harm that triggered an alarm, a second nurse allegedly
refused the incarcerated person’s request for court-ordered medication and informed
him that he was not on a court order for medication. In addition, a third nurse allegedly
denied the incarcerated person’s request for court-ordered medication over the
prison intercom.
Case Disposition
The investigator suspended the inquiry and referred it to the Office of Internal Affairs’
Allegation Investigation Unit for investigation after the investigator discovered
evidence of staff misconduct listed in the Allegation Decision Index. The OIG did not
monitor the investigation following the referral.
Overall Inquiry Assessment
Overall, the department performed poorly. The Centralized Screening Team
improperly routed the complaint for local inquiry because the incarcerated person
alleged that medical staff failed to provide him court-ordered medication. This
type of allegation is staff misconduct listed in the Allegation Decision Index and
designated for investigation by the Office of Internal Affairs’ Allegation Investigation
Unit. The hiring authority unreasonably delayed 48 days to assign an investigator
to the inquiry. The investigator failed to document in the inquiry report whether she
conducted interviews in a confidential setting and whether she established effective
communication with the incarcerated person who submitted the complaint prior to
conducting his interview. The investigator failed to have a copy of the complaint for
reference during the incarcerated person’s interview and required use of the OIG’s
copy to provide a synopsis of the allegations. The investigator asked compound
and inappropriate leading questions during the interview with the incarcerated
person. The investigator asked questions out of chronological order which confused
the incarcerated person and herself. In addition, the investigator interviewed the
incarcerated person and failed to provide a confidentiality admonishment during
the interview. The investigator failed to properly summarize in the inquiry report
her interview with the incarcerated person and failed to document her source of
information such as whether she gained the information from her interview with
the incarcerated person or from a review of medical records. The investigator
failed to investigate all allegations such as the allegation that a nurse denied the
incarcerated person’s request for court-ordered medication over the prison intercom.
Page 7 of 9
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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Contemporaneously Monitored (continued)
The investigator unreasonably delayed 38 days to submit the draft inquiry report to
the Office of Internal Affairs manager. Overall, the investigator was not adequately
trained in the general processes and procedures for conducting a local inquiry and the
required elements of an inquiry report. Throughout the inquiry, the OIG made several
recommendations which the investigator adopted, such as drawing the investigator’s
awareness to the Allegation Decision Index and the process to elevate this complaint
to the Office of Internal Affairs’ Allegation Investigation Unit for investigation after
the investigator discovered evidence of staff misconduct listed in the Allegation
Decision Index.
OIG Case Number Rating Assessment
24-0088378-INQ Poor
Case Summary
On March 2, 2024, two officers allegedly rehoused an incarcerated person in a general
population housing unit even though the incarcerated person wore a white jumpsuit
typically designated for incarcerated persons housed in restricted housing units. A
third officer allegedly opened the general population housing unit’s day room door
and cell door for the first incarcerated person wearing the white jump suit which
triggered a second incarcerated person to assault the first incarcerated person. The
third officer also allegedly failed to properly holster his lethal firearm and failed to
carry a radio on his person when responding to the second incarcerated person’s
assault of the first incarcerated person.
Case Disposition
The hiring authority suspended the inquiry and referred it to the Office of Internal
Affairs’ Investigation Unit for investigation after discovering evidence of staff
misconduct that could result in disciplinary action. The OIG did not monitor the
investigation following the referral.
Overall Inquiry Assessment
Overall, the department performed poorly. The investigator failed to ask all relevant
questions during interviews. For example, the investigator failed to ask the lieutenant
who was a witness if the escort officers should have transported the incarcerated
person to a restricted housing unit for safety concerns instead of a general
population housing unit. The investigator also did not ask the lieutenant to explain
the significance of an incarcerated person donning a white jumpsuit. In addition, the
investigator failed to interview the control booth officer who was a subject of the
inquiry based on a reliance of video-recorded evidence. Thus, the investigator missed
an opportunity to ask the control booth officer if he observed the incarcerated person
dressed in a white jumpsuit, about the meaning of wearing a white jumpsuit, and
if he correctly opened the day room door and the cell door giving the incarcerated
Page 8 of 9
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 Neil Robertson
Chief Deputy
Inspector General
August 2024 Local Inquiry Team Case Blocks
Independent
Published in October 2024 Prison Oversight
Contemporaneously Monitored (continued)
person whose safety was at risk access to the general population housing unit.
Similarly, the investigator failed to inquire why the control booth officer disengaged
his body-worn camera while interacting with the incarcerated person after opening
the dayroom door and the cell door that led to the incarcerated person’s assault. The
Office of Internal Affairs manager failed to identify the investigator’s omissions in the
inquiry report and instead approved the report as adequate. The OIG recommended
the hiring authority suspend the inquiry and refer it to the Office of Internal Affairs’
Allegation Investigation Unit for investigation after discovering evidence of staff
misconduct that could result in disciplinary action. The hiring authority agreed with the
OIG’s recommendation.
Page 9 of 9
10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov