OIG
OIG 2022 Use of Force Monitoring Report
Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General
of the
OFFICE
OIG
INSPECTOR GENERAL
Independent Prison Oversight July 2023
Monitoring the Use-of-Force
Review Process of the
California Department
of Corrections and
Rehabilitation
Electronic copies of reports published by the Office of the Inspector General
are available free in portable document format (PDF) on our website.
We also offer an online subscription service.
For information on how to subscribe,
visit www.oig.ca.gov.
For questions concerning the contents of this report,
please contact Shaun Spillane, Public Information Officer,
at 916-288-4233.
Connect with us on social media
STATE of CALIFORNIA
OIG OFFICE of the Amarik K. Singh, Inspector General
INSPECTOR GENERAL Neil Robertson, Chief Deputy Inspector General
Independent Prison Oversight
Regional Offices
Sacramento
Bakersfield
July 3, 2023
Rancho Cucamonga
The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California
Dear Governor and Legislative Leaders:
Enclosed is the Office of the Inspector General’s report titled Monitoring the Use-of-Force Review Process
of the California Department of Corrections and Rehabilitation. This is the Office of the Inspector General’s
sixth annual report, as mandated by California Penal Code sections 6126 (j) and 6133 (b) (1). This report
addresses 890 of the California Department of Corrections and Rehabilitation’s (the department) use-of-
force incidents that occurred, and for which the department closed its review, between January 1, 2022,
and December 31, 2022.
In this report, we present six monitored incidents in which we identified significant concerns. We include
our findings based on several incidents in which officers did not adequately de-escalate a situation prior
to using force. We also include our findings regarding the department’s use of body-worn and fixed
cameras. Finally, we provide an update to recommendations made in our prior reports regarding the
department’s supervisors’ and managers’ failures to address policy violations identified during use-of-
force incidents and the department’s failure to implement a policy to require prisons to complete a review
of incidents in a timely manner if deferred during the prison’s initial review.
Based on concerns we identified in our monitoring, we provided three recommendations to the
department: 1) to reinstate its communication and de-escalation training as a mandated course to
be completed by all custody staff at least one time each year; 2) to impose progressive discipline for
supervisors and managers who fail to identify and address violations of policies, procedures, and training
as they relate to the use of force; and 3) to implement a policy that requires that all deferred use-of-force
incidents be reviewed by the institution executive review committee or the department executive review
committee within a specific time frame.
Sincerely,
Amarik K. Singh
Inspector General
Gavin Newsom, Governor
10111 Old Placerville Road, Suite 110
Sacramento, California 95827
Telephone: (916) 255-4212
www.oig.ca.gov
Return to Contents
ii | Monitoring the Use-of-Force Review Process, January – December 2022
(This page left blank for reproduction purposes.)
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | iii
Contents
Summary 1
Introduction 3
Background 3
Use-of-Force Options 3
Reporting and Review Requirements 5
Scope and Methodology 7
Monitoring Results 9
Highlighted Incidents of Significant Concern 9
The OIG Continues to Identify Many Incidents in Which
Officers Failed to Use De-Escalation Techniques Prior to
Using Force 21
Body-Worn and Fixed Cameras Have Been Successful
in Identifying Possible Misconduct, but Supervisors and
Managers Do Not Consistently Review All Relevant
Video Imagery 25
The Department Has Not Adequately Addressed
Recommendations in Our Prior Report 28
Recommendations 31
Office of the Inspector General, State of California
Return to Contents
iv | Monitoring the Use-of-Force Review Process, January – December 2022
Illustrations
Figures
1. Distribution of the Application of Force in 890 Use-of-Force
Incidents We Monitored 4
2. Distribution of the 890 Use-of-Force Incidents the OIG
Monitored by Division and Other Entities 6
Tables
Use-of-Force Policy: Definitions of Common Terms vi
Other Terms Used in This Report vii
1. Prisons With Body-Worn Cameras or Fixed Audio-Video
Surveillance Systems in 2022 25
Photographs
1. The Incarcerated Person Stopped Walking
as Officers Approached 10
2. The Incarcerated Person Did Not Display Aggressive Behavior 10
3. The Officer Grabbed and Squeezed an Incarcerated
Person’s Face, Which the Officer Failed to Report 12
4. Two Images of the Weapon Manufactured by an Incarcerated
Person, Which Was Used in the Attack 16
5. Officers Did Not Adequately De-Escalate the Situation and
Used Physical Force When the Incarcerated Person Sat
on the Floor, Refusing to Return to His Cell 23
Graphics
The Office of the Inspector General’s Mandate Concerning
the Use of Force v
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | v
T
he Inspector General
shall monitor the
department’s process
for reviewing uses of
force and shall issue
reports annually.
— State of California
(Penal Code section 6126(j))
Office of the Inspector General, State of California
Return to Contents
vi | Monitoring the Use-of-Force Review Process, January – December 2022
Use-of-Force Policy: Definitions of Common Terms
The force used in an institutional or facility setting when an
incarcerated person’s presence or conduct poses a threat to
Controlled Use of safety or security, and the incarcerated person is located in an
Force area that can be controlled or isolated. These situations do not
normally involve the imminent threat to loss of life or imminent
threat to institutional security.
Department The Department Executive Review Committee (DERC) is a
Executive Review committee of staff selected by, and including, the associate
Committee director who oversees the respective mission-based group.
More force than is objectively reasonable to accomplish a
Excessive Force
lawful purpose.
Great Bodily Injury Any bodily injury that creates a substantial risk of death.
The force used to respond without delay to a situation or
Immediate Use of
circumstance that constitutes an imminent threat to institution/
Force
facility security or the safety of persons.
Any situation or circumstance that jeopardizes the safety
of persons or compromises the security of the institution,
Imminent Threat requiring immediate action to stop the threat. Some examples
include, but are not limited to, an attempt to escape, ongoing
physical harm, or active physical resistance.
The Institution Executive Review Committee (IERC) is a
Institution Executive
committee of executive staff at each prison tasked with
Review Committee
reviewing all reported use of force incidents.
The force that an objective, trained, and competent
correctional employee, faced with similar facts and
Reasonable Force circumstances, would consider necessary and reasonable to
subdue an attacker, overcome resistance, effect custody, or
gain compliance with a lawful order.
A serious impairment of physical condition, including, but
not limited to, the following: 1) loss of consciousness, 2)
Serious Bodily Injury concussion, 3) bone fracture, 4) protracted loss or impairment
of function of any bodily member or organ, 5) a wound
requiring extensive suturing, and 6) serious disfigurement.
Unnecessary Force The use of force when none is required or appropriate.
Source: Article 2, Use of Force, 51020.4 “Definitions,” California Department of Corrections and Rehabilitation,
Adult Institutions, Programs, and Parole Operations Manual. The publication is commonly referred to as the DOM.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | vii
Other Terms Used in This Report
Sworn peace officers at all levels within an institution or
Custody Staff
facility.
The secretary of the department, the general counsel, an
undersecretary, or any chief deputy secretary, executive
officer, chief information officer, assistant secretary, director,
Hiring Authority deputy director, associate deputy director, associate
director, warden, superintendent, health care manager,
regional health care administrator, or regional parole
administrator.
Source: The department’s DOM.
Office of the Inspector General, State of California
Return to Contents
viii | Monitoring the Use-of-Force Review Process, January – December 2022
(This page left blank for reproduction purposes.)
