February 2024 Local Inquiry Team Retrospective Reviews

Amarik K. Singh OIG OFFICE of the Inspector General INSPECTOR GENERAL Neil Robertson Chief Deputy Inspector General February 2024 Local Inquiry Team Retrospective Reviews Independent Published in April 2024 Prison Oversight During the February 2024 review period, the OIG’s Local Inquiry Team retrospectively reviewed 16 random local inquiry cases that were closed by the department from August 2023 through February 2024 in order to assess the department’s performance on local inquiry cases that our office did not contemporaneously monitor. OIG Case Number Rating Assessment 24-0073176-INQ Satisfactory Case Summary Prior to November 26, 2023, an officer allegedly used unprofessional, abusive, and profane language toward incarcerated people inside a housing unit. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed satisfactorily. OIG Case Number Rating Assessment 24-0073652-INQ Satisfactory Case Summary Between January 2023, and June 2023, correctional staff allegedly failed to provide an incarcerated person with his medical shoes and prescription eyeglasses. Case Disposition The hiring authority conducted an inquiry and determined the allegations to be unfounded. Overall Inquiry Assessment The department performed satisfactorily. Page 1 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight OIG Case Number Rating Assessment 24-0073663-INQ Poor Case Summary On or about September 11, 2023, after an incarcerated person participated as a witness in a grievance interview, three officers allegedly harassed the incarcerated person and retaliated against him by conducting a retaliatory cell search that left his cell in disarray. One of the officers also allegedly attempted to intimidate the incarcerated person and acted in a menacing and threatening manner. Case Disposition The hiring authority conducted an inquiry and determined the facts, which provided the basis for the complaint or allegation, did in fact occur; however, the actions were justified, lawful, and proper. Overall Inquiry Assessment Overall, the department performed poorly. The Centralized Screening Team failed to route an allegation of retaliation due to reporting staff misconduct, which is an allegation of staff misconduct listed in the Allegation Decision Index and designated for investigation by the Office of Internal Affairs’ Allegation Investigation Unit. Neither the investigator, the Office of Internal Affairs’ Allegation Investigation Unit manager, nor the hiring authority identified that there was an allegation of retaliation due to reporting staff misconduct, an allegation that should have been elevated to the Office of Internal Affairs’ Allegation Investigation Unit for an investigation because it is an allegation of staff misconduct is contained on the department’s Allegation Decision Index. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officer’s alleged misconduct. The Office of Internal Affairs’ Allegation Investigation Unit manager inappropriately approved the inquiry report as adequate despite the investigator’s omissions in the report. Finally, the hiring authority incorrectly rendered a determination of exonerated for the allegation but should have found the allegation not sustained. OIG Case Number Rating Assessment 24-0073841-INQ Poor Case Summary Prior to October 26, 2023, two male officers allegedly conducted clothed body searches of a female transgender incarcerated person despite the incarcerated person’s election to be searched according to her gender identity. Officers also allegedly used unspecified threats to stop the incarcerated person from complaining about the searches and solicited other incarcerated persons to threaten, humiliate, and harass her. Page 2 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The Centralized Screening Team failed to properly route allegations of harassing an incarcerated person based on gender, creating an opportunity or motive for an incarcerated person to harm another incarcerated person, and threats to an incarcerated person, which are allegations of staff misconduct listed on the Allegation Decision Index and designated for investigation by the Office of Internal Affairs’ Allegation Investigation Unit. Neither the investigator, the Office of Internal Affairs’ Allegation Investigation Unit manager, nor the hiring authority identified that there were allegations of harassing an incarcerated person based on gender, creating an opportunity or motive for an incarcerated person to harm another incarcerated person, and threats to an incarcerated person, which should have been elevated to the Office of Internal Affairs’ Allegation Investigation Unit for an investigation because they are allegations contained on the department’s Allegation Decision Index. The Centralized Screening Team also failed to identify the incarcerated person’s allegation that officers had not followed departmental policy and procedure concerning clothed body searches. Finally, the investigator failed to include a copy of the incarcerated person’s Transgender Access Card as a supporting exhibit to the inquiry report. OIG Case Number Rating Assessment 24-0074225-INQ Poor Case Summary Prior to June 23, 2023, a counselor allegedly failed to properly consider an incarcerated person’s safety concerns and authorized the incarcerated person for housing on a yard where his safety was at risk. In addition, a lieutenant allegedly harassed the incarcerated person about his mental health status and threatened to cause him serious bodily injury or death if he did not comply with the lieutenant’s orders to do everything he demanded. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officer’s alleged misconduct. In addition, the investigator asked leading Page 3 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight questions during interviews with the lieutenant and the counselor and deviated from training and best practices by interviewing the lieutenant prior to interviewing the incarcerated person who submitted the complaint without providing justification in the inquiry report. In addition, the investigator failed to ask clarifying questions during the interview with the incarcerated person regarding the threats of physical harm and death made by the lieutenant against him which could have required referral to the Office of Internal Affairs’ Allegation Investigation Unit for investigation. The Office of Internal Affairs’ Allegation Investigation Unit manager inappropriately approved the inquiry report as adequate despite the investigator’s omissions in the report. The hiring authority failed to make a finding on the second allegation that the lieutenant harassed the incarcerated person about his mental health status and threatened to cause him serious bodily injury or death if he did not comply with the lieutenant’s orders to do everything he demanded. Moreover, the department’s Allegation Against Staff Tracking System database failed to identify the lieutenant as a subject of the inquiry and incorrectly identified the counselor as the sole subject for all allegations. Finally, the department’s September 28, 2023, closure memorandum response to the incarcerated person who filed the complaint predates the hiring authority’s September 29, 2023, approval of the inquiry report. OIG Case Number Rating Assessment 24-0074236-INQ Poor Case Summary Prior to August 27, 2023, officers or kitchen staff allegedly tampered with an incarcerated person’s meals by inserting metal objects into his food on four consecutive days, causing the incarcerated person to experience stomach pain and vomiting. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The Centralized Screening Team failed to route an allegation of endangering an incarcerated person, which is an allegation of staff misconduct listed in the Allegation Decision Index and designated for investigation by the Office of Internal Affairs’ Allegation Investigation Unit. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officers’ alleged misconduct. The investigator failed to summarize the interview with the complainant and failed to include the Advisement of Rights and the Notice of Interview for the staff witnesses as supporting exhibits to the inquiry report. The investigator further incorrectly identified staff witnesses as offender witnesses and made improper conclusions Page 4 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight regarding the evidence collected during the inquiry, which is a responsibility reserved for the hiring authority. The Office of Internal Affairs’ Allegation Investigation Unit manager improperly deemed the investigator’s inquiry report as adequate despite the investigator’s errors and omissions in the report. OIG Case Number Rating Assessment 24-0074218-INQ Poor Case Summary On April 6, 2022, an officer allegedly conducted a cell search that damaged an incarcerated person’s property and then forced the incarcerated person to undergo an unclothed body search that included a body cavity search. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officer’s alleged misconduct. The investigator also failed to interview the officer’s partner from the date of the incident. The Office of Internal Affairs’ Allegation Investigation Unit manager inappropriately approved the inquiry report as adequate despite the investigator’s omissions in the report. Finally, the department unreasonably delayed the inquiry after it received the complaint on November 3, 2022, but failed to refer the complaint to the Centralized Screening Team until October 17, 2023, 348 days thereafter. OIG Case Number Rating Assessment 24-0073857-INQ Poor Case Summary Prior to November 2022, an officer allegedly acted disrespectfully by yelling loudly at an incarcerated person during medication distribution. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegation. Page 5 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to submit a timely request for all video recordings relevant to the inquiry, thus the department deleted the video-recorded evidence pursuant to its 90-day video retention policy. The investigator also failed to document attempts made to determine the date on which the alleged misconduct occurred. The investigator then failed to reference or include departmental policies and procedures pertaining to the officer’s alleged misconduct as supporting exhibits to the inquiry report. In addition, the investigator failed to include the written notice of staff complaint provided to the officer, the advance written notice of interview provided to the officer, and the advisement of rights provided to the officer as supporting exhibits to the inquiry report. The Office of Internal Affairs’ Allegation Investigation Unit manager failed to recognize the investigator’s omissions and approved the report as adequate. The investigator caused unreasonable delays by failing to timely conduct interviews. The investigator, who the hiring authority assigned to the inquiry on December 14, 2022, did not complete the first interview until May 3, 2023, 140 days thereafter. The investigator completed the final interview on November 17, 2023, 338 days after being assigned. Overall, the Centralized Screening Team received the complaint on December 9, 2022, but the hiring authority did not render a final decision until January 22, 2024, 409 days thereafter and 319 days beyond the department’s goal. OIG Case Number Rating Assessment 24-0074195-INQ Poor Case Summary On April 16, 2023, during a medical encounter, a psychiatrist allegedly raised his voice and told an incarcerated person not to speak when the incarcerated person expressed concerns about the medical treatment he received. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the psychiatrist’s alleged unprofessional conduct. The department unreasonably delayed the inquiry and ultimately failed to timely complete the inquiry. Specifically, the Office of Internal Affairs’ Allegation Investigation Unit manager approved the inquiry report on June 5, 2023, but the California Correctional Health Care Services’ Staff Misconduct Team did not forward the inquiry report to the hiring authority until August 1, 2023, 57 days thereafter. The hiring authority then took an additional Page 6 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight 155 days to render a final decision on January 3, 2024, 258 days from the date the Centralized Screening Team received the complaint on April 20, 2023, and 168 days beyond the department’s goal. OIG Case Number Rating Assessment 24-0074043-INQ Poor Case Summary On May 2, 2023, two officers allegedly refused to transport an incarcerated person to a medical appointment. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegation. Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officers’ alleged misconduct. In addition, the investigator failed to interview a witness the incarcerated person identified in his complaint. The Office of Internal Affairs’ Allegation Investigation Unit manager improperly deemed the investigator’s inquiry report as adequate despite the investigator’s omissions in the report. In addition, the department unreasonably delayed the inquiry and ultimately failed to complete the inquiry timely. Specifically, the department assigned the investigator to the inquiry on May 17, 2023, but did not complete witness interviews until January 17, 2024, 245 days thereafter. On January 28, 2024, the hiring authority rendered a final decision on the allegation, 264 days from the date the Centralized Screening Team received the complaint on May 9, 2023, and 174 days beyond the department’s goal. OIG Case Number Rating Assessment 24-0073637-INQ Poor Case Summary On May 23, 2023, a nurse allegedly denied an incarcerated person’s request to speak with a supervising nurse, threatened the incarcerated person, and instructed medical staff not to provide the incarcerated person with water to drink. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Page 7 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight Overall Inquiry Assessment Overall, the department performed poorly. The investigator did not identify any relevant policies and procedures and did not include the chart notes referenced in the inquiry report. The investigator did not conduct interviews in the order of best practices and interviewed the nurse prior to interviewing witnesses and did not provide an explanation for why there was a deviation from best practices. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the nurse’s alleged misconduct. In addition, the investigator did not include as supporting exhibits to the inquiry report documentary evidence referencing the incarcerated person’s history of abusive language towards staff for purposes of secondary gain. The Office of Internal Affairs’ Allegation Investigation Unit manager inappropriately approved the inquiry report as adequate despite the investigator’s omissions in the report. In addition, the department unreasonably delayed the inquiry and ultimately failed to timely complete the inquiry. Specifically, the investigator completed the draft inquiry report on July 19, 2023, but the California Correctional Health Care Services’ Staff Misconduct Team did not forward the inquiry report to the Office of Internal Affairs’ Allegation Investigation Unit for review until August 16, 2023, 28 days later. Upon receipt of the inquiry report on August 16, 2023, the Office of Internal Affairs’ Allegation Investigation Unit did not complete a review of the inquiry report until October 11, 2023, 56 days later. On November 6, 2023, the hiring authority rendered a final decision on the allegations, 154 days from the date the Centralized Screening Team received the complaint on June 5, 2023, and 64 days beyond the department’s goal. OIG Case Number Rating Assessment 24-0071851-INQ Poor Case Summary On June 18, 2023, an officer allegedly failed to provide an incarcerated person his medical drink and then called the incarcerated person a racial slur. A second officer allegedly laughed and called the incarcerated person the same racial slur. A third officer allegedly laughed and then used profanity towards the incarcerated person. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The Centralized Screening Team initially referred this case to the Office of Internal Affairs’ Allegation Investigation Unit where an investigator completed the investigation related to the first and second officer after the incarcerated person who submitted the complaint clarified during his interview that only the first and second officers were involved. The hiring authority Page 8 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight then unnecessarily reassigned the entire case to a locally designated investigator who then reinterviewed the first and second officers, and interviewed the third officer, although the incarcerated person had already stated the third officer was not involved, thereby wasting time and resources by duplicating the investigations. In addition, the investigator failed to request or obtain video-recorded evidence, which could support or refute the alleged misconduct. The investigator documented in the inquiry report that video-recorded evidence was not requested because the incarcerated person who submitted the complaint declined to be interviewed, but that is not a reasonable basis to fail to request potentially relevant evidence. The investigator also failed to reference and include in the inquiry report the applicable policy and procedure standards related to the officers’ alleged misconduct. The Office of Internal Affairs’ Allegation Investigation Unit manager improperly approved the inquiry report as adequate despite the investigator’s omissions in the report. Finally, the hiring authority failed to date the closure memorandum response to the incarcerated person who submitted the complaint and failed to issue a departmentally standard finding for each allegation. OIG Case Number Rating Assessment 24-0074027-INQ Poor Case Summary On July 6, 2023, officers and kitchen staff allegedly attempted to trick an incarcerated person into eating pork when the officers and staff knew the incarcerated person did not eat pork due to religious reasons. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegation. Overall Inquiry Assessment Overall, the department performed poorly. The Centralized Screening Team failed to route allegations of discrimination and harassment, which are allegations of staff misconduct listed in the Allegation Decision Index and designated for investigation by the Office of Internal Affairs’ Allegation Investigation Unit. Neither the investigator, the Office of Internal Affairs’ Allegation Investigation Unit manager, nor the hiring authority identified that there were allegations of discrimination and harassment that should have been elevated to the Office of Internal Affairs’ Allegation Investigation Unit for an investigation because they are allegations contained on the department’s Allegation Decision Index. The investigator did not interview all relevant witnesses, including officers in the vicinity during the time of the incident. The investigator also failed to identify and include in the inquiry report the departmental policy and procedure standards related to the alleged misconduct and failed to obtain all video recordings relevant to the inquiry because the incarcerated person refused to participate in an interview. The Office of Internal Affairs’ Allegation Investigation Unit Page 9 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight manager improperly deemed the investigator’s inquiry report as adequate despite the investigator’s omissions in the report. In addition, the department unreasonably delayed the inquiry and ultimately failed to timely complete the inquiry. Specifically, the department assigned the investigator to the inquiry on July 18, 2023, but did not conduct a first interview until September 23, 2023, 67 days thereafter. The hiring authority rendered a final decision on January 12, 2024, 184 days from the date the Centralized Screening Team received the complaint on July 12, 2023, and 94 days beyond the department’s goal. OIG Case Number Rating Assessment 24-0073660-INQ Poor Case Summary On August 2, 2023, an officer allegedly overtightened an incarcerated person’s handcuffs resulting in numbness and injury to his hands. Case Disposition The hiring authority determined that the inquiry conclusively proved the misconduct did not occur. Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officer’s alleged misconduct. In addition, the investigator did not include as supporting exhibits to the inquiry report all relevant portions of the original incident report. The Office of Internal Affairs’ Allegation Investigation Unit manager inappropriately approved the inquiry report as adequate despite the investigator’s omissions in the report. The hiring authority incorrectly rendered a determination of unfounded for the allegation when, according to the departmental policy, the evidentiary threshold was not met in this case. The hiring authority should have determined there was insufficient evidence to sustain the allegation. OIG Case Number Rating Assessment 24-0074219-INQ Poor Case Summary On October 10, 2023, two officers allegedly acted unprofessionally when they laughed at an incarcerated person after the first officer directed the incarcerated person, as a joke, to seek technological assistance with a State-issued tablet from the second officer. Page 10 of 11 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 February 2024 Local Inquiry Team Retrospective Reviews Published in April 2024 Independent Prison Oversight Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegations. Overall Inquiry Assessment Overall, the department performed poorly. The investigator failed to identify and include in the inquiry report the departmental policy and procedure standards related to the officers’ alleged misconduct. The investigator conducted an interview of two staff witnesses but failed to explain how the witnesses were identified or their relevance to the inquiry and failed to ask relevant follow-up questions after each staff witness stated that they did not recognize the claimant. The investigator also failed to review all available evidence, such as sign in sheets, failed to identify additional witnesses or subjects to the inquiry, and failed to include the Advisement of Rights or Notice of Interview for the staff witnesses as supporting exhibits to the inquiry report. The Office of Internal Affairs’ Allegation Investigation Unit manager improperly deemed the investigator’s inquiry report as adequate despite the investigator’s omissions in the report. The hiring authority determined the inquiry was adequate and rendered a decision on the allegations despite the investigator’s failure to identify additional staff as subjects to the inquiry. OIG Case Number Rating Assessment 24-0073836-INQ Satisfactory Case Summary On December 14, 2023, a sergeant allegedly failed to effectively communicate during a grievance interview by refusing to allow an incarcerated person to explain his account of the grievance and refusing to accept the incarcerated person’s supporting documentation. In addition, the sergeant allegedly acted aggressive, degrading, and condescending towards the incarcerated person during the interview. Case Disposition The hiring authority conducted an inquiry and found insufficient evidence to sustain the allegation. Overall Inquiry Assessment Overall, the department performed satisfactorily. Page 11 of 11 10111 Old Placerville Road, Suite 110, Sacramento, California 95827 5 Telephone: (916) 288-4233 5 www.oig.ca.gov