Heman G. Stark Youth Correctional Facility

O I G FFICE OF THE NSPECTOR ENERAL S W I G TEVE HITE, NSPECTOR ENERAL M R A ANAGEMENT EVIEW UDIT H G S EMAN . TARK Y C F OUTH ORRECTIONAL ACILITY S X R UPERINTENDENT AVIER UIZ O 2000 CTOBER S C G D G TATE OF ALIFORNIA RAY AVIS, OVERNOR OFFICE OF THE INSPECTOR GENERAL MANAGEMENT REVIEW AUDIT REPORT SUPERINTENDENT XAVIER RUIZ HEMAN G. STARK YOUTH CORRECTIONAL FACILITY CHINO, CALIFORNIA OCTOBER 2000 Gray Davis, Governor • Promoting Integrity STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 1 CONTENTS EXECUTIVE SUMMARY............................................................................................................................. 3 INTRODUCTION.............................................................................................................................................. 6 BACKGROUND.................................................................................................................................. 6 OBJECTIVES, SCOPE, AND METHODOLOGY ................................................................. 7 GOVERNOR'S ACTION ITEMS............................................................................................................... 9 FINDINGS AND RECOMMENDATIONS .............................................................................................. 15 FINDING 1 ............................................................................................................................................. 16 FINDING 2 ............................................................................................................................................. 20 FINDING 3 ............................................................................................................................................. 23 FINDING 4 ............................................................................................................................................. 27 FINDING 5 ............................................................................................................................................. 31 FINDING 6 ............................................................................................................................................. 32 FINDING 7 ............................................................................................................................................. 33 FINDING 8 ............................................................................................................................................. 35 FINDING 9 ............................................................................................................................................. 37 FINDING 10 ........................................................................................................................................... 38 FINDING 11 ........................................................................................................................................... 39 ATTACHMENT A .......................................................................................................................................... 42 VIEWS OF RESPONSIBLE OFFICIAL ............................................................................... 43 STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 2 EXECUTIVE SUMMARY California Penal Code Section 6051 requires the Office of the Inspector General to conduct a management review audit of any California Youth Authority superintendent who: (1) has held his or her position for more than four years; or (2) has been recently appointed, unless the Inspector General determines that the audit is not warranted at that time. A management review audit is a review intended to assess the superintendent’s performance in carrying out the essential functions of the facility. In areas where weaknesses are noted, the Office of the Inspector General’s management review team makes recommendations to correct the problems. Pursuant to Penal Code Section 6051, the Office of the Inspector General has conducted a management review audit of Superintendent Xavier Ruiz of the Heman G. Stark Youth Correctional Facility. This report presents the results of the management review audit. Superintendent Ruiz inherited serious problems when he assumed his position at the Heman G. Stark facility on April 2, 1999. Following the murder of a youth correctional counselor at the institution, staff safety concerns created tension between wards and staff resulting in frequent institution-wide lockdowns and the curtailing of ward programs. Allegations of abuse resulted in an Office of the Inspector General investigation, which commenced about the same time Superintendent Ruiz reported to the institution. The investigation revealed numerous improprieties and procedural problems affecting the safety of both wards and staff. As a result, Governor Gray Davis directed Robert Presley, Secretary of the Youth and Adult Correctional Agency, to implement seven action items intended to correct the problems found by the investigation. The Office of the Inspector General’s management review audit found that Superintendent Ruiz has made progress in improving the operation of the Heman G. Stark Youth Correctional Facility. He has adopted policies intended to provide wards with more education, treatment, and other programming opportunities. Specifically, he has rescinded an institution policy that automatically limited all wards entering the facility to one hour of programming per day. He has limited lockdowns to the living units involved in the disturbance, rather than extending lockdowns to the entire institution, and he has discontinued the practice of automatically suspending a ward’s programming for one week whenever the ward is transferred from one living unit to another. Notwithstanding the progress described above, the management review audit revealed that the Heman G. Stark Youth Correctional Facility has not achieved full compliance with the Governor’s seven action items. The most significant deficiencies are in the use-of-force policy and in the ward grievance process. The Office of the Inspector General found that the use-of- force policies of the California Youth Authority and the Heman G. Stark facility are ambiguous, particularly with respect to the use of chemical agents. The Office of the Inspector General also found numerous weaknesses in the ward grievance system at Heman G. Stark and found that not all ward grievances are being investigated, as required by the Governor. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 3 Some of the other principal findings of the management review audit are described below. ● The investigative process at the Heman G. Stark Youth Correctional Facility has numerous deficiencies. The investigative process does not ensure that allegations of staff misconduct are promptly and properly investigated. In addition, management actions relative to investigations that have been undertaken appear to be questionable. The facility’s investigation log does not properly track investigation casework and investigations are not always completed in a timely manner. There is a lack of criteria clearly differentiating Level I and Level II investigations. Investigations are not always completed properly, and some are closed inappropriately. The Heman G. Stark Youth Correctional Facility also has no written policies and procedures governing its investigative process. • Classes at Heman G. Stark Youth Correctional Facility’s Lyle Egan High School are poorly attended and wards’ achievement levels are low compared to students at other California Youth Authority facilities. Absenteeism at Lyle Egan High School averages 24%, compared to an average absenteeism rate at other California Youth Authority high schools of 14% and of 5% at California public schools. This high absenteeism rate does not include other significant periods when no academic or vocational education is provided because of institution-wide lockdowns and other facility-initiated class closures. Of the 15 grade level subject scores calculated for the Standardized Testing and Reporting program, Lyle Egan High School students scored lower than any other California Youth Authority high school students in six subjects in 1998, nine subjects in 1999, and eight subjects in 2000. Moreover, 85% of Heman G. Stark Youth Correctional Facility wards scored below the 25th percentile nationally in the Standardized Testing and Reporting program. The average percentage of wards receiving special education service time also was well below the 90% threshold set by the California Youth Authority Education Services Branch. • Wards at the Heman G. Stark facility are not receiving required treatment services. A sampling of ward files revealed that only one of every three wards in the sample received an explanation of the California Youth Authority’s time cut policy during his orientation. Only one (2%) of the 51 eligible wards in the sample was assigned to school or work within four days of his arrival at his permanent living unit, as California Youth Authority policy requires. In fact, the average interval between a ward’s arrival at his permanent living unit and his assignment to school or work was 94 days. If the orientation period is included, the average interval from a ward’s arrival at the institution to his assignment to school or work was 140 days. Only 68% of the wards in the sample participated in an initial case conference, and not all staff members required to attend were present at such conferences. Only 56% of the wards in the sample received required weekly formal structured counseling sessions. • Deficiencies and inadequate effort in the ward grievance process have resulted in grievances failing to be promptly and appropriately addressed. Of the 173 ward grievances on Heman G. Stark Youth Correctional Facility’s outstanding grievance list as of June 26, 2000, responses for 59 (34%) were late or overdue. Numerically sequenced ward grievances are not reconciled as required to ensure that all are investigated, and large numbers of ward grievance forms are missing. Responses to ward grievances do not always STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 4 address ward complaints and responses are not written on the grievance forms. A number of grievances involving allegations of staff misconduct or staff assaults on wards have received little or no attention from Heman G. Stark Youth Correctional Facility staff. Additional findings involving other aspects of the facility's operation, including institution security, the ward information network, the disciplinary decision-making system, and management and monitoring of wards in temporary detention are described in the main body of this report. Many of the problems noted in the audit are beyond the control of Superintendent Ruiz. Consequently, the superintendent needs strong support and assistance from the California Youth Authority administration to address the issues raised. In addition, because some of the problems stem from lack of oversight and clear policy direction from the California Youth Authority administration, it is likely that many of the deficiencies also exist in other California Youth Authority facilities. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 5 INTRODUCTION California Penal Code Section 6051 requires the Office of the Inspector General to conduct a management review audit of any California Youth Authority superintendent who: (1) has held his or her position for more than four years; or (2) has been recently appointed, unless the Inspector General determines that the audit is not warranted at that time. A management review audit is a review intended to assess the superintendent’s performance in carrying out the essential functions of the facility. In areas where weaknesses are noted, the Office of the Inspector General’s management review team makes recommendations to correct the problems. Pursuant to the provisions of Penal Code Section 6051, the Office of the Inspector General has conducted a management review audit of Xavier Ruiz, superintendent of the Heman G. Stark Youth Correctional Facility. The superintendent is an exempt employee appointed by the Governor. Superintendent appointments do not require California State Senate confirmation. BACKGROUND Xavier Ruiz began his tenure as superintendent of the Heman G. Stark Youth Correctional Facility on April 2, 1999, his second assignment as a superintendent within the California Department of the Youth Authority. Immediately preceding his assignment to the Heman G. Stark Youth Correctional Facility, he served for two months as superintendent at the Southern Youth Correctional Reception Center and Clinic. A California Youth Authority employee for more than 27 years, Superintendent Ruiz’s last long-term assignment was as assistant superintendent of the Preston Youth Correctional Facility in Ione, California. The Heman G. Stark Youth Correctional Facility is one of eleven youth correctional institutions within the California Youth Authority. Heman G. Stark Youth Correctional Facility assists the California Youth Authority in meeting its mission of protecting the public from criminal activity by providing education, training, and treatment services for youthful offenders committed by the courts. Located on 101 acres outside Chino in southern California, the Heman G. Stark Youth Correctional Facility houses approximately 1,268 of the most dangerous youthful offenders (wards) in the California Youth Authority’s custody. Many of these wards are serving lengthy sentences for crimes such as murder, rape, armed robbery, and assault. Although these crimes were committed while the offenders were juveniles, all wards at Heman G. Stark Youth Correctional Facility are between 18 and 25 years of age. Nearly all have transferred from other California Youth Authority facilities or have been committed to Heman G. Stark Youth Correctional Facility for violating parole. No newly committed wards are assigned to Heman G. Stark Youth Correctional Facility. For fiscal year 2000-01, Heman G. Stark Youth Correctional Facility has a budgeted staff of 768.3 full-time equivalent positions and an operating budget of $53,260,400. Staff positions include administrators, medical and dental professionals, administrative support personnel, youth correctional officers, and youth correctional counselors. In addition there are academic and vocational education instructors, administrators, and support staff, all of whom report to the California Youth Authority Education Services Branch rather than to the superintendent. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 6 Wards at Heman G. Stark Youth Correctional Facility are housed in three areas consisting of 12 team living units, each designated by two alphanumeric letters such as A/B and C/D. Within each team living unit are two companies, each designated by one of the letters, resulting in a total of 24 companies at the institution. Wards eat and sleep in their rooms within the team living units and carry on other aspects of daily living. They also participate in programs, including group and individual counseling based on individual needs. Several team living units house general population wards, while others specialize in orienting newly transferred wards (A/B Team), treating sex offenders and violent offenders (I/J Team), treating drug abusers (S/T and U/V Teams), and supervising wards needing special management (O/R Team). Wards leave the living units to participate in other ward programs at various locations on the institution’s grounds. The programs include attending the facility’s Lyle Egan High School, obtaining vocational training in masonry, carpentry, culinary arts, microcomputer operation/maintenance, and other trades, obtaining medical and dental services, attending religious services, and learning good work habits while earning competitive wages working for private employers in the Free Venture program. OBJECTIVES, SCOPE, AND METHODOLOGY The objectives of the Office of the Inspector General’s management review audit were: (1) To assess how well Superintendent Xavier Ruiz has managed the Heman G. Stark Youth Correctional Facility in the first fifteen months of his superintendence; (2) To evaluate the operation of the Heman G. Stark Youth Correctional Facility in order to identify areas of operation the superintendent needs to improve; and (3) To perform a follow-up review of the corrective steps the institution has taken in response to the Governor’s letter of September 24, 1999, directing that seven action items be implemented to address problems at the facility. The Office of the Inspector General’s management review team performed the following procedures in conducting the management review audit. • Interviewed Superintendent Ruiz, members of his administrative staff, and various employees and wards at the institution to gain insight and perspective on various issues. • Administered a survey questionnaire to Heman G. Stark Youth Correctional Facility staff regarding Superintendent Ruiz’s communication with staff and wards. • Conducted on-site visits and inspections of living units, ward programming areas, including Lyle Egan High School and various vocational education sites, administrative offices, and facilities throughout the institution. • Interviewed administrators at California Youth Authority headquarters, including those in the Education Services Branch responsible for academic and vocational education at the various institutions. • Reviewed various laws, policies and procedures, and other authoritative documents related to key institution systems, functions, and processes. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 7 • Gathered and reviewed institution logs, files, records, and transaction documents in various operational areas. • Performed various analytical techniques, including sampling, to assess compliance with legal and procedural requirements. Except as noted in the findings and recommendations section of this report, the Office of the Inspector General found the institution to be materially in compliance with state laws and to be operating in accordance with California Youth Authority and Heman G. Stark Youth Correctional Facility policies and procedures. The Office of the Inspector General observed other minor conditions of non-compliance, but those conditions were deemed immaterial and thus not reportable. The Office of the Inspector General informed Superintendent Ruiz of those conditions. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 8 GOVERNOR’S ACTION ITEMS In September 1999, the Office of the Inspector General completed an investigation into allegations of staff misconduct and insufficient staff training at the Heman G. Stark Youth Correctional Facility. This investigation raised serious concerns regarding the safety of both wards and staff. As a result of the investigation, on September 24, 1999, Governor Gray Davis sent a letter to Robert Presley, Secretary of the Youth and Adult Correctional Agency, requesting “swift action.” The Governor’s letter directed Secretary Presley to initiate seven items of corrective action. These seven action items are listed below, along with the corrective action implemented by the institution and the Office of the Inspector General’s comments on the adequacy of the corrective action. ACTION ITEM NUMBER 1 Conduct an immediate and comprehensive review of California Youth Authority use-of-force policies, including use of weapons, gas, and chemical dispensing devices, wristlocks, and restraints. Corrections in policy omissions and supplemental training must be completed within 60 days. CORRECTIVE ACTION The California Youth Authority has issued revised policies and procedures governing the use of restraint. Superintendent Ruiz provided the Office of the Inspector General with a copy of the California Youth Authority Institutions and Camps Branch Manual draft revision of the restraint policies and procedures. The draft revision, dated October 29, 1999, was issued in final form on February 16, 2000. The policy addresses restraint standards and equipment, chemical restraints, use of the 37mm gas gun, and staff training requirements. Superintendent Ruiz also provided the management audit team with a copy of the California Youth Authority Restraint Policies and Procedures Training Manual, which addresses department restraint standards, objectives, and goals. The superintendent provided records of training sessions conducted November 8, 1999 through November 19, 1999 for youth correctional officers and youth correctional counselors at the Heman G. Stark Youth Correctional Facility. OFFICE OF THE INSPECTOR GENERAL'S COMMENTS Although the Heman G. Stark Youth Correctional Facility has adopted new policies and provided staff training, some staff members apparently still do not fully understand or comply with the facility’s use-of-force policy. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 9 On January 25, 2000, a ward was repeatedly sprayed with chemical agents (MK-IV, Z- 305, Z-505, and MK-IX) for refusing to undergo a strip search after being placed in a holding room. Section 2090 of the California Youth Authority Institutions and Camps Branch Manual specifies that “chemical agents shall not be used as punishment, or used upon a person who is physically restrained or otherwise under control.” Although not physically restrained, the ward was under control. Further, Section 9031 of the Heman G. Stark Youth Correctional Facility Administrative Policy and Operations Manual states, “Do not force searches when placing wards in holding rooms.” Section 9031 clearly states that wards not cooperating with strip searches under these circumstances are to be deprived of all privileges and checked every 15 minutes until they comply. The application of chemical agents is not authorized. During the ensuing investigation, four of the five staff members involved in the incident said that they were unfamiliar with Section 9031 of the Heman G. Stark Youth Correctional Facility Administrative Policy and Operations Manual. The staff person who authorized the use of chemical agents apparently was aware of this policy and chose to disregard it. No action has been taken against this individual. The Office of the Inspector General’s review revealed a number of deficiencies in the internal investigation of this incident (see Finding 1 of this report). This faulty investigation is indicative of the ambiguity at the Heman G. Stark Youth Correctional Facility and the California Youth Authority over the appropriate use of force. Unless stringent action is taken to address inappropriate use of force, the prospect of ward abuse will continue. Additional improvement is needed to fully comply with the spirit and intent of the Governor’s directive. ACTION ITEM NUMBER 2 Conduct an immediate and comprehensive review of room/cell extraction procedures with consideration for the safety of staff and wards. Any weapons and all equipment used in this process must be approved by the director. Retraining on room/cell extraction procedures must be completed within 60 days. Videotape all room/cell extractions, review tapes of all incidents within 24 hours, and keep videotape in evidence for one year. CORRECTIVE ACTION Heman G. Stark issued a revised policy on room/cell extractions on February 16, 2000. Superintendent Ruiz provided the Office of the Inspector General with a copy of a November 4, 1999 draft of the revised policy and with a copy of Heman G. Stark's revised room/cell extraction policy training materials. The new policy states that only departmentally approved equipment can be used in a room extraction. The superintendent sent a memorandum to the chief of security reminding the chief of the revised room/cell extraction policy. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 10 Superintendent Ruiz also provided records documenting that training on room/cell extractions was conducted on April 18 and April 20, 2000 for tactical team members and selected youth correctional officers. OFFICE OF THE INSPECTOR GENERAL'S COMMENTS Although the California Youth Authority has adopted new room/cell extraction policies and procedures and provided staff training on room/cell extractions, the Office of the Inspector General noted a number of deficiencies in the revised procedures. The facility also did not complete the training within the 60-day time frame required by the Governor's directive. ● The February 16, 2000 revised room extraction policy permits the use of chemical agents to remove a ward from his room because the policy does not categorize such action as a room/cell extraction. Therefore, the detailed procedures outlined in the California Youth Authority Institutions and Camps Branch Manual do not have to be followed. In addition, the policy does not set dosage limits on the use of chemical restraints when removing a ward from his cell. ● The policy states that special consideration shall be given to wards with identified medical conditions but is silent as to what these considerations are. ● The protective clothing cited in the room/cell extraction equipment section of the policy is recommended, rather than mandated. The Office of the Inspector General believes that the protective clothing should be mandatory. The Office of the Inspector General reviewed tapes of the two room extractions conducted at the facility since the Governor’s directive. Both room extractions were conducted professionally and in compliance with the new policy issued on February 16, 2000. ACTION ITEM NUMBER 3 Immediately ban the use of 37mm weapons and gas dispensing devices for cell extractions and suspend the use of 37mm weapons in all California Youth Authority facilities until use-of-force policies are reviewed and approved by the agency. CORRECTIVE ACTION On August 13, 1999, the superintendent sent a memorandum to the O/R Team’s treatment team supervisor and the chief of security immediately banning the use of 37mm gas guns for cell extractions. All 37mm gas guns were removed from the facility’s housing units and placed in the emergency equipment room pending departmental policy changes and approval for their use. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 11 A new departmental policy relating to the use of 37mm gas guns was approved on February 16, 2000. Under this new policy, the use of the 37mm gas gun during room extractions is prohibited. The new policy also prohibits directly discharging 37mm gas guns at distances of less than ten feet from the target object. Under current policy at the Heman G. Stark Youth Correctional Facility, 37mm gas guns are not stored in any of the housing units. OFFICE OF THE INSPECTOR GENERAL'S COMMENTS The Heman G. Stark Youth Correctional Facility has complied with the Governor’s directive. The Office of the Inspector General’s audit team did not observe the use of 37mm gas guns in the two room extraction videos reviewed. ACTION ITEM NUMBER 4 Immediately discontinue the Phase III unrestrained group program. CORRECTIVE ACTION On September 28, 1999, the superintendent sent a memorandum to the O/R Team’s treatment team supervisor documenting the decision made during their discussion of September 23, 1999 to immediately discontinue the Level III unrestrained group sessions. OFFICE OF THE INSPECTOR GENERAL'S COMMENTS The Heman G. Stark Youth Correctional Facility has complied with the Governor’s directive. ACTION ITEM NUMBER 5 Immediately eliminate the use of “open prescriptions” for psychotropic medications and review all policies relating to the administration of medications to ensure that proper medical protocol is followed. CORRECTIVE ACTION The Heman G. Stark medical staff informed the Office of the Inspector General that the institution has eliminated the use of open prescriptions for psychotropic medications. The facility’s chief medical officer has reviewed and approved all Heman G. Stark Youth Correctional Facility policies regarding the administering of medications. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 12 OFFICE OF THE INSPECTOR GENERAL'S COMMENTS Heman G. Stark appears to have officially eliminated the use of open prescriptions, and the use of psychotropic medications appears to be judicious. It is Heman G. Stark Youth Correctional Facility policy for all wards on psychotropic medication to be seen by a physician within seven days of the ward's initial receipt of the medication and again within 30 days thereafter. Physicians may continue the prescriptions. However, the Office of the Inspector General found that only 45 of the approximately 1,268 wards at the facility (3.5%) were found to be on psychotropic or anti-depressive medications. A review of the medical records of 10 of the 45 wards on psychotropic medications revealed no open prescriptions. ACTION ITEM NUMBER 6 Complete a comprehensive audit of the ward grievance process within 45 days, including proper documentation of all actions taken at each stage of the process. Eliminate the use of polygraphs as a basis for determining whether to investigate a ward grievance. All ward grievances must be investigated. CORRECTIVE ACTION The California Youth Authority conducted an audit of the ward grievance process and issued a report on November 8, 1999. OFFICE OF THE INSPECTOR GENERAL'S COMMENTS The Office of the Inspector General found that considerable improvement is needed before the Heman G. Stark Youth Correctional Facility is in compliance with the Governor’s directive. The Office of the Inspector General reviewed the California Youth Authority’s November 9, 1999 report entitled, “Review of the Institutional Ward Grievance Procedure” and its three recommendations: 1) standardizing the ward grievance procedure for all institutions; 2) revising departmental policy; and 3) training all staff and wards on ward grievance procedures. The report did not address documentation of actions taken at each stage of the process, as directed by the Governor’s action item. The report neither documents the grievance process nor includes a review of any actual ward grievances for testing compliance with the process. A comprehensive audit of the ward grievance process should include such reviewing and testing. In addition, the report was silent on the need to investigate ward complaints. As a part of the management review audit, the Office of the Inspector General reviewed Heman G. Stark's ward grievance process and procedures. The review disclosed serious deficiencies in the ward grievance process and led the Office of the STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 13 Inspector General to question the accuracy and reliability of the information concerning ward grievances generated by the ward information network system. The audit also disclosed that the Heman G. Stark Youth Correctional Facility does not promptly investigate allegations of ward abuse and that not all ward grievances are being investigated. These conditions are fully described in Finding 4 of this report. In addition, as discussed in Finding 1 of this report, the quality and completeness of the investigations conducted by the Heman G. Stark Youth Correctional Facility and by the California Youth Authority’s Internal Affairs Unit is suspect. There is evidence to suggest that the management of the California Youth Authority may have failed to act properly on some of the investigative results. ACTION ITEM NUMBER 7 Install additional video surveillance cameras in the O/R Team living unit facilities to monitor “blind spots” and to improve observation in areas where coverage is inadequate. CORRECTIVE ACTION Additional cameras were installed in the O/R Team living unit facilities to monitor “blind spots.” OFFICE OF THE INSPECTOR GENERAL'S COMMENTS The Office of the Inspector General found that the California Youth Authority has installed additional cameras in the O/R Team living unit facilities to monitor blind spots. The California Youth Authority purchased 48 video cameras for approximately $85,000 and installed them in the O/R Team’s living unit facilities. These cameras replaced all of the existing cameras in the unit and were installed to view and monitor incidents. The delay in picture frame is minimal (.5 to –1.5 seconds) and a review of the tapes by the Office of the Inspector General revealed an almost “real-time” motion. The tapes are stored for a minimum of 60 days. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 14 FINDINGS AND RECOMMENDATIONS Superintendent Ruiz began his tenure at Heman G. Stark Youth Correctional Facility facing severe challenges. In August 1996, a youth correctional counselor was murdered inside the facility. The murder traumatized the staff and created an atmosphere of tension and concern for staff safety that was still apparent during the Office of the Inspector General’s audit four years later. Following the homicide, the California Youth Authority and former Heman G. Stark Youth Correctional Facility administrators implemented various measures to enhance staff safety. These measures ranged from restricting all wards to their rooms during meals to intensifying the use of institutional lockdowns. Some successful programs at the institution, such as the national vocational competition sponsored by the Vocational Industrial Clubs of America, were eliminated. Tension between staff and wards escalated significantly. In 1999, as part of an investigation into the conduct of the former superintendent and certain staff members, the Office of the Inspector General reviewed aspects of Heman G. Stark Youth Correctional Facility operations. The review uncovered disturbing practices of ward abuse by staff members at the facility’s O/R Team living unit, which houses wards needing special management. On September 24, 1999, as a result of the Office of the Inspector General’s investigation, Governor Davis sent a letter to Robert Presley, Secretary of the Youth and Adult Correctional Agency, requesting immediate action to correct seven conditions found at the facility. Facing a hostile and volatile environment between staff and wards, Superintendent Ruiz initiated policy decisions providing wards with greater access to programming opportunities by: • Placing wards entering the facility in Phase II rather than in Phase I, giving them immediate access to more than one hour of programming per day. Under the former superintendent, wards entering the facility were automatically placed into Phase I for programming purposes. Phase I wards are confined to their rooms for all but one hour per day and receive virtually no programming. • Isolating lockdowns to specific living units rather than extending them to the entire institution. Under the former superintendent, the programming activities of the entire facility were suspended whenever a lockdown occurred. • Discontinuing the practice of automatically suspending programming for one week for any ward transferring from one living unit to another. The percentage of wards in Phase I has dropped significantly as a result of these policy changes. On April 2, 1999, 376 (27%) of the 1,415 wards at the Heman G. Stark Youth Correctional Facility were in Phase I programming. Of the 1,268 wards at the facility on August 14, 2000, only 166 (13%) were in Phase I programming. The superintendent stated that the number of serious physical assaults on staff has decreased. However, the Office of the Inspector General noted there has been an increase in the overall reported number of assaults on staff members. There were 42 staff assault cases reported in 1999. In the first six months of 2000, there were 48 reported assaults on staff members. Many of the incidents in 2000 involved wards spitting on staff members and wards “gassing” staff with urine, feces, and other matter, rather than physical battery on staff. The superintendent attributed some of the increase in staff assaults in 2000 to STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 15 better reporting of incidents. The auditors did note an unusual three-month period early in 1999 when no assaults were reported. Responses to the audit team’s survey questionnaire indicate that the superintendent is highly accessible to staff and wards, thereby strengthening communications throughout the institution. Superintendent Ruiz has adopted an open-door policy, regularly walks the grounds to visit living units, and meets with ward grievance clerks. He holds regular meetings with his administrative staff and willingly meets with union representatives to hear their concerns. He has revived the wards' advisory committee and the citizens’ advisory committee and meets with them regularly to obtain their views on the institution's programs and activities. Even staff critical of his policies acknowledged the superintendent’s willingness to listen. Superintendent Ruiz has improved the operation of the O/R Team. The O/R Team, which intensively manages wards with behavioral problems, was a focal point of the Office of the Inspector General’s 1999 investigation. Superintendent Ruiz has placed the O/R Team under his direct supervision, transferred one of the facility’s best treatment team supervisors into the O/R Team to enhance communication with wards and manage its daily activities, and provided the supervisor with good professional support staff. The superintendent has begun encouraging vocational education programs and activities, which had been de-emphasized by the previous superintendent. The culinary arts and barber licensing programs have been the subjects of recent positive media attention. Superintendent Ruiz approved the development of a Prometric Testing Center at the institution. The testing center offers certifications for seven of the computer classes offered at the high school. These certifications are widely respected. Wards receiving such certifications increase their opportunities for obtaining higher-paying jobs upon release. Despite these accomplishments, the Office of the Inspector General identified a number of areas in which improvements are needed. These areas are described in the findings and recommendations set out below. FINDING 1 The Heman G. Stark Youth Correctional Facility does not have a system to ensure that allegations of staff misconduct are promptly and properly investigated. Moreover, management actions relative to such investigations appear to be questionable. The policy of the California Youth Authority is to investigate complaints in a timely manner, to review the results of these investigations, and to act upon them in such a way that thoroughness, objectivity, and consistency are maintained throughout the department, while the rights of the individual and the prerogatives of the department are protected. In addition, Governor Davis stipulated in his September 24, 1999 letter to Secretary Presley that “all ward grievances must be investigated.” Inherent in this directive is that all internal affairs investigations must be properly conducted. The Office of the Inspector General’s review found numerous conditions that raise questions about the integrity and effectiveness of the Heman G. Stark Youth Correctional Facility’s investigative process. These conditions are: STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 16 • The investigation log at the Heman G. Stark Youth Correctional Facility does not properly track investigation casework. The ward information network report, which is used to monitor and track investigations, was missing critical management data. Many of the cases listed did not have log numbers; at least two cases had the same log number; and a few cases were assigned a false log number (88888888) merely to fill in the log number field. In some instances the field for the investigator assigned was blank or the allegation was missing. Many cases had blank fields for the date assigned, due date, report date, and the date referred to internal affairs. Two pages containing details for 46 cases listed 24 of those cases as having a December 29, 2002 due date. Without an accurate and reliable investigation log, it is not possible for the institution management to effectively oversee the investigative process. • Investigations are not always completed in a timely manner. As of July 2000, the internal affairs log showed seven cases still pending from 1999, two of which were the responsibility of the superintendent. Three of these cases were the responsibility of the California Youth Authority Internal Affairs Unit and two were related to education and are the responsibility of the Education Services Branch. The Education Services Branch reports directly to California Youth Authority headquarters and is not under Superintendent Ruiz’s direct control. Nevertheless, these are cases within the Heman G. Stark Youth Correctional Facility and need to be addressed promptly. Of the three pending cases that are within the jurisdiction of the Internal Affairs Unit, the oldest case is an investigation initiated in May 1999 concerning an allegation of sexual assault. Failing to promptly complete investigations increases the risk of compromising the integrity of the investigative process because relevant evidence may no longer be available. Untimely investigations also limit the California Youth Authority’s ability to take appropriate action against individuals because of the Peace Officers’ Bill of Rights Act and other statute of limitation protections. • Investigators have no clear criteria for categorizing the investigation as a Level I or Level II. The California Youth Authority Internal Affairs Investigations Policy and Procedures Manual defines a Level II investigation as an investigation that includes allegations of physical abuse of wards involving “serious” injury. However, the manual does not define “serious” injury. There is wide latitude to interpret what constitutes serious injury, which leads to inconsistencies in categorizing investigations and to investigative efforts not commensurate with the severity of the alleged misconduct. For example, a case of alleged ward abuse involving excessive force with chemical agents following the ward’s refusal to undergo a strip search was categorized as a Level I investigation. Another case involving an allegation by a ward that he was slammed against a door several times and punched and kicked in his stomach, chest, and back was also investigated as a Level I case. At the Department of Corrections, which houses adult inmates, these cases would have been classified as Category II investigations (the equivalent of California Youth Authority’s Level II) because the department’s policy does not require an inmate to be seriously injured before a Category II investigation is opened. In another case involving allegations that a staff member was dishonest, provided false information, left an assigned post without authorization, provided a ward access to STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 17 confidential files of other wards, and behaved immorally, the investigation record was inconsistent as to whether it was a Level I or Level II investigation. Ultimately, it apparently was considered a Level I investigation because it was never forwarded to the Office of the Inspector General. By statute, the Office of the Inspector General is responsible for reviewing all Level II investigations to ensure that they were properly conducted and that factual evidence supports the investigation’s findings and conclusions. • Investigations were not properly completed. By statute, the Office of the Inspector General reviews all Level II investigations to ensure that they were properly completed. The Office of the Inspector General reviewed 30 Level I and Level II investigations from the Heman G. Stark Youth Correctional Facility, returning 18 to the California Youth Authority Internal Affairs Unit for reinvestigation. Of the 18 cases returned, seven were opened in 1997, two were opened in 1998, and nine were opened in 1999. Five of the 18 cases reinvestigated resulted in adverse actions being recommended against employees. Three of the five adverse actions recommended dismissal, and two recommended a 10% pay cut for 12 months. The California Youth Authority Internal Affairs Unit also has expressed concerns about some of the investigations conducted by the Heman G. Stark Youth Correctional Facility investigative staff. For example, Superintendent Ruiz submitted the case involving the excessive use of force with chemical agents to the California Youth Authority Internal Affairs Unit. The Heman G. Stark Youth Correctional Facility investigation did not sustain the allegations, and recommended that the case be closed. The California Youth Authority Internal Affairs Unit, in a memorandum to the assistant deputy director of the