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 1
Summary
This is the Office of the Inspector General’s sixth annual report, as
mandated by California Penal Code sections 6126 (j) and 6133 (b) (1), which
addresses the California Department of Corrections and Rehabilitation’s
(the department) use-of-force incidents. During this reporting period,
we monitored 890 use-of-force incidents that occurred on or after
January 1, 2022, and for which the department completed its review on or
before December 31, 2022.
Through our monitoring methodology, we assessed staff members’
actions prior to, during, and following each use-of-force incident we
monitored. Because we do not personally observe the use-of-force
incidents that we review, we monitor and assess the department’s
compliance with its use-of-force policies and procedures by reviewing
documentation and other evidence the department maintains and makes
available to us.
In this report, we highlight six incidents of particular concern, including
incidents involving possible staff misconduct that the department failed
to address; a departmental staff member who failed to provide use-of-
force documentation and video recordings, which impeded our ability to
effectively monitor the use-of-force process; and an incident in which a
hiring authority refused to request video recordings from an outside law
enforcement agency that revealed a departmental agent had used and
observed force, but failed to report it.
Additionally, we identified 113 incidents in which the involved officers
had the opportunity to de-escalate the situation prior to using force.
In 44 of those incidents (39 percent), officers failed to effectively
communicate with the incarcerated person or did not adequately
attempt de-escalation strategies. In 2017, the department implemented
mandated training to improve staff communication skills and further its
commitment to resolving conflicts and crises at the lowest level when an
imminent threat is not present. Until 2020, the department included this
training in its required annual training program, but due to the novel
coronavirus pandemic restrictions, the department removed this portion
of the training from the mandatory training schedule. Consequently,
we recommend the department reinstate its de-escalation course as
mandated training for all custody staff.
We monitored 466 incidents that were captured on video recordings. The
department did not add fixed or body-worn cameras to any new prisons
in 2022, but it plans to add body-worn cameras at four prisons and
fixed cameras at 11 prisons in 2023. We are encouraged by some of the
successes of video-recording implementation. Even so, we have concerns
that supervisors and managers did not always evaluate an adequate
amount of video recordings during the review process to determine
whether staff had fully complied with policy and procedures.
Office of the Inspector General, State of California
Return to Contents
2 | Monitoring the Use-of-Force Review Process, January – December 2022
We also provide an update to two concerns and recommendations
made in our last report. First, the department’s supervisors and
managers continue to perform poorly when reviewing use-of-force
incidents and identifying policy and training violations. We identified
367 incidents (41 percent) in which one or more reviewers failed to
identify policy violations. In our last report, we recommended that the
department evaluate its policy to ensure supervisors and managers
capture deviations. The department responded that the current policy is
sufficient to identify deviations and to hold reviewers accountable when
they do not. Despite the department’s assurances, we identified that
hiring authorities provided corrective action to supervisors and managers
who failed to address the deficiencies in only 62 cases (17 percent).
Finally, the department has yet to implement a policy to ensure that
use-of-force incidents which are deferred during an initial executive
review committee meeting are returned to the committee in a timely
manner to resolve outstanding issues and close the use-of-force incident.
In our last report, we noted our concerns regarding the lack of policy
to return incidents to the committee for closure, and we identified
several incidents with extensive delays between initial and final
reviews. To address unreasonable delays, we recommended that the
department develop and implement a policy to require prisons to return
deferred incidents to the committee for closure in a timely manner.
The department responded, stating it has drafted a memorandum and
a new policy to address deferred cases. As of the date of this report, the
department has not implemented a new policy regarding time lines for
deferred cases.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 3
Introduction
Background
Nearly 25 years ago, in the class-action lawsuit Madrid v. Gomez, the
federal court found, among other things, that officials with the California
Department of Corrections1(the department) “permitted and condoned a
pattern of using excessive force, all in conscious disregard of the serious
harm that these practices inflict” in violation of the Eighth Amendment
of the United States Constitution.2
As a result of those findings, in 2007, the Office of the Inspector General
(the OIG) began monitoring the department’s use-of-force review
process. In 2011, after the department made significant improvements to
reform its use-of-force review and employee disciplinary processes, the
federal court dismissed the case. However, as mandated by the California
Penal Code, section 6126 (j), we continue to monitor the department’s
process for reviewing uses of force and to issue an annual report with
our findings.
Use-of-Force Options
According to departmental policy, when determining the best course of
action to resolve a particular situation, staff must evaluate the totality of
the circumstances, including an incarcerated person’s demeanor, mental
health status and medical concerns (if known), and that person’s ability
to understand and comply with orders. Policy further states that staff
should attempt to use verbal persuasion, whenever possible, to mitigate
the need for force. When force becomes necessary, staff must consider
the specific qualities of each force option when deciding which options
to use, including the range of effectiveness of the force option, the level
of potential injury, the threat level presented, the distance between staff
and the incarcerated person, and the number of staff and incarcerated
persons involved. Departmental policy authorizes several force options,
which include chemical agents; hand-held batons; physical strength
and holds; less-lethal weapons;3 and lethal weapons (firearms). See
Figure 1, next page, for the distribution of these applications for this
reporting period.
1. In 2005, the California Department of Corrections was renamed the California
Department of Corrections and Rehabilitation. In 2005, the California Department of
Corrections was renamed the California Department of Corrections and Rehabilitation.
2. Madrid et al. v. Gomez (Cate) et al., 889 F. Supp. 1146 (N.D. Cal. 1995), January 10, 1995.
3. A less-lethal weapon has the appearance of a firearm, but fires less-lethal projectiles,
made of foam, rubber, or wood. A less-lethal weapon has the appearance of a firearm, but
fires less-lethal projectiles, made of foam, rubber, or wood.
Office of the Inspector General, State of California
Return to Contents
4 | Monitoring the Use-of-Force Review Process, January – December 2022
Figure 1. Distribution of the Applications of Force in the 890 Use-of-Force
Incidents We Monitored
1,165
(44%)
N = 2,646
974
(37%) Applications
of Force
292
(11%)
162 50
(6%) (2%) 3
(< 1%)
Chemical Physical Less-Lethal Expandable Other † Mini-14
Agents * Strength Projectiles Baton
and Holds
* Chemical agents include oleoresin capsicum (OC), CN gas, and CS gas.
† Other includes the use of a shield, nonconventional uses of force, and a taser.
Note: Percentages may not sum to 100 percent due to rounding.
Source: The Office of the Inspector General Tracking and Reporting System.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 5
Reporting and Review Requirements
The department is divided into different divisions, including the
Division of Adult Institutions, the Division of Juvenile Justice, and
the Division of Adult Parole Operations. Although each division is
distinct, the divisions have a similar process for reviewing and evaluating
use-of-force incidents.
The Division of Adult Institutions’ policy requires that the reporting and
review process begin after any use of force. This policy requires that staff
who use or observe force submit a written report prior to being relieved
of duty.4
After staff complete their reports, a lieutenant, a captain, and an
associate warden review the complete incident package for content and
sufficiency. Each reviewer may request that staff clarify their respective
reports if any lack clarity or detail. Each reviewer then completes a
critique and independently determines whether staff complied with
policy, procedures, and training. The final level of review at the prison
occurs at the executive review committee meeting, which is chaired
by the warden or chief deputy warden and attended by other prison
managers. Ultimately, the committee chair determines whether staff
complied with policy, procedures, and training. For minor violations,
he or she may order corrective action to address the violation. For more
serious violations, the chair may refer the matter to the department’s
Office of Internal Affairs for an investigation.5
Policy requires a higher level of review by departmental executives for
incidents involving a warning shot from a lethal weapon and incidents
in which an incarcerated person sustains serious bodily injury that could
have been caused by staff’s use of force. The department’s executive
review committees are chaired by the associate director of the respective
mission in which the incident occurred, and the committee is required to
review the incidents within 60 days of the institution’s completed review.
