OIG Semi-Annual Report Volume II January-June 2017

Robert A. Barton Office of the Inspector General Inspector General SEMI-ANNUAL REPORT January-June 2017 Volume II August 2017 Fairness • Integrity • Respect • Service • Transparency Office of the Inspector General SEMI-ANNUAL REPORT January-June 2017 Volume II Robert A. Barton Inspector General Roy W. Wesley ChiefD eputy Inspector General Shmm R. Spillane Public Information Officer August2017 Foreword This 25th Semi-Annual Report covers the time period of January through June 2017. In addition to its oversight of the employee discipline process within the California Department of Corrections and Rehabilitation (CDCR or the department), the OIG also uses a real-time monitoring model to provide oversight and transparency in several other areas within the state prison system. The OIG publishes the Semi-Annual Report in a two-volume format to allow readers to more easily distinguish the various categories of oversight activity. Volume II is a summary of the OIG's monitoring and assessment of the department's handling of critical incidents, including those involving deadly force. It also reports on the department's use-of-force reviews, CDCR's adherence to its contraband surveillance watch policy, and the department's response to the OIG's field inquiries. Since each of these activities is monitored on an ongoing basis, they are combined into one report that is published every six months in this two-volume Semi-Annual Report. We encourage feedback from our readers and strive to publish reports that meet our statutory mandates, as well as offer all concerned parties a useful tool for improvement. For more information about the Office of the Inspector General, including all reports, please visit our website at www.oig.ca.gov. - ROBERT A. BARTON, INSPECTOR GENERAL VOLUME II Table of Contents Summary of Other Monitoring Activities ....................................................................................... 1 Critical Incidents ............................................................................................................................. 2 Crime-Scene Preservation Following Inmate Deaths ............................................................. 4 Prison Rape EliminationAct Incidents ................................................................................... 5 Deadly Force Incidents ........................................................................................................... 6 Negligent Firearm Discharge Incidents .................................................................................. 7 Use-of-Force Monitoring .............................................................................................................. 10 Use-of-Force Meetings Attended and Incidents Reviewed. ................................................... 11 Department Executive Review Committee ............................................................................. 12 Types afForce ....................................................................................................................... 13 Frequency ofUse afForce as an Early-Warning System ..................................................... 15 Division ofA dult Institutions ................................................................................................. 16 Compliance with the Use-of-Force Policy ............................................................................ 19 Apart From Actual Force .............................................................................................. 19 Actual Force Used ......................................................................................................... 20 Non Use afForce ........................................................................................................... 20 Allegation Inquiries ............................................................................................................... 21 Decontamination After Pepper Spray Exposure ................................................................... 21 The Application ofS pit Hoods or Masks ............................................................................... 22 Use afForce onMental Health Inmates ............................................................................... 23 Video-Recorded Interviews ................................................................................................... 28 Division ofJ uvenile Justice ................................................................................................... 29 Division ofA dult Parole Operations ..................................................................................... 31 Office ofCorrectional Safety ................................................................................................. 31 Contraband Surveillance Watch ................................................................................................... 32 Use ofL ow-Dose Body Scans as Reason for Placement on Contraband Surveillance Watch ................................................................................................................ 39 Field Inquiries ............................................................................................................................... 40 Volume II Conclusion ................................................................................................................... 41 Volume II Recommendations ....................................................................................................... 43 Volume II Recommendations from Prior Reporting Periods ....................................................... 44 Appendices .................................................................................................................................... 46 List of Charts Table 1: Number ofS eparate Use-ofF orce Incidents Reviewed, by Division,,,,,,,,,,,,,,, II Table 2: StaffContribution to the Need for Force, by Division,,,,,,,,,,,,,,,,,,,,,,,,,, 14 Table 3: Immediate Force Not Justified, by Division,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 15 Table 4A: Incidents Reviewed and Frequency ofF orce within the Division ofA dult Institutions,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 17 Table 4B: Incidents Reviewed and Frequency ofF orce within the Division ofA dult Institutions (Community Correctional Facilities and Gut-ofState Facilities),,,,,,,, 18 Table 4C: Incidents Reviewed and Frequency ofF orce within the Division ofA dult Institutions (Total Division ofA dult Institutions),,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 18 Table 5: Use ofFo rce, by Mental Health Status, by Institution , , , , , , , , , , , , , , , , , , , , , , , , , , 24 Chart 1: Frequency ofF orce by Type forMe ntal Health Population,,,,,,,,,,,,,,,,,,,,,, 26 Table 6: Frequency ofF orce by Type, Grouped by Mental Health StatuL,, ,,, ,,, ,,, ,,, ,,, 26 Chart 2: Video Recordings, by Mission/Division,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, 29 Table 7: All Contraband Surveillance Watch Cases Reported to the GIG, by Institution, January-June 2017, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, ,, , 33 Chart 3: Duration ofG IG-Monitored Contraband Surveillance Watch Cases,,,,,,,,,,,,,, 34 Chart 4: Contraband Found in GIG-Monitored Cases Lasting Less Than 72 Hours,,,,,,,,, 35 Chart 5: Contraband Found in GIG-Monitored Cases Extending Beyond 72 Hours,,,,,,,,,, 35 Table 8: Contraband Found in Cases Extending Beyond 72 Hours, July 2014 -June 2017 ,,, 36 Chart 6: Contraband Type and Frequency in All GIG-Monitored CaseL ,,, ,,, ,,, ,,, ,,, ,,, 36 Table 9: Contraband Surveillance Watch Cases, by Institution, January -June 2017 ,,,,,,,, 38 Summary of Other Monitoring Activities In addition to the Office of the Inspector General's monitoring of the employee discipline process within the California Department of Corrections and Rehabilitation (CDCR or the department) reported in Volume I, the Office of the Inspector General (OIG) also monitors critical incidents, use-of-force incidents, and contraband surveillance watch cases, and conducts field inquiries. This report summarizes the OIG's monitoring and tracking activities to provide the reader an overview of OIG monitoring activities, and summarizes the monitored incidents in the Appendices attached hereto. The report does not directly correlate to the number of incidents that occurred within this time frame, but rather reflects the number of incidents the OIG assessed and closed for the January through June 2017 reporting period. The OIG maintains a 24-hour contact number in each region to receive notifications. The OIG is able to respond to any critical incident occurring within the prison system 24 hours per day, seven days per week. When timely notified, Special Assistant Inspectors General respond to the scene to assess the department's handling of incidents that pose a high risk for the state, staff, or inmates. Sometimes a Special Assistant Inspector General will respond to the scene even when the department's notification was untimely if the OIG believes the nature of the incident warrants a response. Use of deadly force is the highest monitoring priority among critical incidents. For this reason, the department and the OIG handle these cases with a higher level of scrutiny that includes both criminal and administrative investigations the Office oflnternal Affairs' Deadly Force Investigation Team opens. The OIG monitors these incidents due to the seriousness of the event, but not necessarily because misconduct is suspected. These cases are reported in Appendix D2 of this Volume of the Semi-Annual Report. The OIG also monitors use of deadly force incidents that the Office of Internal Affairs does not investigate and reports these cases in Appendix D I. The OIG also assesses and reports factors leading up to other critical incidents, including the department's response to the incident and the outcome. If appropriate, the OIG makes recommendations. These cases are reported in Appendix E. The department may place an inmate on contraband surveillance watch when suspecting an inmate secreted contraband. The department is required to notify the OIG when placing an inmate on contraband surveillance watch. The OIG monitors the department's use and handling of contraband surveillance watch, with special focus on cases exceeding 72 hours, and reports these cases in Appendix F. Finally, the OIG also provides a process for inmates, CDCR staff, and the public to report misconduct or lodge complaints. The OIG examines complaints and assigns staff members to address field inquiries regarding the complaints. These cases are reported in Appendix G. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 1 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Critical Incidents The department is required to notify the OIG of any critical incident immediately following the event. Critical incidents include serious events that require the department to respond immediately, such as riots, homicides, escapes, uses of deadly force, and unexpected inmate deaths. The following critical incidents require OIG notification: 1. Any use of deadly force, including warning shots or strikes to the head with a baton and/or impact munitions; 2. Any death or any serious injury that creates a substantial risk of death or results in loss of consciousness, concussion, protracted loss or impairment of function of any bodily member or organ, or disfigurement to an individual in the custody or control of the department; 1 3. Any death or serious injury to a department employee if it occurs on-duty or has a nexus to the employee's duties; 4. Any death or serious injury to a parolee or citizen if the death or injury occurs while involved with department staff; 5. Any suicide by an adult individual in the custody or control of the department and any suicide or attempted suicide by a juvenile ward or female inmate in the custody or control of the department; 6. All allegations of rape or sexual assault as defined by the Prison Rape Elimination Act made by an individual in the legal custody or physical control of the department, including alleged staff involvement; 7. Any time an inmate is placed on or removed from contraband surveillance watch or any time an inmate on contraband surveillance watch is transported to a hospital outside of an institution; 8. Any riot or disturbance within an institution or facility that requires a significant number of department staff to respond or mutual aid from an outside law enforcement agency; 9. Any time an inmate is on a hunger strike for more than ten consecutive days, an inmate on hunger strike has lost more than 10 percent of his or her body weight, or when an inmate on hunger strike is transported to a hospital outside of an institution; 10. Any incident of notoriety or significant interest to the public; and 11. Any other significant incident identified by the OIG after proper notification to the department. After notification, the OIG monitors the department's management of the incident. The OIG may respond to the scene or obtain incident reports and follow up at the scene at a later time, depending on the circumstances. The OIG evaluates potential causes of the incident, the department's response, and whether there is possible misconduct or negligence involved. The OIG may make recommendations regarding training, policy, or referral for further investigation of potential negligence or misconduct. If the OIG believes the hiring authority should refer the incident to the Office of Internal Affairs, the OIG monitors the hiring authority's decision. The OIG may monitor an investigation the Office oflnternal Affairs opens. Generally, the OIG 1 As used herein, an individual within the custody and control of the department does not include a parolee. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE2 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA reports critical incidents in the current Semi-Annual Report unless reporting the incident could jeopardize the investigation. In those instances, the Inspector General may decide to withhold a report until the investigation is completed. In conjunction with monitoring incidents involving inmate deaths, the OIG typically also reviews the department's Death Review Committee reports. The committee is comprised of department nurses and physicians who review and analyze medical records regarding every inmate who died while in the department's custody. The committee determines, among other things, the cause of the death, whether the death was preventable, deficiencies in clinical care, and systemic concerns and opportunities for improvement. 2 The assigned OIG monitor reviews the Death Review Committee's report to assist in determining whether the department's actions in response to the death were sufficient and appropriate. The OIG's Medical Inspection Unit members also evaluate the timeliness of the reporting and provide valuable input to the OIG monitor regarding questions on more difficult cases. During this reporting period, the OIG completed assessments of 117 critical incidents, reported in Appendices D and E. Twenty-six of these incidents involved full investigations of use of deadly force. Those 26 incidents are not included in the critical incident statistics, but the OIG's assessments of these incidents are in Appendix D2. The remaining 91 cases pertain to uninvestigated deadly force and other critical incidents the OIG monitored, such as warning shots. The OIG's rating system considers the department's actions prior to, during, and after a critical incident. The OIG rates each incident on all three phases. Each incident may be sufficient or insufficient in more than one phase. Of the 91 critical incident cases, the OIG assessed 42 cases as insufficient in at least one of the assessment ratings. In three cases, the department's actions were insufficient in all three phases, before, during, and after the incident. And, 49 cases were sufficient in all three phases. The details regarding the assessments are found in the Appendices. The OIG relies on the department to provide timely notification of the critical incident so that the OIG can timely respond to the scene and properly monitor an incident at the scene. However, even when notification is untimely, the OIG still monitors the event by collecting reports and conducting follow-up reviews. For cases currently reported in Appendices Dl and E, the department failed to provide timely notification of 9 of the 91 critical incidents, which is 10 percent. Only one of the cases with untimely notification was still assessed as sufficient for all three assessment ratings. Two of the nine cases involving delayed notification involved discharge of a firearm. In one of these cases, the department delayed two days before notifying the OIG that the officer's neglect ofleaving a loaded firearm on a bed at home resulted in the shooting and killing of the officer's one-year-old child. In the second case, an officer allegedly negligently discharged a firearm in an observation booth. The department failed to notify the OIG until the day after the incident, preventing the OIG from providing real-time monitoring of the case. 2 California Correctional Healthcare Services, Inmate Medical Services Policies and Procedures, Volume I, Chapters 29.1 and 29.2. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE3 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The percentage of delayed notifications has improved during the past two reporting periods. During the January through June and July through December 2016 reporting periods, the department did not provide timely notification to the OIG in 20 percent and 18 percent of the cases, respectively. The department's administration previously agreed to emphasize timely notification, and this action seems to be having a positive impact. The OIG looks forward to a continuation of this positive trend in timely notifications. CRIME-SCENE PRESERVATION FOLLOWING INMATE DEATHS During this reporting period, the OIG noted situations wherein staff members prematurely moved inmates' dead bodies, prompting the OIGto make a new recommendation to the department. California Government Code Section 27491.2 provides: a) The coroner or the coroner's appointed deputy, on being informed of a death and finding it to fall into the classification of deaths requiring his or her inquiry, may immediately proceed to where the body lies, examine the body, make identification, make inquiry into the circumstances, manner, and means of death, and, as circumstances warrant, either order its removal for further investigation or disposition or release the body to the next of kin. (b) For purposes of inquiry, the body of one who is known to be dead from any of the causes or under any of the circumstances described in Section 27491 shall not be disturbed or moved from the position or place of death without permission of the coroner or the coroner's appointed deputy. Any violation of this subdivision is a misdemeanor. Three of the cases the OIG is reporting for January through June 2017 were deemed insufficient because staff members moved an inmate's dead body before the coroner's authorization to do so, thereby compromising the preservation of potentially critical evidence and potentially subjecting those involved to misdemeanor criminal charges. In one of these cases, an officer discovered an unresponsive inmate in a cell, and officers and nurses initiated life-saving measures without success. After a physician declared the inmate dead but before the coroner arrived, a lieutenant ordered a nurse to move the inmate's body to the triage and treatment area. The OIG recognized that the department inappropriately moved the inmate's body before the coroner authorized the movement, and the hiring authority provided training to the lieutenant who gave the order. In a second case, another officer found an unresponsive inmate in a cell. This inmate's lips were blue, his body was cold to touch, and he exhibited obvious signs of rigor mortis and lividity to the extent that both arms were frozen in an upward position away from his body. However, officers and nurses initiated life-saving measures, following which they transported the inmate to the correctional treatment center. The OIG again identified that officers moved the inmate's body and searched the cell without the coroner's authorization. The OIG addressed this issue with the hiring authority and, although the hiring authority did not agree there was any staff misconduct, the hiring authority contacted the coroner and district attorney's office to coordinate future expectations. The third case involved another officer who found an unresponsive inmate with a towel wrapped tightly around his neck and the cellmate standing in the cell covered in blood. In this case, not SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE4 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA only did officers move the deceased inmate's body without the coroner's consent, but an officer did not adequately control who entered the crime scene, again thereby compromising the integrity of any investigation. The OIG recommends the department provide training to all custody and medical staff regarding the removal of dead bodies without a coroner's authorization. PRISON RAPE ELIMINATION ACT INCIDENTS In 2003, the United States Congress passed the Prison Rape Elimination Act (PREA), aimed at preventing sexual violence in prison. The California legislature followed suit with the Sexual Abuse in Detention Elimination Act in 2005 and the department instituted a PREA policy in 2006. Before July I, 2015, if an inmate alleged sexual misconduct or assault by a staff member, the department's PREA policy required institutional staff to refer the case to the Office oflnternal Affairs for investigation. If there were criminal allegations, the department was to refer the case to a district attorney's office. There was no procedure for the institution to perform a preliminary inquiry into the allegation. Despite an institution's referral of an allegation to the Office of Internal Affairs, the Office of Internal Affairs routinely denied investigation requests based on its belief there was no corroborating evidence or reasonable belief of misconduct. As a result of the policy, there were cases in which neither the institution nor the Office of Internal Affairs investigated an inmate's allegations ofPREA violations by staff. In 2012, the United States Department of Justice issued a final rule in accordance with PREA that set national standards for protecting inmates. In order to conform to the national standards, the department amended Department Operations Manual Sections 31060, et. seq., 51030.3, 52050.16.4 through 52050.16.6, and 54040, et. seq., effective July I, 2015. The new policies the department enacted in July 2015 restrict hiring and promoting staff members who engaged in sexual violence or sexual misconduct with an inmate and require employees to report sexual violence allegations made against them. The department also added restrictions to clothed and unclothed body searches. The policies require the department to train all staff members regarding preventing, detecting, responding to, and investigating offender sexual violence, staff sexual misconduct, and sexual harassment, with additional training for staff members who perform specialized roles in the PREA process. Institutions are required to take specified preventative measures to minimize staff members incidentally viewing inmates' breasts, buttocks, or genitalia. The policy further requires documentation of any cross-gender unclothed body searches. Institutions must more rigorously review inmate housing assignments. The policy also provides methods for inmates, staff members, and third parties to report sexual abuse and harassment by other inmates or staff members. When an inmate reports alleged sexual misconduct, employees are required to respond with sensitivity while still taking steps to preserve evidence. The hiring authority will assign a Locally Designated Investigator (LDI) to conduct an inquiry. LDis undergo special training for the role. Currently, all institutions have trained LDis. If information obtained indicates a reasonable belief SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGES OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA that staff misconduct occurred, the hiring authority refers the matter to the Office of Internal Affairs for investigation. As part of its duties, the OIG monitors cases involving alleged staff-against-inmate sexual misconduct. During this reporting period, the OIG has no cases to report. There are additional requirements for internal and external audits of the process. In the July through December 2016 Semi-Annual Report, the OIG reported the findings of audits conducted at Wasco State Prison, Mule Creek State Prison, North Kern State Prison, and Folsom State Prison. All were found to comply with PREA standards. Pursuant to a multi-state memorandum of understanding allowing department PRE A-certified auditors to conduct PREA audits, audits were also completed at Chuckawalla Valley State Prison and Ironwood State Prison. In January 2017, the reports issued, reporting both prisons met PREA standards3 DEADLY FORCE INCIDENTS CDCR policy mandates that the Office oflnternal Affairs' Deadly Force Investigation Team conduct deadly force investigations. Deadly force is"[ a]ny use of force that is likely to result in death. Any discharge of a firearm other than the lawful discharge during weapons qualification, firearms training, or legal recreational use of a firearm, is deadly force."4 Use ofless-lethal force methods, such as impact munitions or expandable batons in ways likely to result in death, may constitute deadly force. Examples include intentional blows to the head or unintentional blows that cause great bodily injury. The Office oflnternal Affairs' Deadly Force Investigation Team is described and regulated by Title 15, California Code of Regulations, Section 3268(a)(20), which specifically states the Deadly Force Investigation Team need not respond to warning shots that cause no injury. Therefore, the Office oflnternal Affairs conducts both administrative and criminal investigations for deadly force incidents except for warning shots. The Office of Internal Affairs will not conduct criminal investigations if an outside law enforcement agency conducts the criminal investigation. The OIG, however, monitors all deadly force incidents, including warning shots. The justification for use of deadly force must be present even for warning shots. The department is required to promptly notify the OIG any time CDCR staff use deadly force. When the OIG receives timely notice of a deadly force incident, a Special Assistant Inspector General (SAIG) immediately responds to the incident scene to evaluate the department's management of the incident. The SAIG also monitors the department's subsequent deadly force investigation, if initiated. The OIG believes on-scene response is an essential element of its oversight role and will continue responding to critical incidents involving all potentially deadly uses of force whenever feasible. The very nature of such an incident warrants additional scrutiny and review, regardless of whether any misconduct is suspected or whether the ultimate result of the force is great bodily injury or death. The Deadly Force Review Board reviews Deadly Force Investigation Team incidents. An OIG representative participates as a non-voting member of this body. The Deadly Force Review 3 Additional information regarding these audits can be found at http://www.cdcrca.gov!PREA/Reports-Audits.html. 4 Title 15, California Code of Regulations, Section 3268(a)(9). SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE6 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Board is an independent body consisting of outside law enforcement experts and a CDCR executive officer. Generally, after the administrative investigation is complete, an Office of Internal Affairs' special agent presents the case to the Deadly Force Review Board. The Deadly Force Review Board examines the incident to determine the extent to which the use of force complied with departmental policies and procedures, and to determine the need for modifications to CDCR policy, training, or equipment. The Deadly Force Review Board's findings are presented to the CDCR Undersecretary of Operations, who determines whether further action is warranted. The OIG has always given the highest level of scrutiny to the department's use of deadly force due to the serious implications involved. During this reporting period, the OIG closed a total of 45 potentially deadly force incidents. These include intentional uses of lethal weapons, unintentional blows to the head, warning shots, and other uses of force that could have or did result in great bodily injury or death. Each incident is summarized in Appendix D, which is broken into two categories. Appendix Dl contains cases the OIG monitored but to which the Office of Internal Affairs did not respond. There are 19 such cases for this period. Cases that the Office of Internal Affairs investigated and the OIG monitored are reported in Appendix D2. There are 26 such cases for this reporting period. The number of cases being reported does not correlate with the actual number of times the Office oflnternal Affairs responded to the scene during this reporting period as the OIG only reports a case once all activity is completed. Of the 26 cases being reported in Appendix D2, the Office of Internal Affairs responded to the scene in 19 cases. In 17 of the 19 cases, as well as in one case where the Office oflnternal Affairs did not respond to the scene, the Deadly Force Investigation Team conducted both criminal and administrative investigations. The department timely and adequately notified the OIG in all but one of the Deadly Force Investigation Team cases reported in Appendix D2. NEGLIGENT FIREARM DISCHARGE INCIDENTS The OIG previously reported concerns regarding an alarming number of incidents involving unintentional discharges of a lethal weapon. During the January through June 2016 and July through December 2016 reporting periods, the OIG reported 9 and 14 cases, respectively. During the January through June 2017 reporting period, the OIG is reporting 16 such cases, the details of which are in Appendices D I and D2. Nine of the sixteen cases currently being reported involve discharges that occurred during weapons safety checks or while attempting to otherwise make the weapon safe, such as attempting to clear or secure the weapon. Two of these nine incidents occurred during training, one of which involved remedial training. Some of these incidents occurred while at a training range while others occurred indoors. The other seven incidents involved negligent discharges at times other than during weapons safety checks. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE7 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA During the July through December 2016 reporting period, the OIG reported two incidents involving the "press-check" maneuver, which consists of inserting an ammunition magazine into the weapon and pulling back on the slide to visually and physically inspect the chamber for the presence of ammunition. During the January through June 2017 reporting period, the OIG is once again reporting two such incidents, both of which are included in the nine incidents referenced above. In one such case, an officer errantly placed his finger on the trigger of a semi-automatic handgun and negligently fired a round inside an observation booth. The round penetrated a wooden rack, struck a Mini-14 rifle that was inside the rack, and came to rest at a steel wall behind the rack. Fortunately, there were no injuries. In the second case being reported, a sergeant dropped a semi-automatic handgun and tried to grab the weapon as it was falling. As the sergeant caught the weapon, the sergeant discharged a round, which struck the cement and fragmented. The incident occurred at the armory and again, there were no injuries. In the July through December 2016 report, the OIG reported an incident involving an officer who, after completing qualification training, cleaned the weapon and realized he had not conducted a proper check of the weapon. Not realizing he had inserted a loaded magazine into the weapon, the officer pulled the trigger, causing the weapon to discharge into the ground. The OIG is once again reporting a similar incident wherein a sergeant failed to notice she inserted a magazine into the weapon after cleaning it during remedial training. The sergeant shot herself but fortunately sustained only minor injury. Another incident involved a control booth officer who discharged a Mini-14 rifle in a control booth while practicing sight alignment with a loaded weapon. Yet another incident occurred when an officer discharged a handgun in an observation area overlooking a dining facility where inmates were eating. The OIG reported a similar incident in the July through December 2016 reporting period involving a firearm discharge inside a classroom with several other people present. In 9 of the 16 cases being reported in the January through June 2017 report, the Office of Internal Affairs conducted an administrative investigation. In all nine cases, the hiring authority sustained the allegations pertaining to negligent discharge. The penalties ranged from a letter of instruction to dismissal. In the case in which the officer was dismissed, there was other misconduct alleged, including dishonesty. In two cases, the hiring authority issued letters of reprimand, and in one case, the hiring authority issued a letter of instruction. In three cases, the hiring authority issued salary reductions, and in two cases, suspensions. In the July through December 2016 report, the OIG referenced a report The Office of the Inspector General for the County of Los Angeles issued in December 2015 addressing a similar 5 problem in the Los Angeles County Sheriff's Department The Office of the Inspector General for the County of Los Angeles conducted a study and found a substantial increase in unintended 5 Walter Katz, Deputy Inspector General, Assessing the Rise in Unintended Discharges Following the Sheriffs Department's Conversion to a New Handgun (December 2015). SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGES OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA discharges between 2012 and 2015, during which time the department transitioned to a new weapon. The Office ofthe Inspector General for the County of Los Angeles found the Sheriff's Department training inadequate but also found that, despite training, some of the discharges were attributable to officers failing to follow basic training to keep the index finger off the trigger until ready to fire. Another reason was the lack of a safety mechanism on the new weapons. Although there were some injuries, it is extremely fortunate that there were no deaths as a result of the incidents the OIG is currently reporting. Several incidents occurred either during training, including remedial training, or while the staff member was trying to make the weapon safe. The department's Deadly Force Review Board previously encouraged the department to examine the appropriateness of the press-check practice. Since not all of the incidents the OIG is currently reporting involved the press-check maneuver, it appears there are other possible problems that need to be addressed. In its July through December 2016 report, the OIG recommended the department take action to address the high rate of negligent discharge incidents. As is being reported in the Volume II Recommendations section at the end of this report, in response to the OIG's recommendation, the department is taking steps to address the problem of negligent firearm discharges. The cases the OIG is currently reporting reinforce the need for these actions. The OIG is encouraged by the department's response to the OIG's recommendations and, due to the potential serious consequences, urges the department to expeditiously follow through with its plan. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE9 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Use-of-Force Monitoring The OIG monitors the department's evaluation of staff uses of force and reports its findings semi-annually. The OIG's monitoring process includes attending Institutional Executive Review Committee (IERC) meetings at the Division of Adult Institutions and Institutional Force Review Committee (IFRC) meetings at the Division of Juvenile Justice, where hiring authorities review and evaluate every use-of-force incident for compliance with policy. As part of its oversight process, the OIG analyzes the department's reports and its reviews, and may make recommendations to the department regarding use-of-force policies and procedures. Any departmental employee who uses force, or who observes another employee use force, is required to report the incident to a supervisor and submit a written report prior to being released from duty. The accuracy and completeness of the report is crucial because the department conducts a multi-tiered review process of the submitted reports. A Deputy Inspector General reviews reports and other evidence related to a use-of-force incident and attends the review committee meetings at all institutions. The OIG developed and designed a monitoring tool to enable the OIG to more accurately track and report on types and frequency of force and injuries, as well as to identify pertinent or troubling trends and to provide more valuable feedback to the department and its public safety stakeholders. This tool enables the OIG to collect more detailed information regarding force used, injuries resulting from the use of force, inmate allegations of unreasonable force, and the review committee meeting itself. The OIG monitors the department's compliance with policies and procedures regarding the use of force, as well as subsequent activities, including the review process. The OIG attends as many use-of-force committee meetings as resources allow, but no less than one meeting each month at each prison, juvenile facility, and parole region. During this reporting period, the department reported conducting 861 use-of-force review committee meetings. Of those, the OIG attended 822 review committee meetings, which is 95 percent. In addition, the OIG attended 19 Department Executive Review Committee meetings and 2 Division Force Review Committee meetings, which are discussed below. The OIG is striving for I 00 percent attendance at all use-of-force review committee meetings. When appropriate, the OIG recommends the hiring authority refer an incident to the Office of Internal Affairs for investigation or approval to take disciplinary action without an investigation ifthere is sufficient evidence already available. If the OIG does not agree with the hiring authority's decision, the OIG may confer with higher level department managers. If the OIG recommends an investigation, the OIG monitors and reports the department's response. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 10 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA USE-OF-FORCE MEETINGS ATTENDED AND INCIDENTS REVIEWED During this reporting period, the OIG monitored and closed 3,936 unique use-of-force incidents and allegation reviews.6 All of the incidents discussed in the sections that follow pertain solely to those cases the OIG closed during this reporting period. In some instances, the review committee may decide to defer a case for further information or clarification. The information contained in this report does not include deferred cases since there are no final determinations for such cases. Before attending a use-of-force meeting, the OIG reviews and evaluates all departmental reports and reviews completed. Department reviewers at each level of review are tasked with evaluating reports, requesting clarifications, identifying policy deviations, and determining whether the use of force was within applicable policies, procedures, and laws. The levels of review are: ( 1) the initial review the incident commander conducts; (2) the first level management review a captain conducts; (3) the second level management review an associate warden conducts; and ( 4) the final review where the use-of-force review committee reviews the matter, with the warden, superintendent, chief, or regional parole administrator, or designee, making the ultimate determination. The OIG monitors the review process and raises concerns, if any. The OIG may recommend clarification if reports are inconsistent or incomplete, and confers with the committee. Through this process, the OIG independently concludes whether the force used complied with policies and procedures, and whether the review process was thorough and meaningful. Table 1 illustrates the cases the OIG closed, by division within CDCR. Table 1: Number o(Separate Use-of-Force Incidents Reviewed, bv Division Division Number of Incidents Reviewed Division of Adult Institutions 3,651 Division of Juvenile Justice 255 Division of Parole Operations 26 Office of Correctional Safety 4 Total 3,936 Through involvement at the use-of-force meetings, the department followed OIG recommendations to prescribe additional training, pursue employee discipline, obtain additional factual clarifications, or make policy changes in 336 individual cases (9 percent). 6 Allegation reviews involve reviews of inmate allegations of unnecessary or excessive use of force, by inmate appeal or statements to staff members, that are not directly connected with an incident and, therefore, do not have an incident number assigned. The IERC is required to review the allegations. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 11 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA DEPARTMENT EXECUTIVE REVIEW COMMITTEE Pursuant to California Code of Regulations, Title 15, Section 3268(a)(l9) and the Department Operations Manual, Sections 51020.4 and 51020.19.6, the Department Executive Review Committee (DERC) is a committee of staff selected by and including the Associate Director of the respective mission-based group of institutions. The DERC has oversight responsibility and final review authority over the Institution Executive Review Committees. The DERC is required to convene and review the following use-of-force incidents: • Any use of deadly force; • Every serious injury or great bodily injury; • Any death. The DERC also reviews those incidents referred to the DERC by the IERC Chairperson or otherwise requested by the DERC. In the past, the DERC has also reviewed incidents referred by the OIG. The OIG assigns a Deputy Inspector General to monitor DERC reviews. CDCR's Division of Adult Institutions comprises four mission-based disciplines: Reception Centers; High Security; General Population; and Female Offender Programs and Services/Special Housing7 During this reporting period, all four missions held a total of 19 DERC meetings during which they reviewed 48 incidents. The number of incidents reviewed by miSSIOn IS: • High Security - 20 incidents • Reception Center- 12 • General Population - 2 • Female Offender Programs and Services/Special Housing- 14 In addition, the Division of Juvenile Justice conducted two Division Force Review Committee (DFRC) meetings during which they reviewed ten incidents. The DFRC is similar to the Division of Adult Institutions DERC because they also have oversight responsibility and final review authority of the institutional level force review committees at all Division of Juvenile Justice facilities. The OIG attended 19 DERC and 2 DFRC meetings. During this reporting period, the OIG found that an additional 41 cases met the criteria for DERC review but the department did not conduct the review: 24 in the High Security mission; 8 in the General Population mission; 7 in the Reception Center mission; and 2 in the Female Offender Programs and Services/Special Housing mission. The Female Offender Programs and Services/Special Housing mission includes the Community Correctional Facilities. The OIG recommended the DERC review an additional 29 incidents where inmates suffered serious injury or great bodily injury, including I case where deadly force was used. The case involving the use of deadly force involved a three-on-one inmate attack with inmate-manufactured weapons. The attack stopped after a counselor deployed a grenade and an officer fired one shot for effect from 7 All of the female institutions are part of this mission, as well as the California Medical Facility, the California Health Care Facility, Folsom State Prison, and the Community Correctional Facilities. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 12 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA a Mini-14 rifle. There were no injuries as a result of the incident. The use of force was found to comply with policy, and the OIG concurred. TYPES OF FORCE A single incident may involve different types of force and more than one use of force depending on the circumstances. For example, during a riot, officers may use chemical agents, expandable batons, less-lethal force, and lethal force to address varying threats as the riot progresses. The department also distinguishes between immediate and controlled use of force. Departmental policy defines immediate use of force as the force used to respond without delay when there is an imminent threat to institution or facility security or the safety of persons. Employees may use immediate force without prior authorization from a higher official. Controlled use of force is the force used in an institution or facility setting when an inmate's presence or conduct poses a threat to safety or security and the inmate is located in an area that can be controlled or isolated. Controlled uses of force must also be video recorded. These situations do not normally involve the immediate threat of loss of life or immediate threat to institution security. In January 2016, the department revised its policy to require the use of controlled force if the sole purpose of using force is to gain compliance with a lawful order. All controlled use-of-force situations require the authorization and presence of a first- or second-level manager or, during non-business hours, an Administrative Officer of the Day (AOD). Staff must make every effort to identify disabilities, including mental health concerns, and note any accommodations that may need to be considered when preparing for a controlled use of force. Use-of-force review committees evaluate the types of force used and whether involved staff members complied with use-of-force and related policies. Some of the factors evaluated include the decontamination of inmates following pepper spray exposure, video-recorded interviews, inmate escorts post-incident, and completion of documentation. In the vast majority of cases, the type of force used is appropriate for the situation and does not become an issue for discussion. During this reporting period, staff contributed to the need for force in 65 of the 3,936 incidents closed, which is approximately 2 percent of the cases. While there were varying reasons staff contributed to the need for the use of force, the main reasons were:8 1. Initiating an immediate use of force when there was no threat or when a controlled use of force was appropriate (27 incidents); 2. Improperly opening or failing to secure a cell door or food port, or releasing an inmate (15 incidents); and 3. Failing to de-escalate a situation (8 incidents). In four incidents, staff members initiated the incident. In one case, a visual recording captured an officer verbally challenging an inmate. In a second incident, an officer argued with and used profanity toward an inmate. In a third case, an officer grabbed an inmate's wrist before verbally ordering the inmate to submit to handcuffs. In the fourth case, an officer reopened a cell door 8 Staff may have contributed to the need for the use of force for more than one reason in the same incident. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 13 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA after an inmate made a comment to him as he was being let into his cell. Some other reasons staff contributed to the need for force included ordering an inmate to submit to a medical examination that was not required, failing to listen to an inmate's complaint of pain, or not allowing the inmate to eat for the proper length of time. Table 2 reflects the numbers of cases where staff contributed to the need for force. Table 2: Staff Contribution to the Need (or Force, by Division Total Incidents Where Staff Division Use-of-Force Contributed to the Percentage Incidents Need for Force Division of Adult Institutions 3,651 57 1.6% Division of Juvenile Justice 255 6 2.4% Division of Adult Parole 26 2 7.7% Office of Correctional Safety 4 0 0% Total 3,936 65 1.7% In nine cases, the department imposed disciplinary action, and in one case, the hiring authority referred the matter to the Office of Internal Affairs. The OIG concurred with these determinations. The department provided training or counseling in 50 cases, and the OIG concurred. The hiring authority did not take any action in five cases, and the OIG disagreed in all five. In four of those cases, the OIG disagreed with the hiring authority's finding that the actual use of force complied with policy. In the fifth case, the hiring authority found the actions prior to the use of force to comply, but the OIG disagreed. Overall, the OIG concurred in over 92 percent ofthe cases. Inmates alleged staff violated policies and procedures, or made statements that could be interpreted as allegations of staff misconduct, in 656 of the 3,936 cases the OIG closed during this reporting period, which is 17 percent. This is an increase over the 14 percent reported during the last reporting period. Apart from inmate allegations, the OIG found that staff used immediate force when no force was justified in 70 ofthe 3,936 incidents, which is less than 2 percent. The vast majority of these incidents involved the use of physical force or pepper spray when there was no imminent threat or when a controlled use of force should have been initiated. Three cases involved accidental discharge of pepper spray. In one case, an officer fired a pepper ball launcher when there was no threat and in another case, an officer fired a less-lethal round instead of initiating a controlled use of force. Table 3 on the following page outlines the number of cases by division where immediate force was not justified. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 14 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA Table 3: Immediate Force Not Justified, bv Division Total Incidents Where Division Use-of-Force Immediate Force Percentage Incidents Not Justified Division of Adult Institutions 3,651 56 1.5% Division of Juvenile Justice 255 14 5.5% Division of Adult Parole 26 0 0% Office of Correctional Safety 4 0 0% Total 3,936 70 1.8% FREQUENCY OF USE OF FORCE AS AN EARLY-WARNING SYSTEM The OIG provides wardens with regular reports that show the frequency of force in specific locations and with specific staff. For example, during the January through June 2017 reporting period, the OIG identified 14 officers at 7 different institutions who were involved in ten or more use-of-force incidents. The highest number of incidents in which any officer was involved was 14 incidents. Two officers were each involved in 14 incidents, each officer at a different institution. All 14 incidents at each institution occurred on the same facility. One ofthese officers was also involved in 19 use-of-force incidents reported in the July through December 2016 reporting period. Although the number of incidents involving the same officers is less than reported during the July through December 2016 reporting period, there are still several officers involved in multiple use-of-force incidents, and many of them are involved in the same incidents. While there could be many explanations for officers to be involved in multiple uses of force, this report is primarily used as a tool for the wardens to determine ifthere are potential areas for improvement or to identify risks as it relates to use of force. Another example of how this report and communication with the wardens has benefited the institutions is illustrated when OIG reported that three officers with the highest number of incidents at the same institution were working on the same facility. The facility, which has an inmate population in the Enhanced Outpatient Program (EOP), tended to have frequent inmate fights, resulting in the need for force. The OIG met with the hiring authority at this institution regarding the large number of incidents involving the same officers. The hiring authority was aware of the concerns but still appreciated the report and communication. It is important to note that the uses of force were found to comply with policy and, in the majority of cases, the OIG concurred with the department's review. The OIG maintains an open dialogue with the department to communicate concerns and trends, and to assist in determining whether a particular post or person is potentially at risk. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 15 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA DIVISION OF ADULT INSTITUTIONS Within the four mission-based disciplines under the Division of Adult Institutions, 126,848 inmates were under the department's in-state supervision as of June 30, 20179 Of the 3,936 total use-of-force incidents the OIG closed this period, 3,651 occurred within the Division of Adult Institutions. Table 4A on the next page reflects the number of incidents the OIG closed within the adult institutions during this reporting period. In addition, Table 4B is a separate table for the Community Correctional and Out-of-State Facilities, and Table 4C shows the total numbers. The numbers listed in the column titled "Applications of Force" reflect the numbers of types of uses of force per incident rather than the total number of applications of force. For example, if pepper spray is used three times in one incident, the table only reflects the use of pepper spray once. However, if multiple types of force are used, such as a baton and pepper spray, those applications are reflected as separate applications. As the table reflects, California State Prison, Corcoran had the highest number of incidents and applications of force during this reporting period, with 283 incidents reviewed and 379 applications of force in conjunction with those incidents. California State Prison, Sacramento also reviewed 283 incidents, but with 349 applications of force. California State Prison, Los Angeles County had the second highest number of incidents reviewed, with 247 incidents reviewed, and the second highest applications of force, with 375 applications of force. On the other hand, Chuckawalla Valley State Prison had the fewest number of incidents involving the use of force, with four incidents reviewed and four applications of force. The second fewest incidents occurred at California City Correctional Facility, where the OIG reviewed seven incidents involving nine applications of force. Many variables and conditions can impact any use-of-force incident and, therefore, any conclusions drawn based on this information should be weighed carefully. Factors include the mission, level, and population of the prison, the number of participants, number of responders, accuracy and efficacy of certain force choices, and even weather conditions, since wind may make chemical agents ineffective. This information may be useful, however, in evaluating the possible need for training at particular prisons or identifying areas that may need closer scrutiny so that frequent uses of force do not become commonplace and, consequently, ignored to the detriment of officers or inmates in need of assistance. 9 CDCR data is derived from: http://www. cdcr. ca.gowReports_ Research/Offender_ Information_ Services_ Branch!Monthly!FPOP IAIFPOP 1Adl70 6.pdf. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 16 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Table 4A: Incidents Reviewed and Frequencv o(Force within the Division o(Adult Institutions10 Lethal Less- Force, Institution Incidents Applications Chemical Expandable Other/Non- Institution Physical Lethal Including Identifier Reviewed of Force Agents Baton Conventional11 Force Warning Shots RID R. J. Donovan Correctional Facility 143 157 46% 35% 11% 8% 0% 0% WSP Wasco State Prison 134 184 60% 24% 11% 4% 0"/o 0% NKSP North Kern State Prison 114 140 52% 19% 24% 5% 1% 0% CMC California Men's Colony 95 87 44% 52% 0% 5% 0"/o 0% SQ San Quentin State Prison 95 163 47% 15% 27% 10 "/o 1% 1% CCC California Correctional Center 63 81 40% 32% 10% 17% 0"/o 1% DVI Deuel Vocational Institution 44 62 50% 29% 0% 21% 0"/o 0% CIM California Institution for Men 40 52 54% 27% 12% 6% 2% 0% sec Sierra Conservation Center 38 51 76% 18% 4% 2% 0"/o 0% CRC California Rehabilitation Center 23 28 57% 39% 0% 4% 0"/o 0% COR California State Prison, Corcoran 283 379 43% 32% 13% 7% 4% 0% SAC California State Prison, Sacramento 283 349 47% 34% 11% 6% 2% 0% California State Prison, Los Angeles LAC 247 375 50% 21% 19% 8% 1% 0% County KVSP Kern Valley State Prison 215 335 65% 13% 19% 3% 0"/o 0% SVSP Salinas Valley State Prison 209 276 56% 21% 20% 3% 0"/o 0% CCI California Correctional Institution 159 256 70% 11% 13% 6% 1% 0% HDSP High Desert State Prison 125 188 57% 20% 14% 5% 2% 3% California Substance Abuse SATF 122 163 46% 24% 25% 4% 1% 1% Treatment Facility PBSP Pelican Bay State Prison 50 73 42% 25% 21% 11% 1% 0% CAC California City Correctional Facility 7 9 33% 44% 0% 22% 0"/o 0% MCSP Mule Creek State Prison 176 220 50% 37% 7% 5% 0"/o 0% CAL Calipatria State Prison 126 160 55% 9% 33% 3% 1% 0% SOL California State Prison, Solano 73 90 51% 36% 9% 4% 0"/o 0% CEN Centinela State Prison 64 87 57% 17% 14% 9% 1% 1% PVSP Pleasant Valley State Prison 49 71 61% 25% 10% 4% 0"/o 0% ISP Ironwood State Prison 32 39 49% 21% 15% 13% 3% 0% ASP Avenal State Prison 20 26 73% 15% 0% 8% 4% 0% CTF Correctional Training Facility 18 21 52% 38% 0% 10 "/o 0"/o 0% VSP Valley State Prison 12 14 21% 71% 0% 0% 7% 0% CVSP Chuckawalla Valley State Prison 4 4 75% 0"/o 0% 25% 0"/o 0% CCWF Central California Women's Facility 144 189 47% 47% 2% 3% 2% 0% CHCF California Health Care Facility 131 157 18% 71% 0% 7% 4% 0% CMF California Medical Facility 94 115 55% 32% 0% 12% 1% 0% CIW California Institution for Women 61 64 25% 61% 0% 8% 6% 0% FSP Folsom State Prison 37 60 55% 18% 18% 8% 0"/o 0% 3,530 4,725 51% 30% 10% 8% 1°/o 0°/o Total Incidents Applications Average Average Average Average Average Average CDCR Mission: I Reception Center I High Security I General Population I Female OITender/Special Housing 10 This data is based upon the number of use-of-force incidents the OIG closed during this reporting period. 11 Other/Non-conventional Force includes hand-to-hand combat, use of a shield to apply force, use of an available force tool in an unconventional manner (for example, striking with a chemical agent canister), or other force that utilizes techniques or instruments not specifically authorized in policy, procedure, or training. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 17 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA Table 4B: Incidents Reviewed and Frequency o(Force within the Division o(Adult Institutions (Communitv Correctional Facilities and Out-of-State Facilities)12 Lethal Institution Institution Incidents Applications Chemical Physical L L e e t s h s a ~ l Expandable Other/Non~ In F c o lu rc d e in , g Identifier Reviewed of Force Agents Baton Conventional Force Warning Shots Tallahatchie County Correctional TCCF 44 48 85% 6% SOlo 0% 0% 0% Facility LPCC La Palma Correctional Center 39 43 70% 23% 5% 0% 2% 0% Delano Modified Community DMCCF 22 26 46% 19% 23% 12% 0% 0% Correctional Facility Shafter Modified Community SMCCF 7 7 86% 14% 0% 0% 0% 0% Correctional Facility McFarland Female Community FCRF 6 6 33% 67% 0% 0% 0% 0% Reentry Facility Taft Modified Community TMCCF 3 4 25% 75% 0% 0% 0% 0% Correctional Facility Desert View Modified Community DVMCCF 0 0 0% 0% 0% 0% 0% 0% Correctional Facility 121 134 49% 29% 5°/o 2°/o 0°/o 0°/o Total Incidents Applications Average Average Average Average Average Average Table 4C: Incidents Reviewed and Frequency o(Force within the Division o(Adult Institutions (Total Division o(Adult Institutions) Less- Lethal Force, Incidents Applications Chemical Expandable Other/Non- Physical Lethal Including Reviewed of Force Agents Baton Conventional Force Warning Shots 3,651 4,859 52% 30% 10% 7% 1% 0% Total Total Average Average Average Average Average Average Incidents Applications In addition to tracking types of force, the OIG now also tracks common locations where use-of-force incidents occurred at each institution. Twenty-seven locations statewide had between 20 and 51 use-of-force incidents. The location with 51 incidents was a school area at a juvenile facility. One institution had 42 incidents on the same yard, and a second institution had 30 incidents on the same yard. A total of 17 of the "hotspot" locations were yards and 7 were in housing units, including 1 administrative segregation unit, which had 27 incidents. Additionally, the program type with the highest number of incidents was the Sensitive Needs Yard program at three institutions.13 The two highest numbers of incidents occurred at institutions with level I-IV Sensitive Needs Yard programs. The third highest number of incidents occurred at an institution with level III and IV Sensitive Needs Yard programs. The fourth highest number of incidents was in the general population at one institution, with the fifth highest number of incidents at a juvenile facility. The number of incidents for all of these location program types ranged from 107 to 147 incidents. 12 The OIG started monitoring the Community Correctional Facilities use-of-force incidents on September 13, 2016. 13 Sensitive Needs Yards house inmates with protective custody needs, such as inmates who have been victims of attack, sex offenders, inmates with drug debts, or inmates seeking safety during their incarceration. More information can be found at http :1! www.c dcr.ca.g ov /Blueprint-Update-2016/ An-Update-to-the-Future-of-Califomia Corrections-January-2016.pdf. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 18 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA The OIG also monitors when inmates die or suffer serious or great bodily injury14 as a result of force used. Of the 3,936 incidents the OIG closed between January and June 2017, 58 incidents resulted in serious bodily injury, 1 incident resulted in great bodily injury, and one inmate died following the incident. The incident resulting in great bodily injury involved a two-on-one inmate attempted homicide. Officers used chemical, less-lethal, and lethal force. The officer who used lethal force fired two shots for effect, striking one of the attacking inmates in the hip. The actual uses of force were found to be in compliance with policy. The OIG concurred. The incident involving an inmate death consisted of a large-scale riot in which four warning shots and one shot for effect were fired. The shot for effect struck one of the inmates in the chest resulting in the inmate's death. Other than a chemical agent being used in an improper location, the other uses of force complied with policy, and the OIG concurred. COMPLIANCE WITH THE USE-OF-FORCE POLICY The OIG use-of-force monitoring tool allows the OIG to collect information about whether force used complied with policies and procedures, including whether the department complied with policies and procedures "Apart from Actual Force," "Actual Force Used," and "Non Use of Force." The OIG defines these categories as outlined below. The OIG assesses each incident in all three categories. Therefore, one incident could be discussed in one or more of the three sections addressed below. Overall, the department followed the OIG's recommendations in 336 of the cases the OIG closed during this reporting period. • Apart from Actual Force refers to the department's policies and procedures encompassed within the use-of-force policy, 15 excluding the use of force itself. Examples include whether a medical assessment of the inmate was completed after a use of force, whether reports were thorough and submitted timely, and whether protocols were violated that may have led up to the use of force. • Actual Force Used refers to the force itself. • Non Use of Force refers to activities related to the use of force but not directly within the policy, such as holding cell procedures, escorts, and properly completed medical assessments. Apart From Actual Force For cases the OIG closed during this reporting period, the department found 2,667 out of3,936 incidents within policy for conduct the OIG deems "Apart from Actual Force." This is 68 percent of the total incidents reported and includes 170 incidents in which the department determined not to take action on inmate allegations against staff. 14 As used herein, serious bodily injury refers to injury which results in loss of consciousness, concussion, protracted loss or impairment of function of any bodily member or organ, or disfigurement to an individual in the custody or control of the department. Great bodily injury refers to injury that creates a substantial risk of death. 15 Department Operations Manual. Chapter 5. Article 2. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 19 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The department conducted two internal inquiries. The hiring authority referred 21 cases to the Office of Internal Affairs. For incidents deemed out of policy, the department took disciplinary action in 8 cases, issued counseling in 59 cases, and provided training in 1,057 cases. The department took action on 102 inmate allegations against staff and found 20 incidents involved a reasonable deviation from policy. The OIG concurred with the department's determinations in 3,827 cases, including all cases referred to the Office of Internal Affairs, and disagreed in 109, or 3 percent of cases. Actual Force Used For conduct deemed "Actual Force Used," the department assessed 3,746 of 3,936, or 95 percent, of the incidents within policy. This includes 274 incidents in which the department determined not to take action on inmate allegations against staff. The OIG concurred with the determinations in all but 11 cases, or less than 1 percent. In eight of the cases in which the OIG did not concur with the finding that the use of force complied with policy, the OIG did not believe there was an imminent threat. In another case, the OIG found an officer used a non-approved chemical agent, and in another case, a sergeant failed to give an inmate an order to submit to handcuffs before touching the inmate during a search. In the last case, there were inconsistent reports regarding who placed a spit mask on the inmate. The hiring authority found the use of force to comply with policy but referred the case to the Office oflnternal Affairs for an investigation. Although the OIG agreed with the referral, the OIG did not concur with the finding that the use of force complied with policy because the OIG recommended the hiring authority wait for the outcome of the investigation. The department conducted an internal inquiry in 2 cases and referred 21 cases to the Office of Internal Affairs. The OIG concurred with all of these determinations. The department found 73 incidents involved a reasonable deviation from policy. For the remaining cases deemed to be out of compliance with policy, the department took disciplinary action in 7 cases, issued counseling in 18 cases, and provided training in 68 cases. The department decided to take action on one inmate allegation of staff misconduct. The OIG concurred with all of these decisions. Non Use of Force The department assessed 3,312 of3,936 of the incidents within policy for conduct the OIG deems "Non Use of Force," which is 84 percent of incidents. This includes 249 incidents wherein inmates made allegations of staff misconduct and the department did not take any action. The OIG concurred in all but six of these incidents found to be within policy. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 20 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The department conducted 3 internal inquiries and referred 21 cases to the Office oflnternal Affairs. The department found two incidents involved a reasonable deviation from "Non Use of Force" policies. Of the cases found to be out of policy, the hiring authority took disciplinary action in 9 cases, issued counseling in 20 cases, and provided training in 542 cases. The OIG concurred with all of these determinations except for three (or less than 1 percent) cases involving training. The department decided to take action on 27 inmate allegations of staff misconduct where the non use of force was out of policy, and the OIG concurred with all. ALLEGATION INQUIRIES Department Operations Manual Section 51020.18.2 sets forth specific required actions after an inmate raises an allegation of unreasonable use of force. The requirements include having the inmate medically evaluated, completing a medical report, obtaining and reviewing reports from inmate witnesses, if any, and obtaining a video-recorded interview of the inmate, including recording any injuries. If an inmate makes an allegation during a medical evaluation that staff used unreasonable force, the medical staff member is required to document the inmate's allegation. During its use-of-force review activities, the OIG has identified that the department is not consistent in determining whether an inmate's statement constitutes an allegation of unreasonable force. In one such case, an inmate was repeatedly banging his head on the side of the cell, causing a head injury. The inmate refused orders to stop the self-injurious behavior, and the officer used pepper spray to stop the inmate's actions. The nurse who examined the inmate documented that the inmate alleged the officer used pepper spray for no reason. The IERC determined the inmate's statement did not constitute an allegation of unreasonable force. The OIG disagreed and raised the matter to department executives who agreed with the institution. Clearly, an allegation that an officer used pepper spray "for no reason" is an allegation that the force used was unreasonable. There can be no other logical interpretation. However, based on the department's response to this incident, the OIG recommends the department establish clear guidelines for analyzing inmates' statements related to use-of-force incidents, including accepting an inmate's plain language complaint as a legitimate allegation of unreasonable force to initiate a proper inquiry or investigation. The OIG also recommends the department provide training to all supervisors and managers to ensure inmate allegations are processed according to policy. DECONTAMINATION AFTER PEPPER SPRAY EXPOSURE During the January through June 2017 reporting period, the OIG also noted a lack of consistent documentation when providing inmates with clean clothing as part of the decontamination process. Department Operations Manual Section 51020.15.5 describes the decontamination process, which includes providing clean clothing, and section 51020.17.1 further requires officers to include in their reports their observations of the decontamination process. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 21 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The OIG is reporting 16 incidents where staff members did not document providing inmates with clean clothing as part of the decontamination process. Eight incidents occurred at each of two institutions. Although some institutions require officers to document offering clean clothing, either in an incident report or holding cell log, the department overall takes the position that policy does not require documenting an offer of clean clothing after decontamination. Some institutions also interpret policy to not require any report documenting an offer of clean clothing if an inmate is taken for a medical evaluation or placed in administrative segregation. This interpretation is based on the theory that neither the institution's medical services nor administrative segregation will accept an inmate with contaminated clothing. The OIG raised concerns regarding this lack of documentation with the hiring authorities at each of the institutions referenced above, and ultimately discussed these concerns with departmental executives. Despite the OIG's feedback, the department believes policy does not require staff members to document providing clean clothing to inmates following decontamination. The OIG recommends the department clarify its policy to require staff members to document providing inmates with clean clothing as part of the decontamination process, and to document the time clothing is provided to the inmate. THE APPLICATION OF SPIT HOODS OR MASKS Pursuant to Department Operations Manual Section 51020.16, a spit hood or mask may be applied when staff members believe there is a verbal or physical intent by the inmate to contaminate others with spit or other bodily fluids from the nose or mouth, the inmate is not able to control expelling fluids from the nose or mouth (with the exception of vomit), or the inmate is on authorized security precautions according to the procedures of the unit where the inmate is housed. During the January through June 2017 reporting period, the OIG is reporting nine cases wherein the OIG disagreed with the department's findings that the application of a spit mask or hood complied with policy. A few case examples illustrate the issue. One case involved an inmate who kicked an officer, resulting in the use of physical force. As a result of the force, the inmate was bleeding from an injury above his eye. A sergeant ordered the application of a spit mask even though there were no fluids coming from the inmate's nose or mouth and, therefore, the incident did not meet the criteria for applying a spit mask. Five other incidents occurred at another institution. In one of these incidents. officers used physical force and an expandable baton to subdue a resistive inmate. An officer placed a spit mask over the inmate's face solely to prevent further attempts to assault the officers. A similar incident involved application of a spit mask to prevent blood from an inmate's head wounds, rather than the nose or mouth, from contaminating officers. In the other three cases, officers applied a spit mask because the inmate was agitated, resistive, or acting erratically. In all five cases, the hiring authority disagreed with the OIG's opinion that application of the spit mask did not comply with policy, stating that officers have full discretion for using a spit mask. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 22 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA In addition, the OIG reviewed eight other incidents where the department agreed that application of spit masks was not appropriate because the criteria outlined above were not met. In all eight incidents, the department provided training to involved staff members. Additionally, Department Operations Manual Section 51020.16 provides in part that if a spit hood or mask is applied to an inmate, it is imperative to maintain constant supervision of the inmate to watch for signs of respiratory distress. Policy requires removing a spit mask if an inmate loses consciousness, begins seizing or vomiting, or when any sign of respiratory distress is observed. Absent constant observation, officers cannot adequately monitor for these medical emergencies. During the January through June 2017 reporting period, the OIG identified ten cases in which the department applied spit masks but did not document removing them, preventing the ability to determine whether officers maintained constant observation of the inmates while the spit masks were in place. In six of these incidents, the department provided training to the involved staff members. The department requested and obtained clarifying reports in the remaining four incidents. Until recently, some wardens believed the department's position was that the requirement to maintain constant supervision only applied if an inmate in a spit mask was exposed to pepper spray. However, based on OIG input, the department has clarified the policy to require constant supervision of an inmate once a spit mask has been applied since application of a spit mask can cause respiratory distress regardless of other factors, such as pepper spray exposure. In addition, application of a spit mask can contribute to positional asphyxia when an inmate is placed on his stomach. Serious injuries and death have occurred in the past, which called for the creation of these policies. Failure to require adherence could have fatal results. The OIG recommends the department provide training to reinforce the importance of ensuring the application of spit masks or hoods meets the criteria set forth in the Department Operations Manual. The OIG also recommends the department clarifY criteria regarding the monitoring of inmates after a spit mask or hood has been applied. USE OF FORCE ON MENTAL HEALTH INMATES The department reports during this reporting period approximately 31 percent of its in-custody inmate population were mentally ill inmates participating in the department's Mental Health Services Delivery System at the Correctional Clinical Case Management System (CCCMS) level of care or above. 16 During this reporting period, 40 percent of the total uses of force within the Division of Adult Institutions the OIG closed were on inmates at the CCCMS level or above. 17 16 The department's Mental Health Services Delivery System (MHSDS) provides mental health services to imnates with serious mental disorders or inmates who meet the necessity criteria. The J\!II-ISDS is designed to provide an appropriate level of treatment and promote individual functioning within the least clinically restrictive environment. Mental health care is provided by clinical social workers, psychologists, and psychiatrists. The department provides four different levels of care: Correctional Clinical Case Management System (CCCMS); Enhanced Outpatient Program (EOP); Mental Health Crisis Bed (MHCB); and Department of Mental Health (DMH) Inpatient Hospital Care. A detailed description of the mental health services levels of care can be found on the department's website at http:// www.cdcr.ca.gov !DHCS/Mental_H ealth_P rogram.html. 17 Multiple types of force can be used on a single inmate and an inmate could have been involved in more than one incident during this reporting period. In addition, the inmate's mental health status can change between incidents. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 23 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The OIG's use-of-force monitoring tool allows the OIG to track more detailed statistics and identify trends regarding use of force on all inmates, including mentally ill inmates. Some ofthe data collected includes frequency of specific inmates being involved in uses of force, the classification level of inmates involved in use-of-force incidents, and the locations of use-of-force incidents. The following table outlines the use of force at each institution, broken down by mental health status of the inmate on whom the force was used. Table 5: Use o{Force, by Mental Health Status, by Institution Mental Health Code Total Mental Non-Mental Institution CCCMS EOP MHCB DSH Health Health CCC 0% 00/o 0% 0% 0% 100% CIM 25% 12% 27% 0% 65% 35% ... CMC 15% 37% 8% 0% 61% 39% ~= CRC 28% 00/o 0% 8% 36% 64% u"' DVI 37% 2% 0% 0% 39% 61% = : 0 I NKSP 35% 4% 7% 0% 46% 54% Q. ~ RJD 17% 58% 3% 0% 78% 22% ~ SQ 34% 5% 4% 0% 42% 58% sec 24% 00/o 0% 0% 24% 76% WSP 33% 7% 4% 0% 43% 57% CAC 4% 00/o 0% 0% 4% 96% CCI 52% 00/o 0% 0% 53% 47% COR 30% 34% 3% 0% 68% 32% £... LAC 29% 45% 1% 0% 75% 25% = '"' SAC 21% 58% 2% 0% 81% 19% c)l = -= SATF 24% 14% 8% 0% 46% 54% " 0 il l :~f HDSP 38% 2% 2% 0% 41% 59% ~ KVSP 36% 7% 2% 0% 44% 56% u~ PBSP 19% 10 0/o 2% 0% 31% 69% Qu SVSP 24% 32% 1% 2% 59% 41% ASP 48% 0% 11% 0% 60% 40% SOL 37% 0% 6% 0% 43% 57% = CAL 0% 0% 0% 0% 0°/o 100% 0 = : ~ I CEN 0% 0% 0% 0% 0°/o 100% Q. CVSP 0% 0% 0% 0% 0°/o 100% 0 ll.. -; CTF 45% 0% 0% 0% 45% 55% = tl ISP 1% 0% 4% 0% 5% 95% (5 MCSP 31% 50% 2% 0% 82% 18% PVSP 19% 0% 10% 0% 29% 71% - VSP 27% 300/o 40% 0% 97% 3% ... "' =~ CHCF 2% 32% 15% 48% 97% 3% "C - ~ § CIW 64% 17% 3% 6% 91% 9% o::t:: CMF 26% 26% 5% 1% 59% 41% "''" "; "C CCWF 46% 19% 7% 0% 73% 27% E ~ ~V> FSP 28% 2% 8% 0% 38% 62% Average 22% 12% 5% 2% 40% 60% *Percentages are rounded to the nearest whole number. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 24 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA In addition to these general statistics, the OIG identified five inmates who were involved in five use-of-force incidents and ten wards who were involved in five or more incidents during this reporting period.18 All of the wards were participants in the Wards with Disabilities Program (WDP), 19 which includes wards with mental illness as well as other disabilities. One of these wards was involved in 13 incidents, and a second ward was involved in 9 incidents. Of these 22 combined incidents, 19 incidents consisted of wards fighting. In one incident, a ward was hanging onto a sprinkler, and in another incident, wards attacked staff members. Nineteen incidents involved the use of physical force and pepper spray. Two of the remaining incidents involved less-lethal force and chemical agents, and the third involved pepper spray, physical force, and an expandable baton. In all ofthese incidents, the department found the uses of force to be justified and to comply with policy, and the OIG agreed. An inmate's mental health status may change between incidents. Ofthe five inmates involved in five incidents, one of the inmates was in the CCCMS level of care at the time of all five incidents. A second inmate's mental health status varied between CCCMS and Mental Health Crisis Bed (MHCB) levels of care, and a third inmate's status varied between the Enhanced Outpatient Program (EOP) and MHCB levels of care. The remaining two inmates involved in five incidents were in the MHCB, Enhanced Outpatient Program (EOP), and Department of State Hospitals (DSH) at various times. The majority of all of these incidents involved the use of physical force and pepper spray. Five incidents involved physical force and expandable batons, and in one incident, officers used less-lethal force. The department found all of these uses of force were justified and complied with policy, and the OIG agreed. Chart 1 reflects the frequency of force used by type for both the mental health and non-mental health population. The percentages are based on the numbers of distinct types of force per incident rather than the total numbers of force used per incident. For example, if one officer uses pepper spray and physical force in the same incident, the forces count as two uses of force, whereas if one officer uses pepper spray twice in the same incident, the applications of pepper spray count as one use offorce. 18 The ward or inmate may have been involved in additional uses of force in addition to those reported here, since this report only provides data regarding incidents the OIG reviewed and closed during this reporting period. The OIG attended 95 percent of the review committee meetings statewide. 19 A more detailed description of the criteria for designating wards in the Wards with Disabilities Program can be found in the Wards with Disabilities Remedial Plan at http://www.cdcr.ca.gov!iuvenile justice/docs/adaplan.pdf. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 25 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA Chart 1: Frequency o(Force bv Tvpe (or Mental Health Population • Non-Mental Health • CCCMS or Higher 58% 1% 0% Chemical Physical Less-Lethal Expandable Other/Non Lethal Agents Force Force Baton Conventional Force As Chart 1 reflects, the department uses chemical and physical force on mentally ill inmates more than more severe methods, such as lethal force. Mental health inmates were involved in less than 1 percent of the total uses oflethal force, including warning shots. Table 6 below reflects the frequencies of force used per incident, broken down by type of force and grouped by mental health status. The numbers reported are numbers oftypes of uses offorce per incident. For example, if one officer uses both pepper spray and physical force on the same inmate, these uses of force are counted as two uses of force. However, if one officer applies pepper spray multiple times on one inmate during one incident, those uses only counted as one use of force. Table 6: Frequenq o[Force bl!, Tl!,pe Grouped bl!, Mental Health Status 1 Mental Health Status Non Sub Force Type CCCMS EOP MHCB DSH Mental Total Total Health Chemical Agents 815 441 28 17 1,301 1,216 2,517 Physical Force 349 448 120 71 988 363 1,351 Less-Lethal Force 194 108 0 0 302 347 649 SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 26 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA Of the 912 incidents involving CCCMS inmates, the OIG found immediate force was not justified in 8 incidents. The department identified 21 incidents involving CCCMS inmates where actual force used was out of policy. The department referred five of those cases to the Office of Internal Affairs. In addition, the department imposed disciplinary action in 3 cases, issued counseling in 2 cases, and provided training in 11 cases. The department also found policy deviations in 24 cases, but found the deviations reasonable. The OIG concurred with the department's findings in all of these cases. Of the 869 incidents involving EOP inmates, the OIG found immediate force was not justified in ten incidents. The actual force used on EOP inmates was out of policy in 22 incidents. The department referred four of those cases to the Office oflnternal Affairs. The department imposed disciplinary action in 2 cases, issued counseling in 5 cases, and trained staff in 11 cases. The department found policy deviations in 23 cases, but found the deviations reasonable. The OIG concurred with all of the decisions except for three the department found to comply with policy. In the first case, the inmate refused to allow staff to lock the food port. Officers then used immediate force and sprayed the inmate with pepper spray. During decontamination in the cell, the 15-minute checks took place over a period of only 30 minutes when policy requires a minimum of 45 minutes. Finally, the officers sprayed pepper spray at a distance ofless than three feet without having an imminent threat to justify the deviation from policy. In the second case, officers used physical force to remove an inmate from a committee room when no imminent threat was identified. Officers then used non-conventional force when they tied a sheet around the inmate to secure him to a wheelchair during the escort. In the third case, two officers used physical force to subdue an inmate without articulating the imminent threat. The committee agreed that one officer could have summoned a supervisor, used verbal de-escalation, or summoned assistance. They provided on the job training but still did not find the officer acted out of policy. Of the 136 incidents involving MHCB inmates, the OIG found immediate force was not justified in 2 incidents. The actual force used was out of policy in four incidents. Of those, the department referred two cases to the Office of Internal Affairs, imposed disciplinary action in one case, and provided training in one case. The department found reasonable deviations in two cases. The OIG concurred with all of these determinations except for one in which the department found the use of force complied with policy. That case involved an inmate who became resistive during an escort and used his shoulder to hit an officer in the chest. Four officers used physical force to subdue the inmate. Based on the visual recording, it was not clear when the inmate lunged at the officer. The officer reported the inmate struck him in the chest with his shoulder after they entered the cell, which was not captured on the visual recording. The OIG did not concur with the finding that the use of force complied with policy because it appeared on the visual recording that the officer used physical force when he placed the inmate against the wall and then pushed the inmate into the cell. There was no evidence to justify the use of force before entering the cell. Of the 79 incidents involving DSH patients, there were no incidents where immediate force was not justified. The department found two incidents in which the actual use of force did not comply SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 27 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA with policy and referred one of these to the Office oflnternal Affairs and provided training in the second. The OIG concurred with all of these decisions. As previously mentioned, one inmate can be involved in multiple use-of-force incidents and an inmate's mental health status can change from incident to incident. Therefore, the statistics outlined above pertain solely to the numbers of incidents rather than numbers of inmates. VIDEO-RECORDED INTERVIEWS The department's use-of-force policy requires the department to video record an interview with any inmate who alleged unreasonable force or sustained serious or great bodily injury possibly due to a use of force20 The video recording should be conducted within 48 hours of discovering the injury or allegation. If the inmate refuses, policy requires that the refusal be recorded. However, the actual process for conducting these interviews is inconsistent among the adult institutions. The most common deviations are listed below. The OIG reviewed 705 incidents that required video-recorded interviews. Of those, 409 were conducted within policy and in 296 incidents, the video-recorded interview was either not completed or was not completed according to policy. This equates to a policy compliance rate of only 58 percent. The errors included failure to timely conduct interviews, failure of interviewers to adequately identify themselves or describe the inmates' injuries, failure to conduct a required interview, and failure to video record inmates' refusals to be interviewed. During this reporting period, the OIG also noted four cases wherein the department potentially intimidated an inmate during the recorded interview. In two of those cases, the interviewing sergeant provided the inmate with aMiranda21 admonishment even though the department was not pursuing criminal charges, and in one of those cases, a sergeant interrupted the inmate while the inmate was trying to describe what happened. The hiring authority provided training in both cases. In a third case, the lieutenant conducting the interview did not adequately explain the purpose of the interview. In addition, although a sergeant was also present, the lieutenant allowed an officer also to be present, over the inmate's objection. The lieutenant told the inmate he had battered a staff member and the lieutenant did not feel safe even though a sergeant was also present. The hiring authority provided training to the lieutenant for allowing the officer to be present during the interview. In a fourth case, the interviewing lieutenant was involved in the incident and should not have conducted the interview. Also, the lieutenant conducted the interview in front of the inmate's cell, which provided no degree of privacy from other inmates and possibly contributed to the inmate's refusal to be interviewed. The hiring authority provided training to the lieutenant. 20 Department Operations Manual, Chapter 5, Article 2, Section 51020.17.3. 21 Miranda v Arizona (1966) 384 U.S. 486. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 28 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Based on the OIG's review, the department continues to demonstrate a low rate of complying with policies regarding video-recorded interviews despite the OIG's prior reporting of similar issues. The 58 percent compliance rate is less than the 61 percent compliance rate reported during the July through December 2016 reporting period. Chart 2 reflects the percentages of failures by mission. Chart 2: Video Recordings, bv Mission/Division • Videos Required • Videos Not Completed or Out of Policy 327 10 5 1 1 0 0 8 6 Reception High General Female Division of Division of Office of Community Center Security Population Offender/ Juvenile Adult Parole Correctional Correctional Special Justice Operations Safety Facilities and Housing Out-of-State Facilities DIVISION OF JUVENILE JUSTICE During this reporting period, the Division of Juvenile Justice consisted of three facilities22 and one conservation camp, and was responsible for supervising 636 juvenile wards as of June 30, 2017.23 The Division of Juvenile Justice has its own policy governing the use offorce, including the need for video-recorded interviews under certain circumstances. 24 The OIG assesses the Division of Juvenile Justice's compliance with its own policy. Between January and June 2017, the OIG reviewed 255 use-of-force incidents that occurred at the three juvenile facilities. Consistent with the July through December 2016 reporting period, there were no incidents at the juvenile conservation camp. The OIG attended 95 percent of the 22 0. H. Close Youth Correctional Facility (OHC) and N. A Chaderjian Youth Correctional Facility (NAC) are co located in Stockton. 23 CDCR data is derived from: http://www.cdcr.ca.gov/Juvenile_Justice/docs!DJJ_ADP_Monthly_Report_2017/ADP_MONTHLY_REPORT_2017. 06.p4f 24 Division of Juvenile Justice, Crisis Prevention and Management, Use of Force, April 8, 2013. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 29 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA meetings held at all three Division of Juvenile Justice facilities, an increase over the 88 percent attendance rate during the July through December 2016 reporting period. Of the 255 incidents reviewed, 107 were at N.A. Chaderjian Youth Correctional Facility (NAC), 98 were at O.H. Close Youth Correctional Facility (OHC), and 50 were at Ventura Youth Correctional Facility (VYCF). The OIG agreed with the department that actual force used complied with policy in all but 12 incidents, 7 at VYCF, 3 at NAC, and 2 at OHC. In addition, the OIG agreed with the department that there was one incident at NAC where the use of force deviated from policy but the deviation was deemed reasonable. In that case, two wards were fighting, and an officer used pepper spray from a closer distance than allowed. In eight of the incidents where the use of force was found out of policy, either there was no imminent threat to justify the use of force or officers should have used controlled uses of force rather than immediate force. In all of these eight incidents, officers used physical force or chemical agents. In a ninth case, a counselor attempted to handcuff a ward by himself after the ward had been involved in a fight and was agitated. The department concluded the counselor might have avoided the need for force if he had waited for responding staff members. In another case, an officer did not reassess the need to use a pepper ball launcher between deployments, and in another case, a counselor should have placed the ward in a control hold rather than dragging the ward. Another case involved the failure to give the ward sufficient time to comply with orders before spraying the ward with pepper spray. The last incident involved a riot where counselors and officers used physical force, pepper spray, less-lethal rounds, and a baton. One of the counselors dragged a ward who was refusing to get up instead of placing the ward in a control hold. In all of these cases, the department provided training or counseling, and the OIG concurred. During this reporting period, there were three cases where the OIG did not agree with the department's conclusion that the use of force complied with policy. All three incidents occurred at NAC. In one of these cases, a counselor deployed pepper spray on a ward who was on suicide watch because the ward said he was going to harm himself by trying to scratch an injection site. The OIG raised the fact that the counselor could have contacted a mental health clinician or another counselor to help determine whether the ward was actually harming himself. In a second incident, multiple fights were occurring in the day room, and officers and counselors used pepper spray and other chemical agents, but one of the officers did not articulate an imminent threat before firing a pepper ball launcher within a few seconds of opening the door. In the third incident, a ward refused to leave his room, and an officer used physical force to remove the ward. The OIG believed the officer should not have entered the room as there was no imminent threat or need for immediate force. During the January through June 2017 reporting period, only one of the incidents the OIG reviewed at Division of Juvenile Justice facilities involved an allegation that an officer used unreasonable force. In this incident, a team was escorting a ward for an unclothed body search when the ward turned toward the escorting officer. The officer used physical force to place the ward against the wall. During a counseling session, the ward claimed the officer placed him against the wall for no reason. The facility's review committee found the use of force to comply with policy, and the OIG concurred. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 30 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA DIVISION OF ADULT PAROLE OPERATIONS The Division of Adult Parole Operations consists of two parole regions, northern and southern. As of June 30, 2017, the Division of Adult Parole Operations was responsible for supervising 45,261 parolees25 The OIG reviewed 26 use-of-force incidents: 12 in the northern parole region and 14 in the southern parole region. The OIG attended 94 percent of the Division of Adult Parole Operations use-of-force meetings held statewide during this reporting period. Of the incidents reviewed, the department found that the force used complied with policy in all but one incident. In that one incident, a parolee barricaded himself inside a motor home. Parole agents entered the vehicle and used a taser in an effort to persuade the parolee to come down from an upper bunk. The parolee resisted efforts to apply handcuffs, and agents used physical force. The department determined the agents did not need to immediately enter the motor home to apprehend the parolee and that the agents should have established a perimeter and called for assistance. However, the department also determined the force the agents used after entering the motor home was reasonable. The department provided training to the parole agent who used the taser and training to all involved agents regarding proper protocol for handling parolees barricaded inside a structure. The OIG concurred with the department's determinations. OFFICE OF CORRECTIONAL SAFETY In addition to monitoring use-of-force incidents involving personnel at correctional institutions and in the parole system, the OIG also monitors such incidents involving employees of the department's Office of Correctional Safety. The Office of Correctional Safety is the primary departmental link with allied law enforcement agencies and the California Emergency Management Agency. Major responsibilities of the Office of Correctional Safety include criminal apprehension efforts of prison escapees and parolees wanted for serious and violent felonies, gang-related investigations of inmates and parolees suspected of criminal gang activity, and oversight of special departmental operations such as special transports, hostage rescue, riot suppression, critical incident response, and joint task force operations with local law enforcement. During the January through June 2017 reporting period, the OIG attended the two use-of-force meetings the Office of Correctional Safety conducted. There were four total incidents involving the Office of Correctional Safety. Two of these incidents involved only physical force, the third involved physical force and pepper spray, and the fourth involved the use of a taser and physical force. The department found all of the uses of force to comply with policy, and the OIG agreed. 25 CDCR data is derived from: http://www. cdcr. ca.gowReports_ Research/Offender_ Information_ Services_ Branch!Monthly!FPOP IAIFPOP 1Adl70 6.pdf. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 31 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Contraband Surveillance Watch In 2012, the OIG developed a contraband surveillance watch monitoring program due to concerns the Legislature raised regarding CDCR's contraband surveillance watch process. The Legislature was concerned the department was not applying its policy in a consistent manner. Contraband surveillance watch requires additional staffing for one-on-one observations and is a significant budget driver for CDCR. Additionally, contraband surveillance watch can subject the state to significant liability if abuses occur or inmate health is at risk. On July 1, 2012, the OIG began its formal monitoring of this process. The department's policy for placing an inmate on contraband surveillance watch is found in the Department Operations Manual, Section 52050.23: When it becomes apparent through medical examination, direct observation, or there is reasonable suspicion that an inmate has concealed contraband in their body, either physically or ingested, and the inmate cannot or will not voluntarily remove and surrender the contraband, or when a physician has determined that the physical removal of contraband may be hazardous to the health and safety of the inmate, the inmate may be placed in a controlled isolated setting on [contraband surveillance watch] under constant visual observation until the contraband can be retrieved through natural means, or is voluntarily surrendered by the inmate. The department is required to notify the OIG every time an inmate is placed on contraband surveillance watch and when the department transfers an inmate to an outside hospital while on contraband surveillance watch. The OIG collects all relevant data, including the inmate's name, reason for placing the inmate on contraband surveillance watch, dates and times the department places an inmate on and removes an inmate from watch, and what contraband, if any, was found. The OIG responds to the scene and monitors any contraband surveillance watch case where a significant medical problem occurs, regardless of how long the inmate has been on watch, and in all cases where the watch extends beyond 72 hours. While at the scene, the OIG inspects the inmate's condition along with documentation to determine whether the department is following policy. This on-scene response is repeated every 72 hours until the department removes the inmate from contraband surveillance watch. The OIG discusses any serious policy breaches with institution managers while at the scene. The OIG also formally assesses the sufficiency of how the department conducts each contraband surveillance watch that exceeds 72 hours, as well as select cases that do not exceed 72 hours. Examples of such cases include cases when the department transfers an inmate to an outside hospital or an inmate is suffering serious medical conditions that could be related to the contraband surveillance watch. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 32 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Table 7: All Contraband Surveillance During this reporting period, the department Watch Cases Reported to the 0/G, by notified the OIG of 127 contraband Institution, January-June 2017 surveillance watch cases, slightly fewer contraband surveillance watch cases compared to four ofthe five previous AU Cases Reported to the OIG between reporting periods. In the five prior reporting Institution January and June 2017 periods, the department notified the OIG of by Institution inmates placed on contraband surveillance watch 121, 128, 135, 155, and 206 times ASP 0 CAC 1 respectively. Table 7 contains the number of CAL 9 cases the department reported to the OIG by CCC 6 institution between January 1, 2017, and June CCI 5 30, 2017. This number does not directly CCWF 0 CEN 15 correlate with the number of cases the OIG is CHCF 0 reporting in this Semi-Annual Report since CIM 0 the OIG only assesses and reports those cases CIW 3 CMC 1 where contraband surveillance watch extends CMF 1 beyond 72 hours, where the department COCF-CCF"" 0 transfers an inmate to an outside hospital, or LPCC 1 in other circumstances warranting an TCCF 0 COR 1 assessment. CRC 1 CTF 2 The department may remove an inmate from CVSP 0 contraband surveillance watch when the DVI 2 FSP 3 department reasonably believes the inmate HDSP 3 has relinquished the contraband or the ISP 8 department determines the inmate is KVSP 3 LAC 2 contraband free.27 Normally, the department MCSP 1 should retain an inmate on contraband NKSP 1 surveillance watch for no more than 72 NCYCC 1 hours. PBSP 11 PVSP 6 RJD 1 SAC 4 SATF 4 sec 3 SOL 13 so 0 SVSP 9 VSP 2 VYCF 1 WSP 3 Total CSW Cases 127 26 Community Correctional Facilities operated by the 27 Department Operations Manual, Title 15, Chapter 2, California Out-of-State Correctional Facility Program. Section 52050.23.8. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 33 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA For the January through June 2017 reporting period, the OIG is reporting 49 monitored cases in Appendix F. These 49 cases include 8 cases involving inmates who required medical attention at an outside hospital but where the contraband surveillance watch did not extend beyond 72 hours. The department kept inmates on contraband surveillance watch longer than 72 hours but less than 144 hours in 29 cases. In four cases, the department kept inmates on contraband surveillance watch between 144 and 216 hours. During this reporting period, the department did not keep any inmates on contraband surveillance watch longer than 216 hours (9 days). In addition, other than minor documentation issues, the department sufficiently complied with policies during the watch in all 49 cases. Chart 3 below depicts the percentages of cases by duration for cases the OIG monitored. Chart 3: Duration o( DIG-Monitored Contraband Surveillance Watch Cases Total Contraband Surveillance Watch Cases= 49 •up to 72 Hours DFrom 72 to 144 Hours DFrom 144 to 216 Hours For the January through June 2017 reporting period, "contraband found" includes any contraband the department obtained that led to placing an inmate on contraband surveillance watch. For example, if officers discovered mobile phones or marijuana in an inmate's cell during a cell search and subsequently placed the inmate on contraband surveillance watch, the mobile phone and marijuana would count as "contraband found" to be consistent with the department's practice. However, in the upcoming July through December 2017 reporting period, the OIG will no longer consider "contraband found" to include contraband that led to placing an inmate on contraband surveillance watch. Instead, the OIG will only report contraband found as a direct result of placing an inmate on contraband surveillance watch to ensure there is no abuse during the contraband surveillance watch process. Of the 127 total cases reported to the OIG from January 1, 2017, through July 31, 2017, the department recovered contraband in 46 percent of the total cases for all durations of contraband surveillance watch. The department recovered contraband in 37 percent of the total cases reported to the OIG that did not extend beyond 72 hours. This is less than the 57 percent recovery rate for cases lasting less than 72 hours reported to the OIG during the July through December 2016 reporting period. SEJ1.1I-ANNuALREPORTVOLUMEII JANUARY-JUNE 2017 PAGE34 0FF1CE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Chart 4 below reflects the percentages of contraband found for cases monitored by the OIG between January and June 2017lasting less than 72 hours, including contraband discovered prior to actually placing the inmate on contraband surveillance watch. Chart 4: Contraband Found in OIG-Moniiored Cases Lasting Less Than 72 Hours • Contraband Found D Contraband Not Found 16 Total Cases For cases the OIG monitored and is reporting currently, the department recovered contraband in 70 percent of cases that extended beyond 72 hours, which is a slight decrease from the 78 percent of cases in which contraband was found from July through December 2016. Chart 5 below reflects the percentages of contraband found for GIG-monitored cases extending beyond 72 hours. Chart 5: Contraband Found in OIG-Moniiored Cases Extending Bevond 72 Hours D Contraband Found D Contraband Not Found 33 Total Cases Greater Than 72 Hours SEJ1.1I-ANNuALREPORTVOLUMEII JANUARY-JUNE 2017 PAGE35 0FF1CE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Table 8 below shows a comparison of the percentages of GIG-monitored cases where the department recovered contraband between July 2014 and June 2017 for those cases extending beyond 72 hours. Table 8: Contraband Found in Cases Extending Beyond 72 Hours. July2014 -June 2017 Reporting Period Cases Over Contraband Percentage 72 Hours Found - July-December 2014 59 28 53% I January-June 2015 42 38 90% July-Decem her 2015 39 27 69% I January-June 2016 43 28 65% July-December 2016 40 31 78% I January-June 2017 33 23 70% For the total cases the OIG monitored and is reporting for the January through June 2017 reporting period, the department recovered contraband in 73 percent of the cases. Again, though, this includes contraband discovered prior to placing an inmate on contraband surveillance watch, such as items found during a cell search. As previously noted, this report discusses in detail those cases the OIG monitored in which contraband surveillance watch extended beyond 72 hours, as well as cases where the department transported inmates to outside hospitals. Chart 6 below reflects the types of contraband found for all GIG-monitored incidents for the January through June 2017 reporting period. In some cases, the department recovered more than one type of contraband. Chart 6: Contraband Tvpe and Frequency in AU DIG-Monitored Cases 71% Drugs Inmate Other Phones VVeapons Tobacco Notes SEJ1.1I-ANNuALREPORTVOLUMEII JANUARY-JUNE 2017 PAGE36 0FF1CE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The OIG rated the department on the adequacy of its management of contraband surveillance watch. Of the 49 cases the OIG monitored, the department sufficiently managed the contraband surveillance watch process in 25 cases, or 51 percent. The details regarding the sufficiency assessments are found in Appendix F. As the individual cases reflect, consistent with the prior reporting period, the main reasons for insufficient assessments are inadequate documentation and failure to perform consistent hygiene checks. In addition, the OIG noted a fairly consistent failure to allow range of motion while inmates were restrained. Some other insufficiencies are also worthy of mention for cases monitored during the January through June 2017 reporting period. In three cases, the department placed the inmate in hand isolation devices without proper authorization. In one of the cases, the department identified the error approximately two hours later and removed the devices. However, the department also failed to place the inmate on contraband surveillance watch until more than one hour after officers saw the inmate swallow an unknown object. Additionally, the hiring authority prematurely authorized removing this inmate from contraband surveillance watch within 24 hours, after conceding the delayed initial placement on contraband surveillance watch may have allowed the inmate to discard the contraband. In another insufficient case, the department failed to adequately monitor the inmate during contraband surveillance watch, enabling the inmate to re-ingest contraband. The department recovered concentrated cannabis from the inmate three days after placement on contraband surveillance watch. The department also failed to timely notify the OIG when transferring the inmate to an outside hospital and when removing the inmate from contraband surveillance watch. A final case worth noting is a case where the department placed an inmate in leg restraints for 13 hours without authorization. In the majority of insufficient cases, the department provided training. In some cases, the hiring authority revised local procedures or provided written counseling to those involved. The department's decision to place inmates on contraband surveillance watch complied with policy in all but four cases the OIG monitored. In the one of these cases, the department waited almost one hour after observing the inmate appear to swallow suspected drugs before placing the inmate on contraband surveillance watch, and in a second case, officers did not tape the inmate's jumpsuit in a timely manner after placing the inmate on contraband surveillance watch. In the third case, officers did not conduct an initial unclothed body search, and in the fourth case, the department did not document placing the inmate on contraband surveillance watch. For cases the OIG is reporting for January through June 2017, the department timely notified the OIG when placing an inmate on contraband surveillance watch in all but two cases. During the July through December 2016 reporting period, the department also failed to notify the OIG when placing the inmate on contraband surveillance watch in two monitored cases. In addition, during the January through June 2017 reporting period, the department failed to notify the OIG when inmates were transferred to an outside hospital in 5 of the 17 cases where inmates were transferred to an outside hospital, compared to insufficient notification in 3 of II cases during the July through December 2016 reporting period. Table 9 on the following page details the total SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 37 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA number of contraband surveillance watch cases the OIG assessed for the January through June 2017 reporting period at each institution. Table 9: Contraband Surveillance Watch Cases, hv Institution, January-June 2017 Cases Between Cases Between Cases Less 72 and 144 144 and 216 than 72 Hours Number of Number of Institution *Reported Hours Hours 216~- Cases Rated Cases Rated *Reported *Reported Min January-June Sufficient Insuftlcient January-June January-June 2017 2017 2017 ASP 0 0 0 0 N/A N/A CAC 2 0 0 •• 0 2 CAL 5 1 0 •• 3 3 CCC 1 0 0 ·:0• 0 1 CCI 2 1 0 ·•0 0 3 CCWF 0 0 0 N/A N/A CEN 0 6 0 ••• 5 1 •• CHCF 0 0 0 N/A N/A CIM 0 0 0 0 N/A N/A CIW 1 0 0 •• 0 1 CMC 0 0 0 •• N/A N/A CMF 0 0 0 ·:0• N/A N/A COCF-CCF 0 0 0 ·•0 N/A N/A LPCC 0 0 0 N/A N/A TCCF 0 0 0 ••• N/A N/A •• COR 0 0 0 N/A N/A CRC 1 2 0 0 0 3 CTF 0 0 0 •• N/A N/A CVSP 0 0 0 •• N/A N/A DVI 1 0 0 ·:0• 1 0 FSP 0 0 0 ·•0 N/A N/A HDSP 0 0 1 0 1 ISP 0 3 1 ••• 1 3 •• KVSP 0 2 0 1 1 LAC 0 0 0 0 N/A N/A MCSP 0 0 0 •• N/A N/A NKSP 0 0 0 •• N/A N/A NCYCC 0 0 0 ·:0• N/A N/A PBSP 0 2 0 ·•0 1 1 PVSP 1 1 1 1 2 RJD 0 1 0 ••• 1 0 •• SAC 1 0 0 1 0 SATF 1 1 0 0 0 2 sec 0 0 0 •• N/A N/A SOL 0 6 1 •• 7 0 so 0 0 0 ·:0• N/A N/A SVSP 0 3 0 ·•0 3 0 VSP 0 0 0 N/A N/A VYCF 0 0 0 ••• N/A N/A •• WSP 0 0 0 N/A N/A TotaiCSW 16 29 4 t: 25 24 Cases Contraband Contraband Contraband Recovered: Recovered: Recovered: ~ Sufficient Insufficient ~ 13 Cases 19 Cases 4 Cases =51% =49% NIA =81% =66% = 100% SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 PAGE 38 OFFICE OF TilE IN SPECTOR GENERAL STATE OF CALIFORNIA Typically, the department uses waist restraints on inmates placed on contraband surveillance watch in order to prevent destruction or re-ingestion of contraband. On May 2, 2016, the department began a trial period of unrestrained contraband surveillance watch at three institutions: California Rehabilitation Center; Kern Valley State Prison; and Calipatria State Prison. The policy for these institutions requires that, before using mechanical restraints, the institution must document a specific safety and security need beyond simply the recovery of contraband, and a captain or higher authority must approve the use of the restraints. The criteria for using such restraints is met if it appeared an inmate was concealing a weapon, razor blades, or any item that would pose an immediate risk to the safety and security of inmates or staff. Inmates who attempt to defeat the contraband surveillance watch process would also be subject to the application of restraints. Unrestrained inmates are still monitored according to the remainder of the contraband surveillance watch polices. As in the July through December 2016 reporting period, the OIG continued to assess the department's compliance with policies and procedures at these three trial period institutions pursuant to the revised policy for contraband surveillance watch cases. USE OF LOW-DOSE BODY SCANS AS REASON FOR PLACEMENT ON CONTRABAND SURVEILLANCE WATCH Although the OIG assessed the department's decision to place inmates on contraband surveillance watch as sufficient in a large majority of cases, the OIG noticed a possible trend in using low-dose body scans as the only basis to justify contraband surveillance watch. Therefore, in addition to routine monitoring, between July 1, 2016, and April10, 2017, the OIG also reviewed 183 contraband surveillance watch cases to evaluate the department's use oflow-dose body scans as a basis for placing inmates on contraband surveillance watch. As a result of the review, the OIG found 32 incidents where the department used a low-dose body scan as a basis for placing inmates on contraband surveillance watch. Of these 32 cases, the department recovered contraband from inmates in only 12 cases, which is 3 8 percent of the cases using a low-dose body scan. However, the OIG found a higher recovery rate in those instances where there was a secondary indicator of contraband, such as failure to clear a metal detector or the discovery of contraband during a cell search. In 8 of the 12 cases where the department recovered contraband after using a low-dose body scanner, there were also secondary sources such as direct observation or failure to clear a metal detector. As a result of this review, the OIG recommends the department attempt to obtain a secondary indicator, such as direct observation, failure to clear a metal detector, or contraband found during a cell search, before placing an inmate on contraband surveillance watch based only on a lose-dose body scan. Otherwise, inmates could be unnecessarily subjected to contraband surveillance watch. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 39 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Field Inquiries Since its inception, the OIG has provided a process by which inmates, CDCR staff, and the public can report misconduct or lodge complaints. The OIG receives 250-300 complaints monthly, which go through a screening process. Many are returned because existing administrative remedies have not been exhausted, and many more are resolved informally through correspondence or phone calls with the institution. There are five to ten more serious or unresolved complaints each month that are referred out to regional OIG staff to directly follow up on the department's response. The OIG staff members examine complaints, review the entire case and reports, appear at the scene as appropriate, confer with the department, and determine whether the department's response was appropriate overall. During the January through June 2017 reporting period, the OIG completed the collection of data for 29 monitored complaints. The OIG assesses whether the department takes appropriate action to investigate or address the issue, rather than whether underlying complaints or allegations are substantiated. The assessment includes whether the department developed and maintained sufficient documentation and adequately consulted with the OIG, as well as whether the hiring authority appropriately referred allegations of misconduct to the Office of Internal Affairs and whether the Office of Internal Affairs made appropriate determinations regarding the referrals. Of the 29 cases the OIG concluded between January 1, 2017, and June 30, 2017, the department sufficiently addressed the OIG's inquiry in 26 cases, which is 90 percent. The three insufficient cases involved alleged sexual assault by officers against inmates. The hiring authority did not identify staff misconduct in any of the three insufficient cases. However, in one of the cases, the OIG identified concerns regarding the incident reports and recommended custody and medical staff write objective reports without demeaning comments. The hiring authority agreed and provided training. In a second case, the hiring authority conducted an inquiry regarding the allegations, made a staffing change, and provided locally designated investigator training to the investigative services unit. And in the third case, the hiring authority provided Prison Rape Elimination Act training to a lieutenant, provided locally designated investigation training to all investigative services unit staff, and also made staffing changes. The percentage of sufficient assessments improved from the 87 percent sufficiency rating during the July through December 2016 reporting period. The OIG will continue to examine all complaints and allegations received to help ensure appropriate resolution. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 40 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Volume II Conclusion The OIG publishes two volumes of its Semi-Annual Report to allow the reader to more easily focus on specific areas of the OIG's monitoring. All areas the OIG monitors require transparent oversight to ensure public trust, proper adherence to policy, best practices, safety and security of staff and inmates, and accountability to the taxpayer. Throughout its monitoring activities, the OIG alerts the department to potential risks or problem areas and makes recommendations for improvement. The OIG monitoring helps prevent abuses, potential harm to staff members and inmates, costly litigation, and federal oversight. Critical incidents as described herein have the potential for serious consequences to staff, inmates, and the taxpayers at large. As such, OIG oversight provides independent assessments of how incidents occur, the department's response, and the outcomes. During this reporting period, the department timely notified the OIG of 90 percent of critical incident cases reported in Appendices Dl and E, which is a continued improvement over the 82 percent timely reporting rate during the July through December 2016 reporting period. In addition, the department timely notified the OIG in all but one of the Deadly Force Investigation Team cases, which is consistent with the last reporting period. While monitoring critical incidents, the OIG identified a new area of concern, which consists of staff members potentially destroying critical crime-scene evidence by moving an inmate's body before the coroner's office authorizes the staff member to do so. The OIG provides a new recommendation, listed on page 43, based on this concern. During this reporting period, the OIG attended 822 review committee meetings, and 19 Department Executive Review Committee and 2 Division Force Review Committee meetings, and continues to strive for a 100 percent attendance rate. In addition, the OIG evaluated and closed 3,936 unique incidents. Overall, the committees took appropriate action, and the OIG concurred with the vast majority of the department's determinations regarding use of force, including actual force. However, the OIG also noticed some new areas of potential concern, including inappropriate use of spit masks or hoods and inadequate documentation regarding the decontamination process following application of chemical agents. We are pleased that after bringing the spit mask concerns to the department, leaders took immediate action to clarify policy. The OIG is making new recommendations based on these findings. These recommendations are also on page 43. The OIG also continues to monitor and report on the department's handling of contraband surveillance watch incidents. If department staff members do not follow policies, serious medical issues may occur. During this reporting period, the department again demonstrated a mediocre compliance rate with contraband surveillance watch policies, with 51 percent of the cases deemed sufficient compared with 55 percent during the July through December 2016 reporting period. Lack of documentation continues to be a problem, although the basis for contraband surveillance watch appears to remain fairly consistent since the last reporting period. However, the department's rate of recovering contraband in those cases where it placed an inmate on contraband surveillance watch solely based on the results of a low-dose body scan is a possible SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 41 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA indicator that the department needs to consider using secondary indicators before unnecessarily subjecting an inmate to contraband surveillance watch. At the same time, the department is not keeping inmates on contraband surveillance watch for unreasonable lengths of time and, during the January through June 2017 reporting period, did not keep any inmates on contraband surveillance watch longer than 216 hours. The OIG is making a final recommendation based on the use of low-dose body scanners as a basis for placing inmates on contraband surveillance watch. This report once again contains the department's response to the OIG's complaint intake process. The OIG headquarters intake personnel are able to address most of these complaints informally and return others to the complainant to exhaust administrative remedies. However, the OIG may reach out to institutions to address more serious or unresolved concerns. The department sufficiently addressed the OIG's inquiry in 90 percent of the field inquiry cases during this reporting period, compared with 84 percent in the July through December 20 16 reporting period. The OIG believes this is value added in providing legitimacy to the complaint process. There continue to be areas for the department to improve. The OIG continues to highlight areas of concern, including the continued high frequency of negligent discharge incidents. However, the department continues to be receptive to the OIG's input and meets with the OIG routinely to discuss concerns and possible actions in response to the OIG's recommendations. The OIG believes oversight continues to be crucial to help ensure the transparency of the California corrections system. As in the past, the OIG provides recommendations to the department with the goal of continuing the improvement of the department's processes. The OIG is committed to being an external outlet to resolve complaints when other processes within the system fail. We also remain focused on monitoring the vital areas of critical incidents, use of force, and contraband surveillance watch and providing transparency to the public in these areas. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 42 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Volume II Recommendations The OIG recommends the department implement the following recommendations from Volume II of this Semi-Annual Report, January through June 2017. Recommendation 1.1: The OIG recommends the department provide training to all custody and medical staff regarding the removal of dead bodies without a coroner's authorization. Recommendation 1.2: The OIG recommends the department establish clear guidelines for analyzing inmates' statements related to use-of-force incidents, including accepting an inmate's plain language complaint as a legitimate allegation of unreasonable force, to initiate a proper inquiry or investigation. The OIG also recommends the department provide training to all supervisors and managers to ensure inmate allegations are processed according to policy. Recommendation 1.3: The OIG recommends the department clarify its policy to require staff members to document providing inmates with clean clothing as part of the chemical agent decontamination process, and to document the time clothing is provided to the inmate. Recommendation 1.4: The OIG recommends the department provide training to reinforce the importance of ensuring the application of spit masks or hoods meets the criteria set forth in the Department Operations Manual. The OIG also recommends the department clarify criteria regarding the monitoring of inmates after a spit mask or hood has been applied. CDCR Response: Partially Implemented. The department has clarified the policy to require constant supervision of an inmate once a spit mask has been applied since application of a spit mask can cause respiratory distress regardless of other factors, such as pepper spray exposure. Recommendation 1.5: The OIG recommends the department attempt to obtain a secondary indicator, such as direct observation, failure to clear a metal detector, or contraband found during a cell search, before placing an inmate on contraband surveillance watch based only on a lose dose body scan. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 43 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Volume II Recommendations from Prior Reporting Periods The OIG recommended the department implement the following recommendations from Volume II of the prior Semi-Annual Report, July through December 2016. Recommendation 2.1: The OIG recommends the department develop procedures for and implement better training for safe firearms handling, including addressing negligent discharges with appropriate follow-up to include training or discipline as appropriate. CDCR Response: Partially Implemented. The department does not agree with the OIG that there is a failure to conduct adequate follow-up after negligent discharge incidents. However, the Division of Adult Institutions, Division of Adult Parole Operations, Office of Correctional Safety, and Office oflnternal Affairs established a workgroup to review the use-of-force policy and is incorporating language to include appropriate follow-up such as training or discipline. The department's Office of Correctional Safety developed a training approach in an effort to decrease negligent discharges. The department stopped using the phrase "press check" when referring to the act of verifying the whether a firearm is loaded. The technique is referred to as a "chamber check" and changes were made to instructor course presentations, including a new range master lesson plan to reflect the changes. In addition, the department developed options for reducing or eliminating extensive manipulation of a handgun for armed post weapons exchanges while still allowing an officer to safely determine whether a firearm is loaded. The department is providing training during the 2017 firearms qualification sessions. The department also mandated the use of "dummy rounds" to be used during training regarding how to address malfunctions. The department prepared a new 80-hour range master certification lesson plan, which is currently pending approval by the Office of Training and Professional Development. The plan will include enhanced firearms safety during testing and side bar instructor notes to address areas of concern. Recommendation 2.2: The OIG recommends the department provide training to supervisors regarding the procedures and processes for obtaining timely and appropriate public safety statements. CDCR Response: Not Implemented. The department reviewed the case examples and does not agree the examples present a systemic problem and believes existing regulations regarding public safety statements are clear. The department states it is committed to enforcing the regulations through the progressive discipline process on a case·by·case basis. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 44 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA The OIG recommended the department implement the following recommendations from Volume II of the prior Semi-Annual Report, January through June 2016. Recommendation 2.1: The OIG recommends the department amend Department Operations Manual Section 51020.19.5 to require the Institutional Executive Review Committee to view all available exercise yard or housing unit video recordings as part of the incident review process. CDCR Response: Fully Implemented On March 7, 2017, the Division of Adult Institutions revised Department Operations Manual Section 51020.19.5 to require the Institutional Executive Review Committee chairperson to personally review all video recordings arising from controlled use-of-force incidents and any portion of video recordings capturing an immediate use of force. Recommendation 2.2: The OIG recommends the department amend Department Operations Manual Sections 51020.4 and 51020.19.6 to require the Department Executive Review Committee to review use-of-force incidents within 60 days oflnstitutional Executive Review Committee completion in accordance with recent guidance promulgated by senior CDCR management. CDCR Response: Fully Implemented On March 7, 2017, the Division of Adult Institutions revised Department Operations Manual Section 51020.19.6 to require the Department Executive Review Committee to review required use-of-force incidents within 60 days of completion by the Institution Executive Review Committee. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 45 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA Appendices Appendix Dl contains the assessments for 19 deadly force incidents the OIG Page 47 monitored during the reporting period but the Office of Internal Affairs did not investigate, listed by geographical region. Appendix D2 contains the assessments for 26 deadly force cases the Office of Page 57 Internal Affairs investigated and the OIG monitored during the reporting period, listed by geographical region. Appendix E contains the assessments for 72 critical incidents the OIG monitored Page 81 during the reporting period, listed by geographical region. Appendix F contains the results and outcomes of 49 contraband surveillance watch cases the OIG monitored during the reporting period, listed by the date the Page 113 department placed the inmate on contraband surveillance watch. Appendix G contains the 29 field inquiries the OIG concluded during the reporting Page 138 period, listed by geographical region. SEMI-ANNUAL REPORT VoLUME II JANUARY-JUNE 2017 PAGE 46 OFFICE OF TilE INSPECTOR GENERAL STATE OF CALIFORNIA AppendixDl 19 Monitored Deadly Force Incident Cases Central Incident Date OIG Cate Number C•eType 2016-09-29 16-00019SI-RO Use of Deadly Fon>e Incident Summary On. September 29, 2016, an officer observed three inmatca beating another inmate wbo appeared to be dcfenselcas and llllC()lljCjous. The officer f"ued a wanting shot from a Mini-14 rifle, stopping the fight. The injured inmate received medical treatment at the institution. The OIG responded to the ~CeDe. Disposition The itatitution's executive review committee determined the offioer's use off=e oomplied with policy. The OIG ooncurred. The hiring authority provided training to officers regarding crime ~CeDe and evidence preservation. Incident Alte11D1ent The department's actions following the incident were not adequate because officers did not secure the crime ~CeDe. Prior to Incident Rating During Indclent Rating After Incident Rating Sl1fficicnt Sllflicient Il!ll1flicicnt Astenment Question• o Were the department'• aetlonl prior to, during, and after the crltlcallnddent appropriate? Rupondbtg o.fllcus Mgkct&i to mmnkllll 1M secvrlty of/M C1"tiM SUM prior to removlllg tM lllmatuf rom 1M area. Incident Date OIG Cate Number C•eType 2017-01-11 17-0000112-RO Use of Deadly Fon>e Incident Summary On. J8llll8lY 11, 2017, an officer allegedly !efta loadedh.arulgun on a bed at home. The offioer's thrt»-yearolddaugbterpicked up and diJcharged the band&Wl, killing the offioer'a om>-year-<~ld son. Di1polition The hiring authority identified potential staff miJconduct based on the offioer's alleged clllld endangerment and unlawful storage of a f"rreann and referred the cue to the Of!ioe of Internal Affairs for investigation. The Of!ioe of Internal Affairs opened an investigation, which the OIG accepted for monitoring. Incident Alte11D1ent The department's actions werenotadequatebecause the department failed toproperlyllOtifythe OIG and the Of!ioeoflnternal Affairs andanoffioerallegedlyleftaloadedf"rreann unattended in the presenoe of a minor. Prior to Incident Rating During Indclent Rating After Incident Rating Sl1fficicnt Inauft1cient Il!ll1flicicnt Astenment Question• o Did the hiring authority timely notify the Oflke of Internal Affaln oft he Incident? '11u illltltutlcm dJd Mt Md./Y 1M Ojjle4 ofl nJuna] Affairs. • Did the department timely notify the OIG regarding the crltlcallnddent? '11u d4partmenJI~ of/MIIIcJdmtcmJanuary 11, 2017, buJdJdnotnotVY 1M OIGumiJJanuary 13, 2017, two dtlys ltlW. o Were the department'• aetlonl prior to, during, and after the crltlcallnddent appropriate? '11u d4partmenJ's actknls WM! Mt atkquate becaus~ an o.fllcu ~dly neg/lgMtly l4t a loadM.ftnarm U114tW!du Ill 1M PfUMC4 ofa mlllor. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 47 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA North Incident Date OIG Cate Number C•eType 2015-05-23 15-000IOSI-RO UseofDeadlyFon>e Incident Summary OnMay23, 2015, approximately 100 inmates engaged ina riot on the exercise yard. Anoflicerdeployedagugrenade. A ICCO!ldofficerfm:dsix leu-lethal munds, striking an inmate in the bad< with one round. The seoond officer abc fired a warning shot from a Mini-14 rifle, stopping the fighting. One inmate sllltained injuries C&ll:led by an inmate-manufactured weapon and was treated at the institution. The inmate who was shot in the bad< with the leu-lethalrou.ndsustainedminorinjuriesandretumed to a cell. The OIG responded to the scene. Ditposition The institution's exooulive review committee determined the officers' use of force complied with policy but reoommended training for officers who did 1lOt timely submit reports, llli1'Sel for incomplete medical U:lellmetltl, and managers for failing to complete timely reviews. The OIG concurred. Incident A111e11ment The department's response wu not adequate because nurses did 1lOt sufficiently complete medical usessments, officers did not sufficiently conduct cllecla on inmates or timely submit reports, the captain and usociate warden did 1lOt timely review the incident, and the institution's exooulive review committee did 1lOt timely review the incident. Prior to Incident Rating During Inddent Rating After Incident Rating Su.flicicm Su.flicieltt Insu.flicicm I Attenment Queltiont • Wu the crltka!IDddent adequately documented? Nursu dJd not properly docummt /Mdlclll a.rsusments 07 compuu a 1MdJcoi a.rsusment on OM brmat& ()jflc4rs falkd to CQ11duct 15-mlnute checks on sevual brmatu and falkd to submit 111cJdmt reports prior to the end ofthar slrlft. The captain and assocklU wardm dJd not timely review the /:llckhnt. a Did the ue-of-fora review committee adequately review aud reapoud to the IDeldent? The lllstUutlon's aC!CIItlu M'lew commlttu dJd not compktelts n~vlew lllltll19 mOIIII!s aftu the /:llckhnt. The ~ntfalkd to compuu t1'al1ll1lg doctlm.t.ntattonf07111compuu doctl1Mntatton and late tqi(Jrts. Incident Date OIG Cate Number C•eType 2016-08-14 16-0001852-RO UseofDeadlyFon>e Incident Summary On August 14, 2016, two inmates attacked a third imnate on the exercise yard, repeatedly kicldng the inmate in the head. An officer f'ued one warning shot from a Mini-14 rifle, stopping the attacl<. The department treated the third inmate at the institution. The OIG responded to the scene. Ditposition The institution's exooulive review committee determined that the officer's use of force complied with policy. The OIG concurred. The hiring authority did 1lOt identify any staff misconduct. Incident Attettment The department's response wu satisfactory in all critical aspects. Prior to Incident Rating Durin& Inddent Ratlna After Incident Ratina Suflicient Su.flicieltt Suflicient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 48 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2016-12-12 16-0002130-RO Use of Deadly Force Inddent Summary On December 12,2016, two inmates attacked a third inmate with inmate-~ weapotU on the exercise yard. An ofliQCr deployed a pepper spxay grenade, and two other oflioers fired three warning shots ftom.Mini-14 rifles, stopping the attack. The imnate who was attacked was air-lifted to an outside hospital with serious injuries. The OIG responded to the scene. Di1polition The institution's executive review committee determined thst the oflicets use of force complied with policy. The OIG concurred. The hiring authority did not i.d.elltifY any staff miscoruluct. Inddent Alte1sment The department's response was satisfactory in all critical upects. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Suflicient Sufficient Suflicient I Incident Date OIG Cate Number CaeType 2016-12-16 16-0002148-RO Use of Deadly Force Incident Summary On December 16,2016, two inmates repeatedly punched and kicked a third inmate. AnofliQCr attempted to iue less-lethal rounds, but improperly operated the less-lethallanncber and was unable to fire any less-lethal rounds. The inmates continued attacking the third inmate. The ofliQCr fired one warning shot from a Mini-14 rifle, stopping the attack. Two of the three inmates were treated at the institution for injuries and released. One imnate refused treatment. Di1polition The institution's executive review committee determined the use off orce complied with policy. However, the committee determined the ofliQCr improperly used the less-lethallaun~ causing it to malfunction. The instit11tion's exCCI1tive review committee also determined a different ofliQCr 1111timely submitted a report, a IIUlJC did not adequately document the inmate's injuries, and a lieutenant failed to complete required documentation, ensure the interview was properly conducted, or ensure another medical evaluation was completed. The OIG concurred with the executive review committee's determinations. The hiring authority provided training to address all identified issuea. Incident Alte1sment The department's actions during and after the incident were not adequate because the ofliQCr caused the less-lethal launcher to malfunction. Also, the department did not timely or properly conduct the inmate's interview, a lieutenant did not ensure a medical evaluation was completed, an ofliQCr submitted an untimely report, and a nurse did not adequately document the inmate's injuries. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Suf1icient Insufl1dent Insuflicient Astenment Question• o Were the department'• aetlonl prior to, during, and after the erltleallneldent appropriate? An offlcu Improperly used 1M kss-ktha114ltlldlu causlllg It to maijimctton. The ilrltr4u complalllt offlu dJd 110t eiiSII/'6 th~ lllmau was llltUVI4wed u-ly. The lladmant who cOIIducl&i 1M l1ltuvUwf aJkd to compkU ~ documelltatton, t111Sil'6 1M l1ltuvUw was COflduct&i Ill (lllareafruftom nols~ and dlstraclton, (J1' e11S1l1'6 a110thu medical evaluatton was compkUd ofiM lll}urle.s ~d durlllg 1M IIIIUVWN. An offlcu ~ly submitted a 1'qi<ll1 and a mtne dJd 110t ~ely document 1M lllmaU's lll}urlu. o Wu the erltleallneldent adequately documented? The lladmantwho conduct&i 1M llltuvkwf alkd to compkU 1W/UI1Wl ~ntatton, and a mtne dJd 110t tuhquauly document 1M ilrltr4u's lll}urle.s. o Did the OIG Independently Identify an operational laue or polley \'lola don that reaulted In, or lhould have reaulted In, eorreetlve aedon or a referral to the OIA? The OIG ~d that 1M dqa..-t dJd 110t u-ly llltuvkw 1M lllmate. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 49 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2016-12-26 16-0002162-RO Use of Deadly Force Inddent Summary On December26, 2016, an offiQCr allegedly negligentlydischarJ!:ed arou.ndfroma firearm during a mapons check inside an observation booth. Di1position The hiring authority identified potential staff miacoruluct hued on the officer's alleaed negligent discharJ!:e of a firearm. Therefore, the hirin& authority referred the matter to the Office of Internal Affairs. The Office of Internal Affairs returned the matter to the hirin& authority to take action without an investiaation. The OIG accepted the case for monitoring. Inddent Alte1sment The department's actions were not adequate because an offiQCr alleaedly negliaently discharJ!:ed a firearm and the department did not notify the OIG in a timely and sufficient manner. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufficic:nt Inauftlcient Insufficient A1tenment Queltiont o Did the department timely notify the OIG regard!Dg the erltlcallnddent? '11u UpartmenJ l«llmd of~ tncklmt on ~r 26, 2016, buJ dJd rwt rwtVY ~ OIG UIIJil D«4mbu 27, 2016, tlwebyp reventing~ OIGf rom real-time ltWmtor/ng. o Were the department'• aetlolll prior to, dur!Dg, and after the erltlcallneldent appropriate? An o.fllcu a/kg«lly negllgenJly dlscli<Ug&i a j/lwlrm. Incident Date OIG Cate Number CaeType 2017~1~ 17-0000097-RO Use of Deadly Force Incident Summary On J811ll8lY 9, 20 17, approximately 30 inmates participated in a riot on the exercise yanl. Officers deployed approximately six pepper spray &=&des. Two oftiQCrS imd wamin& shots from Mini-14 rifles, stoppina the attack. The OIG rtapOllded to the scene. Ditposition The institution's executive "'view committee determined that the officers' use of force complied with policy. The OIG concum:d. The hirin& authority did not identify any staff misconduct. Incident Alte1sment The department's "'apo1]SC was satisfactory in all critical aspects. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufficic:nt Sufficient Sufficic:nt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 50 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2017~1-17 17-0000113-RO Use of Deadly Force Inddent Summary On Janwuy 17, 2017, two inmates attacked a third inmate on the exercise yard. Anoffioerfiredone leu-lethal round, and other officers deployt:d peppeupray grenadea. A third officer fired one warning shot from a Mini-14 rifle, stopping the attack. The inmate who wu attacked sustained pwlCture wourula, and the department trlllSported him to an outside hospital. The inmate returned to the institution four days later. The OIG responded to the scene. Di1position The institution's execulivereviewoommitteedetermined that the use offoroecomplied with policy. The OIG concurred. The hiring authoritydidnotidentifystaffmiacoruluct. Inddent Alte11D1ent The department's response was satisfactory in all critical aspects. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufllcient Su.flldeat Sufllcient I Incident Date OIG Cate Number CaeType 2017~2-16 17~1814-RO Use of Deadly Force Incident Summary On February 16, 2017, two inmates attacked and stabbed another inmate on the exercise yard. Three o!IJCers deployt:d pepper spray to stop the attack. One of the officers also used a tear-gas grenade. The second and third officers joined two other officers and struck one of the attacking inmates 18 times with their batons. A sixth officer struck the same attacking inmate one time in the head with a baton, which stopped the attack. The inmate who wu stuck in the head and the inmate who was stabbed were taken to an outaide hospital and returned the same day. The OIG responded to the scene. Disposition The institution's executive review committee determined that the officer's use offoroe complied with policy. The OIG concurred. The hlrin8 authority did not identify any staff misconduct. Incident Alte11D1ent The department's response wu lltiafactory in all critical aspects. Prior to Ineident Ratin& Durin& Incident Ratina After Ineident Ratin& Sufllcient Su.flldeat Sufllcient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 51 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2017~2-18 17-0021832-RO Use of Deadly Force Inddent Summary On February 18, 2017, an officer allegedly negligently diJcbarged a handgun while oonducting a weapouafety cl1eck. The round struck the toMr window facing an unmanned tower and open hillside. The OIG responded to the scene. Di1polition The hiring authority identified potential staff miacoruluct hued on the officets alleged negligent diJcbarge of a firearm. Therefore, the hiring authority referred the cue to the Office ofintemal Affairs for investigation. The Office of Intemal Affairs retumed the cue to the hiring authority to take action without an investigation. The OIG accepted the cue for monitoring. Inddent Alte11D1ent The department's actions were not adequate because an officer allegedly negligently diJcbarged a firearm. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufllcient Inauflldent Sufllcient A1tenment Queltiont o Were the department'• aetloua prior to, duriD&, and after the erltleallnddent appropriate? '11u d4partmem's aclkw-Mt ~ bectlWia an o.f]lar ~ M.g/Jgmtly ~ a.{tlwlrm. Incident Date OIG Cate Number CaeType 2017~2-25 17~021881-RO Use of Deadly Force Incident Summary On February2S, 2017, three inmates repeatedly punched and kicked a fourth inmate on the exercise yard. An officer deployed a pepper spray grenade and then fired one warning shot from a Mini- 14 rifle, but the attack continued until two other officers and a sergeant deployed pepper spray. The OIG responded to the scene. Di1polition The instillltion's executive review committee determined that the use offoroe complied with policy. However, the committee also determined the first officets action of reloading a round into the Mini-14 rifle violated policy. The OIG concurred. The hiring authority provided training to the officer. Inddent Alte11D1ent The department's actions after the incident were not adequate because the first officer reloaded a round into the Mini-14 after the incident in violation of policy. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufllcient Sufficient Insufllcicnt Attenment Queltion1 o Were the department'• aetloua prior to, duriD&, and after the erltleallnddent appropriate? '11u offlcu fdoatkd a rowrd Into 1M MltU-U rljk a]Ur 1M tncJdem In vlolatkm ofpo/Jcy. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 52 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2017~3-15 17-0022086-RO Use of Deadly Force Inddent Summary On March 15,2017, three inmatesattackedafourthinmate on the exercise yard. Anoflicerfiredonewaming sbotfromaMini-14 rifle, which stopped the attack. Two of the inmatessuffered injuries consistent with fighting and wm: transported to an outside hospital. The inmates returned to the institution the same day. The OIG rtaponded to the scene. Di1polition The institution's exooutive review committee dctemtined that the Ule off orce rom.p lied with policy. The OIG concurred. The hirina authority did 1lOt identify any staff miaroruluct but provided trainin& to the lUiliCI reprdins report writin&. Inddent Alte11D1ent The department's actions following the incident wm: 1lOt adequate becallle nlllJCI did 1lOt adequately rom.p1ete required documentation. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufllcient Su.flldent Inaufllcient A1tenment Queltiont o Were the department'• aetloua prior to, durin&. and after the erltleallnddent appropriate? Nurses dJd Mt tllkquQUiy oompkU requbwl documenllllkm. o Wu the erltleallnddent adequately doewnented? Nunu dJd Mt tllkquQUiy oompuu requbwl documenllllkm. Incident Date OIG Cate Number CaeType 2017~~ 17-0022241-RO Use of Deadly Force Incident Summary On April4, 2017, aaergeant allegedly negligently diacllarged a firearm when trying to catch the firearm u it slipped from his hand during a weapons checl<. The OIG responded to the scene. Ditpolition The hiring authority identified potential staff misconduct bued the officer's alleged negligent diacllarge of a firearm and referred the c:ae to the Office of Internal Affairs for investigation. The Office ofI nternal Affairs returned the c:ae to the hirina authority to take action without an investigation. The OIG aceepted the c:ae for monitoring. Incident Alte11D1ent The department's actions were 1lOt adequate becaUie a sergeant allegedly negligently diacllarged a firearm and the department did not obtain a public safety statement. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufftcient Inauftldent Inaufftcient Attenment Queltion1 o Were the department'• aetloua prior to, durin&. and after the erltleallnddent appropriate? Asuget~~~tallegM/yMg/Jgelltlyd~ajln4rmmld/Mr/qa111MntdldMtobtalnapuhllcSII/etystatmlelltftomtk~sugetlllt. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 53 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2017-M-19 17-0022396-RO Use of Deadly Force Inddent Summary On Apri119, 2017, two inmates attacked a third inmate with aninmato-manufactured WQJPonon the exercise yard. Eight officers dep1oyt:d pepper spray and pepper spray grenades. A ninth ofliQC!' fired one warning shot from a Mini-14 rifle, stopping the attack. The third inmate sustained puncture Wllllllda. The department trl1lspOrted the third inmate to an outside hospital and he returned to the institution the aame day. The OIG responded to the scene. Di1position The institution's executive review committee determined that the oftiQCr's use of force complied with policy. The OIG concurred. The hiring authority did not identifY any staff miscorulu.ct. Inddent Alte11D1ent The department's response was satisfactory in all critical aspects. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufllcient Su.flldent Sufllcient I Incident Date OIG Cate Number CaeType 2017~5-m 17-0022590-RO Use of Deadly Force Incident Summary On May 7, 2017, an officer a11eaedly negligelltly dischar&ed a handgun while performing a Weapolll safety check in a dinin& room where nobody else was present. The OIG resporuled to the scene. Disposition The hiring authority identified potential staff misconduct based on the officer's alleged negligent discharge of a firearm. Therefon; the hiring authority referred the case to the Office ofI nternal Affairs for investigation. The Office of Internal Affairs returned the case to the hiring authority to take action without an investigation. The OIG accepted the case for monitoring. Incident Alte11D1ent The department's actions were not adequate becanse an ofliQC!' allegedly negligelltly discharged a handgun, and the department did not obtain a public safety statement. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Sufllcient Insuflldent Insufllcient Astenment Question• o Were the department'• aetlona prior to, durlnt. and after the erltleallnddent appropriate? 11u! d4partmem's aclkw -not alhquau becousa an offlar alkgedly "~disc~ a handgun, and 1M Upartmem did not obtam a pubUc safety skl141M11t.from the ojJial: SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 54 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA South Incident Date OIG Cate Number C•eType 2017-02-11 17-0021m-RO UaeofDeadlyFon>e Incident Summary On February II, 2017, an officer allegedly negligendydiJcharl!ed his peri01]al firearm into a clearing barrel. The OIG responded to the :Klene. Di1position The hiring authority identified potential staff miacoruluct because the officer allegedly 11egligendy discharged a firearm. Therefore, the hiring authority referred the cue to the Office of Internal Affairs for investigation. The Office of Internal Affairs opened an investigation, which the OIG accepted for mmritoring. Incident A111e11ment The department's actions were not adequate because an officer allegedly negligendy diJcharl!ed a firearm. Prior to Incident Rating During Indclent Rating After Incident Rating Snfticicnt I11allfi"ICicnt Suflieicnt A1tenment Queltiont o Were the department'• aetlolll prior to, dur!Dg, and after the erltlcallnddent appropriate? An o.fllcu alhgUly Mgllgent/y dl8cllarg&i a j/lwlrm. o Did the OIG Independently Identify an operatlonal!Jeue or polley \'lolatlon that re.Wted In, or llhould have reiUited In, cerreetlve aetlon or a referral to the OIA? '11u OIG ~d that~ M.g/lgent dJsclul1'ge did not comply with ~ de]HII'tmellt's use-<Jf.j()IU po/Jcy. Incident Date OIG Cate Number C•eType 2017~2-15 17-0021815-RO Use of Deadly Fon>e Incident Summary On February 15, 2017, two inmates attacked a thiniinmate 011 the exerWc: yard. Ano:flicerfiredtwowaming shots fromaMini-14 rifle, buttheattackco11tinued until aiCC011dofficer deployed pepper spray. The department tran.ported the inmate who was attacked to an outside hospital a11d the inmate returned the same dsy. The OIG respo1lded to the IQCll.e. Di1position The institutioo'a execulive review committee determined that the officets use of force complied with policy. The OIG concurred The hirin& authority did 11ot idemify any staff miscoruluct. Incident Atteltment The department's reapmue was satisfactory in all critical aspects. Prior to Incident Rating During Indclent Rating After Incident Rating Sl1fficicnt Sufficient Snfticicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 55 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CaeType 2017~4-00 17-0022226-RO Use of Deadly Force Inddent Summary On Apri13, 2017, a sergeant allegedly negligently discharged a handgun while attempting to clear the fm:arm in an office, and the bullet struck a oomputer speaker. The OIG ~to the scene. Di1position The hiring authority identified potential staff miacoruluct hued 011 the alleged negligent discharge of a firearm. Therefore, the hiring authority referred the case to the Office of Internal Affairs for inveatigati011. The Office of Internal Affairs opened an investigation, which the OIG accepted for monitoring. Inddent Alte1sment The department's acti0111 were not adequate because a sergeant allegedly negligently discharged a fm:arm. Prior to Ineident Ratina Durin& Incident Ratina After Ineident Ratina Suflicient Iaauftlcient Suflicient A1tenment Queltiont o Were the department'• aetfcnq prior to, durlnt. and after the erftleallnddent appropriate? '11u d4partmem's aclkw - Mt ~ bectluse the sergeant a&gedly dJsclulrged ajlPWn~~ In an o.f!lce. strlldng a oo1ti]JUW s;eak.er. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 56 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Appendix D2 26 INVESTIGATED AND MONITORED DEADLY FORCE INCIDENT CASE SUMMARIES Central Incident Date OIG Can Number CateType 2016-01-06 16-0000139-IR Use of Deadly Fon>e Administrative Incident Summary On. J8l!WilY 6, 20 16, an officer, while handling and securing a firearm, allegedly W!intentionally dUcharged one round from the firearm into the weapons storage locker. The Office of Internal Affairs ~to the accne and conducted a criminal investigation. The OIG abo rt:SPonded. Although the Office of Internal Affairs did not identify criminal conduct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office of Internal Affairs abo opened an administrative investigation, which the OIG accepted for monitoring. Administrative lnvettigation Allegation• Finding~ Initial Penalty Final Penalty I. Weapolll I. Sustained Salary Reduction Salary Reduction Di1position The Deadly Force Review Board found that the officer's use of deadly fon>e did not oomply with policy, and the hiring authority imposed a 5 percent salary reduction for three months. The OIG concurred. After the Skdly heari118, the hiring authority decided to reduce the penalty to a otW-worlring-<lay suspe:!aion. The OIG did not concur and elevated the matter to the hiring authority's supervisor. Before the hiring mthority's supervisor could consider the rna~ the hiring mthority rescinded the decision to modify the penalty and reinstated the 5 pen>ent salary reduction for three months. The officer did not file an appeal with the State Peraonnel Board. Di1ciplinary Anenment The department did not comply with proccdurea governing the disciplinary proccu becsuse the department did not timely conduct the disciplinary findings conference or properly conduct the ~lly hearing. The department attorney did not prepare an adequate disciplinary action or adequately cooperate with the OIG. Astenment Queltion1 o Did the HA timely couault with the OIG and the department attorney (If appUeable) regardiDg d!xlpllDary determmatiODa prior to maldDg a fiDal deebloD? 171<! lH4d1y FOtURcn>Uw Board~ 1M cas~ to 1M hlrlllg auJiu>rlty (Ill November J, 2016. Howe-. 1M hlrlllg autiu>rlty dJd 110t consulJ wiJh 1M OIG alld 1M ~nt attorney re.gattlbtg 1M dJscJplillal'y ddumblattons lliiJil Deumber 6, 2016, JJ days tlweajtu. o Wu the draft dlxlpiiDary actloD provided to the OIG for review appropriately drafted u deKrlbed iD the DOM? 171<! drqft disclpUrrtl1"Jf actton dJd Mt QCCU1YlU/y cJU kgal autlwrlty governingp et= ojJiar OOI!fldmtla/Jty qr 1-n/<mn 1M ojJiar ofh is right to rupond to an unlnvolv" mtlnaget: o Wu the dlxlpUury actloD Hned OD the aubjeet (1) appropriately drafted u described iD the DOM? 171<! disciplinary actton served (Ill 1M offlar dJd 110t accuraulycJte kgal autiu>rlty govermngpet= offlar OOI!fldmtla/Jty qr lllf<mn 1M offlar ofh is right to rupond to an unlnvolv" ~r. o U there waa a Sblly hearlllg, was it CODducted punuant to DOM? 171<! Skdly offlar lllapptrlpl"l~ ~ lw aw~~lllvestlgatJon aftu 1M Skdly Maring. o U an neeutlve review was IDvotcd iD the eue, did OIG request the neeutlve review? 171<! OIG souglrJ a hJgher kvd ofm 'Uiw whm th~ hiring aldlwrlty tkckkd to QCC4Pt 1M ~ly o.f!lar's re<XJmmmdalkm to /gn(Jre the Dea4ly F01U &vkw Boaldf lndJng that 1M ojJiar was Mg/Jgmt In vtollltlng tu tk]HI11meiiJ~ use-of.jqrce policy and to 1Wit= 1M pmaJty to a (llle-worldng-<lay suspmston. o Did the department attorney or employee relatiODa oflleer cooperate with and piiiVIde CODt!Dual real-time coiiiUitatlon with the OIGthmughout the dlxlpUury phue? 171<! dqartm~ attorney dJd 110t pi"OVItk th~ OIG a reasoll4bk aJtiOIIIIt oft 1n1e to rm.ow th~ draft dJscJpllllary acJton. o Wu the dlxlpUury phue CODducted with due diligence by the department? 171<! tk/ay Is adbus" 111 a prior quatloll. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 57 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-07-30 16-0001833-IR Usc of Deadly Faroe Administrative Incident Summary On July 30, 2016, an Office of Correctional Safety special agent allegedly shot and killed an injured deer. The Office ofI nternal Affairs did not respond to the soene but conducted a criminal investigation. Although the Office ofI nternal Affairs did not identify any criminal conduct, purauam to departmental policy, it referred the matter to the district attorney's office for review. The Office ofitttemal Affairs also opened an administrative investigatiOll, which the OIG accepted for monitoring. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty No Penalty Imposed No Penalty Imposed l.W~ I. Exonerated Pre-disciplinary Anenment The department did not comply with policies and procedures governing the pre-diaciplinaryproQCII because the hiring authority did 110t adequately or timely respond to or document the incident, and the special agent did not adequately c0111ult with the department attomcy or the OIG or conduct a timely and thorough investigation. The department attomcy did not timely uscas the deadline for taking disciplinary actiOll, adequately C0111ult with the special agent or the OIG, and provided poor legal advice to the hiring authority, and the hiring authority incorrectly folll!d the investigation sufficient. As a result of the failures, witnCIIes bad difficulty remembering the incident, and the Office of Internal Affairs did not collect and preserve crucial evidcllce or thorou&hlyinvestipte the incident Attenment Quettiont a Did the HA timely rapo~~d to the erltleal toddent? '11u hlrlngaullwrltyl~ of/MtncklmJ(JIIJuly 30, 2016, butdJdnotbegtnto review 1M tncklmJUIIIJJAugust 1, 2016, two dayslaUr. a Did the lnatltutlon timely notify the Ofllce of Internal Afraln of the Incident? '11u hiring aullwrlty I~ of/M tncklmJ (Ill July 30, 2016, butfaJkd to notljjt 1M O.fllu oflntuMI Affall'tJ U1ltJJ August 2, 2016, tltru days laUr. a Did the department timely notify OIG of the erltleallnddent? '11u hlrlngaullwrityl~ of/MtncklmJ(JIIJuly 30, 2016, butfaJkd tonotljjt 1M 0/Guntt/August 2, 2016, tltru days laUr. a Wu the HA'a rapoDae to the erltleallnddent appropriate? '11u hiring aullwrltydldnot tlmdynotljjt 1M O.fllu oflntuMI Affall'tJ or oolkcJ and]II'U-IM.ftrearm. a Wu the erltleallnddent adequately documented? '11u dqartment did not atkquatdy document tu loC41Jon ofo r wltfWscu to 1M 111Cide11t. a Did the apedal agent adequately confer with the OIG upon caae Initiation and prior to IIDallzlng the lnveatlgatlve plan? '11u specJ4l agent dJd not oonsult with 1M OIG bqoref ormu/4Jtng tu tnvcuttgattve pkm and dJd notp rovltk 1M OIG wUh a compkt&i tnvcutlgatlu plan. a Did the apedal agent adequately confer with the department attorney upon cue Initiation and prior to llnalldng the lnveatlgatlve plan? '11u specJ4l agent dJd not oonsult with 1M tkpartmmt -Yb qoreformultlttng 1M lnvcutlgadva pliln. a Within 11 ealendar daya, did the department attorney or employee relatlona oflleer eorreetly ._the deadline for taking dladpUnary action and make an entry Into the cue management ayatem confirming the date of the reported Incident, the date ofd laeovery, the deadline for taking dlaeipllnary action, and any n:eeptlou to the deadline bcnm at the time? '11u dqartment atfol?r4y was assigna d August 26, 2016, but dJd not lllllU an entry tnto 1M case _,agemm~ sysum rega7rltng tu tka4/JM for tolcbJg dJscJpltnary acJkm U1ltJJ Aprl] 25, 2017, eJghtmomlrs ~ a No later than 11 ealendar daya following ualgnment oft he caae, did the department attorney eontaet the ualgned apedal agent and the monitor to dlaeua the element. of a thorough lnvatlgatlon of the alleged mlaeonduet? '11u dqartment atfol?r4y MW1' CMklcud 1M ass~ specJ4l agmt or 1M OIG to dl8cuu 1M demMts ofa tMroug/1 tnvcutlgatton. a Wu the lnvatlgatlon thorough and appropriately conducted? '11u OjJ/a ofl ntuMl Affatn did not tlu>rougltly tn.rpect or tcut 1MJ tr-m, lllllU appropl'late efforts to contact perclpum wltfWsu, or adequalely tnvutlgaU wM/Mr 1M special ag Mt alhgedly dJssuatkd wltne!Ssuf rom C0<1Ji61¥lltng wUh 1M lnvcutlgaJion. a Did the HA properly deem the Ofllce of Internal Affaln lnveatlgatlon autlldent or luufftdent? '11u hiring aullwrlty dumed 1M tnvcutlgatkm Sl!fllcJmJ duplu 1M OIG's 1U01tRMfldatkm that 1M OjJia ofl ntuMl Affairs lllllU addltkmtd q[orts to tntuvlewp ercipient wltfWsu to ddumiM wluthu tusp6CJal agent dlssuadad them. from C(J(JJJPattng wUh 1M tnvcutlgaJion. a Did the HA properly determine whether addltlonallnveatlgatlon wu neeeaary? '11u hiring aullwrlty lmpmpulyddum/Md 1M Office ofmumalAffall'tJ OOIIducled a sujfldent tnvcutlgalton C!VM though 1M O.fllu oflntuMI Affall'tJ dJd not t4ke sujf/cUntsteps to tnluvUwp uclplmt wltncusu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 58 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA o Did the deparbnent attorney provide appropriate legal eonsultatlon to the BA regarding the suflldeney of the Investigation and Investigative findings? The department attorney dJd not advise the hiring authority that addJtlonai tnvesUgatkm was necessary to determine whether the special agent dissuaded percipient wltnessu from cooperating wUh the tnvesUgatkm. Did the spedal agent and deparbnent attorney cooperate and provide real-time eolliUltatlon with eaeh other throughout the pre-dfsdpllnary phase? The specJal agent and the department attorney dJd not C(lfiSUjt wlth each other upon case tnltkltkm and prior to jtnaiJ:zlng the tnvutlgatlve plan. Did the BA eooperate with and provide eontlnual real-time eonsultatlon with the OIG throughout the pre-dfsdpllnaryllnvestlgatlve phase? The hiring authority dld notp rovlde the OIG wUh the jonn documenting the lnvesUgative findings. Did the deparbnent eonduet the pre-dfsdpllnaryllnvestlgatlve phue with due dlllgenee? The delays are addrused In prior quuUons. Disposition The Deadly Force Review Board found that the special agent's use of deadly force complied with policy. The hiring authority subsequently exonerated the special agent, and the 010 concurred, based on the state of the investigation provided by the Office of Internal Affairs. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 20I7 Page 59 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2017-01~ 17-0021802-IR Usc of Deadly Faroe Administrative Incident Summary On Janwuy 5, 20 17, an officer allegedly negligently diJcharged a handgun, shooting hiliiJdf in the foot during training. The OIG responded to the ~Ce~~e. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty I. Weapons I. Sustained Letter of Reprimand Letter of Reprimand Pre-disciplinary Anenment The department did not oomply with prooedures governing the pre-diJciplinary prooc:as because the Oflioe of Internal Affairs did not respond to the incident or open a deadly foroe investigation. Procedural Rafinl Subttantive RatinJ InaWBcient Suflicient Attenment Quettiont o Did the Ofllee of IDtemal Affaln adequately rapo~~d to the lnddnt? 171<! OjJ/a ofl nJuna1 AjftnftJ did Mt 1'UJI(Ifld o Did the Ofllee of IDtemal Affaln make an appropriate bdtlal determlnattou regarding the cue? 171<! OjJ/a ofl nJuna1 AffaJn did Mt ope~~ a dNJdJy fOfU tffV&111JgaJJOII despite 1M use ofd eadlyf OfU causlllg a11 llljury. o Did the Ofllee of IDtemal Affaln pnl!)erly determine whether the cue should be opeued u a Deadly ll'orce IDvatlgattoD Team lnvatlgattou? 171<! OjJ/a ofl nJuna1 AffaJn did Mt ope~~ a dNJdJy fOfU tffV&111JgaJJOII. Ditpolition The hiring authority sustained the allegation and iuued a letter of reprimand. The OIG did not ooncu.r with the pensltyb ut did not seek a higher level of review due to oonflicting evidenoe regarding the scriousnessofthe allegedmisconduet. The officerdidnotfileanappeal with the State Personnel Board. Ditciplinary Anenment The department did not oomply with policies and procedures governing the disciplinary prooc:as because the department attorney provided poor legal advice and prepared an insufficient disciplinary actiOll, and the hiring authority imposed an inappropriate penslty. Procedural Rating Subltantive Rating InaWBcient lnsllflicient Attenment Quettion1 o Did the departmnt attorney provide appropriate legal COQU!tattou to the BA regarding dfxlpllnary determlnattous? 171<! Upartm611t attomey ]P'Ovlded poor legal advlu by fatllllg to 1'Ut>mmend 1M app1't1pl'lat6 dlsctpliMiy m4trlx sectton, COII!rlbutlllg to the h/rlllg auJiu>rlty tssuillg a kttu ofr eprlm41td wtead ofa - app1't1pl'lat6 peNJ/Jy ofa salary reduclton. o Did the BA who participated In the ctt.dpllnary eouf-uee seled the appropriate Employee D!xlpUuary Matrb: charges and eau.a for ctt.dpllne? 171<! htrlng authority did Mt selw the matrix cluuge ~tWSt constst611t wWI gross Mg/Jgma Ill handlbrg a firearm despite evldmce ofM gltgena. o Did the BA who participated In the ctt.dpllnary eouf-uee seled the appropriate pnalty? 171<! htrlng authority lulud a kttuofrepl'lm41!d lllltead ofapeNJ/tyM(Jre conststentwUhgross M.gitgence Ill halldllllg ajtl'earm. o Wu the draft ctt.dpllnary acttoD provided to the OIG for review appropriately drafted u daerlbed In the DOM? 171<! draft dlsctpltNli'Jf acJIOII did Mt cUe the correct l4w govut~lllg peace o.fllcu conjld611ttoltty, rquence all ne.cessaty docum611ts, (11' advise 1M officer ofh is right to 1'UfloM to a11 Ullblvolved manager Ill~ wWI policy. o Wu the dfxlpUuary acttoD served OD the lllbject (1) appropriately drafted u described In the DOM? 171<! flnal dlsctpltfllll')f acJIOII did Mt cUe the correct l4w govut~lllgpeace o.fllcu conjldemtoltty (11' advise 1M o.fllcu ofh is right to 1'UpOIId to a11 Ullblvolved manager Ill ~ wWI policy. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 60 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA North Incident Date OIG Ca1e Number CateType 2016-03-09 16-0001204-IR Use of Deadly Fon>e Administrative Incident Summary On March 9, 2016, an oflioer allegedly negligently diJcbarged a round from a handgun during an armory inventory, failed to timelyrqK~<t the negligent diJcbarge, removed the diJcbarged bullet casing from the soene anddiJcardeditatbome, and wu allegedly dishonest to responding officers when he told them nothing had happened. On March 10,2016, theof!icerallegedlycompleteda false armory inventory and wu dishonest to anotheroflioer regarding the inventory, and on March 12,2016, allegedly submitted a fabe memorandum regarding the incident. Administrative Investigation Allegation• Finding~ Initial Penalty Final Penalty !.Dishonesty !.Sustained lMmissal Resignation in lieu of Termination 2. Weapons 2. Sustained 3. Failure to Report 3. Sustained 4.Dishonesty 4. Not Sustained Disposition The hiring authority sustained the allegations, except that the oflioer submitted a fabe memorandum, and dWnissed the oflioer. The OIG concurred with the hiring authority's determinations except for the decision to not sustain the allegation regarding the false memorandum. The OIG did not seek a higher level of review because the other allegations were sustained and the correct penalty imposed. The of!ioer filed an appeal with the State PelJOIIl1el Board. However, pursuant to a settlement agreement, the oflioer resigned in lieu of dismissal and agreed to never seek employment with the department in the future. The OIG concurred because the ultimate goal of ensuring the oflioer did not work for the department wu achieved. Di1ciplinary Anenment Overall, the department sufficiently complied with policies and procedures governing the disciplinary process. Proceclural Rating Subltantive Rating Sufficient Suflicicrl.t I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 61 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-03-19 16-0000928-IR Usc of Deadly Faroe Administrative Incident Summary On March 19,2016, an Office ofintemal Affairs special agent fired two l'OIIIldsatandkilledapitbull thatrantowazdhimoutside his ~ce. The Office oflntemal Affairs and the OIG rtapOl1dt:d to the ~<>ene. Adminittrative lnvettigation Allegations Findings Initial Penalty Fin8l Penalty I. Dbchargc of Lethal WCapo11 I. Exonerated No Penalty Imposed No Penalty Imposed Pre-disciplinary Anenment The department did not oomply with prooedures governing the pre-diJciplinary prooeas because the department delayed completing the investigation. Proceclural Rating Subltantive Rating lniW!k:icm Sufficient Attenment Question• • Did the departmmt coudud the pre-d!KipiiDary/IDveatlgatlve phue with due dlllgmce? 171<! OjJ/a ofl nJuna1 AffaJn did Mt compkU 1M deadlyf ~ lltvutJgatkm wltirJII 90 days of1 M illdtknt d4U punllllllt to th~ tkpartltWit's gui<hlbw. 171<! lltcJdent took piau 011 Maldt 19, 2016, but 1M OjJ/a ofl nJuna1 AffaJrtJ did Mt compkU thelnvutJgatkm lflltll June 27, 2016, 100 days /Mreajlu. Disposition The Deadly Force Review Board found that the special agent's usc ofd eadly force complied with the department's usc-of-foroe policy. The hiring authority aubseqUClltly exonerated the special agent, and the OIG ooncurred. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 62 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-05-16 16-0001456-IR Usc of Deadly Faroe Administrative Incident Summary On May 16,2016, three inmates stabbed a fourth inmate with inmate-manufactured weapons on the exerWc: yazd. Anofficerfiredone round from a Mini-14 rifle, striking one of the attacking inmates and stopping the attack. The department transported the inmate who was shot and the inmate who was stabbed to oullide hospitals, foUowing which both inmates returned to the institution. The Office ofintemal Affairs responded to the scene and condu.cted a criminal investigation. The OIG also resporulcd. Although the Office of!ntemal Affairs did not identify criminal conduct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office ofI nternal Affairs also opened an administrative investigation, which the OIG accepted for motritoring. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty I. Usc of Deadly Faroe I. Exonerated No Penalty Imposed No Penalty Imposed Pre-ditciplinary Anenment The departmem did not comply with policies and procedures govemina the prc-diaciplinaryproceu because the investigative services writ did not handle evidence appropriately and the special agem did not timely complete the investigation. The special agem did not make complete entries in the case management system. Procedural Rati:n& Subltantive Ratln& Inallllicient Inauflicient Attenment Quettiont a Did the IDvestlgatlve terVka wdt, or equivalent IDvestlptlve penonnel, adequately respond to the erltlealiDddent? '11u tnwstJgadve servlca unit lntlpproprltddy oo/UcUd crtm.sune evld4nu, CQIUI/sttng ofb lood-stllJMd ck>tJUng lira brmatu - and hung lira cwt]Ung em a clotlruliM em lira paJk> outsltk ofl ira tlrwstlgatm servlca unJJ, contrary to approprlaU ]PYICJJa fqr JII'Uerv/ng evitk71C4. a Did the apedal agent appropriately enter cue activity Ill the cue management ayatem? '11u sp«J4l agent dJd Mt II1IW aJI ent1')l ~anibtg lira tasks puf011Md em lira day ofl ira illcltknt. a Did the department couduct the pre-d!KipliDary/IDvestlgatlve phue with due dlllgence? '11u OjJ/a ofl nJuna1 AffaJn did Mt compkU lira dNklly f--tnwstlgatton wltirJII 90 days ofl ira illdtknt d4U punllllllt to tlr~ tkpartltWit's gultklbw. '11u lltcJdent took piau May 16. 2016, but the OjJiu oflnte1111li AffaJrtJ dJd Mt cumpkU lira tlrwsUgatton lllltJl August 19, 2016, 95 days t/weaftu. Ditpotition The Deadly Force Review Board found that the officets uae of deadly faroe complied with policy, and the hiring authority subsequently exonerated the officer. The OIG concurred. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 63 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-05-27 16-0001665-IR Usc of Deadly Faroe Administrative Incident Summary On May 27, 2016, approximately 40 inmatea attacked teninmatea on the exercise yard. An offioer fm:d two warning shots from a Mini-14 rifle, stopping the riot. Approximately SO other inmates attacked eight inmatea on an adjacem exercise yard. Two other officers f'tred two rounds each, and a fourth offioer fm:d three warning shots from Mini-14 rifles, stopping the fight. The department trallspOrted nine inmatea to outside hospitals for injuries. Seven inmatea returned to the institution the same day. The other two inmatea returned later. The Office of Intema1 Affairs rtapOllded to the scene and corulu.cted a criminal investigation. The OIG also resporuied. Although. the Office ofI nternal Affairs did not identify any criminal conduct, pursuant to departmental policy, it referred the matter to the district attomey's office for review. The Office of Intema1 Affairs also opened an administrative investigatiOll, which the OIG accepted for monitoring. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty I. Usc of Deadly Faroe I. Exonerated No Penalty Imposed No Penalty Imposed Pre-ditciplinary Anenment The department did not comply with procedures governing the pre-disciplinary process because the Office of Intema1 Affairs did not timely complete the investigation. The department attomey did not review the draft investigative report in a timely manner. Procedural Rati:n& Subltantive Ratlna Inallfficient Sufficient I Attenment Quettiont a Within 11 calendar daya follow!Dg receipt of the lnvatlptlve report, did the department attorney review the report and provide appropriate auJ.tantlve feedback addradllg the thorouglme~~ and clarity of the report? 11u! ~ oflntunal Affairs provltkd 1M drqft report to the tkpfP"tmelrJ attorney on Sqtmlbu 19, 2016. However, 1M tkpartmentattomzy dJd rwt docummtrevl4w of/M report In 1M case "ltiQfJQgemmt systml (11' provide approprlllte substtmdvef udback addressing 1M tlwroug/JMss and cJarlty of1 M 1'(fJX11't unJJI OcJober 12, 2016, 22 days af lu recapt. a Did the department cODduct the pre-dladpllury/IDvatlptlve phue with due diligence? 11u! ~ oflntunaJA.ffalrsdJdrwtC(IIIIpkU /Mdeadlyf~ lltvutJgalton within 90days of/M lndtlentd4Upunllllllt tothetkpfP"tmelrJ's gultklbw. 11u! lnddenttookplauMay 27, 2016, but the OjflaoflnU111illA.ffalrs dJdrwtcompkU 1M lltvutJgadon unJJl Oclober 17, 2016, ourf our months l4tu. Ditpotition The Deadly Force Review Board found that the officers' lliCI of deadly faroe complied with the departments usc-of-faroepolicy. The hiring authority exonerated the officers. The OIG concurred. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 64 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-07-28 16-0001828-IR Usc of Deadly Faroe Administrative Incident Summary On July 28, 2016, an offioer saw a man brandish a knife at numerous peri01]S in and outside of a store. The man refused to surrender the knife and behaved erratically, swinging the knife at bystanders and lunging at the officer. The offioer fued Olle round from his weapon, striking the man in the cheat, causing h.im to fall and drop the knife. Outside law eoforcement responded to the ICC!le. An ambulance transported the man to an outside hospital wbm: be was placed in a medically-induced coma. The hospital removed the man from the medically-induced coma on AU&USt 2, 2016, and placed h.im in intensive care. The department timdyllOtified the OIG. The Office ofintemal Affairs and the OIG responded to the ICC!le. Adminittrative lnvettigation Allegation• Findingt Initial Pell8lty Final Pell8lty No Penalty Imposed No Penalty Imposed I. We:apo~a I. Exonerated Pre-ditciplinary Anenment The department did not comply with procedures governing the prc-diaciplinaly process because the department attomey did not timely provide feedback regarding the investigative report and the hiring authority delayed CO!lducting the investigative fin.dinp 0011ference. Procedural Rati:nJ Subttantive Ratio& InsW!icient Sllf'lieient Attenment Quettiont a Within 11 calendar daya followiDt; receipt of the Investigative report, did the department attorney review the report and provide appropriate aubetantlve feedback addreaiDg the thorouglmaa and clarity of the report? 'l7u QfJic4 ofI ntunaJ A.lfal17 provltkd 1M drqft 1eport to the tkpartmem attorney on October U, 2016, but 1M departmen~ altomey ~ to provide fudback rq:tur/Jng 1M 1eport U1IIJJ November 10, 2016, 27 daysiMreq/W. a Did the department attorney provide written cODflnnatiOD wmmarlz!Dgall crttlcal dlacualouabOllt the Investigative report to the apedal agent with a copy to the OIG? 'l7u dqartment attorney dJd Mt ptrJVItk written conj/rmlltton to 1M OIG Sllltlltllll'tzlllg critical dlscusstons about 1M lltvutJga/Ju Teport.. a Did the HA timely CODiult with the OIG and department attorney (Ifa pplicable), n:prd!Dg the llllfllcleDcy of the IDvestigatton and the IDvestigatlve fiDdiDp? 'l7u QfJic4 ofl ntunaJ Affal17 relur1l&l 1M case to 1M hirlltg autiu>rlty on April U, 2017. However, 1M hlrlng authority dJd Mt <X1IISU1t with 1M OIG alld 1M dqartment attorney regattlbtg 1M sujflcWtcyofiM lltvutlgalton alld 1M lltvutJgatlu./llldill&f U1IIJJ 32 d4ys the18aftu. • Did the department couduct the pre-dlxlpiiDary/IDvestigatlve phue with due diligence? 'l7u tklays a.. addrused In prior quutlons. Ditpotition The Deadly Force Review Board found that the ofl:icets use of deadly foroe complied with policy. The hirin& authority subaeqllC11tly exonerated the ofl:ioer, and the OIG 0011Curred. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 65 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-0S-06 16-0001841-IR Usc of Deadly Faroe Administrative Incident Summary On Alll!lllt 6, 2016, an inmate attacked a second inmate with aninmato-manufactured maponon the exercise yard. Offioers fired scven1en-letball'OIIIIJh and deployed two pepper spray grenades, but the inmatea kept fighti111-An officer fired one round from a Mini-14 rifle at the first inmate and mWed, but the inmatea stopped fi~-The first inmate sustained minor injuries. The department sent the second inmate to an outside hospital for treatment ofs tab wollllds, and be retumed to the institution the next morning. The Office of Internal Affairs responded to the scene and corulucted a criminal investigation. The OIG also responded. The Office of Internal Affairs did not identify criminal misconduct but did not refer the matter to the district attorney's office for review as required by departmental policy. The Office of Internal Affairs opened an administrative investiptiOll, which the OIG accepted for monitorinJ. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty L Usc of Deadly Faroe L Exonerated No Penalty Imposed No Penalty Imposed Pre-ditciplinary Anenment The department did not comply with procedures goveminJ the pre-disciplinary process because offioers allowro inmatea to walk thro\Jih the crime scene, the investigative services unit inappropriately cleared the crime scene, and the department attomcy did not note the exception to the deadline to take diseiplitWY action. Procedural Rati:n& Subltantive Ratln& Inallfficient Suflicierlt I Attenment Quettiont • Wu the BA'a rapo~~~e to the erltleallnddent appropriate? OjJicus alk>wed t1rmlllu W walk tlrrough tha CI'IIM SUM W relum W thdr buJidJngs. '17u tlrvutJgatlve servlca unit ckand lila CI'IIM SUM /J4(11'e specJal agents from lila tU44/y f01'C4 tnvutJgalkm uam t117'lwd aJ lila lnstJMkm. a Did the lnvatlgatlve -mea wrlt, or equlvtient lnveatlgatlve penoDDel, adequately rapcmd to the erltleallnddent? '17u tnvutJgatlve servlca unit ckand lila criiM SUM /J4(11'e lila sp«jal agents from lila tU44/y f01'C4InvestJgad(lll ~-arrlv«J aJ tM lllstiJutkm. a Within 11 calendar daya, did the department attorney or employee relatl0111 oflleer eorreetly uaea the deadline for taldDg dladpUury aetloD md make m entry Into the cue maugement ayatem eoDflnnlng the date of the reported lnddent, the date ofd bmvery, the deadline for taldDg dlaelpllnary aetloD, md my n:eeptlou to the deadline bcnm at the time? '17u dqartment attoi'M)I assasu th~ tkadJJM for taking dJscJpllllary actkm wUiraut nodllg lila crlmlllal tnvutlgaJWII as (Ill appllc4bk =eptlot~. Ditpotition The Deadly Force Review Board found the officer's use offaroe complied with policy. The birinJ authority subsequently exonerated the officer. The OIG concurred. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 66 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Dllte OIG Calle Number CateType 2016-08-06 16-0001842-IR Use of Deadly Force Crintina1 Incident Summary On Alll!lllt 6, 2016, an inmate attacked a second inmate with aninmato-manufactured maponon the exercise yard. Offioers fired sevenlen-letball'OIIIIJh and deployed two pepper spray grenades, but the inmatea kept fighti111. An officer fired one round from a Mini-14 rifle at the first inmate and mWed, but the inmatea stopped fi~. The first inmate sustained minor injuries. The department sent the second inmate to an outside hospital for treatment ofs tab wollllds, and be retumed to the institution the next morning. The Office of Internal Affairs responded to the scene and corulucted a criminal investigation. The OIG also responded_ The Office of Internal Affairs did not identify criminal misconduct but did not refer the matter to the district attorney's office for review as required by departmental policy. The Office of Internal Affairs opened an administrative investigatiOll, which the OIG accepted for monitorinJ. Criminal Invettigation Invettigative Anettment The department did not comply with policies and procedures govemina the investigative process because the investigative services unit did not properly preserve the crime scene, the Office of Internal Affairs did not timely conduct the investigatioll, and the Office of Internal Affairs did not refer the matter to the district attorney's office as required by departmental policy. Procedural Ratina Subltantive Rating lna~Uftcient Insuflicient Attenment Quettiont o Wu the BA'arapo~~~e to the erftleallnddent appropriate? OjJicus alk>wed l1rmlllu W walk through lira criiM scene W 7elum W tJrdr buJ/dJngs. '11u tlwutJgadw serv/ca unit chalwi lira criiM SUM /J4(11'e lira sp«Jal agents (li'P'/wd at lira tnstJiutjon. • Did the lnvatlgatlve aervlees wdt, or equivalent lnvelltlgatlve penonuel, adequately rapond to the erftleallnddent? '11u tlwutJgatlve serv/ca unit chalwi lira criiM SUM /J4(11'e lira sp«Jal agents (li'P'/wd at lira tnslltuiUm. o Did the erfmlna1 Deadly lloree IDvatlgatlon Team apedal agent eonduet alllnteniewa within 71 houn? '11u sp«Jal agent dJd Mt <X>IIduct alJ/IIJuvlews wlthill 72 hours. o Did the Olllee of IDternal Af&ln appropriately determine whether th-wu probable eauae to belteve a erfme wu committed and, Ifp robable eauae eDited, wu the lnvatlgatlon referred to the appropriate agency for proaeeutlon? '11u ()JJic4 ofI ntunaJ A.. !fairs dJd Mt rqer tlu matter w lira dJstrlct attom4)1's o.f!lc4 as requbwl byp o/Jcy. • Did the department conduct the pre-dfxlpllnary/lnvatlgatlve phue with due dlllgence? nu sp«JaJ agent spent mo"' tJum 90 hOW'S ]11'ffpQrlng and compkllng ~~ra 34axa d1Y!ft t~wutJgattve report. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 67 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-1~12 16-0001975-IR Usc of Deadly Faroe Administrative Incident Summary On October 12,2016, two inmatesstabbedathirdinmate with inmate-manufactured weapons. Anoflicerfiredonemundfroma Mini-14 rifle atone of the attacking inmates but missed. The inmates stopped figbtinJ. Oflicera trallspOrted the stabbed imnate to an outside hospital and later returned the inmate to the institution. The Office of Intemal Affairs rcaponded to the scetle and conducted a criminal investiption. The OIG also rcaponded. The Office ofI nternal Affairs did not identify criminal conduct but did not refer the matter to the district attorney's office as required by departmental policy. The Office of Intemal Affairs also opened an administrative investigatiOll, which the OIG accepted for monitoring. Adminittrative lnvettigation Allegation• Findingt Initial Pell8lty FirWPell8lty I. Weapons I. Exonerated No Penalty Imposed No Penalty Imposed Pre-ditciplinary Anenment The department did not comply with procedures goveming the pre-disciplinary process because the investigative services writ did not timely provide evidence to the Office ofintemal Affairs and the departmentattomcy did not timely note one oft he exceptions to the deadline to take disciplinary action. Procedural Rati:nJ Subttantive Ratio& InsW!icient Sllf'licient Attenment Quettiont a Did the IDvestlgatlve terVka unit, or equivalent IDvelltlgatlve penonuel, adequately respond to the erltlealiDddent? 11u! tnvutJgaJJve serv/ca unit dJd notp rovltk requuud evldena to the ~ oflnurnal Affairs untJJ eJglrJ wukJ q!Ur the lncklent and /nidal req~Wt a WlthiD 11 calendar daya, did the department attorney or employee relatiODI ofllcer correctly._ the deadline for taldDg d!KipUury actloD md make m entry IDto the cue management ayatem eoDflnnlng the date of the reported IDddent, the date ofd bmvery, the deadline for taldDg d!KipUury actloD, md my n:ceptlona to the deadline bcnm at the time? 11u! Upartment attoi'M)I ~ assigned on Novemhu 3, 2016, but dJd not assess one oft he exupttons to tu tkad/JM to IIW dlscJpltnary action untJJ May 23, 2017, six months q/Ur assignment. Ditpotition The Deadly Force Review Board f0011d that the oflicets uae of deadly foroe complied with policy. The hiring authority exonerated the officer. The OIG collCII1Ted. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 68 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Dllte OIG Calle Number CateType 2016-10-12 16-0001976-IR Use of Deadly Force Crintina1 Incident Summary On October 12,2016, two inmatesstabbedathirdinmate with inmate-manufactured weapons. Anoflicerfiredonemundfroma Mini-14 rifle atone of the attacking inmates but missed. The inmates stopped figbtinJ. Officers trallspOrted the stabbed imnate to an outside hospital and later returned the inmate to the institution. The Office of Intemal Affairs rcaponded to the scetle and corulucted a criminal investiption. The OIG abo rcaponded. The Office ofI nternal Affairs did not identify any criminal conduct but did !lOt refer the matter to the district attorney's office for review as required by departmental policy. The Office of Intemal Affairs abo opened an administrative investigatiOll, which the OIG accepted for monitoring. Criminal Invettigation Invettigative Ane11ment The departmem did not comply with procedures governing the investigative procesa because the Office of Intemal Affairs did not timely complete the investigation or refer the matter to the district attorney's office. Prouclural Rating Subltantive Rating lniW!icicm Suflicic:n.t Attenment Quettiont o Did the Oll1ce of IDtemal Af&ln appropriately determine whether th-was probable eau.e to believe a crime wu committed and, If probable eau.e em.ted, was the IDvestlgatloD referred to the appropriate ageney for proNCUtlon? 11u! ~ofI ntunaJ Affairs dJdnot ,.qer tlu malter to tlra dJstrlcJ attorney's o.f!lca as po/Jcy requlru. o Did the department cODduet the pre-dfxlpliDary/IDvestlgatlve phue with due diligence? 11u! lncJdmt tookplilca on October 12, 2016, buJ the ()jfla oflnUmill Affairs dJd not compkU the brvutlgadon UlltJl February 2, 2017, 113 dtlys qfW the lllcJdmt SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 69 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-1~17 16-0002116-IR Usc of Deadly Faroe Administrative Incident Summary On October 17,2016, anoffioerallegedlynegligentlydischargedhisdutyweapon while conducting a weapons checkatarange, and the bullet struck: the ground. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty I. Weapons I. Sustained Letter ofI nstruction Letter of Instructio11 Pre-disciplinary Anenment The department sufficiently complied with policies and~ governing the pre-discipliiwy process. Procedural Rafinl Subttantive RatinJ Sufficient Sllf'licie11t Ditpolition The hiring authority sustained the allegation and issued the officer a letter ofin.struction. The OIG did notcOllC\11' with the penalty but did not seek a higher level ofr eview. Disciplinary Anenment The department did 11ot comply with~ governing the disciplin.ary process because the department attorney provided flawed legal advioe to the hiring authority and the hiring authority did not impose any discipline. Procedural Rating Subttantive Rating InsiUiicicnt Sllf'licie11t I Attenment Quettiont o Did the departmmt attorney provide appropriate legal CODIUltatlon to the BA regarding diK!pllnary determinations? '171<! dqartment atkii'My advlsu 1M hlrlngautlrorUy 1M offlcu's misconduct was llllllltUIUONd alld acdtlenkd alld, tlwqore.,formal dJscJpliM was Mt W<ll't'anted. Ho-, 1M officer's actJons were gmssly Mgllgent alld his ill tent was tlwqore lmln4teri4L o Did the BA who partldpated In the dildpllnary eoufennee select the appropriate Employee DIKipUnary Matrb: charges and eauaa for diK!pllne? '171<! hiring autiu>rUy did Mt sdut Ill~ approprlau alkgatkm that 1M offlcuf aJkd to ob!Jerv~ tllld perform wiJJIIII 1M SCOJM oft l'aJirlllg. rea.sonlllg that since 1M lllcldMt ~ at the jlrlllg ~ 011 1M - d4y as 1M tratnlllg. Ill~ offlcu was not yet tl'atMd. However, 1M lltcJMnt occurr&i ~r 1M officer nuJv&i tl'allllllg. o Did the BA who partldpated In the dildpllnary eoufennee select the appropriate pmalty? '171<! hiring autlu>rUy took cOI'reCtlve actkm rotJru thtlll Impose formal dJscJpiJM. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 70 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-11-30 16-00021 06-IR Usc of Deadly Faroe Administrative Incident Summary On November30, 2016, an officer fired one round from a Mini-14 rifle at an inmate who was attacking a second inmate with an inmato-manufactured mapon on the exerWc: yazd. The round did not strike its intended taraet, but the inmates stopped fighti111. The second inmate sustained stab wouruls, and the department transported him to an outside hospital. The inmate returned to the institution within one Mel<. The Office of Intema1 Affairs responded to the scet1e and conducted a criminal investigation. The OIG also responded. The Office of Intema1 Affairs did not identity any criminal conduct but did 11ot refer the matter to the district attorney's office for review u policy requires. The Office ofI nternal Affairs also opelled an administrative investigati011, which the OIG accepted for morutoring. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty No PCI!alty Imposed No PCI!alty Imposed I. Weapons I. Exonerated Pre-ditciplinary Anenment The department did 11ot comply with procedures governing the prc-disciplitwy process because the i11vestigative services writ prematurely processed and clem:d the crime sce11e and the department attorney did not timdyusess &ll.exceptiOll. to the desd1i1l.C to take discipli11aryaction. The special agentdid110tinclude a relevant exhibit in the drafti11vestigative report. Procedural Ratina Subltantive Ratina hlsWftcient Sufllcicnt Attenment Quettiont a Did the IDvestlptlve services wdt, or equivalent IDvelltlgatlve penonuel, adequately respond to the erltlealiDddent? 'l7u tnwstJgadve serv/c4s unit procased and ck4red the crime sc-bqqre the tk44Jy f()IU tlrwsdgaJkm uam vl4w«l the seen& a WlthiD 11 ealendar daya, did the department attorney or employee relatiODI oflleer correctly._ the deadline for taldng dadpUury actloD md make m entry IDto the cue management syatem eoDflrmiDg the date of the reported IDddent, the date ofd bmvery, the deadline for ta1dng diKipUury actloD, md my n:ceptlona to the deadline bcnm at the time? 'l7u d4partmenJattorM)IlWIS assigned on December 19, 2016, buJdJdrwtassus an exception w the tkadl/Mfor tllldngdJsclpllntlryacJkm klwwnat the time unJIJMay 22, 2017,./M IIWIIths qftu a.sslgmnmt. a Wu the IDvestlgatlve draft report provided to the OIG for review thorough md appropriately dnfted? 'l7u draft report did rwt illcJutk the vid«> ~ ofthelllci<Wit as an exhibit Ditpotition The Deadly Force Review Board fOUlld that the officer's use of deadly foroe complied with policy. The hiring authority subsequ.emly exOIICl"ated the officer, and the OIG COI!Cillred. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 71 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Dllte OIG Calle Number CateType 2016-11-30 16-00021 07-IR Use of Deadly Force Crintina1 Incident Summary On November30, 2016, an officer fired one round from a Mini-14 rifle at an inmate who was attacking a second inmate with an inmato-manufactured mapon on the exerWc: yazd. The round did not strike its intended taraet, but the inmates stopped fighti111. The second inmate sustained stab wouruls, and the department transported him to an outside hospital. The inmate returned to the institution within one Mel<. The Office ofintemal Affairs responded to the scet1e and coruiucted a criminal investigation. The OIG also resporuied. Although. the Office ofintemal Affairs did not identify criminal conduct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office of Intema1 Affairs also opened an adminiatrative investigation, which the OIG accepted for mollitoring. Criminal Invettigation Invettigative Anettment The department did not comply with procedures goverllill8 the investigative process because the investigative services writ prematuldy cleared the crime scene and the Office of Intema1 Affairs did not timely complete the investigation. Procedural Rating Subltantive Rating lm~Uticicm Suf'licicnt Attenment Quettiont o Did the IDvestlgatlve terVIces unit, or equivalent IDvelltlgatlve penonuel, adequately respond to the erltlealiDddent? 11u! tnvutJgaJJve serv/ca unit procased and cktlred the crime sc-bqqre the tUmJJy force tlrvudg(Ukm team vl4w«l the seen& • Did the department cODduct the pre-dfxlpliDary/IDvestlgatlve phue with due diligence? 11u! OjJice ofI ntunaJ Affairs dJd not complete the deadly force tnvudg(Ukm within 90 days oft he lncJdmJ dille ]1UI"Suant to the tkpfP"tiMnt's gukklbw. 11u! lncJdent tookp laa em November 30, 2016, but the OjJice ofI nJunal Affairs dJd not cqmplete the tnvutJgaJJon untJJ May U, 2017, 175 days ~ Incident Dllte OIG Calle Number Ca.eType 2016-12-14 16-0002142-IR Use of Deadly Force Crintina1 Incident Summary On December 14,2016, two inmates attacked a third inmate withstabbi"'motions on the exerWc: yazd. The third inmate was onhUback:andappeared unable to defend himself. An officer fired one warning shot from a Mini-14 rifle, but the inmates continued fi~. The officer fired two more rounds at the two inmates but missed. Six officers deplo)'tld pepper spray grenades. One of the officers used a chemical agent grenade, stoppi"' the attack. Officers discovered two inmato-manufactured weapons. The inmate who was attacked sustained 75 puncture wounds and was transported to an outside hospital and subaequently returned to the institlltion. The Office of Intema1 Affairs responded to the scene and conducted a criminal investigation. The OIG also resporuied. Although. the Office ofintemal Affairs did not identify criminal conduct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office ofI nternal Affairs also opened an adminiatrative investigation, which the OIG accepted for mollitori"'. Criminal Invettigation Invettigative Anettment The department did not comply with the procedures goverllill8 the investigative procesa because the Office of Intema1 Affairs did not timely complete the interviews or the investigation. Procedural Ratin& Subltantive Rating I111Wflcicm Sul'liciCll.t Attenment Quettiont • Did the er1m1Dal Deadly ll'orce IDvestlgatiDn Team spedal agent conduct alliDtervlews wlthiD 71 hOlln? 11u! lncJdmJoccumd emD«4mber 14, 2016, but/he Ojjle4oflniUnaJAffalrs dJdnotcomplete all llltuvkwsulltJJDecmlber 20, 2016. o Did the department cODduct the pre-dfxlpliDary/IDvestlgatlve phue with due diligence? 11u! OjJice ofI ntunaJ Affairs asslgMd a specJ41 agent em D«4mber 14, 2016, but the spec141 agent dJd not complete the tnvutJgatJcm untJJ Aprll6, 2017, 113 days theNJ.ftu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 72 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Dllte OIG Calle Number CateType 2016-12-20 16-0002153-IR Use of Deadly Force Crintina1 Incident Summary On December20, 2016, nearly 100 inmates participated ina riot on the exerWc: yazd. QffiQerS deployt:d pepper spray, pepper spray grenadea, and less-lethal rounds. The inmates oontinued fighting, and two offiQerl each filed one warnina shot from Mini-14 rifles. One of the offiQerl filed a ICCOlld round, striking an inmate who was kicking another inmate in the head. The department lrallspOrted the inmate who was kicked in the head and an inmate who sustained loa of CODJciouaneu to an outside hospital. Both inmates returned to the institution the next day. The department lrallspOrted the inmate struck by the Mini-14 round to an outside hospital, following which he a1ao returned to the institution. The Office of Internal Affairs responded to the scene and corulucteda criminal investigation. The OIG a1ao responded. Although the Office ofilltemal Affairs did not identify any criminal conc1uct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office ofilltemal Affairs a1ao opened an administrative investigatiOll, which the OIG accepted for monitorill8. Criminal Invettigation Invettigative Atte11ment The department sufficiently complied with. policies and proceclurta governing the investigative process. Procedural Ratina Subltantive Rating Sufficient Suf'licicnt I Incident Dllte OIG Calle Number Can Type 2017-01-24 17-0000 126-IR Use of Deadly Force Crintina1 Incident Summary On January 24, 2017, two inmates attacked a third inmate with. stabbing motions on the exerWc: yazd. The third inmate was on the J!'Ound and bleeding profusely. An officer filed one round from a Mini-14 rifle, stopping the attack. The department transported the third inmate to an outside hospital. The Office of Internal Affairs responded to the scene andoonducted a criminal investigation. The OIG a1ao responded. Alth.oll8h the Office of Internal Affairs did not identify any criminal conc1uct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office of Internal Affairs a1ao opened an administrative investigatiOll, which the OIG accepted for monitorill8. Criminal Invettigation Invettigative Attettment The department sufficiently complied with. policies and proceclurta governing the investigative process. Procedural Ratina Subltantive Ratina Sufficient Suf'licicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 73 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Dllte OIG Calle Number CateType 2017-m-11 17-002181(}-IR Use of Deadly Force Crintina1 Incident Summary On February II, 2017, two inmates repeatedlypiiiiChed a third inmate on the exercise yard. Anoflicertm:done len-lethal round but mWed. The officer tm:d a second leu-lethall'OIIIld, hitting one of the attacking inmates on the bead. The officer f"tred a third leas-lethal round at the second attacking inmate, hitting the inmate on the knee. The inmate who was hit on the head lost OO!lJciousncas and the department transported him to an outside hospital. The Office ofintemal Affairs rtapOllded to the ICeliC and conducted a crintina1 invcatiption. The OIG abo rtapanded. Although the Office of Intemal Affairs did 1lOt identifY any criminal conduct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office of Intemal Affairs abo opened an administrative invcatiption, which the OIG accepted for mmritori"8- Criminal Invettigation Invettigative Anettment The depsrtment did not romply with procedures governing the invcatigative process because the special agent never interviewed two key witneues. Prouclural Rating Subltantive Rating lniW!icicm Sufficient Attenment Quettiont o Did the er1miDa1 Deadly ll'oree Investigation Team IIPCdal agent eonduct alllnteniews within 71 houn? '11u S]UCkll agent dJd not lntuvl4w two tnmaus tnvolv«l tn ~ lncklmtwWrtn 72/wurs. • Were all oft he lnter\'fem thorough and appropriately rondueted? '11u S]UCkll agent -rt nt~ OM of~ aJtQcJdng brmatu or~ attllcUd lrmtaU. o Wu the Investigation thorough and appropriately rondueted? '11u S]UCkll agent -rt nt~ OM of~ aJtQcJdng brmatu or~ attllcUd lrmtaU. Incident Dllte OIG Calle Number Can Type 2017-03-09 17-0022034-IR Use of Deadly Force Crintina1 Incident Summary On March 9, 2017, two inmates attaeked a third inmate on the exercise yard. An officer tm:d one shot from a Mini-14 rifle, striking one of the attacking inmates in the arm, stopping that inmate's attack. The second inmate continued his attack. The officer tm:d a second shot from the Mini-14 rifle but missed the intended tl1'8el A second officer deployed a pepper spray grenade, but the attack eontinued A third officer struck the second inmate once with a baton, stopping the attack. The department tranaferred the inmate who was struck by the Mini-14 round to an outside ha.pital wbm: he unde<M:nt SlllJ!ery. The inmate returned to the institlltion on Mardi 16, 2017. The other inmates ~ trQted at the institlltion for injurica rdated to the attack. The Office of Intemal Affairs rtapOllded to the scene and conducted a crintina1 invcatigation. The OIG abo responded. Although the Office ofintemal Affairs did !lOt identify any crintina1 ronduct, pursuant to deparlmental policy, it referred the matter to the district attorney's office for review. The Office ofintemal Affairs abo opened an administrative invcatigation, which the OIG accepted for motritoring. Criminal Invettigation Invettigative Anettment The depsrtment sufficiently complied with policica and procedures governing the invcatiptive process. Prouclural Rating Subltantive Rating Sufficient Sufficient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 74 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA South Incident Date OIG Ca1e Number CateType 2015-12-30 15-0002925-IR Use of Deadly Fon>e Administrative Incident Summary On December30, 2015, a :lerl!eant allegedly diJcharged a !irQrm and shot herself during remedial fireartm training. The department tran.ported the :lerl!eant to an outside hospital where she was treated for a minor injury and rdeased. The Office ofI nternal Affairs responded to the ICC!Ie and oonducted a criminal inveatigation. The OIG alJo rt:SPOnded. Although the Office of Internal Affairs did not identify criminal conduct, pursuant to departmental policy, it referred the matter to the district attorney's office for review. The Office of Internal Affairs also opened an admi11Utrative inveatigation, which the OIG accepted for monitoring. Administrative lnvettigation Allegation• Finding~ Initial Penalty Final Penalty I. Sustained Letter of Reprimand Letter of Reprimand I. Vkapons 2. Unfounded 2. Vkapons 3. Unfounded 3. Neglect of Duty 4. Unfounded 4. MUuse of State Equipment or Property Pre-disciplinary Anenment The department did not oomply with pn:l(ledures governing the pre-disciplinary pmoess because the hiring authority did not timely oonduct the inveatigative findings oooferenoe, the department attorney did not provide written confirmation regarding the inveatigative report, and the employee rdations officer erroneously added allegations. Procedural Ratin& Subltantive Ratln& InaiUiicient Suflicient Astenment Queltion1 o Did the departmeut attorney provide wrltteu conflrmadou aummarlzlng all critical dbeualou about the lnveatlgatlve report to the apeelal ageut with a eopy to the OIG? 171<! tkpartment atkii'My dJd Mt ptrJVItk wrlttm oonjtrmatloll to 1M OIG sumltllll'tzlllg CI'UJcal dlscusslolls about 1M lltvutJgatju rep<JI't. o Did the HA timely CODIUit with the OIG and departmeut attorney (Ifa pplicable), regarding the IUfllcleDcy of the IDveatlgatlon and the IDveatlgadve fiDdlngJ? 171<! Ojflu ofI ntuna1 AffaJn rqenwi th~ matter to tM hlrlllg authority 011 July 26, 2016. H~ tM hlrlllg authority dJd Mt COIISult with th~ OIG (llld tkpa~Wmt attomey regarding tM sujJicWJcy ofiM illvestlgatton (llld 1M illvestlgaJWejtndblgs lllltJl August 24, 2016, 30 days IMreaftu. o Wu the CDCR llorm 402 documeudng the fiDdlngJ properly completed? 171<! empfqyea relatlolls ojJic4r0'1'(JM(JUSlyadtkd 7IU1M1'0U!I alkgatlolls In 1M=~~-systml thaJ 1M hlrlllg authorltydldMtaddrus at 1M lllvestlgadveflrrdings <XII!{uenc4 but h4d to be doCUIIIent&i 011 1M form ~nttng 1M illvestlgattve findings. o Did the departmeut couduct the pre-daclpllury/IDveatlgadve phue with due dlllgeuce? 171<! tk/ay 1s addrusu 111 a prior quatloll. Di1polition The Deadly Force Review Board found that the :lerl!eant'S use of deadly fon>e did not oomply with policy. The hiring authority sustained an allegation of negligent discharge of a !irQrm and imposed a letter of reprimand. The hiring authority found that additional allegations bad been added in error and, therefore, determined the inveatigation conclusively proved the alleged misconduct did not occur. The OIG did not ooncur with the penalty but did not seek a higher level of review because the penalty was within the disciplinary guidelines. The officer filed an appeal with the State Personnel Board. Prior to the State Personnel Board pmoeedings, the department entered into a settlement agreement with the officer agreeing to remove the letter of reprimand from the officer's official personnel file after one year. The OIG did not concur because the department did not identify any new evidence, flaws, or risQ justifying the modification, but the OIG did not seek a higher level of review because the reduction was minor and did not significandy change the overall penalty. Di1ciplinary Anenment The department did not oomply with pn:l(ledures governing the disciplinary pmoess because the hiring authority did not conduct the disciplinary findings oooference in a timely manner or adequately consult with the OIG and modified the penalty without sufficient justification. The department attorney did not adequately consult with the OIG. Procedural Ratina Subltantive Rating InaiUiicient Suflicient Astenment Queltion1 o Did the HA timely CODIUit with the OIG and the departmeut attorney (If applicable) regarding dlxlpiiDary determlnadoua prior to maldng a fiDal decb!OD? SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 75 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA 171<! n-i1y FOtU RC!VWN Board compkt&i 1Js lltvutlgatkm alld rej'err«l 1M mattu to tM hlrlllg autiu>rlty M .luM 30, 2016. HOW<!-. 1M hJrlllg autlrorlty did not consult with 1M OIG alld 1M ~nt attomey regattlJng 1M dJscJplllrmy ddumlllattons lllltJl August U, 2016, 55 d4ys tJwwJftu. o U there waa a Nttlemeut agreemeut, waa the aettlemeut coulbteDt with the DOM factora? 171<! dqartmentdld110t ltkntJjjl anynew~vilkllu,fosws, (11' risks justifying 1M modJj/catlon. o Did the HA CODIUit with the OIG and departmeut attorney (If applleable) before modifyiDg the penalty or agreeiDg to a aettlemeut? 171<! hJrlllg autlrorlty did 110t consult with 1M OIG b~-agruJng to a settkment. o U the penalty waa modified by departmeut action or a aettlemeut apeemeut, did OIGconcur with the modlfleatlon? 171<! OIGdidMtCOfiCW'wlth IM~modJj/catlo1l b&:4us~IM tkpa..-tdid110t ltk11tJjjlanynewevilknce.,fosws, (Jf'rlflksjustifytllg 1M modJjlcatton. o Did the departmeut attorney or employee relatl0111 oflleer cooperate with and piiiVIde coutlnual real-time co118111tatlon with the OIGthmughout the d!KipUnary phue? 171<! dqartment attomey did Mt pi'(IVIde th~ OIG with a draft of1 M sdthmult agrum.Mtj(Jf' ll!lM\1( o Did the HA cooperate with and pro\'lde continual real-time coullllltatlon with the OIG throughout the d!KipUnary phue? 171<! hJrlllg autlrorltydldMtconsult with 1M OIGprlor to agruJng to 1M settl41Mnt. o Wu the d!KipUnary phue couducted with due dlllgeuee by the departmeut? 171<! delay Is adbe.uu In a prior qua~ ton. Incident Date OIG Can Number CateType 2016-05-20 16-0001700-IR Use of Deadly Fon>e Administrative Incident Summary On. May 20, 2016, an officer allegedly wrintentionally diJcharged his penonal firearm inside an institutional firearm storage locker arui was allegedly dislumest in his report regarding the incident. Administrative Invettigation Allegation• Finding~ Initial Penalty Final Penalty Suspension Suspension I. DiJcbarge of Lethal Weapo11 !.Sustained 2. Disllotuty 2. Not Sustained Dispolition The hiring authority sustained the allegation the officer negligently diJcharged a firearm, but 1lOt that the officer was dishonest, and impaled a two-worlring-ilay suspension. The OIG COllCU1"I"ed. The officer filed an appes1 with the State Personnel Boanl. Prior to State Personnel Board proceedinp, the department entered into a settlement agreement with the officer qreeina to remove the c!Uciplinlry action from the officer's official personnel file after 12 months. The OIG did 1lOt concur. HOIII'Wcr, the settlement terms did 11ot merit a higher level ofr eview because the pcll81ty was within the appropriate range for the miacoruluct Di1ciplinary Anenment Overall, the department sufficiently oomplied with policies arui procedures govemin& the diJciplinaryprooess. Proceclural Rating Subltantive Rating Sufficient Suflicicrtt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 76 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-05-24 16-0001654-IR Usc of Deadly Faroe Administrative Incident Summary On May 24,2016, an officer allegedly dischargedhU fm:anninan observation 8lQ which overlooked the dining facility where several inmatea were eating, with asccond officer present. An U1llmown projectile struck the sccond officer in the back of the head. The Office of Intemal Affairs rcapondt;d to the scene and conclucted a criminal investigation. The OIG also reapondt;d. Although the Office of Internal Affairs did !lOt identifY criminal conduct, pursuam to d.epartmental policy, it referred the matter to the district attorney's office for review. The Office ofI nternal Affairs also opened an administrative investigation, which the OIG accepted for monitoring. Adminittrative lnvettigation Allegation• Findingt Initial Penalty Final Penalty I. Weapons I. Sustained Sslary Reduction Sslary Reduction Pre-disciplinary Anenment The depsrtment did not comply with procedures governing the prc-diaciplinary process because the investigative services writ neglected to photograph the scene and the Office oflntemal Affairs did 1lOt timely conduct the investigation. Procedural Rati:nJ Subttantive Ratina InsWI'k:ient Suflicient Astenment Questiont a Did the IDvestlgatlve terVIces unit, or equivalent IDvelltlgatlve penonuel, adequately respond to the erltleaiiDddent? 11u! tnvutJgaJJve servica unit nqkcUd w plwwgraph 1M scen& a Did the crlmiDal Deadly :Foree IDvestlgatlon Team apedal agent conduct alliDteniewa wlthiD 71 houn? 11u! tWltl1y fOIU lllvutJgatlon team dJd Mt llrJuvlew 1M o.fllcu lllltll May 31, 2016, seve~~ d4ys aftu 1M lllcJdMt a Wu the IDveatlgatlon thorough and appropriately conducted? 11u! tnvutJgaJJve servica unit dJd Mt plwwgraph tM sc-. • Did the department conduct the pre-dladpllnary/lnvestlgatlve phue with due diligence? 11u! ~ ofh ltunaJ Affairs dJd Mt compuu 1M deadly f(JIU tnvutJgatlon wllhJn 90 d4)IS of1 M l1lcJdMt dtlU ]1UI"Sutmt w the tkpfP"tmDit's gukklbw. 11u! lllcJdem oCCU178d on May 24, 2016, but the OjJla ofm u111ill Affairs dJd Mt =npkU 1M tlrvudgatkm lllltll Septembu 12, 2016, lll d4ys ~ Ditpolition The Deadly Force Review Board found that the officer's usc of deadly foroe did 1lOt comply with policy. The hiring authority sustained the allegation and imposed a 5 percent salary reduction for 13 motlths. The OIG concurred. The officer filed an appeal with the State Personnel Board but withdrew rn. appeal. Disciplinary Anenment The depsrtment sufficiently complied with policies and procedures governing the disciplinary process. Procedural Rating Subttantive Rating Sufficient Suflicient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 77 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-07-{11 16-0001889-IR Usc of Deadly Faroe Administrative Incident Summary On July I, 2016, a serxeant allegedly negligently diJclwged a !ilQiml into a nearby residence. Adminittrative lnvettigation Allegation• Findingt Initi81 Penalty Final Penalty I. Neglect of Duty I. Sustained Salary Reductioo Modified Salary Reductioo Disposition The hiring authority sustained the allegatiooandimposed aS percent salary reductioo for 12 months. The OIG ooncurred. The serxeant filed an appeal with the State Peaonnel Board. Prior to State Peaonnel Board pmoeedings, the department entered into a settlement agreement with the serxeant reducing the penalty to a S pen>ent salary reductioo for ten months. The OIG ooncurred because the serxeant showed remorse and paid restitution. Disciplinary Anenment Overall, the departmettt sufficiently complied with policies and procedures governing the disciplinary process. Procedurll Rating Subltantive Rating Suffidcttt Sufftcicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 78 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-09-29 16-0002081-IR Usc of Deadly Faroe Administrative Incident Summary On September 29, 2016, an offioer allegedly negligently c!Ucbarged a round from a Mini-14 rifle in a oontml booth while practicing sight alignment with the rifle. Adminittrative lnvettigation Allegation• Findingt Initial Pen•ty Fin•Penmty I. weapons I. Sustained Suspellsion Suspension 2. weapons 2. Not Sustained Pre-disciplinary Anenment The department's handling of the pre-diJciplinaryprocess was substantively insufficient because the department attorney did not attend the initial investigative findings oonfenmee and the hiring authority did not add appropriate allegations. Proceclur• Rating Subltantive Rating Sufficient Insufficient Attenment Question• o Did the departmmt attorney provide appropriate legal CODIUltatlon to the BA regarding the auflldeDcy of the IDvatlgatlon md IDvatlgatlve fiDdlnga? 171<! tkpartment attomey dJd Mt a/Wid 1M l1lltl4l tllvestJgaJtve jtndJIIgs Cbflj~. maJdng a second tllvestlgaJtvef tndbtgs Cbfljuence MCtiSSai'JI. o Did the BA who partldpated Ill the fiDdlnga conference appropriately detenniDe the IDvatlgatlve fiDdlnga for eaeh allegation? 171<! hiring aullwrlty did Mt add a/kgalkw rega7rlbrg 1M ojJiar'sfallure w maintain 1M MtnJ-14 rifle acC<>1ding wp oiJcy duplte tlu OIG's -llllatWn and evldmcuu]IJXJ'1Ing 1M a/kgatlons. Ditpolition The hiring authority sustained an allegation of gmas negligence in handling a duty weapon, but not a ~less handling of a weapon allegation, and imposed a 5(}-worlring-<lay suspension. The OIG ooncurred. The offioer filed an appeal with the State Peraonncl Board that be later withdrew. Ditciplinary Anenment The department sufficiently oomplied with policies and procedures governing the c!Uciplinary process. Proceclur• Rating Subltantive Rating Sufficient Suflicicrtt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 79 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Dllte OIG Calle Number CateType 2017-{11-30 17-{1000 139-IR Use of Deadly Force Crintina1 Incident Summary On Janwuy 30, 2017, two inmates attacked a third inmate with inmato-manufacturt:d weapons on the exercise yard. 'IWo offioers dep10)'tld pepper spray grenadea but the attack continued. An officer fired one round from a Mini-14 rifle for effect at the attacJdn& inmate, striking him in the abdomen. A fourth inmate joined the attack on the inmate being stabbed. A ICCOlld officer fired one warning shot from a Mini-14 rifle, but the attack continued. The first officer fired three additional warning shots, stopping the attsck. The inmate who was shot and the inmate who was stabbed were taken to an outside hospital. The inmate who was stabbed returned to the institution the same day, and the inmate who was shot returned on February 2, 2017. The Oflioe of Internal Affairs responded to the scene and corulucted a criminal investigation. The OIG also resporuled. Although the Oflioe ofI nternal Affairs did !lOt identify criminal coruiuct, pursuant to policy, it referred the matter to the district attorney's offioe for review. The Oflioe of Internal Affairs also opened an administrative investigation, which the OIG accepted for mmritoring. Criminal Invettigation Invettigative Anettment The department did 11ot comply with procedures governing the investigative process because the Oflioe of Internal Affairs did 11ot timely complete the i11vestigatio11. Procedural Ratina Subltantive Rating lm~Uticicm Suf'licicn.t Attenment Quettiont • Did the department cODduct the pre-dfxlpliDary/IDvestlgatlve phue with due dlllgenoe? 11u! ~ ofI ntunaJ Affairs dJd not compuu 1M deadly fOtU brvutJgadqn within 90 days of1 M lncJdmJ dtlU pursuant to the tkpartmmt's gukklbw. 11u! lncJdent tookp laa em January 30, 2017, but 1M~ oflntunal Affairs dJdnotcqmpkUthelnvutJgadqn untll.Junel2, 2017, 133 daysiMPW!/W. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 80 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA AppendixE 72 Critical Incident Cases Central Incident Date OIG Cate Number CateType 2016-05-25 16-0001636-RO Suicide Incident Summary On. May 25, 2016, an officer fourui an inmate ~!angina from a noose in hia cell. Officers cut the noose, and officers, lllll"lca, and paramedics performed lif~>-aaving measures but were WlSucceuful, and a paramedic pronOIIIIQCld the inmate dead. Ditposition The COI"Ollel" determined the cau.e of death was ~!angina and the manner of death was suicide. The department's Suicide Case Review Committee determined the suicide was !lOt f=aeeable but was preventable. The hiring authority identified potential staff miJcoruluct based 011 three officers' alleged failure to relieve preuure 011 the inmate's airway. The hiring authority referred the cue to the Office ofilltemal Affairs for investigati011. The Office of I1ltemal Affairs returned the matter to the hiring authority to take acti011 without an investigati011. The OIG accepted the case for monitoring. Overall Attenment The department's acti0111 were !lOt adequate becau.e officers allegedly failed to rdieve prt:~~ure 011 the inmate's airway before cutting the noose, and the Office of I1ltemal Affairs did !lOt make appropriate determinati0111. Prior eo Incident Ratina Durin& Incident Ratina After Incident Ratina Sufftcicnt Inauftldcnt Insufftcicnt Attenment Queltiont a Were the department'• aetton. prior to, durin(. and after the erltleallnddent appropriate? OjJicgs aJkgedJyf aJUd W rdJeve ]1l"USIIn 011 tM 11JmaU ~ airway b~01e cutting tM MOS& a Did the OIA mde an appropriate Initial determination regarding the eue? 171<! ()jJ/a ofl ntuna1 AffaJn did Mt ope~~ a11 tlwestJgatton or ~ 1M o.fllcus altlrough IMn W<!'l! quutlons ngaldlng whMI o.fllunf ound tM Ill-and 1M tratntng 1M o.fllcus receJved. o U the hlrlnt; authority lllbmltted a requeat for reeoualderatlon to the OIA, wu an appropriate deeblon made regarding the requeat? 171<! ()jJ/a ofl ntuna1 AffaJn 1"¢8«1 1M hlrlllg autiu>rUy's 111(/UUt w tntuvl<lw tM ojJlcus w ddum/M wlraher they collutkd when drafting their reports thspt~ Indications they h4d. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 81 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-06-04 16-0001722-RO In-Custody Inmate Death Incident Summary On June 4, 2016, an officer found an inmate on the floor of his cell alert, but unable to stand 11p. The department transported the inmate to an outside hospital where he died on June 8, 2016. Disposition The coroner determined the c:ai1SC of death wu multiple organ failure caused by diltiazem intoxication and the manner ofd eath wu accidental. The department's emert~ency medical response review committee identified thstDillSCS did not arrive with appropriate tran.port equipment or adequ.stely document the incident. The hiring allthorityprovided training to three nurses. The department's Death Review Committee found thstDillSCsdidnot timelynotifythephysicianon~ or contact the outsidelawenforcementenlcrt!encynumber. Au resultoftrn. review, the department updated its local Cnlert!ency response policies and procedl1res to inclllde specific language regarding contacting the 011tside law enforcement emergency number and provided training to 30 medical staff to inclllde Dl1lSCS and psydtiatric technicians. Overall Attettment The department's actions were not adeq111te bec:allSC Dl1lSCS did not respond with appropriate tranaport eqllipment, adequately document the incident, or timely contact the physician on-call or the outside law enforcement Cnlert!ency nwnber. Prior to Incident Ratlna Durin& Incident Ratina After Incident Ratlna Sul'licient Insllflicient Insul'licient Attettment Questiont o Did the hiring authority timely reiJ)ODd to the crltlcaliDddent? A nurse falkd w rupond w tJu scene wUh proper trrmsport NJU/pmenl, causing a delay In trarrsportlng tJu lmnau w tJu triage and treatmDJt area. Nursu Mglecud w oonlllcJ tJu outskh law ei(OIUIMIII emergenzy IIU1IIbu 01' tJu plryslcJan 071-cali f01' - tJum 15 mlnuJu qfterlt was tktumlned tJu lnmtlte reqmrwl a hlglru kvel ofc are. a Were the department'• aetfcnq prior to, duriDf. ud after the crltlcallnddent appropriate? A nurse falkd w rupond w tJu scene wUh proper trrmsport NJUipmenl. Also, nursu did not tJmay oontact the outskh law el(orcemmt emergenzy IIU1IIbu 01' atkquately dOCUIMIIt tJu l1lcJdmt date and time 01' tJu lnmtlte ~ I1IJtkll m«/Jcal assusment wlu!n arrlvtng w the triage and treatment area. a Wu the crltlcaliDddent adequately docwnented? Nursu did not atkquately docummt tJu lnckknt dau and time 01' tJu lmnatd IIUtkll m«llcal assessment. Incident Date OIG Cate Number CateType 2016-06-11 16-0001734-RO Suicide Incident Summary On June II, 2016, an officer found an inmate hanging from a noose in his cell. Officers entered the cell, and two officers began lifo-~aving meu11re1. A Dl1lSC arrived and assisted fwr officers with lifo-..ving meu11re1 which continlled dl1ring tran.portofthe inmate to the triage and treatment area where a physician pro110I11]Ced the inmate dead. Disposition The coroner reported the ca11se ofd eath wu uphyxia dl1e to hanging. The depertment's Death Review Committee determined the death wu not preventable. The department's Suicide Caae Review Committee found the inmate's suicide wu not foreseeable and not preventable. The hiring a11thority did not identify any staff mUconduct. Overall Astettment The department's response wu ~atisfactory in all critical aapects. Prior to Incident Ratlna Durin& Incident Ratina After Incident Ratlna Sul'licient Sllflicient Sul'licient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 82 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-06-28 16-0001766-RO In-Custody Inmate Death Incident Summary On June 28, 2016, an officer found an ~ve inmate in a cell. 1'btee officers, two paychiatric technicians, and a nune initiated life-aving measures and transported the inmate to the triage and treatmellt area where a physician prollOimced the inmate dead. Ditpolition The coroner determined the caU~C of death wu opiate overdo1e and the manner of death wu accidental, ~elf-induced overdoiC. The department's Death Review Committee found the cause of death wu a narcotic overdoiC and the death wu not preventable. The investigative .ervices unit sufficiently investigated the SOII1'CC of the drugs but did not determine the SOII1'CC or locate additional drugs. The hlring authority oontacted the coroner and district attorney's office to coordinate future expectations. Overall Attettment The department's actions following the incide1lt were not adequate becaU~C offioera moved the inmate's body and searched the cell without proper anthoriD!ion. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Sufficient Il!lllflicicnt Attettment Quettiont o Did the IDvestlgatlve terVIces wdt, or equivalent IDveltlptlve penonnel, adequately respond to the erltleaiiDddent? OjJicus moved the tmnau's body and s~ed Ills uJl b4ore the CQ1f!Mr's autlwriz~Ukm. • Did the OIG IDdependently Identify an operational '-ue or polley \'iolatlon that relulted ID, or should have rault ed In, correetlve action or a referral to the OIA? '11u OIG ldmJVIed that offlcgs m<>Ved the tmnau's body and s~ the uJl IJ4ore obtaining the coronu's autlwriz~Ukm and ~ell corractlve actkm to ensure staturory complklnce In the jiUure. Incident Date OIG Cate Number Can Type 2016-06-28 16-0001768-RO In-Custody Inmate Death Incident Summary On June 28, 2016, an inmate complained of difficulty breathing, then vomited and lost consciOIIIIICSS while being taken to the triage and trQtmellt area, where he became ~ve. N\ll'ICS performed Iife-aving measures and a paramedic prollOimced the inmate dead after oonsulting with a physician at an outside hospital. Ditpolition The coroner determined the C&lliC of death wu heart diseaiC and the manner of death wu llaiU1'al. The department's death review committee determined the cause of death wu myocardial infarction and not prevemable. The hlring authority identified potelltial atalfm isconduct baled on a nune's alleged delay in calling an ambulance and provided training to the nune. Overall Attettment The department's actions during the incidellt were not adequate because a nune allegedly delayed calling an ambulance. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sufliciem Inauft"tcient Sufliciem Attettment Quettiont o Were the department'• aetlolll prior to, duriDg, and after the erltleallnddent appropriate? A 1111/'SS aJhgedJy tk/ayed appmxJIII4Uly eJght 1111m1tu IJ4ore ca1Jillg an amhulanc& SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 83 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-07-12 16-0001789-RO In-Custody Inmate Death Incident Summary On July 12, 2016, an offioer found an ~ve inmate on the floor of rn. cell. A nurJe responded but did not initiate life-saving measures due to obvious signs of rigor 1IIOltU and dependent lividity. Nunca trallspOrted the inmate to the triage and treatment a= where a physician proiiOUllCed him dead. Ditpolition The coroner determined the inmate died of heart dUeue and the manner of death wu natural. The emergency medical responJe review committee determined a nurse did not adequately document why she did not initiate life-saving measures, and a 1e00nd nUl'IC did not document when she arrived and left the ICe!le. The hiring authority for the nunca provided training. Overall Attettment The department's responJe wu not adequate becauae two nunca did not adequately document the medical eme111ency. Prior eo Incident Ratina Durin& Incident Ratina After Incident Ratina Sl1fficicnt Sufficient Inal1fficicnt Attettment Quettiont o Were the department'• aetfcnq prior to, durlnt. and after the erftleallnddent appropriate? '11u d4partmem's aclkw qfW ~ l1lcJdmt wue not approprltlU b6CaUSe two nursu dJd not adequaWy document their observatkms. • Wu the erftleallnddent adequately documented? '11u ettWge71CJ11MdJc41 1U]X171Se ...view e<>mmlttu tkt4nniMd a nurse dJd not adequately documem why she did not tmtltlU life-savtng mea8U1U and a see<>nd nurse dJd not docume711 when she arrived and l4t ~SUM. Incident Date OIG Cate Number Can Type 2016-07-21 16-0001805-RO In-Custody Inmate Death Incident Summary On July 21, 2016, an offioer dUeovered an unresponsive and bloody inmate on the cell floor with a towd wrapped tightly around rn. neck. Offioera removed the oellmate, who wu standing in the cell covered in blood. Three offioers and two nunca removed the towel and initiated life-saving meuures but were IIIIIII4lQC:Isful, and a paramedic proiiOU1lCed the inmate dead. The investigative services unitcondueted an investigation, and the department referred the matter to the district attorney's office. Ditpolition The coroner reported the caUK ofd eath u neck compression and the manner of death u homicide. The department's Death Review Committee descnDed the caUK ofd eath u severe neck compression with blwrt injuries and the death wu not preventable. The department's in-«11 usault review determined the inmates were properly housed together in compliance with departmental guidelines. The hiring authority determined the inmate's body wu moved withmlt the coroner's authorization and an officer did not adequately control and document the crime scene. The hiring authority provided training to address both issues. Overall Attettment The department's responJe wu not adequate becauae the department did not timely notify the OIG and the inmate's body wu moved without the coroner's consent. The department's action foDowill& the incident were not adequate becauae an offioer did not adequately cOlltrol and document entry into the crime scene. Prior eo Incident Ratina Durin& Incident Ratina After Incident Ratina Sl1fficicnt Inaufl1dent Insl1fficicnt Attettment Quettiont • Did the department timely notify the OIG regarding the erftleallnddent? '11u Upartmem delay«~ one lwur and 13 mlmllu bqore notVY/IIg ~ OIG of~ Inmate's tUmh. o Were the department'• aetfcnq prior to, durJnr. and after the erftleallnddent appropriate? '11u ~~~mate's body was tnOVed withoutp rior autlrarlzatton from ~ COI'01IU, and acuss to ~ C1'tiM SU/Ie was not adeqU4Uly C<>71trolhd and documented. o Wu the erftleallnddent adequately documented? An offlar dJd not document hJs ucqrt ofm «<Jcalp ersomr.ei to ~ C1'tiM SUM. • Did the OIG Independently Identify an operational lillie or policy vlnlatlon that relulted In, or ahould have reaulted In, correetlve action or a referral In the OIA? '11u OIG ldmJVIed that~ body was moved wltlwut ~ C<>roMr's autlwrlzaJkm and an ojflc4rf ailed to (/(JcUIMflt emry l1lto ~ C1'tiM SU~~e by 1MdJc4J stqff. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 84 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-07-25 16-0001806-RO Suicide Incident Summary On July 25, 2016, an offioer dUeovered an inmate banging from a no01e in a cell. Two offioers cut the no01e and lowered the inmate. A third offioer began life-taving measurea. Three IIUlJCI CO!llinu.edlife-taving measurea wbile transporting the inmate to the triage and treatment area. During transport to an outside hospital, a paramedic prollOUIICCd the inmate dead after consulting with a physician. Ditpolition The Q()l'()1](:r and the department's Death Review Committee determined the cause of death was suffocation and the manner of death was suicide. The department's Suicide Case Review Committee determined the suicide wu not foreseeable but was preventable. The hiring authority did not identify any staff misconduct. Overall A11e11ment The department's rtaponJe wu satisfactory in all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating SulBcicnt Sufficient SulBcicnt I Incident Date OIG Calle Number Calle Type 2016-1~08 16-0001964-RO Suicide Incident Summary On October 8, 20 16, an offioer dUeovered an inmate with a noose around his neck. Offioers removed the no01e and initiated life-taving measurea which continued during transport oft he inmate to the institution's emergency room where a physician pronoul](led the inmate dead. Di1polition The Q()l'()1](:r and the department's Death Review Committee determined the cause of death was suffocation and the manner of death was accidental. The hiring authority did not identify any staff misconduct. Overall At~e~~ment The department's rtaponJe wu satisfactory in all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating SulBcicnt Sufficient SulBcicnt I Incident Date OIG Calle Number Ca~~eType 2016-1~10 16-0001974-RO Suicide Incident Summary On October I 0, 2016, offioers found an inmate hanging from a n001e. Officers removed the no01e and a SClJ!eant, offioer, and three IIUlJCI initiated life-aving measurea. The department transported the inmate to an outside hospital where the inmate died on October 14, 2016. Ditpolition The Q()l'()1](:r and the department's Death Review Committee determined the inmate's cause of death wu suffocation by banging and the manner was death was suicide. The department's Suicide Case Review Committee determined the suicide to be foreseeable and preventable. The hiring authority identified potential staff misconduct based on an offioer allegedly not securing a cell during an emergency medical response and later submitting a false report. The hiring authority referred the matter to the Office of Internal Affairs for investigation. The Office of Internal Affairs opened an investigation, which the OIG accepted for monitoring. Overall A11e11ment The department's actions were not adequate because an offioer allegedly failed to properly secure a cell and allegedly submitted a false report. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating SulBcicnt lnallfl1cient Insl1fficicnt A11e11ment Queltiont o Were the department'• aetfcnq prior to, d11rln(. and after the erftlcallnddent appropriate? An offlar alk~ly falkd to J1I'O]Jel'ly s~ a ull during a 1Mdlcalamerge1IC)I and sulmiJJUd a false 1f!PO"t report rega"ldl1lg th4 lncJdmt SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 85 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-1(}.28 16-0002021-RO In-Custody Inmate Death Incident Summary On October 28, 2016, an inmate fell in the dayroom and complained of not feeling Mill. An officer and tbtee 11Ul'les "'sponded, and one DUl'IC initiated life-taving meulllQ. The department trariSpOrted the inmate to an outside hospital where a physician prollOIIIICCd him dead. Ditpolition The coroner determined the caU~e of death to beprobabie heart attack rt:aulting from coronary artery diJeue and the manner of death to be natural. The department's Death Review Committee also determined the cause ofd eath was a heart attack secondary to ooronary artery diJeue and the death was not proventabie. The hiring authority for the 11Ul'lel identified potential staffm isconduct based on the alleged failure to timely initiate life-taving meulllQ and failure to timely~ reports. Themo re, the hiring authority for the 11Ul'lel "'ferred the matter to the Oflioe of Internal Affairs for investigation. The Oflioe of Internal Affairs opened an investigation, which the OIG did not acoept for monitoring. The hiring authority for the offioers did not identify any staff misconduct. Overall Attettment The department's actions were not adequate beC&Ille 11Ul'lel allegedly did not initiate life-taving meulllQ in a timely manner and failed to ~ timely reports, and the hiring authority for the 11Ul'lel did not timely mer the matter to the Oflioe of Internal Affairs. Prior to Incident Rating During Indclent Rating After Incident Rating Snfticicnt lnallfl1dcnt Illlllfficient Attettment Question• o Were the department'• aetton. prior to, d11rlnt. and after the erftkallnddent appropriate? 1Wo nUI'Su ~ tklayed t1UtklJJng lifuavblg 1MQSU1'U andfa&d to diMly =npkU re]X111s 18g(l1'dJng ~ llrcJdmt a Did the OIG Independently Identify an operatlonallallle or polley \'lolatlon that reaulted In, or should have reaulted In, correetlve aetlon or a referral to the OIA? '11u OIG ~d a tkJay 111 lnJJiatjng /ifHavblg ltWISU1U. o Did the hiring a11thorlty make a timely dedaton regard!JII whether to refer any eond11et related to the erltkallnddent to the OIA? '11u dqartment l~ of~ alkged 111/sc(mduct on October 10, 2016, but ~ hlrlllg auJlturlJyf or ~ riUI'SU dJd not refer the mtldu to ~ Ojjlce ofI ntunal Affaln lllltJl D«emhu 30, 2016,81 dtlysqftuthedtdeofdlscovery. Incident Date OIG Cate Number Can Type 2016-11-29 I6-0002100-RO In-Custody Inmate Death Incident Summary On November 29, 2016, an officer found an ~ponsive inmate in a oell. Oflioers and 11Ul'les initiated life-taving meulllQ. A paramedic prollOIIIICCd the inmate dead. Ditpolition The coroner determined the caU~e of death wu heroin and methamphetamine intoxication. The department's Death Review Committee concluded the caU~e of death wu a drllg overdose and not P""Ventabie. The investigative services llnit sllfliciently investigated the SO\lnle oft he drllga bllt did not determine the SOIInlC. The hiring authority did not identify any staff miaeondlwt but provided training to the lieutenant "'garding crime aoene prt:aervation. Overall Attettment The department's actions dllring the incident were not adequate beC&Ille a lieutenant ordered a DUl'IC to move the inmate's body bef~ the coroner arrived. Prior to Incident Rating During Indclent Rating After Incident Rating Snfticicnt Inallflicient Snfticicnt Attettment Question• o Were the department'• aetton. prior to, d11rlnt. and after the erftkallneldent appropriate? A lUutellam IIIMrrectly ordued a riUI'SS to 11Ymsp01't ~ blmllts's body to~ trlllge and-area before ~ C(JfljriU arrlvsd. a Did the OIG Independently Identify an operatlonallallle or polley \'lolatlon that reaulted In, or should have reaulted In, correetlve aetlon or a referral to the OIA? '11u OIG ~d that a Uaumant e17'811 111 ordutng a nurse to tl'a1Jsport ~ blmllt6's body to ~ trl4ge and -ent area bqore the C(1fljriU Q1'1'Md. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 86 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-12-14 17 -0000062-RO HWlicr Strike Incident Summary On December 14,2016, aninmatebeganahungcrstrike anddidnotstatethereasonfornoteating. OnDecembcr31, 2016, andJanwuy 11,2017, the department transferred the inmate to an outside hospital due to low vital signs. The inmate returned to the institution on January 16,2017, and ended the hunger strike onJanwuy 17, 2017. Ditpolition The department made lQIIOII&ble attempts to address the inmate's ooneems. The hiring authority did not identify any stalf misconduct. Overall A11e11ment The department's actions were not adequate beeauae the department did not notifY the OIG in a timely and sufficient manncrpreventin& the OIG from real-time monitoring of the cue. Prior to Incident Rating During Inddent Rating After Incident Rating Sufllcicnt Inauflldent Suffident A11e11ment Queltiont a Did the department timely notify the OIG reprd!Dg the erltleallnddent? 'l7u tkpartmem did Mt Mti/Y the OIG the tmnau was sent w an outside lwsplkll. Incident Date OIG Calle Number Ca.eType 2017~1~1 17-0000059-RO In.CU.tody Inm.ate Death Incident Summary On Janwuy I, 20 17, an offioer diJoovcred an unrei)IOIWve inmate in his oell. Four officers, a sergeant, and a psydliatric teclmician performed lifo-saving measures. A nurse oontinued the lifo-saving measures. The department tran.ported the inmate to an outside hospital where a physician pronounced the inmate dead. Ditpolition The coroner determined the cause of death wu heroin intoxication and the manner of death wu accidental. The investigative services unit investigated but could not determine the source of the hemin. The hiring authority did not identify any stalf misconduct. Overall At~e~~ment The department's rtapon~e wu satisfactory in all critillll upoots. Prior to Incident Rating During Inddent Rating After Incident Rating Suffident Sufficient Suffident I Incident Date OIG Calle Number Calle Type 2017-04-30 17 -0022560-RO HWlicr Strike Incident Summary On April30, 2017, an inmate initiated a hunger strike because of a perceived due prooess violation. On May 3, 2017, the department tran.ported the inmate to an outside hospital because the inmate claimed he lost oonsciouaneu. OnMay4, 2017, the inmate ended the hunger strike and returned to the institution. Ditpolition The department made lQIIOII&ble attempts to address the inmate's ooneems. The hiring authority did not identify any stalf misconduct. Overall A11e11ment The department's rtapon~e wu satisfactory in all critillll upoots. Prior to Incident Rating During Inddent Rating After Incident Rating Suffident Sufficient Sufficient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 87 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA North Incident Date OIG Cate Number Can Type 2015-0~9 IS-0001566-RO In-Custody Inmate Death Incident Summary On Alll!lllt 9, 20 IS, three oflioers found an inmate attempting to self-induce vomiting. Moments later, the inmate oollapled. Three oflioers began lifwaving measures, and a ~er~~eant, time additional officers, and two lUil'lea ...Uted, but were unsiWoeuful. A physician pronounced the inmate dead. Ditpolition The coroner determined the manner of death wu accidental and the cauae of death wu methamphetamine overdoac. The departmenrs Death Review Committee CO!lcludt:d the inmate died ofa dru& ovenloae and the death wu 1lOt preventable. The investigative services unit sufliciemly investipted the aource of the drup but did !lOt determine the aource or locate additional drup. The hiring authority did 1lOt identify any staff misconduct. Overall Attenment The department's ~during and after the incident wu itauflicient because rt:~ponding oflioers and lUil'lea did 1lOt timely uaess or provide lifwaving measlllQ to the inmate or complete adcquatedocwnentation. Prior to lneident Ratina Durin& Indclent Ratina After lneident Ratina Sufficient Insufllcient Insufficient Attenment Queltiont • Were the department'• aetloua prior to, duriD(. and after the erltleallnddent appropriate? OjJicus and 71W'SU dJd Mt tbMly as sus wlraJru 1M l1rmaU 18{/UJ1wllmm«ik~U life-saving m-.r andfaJJ" to tuhquauly tiocu~Mnt the tncldml by omitting when they assus" the t1rmtiU. OjJicus waJUd 12 mlnutu ajW tlu lncklmt began and seven mlnutu qftu nursu arrived /J401'e provldJng life-saving measuru. a Did the OIG Independently Identify an operational laue or polley vlnladon that n:.Wted In, or ahOIIId have relllllted In, correetlve action or a referral to the OIA? '171<! OIG ltlentJjUd that offlcus and 71W'SU f~ to tbMiy assus and ]iiY1VUk lifHaVIIIg measuru to 1M l1rmaU and compkU a<hquaU documttntatton. a Did the hiring authority appropriately determine whether to refer any oonduct to the OIA related to the erldcallnddent? '171<! hiring authority disagrs" wtth the OIG's ddennllratton that offlcus and 1111/'SU submltt" tna<hquaU documMtatloll andf ~ to tbMiy assus the Inmate andp fOllltk ~/cal care. '17!uqore, 1M hirl11g authorUy dJd Mt rqu 1M matter to 1M Office ofintemalAffatrs. Incident Date OIG Cate Number CateType 2015-11-02 IS-0002298-RO In-Custody Inmate Death Incident Summary On November2, 2015, an officer diaoovered an unresponsive inmate in his cell. Two other officers, a ~e<geant, and two lUil'lea began lifwaving measures, which continued during transport to the correctional treatment center. A physician subsequently prollOunced the inmate dead. Ditpolition The department's Death Review Committee determined the case of death wu methamphetamine and heroin overdoac and the death was not preventable. The investigative services unit sufliciemly investipted the aource of the drup but did !lOt determine the aource or locate additional drup. The hiring authoritydidllOtidentifyanystaffmisconduct. Overall Attenment The department's ~was satisfactory in all critical aspects. Prior to lneident Ratina Durin& Indclent Ratina After lneident Ratina Sufficient Suflident Sufficient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 88 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2015-11-24 16-0001762-RO In-Custody Inmate Death Incident Summary OnNovember24, 2015, aninmatejumpedfrom the second tier onto the ground below. OnMazdt4, 2016, the inmate diedofhisinjuriea at an outside hospital. Disposition The inmate died due to medical complications rdated to jumping from the tier. The department's Suicide Case Review Committee found the death wu f<m:aeeab1e and preventable and found multiple failures by mental health clinicians to properly aueN the suicide risk. The department reviewed mental health clinicians' records and provided training. The department referred the nursing wues to the department's Nursing Profeasional Practice Committee. The department abo modified training for mental health clinicians to diiCIW communicating the reasons for placing iiilii.atea on or removing them from mental health crisis bed or suicide watch ltltUI. The department also created a policy that when a mental health clinician becomea aware that an inmate previOIIIIyattempted suicide by jumping off a tier, the mental health clinician must consult with a medical physician and recommend the inmate for first floor housing. Overall Attettment The department's actions prior to the incident wm: 1lOt adequate because the institutio11 inappropriately housed the inmate and lUllSCa and physicians did 11ot provide sufficient medical care. The department's response wu 110t adequate because lllll'SCS did 1lOt make timely emergC11cy 110tification or lll'le appropriate medical trlllsport of the inmate and failed to complete adequate documentation. Prior to Incident Rating During Indclent Rating After Incident Rating InsufficictU Insllfl1cient Insufficient Astettment Question• o Were the department'• aetton. prior to, durlnt. and after the erftlcallnddent appropriate? PrWr to ~ lncJdml, tu tnstJmlkm lwusad ~ lnmau In a seccnd tJu c4lJ qftu ~ lnmau told a psychiatrist lu had thoughts ofj umping off~ seccnd tiD; nursuf alkd to stagger thar 15- llll1ruU rotmds, and psychlatrlsts did not properly assus ~ suJckk risk. During ~ lncJdml, nursu did not illfiMdJaWy call thalaw oif~nt emetgDrcy numbu qftu kamlng ~ lnmau fdl from ~ sacond tier, nursing ncuttJs conta/Md cmiflJctlng 111/0I'Itlatlofl, and a nurs~ falkd to lllg<! IIYmsjsmng ~ lnmau by ambu1411cs. Af lu ~ illcldmt nursu did not documsntnotljjllng apltyslckm wh6ll ~ mma~ lostslgnljlcant weight, stagger thar 15-m~ rowrds, weigh~ lnmau twice wed;/)\ or document th~ amount off ood th~ lnmau ate. Incident Date OIG Cate Number CateType 2016-01-14 16-0000225-RO Suicide Incident Summary On JanllarY 14, 2016, an officer diseoveredaninmate ha1l&inl from a 1100SC in his cell. Officers Cllt the 1100SC, lowered the inmate, and initiated lifo-saving measures. Two lUllSCa conti111led lifo- saving measures lUilil paramedics arrived and pro1101l11CCd the inmate dead. Disposition The coroner determined the ca\lle of death wu uphyxia due to hanging. The department's Death Review Committee determined the ca\lle ofd eath wu suicide due to uphyxiation by hanging. The department's Suicide Case Review Committee found the inmate's suicide wu f<m:aeeable and prevC11table. The committee questioned the decWon to reduce the inmate's mental health level of care prior to his death and a cmss-diJcipline concern that information regarding the inmate's recent court appearance bad 110t bee11 rela)'tld to mental health clinicians. The department implemented procedures to change documentation requirements to improve the continuity of care and implemented a proceu for inmatca' attorneys to contsct the department to report co11cer111 regarding their clients' mental health stlt\ls following court appesranccs. The department also provided training to 19 mental health clinicians regarding the new docwncmation requirements. Overall Attettment The departments response wu satisfactory in all critical upects. Prior to Incident Rating During Indclent Rating After Incident Rating Sufficient Sufficient Sufficient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 89 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-02-06 16-0000421-RO In-Custody Inmate Death Incident Summary On February 6, 2016, an inmate collapsed in the cltapel. QffiQCrS and nursea initiated lifo-saving measures and transported the inmate to the triage and treatment 8lQ where lifo-saving efforts COlllinu.ed. The inmate regained a pube and reapiratioo but stopped breathing during trallsport to an outside hospital where a physician pronounced the inmate dead. Ditpolition The coroner determined the inmate's death wu accidental due to a ruptured intracranial aneurysm contributed to by methamphetamine toxicity. The department's Death Review Committee determined the cause ofd eath wu cardiovascular disease and the death wu not preventable. The inveatigative servicea unit sufficiently inveatigated the SOII1'Ce of the drugs but did not determine the SOII1'Ce or locate additional drugs. The hiring authority did not identify any staff misconduct. Overall Attettment The depsrtment's response wu satisfactory in all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Suflicicnt Sufficient Suflicicnt I Incident Date OIG Cate Number Cate'l'ype 2016-03-05 16-0000703-RO Suicide Incident Summary On March S, 2016, a nurse discovered an unresponsive inmate face down 011 a bunk. A sergeant and five offiQCrl entered the cell and removed a noose from the inmate's neck. Three nurses and three offiQCrl performed lifo-saving measures until a physician pronounced the inmate dead. Ditpotition The depsrtment's Suicide Cue Review Committee concluded the cause of death wu uphyxiatioo by hanging, the manner ofd eath wu suicide, and that the death wu foreseeable and preventable. The depsrtment provided instructioo to clinicians, physicians, and nurses regarding classifying and documenting inmate aclf-harm events, reviewed local policiea and procedures regarding preparatioo of incident reports for inmate aclf-harm incidents, added clinical staff and provided training to clinicians regarding discharge rcquiremettts, documenting interdisciplinary treatment team meetings, and reminding clinicians to include inmates in the treatment planning process. The depsrtment also provided training to clinicians regarding properly documenting treatment and evaluating cbrotric risk for suicide. The department also revised its procedures for submitting psychiatry-related documentation. Overall Attettment The depsrtment's actions prior to the incident mre not adequate because the depsrtment did not adequately complete assessments or documentatioo and failed to ensure the inmate attended important treatment meetings. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Insuflicicnt Sufficient Suflicicnt Attettment Quettiont o Were the department'• aetlonl prior to, during, and after the crltlcallnddent appropriate? Prior to 1M tncJdMt, tM rk~ dJd Mt properly or ttmay docummt or assess 1M Inmate's suldrk attempts, prepa~ tllcJdMt ~ports aftu 1M Inmate's sulcJrk attempts, u-lycompkte 1M Inmate's treatment plan and dJsclri11'ge docummts when he was rehml".from a mentol Malth crisis b«<, (/(Jcument that 1M lmnate aJtenikd tnterdJsclpllnary treatment team muttngs, or that~ was a treatment plan for 1M lmnate whlk M was 111 a mental ualth crisis b«<, -~1M Inmate attenrkd bltoriJscJpllnary treatment team muttngs, or accwYltelydccument 1M Inmate's m«<Jcalkm. AddJtkmally, 1M rkpartment] II'UCrlbed new psyclwtroplc medJcadons for 1M Inmate buJ fa&d to (/(Jcument that a psychtotrlst met with 1M Inmate for a new evaluation, us" ouldatedmentol Malthforms, and poorly (/(Jcumented 1M lmnate's sulcJrk rlskewdualkms. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 90 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-04-26 16-0001299-RO Suicide Incident Summary On Apri126, 2016, officers oblervedan inmate jump from the fifth tier of a housing unit. NurJe1 providedlife-taving measlllQ and tran.ported the inmate to the triage and treatment area. Paramedics arrived and trariSpOrted the inmate to an outside hospital. On April30, 2016, a physician prollOUI!Ced the inmate dead. Di1polition The ooroner reported the ca\IIC ofd eath was oomplication from blunt force injuries and the manner of death was suicide. The departments Death Review Committee determined the inmate's death was not medicallyP"Oventable but 11Ul'ling documentation and the activation of emergency medical response could be improved. The hiring authority referred the matter to the Nursing Professional Practice Committee. The depsrtmenrs Suicide Case Review Committee ooncluded the suicide was not foreseeable or P""Ventable. Overall A11e11ment The depsrtment's response was satisfactory in all critical aspects. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Sl1fficicnt Sufficient Sl1fficicnt I Incident Date OIG Calle Number Can Type 2016-05-02 16-0001307-RO In-Custody Inmate Death Incident Summary On May 2, 2016, an officer found an ~ve inmate on the floor in his cell after other inmates informed officers the inmate had been calling for help for almost 30 minutes. Officers removed the cellmate from the cell, and an officer and nurse initiated life-taving meulllQ. The department transferred the inmate to an outside hospital where a physician pronounced the inmate dead. The depsrtment referred the case against the cellmate to the district attorney's office. Di1polition The depsrtment's Death Review Committee determined the caiiiC of death wu traumatic brain injury with severe head trauma and the manner of death wu homicide. The hiring authority identified potential staff misooruluct based on three officers' alleged failure to ensure the inmate's wcll-being. The hiring authority referred the case to the Office of Intema1 Affairs for investigation. The Office oflntemal Affairs opened an investigatiOll, which the OIG accepted for monitoring. Overall As~e~~ment The depsrtment's actions were not adequate becaiiiC three officers allegedly did not ensure the inmate's wcll-being and delayed responding and the department did not timely notify the OIG. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Insl1fficicnt Insuftlcient Sll.fllcient As~e~~ment Question• o Did the departmeut timely uotlfy the OIG regard!Dg the erltlcalluddeut? 171<! dqartment notJjkd 1M OIG ojtM Ill mate's Uath by em4Jl message Ills~ ad ofb y Ukp/JOM and did 110t 110tljy th~ OIG 1111tll Marly OM and oM-half hOiil1l qftu 1M lllmate 's tkath. o Were the departmeut'a aetlolll prior to, dur!Dg, ud after the erltlcalluddeut appropriate? 171<! dqartment's actton prior to 1M lllcJtknl WM! 110t atkquate becaus~ tJrru oJ]lcus aJkgMJy fa&d to -~ 1M Inmate's well-bdng and durlllg 1M 111Cldent, the ojjlcus alkgedlydelayed 1'Up(lfldillg qftu lltm4ta 110tJjled them of/M lllcldent. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 91 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Ca1eType 2016-05~ 16-0001349-RO Inmate Serima/Great Bodily Injury Incident Summary On MayS, 2016, two offioersllled physical force to oontrol a ~ting inmate and the inmate's bead struck a gate and the ground. The inmate received treatment at the institution, following which the depsrtment transported the inmate to an outside hospital. The inmate returned to the institutioo the same day. Di1polition The institution's executive "'view committee determined the use off orce complied with policy. The OIG ooncurred. The hiring authority did not identify any staff misconduct. Overall A11e11ment The depsrtment's reapotUe was aatiafactory in all critical upoots. Prior to Incident Rating During Inddent Rating After Incident Rating Suflk:icnt Sufficient Sl1flk:ic:nt I Incident Date OIG Calle Number Can Type 2016-05-23 16-0001635-RO In-Custody Inmate Death Incident Summary On May 23, 2016, an inmate informed officers a aecond inmate hit him in the face with a cup. Officers eaoorted the imt inmate to the triage and treatment area, following which the first inmate returned to the cell. The first inmate subaequetttly returned to the triage and treatment ~a and became Wlrolllcious. The depsrtment air-lifted the imt imnate to an outside hospital wb= a physician prol1011l1Ced the inmate dead two days later. The investigative services unit investigated the incident and merred the cue to the district attorney's office. Di1polition The corotler determined the cause of death was blunt force injury and the tnamiC1' of death was homicide. The depsrtment's Death Review Committee COll.cluded the inmate's death was not P"'Ventable. The hiring authority did not identify any staffm iaoondnct. Overall As~e~~ment The depsrtment's reapotUe was aatiafactory in all critical upoots. Prior to Incident Rating During Inddent Rating After Incident Rating Sl1flk:ic:nt Sufficient Suflieient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 92 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-05-27 16-0001669-RO In-Custody Inmate Death Incident Summary On May 27, 2016, an inmate alerted an officer that rn. cel1mate was having a~. Nllllel initiated life-saving measures and transported the inmate to the triage and treatment a= where a physician protlOIIIICCd him dead. Ditpolition The coroner determined patho1ogyand torioo1ogy results did not reveal a definite caUJC of death. The department's Death Review Committee did not identify ac&U~C of death or whether it was preventible. The hiring authority for the nurse provided training to the nurse regarding report writing. Overall Attettment The department's actions foUowing the incident were not adequate because the depsrtment failed to timely llOtity the OIG, the investigative services writ failed to take pictures of the decesaed inmate's cellmate, and a nurse did not complete adequate documentation. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating SulBcicnt Sufficient Il!lllf'licicnt Attettment Quettiont o Did the department timely notify the OIG reprdiDg the erltlcallnddent? '11u UpartmenJnotVW 1M OIG two hours qftu a plryslckm ~1M tlrmtlu tkad. • Did the IDvestlgatlve terVIces wdt, or equivalent IDvestlgatlve penoDDel, adequately respcntd to the erltlealiDddent? '11u tnwstJgadve servlca Wilt dJd not take plauru of/M .u-ued1 1fmtlU's ul1maU to documenJ 1-n}urW (17/ack tllow>f. o Wu the erltlealiDddent adequately documented? A. nuns dJd nota~ compkU a medk41 QS!Jusmentform. Incident Date OIG Cate Number Can Type 2016-05-29 16-0001680-RO In-Custody Inmate Death Incident Summary On May 29, 2016, an inmate reported having cheat pains and not feeling wcll. The depsrtment transported the inmate to an ouWde hospital where a physician protiOUllCCd him dead. Ditpolition The coroner determined an autopsy was not required bec&U~C the inmate died ofn atural CallieS. The depsrtmen(s Death Review Committee determined the death was possibly preventible due to a delay transporting the inmate to an outside hospital. The emCIJ!ency medical response review committee determined that nurses dela)'tld calling emC!J!ency medical services. The hiring authority provided training to the nllllel. Overall Attettment The depsrtmen(s actions during the incident were not adequate because nlllJel did not administer required medication or make timely notifications. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating SulBcicnt Insufficient SulBcicnt Attettment Quettion1 a Were the department'• actlou prior to, durlllg, and after the erltlcallnddent appropriate? Nursu dJd not admbtlstu suhllllgualfiiJroglycerill aCCUidbtg to protocol, timely notifY 1M on~ plryslclall of/M ~ (17 timely C<llltact emugency medlcalsuvlcu to tl'ansport 1M t1rmtlU to an outside hospital. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 93 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-08-31 16-0001939-RO In-Custody Inmate Death Incident Summary On Alll!lllt 31, 2016, an officer diJeovered an inmate in his cell covered with blood and \l.lm:Sl)Ol]Sive. QffiQCrS removed the ceUmate from the oell, and offiQCrl and 11Ul'ICS traiuported the inmate to the tria&e and treatment area. The department traiuported the inmate to an outside OO.pital where he died on September 21, 2016. The department referred the matter to the district attomey's office for prosecution. Ditpolition The coroner concluded the inmate died of oomplications from blunt fon>e injury to the head. The department's Death Review Committee determined the death wu not medically preventable. The department oonducted an in-<>ell uaault review and ooncluded the inmates were appropriately hollled. The hiring authority did not identify any staff miJoondu.ct. Overall Attettment The department's reaponae wu satisfactory in all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficient Sufficient Sl1fficient I Incident Date OIG Cate Number CateType 2016-09-01 16-0001886-RO Suicide Incident Summary On September I, 2016, an officer found an inmate banging from a noose in his cell. QffiQCrS entered the cell and lowered the inmate, and four offiQCrl began life-taving measures. A 11Ul'IC continued life-taving measures u offiQCrl tran.ported the inmate to the triage and treatment area where life-taving measures continued until a physician proiiOiliiQCld the inmate dead. Ditpolition The department's Death Review Committee determined the inmate died from suffocation by banging and the death wu not preventable. The Suicide Cue Review Committee found the suicide wu not foreseeable orp reventable, but the reportidemified concerns regarding follow-up consultltions, suicide risk useuments, and documentation. In response to the report, the department revbed its operati"'! procedures regarding follow-up usessments, provided traini"'! to more than 60 staff members regarding suicide risk usessments, and COIUlJcled the psychologist wbo incorrectly filed patient information. Overall Attettment The department's actions prior to and after the incident were inadequate because the the department did not conduct a timely usessmentofthe inmate, properly conduct and document suicide risk usessments, or oorrecdy me inmate information. The department did not adequately consult with the OIG. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Insl1fficient Sufficient IIIIUfllcicnt Attettment Question• o Were the department'• aetlonl prior to, dur!Dg, and after the crltlcallnddent appropriate? 171<! tkpartment's haNIJJng of1 M tncJdMt prior to alld aftu 1M tncJdMt W<lS Iliad~ b&:4use 1M 1M department did not conduct a timely foiiow-up asselSSitl6llt with 1M ilrln4t6, propuly collduct alld document 1M Inmate's sulcJtk risk, alld a psychologist pt'Of;1'68S 110tu colltaJMd llljormatton putlltning to a110tlwp atlult. o Did the Investigative aervlcea unit, or equivalent lnvettlgatlve penonnel, adequately reapond to the crltlcallnddent? 171<! illvutJgatlve s61'VIcu tmJJ neglected to 110UJY the OIG of1 M autopsy daJe alld Ume pnventJng 1M OIGf rom real-time monJtorllrg of1 M autopsy. • Did the department adequately oonault with the OIG "'gardlng the crltlcallneldent? 171<! tkpartmentdld110tSI!!fldently COIISilltwiJh 1M OIG by negkctlllg to 110tJjjl the OIGofiM daU alld time of/M autopsy. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 94 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-09-09 16-0001908-RO In-Custody Inmate Death Incident Summary On September9, 2016, two offioers found an inmate unresponsive on the floor of a cell after his oeUmate reported killing the inmate. Offioers and 11Ul'lesperformed life-aving measures. The dcparunent transferred the inmate to an outside hospital where a physician pronounced him dead three days later. The dcparunent referred the cue apinst the oeUmate to the district attorney's office. Ditpolition The itatitution's death review determined the primary cause of death was brain injury du.e to strangulation. The dcparunent's Death Review Committee determined the death was not medically preventable. The dcparunent oonducted an in~ell assault review and determined the inmates ~ housed together in oomplianoe with policy. The hiring authority did not identify any staff miseonduct. Overall Attettment The dcparunent's reapollSC was satisfactory in all critical aspects Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Sufficient Sl1fficicnt I Incident Date OIG Cate Number Can Type 2016-09-10 16-0001909-RO In-Custody Inmate Death Incident Summary On September 10, 2016, an inmate informed offioers his oeUmate was unresponsive. An oflioeranda 11Ul'le initiated life-aving measures and transported the inmate to the triage and treatment arQ. Three additional officers and two other 11Ul'leS took over life-aving measures until paramedies arrived and, after consulting a physician, pronounced the inmate dead. Ditpotition The coroner determined the cause of death was cardio-respiratory failure with sepsis from abdominal inflammation and the manner of death was accidental due to high levels ofm ethamphetamine and hydromorphone. The departmen(s Death Review Committee determined the cause of death was sepsis and not preventable, and found no death-related departures from the standard of care. The investigative services unit made reuOMble efforts to determine whether the inmate had drup in his cell. The hiring authority did not identify any staff miscoruiuct Overall Attettment The dcparunen(s reapollSC was satisfactory in all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Sufficient Sl1fficicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 95 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-09-14 16-0001947-RO HWlier Strike Incident Summary On September 14, 2016, an inmate began a hunger strike becaule of housing wu.es, damaged and lost personal property, and the department's refulal to provide an ankle brace. On September26, 2016, the dtpsrtment transported the inmate to an outside hospital due to hunger striko-related medical collCCfiiJ. The inmate returned to the inatitutio11 the same day and ended his hunger strike 011 October 11, 2016. Ditpolition The departme11t made reasonable attempts to address the inmate's collCCfiiJ. The hiritlg authority did not identify staff misconduct. Overall A11e11ment The departme11t did 11ot timely notify the OIG after transferri11g the inmate to an ouaidc hospital. The departmem's actioo followi11g the incidc11t wm: not adequate because the departme11t delayed C011ducti11g an inquiry into the inmate's allegati0111 ofp ote11tia1 staff misconduct. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt I11suft1cicm I11SI1fficicnt I A11e11ment Queltiont o Did the department timely notify the OIG reprd!Dg the erltleallnddent? '11u UpartmenJ did 11<>t Mti/Y the OIG thilt the tkpa-trrmsfernd the t1rmtlU to an outsltk lwspttal untJJ thef ollowing day. o Were the department'• aetloua prior to, duriDg, and after the erltleallnddent appropriate? '11u UpartmenJ did 11<>t Mti/Y the OIG the lnmau was transported to an outsltk lwspttlll whlk em hunger strlb or OOIIduct a tbMly tnquJry Into alkgalkw ofp otmillll stqffm Jsconducl. Incident Date OIG Calle Number Can Type 2016-09-18 16-0001920-RO Itl-Custody Inmate Death Incident Summary On September 18, 2016, an inmate began shakitlg U11C011trollably and smating profuaely in. the vWtill.g area. A11 officer and 11\lraC tran.ported the inmate to the triage and treatmem area where a 11urSC admin.istered an antidote for opiate overdose, but the inmate's heart and breathin.g stopped. A 11\lraC began lif~>-~avin.g measures until a paramedic took over, and a physician pro110U11ced the inmate dead. Di1polition The coroner determin.ed the cause of death was methsmphetsmin.e overdose and the department's Death Review Committee detcrmin.ed the death was U11expected and not prevelltable. The in.vestigative services wlit adequately in.vestigated the source of the drugs but did not detcrmin.e the source or recover additi011al drugs. The birin.g authority did not ideo.tifyanystaffmiacoruluct. Overall At~e~~ment The departme11t's respo111e was satisfactory in. all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Suflicicnt Sufficie11t Suflicicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 96 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-09-20 16-000212(}-RO HWlier Strike Incident Summary From Septembcr20, 2016, throughNovembcr23, 2016, an inmate engagedinabungerstrike because he diagreed withaguiltyrmding onarulesviolationreport. On December 5, 2016, the inmate re~~C~~W:d the hunger strike because he diagreed with the department's determinations reprding his housing and elusification. On December 7, 2016, the institulion tranlported the inmate to an outside hospital when: he continued the hunger strike. OnDecember29, 2016, the inmate ended the bungerstrikebutremainedat the hospital to bep11reintroducing food. The inmate lost a total of 32 penlCllt of his body weight during the hunger strikes. On Jamwy 13, 2017, the inmate was released from the hospital and tranlfcrred to a differe11ti11stitulion. Disposition The departme11t made reasonable attempts to address the inmate's co11Ccr111. The hiring authority did 110t identify any staff miscoruiuct. Overall A11e11ment The department's n:spoo.se was satisfactory in all critical upect:s. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Sufficient Sl1fficicnt I Incident Date OIG Calle Number Can Type 2016-1~11 16-0001969-RO m-Custody Inmate Death Incident Summary On October II, 2016, an officer found an inmate ~ve after his cellmate reported stran&lin& the inmate. A nurse responded but did 11ot initiate life-savill.g meuures due to obvious si8111 of death, rigor mortis, and lividity. Officers tranlported the inmate to the tria&e and treatme11t area when: a physician p~ him dead. The hiring authority referred the cue apill.st the cellmate to the district attorney's office. Di1polition The corotlel" COll.Ciudcd the cause ofd eath was lipture stnulgUiation. The department's Death Review Committee determined the death was 110t prevelltable. The department's in- «<I assault review concluded the department housed the inmatea in compliance with policy. However, during the review, the departme11t 110ted documelltation discrepancies repnlin.g the inmates' cue factors. Since the errors lll'ml minor and remote in time, they did 110t chan&e the elusification. One of the lieule11a11tl who made an error 110 longer worked for the departme11t and the other 110 10118er worked at the i111titulion. Therefore, the hiring authority decided 110t to provide training. After the OIG idemifiedpote11tialstaffmiscoruluct, the biri11g authority submitted a request forinvestigatio11 to the Office ofilltemal Affairs for an officer's alleged failure to conduct the required inmate count and for falsely docume11ting havi11g done so. The Office ofl11temal Affairs ope11ed an investigation, which the OIG accepted for monitori11g. Overall At~e~~ment The department's actions lll'mlll.Ot adequate because docume11tation contained errors, an officer allegedly failed to coll.duet a proper inmate count and was disholl.est, and the hiring authoritydidll.Ot timely refer the matter to the Office ofilltemal Affairs. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating I11SI1fficicnt Sufficient Insuflicient A11e11ment Queltiont a Were the department'• aetfcnq prior to, durlnt. and after the erftleallnddent appropriate? Documenltllkm 7egardlng ~ llrmllw' classlflco&m contllJMd dJscre]HmcUs. An officer alkgedJyf alkd to =rducJJ 1I'OPU COUIIIs and falsely documenud doing so. a Did the OIG Independently Identify an operational laue or polley \'lola don that rellllted In, or mould have rellllted In, corrective action or a referral to the OIA? 171<! OIG illlkpentkntly ~d tlult (Ill o.fllurall~ falkd to =rducJJ 1I'OPU COUIIIs and falsely docwnenud doing so. a Did the hiring authority make a timely dedalon regard!JII whether to refer any conduct related to the erldcallnddent to the OIA? 171<! dqortmentl~ of~alkgedmlsconducton October 11, 2016. but~ hlrlllgautl!orltydJdnotrqer ~molter to~ Ojflu oflntunalA.ffalnlllltJlMay3, 2017, mo~ tlulnslx IIIOIIths aftu ~ doU ofd l.scovery. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 97 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-1~11 16-0001970-RO In-Custody Inmate Death Incident Summary On October II, 2016, an officer and nurse found an unresponsive inmate in rn. cell. The officer and nurse did not initiate life-aving meulllQ due to obvious signs of death, rigor mortis, and lividity. Officers transported the inmate to the triage and treatment area where a physician pronounced the inmate dead Ditpolition The ooroner determined the cauae of death wu heart attack. The department's Death Review Committee determined the death wu not preventable. The hiring authority did not identify any staff misconduct. Overall Attettment The departmem's rtapOOJe wu satisfactory in all criticsl aspects. Prior Co Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Su.f!iciem Suflieicnt I Incident Date OIG Cate Number Ca.eType 2016-1~15 16-000im-RO In-Custody Inmate Death Incident Summary On October 15, 2016, an officer saw an inmate being stabbed by a second inmate with an imnatt>-manufactured MapOn. The attacking inmate complied with orders to stop. Nurses initiated lif~>o saving meulllQ on the attacked inmate and tran.ported him to the triage and trQtment area where a physician pronounced him dead The department referred the matter to the district attorney's office. Ditpolition The ooroner determined the cauae of death wu multiple stab wounds to the torso. The department's Death Review Committee concluded the death wu not preventable. The hiring authority did not identify any staff misconduct. Overall Attettment The department's response wu satisfactory in all critical upects. Prior Co Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Su.f!iciem Sl1fficicnt I Incident Date OIG Cate Number CateType 2016-1~26 16-0002016-RO In-Custody Inmate Death Incident Summary On October 26, 2016, a nurse discovered an inmate having a ~ in rn. cell and transported the inmate to the infirmary where the inmate stopped breathing. Nurses performed life-aving measures and an ambulance transported the inmate to an outside hospital where a physician pronounced him dead Ditpolition The departmem's Death Review Committee determined theprimarycauae of death wu ventricular arrhythmia and the inmate's death wu not preventable. The hiring authoritydidnotidentifyany staff miJconduct. Overall Attettment The departmem's actions following the incident were not adequate becauae the hiring authority did not timelyoonsult with the OIG. Prior Co Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Su.f!iciem Insl1fficicnt Attettment Quettiont o Did the department adequately con.Wt with the OIG regardiDg the erltleallneldent? 11u! hiring aullwrlty did rwt tlmdy rupond to ~ OIG's lnquJrlu and Uk]JhcM colls. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 98 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-1(}.30 16-0002020-RO In-Custody Inmate Death Incident Summary On October 30, 2016, offioers found an inmate unresponsive in his cell and initiated lifo-laving measures. Nurses oontinued lifo-~aving measures and transported the inmate to the itatitution's emergency room where a physician pronounced the inmate dead. Ditpolition The coroner determined the inmate died of a heroin overdole. The department's Death Review Committee determined the death wu not preventable but alJo found that !Uil'les did not administer a heroin antidote and could have directed offioers to take over lifo-~aving meuures 10 they could administer the antidote. The Death Review Committee referred the matter to the department's Nursing Professional Practice Committee. The hiring authority investigated the 10\lnle of the heroin but wu unable to identify the 10\lnle. Overall Attettment The department's actions during the incident were not adequate because !Uil'les did !lOt adequately respond to the incident Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Insuft1cient Sl1fficicnt Attettment Quettiont o Were the department'• aetloua prior to, durin&, and after the erltleallnddent appropriate? '11u tkpartmenJ~ actkw during~ tncJdmt wen not adequt~U becmua musu dldnotadmlnlstu m«/Jcatkm to cOIIIJWact ~ potmtltll Ufe-tlrreatmtng ~ws ofa drug c>Velrk>sa and dJd not dJr«t ojJicers to taka over/Jve-savtng m«JSUPU so thzy CX>Uld admbrJstu the m«llcattorl. Incident Date OIG Cate Number CateType 2016-ll.m 16-0002024-RO In-Custody Inmate Death Incident Summary On November 2, 2016, two offioers, a counaelor, and a nlll'IC responded to a call for usistanoe and discovered an unresponsive inmate in his cell with his cellmate hunched over him. The nurae initiatedlife-aving measures. Oflioers and nurses transported the inmate to the triage and treatment area where a physician pronounced the inmate dead. Ditpolition The coroner determined the cauae of death to be acute methamphetamine intoxication. The department's Death Review Committee determined the inmate's death wu not preventable. The OIG identified that officers had a reuonable suspicion that the inmate and his cellmatepossessed drugs but did not place the inmate on contraband surveillance watch. The hiring authority provided training to the offioers regarding contraband surveillance watch. Overall Attettment The department's actions prior to the incident wm: not adequate becauae the department failed to place the inmate oncontrabsnd surveillance watch. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Insl1fficicnt Sufficient Sl1fficicnt I Attettment Quettion1 • Were the department'• aetloua prior to, durin&, and after the erltleallnddent appropriate? PrWr to ~ i1lcldmt, tu tk]H1111tWrJ fa&d to pit= ~ tlrmtlJe on contraband swwJJJance watch dupiU a reasOIIIlbk susplckm the brmate and his ullmtlU pouused drugs. o Did the OIG Independently Identify an operational laue or polley \'lola don that relllllted In, or mould have relllllted In, correetlve action or a referral to the OIA? '11u OIG ldentljUd that based on llljo71NJJ1on a rellabk source ]N'Ovlded to tu lllvutlgatlve s~ Wilt and ~ IIIIMU's belr4vlor during a search for COfltraband on ~ d4y ~ lllm4U died, ojJicers slwuld ~ pli=d ~ brmate on contraband SUIWIIltma watch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 99 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-12-06 16-0002113-RO In-Custody Inmate Death Incident Summary On December6, 2016, an officer oblerved an unresponsive inmate on the floor in a oell. The officer and nurJel performed lifo-saving meuures until a physician pmnolllWCld the inmate dead. Disposition The QOl'011er determined the c:aU~e of death to be severe heart diJeue. The department's Death Review Committee determined the death was natural and u.nexpected and the emergency medical response was appropriate. The hiring authority did not identify any staff misconduct. Overall Attettment The department's response was satisfactory in all critical upects. Prior to Incident Ratina Durin& Inddent Ratina After Incident Ratina Sufllcicnt Sufficient Sl1flicic:nt I Incident Date OIG Cate Number Can Type 2016-12-25 16-0002161-RO In-Custody Inmate Death Incident Summary OnDecember25, 2016, anofficersawaninmate inftotrtofacell with blood coming from his nose and mouth. The inmate collapsed and becsmeunresponsive. Two other officers and amuse initiated life-aving meuures. Paramedics arrived and CO!llinued lifo-saving efforts until a physician prollOUI!Ced the inmate dead. Ditposition The QOl'011er determined the c:aU~e of death was upiration related to lung cancer. The department's Death Review Committee determined the death was not medically preventable. The hiring authority did not identify any staff miscoruluct. Overall Attettment The department's response was satisfactory in all critical upects. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Sl1flicic:nt Su.fficient Sl1flicic:nt I Incident Date OIG Cate Number CateType 2016-12-27 16-0002160-RO In-Custody Inmate Death Incident Summary On December 27, 2016, an officer found an unresponsive inmate on his bed. Two officers and two nurses performed lifo-saving measures and transported the inmate to the triage and treatment azea where life-.aving meuures continued until a physician pmnolllWCld the inmate dead. Ditposition The department's Death Review Committee determined the inmate died from a sudden heart attack and the death was not preventable. The hiring authority did not identify any staff misconduct. Overall Attettment The department's response was satisfactory in all critical upects. Prior to Incident Ratina Durin& Inddent Ratina After Incident Ratina Sufllcicnt Sufficient Sl1flicic:nt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 100 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-12-28 17-000011(}-RO HWlicr Strike Incident Summary On Decembcr28, 2016, an inmate initiated ahWlicr strike claiming his hoiWng needs were not being met. The inmate ended the h\lllicr strike on January 20, 2017. Disposition The department made lQIIOD&b1e attempts to addrt:ss the inmate's (l()l](lems. The hiring autboritydidnotidentifyanystaffmisconduct. Overall As~e~~ment The department's ~ wu satisfactory in all critical aspects. Prior to Incident Rating During Inddent Rating After Incident Rating Sufllcient Su.flldent Sufllcient I Incident Date OIG Calle Number Ca~~eType 2017-01-05 17-0000101-RO HWlicr Strike Incident Summary On January 5, 2017, aninmatebeganah\lllicrstrikedueto safety(l()l](lems. OnJanuary9, 2017, the inmatefellandthe department trallspOrtedhimtoanoutsidehospital. The inmate returned to the institution the same day. On January 12, 2017, the inmate became unreaponJive, and the department tra1lspOrted the inmate to an outside hospital spin. On the same day, the inmate ended his hWlicr strike and returned to the institution. Disposition The department made lQIIOD&ble attempts to addltaa the inmate's (l()l](lems. The hiring authority did not identify any staffmUconducl Overall As~e~~ment The department's ~was satisfactory in all critical aspects. Prior to Incident Rating During Inddent Rating After Incident Rating Sufllcient Su.flldent Sufllcient I Incident Date OIG Calle Number CateType 2017-01-20 17-0000141-RO In-Custody Inmate Death Incident Summary OnJanuary20, 2017, the department sent the inmate to an011tside hospital for treatment where hediedonJanuary26, 2017. Disposition The department's Death Review Committee determined the inmate died due to infl~ and pneumonia and the death wu not preventable. The hiring authority provided training to the lieutenant nlgsrding "'PP<t writing. Overall As~e~~ment The department's actions following the incident were not adequate becau.e a lieutenant did not adequately document the incident. Prior to Incident Rating During Inddent Rating After Incident Rating Sufllcient Su.flldent Insufllcient As~e~~ment Questiont • Wu the erltlea!IDddcnt adequately documented? A lkutmtmt dJd not l1lcJutk a char and ooncise tlmd/M ofe venls or tlmd/M of~ notVIcatk>nsln his report. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 101 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2017~1-25 17 -0000143-RO HWlicr Strike Incident Summary OnJanwuy2S, 2017, an inmate initiatedahungcrstrike due todenialoflawh"brazydoouments,pmgramrt:atriction, and housing status. OnJanuazy29, 2017, the inmate fell, injuring his leg, and the department transported him to an outside hospital. The inmate returned to the institutioothesameday. OnFebruary21, 2017, the inmateendedbishungcrstrike. Ditpolition The department made lQISOII&ble attempts to address the inmate's (l()11(lems. The hiring autboritydidnotidentifyanystaff..U.oonduct but provided training to management and superviJory staff regarding timely notification to the OIG. Overall A11e11ment The department's actions were not adequate because the department did not notify the OIG in a timely and sufficient manner preventing the OIG from real-time monitoring of the case. Prior eo Incident Ratina Durin& Incident Ratina After Incident Ratina Sufficient Insllfl"lcient Sufficient A11e11ment Queltiont o Did the department timely notify the OIG regardiDg the erltleallnddent? '11u UpartmenJ did Mt Mt!/Y the OIG the lnmau was transp<>l'ted w an outskh lwspltlll whJk em hunger strlk& Incident Date OIG Calle Number CateType 2017~1-30 17-0000135-RO In-Custody Inmate Death Incident Summary On Janwuy 30, 2017, an offiQC!' dUeovered an unresponsive inmate on the floor of a oe11 he shared with a oellmate. The inmate had cuts 011 his face and blood on his shorts and legs. A sergeant, three offioers, and two nurses performed life-ssving measures. The department transported the inmate to an ambulance where a paramedic pronounced the inmate dead. The department referred the matter to the district attorney's office. Ditpolition The coroner (l()11(lluded the cause ofd eath was asphyxia due to external compressioo of the neck with blunt force trauma to the head and chest. The department's Death Review Committee determined the death was not preventable. The institution's in-«ill assault review concluded the inmates were housed within departmental guidelines. The hiring autboritydidnotidentify any staff nn.conduet. Overall A11e11ment The department's respmue was sstisfactory in all critical aspects. Prior eo Incident Ratina Durin& Incident Ratina After Incident Ratina Sufficient Sufficient Sufficient I Incident Date OIG Calle Number Ca~~eType 2017-02-11 17~1834-RO HWlicr Strike Incident Summary On February 11,2017, aninmatebepnahWlicrstrikebecausehe was notallOIIW:dtopouesspersonalproperty. On February 17,2017, the department transferred the inmate to an outside hospital for treatment of a prior injwy. The inmate ended his h\lllier strike at the hospital and returned to the institutioo the same day. Di1polition The department made lQISOII&ble attempts to address the inmate's COnQC!'nl. The hiring authority did not identify any staff nn.conduct. Overall At~e~~ment The department's respmue was sstisfactory in all critical aspects. Prior eo Incident Racma Durin& Incident Ratina After Incident Racma Sufficient Sufficient Sufficient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 102 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2017-m.-28 17-0021895-RO In-Custody Inmate Death Incident Summary On February 28, 2017, an officer found an wm:sponsive inmate on the floor of a cell. Officers and anlll'IC performed life-saving meu=•· Paramedi<>a arrived and continued life-saving meu=s Wllil a paramedic pronOWlCed the inmate dead. Ditpolition The dePartment's Death Review Committee determined the cause of death was lung cancer and the death was not preventable. The hiring authority did not identify any staff misconduct. Overall Attettment The dePartment's rtaponJe was satisfactory in all critical upects. Prior to Incident Ratina Durin& Inddent Ratina After Incident Ratina Sufllcicnt Sufficient Sl1flicic:nt I Incident Date OIG Cate Number CateType 2017-03-11 17 -00'22200-RO Hunger Strike Incident Summary On March. II, 2017, aninmateinitiatedahungeratrikebccauae be wanted protective framea for his glauea. The inmate ended his hungerstrikeonAprillO, 2017. Ditpolition The dePartment made reasonable attempts to addresa the inmate's concerns. The hiring authority did not identify any staff misconduct However, to improve the reliability of information repnling an inmate's weight while on hunger strike, the hiring authority instituted a practice requiring documentation repnling whether the inmate is wearing a medical device while bein& weighed while on hunger strike. Overall Attettment The dePartment's rtaponJe was satisfactory in all critical upects. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Sl1flicic:nt Su.fficicnt Sl1flicic:nt I Incident Date OIG Cate Number CateType 2017-00-15 17~022102-RO Other Sigtrificant Incident Incident Summary On March. 15, 2017, approximately 30 inmates attacked four officers in a dining hall. Officers \lied physical force, pepper spray, and two less-lethal munds to stop the attack. The officers sustained minor injuries and a responding counaelor suffered a broken thumb. An inmate sustained an orbital fracture. The &psrtment transported the inj=d inmate to an outside hospital and the inmate returned to the instit11tion the same day. Ditpolition The institution's executive review oommittee determined the use offon>e was within policy. The OIG concurred. The hiring authority did not identify any staff misconduct Overall Attettment The dePartment's rtaponJe was satisfactory in all critical upects. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Sufftcicnt Su.fficicnt Sufftcicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 103 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2017-00-26 17 -0022231-RO HWlier Strike Incident Summary On March 26,2017, an inmate initiated a hunger strike due to the possibility ofbeing transferred to another institution. OnMazdl30, 2017, the departmenttraluported the inmate to an outside hospital for dehydration, high blood preuun; and risk ofs troke. The inmate remaitted in the outside hospital until be erulcd the hunger strike 011 Apri129, 2017. Di1polition The department made lQISOII&ble attempts to address the inmate's ooneems. The hiring authority did not identify any stalf misconduct. Overall A11e11ment The department's rtapOtUe was satisfactory in all critical aspects. Prior to Incident Rating During Inddent Rating After Incident Rating Sufllcicnt Sufficient Sl1flicic:nt I Incident Date OIG Calle Number Case Type 2017-04-21 17-0022437-RO Inmate SeriOili/Great Bodily Injury Incident Summary On April21, 2017, an officer allegedly failed to sec= two housing writ doors, allowing an inmate to leave his housing unit, enter another housing unit, and attaek aseCOll.d officer with two imnate- manufactured Map011S. The seCOl1d officer used pepper spray and physical force, and two other officers used physical force to subdue the inmate. The seCOll.d officer suffered pil1lCtUre wounds and a laccrati011 to his ear. A sergeant traiuported the seCOl1d officer to an outside hospital and be was rdeased the same day. The department traiuported the inmate to an outside hospital for possible bead and n"b injuries. The inmate also returned to the instituti011 the same day. Di1polition The hiring authority identified potentialst iff miscoruluct based 011 an officer's alleged failure to sec= the two doors. Therefore, the hiring authority referred the ease to the Office ofilltemal Affairs for investigation. The Office of I1ltemal Affairs agreed to interview the officer. The OIG accepted the ease for mmritoring. Overall As~e~~ment The department's acti0111 prior to the incident were not adequate because an officer allegedly failed to sec= two doors, allowing the inmate to attaek another officer. Prior to Incident Rating During Inddent Rating After Incident Rating Inauflicient Sufficient Sl1flicic:nt As~e~~ment Queltion1 o Were the department'• aetlonl prior to, during, and after the crltlcallnddent appropriate? An offlcu a/hg«lly f4t two doors open, aJ/owlflg anlltmau to exit OM sectJ011 and mtu a suond ssctkm wllue M atklcku a110tllu offlcu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 104 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Ca1eType 2017~-m 17-0022537 -RO Inmate Serima/Great Bodily Injury Incident Summary On May 2, 2017, an inmate hit an officer with a cane, and three officers IUCd physical force to rt:atrain the inmate. The department tran.ported the inmate to an outside hoapital. The inmate suff=d a lerious injury. Ditpolition The hiring authority identified potential staff misoonduct based on officers' alleged l111lQISOII&ble use of force and failure to 84lCIInlteiyreport use of force. Therefore, the hiring authority referred the case to the Office of Internal Affairs for an investigation, which the OIG acoepted for monitoring. Overall A11e11ment The departmem's actions were not adequate because officers allegedly used l111lQISOII&ble force on an inmate, rt:aulting in lerious injury to the inmate, and failed to 84lCIInltely report the use of force. Also, an officer failed to complete adequate documentation, and the Office of Internal Affairs did not add a dishonesty allegation. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Inauft"tcient Il!lllfficient A11e11ment Queltiont o Were the department'• aetloua prior to, durin&, and after the erltleallnddent appropriate? OjJicus alkgedJy us«l ~kj(JIU ruuJdng In serious lnJUI'JI to an imMU.faJUd to QCCWYIJdyreport ~use ojj(JIU, and an ojJIUI'f alkd to adequatdy document a holding cal wg. • Wu the erltleallnddent adequately doaunented? OjJicus alkgedJyf aJUd to QCCWYlJdy report~ use use ojj(JIU and an ojJIUI'f aJUd to atkquatdy document a holdbJg cal log. o Did the OIA make an appropriate Initial determination regarding the cue? 171<! OjJ/a ofl nJuna1 AffaJn did not add a dishonesty alhgatkm/ 01' each ojJIUI' dupiU ln/0111f4tlon suggesting ~ offlcus lUd In rqortlllg ~ j(JIU us«l and wUMssed. Incident Date OIG Calle Number Calle Type 2017~-25 17 -0022825-RO Hunger Strike Incident Summary On May 25, 2017, 74 inmates in an administrative segregatio11 writ declared hull.ger strikes because they wanted exetcise equipment in the administrative segregation writ exercise yard, cleaner exercise yards, cleaning supplies, access to law clerks and more access to the law h'braty, rehabilitative programs and education, and the same privileges as inmates insecurity housing writs. The inmates abo complained that some officers were too loud while oonducting security checks. As of June I, 2017, the inmates ended their hull.ger strikes. Ditpolition The department made reasonable attempts to addlQs the inmates' concerns. The hiring authority did not identify any staff misoonduct. Overall At~e~~ment The departmem's response was satisfactory in all critical aspects. Prior to Inclclent Rating During Inddent Rating After Inclclent Rating Sl1fficicnt Sufficient Suflicient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 105 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA South Incident Date OIG Cate Number Can Type 2016-02-15 16-0000758-RO In-Custody Inmate Death Incident Summary On February 15, 2016, officers found an unresponsive inmate bleeding from his head and nose. The department transportedtheinmatetoanoutsidebospital wb= be diedonMazdt9, 2016. The hiring authority referred the matter to the dUtrict attorney's office to investigate possible homicide by another inmate. Ditpolition The coroner determined the cause of desth was blunt force head trauma. The depsrtmettt's Death Review Committee concluded that the death was !lOt medically preventable. The hiring authority did not identify any staff mUconduct. Overall Attenment The departmettt's ~was satisfactory in all critical aspects. Prior to Incident Rating During Incident Rating After Incident Rating Sufftcicnt Sufficient Sufftcicnt I Incident Date OIG Cate Number CateType 2016-03-18 16.0000866-RO In-Custody Inmate Death Incident Summary On Mazdt 18,2016, officers dUcovered an unresponsive inmate in his cell. The officers removed the cellmate and initiated lifo-savi"i meuum~ on the inmate. Outside firefighters arrived and pro1IOiliiCed the inmate desd. Ditpolition The coroner reported the ca\IIC ofd eath as mixed drug toxicity but the manner of death, based on evidence ofb lunt force trauma, is undetermined. The investigative services unit took lQIIOII&ble steps to identify the source of the drugs and outside law enforcement is investigati"'. The departmettt's Death Review Committee concluded the death was not medically preventable. The hiri"' authority did not identifY any staff misconduct. Overall Attenment The departmettt's ~was satisfactory in all critical aspects. Prior to Incident Rating During Incident Rating After Incident Rating Sufftcicnt Sufficient Sufftcicnt I Incident Date OIG Cate Number Can Type 201~3 16-0001014-RO In-Custody Inmate Death Incident Summary On Apri13, 2016, officers dUcoveredan unresponsive inmate oovered in blood ina cell. Officers and nurses performedlifo-savi"i meuum~ until a physician pronounoed the inmate desd. Outside law enforcement is investigating the incident. Ditpolition The coroner concluded the cause ofd eath was homicide. The depsrtment oonducted an in-«11 assault review and determined the institntion complied with policies when housing the two involved inmates. The department's Death Review Committee concluded the inmate's desth was unexpected and medically not preventable. The hiring authority did not identify any staffmisoonduct. Overall Attenment The departmettt's ~was satisfactory in all critical aspects. Prior to Incident Rating During Incident Rating After Incident Rating Sufftcicnt Sufficient Sufftcicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 106 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-04-14 16-0001147-RO In-Custody Inmate Death Incident Summary On Apri114, 2016, an offioer found an inmate banging from a noose in the oell. Two officers, three nurJe1, and peramedica performed life-taving measurea but were unsll(l(lQsful. A paramedic pro1IOiliiCCd the imnate dead. Ditpolition The coroner determined the cauae of death to be asphyxiation by hanging and the department's Suicide Case Review Committee reported the death as f<m:aeeable and preventable suicide. The hiring authority identified potential staff miaoonduct based on the officer's alleged failure to perform a proper security check, entering the oell without notifying a sergeant, and failure to timely submit an incident report. Therefore, the hiring authority referred the matter to the Offioe of Internal Affairs for investigation. The Offioe of Internal Affairs opened an investigation, which the OIG accepted for monitoring. Overall Attettment The depsrtment'a actions were not adequate becauae an offioer allegedly failed to adequately oonduct a security check, entered the inmate's cell prior to notifying a supervisor, and failed to timely complete an incident report. The hiring authority did not timely refer the matter to the Offioe ofintemal Affairs. Prior to Incident Ratlna Durin& Incident Ratina After Incident Ratlna Insufficient Inallflicient Il!lllfficicnt Attettment Questiont o Were the department'• aetfcnq prior to, durlnt. and after the crltlcallnddent appropriate? PrWr to tJu lncJdml, an <>.filar~ dJd rwt ~r tJu brmau had a 111008e around hu neck during as~ ch«k. During tJu illcJdm4 tJu offlar allegedly en/41Wd tJu tmnau ~ uJl prior to rwtlfjllng a supervUor. AJW tJu illcJtkn4 tJu offlar allegedly did rwt CQmp/m an i1lcJdmt 1f!POI1 bqore going offd uty. • Wu the crltlcallnddent adequately doClllllented? '11u ojJicu allegedlyf ailed to rompkte an i1lcJdmt 1eport bqore gotng offd uty. o Did the hiring authority make a dmely deelalon regardiJII whether to refer any eonduet related to the erltlcallnddent to the OIA? '11u dqartmentlearned oftlualkgedmlscmlductonAprll U, 2016, buttlu hlrlngautlturlJydJdrwtrqu tJu mattu to tJu OjJiu ofbttunalAffalr.lunJJJJanumy 18, 2017, 279 d4ys qftu tJu date ofd iscovery. Incident Date OIG Cate Number Can Type 2016-05-13 16-00014SS-RO In-Custody Inmate Death Incident Summary On May 13, 2016, an inmate complained of stomach pains and vomiting. The depsrtment transported the inmate to an outside hospital where the inmate was found to have a bindle ofm arijuana in his intestine. A physician surgically removed the bindle, but the inmate sllfferedsurgical complications. A physician pronounced the inmate dead on May 14,2016. Ditpolition The coroner concluded the cauae ofd eath was hypertrophic cardiomyopathy. The department's Death Review Committee concluded the cauae of death was medically non-preventable cardiovascular disease. The hiring authority did not identifyanystaffmiaconduet. Overall Attettment The depsrtment's response was satisfactory in all critical aspeeta. Prior to Incident Ratlna Durin& Incident Ratina After Incident Ratlna Su.flicient Su.fficient Su.flicient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 107 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-05-30 16-0001667- RO In-Custody Inmate Death Incident Summary On May 30, 2016, an inmate oollapaed while working in the kitchen. Officers and nlllJCI performed life-aving measures that w= 111Uucceuful, and a physician pronounced the inmate dead. Disposition The Q()l'()11C:r determined the inmate died of methamphetamine toxicity. The department's Death Review Committee found that the death was not medically preventable. The department UlUuccessfully attempted to locate the 10\ln>C oft he drugs. The hiring authoritydidnotidentify anystlffmisoonduct Overall Attettment The department's rtapOtUe was satisfactory in all critical aspects. Prior to Incident Ratina Durin& Inddent Ratina After Incident Ratina Sufllcicnt Sufficient Sl1flicic:nt I Incident Date OIG Cate Number Can Type 2016-06-08 16-000I"ni-RO In-Custody Inmate Death Incident Summary On June 8, 2016, an officer found an urueaponsive inmate ina cell. Officers andnlllJCI performed life-aving measures but they were UlUucceuful, and aphysicianpronounced the inmate dead. Ditposition The Q()l'()11C:r ooncludcd the inmate sustained heart poiaotring due to acute fentanyl intoxication. The departmenrs Death Review Committee determined the inmate's death was not medically preventable. The investigative services unit found fentanyl in the cell. The department took appropriate steps to identify the source oft he dmp and provided trainin& to custody stiff repniina fentanyl. Overall Attettment The department's rtapOtUe was satisfactory in all critical aspects. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Sl1flicic:nt Su.fficient Sl1flicic:nt I Incident Date OIG Cate Number CateType 2016-06-15 16-0001737- RO In-Custody Inmate Death Incident Summary On June 15, 2016, officers found an unresponsive inmate in his cell. The officers and nlllJCI attempted life-aving measures but were not succesaful. After oonsulting a physician, a paramedic pronounced the inmate dead. Ditposition The Q()l'()11C:r determined the inmate died of heroin intoxication. The department's Death Review Committee found the death was not medically preventable. The department UlUuccessfully attempted to locate the 10\ln>C of the drugs. The hiring mthority did not identify any stiff miaconduct. Overall Attettment The department's rtapOtUe was satisfactory in all critical aspects. Prior to Incident Ratina Durin& Incident Ratina After Incident Ratina Suflicient Su.fficient Suflicient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 108 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-0S-14 16-0001853-RO In-Custody Inmate Death Incident Summary On Alll!lllt 14, 2016, oflioers found an \llll'eapotaive inmate face down on the floor of a cell. Offioers and a nune initiated life-saving measures and transported the inmate to the triage and treatment ana Paramedics arrived and tock over life-saving measures until a physician pronounced the inmate dead Ditpolition The ccroner indicsted the inmate died of acute methamphetsmine and opiate intcrication. The depsrtment's Death Review Committee determined the death was not medically preventable. The hiring authority tock steps to investigate the SC\Il'QC of the drugs. The hiring mthority did not identify any staff misconduct. Overall Attettment The depsrtmem's rtaponJe was satisfactory in all criticsl aspects. Prior Co Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Su.fticiem Suflieicnt I Incident Date OIG Cate Number Ca.eType 2016-09-16 16-0001921-RO In-Custody Inmate Death Incident Summary On September 16, 2016, an officer found an \llll'eapotaive inmate. Two oflioers and two 11urses initiated life-saving measures. The department transported the inmate to an outside hospitsl where a physician pronounced him dead. Ditpolition The ccroner determined the cause of death was heroin and methampbetsmine toxicity and 11UIII11er of death was accidemal. The depsrtment's Death Review Committee a1sc concluded the Callie of death was heroin and methamphetsmine toxicity and the death was not medically preventable. The hiring authority did not identify any staff misconduct. Overall Attettment The depsrtmem's actions followi11g the incide11t were not adequate because the institution did not investigate the SC\Il'QC of the drugs. Prior Co Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Su.fticiem I11Suf'lieicnt Attettment Question• • Were the department'• aetlonl prior to, dur!Dg, and after the erltleallnddent appropriate? 171<! 111/JtUuJI(Jflfalkd to lltvutjgaU tM SOIII'Ce oftM drugs tJrat C4USU tk~ lnmau's tkath. Incident Date OIG Cate Number Cate'l'ype 2016-11-20 16-00020~RO Suicide Incident Summary OnNovember20, 2016, anoflicerfoundan \llll'eapotaive inmate in a cell with a bag over his headandastrip oftomsbirtsecuring the bag tohis11eck. Offioers andparamediesperformedlife- saving measures but wen: Ul!Succeuful, and a paramedic pnmounced the inmate dead Ditpolition The ccroner determined the 11UIII11er of death was suicide and cause of death was suffocation. The depsrtmem's Suicide Cue Review Committee determined the death was f=aeeable but not prevmtlble. The depsrtmem's Death Review Committee concluded the death was a no11-preve11table suicide. The hiring authority did not identify any staff milconduct. Overall Attettment The depsrtmem's respotUe was satisfactory in all criticsl aspects. Prior Co Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Su.fticiem Sl1fficicnt I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 109 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2016-12-02 16-0002112-RO In-Custody Inmate Death Incident Summary On December2, 2016, officers disoovert:d an wm:spo!Uive inmate in his cell. Officers removed the inmate from the cell and initiated life-saving measures. Fourn\ll'lea arrived and oontinuedlifo- saving efforts Wlli1 paramedica arrived, and a physician at an outside hospital pronounced the inmate dead. Ditpolition The coroner identified the calliC of death as heart dilease. The department's Death Review Committee concluded the death was possibly medically preventable. The hiring mthority identified potential staff misconduct based on the transporting officers' alleged failure to contact emergency medical services after teaming the inmate was having a diabetic emergency during tran.port. The hiring authority referred the case to the Office of Internal Affairs for investigation. The Office of Internal Affairs opened an investigation, which the OIG accepted for monitoring. Overall Attettment The department's actions prior to the incident mre !lOt adequate becalliC officers allegedly did !lOt adequately provide medical assistance to the inmate and the hiring authority delayed referring the matter to the Office of Internal Affairs. Prior to Incident Rating During Indclent Rating After Incident Rating InaufliciaU Sufficient Sllfficicm Attettment Quettiont o Were the department'• aetloua prior to, durlnt. and after the erltleallnddent appropriate? OjJicus /1Ymsp<1l'tJng ~ t1rmtlU alk~ fa&d to CQII/acJ emergency m«<Jctllserv/ca when kamlng ~ tKmtde was having a dJabedc emogency during transport. o Did the hiring authority make a tlmdy dedalon reprdlnz whether to refer any eonduet rdated to the erltlcallnddent to the OIA? 11u! tkpartmem letli'Md of~ alkged mls<xmducJ on Ikcmlbu 2, 2016, buJ ~ lrJrlng auJiwrlty dJd not refer the mattu to ~ Ojjlce ofl 7llunal Affalrtl U1ltJl JtmUal')t 17, 2017, 46 days qfter ~ daU ofdlsctwery. Incident Date OIG Cate Number Ca.eType 2016-12-10 16-0002129-RO In-Custody Inmate Death Incident Summary On December I 0, 2016, officers found an wm:spo!Uive inmate in a oell after his oellmate called for help. Officers, a IllllJC, and paramedics performed life-saving measures that Mre IIIIIUCcessful, and a physician pmnoiiiiCed the inmate dead. Outside law enforcement u conducting a homicide investigation. Ditpolition The coroner determined the inmate died of a blood clot in the lungs partially due to an earlier injwy from a fight with another inmate. The department's Death Review Committee determined the death was not medically preventable. The hiring &llthority did not identify any staff mUconduct. Overall Attettment The department's response was satisfactory in all critical aspects. Prior to Incident Rating During Indclent Rating After Incident Rating Sllfficicm Sufficient Sllfficicm I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 110 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Calle Number Calle Type 2016-12-31 17 -0000122-RO HWlicr Strike Incident Summary On Decembcr31, 2016, an inmate began a hunger strike because his peaona1 property had been oonfiscated. On Janwuy 27, 2017, the inmate ended his hunger strike but on Februazy 6, 2016, m~umcd the hungerst rike due to dissatisfactio11 with replacemem property a11d bei11g detried appliarlces 11ecesaazy to cope with his disabilities. A3 ofM arch 19, 2017, the inmate lost 31 penlCllt of his ori&iJ!al body weight. On March 20, 2017, the d.epartmel1t tran.sferred the inmate tom outside hospital. The inmate returned to the in.stitulion on March 21, 2017, a11d C11d.ed the hunger strike onMarch23,2017. Disposition The department made lQIIOII&ble attempts to addmls the inmate's COIIQCl"l]S. The hiri11g authority did 110t idemtify any staff mUcoruiuct. Overall A11e11ment The department's miP011IC was satisfactory in. all critical upect:s. Prior to Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Sufficient Sl1fficicnt I Incident Date OIG Calle Number Can Type 2017-02-06 17-0021707-RO m-Custody Inmate Death Incident Summary On February 6, 2017, m offiQCt discovered an unresponsive inmate in. his cell. 1\vo officers mda nurse performed lifo-savin.g meuures until paramedics arrived a11d pmnoullced the inmate dead. Di1polition The COI"Ollel" d.etermi11ed the cau.e of death to be a heroin. overdose. The department's Death Review Committoe d.etermi11ed the death was 110t medically preventable. The department attempted to idemtify the source of the heroin. but was lii!Successful. The hiri11g authority did 110t idemtify my staff mUcoruiuct. Overall As~e~~ment The department's miP011IC was satisfactory in. all critical upect:s. Prior to Incident Rating During Incident Rating After Incident Rating Sl1fficicnt Sufficient Sufficient I SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 111 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Incident Date OIG Cate Number CateType 2017-M-24 17- 0022463-RO In-Custody Inmate Death Incident Summary On Apri124, 2017, an oflioer dUeovered a non-responsive inmate in rn. cell. The officer performed life-aving meuurea, which were not s~ because the inmate bad been dead for several days. Ditpolition The hiring authority identified potential staff misconduct based on several oflioers alleged failure to conduct proper inmate (l()l11]ts, licxmsed paychiatric technicians alleged failure to administer and monitor the inmate's medications, and alleged false reporting regarding contact with the inmate after rn. death. The hiring authority referred the matter to the Office of Internal Affairs. The Office of Internal Affairs opened an investigation to address allegations against eightoflioers, two licxmsed pa)'tlru.tric technicians, and one teacher. The OIG acoepted the case for monitoring. Overall Attettment The department's rtapOtUe was !lOt adequate because oflioers and licxmsed paychiatric technicians allegedly failed to properly monitor the inmate before he died and detect the inmate was dead. Also, the department did not adequately notify the OIG and the Office of Internal Affairs did not approve an investigation into alleged miaconduct by four additional offioers and three additional licxmsed paycru.tric technicians even though the allegations are supported by evidence. Prior to Incident Ratlna Durin& Incident Ratina After Incident Ratlna Insuflicicnt Insufficient Inauflicicnt Attettment Quettiont o Were the department'• aetton. prior to, durin(. and after the erltlcallnddent appropriate? OjJicgs and UansedpsychJatrlc uehmcJtms a&gedlyfalkd wJ 1IY1PU/y monlwr tlu tnmau and tkUa t1u tnmau was tUmlfqr tJrru days. 'l7u tkpartmemfalkd w rwtl/Y tlu OIGoftlu dtlU and ti1M oftlu autopsy. o Did the OIA mate an appropriate Initial determination regarding the cue? 'l7u QfJic4 ofI ntunaJ Affairs ,.qiued w tnvutJgau slmJltlr alkged mlsconducl byf our adtiJtWntll ojJicers and tlrru adt/JtWnalllansed psyc}Uatrlc UClJnJcJtms whm there was Sl!!flcJmt evltlma tlu tnmau was tkadfor as kmg as three dtlys, and tlu ojJicers and llansedp syc/JJatrlc uelmlcltms slwuld /rave dJscovered tlu tnmau. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 112 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA AppendixF 49 Contraband Surveillance Watch Cases Central Date PIKed Oil Contraband Wateh Date Taken off Contraband Watdl Reaton for Placement Contraband Found 2016-12-04 2016-12-04 I. Drugs I. Drugs Inddent Summary 16-15446-CW On December 4, 2016, the department placed an inmate on contraband surveillance watch after officers saw the inmate swallow an unknown object. Officers lleanlhed the inmate's cell and found a bindle of suspected heroin. The department transPorted the inmate to an outside hospital where the inmate remained on contraband surveillance watch. An imaging IICan sboM:d no additional biDdies or foreign objects inside the inmate. The department removed the inmate from contraband surveillance watch and retnmed the imnate to the institution the same day. During that time, the department recovered no comrabsrui from the imnate. Intufllcient The department did not lllfliciently comply with policies andp rocedura aovemina conlraband survcillance watch durin& the f0111' boun oft he conlrabaDd survcillance watch. The dcplllment did not apply restraints, proYide the inmate with hygiene opportllnitics, or complete required documcnlation. The birina authority provided lrlinin8 to addral the documentatiort deficiencies. Attettment Questiont • Did applleatlon of restraints eomply with CSW polldcs and proeedures? '11u dqartmentdldMtapplyrutralnts. a Did the departmeut comply with polldes and procedures governing hygleue requiremeuts? OjJ/cus did Mt pi'(IVUk 1M t111Mte acuss to pmper lrygW~L a Did the departmeut complete appropriate doauneutatlon? OjJicus did Mt document applying "I'Utralnts or 1M IMI4te's acttvtdufor 1M duration ofiM tlrmtlte's plaammt 011 COIIJI'aband SU1Wilkme4 walclr. a Overall, did the department subltantlally comply with CSW policies and procedures? '11u Upartment did "fiOt properly document tM tncldml. a Did the hiring authority ldeutlfy a policy vloladon or laue and take com:cdve action, lndudlng training? '11u hlrlllg auJiu>rlJy traiMd 1M offlcus who faJkd to document the Inmate's actMdu wiUh 011 C<IIIJI'aband Slli'Vdllanu walclr. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 113 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2016-12-17 2016-12-22 I. Drop I. Drop Incident Summary 16-15455-CWRM On. December 17, 2016, the department placed an inmate on contrabarui surveillance watch because an officer saw the imnate swallow an Ulllmown object. The department removed the inmate from contraband surveillance watch on December 22, 20 16, five days later. During that time, the department recovered heroin from the imnate. Incident Aneltment Intuflident The department did not IW!icienlly comply with policies and procedures aovemina COt1lrlband IUrYeiUancc watch. Scqeant. did not COIIIiltc:Dlly complete ra[Uired sllpCIWory cbcckJ, and ofllcm did not complete Rl([uired documentation or conaiatently provide the inmate proper band ~ypcne. The department provided training to llddraa the deficiendes. Attenment Quettiont o Did the department comply with polldes aDd procedures govendng hygiene requirement.? OjJicgs dJd not conslstmtly] PfiVIth the tmnate with lrmrd-WtlShlng (lj1JX)11Unldu prior w m~ and aftu using the 1VIroom. o Did the department complete appropriate documentation? OjJicgs dJd not conslstmtly document that~ medJc41 assusments wo. cqmpkt4d. o Overall, did the department aubltantlally comply with CSW polleles aDd procedures? Sergeants dJd not cONJisWitiy C<lllduct supuvlsory chechl, and offlcen did not conslstmtly document that~ medJc4J assessments - compkted or that tM Inmate WtlS ]PfiVIded proper hand hygieM. o Did the hiring authority Identify a policy violation or lllue aDd take corrective action, Including training? '11u hiring authorityp rovlthd training w offlcen and s~ants w addrus the d4JcUrrcUs. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~1~8 2017-01-16 I. Drop I. Drop Incident Summary 17-15464-CWRM On. J8l!WilY 8, 20 17, the department placed an inmate on contraband surveillance wale~ because an officer saw the inmate swallow an U1llmown object from a milk carton durin& visiting. The department removed the inmate from contraband surveillance watch on J8l!WilY 16, 2017, eight days later after recovering heroin from the inmate. Incident Attettment Sufficient Overall, the dcpartmentiWlicieD!Iy complied wimpolicies andprocedma aovemin& conttabandsurveillancewatcll. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 114 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~1-15 2017-01-18 I. Suspicioua Activity I.Drup Incident Summary 17-15468-CW On. J811ll8lY 15, 2017, the department tranJportedan inmate to an ouWde hospital becauae an officer saw him swallow asuspecteddrug bindle durin& visiting. The inmate refused all medical usessments, and the department returned the inmate to the institnti011andplaced him 011comraband surveillance watch the same dsy. On. January 17, 2017, the imnate retrieved andre-ingested the suspected drug bindle. The department returned the inmate to an ouWde hospital where he remained 011 contraband surveillance watch. The department removed the inmate from contrabsnd surveillance watch and returned him to the institnti011 011 J811ll8lY 18, 2017, three dsys after placement, after recovering concentrated cannabis from the inmate. Incident Atleltment Intuftident The dcpertment did not sWficlcnlly comply with policies andp rocedura aovernina conlraband IUrVeillance watch. The dcpertment did not edcquatdy notify the oro, an of1icer did Dot e011tinually monitor the inmate, aDd a ICII;eant did not ulip lWI:I officers while the inmate wu umatrained. Seraeants and of1icers did Dot conliltcrllly complete mquimi documcntati011 and III{IC'viaory cbceka. The dcputmcnt provided COilDICiin& and trllnin& to addrcu the ddicicncies. A1tenment Queltiont o Did the department comply with polldesaDd procedures governing hygiene requirements? OjJicus dJd not conslstmtly] PfiVIth the lnmau tlu op]K111u1Uty w wash his htmtls prior w 1Mabi and qfW using the rutroom. o Did the department comply with polldesaDd procedures governing the Inmate's removal from CSW? 11u! thpartmem did not notifY the OIG when removing the imMtef rom 001111Ylband swwJllance wt~tch. o Overall, did the department substantially comply with CSW polleles aDd procedures? 11u! thpartmem did not notifY the OIG when trtlll!lfurlng the lmMu w an outside hospital or when removing thelnmauf rom C<llltl'aband Slll'lfeJ//anu watch. An offlur dJd not continually IMIIItor the lmMU. and a sugeant dJd not assign two offlcus during ~~~WStrained ttma, resulting In the lnmau rdrlevlng and r&-tngestJng the contraband. OjJicus dJd not consistently txmducJ ~d security clr«ks oft he Inmate's jumpsuit or ]1lf1VIth the Inmate proper hand hyglm& Sergeants dJd not conslstmtly cqmpkte 1W/IIbWl supervisory clr4ckr. o Did the OIG Identify a polley violation 01' l. .u e that resulted In, 01' should have resulted In, corrective action, Including training? 11u! thpartmem did not notifY the OIG when trtlll!lfurlng the imMte w an outside hospital or removing the lnmauf rom 001111Ylband Slli'VeJI/ane4 wt~tch. 11u! tkpa-provltkd training w ltlllNig'6rs w addrus the d41cJmcks. o Did the hiring authority Identify a polley violation 01' '-ue aDd take corrective action, In dueling training? 11u! hiring authority~~ that the admlnls/l'atM offlur oft he di1y dJd not make 1W/IIbWl notVIcatJons, an offlur dJd not continually IMIIItor the lnmau, and a se-,geant dJd not assign two offlurs during unrutralned tlltw. 11u! hiring authority also ltlmtl/ied that o.f]lars dJd not conslsteniJy cond uel ~security clr«ks oft he lnmau 's }umpsujt orp rovitk the Inmate proper hand hyglm& Sergeants dJd not conslstmtly cqmpkte 1W/IIbWl supervisory clr4ckr. 11u! thpartmmt ]PfiVIded coUIISd/ng w the s~antand offlur who dJd notp rovitk consW11t oluervatkm, and ]1lf1VIthd training w managers and offlurs w addrus the other thjlcJencUs. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 115 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-m.-13 2017-02-14 I. Drop I. Nothin& Incident Summary 17-15489-CW On. February 13, 2017, the department placed an inmate 011 contraband surveillance watch after an officer ol»erved him place an U1llmowll. item in his mouth during a rarulom cell search. The department removed the inmate from COll.trabarui surveillance watch 011 February 14, 2017, Ol1C day later, after an x-ray revealed 1lO foreign object. During that time, the department recovered 1lO oontraband from the inmate. Incident Anelllllent Intuflident The department did not su.fticielldy comply witlt policicl and procechua aoveminll COIIlraband 111rYc:i111mle watch. The department premawrely removed the inmate from oontraband surveillazlce watcb, nealected to timely notify the OIO of the inmate'sremoval, and did not conaiatentlyprvvidc the inmate witlt PIUJICl'hYJicnc 01' ranee of motion opportllniticl. A llliiiC did not conduct a mquired medical UICIII<IlCnt. The hirina &lltborityprovidcd trainina to an IUOCiatc warden, captain, ICI'IC8lltl, of'liCCII, and adminiltrativc officers of the day to addreN some dcficicrlcicl. The hirina aulhority dccidcd not to take action in rcapol!IC to the IUIIIC'a Wlurc, d=nina it an iuuc for ICI'IC8DIImi officers. Attettment Quettiont o Did the department comply with poildaaDd procediii'CII governing hygiene requirement.? OjJicus dJd not conslstmtly] PfiVIth the Inmate with the o]1JK111u1Uty to wash his htmtls prior to meals and qfW using the P'Utroom, 07 ,_,ve /l'ashfrom the cell. • Did the department cODduct reqlllred medical ...a amenta? A nUI'Se dJd not compkte a~ 1MdJca1 assusmmt prior to the lmnate's pla'c4mem on contraband survellkmce lWltch. o Did the department comply with polldaaDd procediii'CII governing the Inmate'• removal from CSW'l 171<! hlrlllg authorlJyprem4turely authori:z«l-illg the Inmate .from Cflflti'Qband SIIIWJJJ4nce watcll within one d4y ofpla'c4ment qfW an JHYI)IreWilkd noforelg"fl object and did not timely notJjjl the OIG oft he -aL o Overall, did the department subltantlally comply with CSW policies aDd procediii'CII? 171<! thpartment n~ to timely notJjjl the OIG when renwvtng the Inmate from controband SUI'Vellltma watch and removed the Inmate b4ore utab/Jshlng a reascmabk baJ4 the Inmate was .fru ofc ontroband. Ojjlcus did not co"fiSistmtiy ]1lf1VIth the Inmate with propu hyglme 07 rvmge ofl tWtlo"fl 0]1JX»''umtlu, and a "fiUI'Se dJd not conduct a requbwl m«/Jcal assusmellt. • Did the OIG Identify a policy violation 01' l. .u e that raulted In, 01' ahould have raulted In, corrective act!OD, Including training? 171<! OIG ldmJVIed the tkpa-prematul'ely removed the Inmate from controband suTVel/itma watch and dJd not tlmay not!/Y the OIG oft he Inmate) remowtl. The htrillg authorlty tmpkmented new po/JcJu and provided l1'alnlng to an assockUe wt11dm, captaln,fow se7ge(11111, two ojJiars, and admlnJstradve offlars oft he d4y to addl'us thue ~lmclu. • Did the hiring authority Identify a policy vloladOD 01' laue aDd take com:cdve actiOD, lnduding training? 171<! hlrlllg authorlJy ltimtVUd that ojJiars dJd not conslstmtly provide the Inmate hygi4M 07 rvmge ofltWtkm OJ1JKII'tu1Utlu, and that a "fiUI'Se dJd not compkte an tmdal medlcaJ assusmmt. 171<! hlrlllg authorlJy provilkd tralnillg to an assocJate wrl1'dm, captain, sugeanls, and ojJial's. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 116 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-m.-24 2017-02-28 I. Drop I. Nothin& Incident Summary 17-15497..CWRM On. February24, 2017, the department placed an inmate 011 contraband surveillance watch after anx-rayat an outside hospital revealed a bindle ofsuspeeteddrup in the inmate's abdomen. The inmate returned the instituli011 the same day. The deparlmellt removed the inmate from COl1lraband surveillance watch 011 February 28, 2017, four days after placement. During that time, the department recovered no contraband from the inmate. Incident Anelllllent lntuflident The department did not su.fticiell!ly comply with policicl andp rocechua aoveminll COIIlraband 111rVei11ance watch. The department did not consiatenl1y proyidc the inmate proper ~ypcne or ranae ofmotioo:t opportUDitict, orCClllduilt ""'Uircd medical •-mcnll. The hirin& llllboritypro'lided training to lddzauomedcficicnciea. The hirln& llllboritydccidcd 1'lot to takucti011in raponae to the =-' failu rea, dccntina it an iuue for ICfiC8I1II and oflicers. Astenment Questiont o Did applleatlon of restraints eomply with CSW polldea and procedures? OjJicus dJd Mt J1'(IVItk all~ range ofm oiWn opportunJIUs. • Did the department comply with polldea and procedures governing hygiene requirements? OjJicus dJd Mt conslstmtly ]PfiVIth the Inmate access to hand lrygkM qfW Wl/ng the rutroom and prior to meals on muldpk ocC411ons. o Did the department cODduct required medical au-ents? Nurses dJd Mt conduct~-dJc41 assusments whlk on cOfltiYJballd ~ watch. o Overall, did the department subltantlally comply with CSW policies and procedures? '11u thpartment did Mt conslstmtlyJ 1'(IVItk the lnmau proper h)IKI4M 01' range ofm oiWn opportunJIUs, 01' canduct ~ medJc41 assusments. • Did the hiring authority Identify a policy vlolatiOD or luue and take corrective action, Including training? '11u hiring authorityp rovlthd training to the Involved captain, /Uutmants, spgeants, and officers to to addrus the tkjlcJmclu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 117 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-m.