Institutions and Camps Branch, itemized three and one-half pages of concerns. The memorandum noted that the investigation had concluded that the staff members’ actions were not in compliance with Institutions and Camps Branch policies relating to the use of chemical agents and questioned why the allegations were not sustained. In another example, Superintendent Ruiz recommended that a case be closed, stating that the allegations were not sustained. A California Youth Authority internal affairs captain who subsequently reviewed the case noted “numerous areas that concern me and need to be addressed prior to approval of this investigation as being complete.” The captain questioned the interview techniques used in the investigation and why interviews were not taped, as well as why one of the wards involved in the incident was not interviewed. The case was closed without further investigative effort. • The California Youth Authority closed investigations despite strong indications that the investigations may not have been properly conducted or that available evidence did not support the investigation conclusions. In the case involving excessive force through the use of chemical agents, the California Youth Authority Internal Affairs Unit identified a number of issues that suggested the investigation was flawed. The assistant director of the Institutions and Camps Branch, while apparently agreeing that the investigation had reached an invalid conclusion, approved the case’s closure without taking action against the individuals involved. In the case involving allegations of dishonesty, leaving a post without authorization, misrepresentation, providing ward access to other wards’ confidential files, and immorality, Heman G. Stark's investigation sustained all five charges and Superintendent Ruiz recommended dismissal. California Youth Authority headquarters, citing a precedent-setting STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 18 State Personnel Board case decision, rejected the sustained charges of providing unauthorized access to confidential files and immorality and reduced the disciplinary action from dismissal to a letter of reprimand. The Office of the Inspector General reviewed the California Youth Authority legal office’s file and has questions about the propriety of this decision. During an interview held on September 13, 2000, the chief legal counsel of the California Youth Authority acknowledged to the Office of the Inspector General that some evidence in the case may not have been adequately considered in the department's decision to issue a letter of reprimand to this employee instead of taking more stringent action. The same employee was the subject of a subsequent investigation for a different matter. Superintendent Ruiz, informed that the investigation had not sustained the allegation, notified the employee that he had been exonerated before the investigation’s results had been formally approved by the assistant deputy director of the Institutions and Camps Branch. Although the California Youth Authority Internal Affairs Unit had questions and concerns about the investigation, the assistant deputy director approved its closure. • The Heman G. Stark Youth Correctional Facility does not have clear written policies and procedures governing its investigative process. When members of the Office of the Inspector General’s audit team requested the institution’s written policies and procedures, they were given what appeared to be a list that had been typed specifically in response to the team's request. When written procedures do not exist, there is a lack of consistency and accountability in the investigative process. RECOMMENDATION The Office of the Inspector General recommends that Superintendent Ruiz systematically manage internal affairs investigations of alleged staff misconduct, with the goal of improving their effectiveness and timeliness. At a minimum, his management methodology should include: • Accurate, complete, and timely logs for tracking investigations. • Careful monitoring of individual investigations to ensure thoroughness, proper disposition, and prompt completion within the framework established by the Peace Officers Bill of Rights and other statutory limitations. • Development and inclusion in the Heman G. Stark Youth Correctional Facility Administrative Policy and Operations Manual of written policies and procedures governing internal affairs investigations. The Office of the Inspector General recommends that the California Youth Authority take the following actions: • Adopt clear criteria for differentiating between Level I and Level II investigations. If “serious injury” continues as a criterion for differentiation, thoroughly define the term. Update the California Youth Authority Internal Affairs Investigations Policy and Procedures Manual. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 19 • Establish policies and procedures to ensure that judgments regarding the disposition of investigation cases are consistent with the evidence presented. FINDING 2 Heman G. Stark Youth Correctional Facility educational and vocational classes are poorly attended and wards’ academic achievement is low in comparison with other California Youth Authority facilities. An integral component of the California Youth Authority’s mission is to provide education, training, and treatment services to wards in order to return them to society with the skills necessary to succeed and avoid a return to criminal behavior. To this end, the California Youth Authority has adopted various policies and procedures that stress the importance of academic and vocational training. Further, a stipulation and order resulting from the 1990 Nick O. v. Terhune case states that the California Youth Authority is to provide eligible wards with a free, appropriate public education consistent with their unique needs. Despite Superintendent Ruiz’s effort to increase ward programming, the Office of the Inspector General’s review of the academic and vocational education programs at the Heman G. Stark Youth Correctional Facility found that the wards’ educational needs are not being met. Specifically, the Office of the Inspector General found the following: • Among all California Youth Authority high schools, Lyle Egan High School (the high school at Heman G. Stark) ranks at or near the bottom in standardized test scores, and these scores are declining. In 1998, 68% of the wards taking the standardized testing and reporting test placed below the 25th percentile. This increased to 78% in 1999 and 85% in 2000. Of 15 grade-level subject scores, Lyle Egan High School students scored lowest of all California Youth Authority high schools in six subjects in 1998, nine subjects in 1999, and eight subjects in 2000. • Student absenteeism averaged 24% at Lyle Egan High School for the months of January 1999 through June 2000. (June 1999 data were not available and thus were excluded from the average calculation.) The absence percentage at Lyle Egan High School is the highest among California Youth Authority institutions. Absence percentages at other California Youth Authority institutions from July 1999 through July 2000 ranged from 10.2% to 22.2%, with the average percentage 14%. The absence percentages cited exclude absences caused by institution-wide lockdowns and other class closures initiated by the facility. In contrast, the California public school student absenteeism average is approximately 5%. • There are significant periods when no academic or vocational education is provided due to lockdowns and other facility-initiated class closures. For example, in April 1999, 13 instructional days and 542 class periods were cancelled. In January 2000, ten instructional days and 308 class periods were cancelled, and in April 2000, eight instructional days and 399 class periods were cancelled. • The average percentage of wards receiving special education service time is far below the 90% threshold set by the California Youth Authority’s Education Services Branch. For the months of January 1999 through May 2000, auditors identified the following special education service time percentages: STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 20 Resource Specialist Program.................54% Special Day Classes...............................38% Speech/Language Treatment..................54% School Psychologist Therapy.................52% Poor attendance and low academic and vocational educational achievement significantly affect both wards and the California Youth Authority. Most importantly, inadequately educated wards are less prepared to acquire the jobs necessary to facilitate their return to productive lives in free society. Further, wards who are not attending academic and vocational education classes are not receiving the programming prescribed by the California Youth Authority and the Youthful Offender Parole Board. As a result, they may remain in state custody, at state expense, longer than necessary. Poor attendance and low achievement also jeopardize the accreditation of Lyle Egan High School, potentially diminishing the value of a diploma or certificate earned from the Heman G. Stark Youth Correctional Facility. In 1996, the California Education Authority was created as a school district within the California Youth Authority, and the Western Association of Schools and Colleges began visiting and accrediting California Youth Authority high schools. After a recent visit to the Heman G. Stark Youth Correctional Facility, the Western Association of Schools and Colleges granted Lyle Egan High School candidacy accreditation for only one year rather than full candidacy for three years. By way of contrast, other California Youth Authority high schools have received full accreditation for six years. Wards not attending classes also are not generating average daily attendance for the California Youth Authority. Average daily attendance is the basis by which the California Youth Authority receives state lottery funds. Lastly, there can be significant legal costs if the Heman G. Stark Youth Correctional Facility fails to achieve compliance with legal mandates. Although a June 8, 2000 letter by a monitor from the Youth Law Center credits the facility with making excellent progress toward compliance with the Nick O. v. Terhune stipulation and order, failure to fully comply by the January 31, 2001 deadline could result in penalties and the imposition of costly conditions. Several factors contribute to the wards’ poor attendance and low achievement in academic and vocational education programs. The policies and practices of the Heman G. Stark Youth Correctional Facility administration and the Education Services Branch are a significant component. However, the wards themselves must bear some of the responsibility. Unless they are willing to attend class, make the commitment to learn, and cooperate with each other and the faculty to create a safe atmosphere conducive to learning, it is unrealistic to expect high levels of achievement. The Office of the Inspector General identified the following conditions that have contributed to the Heman G. Stark Youth Correctional Facility’s problems with its educational programs: • The former superintendent’s policies emphasized staff safety at the expense of ward programming. Automatically classifying new wards as Phase I for programming purposes, using facility-wide lockdowns, and, with any living unit transfer, automatically suspending a STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 21 ward’s programming for one week, severely curtailed programming opportunities. Superintendent Ruiz has rescinded these policies. • The Heman G. Stark Youth Correctional Facility has a shortage of teachers and qualified substitutes who are willing to work inside the facility. Teaching inside a youth correctional institution is potentially dangerous, and the current compensation is not competitive. According to some teachers and administrators, the Heman G. Stark Youth Correctional Facility has lost several teachers (and failed to hire others) because these instructors have accepted higher-paying positions with local school districts. The Office of the Inspector General confirmed that the local school districts’ pay scales were, on average, about 16% higher than those offered by the California Youth Authority. The teacher shortage is especially severe in special education. There were five special education instructor and resource specialist vacancies that remained unfilled during the course of the audit team’s fieldwork. • Classes are frequently canceled due to “trade holds.” “Trade hold” is a generic term for various events that cause a single class or all classes to be cancelled. These include interruptions in utility services, such as water and electricity, failures of the personal security system (Unisec) devices worn by education staff, and teacher shortages due to illness, vacation, extended leave, and other events. • Some education staff members have little enthusiasm towards their work. Some instructors seemed to seek out reasons to cancel classes. The instructors also show little concern with accuracy in reporting attendance. The audit team reviewed 21 monthly teacher/instructor average daily attendance reports and found errors in every one. For example, a math teacher adding 424 and 147 incorrectly reported 671 units instead of 571. The education staff does not interact with the trade advisory committees required by the Education Services Branch Manual Sections 3410 and 3420. Good trade advisory committees can identify ways of improving vocational education programs and enhancing wards’ job opportunities. Although the institution has a roster of trade advisory committee members, few are actively involved, as required by Education Services Branch Manual Section 3420. The committees do not meet regularly and no longer participate in vocational education open houses. The Office of the Inspector General interviewed seven trade advisory committee members, three of whom said they had never visited the institution. RECOMMENDATIONS In order to improve attendance and academic and vocational achievement at the Heman G. Stark Youth Correctional Facility, the Office of the Inspector General recommends that Superintendent Ruiz: • Continue the policies of unit-specific lockdown versus institution-wide lockdown, Phase II entry instead of Phase I entry into the institution, and continued programming for wards moving between living units in lieu of one-week programming suspensions. • Work with ward representatives and institution education administrators as well as Education Services Branch administrators to provide the best possible learning environment. Within the framework of institutional security, the superintendent should encourage the exchange of ideas through regular meetings and the resumption of STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 22 activities such as the Vocational