Number of Use-of-Force Incidents
We monitored 890 use-of-force incidents that occurred on or after
January 1, 2022, and the department completed its review on or before
December 31, 2022. Most of the incidents we monitored occurred at
adult prisons (812), with a smaller share occurring in juvenile facilities
(47), or within the communities where offenders were on parole (17)
(Figure 2, below). We also reviewed a few incidents of force applied
by the department’s Office of Correctional Safety (14), which acts as a
liaison with other law enforcement entities and apprehends fugitives in
the community.
4. DOM, Section 51020.17.
5. DOM, Section 51020.19.
Office of the Inspector General, State of California
Return to Contents
6 | Monitoring the Use-of-Force Review Process, January – December 2022
Figure 2. Distribution of the 890 Use-of-Force Incidents the OIG Monitored, by Division
and Other Entities
Office of Correctional Safety
14 (2%)
Division of Adult Parole Operations
17 (2%) N = 890
47 812 Division of Adult
(5%) Incidents (91%) Institutions
Division of Juvenile Justice
Source: The Office of the Inspector General Tracking and Reporting System.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 7
Scope and Methodology
Scope
The 890 incidents that we monitored occurred on or after
January 1, 2022, and were reviewed and closed by the department on or
before December 31, 2022. There were 7,592 use-of-force incidents that
occurred within the department during this period, but if the review
and closure of a monitored incident occurred after December 31, 2022,
we include our assessment of that incident in a future report.
We randomly selected 552 of the 890 incidents we monitored. In
addition, our inspectors reviewed nearly all of the department’s use-
of-force incidents to select another 338 incidents based on their
characteristics (e.g., serious bodily injury to an incarcerated person
caused by force, a riot, a controlled use of force, incidents involving
possible misconduct) and the workload of our inspectors.
Between January 1, 2022, and December 31, 2022, our inspectors
visited every adult prison and juvenile facility,6 as well as the northern
and southern parole regions, and attended 501 of the department’s
1,580 review committee meetings (32 percent).
Methodology
The OIG monitors the department’s adherence to its policies,
procedures, and training concerning the use-of-force and the
department’s subsequent review process. To evaluate the effectiveness
of the department’s process of handling use-of-force incidents and
its compliance with policies and procedures, our staff review various
rules and regulations relevant to the department’s use-of-force
practices. We also review the department’s use-of-force policy, related
training modules, and other applicable operational policies. To further
understand the department’s procedures, we also observe use-of-force
training at some prisons.
Because we did not personally observe use-of-force incidents, our
assessments relied on departmental staff’s written accounts of each
incident and recordings from fixed cameras or body-worn cameras,
when available.7
6. The department currently operates 34 adult prisons and three juvenile facilities. The
department closed Deuel Vocational Institution on September 30, 2021.
7. In 2022, a total of nine prisons had fixed or body-worn cameras. The department did not
implement cameras at any more prisons in 2022.
Office of the Inspector General, State of California
Return to Contents
8 | Monitoring the Use-of-Force Review Process, January – December 2022
Following a review of the use-of-force incident documentation, our
inspectors attended the prisons’ review committee meetings. Although
our inspectors served as nonvoting attendees at these meetings, they
provided real-time feedback and recommendations to the committees.
The latter may include recommending obtaining clarifications from
involved staff when the initial report is not clear, recommending
corrective action for policy violations, or recommending a referral to the
Office of Internal Affairs in instances in which our inspectors identified
potential staff misconduct. For some cases in which we disagreed
with the hiring authority’s decision, we elevated the matter to the
department’s executive management for consideration.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 9
Monitoring Results
While overall the department performed adequately in a majority of
the 890 incidents we monitored, we expect the department to perform
well in all aspects prior to, during, and following each incident, and to
proactively identify and address deficiencies once realized. In this report,
we provide our stakeholders with transparent assessments of incidents
and issues we identified that are of significant concern.
Highlighted Incidents of Significant Concern
An Officer Used Unreasonable Force on An Incarcerated
Person Who Posed No Threat to the Officer and Submitted
an Inaccurate Report, Yet Department Officials Refused to
Acknowledge the Existence of Potential Misconduct and Failed
to Refer the Incident for Investigation
In this incident an officer did not attempt to de-escalate his initial
interaction with an incarcerated person. The officer subsequently used
unreasonable force against the person even though the person did not
pose an imminent threat to the officer’s safety. In addition, the officer’s
report deviated significantly from the actions captured by the officer’s
body-worn camera. After we raised these concerns with managers at the
institutional and executive levels, the department failed to address the
policy violations and apparent misconduct we brought to its attention.
This case involved an incarcerated person who was a participant in
the department’s mental health program in the Enhanced Outpatient
Program (EOP) level of care. The incident occurred on the exercise yard
of the prison’s designated EOP yard. According to the officer’s report,
the incarcerated person reported to his job at the culinary operation,
but refused the required clothed-body search. The officer ordered the
incarcerated person to return to his cell, to which order the incarcerated
person initially complied by starting to walk across the exercise yard
toward his housing unit. The officer’s report stated that the incarcerated
person then began to “demonstrate odd aggressive behavior kicking
his bowl onto the ground and yelling something incoherently.” The
incarcerated person started to walk back towards the culinary operation
and that he “appeared to be angry with a strained scowl on his face.”
The officer stated that to “de-escalate” the situation, he instructed the
officer working in the tower to “put the yard down,” which is a signal
to activate an audible alarm and announce over the loudspeaker that the
incarcerated people should lie or sit on the ground. The initial officer
reported that the incarcerated person continued to advance toward him.
To effect custody, the initial officer took control of the incarcerated
person’s wrist and shoulder, turned the incarcerated person away
from him, and then placed handcuffs on the incarcerated person
(see Photos 1 and 2, following page.)
Office of the Inspector General, State of California
Return to Contents
10 | Monitoring the Use-of-Force Review Process, January – December 2022
Photo 1. The incarcerated person stopped walking as officers approached.
Photo 2. The incarcerated person did not display aggressive behavior.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 11
Our initial concern with the report involved the officer’s attempt to
“de-escalate” the situation by instructing the tower officer to activate
the alarm and order the yard down. Activating an alarm and ordering
the yard down is not a department trained de-escalation tactic to use
with an incarcerated person with mental health concerns who does not
pose an imminent threat. However, the more concerning issues appeared
after we reviewed the body-worn camera recording from the incident,
which showed significant discrepancies compared with the officer’s
report, including:
• The body-worn camera recording revealed that the officer
was on the opposite side of the chain-link yard fence from the
incarcerated person, a detail not provided in the officer’s report.
To engage the incarcerated person, the officer had to unlock a
gate and enter the exercise yard, where the incarcerated person
could have been contained if necessary.
• The incarcerated person appeared incoherent, and at one point,
held his hand up to his ear, as if he did not understand what the
officer was telling him. The incarcerated person did not appear
to make eye contact with the officer.
• The incarcerated person stopped walking approximately 10 to 15
feet from the officer, which contradicted the officer’s report that
the incarcerated person “continued to advance towards me.”
• The officer ordered the incarcerated person to “Get on the
fucking ground! I’m not playing with you, man.” This verbal
order was not included in the officer’s report.
• The officer’s report also did not include any mention of
the officer’s use of physical force which he applied to push
the incarcerated person against the yard fence while he
applied handcuffs.
Reviewing staff did not identify any policy violations during any of the
different levels of review that occurred before the incident was presented
at the prison’s executive review committee. During the prison’s executive
review committee meeting we raised the concerns noted above, but
the committee chair—an associate warden—stated he had no concerns
with the officer’s actions and had no concerns with the differences in
the officer’s report compared with his body-worn camera imagery. We
attempted several times to raise our concerns with the warden, who has
since retired, but received no response.
We elevated the incident to the associate director of the department’s
High Security Mission who agreed to review the incident. Nearly one
month later, we received an email that stated, “The High Security
Mission has carefully reviewed [the incident] and has determined no
further action will be taken.” We disagreed with the associate director’s
Office of the Inspector General, State of California
Return to Contents
12 | Monitoring the Use-of-Force Review Process, January – December 2022
position and believe the officer’s actions should have been referred to the
Office of Internal Affairs for investigation.
An Officer’s Body Camera Showed that the Officer Used
Excessive Force and Failed to Report It, Yet the Department
Refused to Refer the Officer’s Actions for an Investigation
In another concerning incident, an officer reported that he used physical
force on an incarcerated person during an escort, but the officer’s body-
worn camera revealed the officer had used excessive force that he failed
to report. The officer reported that, during the escort, the incarcerated
person dropped his body and thrust his body backward, toward the
officer. The officer reported that he used force by placing his hand on
the incarcerated person’s back and pushed him toward the ground,
where he and another officer “rolled [the incarcerated person] onto his
stomach to stop his resistance.” Based on the officer’s report, the use-of-
force appeared to be justified and appropriate. The officer’s body-worn
camera, however, revealed that after the officer pushed the incarcerated
person to the ground, he grabbed the incarcerated person’s face and
squeezed it for approximately four seconds, which the officer neglected
to report (see Photo 3, below).
Photo 3. The officer grabbed and squeezed an incarcerated person’s face, which the officer failed to report.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 13
The first-level review at the prison (conducted by a lieutenant
identified that the officer used unreasonable force when he grabbed
the incarcerated person’s face. During the prison’s executive review
committee meeting, we recommended that the officer’s misconduct be
referred to the Office of Internal Affairs, but we learned that the warden
had already issued a nonpunitive Letter of Instruction to the officer for
using unreasonable force. The Letter of Instruction did not address the
officer’s failure to report the force—a separate allegation of misconduct
that the OIG recommended be referred to the Office of Internal Affairs,
but the warden declined.8
We elevated the issue to the associate director of the department’s High
Security Mission, who reviewed the matter and returned the incident
to the prison “for further review and contemplation of Administrative
Review.” When we contacted the acting warden for a status update—
the previous warden had retired—the acting warden responded that he
had not reopened the case “due to a backlog of [incidents].” We notified
the acting warden that the statute of limitations to impose disciplinary
action was rapidly approaching, and he responded that the previous
warden made a decision and that he, as the new acting warden, was not
going to take any further action.
When we relayed the acting warden’s failure to address the issue to the
associate director, one of the associate director’s subordinates responded
that the warden had “determined the [Letter of Instruction] was
sufficient” and that “based on the corrective action given, the [warden]
cannot complete an admin review and discipline [the officer] again. Also,
the [statute of limitations] is soon to expire.”
The response from the associate director’s office is flawed because the
warden never issued corrective action against the officer—and never
disciplined him—for failing to report his unreasonable use of force.
Further, the non-punitive letter of instruction did not preclude the
warden from referring the allegations to the Office of Internal Affairs.
A Departmental Investigator Stopped an Inquiry and Informed
the Warden that a Reasonable Belief of Misconduct Existed,
but the Warden and Departmental Management Refused to
Refer the Matter to the Office of Internal Affairs, Causing the
Officers’ Actions to Go Unaddressed
In this incident, supervisors and managers at the prison, and a
departmental investigator, determined there was sufficient evidence to
believe that officers used unreasonable force, yet the warden failed to
refer the officers’ alleged misconduct to the Office of Internal Affairs.
8. According to the department’s employee disciplinary matrix, an officer’s failure to
report his or her own unreasonable force carries a base penalty of dismissal (DOM,
Section 33030.19).
Office of the Inspector General, State of California
Return to Contents
14 | Monitoring the Use-of-Force Review Process, January – December 2022
Officers escorted an incarcerated person to his cell. As the officers
removed the handcuffs, the incarcerated person pushed his arm through
the closed cell door’s food port. Officers used physical force and chemical
agents to attempt to gain control of the incarcerated person’s hands
and push them back through the food port. The lieutenant, the captain,
and an associate warden who reviewed the incident all agreed that
the officers violated policy by using immediate force, and instead, the
officers should have initiated a controlled use of force.9
Pursuant to policy, the prison paused its review of the incident because
the incarcerated person alleged the officers used unreasonable force,
and referred the allegation to the department’s Allegation Inquiry
Management System (AIMS). The AIMS investigator, who had not yet
conducted any interviews, stopped his inquiry and returned the case to
the prison, concluding, “This allegation inquiry was stopped based upon
the belief of the investigator that a reasonable belief of misconduct likely
to result in adverse action has been reached.”
An associate warden reviewed the incident and allegation during the
prison’s executive review committee meeting—nearly three months
after the AIMS investigator determined there was a reasonable belief of
misconduct—and concluded that the officers did not violate any policy.10
We were not provided with any documentation to indicate that the
warden, who has since retired, reviewed the matter after it returned from
AIMS, and he did not respond to our requests to review the incident and
alleged misconduct.
We elevated our concerns to the associate director of the department’s
High Security Mission, who reviewed the matter and returned the
incident to the prison “for further review and contemplation of
Administrative Review.” Similar to the previous incident discussed in this
report in which an officer used excessive force and failed to report it, the
acting warden failed to refer the matter to the Office of Internal Affairs
and allowed the statute of limitations to expire.
We notified the associate director that the acting warden took no
action in response to the associate director’s request that the warden
review the incident further. One of the associate director’s subordinate
managers responded to the OIG, stating that the warden did not sustain
the allegation and had closed the incident. The manager also asserted
that the warden could not refer the matter again for the same allegation.
This response is inconsistent with the associate director’s earlier
response. If the associate director believed the warden could not take
9. DOM, Section 51020.11.3, requires the officer to verbally order the incarcerated person to
relinquish control of the food port. If the incarcerated person does not relinquish control,
the officer shall back away and advise a supervisor of the situation. Controlled force may be
initiated while custody staff continues to monitor the incarcerated person.
10. Departmental policy states that the institution head (warden) or chief deputy warden
shall normally serve as the chairperson and final decision maker at the executive review
committee meeting (DOM, Section 51020.19.5).