Industrial Clubs of America competition and open houses. The deputy director of the Education Services Branch and the institution’s education administrators should: • Promptly fill teaching vacancies, especially those in academic/special education. Work to provide competitive teacher compensation by upgrading pay scales, using compensation exceptions provided for by law and other suitable methods. • Make every effort to compile a list of qualified substitute instructors so that classes can continue without cancellation when an instructor is sick, takes vacation, or is otherwise absent. • Explore ways to lessen the disruption or cancellation of classes due to other types of trade holds. For example, the causes of Unisec failures should be examined and corrected. • Ensure that all class cancellations are for valid reasons and that all alternatives to cancellation have been explored. • Insist on the accurate reporting of ward attendance by instructors. Provide training as necessary and implement supervisory review and signature controls. • Consider resuming programs and activities such as open houses and the Vocational Industrial Clubs of America competition. • Ensure the use of trade advisory committees as outlined in Sections 3410 and 3420 of the Education Services Branch Manual. • Comply with all recommendations of the Western Association of Schools and Colleges in order to obtain full accreditation for Lyle Egan High School. • Comply with all requirements of the Nick O. v. Terhune stipulation and order. FINDING 3 Wards have not been provided with required treatment services. Wards at the Heman G. Stark Youth Correctional Facility are consistently denied the treatment services to which they are entitled by the Welfare and Institutions Code and Title 15, Division 4, of the California Code of Regulations. Consistent with these laws, Section 4000 et seq. of the California Youth Authority Institutions and Camps Branch Manual specifies the various types and frequency of treatment services wards are to receive. The Office of the Inspector General reviewed a sampling of 86 ward files from 10 of the 12 living units. This sample represented 6.8% of the ward population at Heman G. Stark Youth Correctional Facility during the audit team’s review. The audit team’s review of the files found: • Only 57 of the 86 wards in the sample (66%) received an explanation of the California Youth Authority’s time-cut policy during their orientation. The time-cut policy awards up to nine days per month in credit toward a ward’s release based on his progress in meeting STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 23 treatment objectives. Section 4070 of the California Youth Authority Institutions and Camps Branch Manual states that ward orientation is to include an explanation of the California Youth Authority’s time-cut policy. • Although Section 4010.2 of the Institutions and Camps Branch Manual requires wards to be assigned to school or work within four days of arrival at their permanent living unit, only one of 51 eligible wards in the sample was assigned within that timeframe. In fact, the average interval between a ward’s arrival at his permanent living unit and his assignment to school or work was 94 days. If time spent in the orientation period is included, the average interval between a ward’s arrival at the institution to his assignment to school or work was 140 days. • Wards’ initial case conferences lacked proper staff representation. According to Institutions and Camps Branch Manual Section 4025, the superintendent is to ensure that each living unit has a case conference committee that, at a minimum, consists of the ward’s youth correctional counselor, parole agent, and when possible, a teacher. Institutions and Camps Branch Manual Section 4030 specifies that at the ward’s initial case conference, the case conference committee is to obtain input from the ward, assess the ward’s needs, and set realistic, deadline-driven treatment objectives. The Office of the Inspector General found that parole agents individually met with wards to provide an orientation. No youth correctional counselor or teacher was present. At Heman G. Stark, the youth correctional counselor is normally the one to set the treatment objectives. None of the initial case conference reports in the sample files contained individually determined treatment objectives. • Only 68% of the wards in the sample received progress case conferences. Section 4035 of the Institutions and Camps Branch Manual states that the case conference committee is to hold a progress case conference no more than 60 days following the initial case conference. Also, in the cases sampled, while a youth correctional counselor attended most of the meetings that did take place, along with the ward and the parole agent, a teacher was not present. Moreover, because individual treatment objectives had not been set earlier, these meetings did not satisfy the intent of the progress case conference. • Only 48 of the 86 wards (56%) in the sample received required weekly formal structured counseling sessions as specified in the Institutions and Camps Branch Manual. This problem is particularly acute in the O/R Team living unit where, of the 11 ward files sampled, nine contained evidence of counseling an average of every other week and the remaining two showed no evidence of counseling contact whatsoever. Further inquiries by the auditors disclosed that O/R Team wards were not provided with counseling while waiting for court prosecution or while on temporary detention. One ward was housed in the O/R Team living unit for 90 days without being assigned a counselor. Upon being notified of the lack of counseling for O/R Team wards, the new treatment team supervisor met with his staff and immediately took steps to correct the problem. • The sample files included those of 25 wards participating in formalized drug programs. Nine of those 25 files (36%) did not contain sufficient documentation to substantiate that the wards received counseling sessions in compliance with program requirements. Two living units, S/T Team and U/V Team, have formalized drug programs and participate in the residential substance abuse treatment program funded by the Office of Criminal Justice Planning. The program requires wards to complete 180 hours of formalized drug program STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 24 counseling in order to be referred for parole. The counseling is to be provided in blocks of five hours per week: a one-hour session with the youth correctional counselor and two two- hour sessions with designated substance abuse counselors. The nine files documented less than one counseling contact per week with the ward’s youth correctional counselor. In addition, the residential substance abuse treatment coordinator could not substantiate the wards’ attendance at the twice-weekly two-hour formalized drug program groups. Asked to provide records of ward attendance, one substance abuse counselor stated he had destroyed them. In response to the Office of the Inspector General’s identification of this problem, the Unit III program administrator developed a residential substance abuse treatment attendance record-keeping system. • Only 10 of 28 applicable ward files in the sample (36%) contained documentation that the ward had received required urinalysis testing within 72 hours of placement into the residential substance abuse treatment program. The residential substance abuse treatment program requires wards entering a formalized drug program to be screened for drug abuse by undergoing urinalysis testing within 72 hours of program placement. In addition, wards exiting a formalized drug program are to be drug-screened by urinalysis within 30 days of exiting from the formalized drug program. The Office of the Inspector General found that of 16 wards who participated in the formalized drug program and were subsequently released on parole during June 2000, only eight (50%) were tested within the 30-day limit. In response to this finding, the formalized drug program’s senior youth correctional counselor developed improved procedures for urinalysis entry and exit testing. Institutions are allowed to request variances from California Youth Authority policy. Such requests must be 1) in writing and 2) approved by the deputy director of the Institutions and Camps Branch. The Heman G. Stark staff was unable to provide the audit team with any written, approved variances concerning the Institutions and Camps Branch Manual requirements cited above. Wards deprived of fundamental assessment, counseling, and testing activities designed to facilitate their growth and development are inadequately prepared for reintegration into society. Their chances of leading productive lives are diminished and they are at greater risk of committing crimes and returning to state custody. The short- and long-term objectives laid out in a well-prepared individual treatment plan are the cornerstone of a successful treatment program. If the initial case meeting does not include input from the youth correctional counselor (the ward’s supervisor) and a teacher to determine objectives based on the factors underlying the ward’s commitment offense, personal characteristics, educational needs, and other information, the resulting individual treatment plan is of questionable value. Further, wards' performance in meeting treatment objectives is the basis for evaluating their eligibility for time-credit reductions (time cuts). The prospect of a recommendation for a time cut keeps wards focused on their overall treatment objectives. The degree to which the institution neglects to orient all wards to the time-cut policy and fails to hold initial and progress case conferences may minimize the degree to which wards will attempt to understand their anti-social behavior and accept learning methods to lessen such behavior. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 25 An accepted indicator of treatment program effectiveness is the absence of violence. Wards who have sound individual treatment plans and who are aware of the behavioral incentives offered by time cuts tend to perpetrate fewer assaults on staff and other wards. Failure to provide prescribed levels of proper assessment and counseling services can contribute to violence in the institution. The Office of the Inspector General identified a number of reasons why fundamental assessment and counseling services have been inadequate. As cited in Finding 2, the policy of institution- wide lockdowns versus unit-specific lockdowns in response to incidents has significantly affected all ward programming, including treatment programs. When lockdowns occurred, treatment programs virtually ceased. In addition, the policy of Phase I entry to the institution kept new wards confined to their rooms for all but one hour per day. Again, for Phase I wards, assessment and counseling services were subordinate to physical exercise and other activities. Consequently, little was accomplished. Lastly, the policy of confining wards to their rooms for one week during living unit transfers also had some impact. Superintendent Ruiz has changed these policies. Other factors contributing to inadequate ward treatment services include: • Confusion among the parole agents regarding policies and procedures governing the scheduling system for case conferences. Following the initial case conference many parole agents routinely schedule the first progress case conference out to 90 days rather than 60 days. Some said they believed they had 90 days to schedule the progress case meeting. Others said that 60 days was an impractical requirement given the difficulty of scheduling all parties to a conference. • Supervisors did not adequately monitor parole agents’ work. There was little evidence in ward case files or other documents that the treatment team supervisors (who are responsible for monitoring the work of their subordinates, the parole agents) were noting problems of the sort identified in this report and instructing their subordinates to take corrective action. Parole agent IIIs also did not monitor ward case files. • Lack of coordination between the treatment staff and the teaching staff, resulting in teachers not participating in ward assessment and counseling. The Office of the Inspector General found no evidence of an effort to schedule the availability of teachers into the ward case conference process. According to some staff, this problem goes back to philosophical differences between the former superintendent and officials in the Education Services Branch, which supervises teachers. Staff members reported that the disagreement created an attitude of indifference on the part of staff. • An apparent agreement between the former superintendent and representatives of Bargaining Unit 6 of the California Correctional Peace Officers Association extending the weekly counseling requirement of Institutions and Camps Branch Manual Section 4050.3 from every week to every other week. The Office of the Inspector General found no written copy of such an agreement or a written amendment to the current collective bargaining contract with the California Correctional Peace Officers Association. Further, the auditors found no record that the deputy director of the Institutions and Camps Branch had granted such a policy variance. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 26 Superintendent Ruiz acknowledged there are significant problems with the treatment system, including ward assessment and counseling. He stated that the deputy superintendent had formed a committee to review and correct these problems. RECOMMENDATIONS In addition to continuing his policies of Phase II entry and isolating lockdowns to living units, Superintendent Ruiz should take the following actions to improve ward assessment and counseling: ● Ensure that the A/B Team living unit’s orientation curriculum contains a section devoted to the California Youth Authority’s time-cut policy and that the policy is discussed appropriately with newly arrived wards. Document this discussion in the ward’s records. ● Develop a casework management system that meets the content and frequency criteria laid out in Section 4000 et seq. of the Institutions and Camps Branch Manual. Of particular importance is the prompt and proper conducting of an initial case conference that includes all parties, including the youth correctional counselor. Part of this system should be a scheduling component that facilitates the availability of the ward, the parole agent, the youth correctional counselor, a teacher, and other staff as necessary. ● Clarify policies governing assessment and counseling procedures in order to eliminate confusion regarding issues such as 60-day versus 90-day progress conferences. ● Hold treatment team supervisors and parole agent IIIs accountable for monitoring the work of parole agents. ● Work with the education administrators at the Heman G. Stark Youth Correctional Facility to ensure teacher availability and participation in ward assessment and counseling. ● Notwithstanding that there may be a contractual agreement regarding the frequency of formal counseling, the superintendent and the California Correctional Peace Officers Association should immediately restore the frequency of formal counseling to the once-per-week California Youth Authority standard. FINDING 4 System deficiencies and inadequate effort have resulted in ward grievances not being promptly and appropriately addressed. One of the results of the Office of the Inspector General’s 1999 investigation at the Heman G. Stark Youth Correctional Facility was the Governor’s directive that the Secretary of the Youth and Adult Correctional Agency conduct a comprehensive audit of the facility’s ward grievance process and investigate all ward grievances. As a part of its management review audit of STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 27 Superintendent Ruiz, the Office of the Inspector General reviewed the Heman G. Stark Youth Correctional Facility’s ward grievance process. The Office of the Inspector General found numerous conditions to suggest that Heman G. Stark Youth Correctional Facility management and staff have not implemented the necessary policies and procedures to ensure that ward grievances are promptly and properly addressed. Specifically, the Office of the Inspector General found: • No assurance that all ward grievances are processed. All ward grievance forms are pre- numbered to ensure accountability. The Heman G. Stark Youth Correctional Facility Administrative Policy and Operations Manual requires treatment team supervisors to reconcile the numbered grievances at the end of each month and to forward the reconciliation to the ward rights coordinator. Staff at the Heman G. Stark Youth Correctional Facility could not provide any documentation demonstrating that the required reconciliations have been, and are being, performed. According to one staff member, there is not enough time to perform the reconciliation. However, unless all grievance forms are accounted for, institution administration has no assurance that all grievances have been processed and cannot validate or refute recurring ward allegations that staff members intentionally destroy ward grievance forms. • Ward grievances are not addressed promptly. The Heman G. Stark Youth Correctional Facility Administrative Policy and Operations Manual, Section 9033.6.2, states that ward grievances are to be responded to within seven calendar days of filing. The audit team’s review disclosed that, of the 173 ward grievances on the Heman G. Stark facility's outstanding grievance list as of June 26, 2000, the responses for 59 (34%) were late or overdue. • Reports to the California Youth Authority headquarters were inaccurate. Because of system and programming errors, the Heman G. Stark Youth Correctional Facility consistently understated the percentage of late grievances in its report to California Youth Authority headquarters. For the first five months of 2000, the Heman G. Stark facility reported monthly percentages of late grievances that ranged between 4% and 10%. However, of 150 grievances sampled from the same period, the Office of the Inspector General found that 36 (24%) were responded to after the seven-day deadline. • The criterion for “adverse action grievance” is inconsistent with the Institutions and Camps Branch Manual. The California Youth Authority Institutions and Camps Branch Manual defines an adverse action grievance as a grievance alleging staff misconduct that could result in adverse or disciplinary action being taken. Adverse action grievances should be given high priority and thorough scrutiny. However, the Heman G. Stark Youth Correctional Facility Administration and Operations Manual limits the scope of an adverse action grievance to include only staff misconduct that could reasonably be expected to result in adverse action. By imposing a more narrow definition than that of the California Youth Authority, the Heman G. Stark facility is at risk of assigning lower priority and less effort to investigating grievances involving staff than is intended by California Youth Authority policy. The Office of the Inspector General discussed this issue with the assistant deputy director of the California Youth Authority Institutions and Camps Branch. The assistant deputy director STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 28 responded to this issue, as well as others relating to the ward grievance system, in an April 4, 2000 memorandum to the Office of the Inspector General. In the memorandum, the assistant deputy director stated that ward grievance procedure training was provided in March 2000 to the institution ward rights coordinators. The training was said to include the definition of an “adverse action grievance” as provided in the Institutions and Camps Branch Manual. The coordinators were instructed to return to their respective sites and train staff by March 31, 2000. As of July 2000, revisions to the Heman G. Stark Youth Correctional Facility Administration and Operations Manual had not been made. • Large numbers of ward grievance forms are missing. Ward grievance forms are summarized and entered into the Heman G. Stark facility's ward information network, a computerized system for compiling and managing ward data. The ward grievance form (YA 8.450), however, remains the official legal document in the ward grievance process and serves as the support for and basis of the original ward complaint. Despite the form’s importance, of 43 ward grievances the Office of the Inspector General selected as a sample from the ward information network, the institution staff could not locate 12 (28%) of the actual ward grievance forms. Subsequent to the end of audit fieldwork, the Heman G. Stark facility found three of these missing grievances. Without the actual form, critical information such as the detailed complaint in the ward’s own words, and the staff’s written response is unavailable. Therefore, it is not possible to evaluate whether the grievance was addressed appropriately. For example, the Office of the Inspector General found that a ward filed a grievance on January 30, 2000, reportedly because he had been placed in the O/R Team’s special management unit for ten months during which he was not allowed to participate in programming as ordered by the Youth Offender Parole Board. According to the ward information network system, the ward requested to be transferred to another institution or to a general population unit for programming purposes. The system shows a response date of July 20, 2000 (nearly six months later) with a comment, “transferred back to Chad in February of 2000.” Without the actual grievance form, it is impossible to determine the precise nature of the complaint and whether it was fully addressed. • Responses do not always address ward complaints. For example, the Office of the Inspector General found that one ward filed a grievance in which he claimed he was missing personal property as a result of a living unit transfer. The resolution given on the ward information network system was that the senior youth correctional counselor was “trying to locate the property” and that if the property was not found, the ward would be given a claim form to fill out. As no explanation was given as to whether the property was found, whether the ward received a claim form, or whether the grievance was actually resolved, the response did not address the grievance. • Written responses are not provided on the grievance forms. In a sample of 22 ward grievance forms reviewed by the Office of the Inspector General, the response section on every one was left blank. Without a written staff response, it is impossible to determine whether the grievance was properly addressed. The Office of the Inspector General found that little or no action has been taken on a number of ward grievances involving allegations of staff misconduct and staff assaults on wards that warrant investigation. From the 173 ward grievances listed as outstanding on June 26, 2000, the STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 29 Office of the Inspector General reviewed a sample of 43 cases comprised of all open adverse action grievances, emergency grievances, and regular grievances over one month old. The Office of the Inspector General also reviewed another sample of nine grievances relating to wards on temporary detention. The review disclosed the following: • Of the 22 complaints designated as adverse action grievances, five (23%) had still not been assigned for investigation as of August 8, 2000. Three of these grievances were filed in 1999. The oldest of these grievances was for an alleged staff-on-ward assault, which was initially denied after being filed as an emergency grievance. It was subsequently re-filed on October 6, 1999 as an adverse action grievance, in which the ward requested an investigation. The staff person who allegedly assaulted the ward in this grievance is the same staff member who, in a January 25, 2000 incident, repeatedly sprayed a ward with chemical agents for refusing to undergo a strip search. (This incident is described earlier in this report in the Office of the Inspector General's comment under Governor's Action Item Number 1.) The Office of the Inspector General found no evidence that the matter was further investigated. Further, the institution staff was unable to locate the actual ward grievance form or any response to the grievant. Heman G. Stark staff told the Office of the Inspector General that an investigation had not been initiated because the fact-finding process was not yet complete. • A ward alleged that he was excessively sprayed with mace and assaulted by a youth correctional counselor and back-up staff who kicked a food tray at him. The grievance was filed in May 2000, and the ward grievance form was subsequently lost. Although the ward information network system indicates that this grievance was forwarded to the superintendent for review, no action has been taken to investigate the alleged assault. • A ward alleged that he was physically assaulted by several staff members who hit his head on the door and wall of his room while placing him in the room. He stated in his grievance that he was willing to take a polygraph test. He filed a grievance in March 2000, written on a lined paper with a note: “I have been asking every staff that has been on banks for a (sic) emergency grievance since 10:30 A.M. and all staff have refused my request.” The Office of the Inspector General could find no evidence that any action had been taken to investigate this grievance. • Three of the grievances reviewed involved wards in temporary detention alleging staff misconduct. One grievance, alleging abuse of authority, received a response of, “Your grievance is denied.” Another grievance concerned an allegation of a staff-on-ward assault. There is no evidence that a fact-finding inquiry or investigation was conducted to address any of these grievances. RECOMMENDATION In order to improve the ward grievance process, the Office of the Inspector General recommends that Superintendent Ruiz establish an action plan to correct the serious deficiencies noted in this report. The plan should include a timeline for implementation and should include measures to accomplish the following: STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 30 ● Immediately investigate all backlogged adverse action grievances. Forward a copy of each investigation to the Office of the Inspector General for review. ● Change the criterion relating to adverse action in the Heman G. Stark Youth Correctional Facility Administration and Operations Manual to accurately reflect policy set in the California Youth Authority Institutions and Camps Branch Manual. ● Investigate all future ward grievances as specified in the Governor’s September 24, 1999 letter to Youth and Adult Corrections Agency Secretary Robert Presley. ● Develop a system for ensuring that all ward grievance forms are properly reconciled, centrally located in the wards rights office, and fully completed. The system should also ensure that every complaint is promptly and adequately addressed. ● Provide training to all staff members and ward grievance clerks involved in the ward grievance process. The training should cover the system recommended above as well as the specific procedures described in the Heman G. Stark Youth Correctional Facility Administrative Policy and Operations Manual. ● Establish an oversight function to monitor the ward grievance process and report any deficiencies directly to the superintendent on a regular basis. The superintendent should ensure that staff members are held accountable for their responsibilities in the ward grievance process. The importance of an efficient and effective ward grievance process is recognized in the Governor’s September 24, 1999 directive to the Secretary of the Youth and Adult Correctional Agency. The Heman G. Stark Youth Correctional Facility should devote considerable additional effort and make significant improvements in order to fully comply with the spirit and intent of the Governor’s directive. FINDING 5 All wards, including those in Phase II and III, have been confined to eating in their rooms since the 1996 staff murder, hampering socialization efforts. An integral component of group living is dining together in a cafeteria setting. The socialization afforded by group dining can have a positive effect on ward development and behavior. The California Youth Authority recognizes the importance of group dining. Section 1490 of the California Youth Authority Institutions and Camps Branch Manual states that “Food service shall be integrated into the operation of the total institutional program.” Further, the superintendent is to be aware of the importance of the food program to wards and prevent infringement of ward programming on the food program. Wards at every facility in the California Youth Authority, with the exception of the Heman G. Stark Youth Correctional Facility, are served meals in cafeteria settings. Although the Heman G. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 31 Stark facility is equipped with cafeterias, all wards at the facility, including those in Phases II and III, are confined to their rooms during mealtimes. According to institution staff, wards are confined to their rooms for security reasons. Prior to the 1996 staff murder, wards ate their meals together in the cafeterias. However, it was determined that conditions in the institution and those in the cafeterias were too dangerous to continue the practice. The proliferation of gangs and the availability of utensils, hot liquids, knives, and other potential weapons in the cafeterias heighten the risk of assaults on staff and wards as well as large-scale incidents among rival groups. Although the safety of staff and wards must be given highest priority, ward socialization is also important. The downsizing of the ward population from approximately 2,000 at the time of the murder to 1,268 as of August 14, 2000 has somewhat eased the security situation. Consequently, the time may be appropriate to begin reintroducing the group dining concept. RECOMMENDATION The Office of the Inspector General recommends that Superintendent Ruiz reintroduce cafeteria dining for wards whose behavior has made them an acceptable risk. This reintroduction should be carefully planned, continually evaluated, and phased in gradually, with full implementation by July 1, 2001. FINDING 6 Northern Hispanic wards are transferred from N.A. Chaderjian Youth Correctional Facility to the Heman G. Stark Youth Correctional Facility for punitive purposes, rather than for treatment. California Youth Authority Institutions and Camps Branch Manual, Section 7200, governs the confinement of wards in special management units such as the O/R Team living unit. The manual states that: The purpose of secure detention units…is to maintain the order of the institution. This provides a highly structured, safe, secure, humane environment for the temporary confinement of wards who meet the established temporary detention or disciplinary decision-making system criteria. A“reciprocal de facto agreement” between the N.A. Chaderjian Youth Correctional Facility in northern California and Heman G. Stark Youth Correctional Facility provides for each institution to accept from the other Northern and Southern Hispanic wards who are posing violent or disruptive behavioral problems. (Northern and Southern Hispanics often fight when mixed.) These two institutions have special management unit programs that can be completed in approximately 90 days, although the policies do not specify an exact length of stay. On occasion wards spend up to 120 days in special management units. The Office of the Inspector General’s review disclosed that the O/R Team’s special management unit houses 15 Northern Hispanics whose confinement is planned for six months — twice the normal length of stay. Nearly all of these wards are transfers from the N.A Chaderjian Youth Correctional Facility. The wards are confined to their rooms for 23 hours per day and receive only minimal programming. Moreover, according to O/R Team living unit staff, the last stage of STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 32 the three-stage special management unit program is reintegration into the institutional general population. However, the staff reports that it is unsafe for Northern Hispanics to reintegrate into the general population at the Heman G. Stark facility because of the large Southern Hispanic population. Therefore, these wards have no means of successfully completing the last stage of the special management unit program. Asked why Northern Hispanics were being transferred to the Heman G. Stark Youth Correctional Facility in southern California, staff members replied that wards were being taught a psychological lesson similar to a “scared straight” message. The foregoing practice appears to be unfair and inconsistent with the “safe, secure, humane environment” concept cited in the California Youth Authority Institutions and Camps Manual, Section 7200. RECOMMENDATION The director of the California Youth Authority should work with Superintendent Ruiz and the N.A. Chaderjian Youth Correctional Facility superintendent to cease the inter-facility transfers of Northern Hispanics and to ensure that all special management unit confinement is based on programming criteria rather than a pre-determined length of stay. FINDING 7 The management and monitoring of wards in temporary detention needs improvement. Wards placed in temporary detention are confined to locked rooms either in their normal living units or in a special management unit for reasons noted on an “authorization for detention or program restriction” form (YA 8.415) or as a consequence of a disciplinary decision-making system disposition. A ward may be placed in temporary detention for such reasons as being a danger to other wards, staff, or himself; being in danger from others; posing an escape risk; or awaiting transfer to the Department of Corrections, the O/R Team living unit, or court. It is critical that wards in temporary detention be carefully monitored. They are confined for 23 hours per day and are allowed out for only one hour of large muscle exercise daily. Their programming is put on hold and they can suffer developmentally and psychologically. There is no defined period for how long a ward can remain in temporary detention. However, both the California Youth Authority and Heman G. Stark Youth Correctional Facility have policies and procedures intended to ensure that the status of a ward in temporary detention is monitored frequently, that time extensions are approved by progressively higher levels of authority, and that the ward receives all the services allowed while in temporary detention. Notwithstanding these policies and procedures, the Office of the Inspector General found the following: • Superintendent Ruiz does not receive accurate information on the number of wards in temporary detention. The superintendent’s daily report of wards in temporary detention (the ward information network current temporary detention summary report) does not accurately reflect the number of wards actually in temporary detention. The temporary detention summary report for June 27, 2000, the report current at the time of the management review STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 33 audit, identified seven wards in temporary detention at the O/R Team living unit. However, the auditors’ site visit to the O/R Team control room found 27 wards in temporary detention. Further, only four of the seven wards actually identified on the report for the O/R Team living unit were actually in temporary detention. The other three wards were not in temporary detention at the O/R Team living unit. Thus, the report accurately reflected only four of the 27 wards in temporary detention at the O/R Team living unit. In addition, in most cases the report did not accurately reflect the dates extensions were approved or the ending date of the extension. • Staff members at the O/R Team living unit do not use the ward information network system to document wards in temporary detention. Instead, staff members prepare a daily O/R-temporary detention audit. This audit lists all wards in temporary detention at the O/R Team living unit. It includes wards’ names, the living unit they come from, their California Youth Authority identification number, file number, date received, extension date (if applicable), and comments. This audit accurately reflected the number of wards in temporary detention at the O/R Team living unit. However, of the 27 wards listed in temporary detention, seven (26%) had an incorrect extension date when compared with the YA 8.415 form. In one instance, the extension date on the O/R- temporary detention audit was blank, and in two instances the temporary detention was to extend until February 28, 2000, when the date of the audit report was June 27, 2000. In four instances the date extension was off by one day. • Wards in temporary detention are not receiving the counseling required by the California Youth Authority’s Special Management Unit Handbook. The handbook states that wards not attending school should receive approximately ten minutes of daily counseling from a youth correctional counselor. However, of the 27 wards in temporary detention at the O/R Team living unit, the auditor could find evidence of counseling for only the three wards (11%) who had been referred from the E/F Team living unit. O/R Team living unit control staff indicated that it was the responsibility of the youth correctional counselor from the ward’s original living unit to come over and counsel his or her wards. • Wards do not always sign the YA 8.415 authorization for detention or program restriction form. These forms are important because they notify the ward of the reason he is being placed in temporary detention, how long the temporary detention will last, and what his appeal rights are. When signed, the forms are the ward’s acknowledgment of such notice. Of 14 YA 8.415 forms sampled for wards in temporary detention in living units other than the O/R Team, three (21%) were not signed by the ward when he was placed in temporary detention. Further, there was no notation on the form that the ward had refused to sign. All YA 8.415 forms were not only signed by the ward upon entry into temporary detention at the O/R Team living unit, but also were signed at each extension point even though signatures at extension points are not required. There are several reasons these problems exist. O/R Team living unit staff said that they did not know they were required to enter ward temporary detention information into the ward information network system. They knew only of the O/R Team living unit temporary detention audit process. O/R Team living unit staff also said that the inconsistencies in the extension dates between the audits and the YA 8.415 forms were simply the result of staff errors. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 34 There is little oversight of the temporary detention process at the facility. Currently, program administrators are responsible for the wards in temporary detention at the administrators' respective living units. The superintendent has no mechanism to ensure that the living units are complying with temporary detention policies and procedures or that the current ward information network temporary detention summary report is accurate. Moreover, little monitoring is being done at the California Youth Authority level. Headquarters began a limited review of reporting in this area only in the summer of 2000. According to the assistant deputy director for the Institutions and Camps Branch, a budget change proposal is being written to fund a compliance unit that would review temporary detention. In addition, the California Youth Authority is developing a computerized monitoring effort. RECOMMENDATION: The Office of the Inspector General recommends that Superintendent Ruiz take the following actions to improve the management and monitoring of wards in temporary detention: ● Immediately distribute a policy reminder to all appropriate staff members regarding the policies and procedures to be followed in managing and monitoring wards in temporary detention. At a minimum, this policy reminder should state that: ●All living units must monitor and track wards in temporary detention using the ward information network system. ●All staff must ensure that wards sign the YA 8.415 form upon entry into temporary detention or note on the form that the ward refused to sign. ●Wards in temporary detention should receive the minimum ten minutes of counseling a day. This counseling should be appropriately documented. ● Routinely conduct spot audits of the ward information network current temporary detention summary report to ensure that the ward information network system accounts for all wards in temporary detention. ● Hold program administrators accountable for the proper administration of temporary detention in their respective living units. The Office of the Inspector General also recommends that the California Youth Authority oversee the management and monitoring of wards in temporary detention at its institutions. FINDING 8 The disciplinary decision-making system needs improvement. The disciplinary decision-making system is a process developed by the California Youth Authority to ensure that wards have the right to due process in disciplinary matters. The California Youth Authority Institutions and Camps Branch Manual, Sections 7300 through 7495, STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 35 itemizes specific policies and procedures to be followed in disciplinary actions. The manual categorizes ward violations as minor misconduct, Level A (intermediate misconduct), and Level B (serious misconduct). Effective May 1, 2000, the disciplinary decision-making system at the Heman G. Stark Youth Correctional Facility was maintained on the WIN 2000 database. This new database is part of a statewide change in policies and procedures governing the disciplinary decision-making system. The Office of the Inspector General determined that the Heman G. Stark Youth Correctional Facility needs to improve its administration of the disciplinary decision-making system to make ward disciplinary actions more consistent with the policies and procedures cited above. The Office of the Inspector General found the following: • A large percentage of cases are misclassified. In a sample of Level B disciplinary cases with incident dates of April 2, 2000 through June 29, 2000, 16 (80%) of the 20 cases sampled from the WIN 2000 database were actually Level A cases, which are subject to a briefer resolution process. • Many cases on the WIN 2000 database are duplicates. The Office of the Inspector General found 47 cases on the database that had the same ward name, same incident date, and consecutive incident numbers. The disciplinary decision-making system administrator said the problem was caused by a programming error that created separate incident numbers for each witness to a single incident. The administrator reported that the problem has now been corrected. ● Cases often exceed the statutory time limit. Under Section 7410, all discipline cases must be completed within 24 calendar days of the incident unless time extensions are granted. Of 24 Level B cases sampled with incident dates occurring in the first month of the new system, 12 (50%) were dismissed because they had exceeded the 24-day limit for resolution. This rate contrasts with a late resolution rate of only 3.5% the auditors found in 2000 prior to the system change. The effects of the problems described above are significant. Without timely resolution of disciplinary cases, wards do not realize the consequences of their actions and may be less inclined to observe rules and regulations intended to protect staff and wards and to enhance the accomplishment of their programming. Further, the misclassification of ward violations can lead to either excessive or insufficient discipline. Finally, duplicate cases on the WIN 2000 database clog the system with meaningless data and reduce the system’s usefulness. The problems with the disciplinary decision-making system largely result from a lack of staff training. The California Youth Authority made significant changes to disciplinary decision- making system policy effective March 1, 2000, and the institution implemented the change on May 1, 2000. The disciplinary decision-making system staff told the Office of the Inspector General that the new policy change and the new WIN 2000 database produced difficulties for most facility staff in