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 15
any further action, there would have been no reason to return the matter
to the prison for “further review and contemplation of Administrative
Review.” The response is also inconsistent with information we reviewed
indicating that the warden never actually reviewed the matter after the
AIMS investigator returned it to the prison because of their opinion that
a reasonable belief of misconduct existed. Contrary to the manager’s
response, the previous inquiry by AIMS did not prevent a formal
investigation. In fact, when the inquiry reveals sufficient information
to warrant an investigation, departmental policy requires the warden to
refer the matter to the Office of Internal Affairs.11
Officers Failed to Supervise a Dayroom Filled with Incarcerated
People, Which Provided One Incarcerated Person the
Opportunity to Stab a Second Incarcerated Person 82 Times,
Killing Him
In this incident, two officers were assigned to posts that required them
to be physically present on a dayroom floor and monitor the actions of
the incarcerated people in the dayroom. A third officer was assigned to
monitor the dayroom from a control booth. For reasons the department
was unable to explain, the officer assigned to the control booth left the
building, and one of the officers assigned to the floor entered an office,
instead of remaining at his assigned post on the dayroom floor. The
second-floor officer assigned to monitor the incarcerated population by
walking the floor was reassigned to the control booth. Therefore, there
were no officers physically on the floor of the dayroom to monitor the
incarcerated population’s activity. There were at least 22 incarcerated
people in the dayroom at the time of the incident. During this period,
one incarcerated person attacked and murdered another incarcerated
person. While one officer remained in an office, the other floor officer
who was now working in the control booth, was observing medication
distribution in another housing unit when he heard yelling. That control
booth officer eventually responded to the area of the attack and fired two
less-lethal rounds at one of the involved incarcerated people to stop the
attack. At the time of the incident, there were no officers physically on
the floor of the dayroom to monitor the incarcerated population.
The medical examiner who conducted the autopsy determined that the
deceased incarcerated person had been stabbed 82 times, which caused
his death (on the following page, see Photo 4 for two views of the weapon
used in the attack). We provided our concerns to the warden that, based
on the documentation and photographs of the incident, it was clear
this was a substantial, extended, and intense attack. It occurred while
the two officers assigned to monitor the incarcerated population were
absent from the housing-unit dayroom. One officer was reassigned
and observing medication distribution in another housing unit and the
other officer was inside an office. Despite these obvious concerns, the
11. DOM, Section 31140.14.
Office of the Inspector General, State of California
Return to Contents
16 | Monitoring the Use-of-Force Review Process, January – December 2022
warden refused to consider them
and chose not to take any action in
response to what appears to have
been a significant neglect of duty
by these officers. We elevated the
matter to an associate director, who
acknowledged the officers were
absent from the dayroom during
the incident. However, the associate
director, without the benefit of an
investigation, concluded there was
“absolutely no misconduct” on the
part of the officers and refused to
refer the incident to the Office of
Internal Affairs for an investigation.
Photo 4. Two views of the weapon that was manufactured
by an incarcerated person, which was used in the attack
(above and right).
Staff’s failure to properly
supervise incarcerated
persons gave one
incarcerated person
the opportunity to stab
and murder another
incarcerated person
and, the department’s
associate director
failed to address the
potential misconduct.
A Warden Failed to Hold an Officer Accountable for Firing a
Less-Lethal Projectile Round at a Distance That Exceeded What
Department Policy Allows
In another incident, two incarcerated people attacked and stabbed a third
incarcerated person on a recreation yard. To stop the attack, officers
used chemical agents and fired two 40mm less-lethal sponge rounds
at the attackers from an elevated post (observation tower). The rounds
struck the ground without striking the incarcerated person who was
the intended target. We reviewed the video recording and photographic
evidence of the incident, which showed that the officer appeared to have
fired the less-lethal rounds beyond the maximum distance of 105 feet
permitted by the department’s training, which states: “Staff shall not
deploy any impact munitions beyond [their] maximum effective range,”
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 17
and “Firing a projectile beyond its maximum effective range will reduce
its effect once it strikes its target and increases the likelihood of missing
the target.”12
In response to a recommendation in our 2020 report, the director of
Adult Institutions issued a memorandum which directed wardens
to complete a diagram or schematic for each of
their elevated posts with markings that delineate the
maximum range for each type of less–lethal rounds
currently in use at their institution. This will include
observation yard towers, control booths, dining
halls, etc. Each completed diagram or schematic
shall then be posted in each elevated post where
any less–lethal ammunition is used.
. . . . .
Firing a projectile beyond the maximum effective
range will reduce its efficacy once it strikes its target
as the projectile loses its velocity and accuracy. As
distance increases, the likelihood of missing the
intended target increases. All approved munitions
shall not be utilized outside of the guidelines of the
manufacturer’s recommendations.
One of our inspectors physically examined the scene of this incident
with a sergeant and confirmed that the officer fired the less-lethal round
many feet beyond the maximum distance of 105 feet that departmental
policy allows. The inspector entered the tower and confirmed the prison
had posted the schematic diagram, visible to staff assigned to the tower,
which depicted the maximum distance officers were permitted to fire
each type of less-lethal round. The sergeant agreed with the OIG that
the round had been fired from beyond the maximum distance permitted.
During the executive review committee meeting, we raised concerns
about the officer firing the round from beyond the maximum distance.
The warden disagreed with both the department’s training and the
department’s memorandum reminding staff that they cannot fire a less-
lethal weapon from a distance beyond the weapon’s maximum range.
The warden ignored these clear policy violations, closed the incident,
and determined that staff acted in accordance with policy, procedures,
and training.
12. California Department of Corrections, Basic Correctional Officer Academy, Impact
Munitions and Assuming an Armed Post.
Office of the Inspector General, State of California
Return to Contents
18 | Monitoring the Use-of-Force Review Process, January – December 2022
A Prison’s Use-of-Force Coordinator Impeded Our Review of
Use-of-Force Incidents by Failing to Provide Us With Necessary
Documents in Violation of the Penal Code, and the Warden
Failed to Timely Address the Misconduct
At one prison, a use-of-force coordinator failed to provide our
inspector with multiple use-of-force-related documents which included
staff reports that describe details of the use-of-force incident, and
incarcerated people’s medical information that identifies potential
injuries an incarcerated person may have received during an incident. We
identified more than 20 occasions in which the prison failed to provide
some, or all, of the use-of-force records necessary for our inspector to
appropriately monitor these incidents. When prison staff do not provide
all necessary records, we cannot properly monitor use-of-force incidents
and may not identify potential staff misconduct and policy violations that
we would otherwise be aware of if we had all relevant documents.
California Penal Code section 6126.5 specifically identifies that the
OIG has unfettered access to the department’s records and requires
departmental officials to grant the OIG access to its information and
records. The code states:
(a) Notwithstanding any other law, the Inspector
General during regular business hours or at any
other time determined necessary by the Inspector
General, shall have access to and authority
to examine and reproduce any and all books,
accounts, reports, vouchers, correspondence files,
documents, and other records, and to examine the
bank accounts, money, or other property of the
Department of Corrections and Rehabilitation in
connection with duties authorized by this chapter.
Any officer or employee of any agency or entity
having these records or property in their possession
or under their control shall permit access to, and
examination and reproduction thereof consistent
with the provisions of this section, upon the request
of the Inspector General or the Inspector General’s
authorized representative. (c) Any officer or person
who fails or refuses to permit access, examination,
or reproduction, as required by this section, is guilty
of a misdemeanor.
Our inspector and the inspector’s supervisor contacted the warden
several times in person, by email, and telephone regarding the failure
to provide use-of-force related documents to our inspector. Initially,
the warden failed to address the conduct of his staff. However, after
further discussion with the warden, he did begin the progressive
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 19
discipline process with the use-of-force coordinator through training and
corrective counseling. However, the use-of-force coordinator still failed
to send all use-of-force incident packages to our inspector. We elevated
our concern to an associate director, and he reported he was unable to
direct a warden to take any particular action and was only able to make
recommendations for the warden to address our concerns.
However, approximately nine months after we initially brought our
concerns to the warden, he issued disciplinary action (salary reduction)
to the use-of-force coordinator for their failure to provide us with the
documents we need to perform our use-of-force reviews. Despite this
issuance of the disciplinary action, the same use-of-force coordinator has
again failed to provide multiple use-of-force related documents to our
inspector, as recently as May 2023. This failure raises significant concern
that the department is unwilling to hold its staff, including supervisors
and managers, accountable for their conduct.
Even more concerning is the department’s impeding our ability to carry
out our statutory responsibilities. The department’s failure to provide
all records related to a use-of-force incident prevents us from providing
transparent and independent oversight of the State’s prison system. As
referenced above, the penal code is very clear regarding our access to
department records, and we expect departmental managers to be fully
aware of our authority. The need for OIG staff to continually remind
departmental staff of our authority to request and receive documents
is unacceptable.
The Department Failed to Request Video Recordings From
Another Law Enforcement Agency of the Department’s Officers
Using Force
The department’s Office of Correctional Safety provides investigative,
and security services for the department, and serves as a liaison for
the exchange of information with other law enforcement agencies and
Governor’s Office of Emergency Services. The Office of Correctional
Safety conducts the majority of its work outside the prisons, frequently
alongside other law enforcement agencies that use and maintain video-
recording technologies.
In February 2020, during an executive review committee meeting we
recommended the Office of Correctional Safety request and review
any video recordings, including body-worn, fixed, and in-car camera
recordings that may have captured the department’s staff using force.
The Office of Correctional Safety agreed with our recommendation.
In March 2022, we monitored a use-of-force incident that occurred
inside a local detention facility when special agents from the Office of
Correctional Safety were in the process of transferring an individual
to the local jurisdiction. At the local facility, the individual continually
Office of the Inspector General, State of California
Return to Contents
20 | Monitoring the Use-of-Force Review Process, January – December 2022
refused to stay seated on a bench as the agents were processing the
individual into the local facility. After several verbal warnings, an agent
[Special Agent 2] used physical force to gain compliance of the individual.
The executive review committee reviewed this use-of-force incident,
and determined the agents acted within policy and training, but none of
the reviewing supervisors, managers, or the hiring authority requested
or reviewed the video recording of the incident. We recommended the
department obtain and review the video recordings.
Not until 157 days after the incident occurred did the department
request and review the video recording of this incident which depicted
the actions of the Office of Correctional Safety agents. In response to
the department’s reviewing the video recording, the hiring authority
submitted a request for an investigation based on the incident video. The
deputy chief who served as the chair of the executive review committee
meeting reported that
upon review of the video it appears [Special
Agent 1] may have observed some of the above-
described force used by [Special Agent 2]. Also,
it is possible [Special Agent 2] used his hands and
body weight on the arrestee to keep him from
standing up. However, the camera angle and
resolution does not conclusively reveal whether
[Special Agent 2] used force.
The video of the incident revealed an agent [Special Agent 2] used
physical force to restrain an individual, appeared to observe the physical
force used by another agent and, failed to report the force used and
observed. The investigation determined a special agent [Special Agent
2] failed to report he used and observed force during this incident, and
the hiring authority issued disciplinary action (salary reduction) to the
special agent. However, the hiring authority failed to address the actions
of the managers and the supervisor who reviewed the incident and failed
to identify misconduct during their review.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 21
The OIG Continues to Identify Many Incidents
in Which Officers Failed to Use De-Escalation
Techniques Prior to Using Force
The department’s use-of-force policy directs staff in the
following manner:
It is the expectation that staff evaluate the totality
of circumstances involved in any given situation,
to include consideration of an inmate’s demeanor,
bizarre behavior, mental health status if known, [and]
medical concerns, as well as ability to understand
and/or comply with orders, to determine the best
course of action and tactics to resolve the situation.
Whenever possible, verbal persuasion should be
attempted to mitigate the need for force.13
Staff are also reminded of this expectation in the department’s
Communication and De-escalation training course: “It is extremely
important to reduce the need to use force by first attempting to
effectively communicate with inmates,” and “In order to avoid potentially
violent situations when an imminent threat is not present, verbal de-
escalation should be attempted.”14
Of the 890 use-of-force incidents we monitored in 2022, we identified
113 incidents in which the involved officers had the opportunity to
de-escalate the situation prior to using force. In 44 of those incidents
(39 percent), officers either failed to effectively communicate
with the incarcerated person or did not adequately attempt de-
escalation strategies.
The de-escalation failures occurred at multiple prisons, but several
cases at one prison in particular illustrate the concern. We identified
24 incidents in which officers at the prison appeared to use force on an
incarcerated person without attempting to de-escalate the situation. We
raised the concern to the warden, who agreed with our position and told
us he would provide de-escalation training to the prison’s supervisors
and managers. After the conversation with the warden, we observed some
improvement in the prisons’ managers identifying issues and taking
appropriate actions to de-escalate situations. In one instance, officers
used immediate physical force on an incarcerated person who refused to
leave an exercise yard, but who posed no imminent threat.
13. DOM, Section 51020.5.
14. California Department of Corrections and Rehabilitation, Basic Correctional Officer
Academy, Communication, and De-escalation Techniques.
Office of the Inspector General, State of California
Return to Contents
22 | Monitoring the Use-of-Force Review Process, January – December 2022
The reviewers found the actions out of policy, and the executive review
committee ordered corrective action for the officers because they should
have considered a controlled use-of-force and did not attempt to de-
escalate the situation prior to using force.
Soon after, however, we identified additional deficiencies that went
unaddressed by the prison’s supervisors and managers. When we raised
this concern to the warden, he changed his earlier position and told us
that de-escalation is a “gray area” and he “can’t really tell the officers
how to handle those situations.” We elevated several incidents to the
associate director of the department’s High Security Mission, all of
which had included similar circumstances and involved an incarcerated
person who refused to comply with an officer’s orders, but posed no
imminent threat. In our opinion, officers had the opportunity to de-
escalate the situation prior to using force, but failed to do so.
• One case that illustrates the above concern involved an
incarcerated person in the department’s mental health program,
a participant at the Enhanced Outpatient Program (EOP) level
of care.15 While recalling incarcerated people in a housing unit’s
dayroom, an officer ordered an incarcerated person to return to
his cell. The incarcerated person stated, “I am not going back
to my cell.” The incarcerated person walked toward his cell,
dropped an item of clothing near his cell door, then continued
to tell officers that he would not go back into his cell. When an
officer approached the incarcerated person to apply handcuffs,
the incarcerated person sat on the floor next to the officers’
podium. An officer could be heard on the radio, stating, “I have
an inmate refusing to take it back to his cell, sitting on the
floor.” The officers then sounded an audible alarm and used
physical force to place handcuffs on the incarcerated person.
In our opinion, the officers did not adequately attempt to de-
escalate the situation prior to using physical force. Furthermore,
the incarcerated person posed no imminent threat to the
officers to justify their use of immediate force.16 (See Photo 5,
following page.)
15. The Enhanced Outpatient Program (EOP) provides the most intensive level of
outpatient mental health care within the department’s Mental Health Services Delivery
System (MHSDS). The program is characterized by a separate housing unit and structured
activities for mentally ill inmate-patients who, because of their illness, experience
adjustment difficulties in a General Population (GP) setting, yet are not so impaired as to
require 24-hour inpatient care. Mental Health Services Delivery System Program Guide
Overview.
16. DOM, Section 51020.4: “Immediate use of force is the force used to respond without
delay to a situation or circumstance that constitutes an imminent threat to institution/
facility security or the safety of persons. Immediate force may be used without prior
authorization from a higher official. Immediate force may be necessary to subdue an
attacker, overcome resistance or effect custody. If it is necessary to use force solely to gain
compliance with a lawful order, controlled force shall be used.”