accurately and correctly filing disciplinary cases. All cases are now filed electronically on the WIN 2000. The behavior reports, investigation reports, and disciplinary action forms that had been produced manually are now written into the computer from a template. However little training was provided on the new procedures and facility staff STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 36 encountered problems in entering data and maneuvering through the database, which resulted in widespread errors. At the time of the Office of the Inspector General's fieldwork, facility staff were receiving disciplinary decision-making system WIN 2000 database training. In addition, the Office of the Inspector General found no evidence that facility management was routinely monitoring the timeliness and disposition of disciplinary decision making system cases. RECOMMENDATION The California Youth Authority and Superintendent Ruiz should carefully monitor the disciplinary decision-making system to ensure that staff training has resulted in the improvements necessary to make the disciplinary decision making system and the WIN 2000 effective tools. Superintendent Ruiz should also monitor the performance of the new disciplinary decision-making system to ensure that issues such as timeliness arising during the system transition are effectively addressed. FINDING 9 Staff performance appraisals and probationary reports are overdue. Evaluating and providing timely feedback to employees on their performance is an important part of effective management. Employees informed of positive and negative aspects of their job performance can continue to develop their strengths while working to correct their deficiencies. The result is more productive employees whose efforts help accomplish the organization’s mission and goals. Employee performance appraisals documenting consistently unsatisfactory performance can also provide justification for dismissal. The State of California recognizes the need for and value of performance appraisals by requiring such appraisals for state employees. Government Code Section 19992 states that a system shall be in place to evaluate the performance of state employees and that performance reports shall be kept on file and made available to each employee. Government Code Section 19172 requires evaluations of the work and efficiency of state employees during their probationary periods. Probationary reports are especially important. New employees need prompt feedback and it is easier to terminate poor performers during probation, before they have achieved permanent status. The Office of the Inspector General’s review disclosed that Heman G. Stark Youth Correctional Facility staff do not receive performance appraisals and probationary reports on time. Permanent employees are to be evaluated annually; probationary employees generally are appraised more frequently, every 60 days or every 120 days depending on their job classification. The auditors' review of a sample of 29 personnel files revealed 12 files (41%) that did not contain the required performance appraisals or probationary reports commensurate with the employee’s status at the institution. These evaluations were overdue by three months to 27 months, or even longer. Of particular concern was the absence of annual performance appraisals for all seven teachers in the sample. Given the significant education problems cited earlier in this report, timely appraisals of teacher performance are a necessary ingredient to improving education quality. Another file, STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 37 that of a key staff member, contained only the second of three required probationary reports. This second probationary report was critical of the individual’s performance and recommended dismissal unless there was significant improvement by the third probationary report. The third probationary report was not filed and the employee now has permanent status. Personnel office staff said that many supervisors and managers regard generating performance appraisals and probationary reports as a low priority compared with their other duties. Personnel staff told the Office of the Inspector General that they systematically track appraisals and reports and notify the responsible parties when they are due. They do not, however, keep a delinquent report log or document all contacts made with supervisors and managers. RECOMMENDATIONS The Office of the Inspector General recommends that Superintendent Ruiz take the following actions to assure the prompt evaluation of employee performance: ● Notify all staff of the importance of performance appraisals and probationary reports to the mission of Heman G. Stark Youth Correctional Facility. ● Instruct the personnel officer to log all delinquent appraisals and reports, including all contacts with supervisors and managers. This log should be submitted to the superintendent monthly and made a topic of management meetings. ● Provide a copy of the above log to the education administration at the Heman G. Stark Youth Correctional Facility. ● Work with the education administration to hold supervisors and managers accountable for the timely generation of performance appraisals and probationary reports. ● Include this responsibility in supervisors’ and managers’ own performance expectations and appraisals. FINDING 10 Facility safety and security could be enhanced There have been no escapes or suicides at the Heman G. Stark Youth Correctional Facility during Superintendent Ruiz’s tenure. The last escape was eight years ago and the last suicide was in 1997. However, the Office of the Inspector General found that the following areas of facility safety and security could be improved: ● Living units do not have suicide risk lists. The California Youth Authority Institutions and Camps Branch Manual, Section 5528, requires the establishment of suicide risk lists in ward living units to make staff aware of wards who are at risk of committing suicide. However, only six (55%) of 11 living units the auditors visited had suicide risk lists. Moreover, while Section 5530 directs staff to intervene immediately in the event of a suicide attempt, most staff did not have the equipment to quickly handle suicide attempts by hanging. Of the 11 STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 38 living units visited, only one (9%) had a suicide cut-down kit. Although this living unit (I/J Team) houses the most emotionally disturbed wards, suicide is a risk in any living unit. Staff in the living units without cut-down kits agreed the units should have them. • Random searches are not conducted. Random searches of all persons (including custody and non-custody employees) and their possessions is a necessary part of institutional security. Without such searches, contraband such as drugs and weapons can enter the facility, and state property can be stolen by people leaving the facility. The California Youth Authority, recognizing the importance of such searches, provides search guidelines in Sections 5065 through 5075 of the California Youth Authority Institutions and Camps Branch Manual and requires submitting to searches as a condition of employment. While the visitor search program was found to be effective, the Office of the Inspector General noted that security personnel are not thoroughly or randomly searching institution staff at the vehicle sally port or the main entrance to the facility. This is especially important because random drug tests of 1,892 wards in fiscal year 1998-99, resulted in 48 (2.5%) wards testing positive, indicating that drugs are being introduced into the facility. Moreover, a number of staff stated that they believed drugs and other contraband are being introduced by a small number of employees. • Section 5066 of the California Youth Authority Institutions and Camps Branch Manual search guidelines requires that visitor searches and results be logged. This requirement is important because the facility has the right to suspend visitation privileges of visitors found to have brought contraband into the facility. The Office of the Inspector General determined that this information is not logged. Without a written record of the information, there is less likelihood that undesirable visitors can be kept out of the institution. RECOMMENDATION In order to improve safety and security at the Heman G. Stark Youth Correctional Facility, the Office of the Inspector General recommends that Superintendent Ruiz take the following actions: ● Ensure that all living units maintain suicide risk lists and are equipped with cut-down kits. ● Ensure that security personnel conduct thorough random searches of employees (custody and non-custody) and their possessions at the vehicle sally port and the main entrance to the facility. ● Require the logging of visitor searches and their results. FINDING 11 The ward information network system has numerous weaknesses. The California Youth Authority’s ward information network system can be a valuable tool in managing voluminous amounts of ward information. However, the Office of the Inspector General found that the system lacks certain general controls intended to guarantee the reliability of the computer-processed data. Specifically, auditors discovered that facility staff have unrestricted access to the ward information network system, a breach of physical security that STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 39 has provided the opportunity for the system at Heman G. Stark Youth Correctional Facility to be “custom programmed” without a California Youth Authority system analyst’s knowledge or approval. Further, auditors determined that there is no formal protocol for facility staff to submit ward information network programming requests to the California Youth Authority and no California Youth Authority protocol for confirming that requests and suggestions have been received and are being considered. This has resulted in incorrect or incomplete programming of certain applications in Heman G. Stark Youth Correctional Facility’s ward information network system. In the area of education, for example: • The system does not delete all parolees from class rosters. Facility staff members have documented instances in which students continue to appear on teachers’ class rosters after having been discharged from the institution. This creates a difficult situation for teachers, security, program administrators, and for the office staff who are issuing the daily absence lists. A student who has left the institution is supposed to have all of his classes automatically purged by the ward information network system. In some instances, however, the system is failing to remove such students from the class roster. • School rosters are incorrect. School rosters printed by living unit staff do not reconcile with teacher’s rosters. This inconsistency creates confusion in the movement of wards to school, which is a safety concern. It also can affect school attendance. A ward signed up for school but not identified on the living unit movement roster is not delivered to school. As a result the ward is marked absent. There are instances in which a ward who is not assigned to school is delivered to class. These wards must then be returned to their living units. • The high school graduation plan is not automated on the ward information network system. This deficiency requires six registrars to spend an estimated one month to complete that project by hand for all 1,200 non-graduates at the institution. Further, the ward information network system does not contain data on the grade level for each student. Without this information, the institution cannot efficiently administer the Stanford Test of Academic Skills under the mandatory Standardized Testing and Reporting System. • Class count reports are incomplete. The ward information network class count report fails to list information on classrooms numbered in the range of 10 through 100. Staff noted that a “glitch in the ward information network system doesn’t allow (staff) to print classes between (room numbers) 10 and 100.” • Grade point averages are not included in the ward information network system. The Heman G. Stark Youth Correctional Facility annually awards a plaque to the graduating ward with the highest grade point average. All grade point averages have to be calculated manually since the grade point average cannot be computed on the ward information network system. In other areas: • The system does not report accurate due dates for ward grievance responses. The ward grievance report itemizes due dates for each grievance 30 calendar days after the “clerk STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 40 received date” of the grievance. As cited in Finding 4 of this report on the ward grievance system, the due date for regular grievances is seven calendar days. The institution ward rights coordinator concurred that the 30-day due date is incorrect. The ward information network system does have a second field to record the correct due date on the menu screen, but this field has not been programmed to print. • Ward trust fund reports are incomplete and misleading. The batch logs produced by the ward information network system do not paginate correctly. On the final record of each page, ward identification information, including the ward's name and California Youth Authority number, is left off the report so that it appears that the transaction appearing at the bottom of the page belongs to the preceding ward. • Ward canteen rosters are incomplete. Some names are omitted from the canteen roster used to allow wards to purchase items. These omissions cause delays in canteen operations because canteen staff members have to telephone the accounting office to obtain information on the fund balances of wards who were omitted. RECOMMENDATIONS To improve the usefulness of the ward information network system, the Office of the Inspector General recommends the California Youth Authority take the following actions: ● Review California Youth Authority policies and procedures governing the ward information network system to ensure that they accomplish the following: ● Restrict access to the ward information network system consistent with sound general and application controls. ● Control and prioritize ward information network system programming requests consistent with the needs of the California Youth Authority, the institutions, and other parties. ● Provide feedback to the institutions and other ward information network system users regarding the status of their programming requests. ● Enforce the above policies and procedures by periodically auditing the ward information network system system. In addition, the Office of the Inspector General recommends that the superintendent develop the appropriate requests to correct known system deficiencies including those cited above. STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 41