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 23
Photo 5. Officers did not adequately de-escalate the situation and used physical force when the
incarcerated person sat on the floor, refusing to return to his cell.
In July 2017, the department deployed the multiple interactive learning
objective (MILO) simulator to improve staff communication skills and
further its commitment to resolving conflicts and crises at the lowest
level when an imminent threat is not present. The training consisted
of numerous prison-based, interactive scenarios conducted by certified
instructors who direct the scenario based on the participant’s verbal
interaction, which is projected on a screen in front of the participant.
The scenarios do not initially present the participant with an imminent
threat. However, depending on the participant’s ability to use de-
escalation techniques, the scenario may present a threat that requires the
participant to deploy a use of force.
According to the lesson plan, the techniques are designed to prevent
situations from escalating as well as aid participants in identifying
incarcerated people with mental illness or cognitive impairment. The
lesson plan acknowledges that failure to recognize and respond to
incarcerated people who are in conflict or crisis may result in future
litigation for the department.
Until 2020, the MILO training was included in the department’s required
annual training for correctional staff, but due to the novel coronavirus
pandemic restrictions, the department removed this training module
from the mandatory training schedule. In January and February 2023,
we contacted several prisons and discovered that none were currently
offering MILO training and that de-escalation training had not been
provided to custody staff for the past three years. The training unit at
the department’s academy confirmed that MILO had not been reinstated
as a required course even though the pandemic restrictions have been
nearly eliminated. According to the lieutenant with whom we spoke, the
Office of the Inspector General, State of California
Return to Contents
24 | Monitoring the Use-of-Force Review Process, January – December 2022
department intends to implement the training again later this year, but
the course’s reimplementation still needs final approval.
In our last report, we raised the same concern and recommended that
the department evaluate its current policies and training objectives
as they relate to communication and de-escalation. Unfortunately,
the department declined to take any action in response to our
recommendation, responding, “Currently policy is sufficient, and the
department will not be making any changes to its current training and
policies.” In our opinion, the current policy and curriculum are not
sufficient without mandated, regularly scheduled classes to train staff on
de-escalation techniques.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 25
Body-Worn and Fixed Cameras Have Been
Successful in Identifying Possible Misconduct,
but Supervisors and Managers Do Not
Consistently Review All Relevant Video Imagery
In September 2020, a United States District Court ordered the
implementation of video-surveillance cameras and body-worn cameras
at the Richard J. Donovan Correctional Facility to achieve compliance
with the Armstrong Remedial Plan. The remedial plan mandated that
the department draft policies and procedures regarding camera use and
the retention period for video recordings obtained through cameras.
In March 2021, the Court ordered similar remedial measures at five
additional prisons.17
In 2022, a total of nine prisons had fixed cameras, and six prisons used
body-worn cameras (Table 1, below).18 In 2023, the department plans to
implement body-worn cameras at an additional four prisons, and fixed
cameras at an additional 11 prisons.
Table 1. Prisons With Body-Worn Cameras or Fixed Audio-Video
Surveillance Systems in 2022
Audio-Video
Surveillance Body-Worn
Prison System Camera
California Institution for Women
California State Prison, Corcoran
California State Prison, Los Angeles County
California State Prison, Sacramento
Central California Women’s Facility
High Desert State Prison
Kern Valley State Prison
R. J. Donovan Correctional Facility
Substance Abuse Treatment Facility (Corcoran)
Source: The California Department of Corrections and Rehabilitation’s Audio-Video
Surveillance System and Body-Worn Camera Implementation Schedule.
17. The five prisons included in the 2021 Remedial Plan include California Institution
for Women; California State Prison, Corcoran; Kern Valley State Prison; California
State Prison, Los Angeles County; and Substance Abuse Treatment Facility and State
Prison, Corcoran.
18. Cameras were not implemented at any new prisons during our 2022 monitoring period.
Office of the Inspector General, State of California
Return to Contents
26 | Monitoring the Use-of-Force Review Process, January – December 2022
We monitored 466 incidents in 2022 that were captured on body-worn
cameras, fixed cameras, or both.19 We acknowledge that the ability to
recall every detail may be impaired during a use-of-force incident, and
there may be minor discrepancies between an officer’s written report and
the recording from the body-worn or fixed camera. For example, if an
officer wrote in his report that he applied pepper spray to an incarcerated
person from a distance of eight feet, but the recording revealed that the
officer sprayed the incarcerated person from closer to six feet, we would
not take exception to the discrepancy. Rather, our assessment included
whether staff reports contained material differences from the events
captured on body-worn or fixed cameras. We identified several incidents
in which we believed the video recording revealed a material difference
that could not be attributed to a staff member’s inability to recall.
One prison’s response to discrepancies identified on the prison’s fixed
cameras was particularly alarming. We identified at least 18 incidents
in which video recordings showed that medical staff were present
during a use-of-force incident but either failed to report the use-of-force
they appeared to observe or failed to submit a report at all.20 In one of
the incidents, an incarcerated person who was sitting on a chair in a
dayroom threw water on an officer after receiving his medication. In
response, the officer physically forced the incarcerated person to the
ground. During the executive review committee meeting we watched the
video recording that was captured by the fixed camera in the dayroom.
The recording revealed several medical providers present in the dayroom
who appeared to see the officer force the incarcerated person to the
ground, but failed to submit a report as required by policy. None of the
prison’s supervisors or managers who reviewed the incident prior to the
executive review committee identified this potential misconduct. We
recommended the hiring authority, an acting warden, refer the matter
to the Office of Internal Affairs for an investigation, as required by
departmental policy. The acting warden refused to refer the case based
on her mistaken belief, that she was unable to address the misconduct
because medical staff do not report to the warden.21 We elevated our
concerns to an associate director and a director, each of whom assured
us that the acting warden would refer all use of force cases involving
potential misconduct for investigation, regardless of staff reporting
structure. After 348 days of the first incident, the acting warden finally
19. The prisons in Table 1 are part of the department’s implementation plan for body-worn
cameras and new fixed-camera systems. The 466 incidents include incidents captured on
those systems in addition to incidents captured on the department’s older camera systems
that exist at certain prisons, but that will eventually be replaced by the newer AVSS.
20. DOM, Section 51020.17: “Any employee who uses force or observes a staff use of force
shall report it to a supervisor as soon as practical and follow up with the appropriate
documentation prior to being relieved from duty.”
21. DOM, Section 33030.19: To illustrate the severity of the misconduct, according to the
department’s disciplinary matrix, the baseline penalty for failing to report force witnessed
is a 10 percent salary reduction for three to 12 months, or suspension without pay for six to
24 work days.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 27
referred the first of the 18 use-of-force incidents described above to the
Office of Internal Affairs. As of this report, the acting warden has still
not referred any of the 17 remaining cases for investigation. Based on the
acting warden’s failure and delay in referring cases for investigation, the
department risks violating the statutory time period in which it has to
address potential misconduct.
Supervisors, managers, and executive review committees do not always
review all relevant video recordings to determine compliance with policy
and training.
The department’s operating procedures for body-worn and fixed cameras
instruct that when preserving recorded data, all angles should be
captured and “not only footage of the actual incident but footage of the
events leading up to the event or subsequent footage following the event,
should be reviewed and copied to the extent that such footage provides a
more thorough picture of the entirety of the incident.”22
Our observations revealed that the incident commander (lieutenant) for
each use-of-force incident has the discretion to determine the length
of video recording they believe is necessary to include for each use-of-
force incident. This discretion may result in only a portion of the actual
incident video recording being submitted for review, as opposed to the
entire video recording which depicted the actions of staff before, during
and after an incident. Similarly, an executive review committee also has
the discretion to watch only a portion of the incident video recording, as
opposed to the entire video recording, which depicted the actions of staff.
If multiple cameras captured the incident, the committee may select
only one recording to watch during the meeting, without considering the
content of the other video recordings.
As we have identified above, de-escalation techniques are an important
process that can reduce or even avoid a use-of-force incident. Having
access to an appropriate amount of a video recording will assist
departmental reviewers in determining whether staff attempted to
communicate with the incarcerated person and resolve the situation
without using force.
We are encouraged by the department’s continued expansion of
surveillance cameras, and will continue to monitor progress, and provide
feedback and recommendations as necessary.
22. Memorandum from the Director of Adult Institutions, June 2, 2021.
Office of the Inspector General, State of California
Return to Contents
28 | Monitoring the Use-of-Force Review Process, January – December 2022
The Department Has Not Adequately Addressed
Recommendations in Our Prior Report
Supervisors and Managers Continue to Fail to Identify Policy
and Training Violations, and Wardens Infrequently Address
the Failures
In three of our last five reports, we identified that during required review
and critique for each use-of-force incident, supervisors and managers
often failed to identify staff’s noncompliance with departmental policy,
procedures, and training. In each report, we recommended that the
department evaluate its review process and ensure that supervisors and
managers are held accountable.
In response to our report published in 2018, the then-acting director
of the Division of Adult Institutions (and the current Secretary of the
department) issued a memorandum reiterating that wardens “shall follow
established monitoring methods for progressive discipline for similar
and/or same violations.”23
In 2020, we published a report raising the same concern and urged the
department to reevaluate the process. The director of the Division of
Adult Institutions, issued a memorandum reiterating the expectation
that “the review process at all levels be thorough and meaningful.” The
memorandum included direction to the wardens “to monitor the levels
of review and impose training or corrective action on those failing to
complete a satisfactory review.”24
In our report published in 2022, we identified 444 incidents (46 percent
of the incidents we monitored) in which one or more reviewers failed to
identify a deficiency in a use-of-force incident. To address that concern,
we recommended that the department develop a method to ensure
that reviewers at all levels adequately review and identify policy and
training violations. We also recommended that the department impose
progressive discipline for supervisors and managers who repeatedly
fail to complete satisfactory reviews. The department declined to take
any action, responding that the current policy contained the language
required to comply with the recommendation.
During this reporting period, we saw little improvement in the area.
We identified 367 incidents (41 percent of the incidents we monitored)
in which one or more reviewers failed to identify policy violations.
However, hiring authorities provided corrective action to supervisors
23. Memorandum, Responsibilities for Tracking Employee Progressive Discipline Related
to the Use of Force, Director of Adult Institutions (Acting), January 11, 2019.
24. Memorandum, Review of Use of Force Incidents, Director of Adult Institutions,
September 1, 2020.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 29
and managers who failed to address the deficiencies in only 62 cases
(17 percent).
While the department’s current policy may contain the language
required to comply with our previous recommendations, we have found
little evidence that hiring authorities follow the policy or the directives
from departmental management to hold supervisors and managers
accountable for not identifying policy violations. The multiple-level
review process is important to ensure that deviations from policy,
including possible misconduct, are identified and corrected.
Despite Our Recommendation in Last Year’s Report, the
Department Has Yet to Implement a Policy to Ensure Deferred
Use-of-Force Incidents Are Reviewed Timely
Departmental policy requires prisons’ executive review committees to
conduct a review of every use-of-force incident. During this review, the
committee may defer closing the incident for a variety of reasons, such
as to request clarification from involved staff, refer potential misconduct
to the department’s Office of Internal Affairs, or refer the case for an
internal administrative review.25 Policy requires the committees to
conduct an initial review within 30 days of the incident, but there is no
policy requirement for the committees to re-review the incident within
a specific period. The requirement to expeditiously review and close-
out incidents is imperative to ensure policy and training violations are
promptly addressed with corrective action to reduce the chance of repeat
offenses. When the hiring authority identifies potential staff misconduct,
he or she has a duty to promptly refer the matter to the Office of Internal
Affairs to ensure the statutory deadlines for imposing disciplinary
actions are met.
In our last report, we noted our concerns regarding the lack of policy to
re-review incidents and identified several incidents with extensive delays
between the initial and final review. To address unreasonable delays, we
recommended that the department develop and implement a policy that
would require deferred incidents be re-reviewed within a timely manner.
The department responded, stating its staff have drafted a memorandum
and new policy to address deferred cases. As of the date of this report,
however, the department has still not implemented a policy setting time
limits for deferred cases to be reviewed.
As of December 31, 2022, 89 incidents remained in deferred status; the
oldest incident was still in deferred status 671 days after the initial review.
25. To our knowledge, administrative review is not a term or process defined in policy. Based
on our observations, hiring authorities use this process to further consider what action, if
any, to take following an incident.
Office of the Inspector General, State of California
Return to Contents
30 | Monitoring the Use-of-Force Review Process, January – December 2022
We appreciate that the department acknowledged our previous
recommendation and plans to implement a new policy to ensure
incidents are re-reviewed in a timely manner after an initial deferral.
However, we made the recommendation in August 2022 and the
department has yet to act, causing further risk that policy violations or
misconduct are not being addressed promptly.
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force Review Process, January – December 2022 | 31
Recommendations
For this reporting period, we offer three recommendations to
the department:
Nº 1. Due to continued concerns regarding officers not adequately
attempting to de-escalate situations prior to using force, the OIG
recommends that the department reinstate its communication and
de-escalation training as a mandated course to be completed by all
custody staff at least one time each year.
Nº 2. The department continues to fail to address all levels of
review, including sergeants, lieutenants, captains, associate
wardens, use-of-force coordinators, and wardens when the
reviewers fail to identify violations of departmental policies,
procedures, and training. We have previously recommended in our
use-of-force reports that the department track and monitor the
levels of review and impose progressive discipline for reviewers
who fail to complete satisfactory reviews. The department
responded it had already addressed this matter with the September
1, 2020, memorandum from a director. Despite this memorandum
being issued, wardens continue to fail to impose progressive
discipline for deficiencies in the review of use-of-force incidents.
We recommend that the department address this continued
deficiency by imposing progressive discipline for supervisors and
managers who fail to identify and address violations of policies,
procedures, and training as it relates to the use of force.
Nº 3. In our 2021 monitoring the use-of-force report, we
recommended that the department develop and implement a policy
to require that deferred use-of-force incidents be re-reviewed by
the prison’s executive review committee in a timely manner and
that the department track the department’s compliance with the
new policy. Despite an associate director verbally reporting that he
would create a workgroup to develop a policy, the department has
not implemented a new policy requiring that deferred use-of-force
incidents be returned to the executive review committee within
a specific time frame. We again recommend that the department
implement a policy which requires that all deferred use-of-
force incidents be reviewed by the institution executive review
committee or department executive review committee within a
specific time frame and impose progressive discipline for hiring
authorities who fail to comply with the policy.
Office of the Inspector General, State of California
Return to Contents
32 | Monitoring the Use-of-Force Review Process, January – December 2022
(This page left blank for reproduction purposes.)
Office of the Inspector General, State of California
Return to Contents
Monitoring the Use-of-Force
Review Process of the California
Department of Corrections
and Rehabilitation
OFFICE of the INSPECTOR GENERAL
Amarik K. Singh
Inspector General
Neil Robertson
Chief Deputy Inspector General
STATE of CALIFORNIA
July 2023
OIG