-28 2017-03-(ll I. Drop I. Nothin& Incident Summary 17-15499-CW On. February28, 2017, the department placed an inmate 011 contraband surveillance watch after officea obterved the inmate place an Ulllm0W11 object in his mouth andappesr to have swallowt:d it The departm.Cllt removed the inmate from contraband surveillance watch 011 March 1, 2017, Ol1C day later. During that time, the departm.Cllt recovered 1lO CO!llraband from the inmate. Incident Aneltment Intuflident The departm.Cllt did not JU.ftlcienlly comply with policies and procedures aovernina COIIlrlband surveillancc watch. The departm.Cllt did !lOt place the inmate on COll.trabend surveillallCC watch in a timely manner and premaiWdy removed the inmate from contraband awvei1lazlce watch, ncatected to obtain autbori2ation to apply band iJolatioll devices, and did not collSiatenlly complete mtllimi documentati011 or proYidc the inmate with ace- to band b.YJiene. The birin& authority provided traillin& to addzeu the deflcic:Ddes. Attenment Quettiont o Did the department comply with polldes aDd procedures when the Inmate wu placed OD CSW? '11u d4partmem plaad ~ t1rmtlU em 001111Ylband surwJlkmca watch al~tWSt ana lwur qftu ojficus observed tu lnmau (I]1JH(U" to swal/Qw suspUUd drugs. o Did application ofHaDd bolatlon Devlca comply with CSW policies and procedures? '11u Upartmemplaad ~ t1rmtlU In hand lsoladon Uvlcu wltlwut}ustl/klltkm or tha wt~"ldm's or chJ4 dquty lWI"Idm's approval. '11u tkpartmmtJdmtVUd ~ enYP" and ~d ~ hand lsollltJem tkvlcu approxlnltlUJy two /wu17 loW. o Did the department comply with polldes aDd procedures governing hygiene requirement.? Ojflcus dJd Mt conslstMt/y plm'ltk the Inmate access to hand lrygUM prior to mu/s and qftu 1181ng ~ rutmom. o Did the department complete appropriate documentation? Offlcus dJd Mt documem tu type ofr utralnts 118«1. o Did the department comply with polldes aDd procedures governing the Inmate's removal from CSW? '11u hiring authorityp rematurely authorl ull removing the Inmate from C(lff/I"QfHmd SIIIWIJklnu watch within 24 /wu17 ofp lilc4ment q!Ur Mtlng tu tklayed p~nt lllilY have alk>w«< ~ t1rmtlU IbM to discard tu collt1Ylband. o Overall, did the department substantially comply with CSW policies aDd procedures? '11u d4partmemdelayedp/4cJng ~ lnlllilteem contraiHmdswwJI"Imlu watcll, dldMtcompkU aUquat6 docvmenl4tton,plaad ~ t1rmtlU In hand lso/4tlcmdevlcu without approval, and removed tu lnmau from contrabtmd swwJJJanu watch before utabllshlng a reascmabk beJUf ~ t1rmtlU lWII contrahand-.fru. o Did the OIG Identify a policy violation or l. .u e that raulted In, or should have resulted In, COJTCCtlve aetlon,lncluding training? '11u UpartmenJ prematurely removed ~ t1rmtlU from contraband survelllanca lWitch. o U the OIG Identified a policy violation or baue that resulted In, or should have resulted In, COJTCCtlve aetlon, Including training, did the department tate COJTCCtlve action or provide training? '11u hlringauthoritydldMtagru that~ tkpartmmtprematurelyremovedtulnmaufrom C(lff/I"QfHmdSIIIWIJklnu lWitch. o Did the hiring authority Identify a policy vloladon or blUe aDd take com:edve aet1on, Including training? '11u hiring authority ldmtJjlM ~ tklayed placement em 001111Ylband surwJlkmce watch and that offlcutJ dJd not adequately compkU ~ documenlatton. 17Je hJrlng authority ]P'Ovld&l training to lkutmanls, sugeants, and ojficus. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-03-05 2017-03-09 I. Suspicious Activity I. Drop Incident Summary 17-15506-CWRM On. March S, 2017, the departm.Cllt placed an inmate 011 contraband surveillance watch after officea observed the inmate place multiple U1llmOWl1 objects into his mouth and swallow them during a visit While under COII.Stant observation, the inmate retrieved andre-ingested the suspected drugs. On. March 8, 2017, the department transported the inmate to an outside b.ospital wb= the inmate remained 011 COll.trabend surveillance watch and refused treatmCllt The department obtailled a searcil warrant and pb.ysicialls induced multiple bawd movemellts whicil revealed seven bindles and Ol1C empty bindle of suspected drugs. All x-ray revealed additiOllal foreign objects. The inmate remailled at the hospital and two additional bindles of suspected drugs were recovered. The departm.Cllt returned the inmate to the institution and removed him from contraband surveillance watch011 Marcb.9, 2017, four days after placement. During that time, the departmCllt reoovered heroin from the inmate. Incident Aneltment SuffiCient Overall, the department JU.fticienlly complied with policies and procedun:t aovemill& COlllraband surveillance watcil. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 118 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-16 2017-04-19 I. Drop !.Drop 2. Inmate Note Incident Summary 17-155211-CW On. Aprill6, 2017, the department placed an inmate on COlllrabandsurveillance watch because a bodyscanshowro an object in the inmate's anal cavity and ase!Jeantrecovemi a bindle of methamphetamine and inmate notes from the inmate's mouth. Thedcparlmentremovedtheinmate fromCOlllrabandsurveillance watchonAprill9, 2017, three days later. During that time, the department recovemi no additional contraband from the inmate. Incident Atleltment lntuftident The department did not IIU.fficlcnlly comply with policies andp rocedura aoverninl conlraband IUrVeillance watch. The department reWned the inmate on COIIlrlband surveillance watdllonaer than justified and did not consistemly provide the inmate with ranac of motion opportullities, band hyJienc, or CCDh1ct required mcdical ~cnll. The hirina anthority provided trainina to a captain, =-' 1iculcrwds, seracantJ, and officcrJ to address the ddicicncies. The hirina authority decided not to take ICiion in reaponsc to the failll!CI, dccmina it an iuuoc fOl' seracants and officcrJ. A1tenment Queltiont o Did the department comply with polldes aDd procedures governing hygiene requirements? OjJicus dJd not conslstmtly] PfiVIth the lnmau with hygleM (1J1JK1l1lmJJUJ qfW PVtroom use and /Jq<m m~. o Did the department cODduct reqWred medicalueessments? Nursu dJdnotcompku~m~ assusments. o Did the department comply with polldes aDd procedures governing the Inmate's removal from CSW'l 171<! thpartmentdldnotassus tu lnmaulllllll qfW thefOIII'th bowei~~U~Ve~~~ent lnstMd ofq fW the thllrl bowel movement (l!Jpo/Jcy fUJIIb'u. o Overall, did the department subltantlally comply with CSW policies aDd procedures? 171<! thpartmem did not timely anus the lnmau qfW bowel movements, causing the 11f1Ntlte to be em <XIII/1'oband swwllltma watch one day longer than MCUsary. Ojjlcers did not conslsumly ]PfiVIde the lmnau with range ofm otion opportunltlu or hand hygi4M, and 71W'SU negkcUJ to =rducJ ~d medlc41 assusme7Jis. o Did the OIG Identify a policy violation or lnue that raulted In, or should have resulted In, COJTectlve action, Including training? 171<! OIG ldmJVUd that the thpartiMnl retained the lnmau em CQII/:rrlband swwllltma Wlltch longer than reasonably MCUSa1'Jf. 171<! hiring autlwrlty] P'OVkUd training to the Involved captllbr, /Uutmants, sugeants, and of]lcus to addrus removal crlWitl. o Did the hiring authority Identify a policy vloladOD or laue aDd take corrective action, Including training? 171<! hiring authority ldmtljlM that ojJicus dJd not athqu.mly compkte ~d doCIIIMIItatlem and] P'OVkUd training to sugeants and officers. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 119 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-23 2017-04-26 I. Suspicioua Activity I.Drup Incident Summary 17-15537-cw On. April23, 2017, the department placed an inmate on contraband surveillance watch after officers obterved an unlmowll. object fall from the inmatca rectal area durin& an an unclothed body search. The depsrtmentremoved the inmate fromcontrabandsurveillancewatchonApril26, 2017, three days later. Durin& that time, the deparlmentrccovemino additional contraband from the inmate. Incident Anelllllent lntuflident The department did not su.fticiell!ly comply witlt policicl and procechua aoveminll COIIlraband llln'eillance watch. The department did not apply ratraints, complete rcquiled docwnc:nlation, or provide the imnate witlt proper hYJicne. The department updated its local policicl and procedura, and the birin& authority provided trainin& to eddras the ddiciencicl. Attenment Quettiont o Did the department comply with polldes aDd procedures when the Inmate wu placed OD CSW? '11u d4partmem did Mt dcctliMIIt pltlcJng 1M tmnata on conuaband survelllanc4 lWltcll. o Did application of restraints comply with CSW policies aDd procedures? '11u d4partmemdld1Wtapplyrutralnts. o Did the department comply with polldes aDd procedures governing hygiene requirements? OjJicus did Mt ]P'Ovlde 1M IR/tlaU wUh proper hand hygieM or trrJsh mnovaL o Did the department complete appropriate documentation? OjJicus did Mt dccumentappllc4tWn ofrutralnts, that tha brmau ~d1W/IlbWlm«<Jctd assusmmts, 1M brmate's actlv#Usfor 1M duradon ofcontraballdsU1Willance Wtltch, or pltlcJng 1M brmate on conuaband SU1Willmra lWltcll. o Overall, did the department subltantlally comply with CSW policies aDd procedures? 11u d4partmem did Mt alhquauJy dccumem the mcldml. o Did the OIG Identify a policy violation or lasue that resulted In, or should have resulted In, corrective action, lnduding training? '11u hiring authority updated Its local opuYJiillg~ to mcbuk dccumentatton requll'ements and expectations. '11u hiring authority also ]P'Ovlded training to 1M cltUft kputy wanlm, associate Wtlfrklrs, ctl]Jtabls, lteutenants, sergeants, and offlcus. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 120 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-30 2017-05~ I. Drop I. Drop Incident Summary 17-15539-CWRM On. April30, 2017, the department placed an inmate on contraband surveillance watch after officers obterved U1llmowll. objects being transferred between the inmate arui his visitor durin& a kias. On. May 3, 2017, the deparlmem transported the inmate to an outside hospital, where the inmate remained on contraband surveillance watch, arui obtained a search. warrant. Physicians induced multiple bowel movements, arui the department recovered bindles containing methamphetamine, marijuana, arui hemin. On. May 4, 2017, after an imaging l4'8n shoMd no oontraband, the deparlme1lt raumed the inmate to the institution arui removed him from contraband surveillance watch, four days afterplacemenl. Incident Atleltment lntuftident The department did not sWficicnlly comply with policies arui procedura governina conlraband JurveillaDce watch. The department did not notify the oro of the inmate'• removal from coalraband aurveillallcc watch Ot" complete adequate documentation. The hirin& authority provided trainina to add-. the deficiencies. Attenment Questiont o Did the department complete appropriate documentation? OjJicus dJd Mt documentp rovldJng the Inmate with IIYUh removal and hilnd hyglme during two shUts. o Did the department comply with polldesaDd procedures governing the Inmate's removal from CSW? '11u Upartment did Mt Mti/Y the OIG when removing the tmMu from oontral>and sUIWJllance watch. o Overall, did the department subltantlally comply with CSW polleles aDd procedures? '11u UpartmentdldMtMti/Y the OIGwhen removillg the tmMufrom oontral>andsUIWJllance watch orcompkte atkqtuUe doclliMIIIIlJJot1. o Did the OIG Identify a polley violation or bsue that raulted In, or should have resulted In, corrective action, Including training? '11u Upartment did Mt Mti/Y the OIG when removing the tmMu from oontral>and sUIWJllance watch. '11u hJrlng autlwrlty provided training to the IUulmanJ. o Did the hiring authority Identify a polley violation or blUe aDd take corrective action, Including training? '11u Upartment I~ thilJ o.f!lcus dJd Mt compkte atkquate docummtatlon. '11u hJrlng authilriJyprovlded training to o.f!lars and s~nts. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-05~ 2017-05-09 I. Suspicio111 Activity !.Nothing Incident Summary 17-15542-CWRM On. May 4, 2017, the department placed an inmate onoomraband surveillance watch after the inmate refused to submit to a metal detector ami body search. The department removed the inmate from contrabarui surveillance watehon May 9, 2017, five days later. During that time, the deparlme1lt reoovered no comraband from the inmate. Incident Alleltment lntuffiCient The department did not IIWflciCIIlly comply with policies andp rocedura aovernitt& conlraband aurveillaDce watch. The department did not cooaiJtenlly provide the inmate proper hand h)'liene, coruhlct cell U!Jpections, reatramt checb, and required searches, Ol" document required medical UJesllmCI!II. The depertment provided tramma to eddreu the deficicndeJ Attenment Questiont o Did the department comply with polldesaDd procedures governing hygiene requirements? OjJicus dJd Mt conslsUIIt/y afford the tmMu the opp011u/11Jy to wash his lrmrtls prior to lll&lls and aftu using the rutiOom. o Did the department complete appropriate documentation? '11u o.f!lcus dJd Mt conslst611t/y document the tmMu rudved required medical asst~SSme~~ts. o Overall, did the department subltantlally comply with CSW polleles aDd procedures? '11u Upartment did Mt constsUIItly ]P"(1Vkk the lnmau proper hand h)IKI4M. constsUIItly conduct restraint checks, ulllnspecJions, and required searchu, or cO"NIIsUntly docUIMIII medical assusments. o Did the hiring authority Identify a polley violation or blUe aDd take corrective action, Including training? '11u hJrlng authorUyp fOVItkd tralllillg to Involved serg-and o.f!lcus to adtlre.u the tk~. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 121 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA North Date PIKed on Contraband Wateh Date Taken off Contraband Watdl Reaton for Placement Contrmand Found 2016-11-30 2016-12-02 I. Suspicious Activity !.Drugs 2.0ther Incident Summary 16-15443-CW On. November 30, 2016, the department placed an inmate on contraband surveillance watch after an officer observed a clear lubricsnt around the inmate's anal cavity durin& an unclothed body search. On. December 1, 20 16, officers discovered thtee pieces ofb roken latex in the inmate's bowel movement arui requested a medical evaluation. The department transported the inmate to an outside hospital after a lllllSC determined the inmate needed a higher level of can:. The inmate returned to the institution the folio win& day arui remained on contrabarui surveillance watch until December 2, 2016. During that time, the department recovered synthetic cannabinoid from the inm.ste. Incident Anetltment lntuflldent The department did not IIU.fliciently comply with policies andp roccdiua aovernina COt1lraband ~UrYeillance Wltclt. The department did not adequately notify the oro when transfenin& the inmate to an Ol1tside bolpital. The hirina authority provided trliniDa to administrative ofli<>cn of the day to addraa this dcficiency arui provided trliniDa to ofliccn to emw e that required docume!!lation is completed. Atsenment Queltiont • Did application of restraints eomply with CSW polldes and procedures? OjJicgs dJd not ]1IYJVItk ~ l"lfmtlU with range ofl tWtlon OIIC<I out off our requlrwi tlmu. a Did the departmeut comply with polldes and procedures governing hygleue requiremeuts? OjJicgs dJd not ]1IYJVItk ~ l"lfmtlU with lumd hygUM OIIC~ out off our NJu/r&i tlmu. a Did the departmeut complete appropriate doeumeutatlon? OjJicgs dJd not document pmvldlng the Inmate with range ofm otion OM time, hlmd lrygleM OM time, ullllrspecJimrs, n.stiYlllrt cMds, altd 15 -mlnute cMcks. a Overall, did the department subltantlally comply with CSW polleles and procedures? 'l7u Upartment did not notifY til~ OIG when the tkpartment trrmsferrwl ~ Inmate to an outsltk lrospltol wlrlk on ccmJraband survellltma watch. a Did the OIG ldeutlfy a polley violation or l11ue that raulted In, or should have resulted In, corrective action, Including training? 'l7u UpartmentdldnotnotlfY the OIGwhen trtw~femng ~Inmate to an outslddospllal 'l7u tkpartmentpmvltkd training to admJI!Jst~YJJ~u offlcus of~ day to et1Sl11'6proper notVJcatlon 18 matk to ~ OIG when ~ tkpar-transfers an Inmate to an outsld~ lrospllal a Did the hiring authority ldeutlfy a polley vloladon or laue and take eom:edve action, Including training? 'l7u Upartmentprovltkd trallling to offlcus to SMII'6 th4t required documentlltlon 18 compld&i. Date PIKed on Contraband Wateh Date Taken off Contraband Watdl Reaton for Placement Contrmand Found 2016-12-13 2016-12-17 I. Mobile Phone I. Mobile Phone 2.0ther Incident Summary 16-15454-CWRM On. December 13,2016, the department placed an inmate on contraband surveillance watch after a metal detector indicated the presence ofm etal inside the inm.ste. The department removed the inmate fromcontrabandsurveillancewatchonDecember 17,2016, four days lsterafterrccovering a mobile phone, a phone adapter, andacbargins csblefrom the inmate. Incident Anetltment Suflldent Overall, the deparlmentiiU.flicientlycomplied with policies llldproccchua aovemin& contrabiDd•urveillaDcewatch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 122 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2016-12-24 2016-12-28 I. Suspicioua Activity I. Nothin& Incident Summary 16-15460-CWRM On. December24, 2016, the department placed an inmate on eotttrabarui surveillance watch. after an officer observed the inmate swallow an U1lknowl1 object. The department removed the inmate from contraband surveillance watch. on December 28, 20 16, four days later. During that time, the department recovered no contrabarui from the inmate. Incident Aneltment Suflident Overall, the dc:partmcntaW!icienllycomplied with policies andproccchua aovemin& contrabandaurveillance watch. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-01~ 2017-01-14 I. Drup I.Nothing Incident Summary 17-15466-CWRM On. January 9, 2017, the department placed an inmate on contrabaruisurveillance watch after an officer observed the inmate swallow a bindle containing a white substance during a clothed body search. The department removed the inmate from contraband surveillance watch. on January 14, 2017, five days later. During that time, the department recovered 110 contrabarui from the inmate. Incident Aneltment SuffiCient The department •llfrtcicntly complied with policies and proccchua aovemin& contrabarui Jurveillancc watch.. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-02-08 2017-02-15 I. Suspicioua Activity I. WCIJ!IODI 2.Drup 3. Inmate Note Incident Summary 17-15484-CWRM On. February 8, 2017, the department placed an inmate on contrabarui surveillance watch after officers observed him swallow a suspected drug bindle during a cell search. The department removed the inmate from eotttrabarui surveillance watch. on February 15,2017, seven days later. During that time, the department recovered a mapon, methatnpbctlmine, arui inmate notes from the inmate. Incident Aneltment Suflident Overall, the dc:partmcnt aW!icienlly complied with policies and proccchua aovemin& contraband surveillance watch. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-02-14 2017-02-16 I. Drup I. Nothing Incident Summary 17-15491-CW On. February 14, 2017, the department placed an inmate on contraband surveillance after officers observed the inmate havina convulsions. Officers trlnsported the inmate to the triage arui treatment area where the inmate admitted ingesting five bindles of methatnphetlmine. The department trlnsported the inmate to an outside hospitd where the inmate remained on contrabarui surveillance watch. The department removed the inmate fromcontrabaruisurveillancewatcb.onFebruary 16,2017, two days after placement, arui the inmate retumedfromtheoutlide hospitd on February 17, 2017. Durin& that time, the department recovered no contrabarui from the inmate. Incident Aneltment Suflident Overall, the dc:partmcnt aW!icienlly complied with policies and proccchua aovc:mina contraband aurvcillance watch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 123 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-m.-22 2017-02-25 I. Suspicioua Activity I. Mobile Pbotl.e 2.Drup Incident Summary 17-15495-CWRM On. February22, 2017, the department placed an inmate 011 contraband surveillance watch becauae a metal detector indicated !be presence of metal inside the inmate. The department removed the inmate fromcontrabandsurveillancewatch011February2S, 2017, three dsyslater. During that time, thedepartmentrecoveredmarijuanaandamobilepbone from the inmate. Incident Ane11111ent Suflident Overall, the department sufficienlly complied with policiea and procedura aovcmin& contraband surveillance ftiCb. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-03-03 2017-03-06 I. Suspicioua Activity I. Nothing Incident Summary 17-15502-CWRM On. March 3, 2017, the department placed an inmate 011 contraband surveillance watch after he made a apontaneoua statement to the "'gist=di!Ul'IC stating that he wu experiencing abdominal pains becauae he had se=ted contraband in his rectum. The department ~ved the inmate from contraband surveillance watch 011 March 6, 2017, three dsyslater. During thst time, the department recovered no COll.traband from the inmate. Incident Ane11111ent SuffiCient Overall, the departmentsufficienllycomplicd withpoliciea andprocedura aovcmin& contrabandsurveillanceftleb. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-03-16 2017-03-19 I. Mobile Pbotl.e I. Mobile Pbotl.e 2.0ther Incident Summary 17-15512-CWRM On. March 16, 20 17, the department placed an inmate 011 contraband surveillance becauae a metal detector indicated the presence of metal inside tbe inmate. The department removed the inmate fromcontrabandaurveillancewatch011Manm 19,2017, three dsyslater. During that time, the departmentrecoveredamobilepbooeandapbone cbargerfrom the inmate. Incident Ane11111ent Suffident Overall, the departmentsufficienllycomplicd with policies andprocedura aovcmin& contraband surveillance ftiCb. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-03-17 2017-03-23 I. Suspicioua Activity I. Inmate Note Incident Summary 17-1551~WRM On. March 17, 20 17, the department placed an inmate 011 contraband surveillance watch after an officer observed l11bricati011 around the inmate's rectum and a low dose body scan shoM:d a foreign object in the inmate's pelvic region. The department removed the inmate from COll.traband surveillanoe watch 011 March 23, 20 17, six dsyslater. During that time, the department recovered inmate notes from the inmate. Incident Anelllllent Sufficient Overall, the department sufficienlly complied with policies and procedura aovcmin& contraband surveillaDce ftiCb. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 124 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-20 2017-04-25 I. Suspicioua Activity I. Inmate Note Incident Summary 17-1553~~ On. April20, 2017, the department placed an inmate on contraband surveillance watch after a low dose body scan revealed an object in his abdomen. The department removed the inmate from contraband surveillance watch on April25, 2017, five days later. During that time, the department recovered inmate notes from the inmate. Incident Aneltment Intuflident The department did not JW!icienlly comply with policies and procedures governina COt1lrlband surveillance watch. Officers placed the inmate in leg rcatrlint. without autboriutioo. The birin& aulborityprovidcd trainin& to addra• the ddk:iency. Attenment Quettiont • Did applleatlon ofratralntl eomply with CSW polldel and procedura? OjJicgs plilc" the Inmate In kg rui1Yiims f(17 13 /wu17 wlllwut autlwrtzatWn. o Overall, did the department •ubltantlally comply with CSW pollela and pmeedura? OjJicgs plilc" the Inmate In kg rui1Yiims wWwut autlwrlzaJJon. a Did the hiring authority Identify a polley vloladou or laue and take eom:edve aetiOD, lndudlng training? '171<! hiring autiu>rUy ldentJjled that offlcusp lae«ll~ rui1Yiims 011 the Inmate without authorization and pfrJllltkd trallllllg to tu ojJicus. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-22 2017-04-26 I. Suspicioua Activity I. Drugs Incident Summary 17-15535-C~ On. April22, 2017, the department placed an inmate on contraband surveillance watch after officers observed lubricant in the inmate's rectal area during an undothed body acarch. The department removed the inmate from contraband surveillance watch on April26, 2017, four days later. During that time, the department recovered two bindle. of amphetamine and opiatca from the inmate. Incident Aneltment SuffiCient Overall, the departmentJWlicienllycomplied withpolicia andproocchua aovcmin& conttabandaurveillanccwatch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 125 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~~1 2017-05~8 I. Suspicioua Activity I. Other Incident Summary 17-15541..CWRM On. May 1, 2017, the dcpartmetl.tplacedaninmate oncomraband surveillance watch after officers observed the inmate place U1llmown objects into his rectal area. The dcpartmetl.tmnoved the inmate from contraband surveillance watch on May 8, 2017, seven days later. Durin& thst time, the dcpartmet1t recovemi a label from a mobilo-phone data card from the imnate. Incident Aneltment Intuflident The department did not JW!iciently comply with policies and procedures aovemina COt1lrlband surveillancc watch. The department did not coaaiatenl1y provide the inmate the opportUnity for band bypenc, coaduct inmate welfare cbeckl, or complete edequate documentation. The department provided training to eddreu the deflciencies. Attenment Quettiont • Did the department comply with polldes aDd procedures govendng hygiene requirements? OjJicgs dJd not ]1IYJVItk ~ l"lfmtlU htmd lrygUM oppornmlly /J4(11'e meals on 8 of~ requ/1wl21 ttma. a Did the department complete appropriate documentation? OjJicgs dJd not document providing the Inmate htmd lrygUM OJIIX1'tulUty /J4(11'e meals on 8 of~ requ/1wl21 tlmu. Sugeams dJd not documellt rollliuctbrg lllmllte weif(l1'8 cJruks on 5 of ~ requ/1wl21 ttma. o Overall, did the department aubltantlally comply with CSW polleles aDd procedures? OjJicgs dJd not ]1IYJVItk ~ l"lfmtlU adequate oppornmllyf or htmd lryglme (llld dJd not document ~ lssualrce (llld removal ofa mattn.ss (llld blallket on one occaslo11. Sugeants dJd not COIIducJ Inmate welf-cJruks on 5 of~ requ/1wl21 times. • Did the hiring authority Identify a policy violation or luue aDd take corrective aetiOD, IDdudlng traln!Dg? '11u hlrlllg authority I~ that ojJiars dJd not document l1rmllte lryglma, trash removal, (llld ~ ls.nul~JU and removal ofa mattn.ss (llld blank& AddiJkmally, spgeallts did not C(JIIducJ requ/1wllllmllte welt-~. '11u hlrlllg authorlty]11YJV1tkd training to~ brvolV«llkutmtmts, s~allts, (llld ojJicers. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~.00 2017-05-14 I. Drop I. Drop Incident Summary 17-15549-CWRM On. May 9, 2017, the dcpartmetl.tplacedaninmate oncomraband surveillance watch after officers discovemi heroin during a cell seazch. Officers attempted to conduct an unclothed body search. but the inmate refused to lift his tongue and was observed swallowing. The inmate remained on contraband surveillance watch until May 14,2017, five days later. During thst time, the department recovered additional heroin from the inmate. Incident Aneltment The department suffiCiently complied with policies and procedures 110vcmin& contraband IUlVeillance watch. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~-10 2017~-11 I. Drop I. Drop Incident Summary 17-15552..CW Oll.May4, 2017, the dcpartmetl.ttraluportedaninmate to an outside hospital after the inmate admitted to an officer swallowing two bindlesofmethamphetlmine. Oil. May 10,2017, the department placed the inmate on contraband surveillance watch while at the outside hospital after an x-ray confirmed the presence of a foreign object. The department removed the inmate from contraband surveillance watch and l\ltumed the inmate to the institution on May II, 2017, one day later. During that time, the department recovemi two bindles of suapected methampbetsmine from the inmate. Incident Aneltment Suff"acient Overall, the departmentJWlicientlycomplied with policies andproocchlres govemin& contrabaDdaurveillancewatcb. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 126 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~-24 2017-05-29 I. Suspicioua Activity I. Inmate Note Incident Summary 17-15560-CWRM On. May 24,2017, the department placed an inmate oocontrabarui surveillance watch after the inmate failed to pall a metal detector. The department removed the inmate from contrablftd surveillance watch 011 May 29, 2017, five days later. Durin& that time, the department recovered inmate notes from the inmate. Incident Aneltment Suflident Overall, the dc:partmcntaW!icienllycomplied withpoliciea lftdproccchua aovemin& contrabandaurveillance watch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 127 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA South Date PIKed Oil Contraband Wateh Date Taken off Contraband Watdl Reaton for Placement Contraband Found 2016-11-18 2016-11-22 I. Drugs !.Drugs Incident Summary 16-15433-CWRM On. November 17,2016, aninmaterepcrtedswallowin& heroinaruihavin& chcstpsins. The depsrtmcattransported the inmate to anoutaide hospital. On. November 18,2016, an x-ray revealed a foreigt1 object in the inmate's abdomen arui the department placed the imnate 011 contraband surveillance watch.. The inmate returned to the inltitnti011 011 November 21, 2016, arui the depsrtmcat removed him from contraband surveillance watch. 011 November 22, 2016. Durin& that time, the depsrtmcat recovered methamphetamine from the inmate. Incident Aneltment SuffiCient Overall, the department sufticieatly complied with policiea a11d procedura aovcmin& coatnlbaad swveillaDcc ftiCb. Date PIKed Oil Contraband Wateh Date Taken off Contraband Watdl Reaton for Placement Contraband Found 2016-11-26 2016-IUll I. Drugs I. Nothin& Incident Summary 16-15437-CWRM On. November 26, 2016, the department placed an inmate 011 contraband surveillance watch. after an officer observed the inmate with lubricant around rn. anal cavity during an unclothed body search. The department removed the inmate from COll.trabarui surveillance watch. 011December I, 2016, five days later. During that time, the department recovered no contraband from the inmate. Incident Aneltment lntuffident The depsrtmcat did not suftlcicntly comply with policies and~ aovcmin& contraband surveillance watch.. Officers did Dot adequately provide or docwncat hand hyJicnc. The hirin& aulhorityprovidcd trainina a11d iuucda mcmoramlam to all Cllltody staff to addzal the ddicicllcics. A1senment Queltiont o Did the department comply with polldes aDd procedures governing hygiene requirements? OjJicus provltkd 1M l1rmaU wWI hand hygi4Mprlor to meals (11'qftuuslng 1M rutroom 10 ofiM l77WJU/Iwl tbMs. • Did the department complete appropriate documentation? OjJicus dJd not alhquauly docummt hand hyglm& o Overall, did the department substantially comply with CSW polleles aDd procedures? OjJicus dJd not alhquaulyp rovld~ hand lryg~u~L o Did the hiring authority Identify a policy violation or !Jeue aDd take corrective action, lndudlng training? 11u! hiring autlwrltyp rovkkd training to Ueutmants and serg«m~s and l.uu4d a ~lldum to aU custody stqffr egarding documenltllkm -.quJremenu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 128 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2016-11-27 2016-12-03 I. Drop I. Nothin& Incident Summary 16-15439-CWRM On. November 27, 2016, the department placed an inmate on contrabarui surveillance watch after an officer observed the inmate with lubricam around his aMI cavity durin& an unclothed body sesrch. The department removed the inmate from contraband surveillance watch on December 3, 2016, six dsys later. Durin& thst time, the department recovered no contrabarui from the inmate. Incident Aneltment Intuflident The department did 11.ot JU.fficiently comply with policies and procedures aovemina COIIlrlband IUrYeillancc watch. Officers did t10t adequately provide or document range of motion rdeaJQ or band bypelle. The hirin& au!borityprovided trainill& and iuued a mc:m018lldum to all Cllatody •taff to addzeu the ddk:ienda. Attenment Quettiont • Did application ofrelltralntl eomply with CSW pollda and procedure~? OjJicgs J1'(IVItkd 1M l1rmaU wiJh range ofM(J/Wn rekasu 9oft~ l11WJU/Nl limes and dJd 710t document 1M duratkm oftlle rekasef0111' limes. • Did the departmmt comply with pollda and procedure~ governing hyglme requiremmts? OjJicgs J1'(IVItkd 1M l1rmaU wiJh hand hygieM /J401e m«lls or qfW using 1M restroom 17 of1 M 281WJU~nd limes. a Did the departmmt complete appropriate doeummtatlon? OjJicgs dJd 710t atkqualely document hmld hygiene or range of1 n(JtW7I reW/su. • Overall, did the department subltantlally comply with CSW polleles and procedure~? OjJicgs dJd 710t atkqualely] Pm'lde range of1 n(JtW7I or hand hyglm& • Did the hiring authority ldmtlfy a polley vloladou or laue and take eom:edve aetiOD, lndudlng training? 'l7u hiring authorityp rovkhd training to Ueu~mtm~s and serg«m~s and lsswd a IMifl()rQifllum to all custody stqffr egarding requlrmlmts for hyglme and range of1 n(JtW7I rehasu. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2016-12-12 2016-12-16 I. Drop I. Nothing Incident Summary 16-15453-CWRM On. December 12, 2016, the department placed an inmate on contrabarui surveillance watch after the inmate told a nuae that he swallowed a bindle oontaining possible nan>otics and had stomach paills. The department removed the inmate fromcontrabandsurveillancewatchollDecember 16,2016, fourdsys later. During thst time, the department recovered no contraband from the inmate. Incident Aneltment SuffiCient Overall, the departmelltJU.ffieientlycomplied with policies andprooechlrct aovemina contraband•urveillancewateh. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2016-12-18 2016-12-24 I. Drop !.Drop Incident Summary 16-15457-CWRM On. December 18,2016, the department placed an inmate on contrabarui surveillance watch after officers saw the inmate swallow suspected drug bindlCI during visiting. The department removed the inmate from contraband surveillance watch on December 24, 2016, six dsys later after recovering marijuana from the inmate. Incident Aneltment Suflldent Overall, the departmellt JU.ffieiently complied with policia and prooechlrct aovemia& contraband surveillance watch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 129 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2016-12-31 2017-01~ I. Drop I. Nothin& Incident Summary 16-15462..CWRM On. December31, 2016, the department placed an inmate on eotttrabarui surveillance watch. after an officer observed the inmate reach into his pa1lta, place something in his mouth, and swallow. The department removed the inmate from contraband surveillance watch. on J81U18l)' 4, 2017, four days later. During that time, the department recovered no contraband from the inmate. Incident Aneltment Suflident Overall, the dc:partmcntaW!icienllycomplied with policies andproccchua JOYemin& contrabandaurveillance watch. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-01-01 2017-01-10 I. Drop I. Drop Incident Summary 17-15463..CWRM On. 181Ul8l)' I, 20 17, the department placed an inmate on contraband surveillance watch becauae an officer saw the inmate swallow an unknown item from a bag during vWting. The department removed the inmate from contraband surveillance watch. on J81U18l)' 10,2017, nine days later. During that time, the department recovered heroin from the inmate. IntuffiCient The department did not IW!icienlly comply with policies and proccdura governina contraband JlllYeillaDce watch.. Officers did Dot COilliJten.dyprovidc ranae of motion rdeue• Ol" band hypenc and did Dot complete adequate documentation. The hirin& authority provided trainina to addras the dcflcierlcies. A11enment Quettiont o Did appUcatlon ofreatrainb comply with CSW polldea and proeedurea? OjJ/cus dJd Mt C(111Sis1Mt/y plm'ltk range ofmotkm rmasu. o Did the department comply with polldes and procedurea governing hygiene requirement.? OjJicus dJd Mt C(111Sistm/ly plm'ltk the Inmate tlu op]K111u1Uty to wash his htmtb qfW using the rutroom and bqore m«lls. o Did the department complete appropriate documentation? OjJicus dJd Mt alhquatdy docummt the ruu/1.!1 ofb<~Wd movements, hand lryglme, "IYlfJge ofmotkJII, or blankd Issuance and removal. o Overall, did the department aubatantlally comply with CSW polleles and procedurea? OjJ/cus dJd Mt C(111Sis1Mt/y plm'ltk range ofmotkm rmasu or hand hygleM and dtdMtcompkU a.hquate docUIMIItaJJon. o Did the hiring authority Identify a policy violation or '-ue and take corrective action, lndudlng training? '11u hiring authorityp rovilkd training to o.f!lcgs regarding lryglme, "IYlfJge ofm otkm, b<IWd movement ruu/1.!1, and bltmka lnutmu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 130 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~1-22 2017-01-25 I. Drop I. Drop Incident Summary 17-15472..CWRM On. J811ll8lY 22, 2017, the department placed an inmate on contraband surveillance watch after an officer discovered the inmate with a bq containin& 17 bindles of suspected drup. The inmate later complained of stomach. pain, and the departmellt transported him to an outaidc hospital, where the inmate remained on contraband surveillance watch. On. J811ll8lY 25, 2017, the inmate returned to the institution, and the department removed him from contraband surveillance watch. During that time, the department recovered heroin and methamphetamine from the inmate. Incident Anelllllent Intuflident The department did not IU.fliciently comply with policies andp rocechua aoveming COIIlraband 111rYc:i111mle watch. Officers did not adequately provide or document hYJiene or range of motion. The department provided tramin& to addreu the deficiencies. A11enment Quettiont • Did appUeatlon of restraints comply with CSW pollelea and procedures? OjJicus JIIY>Vitkd 1M l1rmaU wiJh range ofm otum releases only four of1 M 1W/Ul1Wl seven llmu. • Did the department comply with polldeaaDd procedures governing hygiene requirements? OjJicus JIIY>Vitkd 1M l1rmaU wiJh hand hyg14M /J4018 m«lls or qfW using 1M rutroom 35 ofiM 1W/Ul1Wl 53 llmu. • Did the department complete appropriate documentation? OjJicus dJd Ml atkquauly tloclmwlt ra~~gs ofm otJ011 or hmld hyglelu. • Overall, did the department subltantlally comply with CSW policies aDd procedures? OjJicus dJd Ml atkquauly] Pm'lde range ofm oiJOII or hand hyglm& • Did the hiring authority Identify a policy violation or Issue aDd take corrective action, Including training? '11Je hiring aut/wrltyp rovided training to ojficus 18gard/ng range ofm oiJOII Olld Inmate hygieM Olld provlthd training to a sergeantf or Ml oommulllcalblg 1M status of1 M l1rmaU to 1M watch CQMIIIO/IdQ during 011e shUt. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~1-28 2017-~ I. Suspicious Activity !.Nothing Incident Summary 17-1547~WRM On. J811ll8lY 28, 2017, the department placed an inmate on contraband surveillance watch after the inmate told officers he swallowed razor blades, and an l<-ray at an outaidc hospital revesled a foreign object in the inmate's abdomen. On. J811ll8lY 29, 2017, the inmate returned to the institution and remained on contraband surveillance watch. On. Febnwy 2, 2017, the department transported the inmate to an outaidc hospital and removed the inmate from contraband surveillance watch after a negative l<-ray. The department recovered no contraband from the inmate. Incident Anelllllent Sufficient Overall, the departmcntsu.flicientlycomplicd with policies andprocechua aovemin& contrabandaurveillance watch. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 131 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-m-o5 2017-02-10 I. Drop I. Drop Incident Summary 17-15481..CWRM On. February 5, 2017, the department placed an inmate on contraband surveillance watch after officers discovemi biDdies of druas in a bq from which the inmate was eatinJ in the visiting room. On. February7, 2017, the department transported the inmate to an outside hoapital, where the inmate remained on contraband surveillance watch, after the inmate complained of stomach pain. The department returned the inmate to the m.titutiononFebruary9, 2017, and removed the inmate from contraband surveillance watch on February 10,2017. During that time, the departmentrecovemi marijuana from the inmate. Incident Atleltment lntuftident The department did not su.flicicnlly comply with policies and procedures 1!CJYCr11in1 conlraband IUrVeillaDce watch. Officers did not consiJtendyprovide range of motioo or band hYJlicnc, remove tnllh, or iasuc a blanket, and did not complete lldcquate docwncnlatiorL The hirina authority provided trlinina to llddreas the dcficicndes. Astenment Questiont o Did application of restraints eomply with CSW polldcs and procedures? OjJicus J1'(IVItkd 1M l1rmaU wWI range ofm<>tum rekasu cmly six of/M ~1m tlmu. o Did the department comply with polldes and procedures governing hygiene requirements? OjJicus J1'(IVItkd 1M l1rmaU wWI hand hyg14M b4ore m«lls or qfW Wl/ng 1M rutroom Ollly 24 of/M reqmred 391/mu. o Did the department complete appropriate documentation? OjJicus dJd Ml atkquau/y documellt hmld hygleM, ra~~ge ofm <>IIOII, 11Yi!Jh rem<>val, or blmlkd lsSU~~~~Ce. o Overall, did the department subltantlally comply with CSW policies and procedures? OjJicus dJd Ml con.rlstmtly] PfiVIth range ofm<>IIM ~u or hand hygleM, remove 11Yi!Jh, or luue and remove 1M llrmaU's blanket. o Did the hiring authority Identify a policy violation or lsaue and take corrective action, Including training? '11u hiring authorityp rovllkd training to se7geanls and offlcus regarding 1M reqmremenu for hand hygleM, range ofm <>llon, 11Yi!Jh removal, and blallka luutlna. Date Placed on Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-02-21 2017-02-24 I. Drop I. Drop Incident Summary 17-15492..CWRM On. February 21, 2017, the department placed an inmate oo contraband surveillance watch after officers found asubstance on the inmate's hands and buttocks during an undoth.ed body search. The department removed the inmate from COiltrabarui surveillance watch on February 24, 2017, three days later. During that time, the depsrtmentrecovemi three biDdies with an Ulllmownsubstance from the inmate. Incident Alleltment lntuftident The department did not JW!icicnlly comply with policies and procedures 1!CJYCr11in1 conlraband surveillaDce watch bccauac: the department did not timely DOtify the OIG when placina the inmate Oil contraband IUrVeillance watch. The department provided trlinina to a lieutenant to add.raa the late notification. Attenment Question• o Did the department timely notify the OIG Regional AOD when the Inmate wu placed on CSW? '11u dqartment did MIMIIjjt Ills OIG 111111ltwo Mill'S and Ull mlllutu qfWp lacing 1M l1rmaU 011 C<llllraband Slli'Vdllanu watch. o Overall, did the department aubltantlally comply with CSW policies and procedures? '11u dqartmentdidMIIIme/yllotljjt 1M OIG. o Did the hiring authority Identify a policy violation or lsaue and take corrective action, Including training? '11u hiring authorityp rovllkd training to a UaueMIII regarding Mll/kaiiM protocols. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 132 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-m.-24 2017-02-24 I. Drop I. Drop 2.0ther 3. Mobile Plume 4. Tobacco lnddent Summary 17-15496-CW OnFebruary23, 2017, oflioersdisoov=d tobacco, heroin, a mobile phone, a phone charger, mobile-phone data cards, and syringes during a cell seardt. The department transported the inmate to an outside hospital after a body ~Can revealed a foreign object in the inmate's abdomen. While at the outside hospital, the inmate voluntarily nilinquW!ed one bindle of tobacco. On February 24,2017, the department returned the inmate to the institution and placed the inmate on contraband surveillanee watch after an x-ray revealed an additional foreign object. While on contraband surveillanee watch, the department returned the inmate to the 011tside hospital, where a physician removed plastic material from the inmate. The department removed the inmate from contraband surveillance watch at the hospital and returned the inmate to the institution the SI1IIe day. The department reoov=d no additional contraband from the inmate. Intuftident The department did not au.fficicmly comply with policies andp l'OCCdures aovemina contraband surveillance watch. The department did not adcquatdy notifY the OIO. Officers applied lwld ilolation devices without proper authorization and did not corlliltadly provide the inmate with band hYJicnc or complete lldcquate documentation. The hirina authority provided trlinina to llddral ICXIlC of the dcficicndes. Astenment Quettion1 o Did the department timely notify the OIG Rcgloual AOD when the lmnate wu placed OD CSW? '171<! Upartment did Mt Mtljjt tile OIG 1111Ul tilru lraun aftup lacing the Inmate on COtltrabmrd SUIVdiklllu watch. o Did the department comply with polldes and procedures when the IIIDUlte wu placed OD CSW? OjJicus did Mt COflduct (Ill IIUtJaJ ltllciotiled body search. o Did appllcatiOD of Hand bolatiOD Devices comply with CSW policies and procedures? '171<! dqartmem plaad the lllmate 111 hand lsolatkm Uvlcu w/JiwuJ Jl'fJPU authortzatjOfl. o Did the department complete appropriate documentatiOD? OjJicus did Mt document an 1111t14lllllciotlled body s&UCll or aUquauly doc-hand hygUM or supervisory cMds. o Overall, did the department subltantlally comply with CSW policies and procedures? '171<! dqartmem did Mt timely notifY the OIG oft he placOMIIJ on COflt1Ylband ~ watch andf ailed to Mti/Y the OIG q/Ur transporting the Inmate to (Ill outsltk hospital. Ojjlcers plaad the 111mate 111 hand lsolatton dmcu wWwuJ autllorlzalkm and did Mt oonduct (Ill t~UtJal UIICWtiled body search, COfiSistmJly provltk 111maulrygime, or adequaUJy documem the illcldmt. o Did the OIG Identify a policy vlolatiOD .,..t. .u e that raulted ID,.,.. should have resulted ID, corrective actiOD, 1Ddudi111 traiDIDg? '171<! OIG ldmJJjUd ~ 111 hand hyglme and ~rvlsory cMds. o Did the hlriDg authority Identify a policy vloladon .,.. laue and take com:cdve actiOD, IDdudiJII traiDIJII? '171<! hirlltg authorityp fOllltkd trailllllg to an assodaU wanlmfor Mt obtailllllg authorizatkm from the wardm or chUfd eputy Wfll'dm prior top lacmg the 111mau 111 hand lsolatkm Uvlcu. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 133 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-00-19 2017-03-22 I. Drop !.Drop Incident Summary 17-15517..CWRM On. March 19, 20 17, the departmem placed an inmate 011 contraband surveillance watch after officers observed an U1llmown objectp rotrudina from the inmate's rectum durin& an Ullclothed body search. On. March 20,2017, the departmettt transported the inmate to an outside hospital after the inmate complained of abdominal pain. The depanmettt removed the inmate from contraband surveillance watch011Marcb.22, 2017, aruiretumed the inmate to the inatitnti011011March23, 2017. Durin& that time, thedepanmettt=overedmarijuanafrom the inmate. Incident Anelllllent Intuflident The dc:partmem did not su.ftlciell!ly comply with policies and procechua aoveminll COIIlraband lllrYeiUiuce watch. Of1'klcn did not adequately document the incidcat, arui the department did not timely inform oflicers of the decision to remove the inmate from COIIlraband surveiUiuce watch. The birin& authority pruvidcd training to eddreu the deficienciel. Attenment Quettiont • Did the department comply with policies aDd procedures governing hygiene requirements? OjJicus dJd not consl.rtmtly ]PfiVItk hand and rutraJnt lryglm& • Did the department complete appropriate documentation? OjJicus dJd not consl.rtmtly =npkte the 18qulml acJJviJy k>gqr adeqUIIU]y ~nt hand andrutraJnt lryglm& • Did the department comply with policies aDd procedures governing the Inmate's removal from CSW'l 171<! tkpartmentdldnot llljorm o.fllcus monltorllrg the Inmate at the outsltk haspltallllltll eJght hours after a captain autlu>rl:zed endblg the C(Jfltl"aballd SW'V6111mlu lWicJt. • Overall, did the department subltantlally comply with CSW policies aDd procedures? 171<! tkpartment 11Y11rsjJ<11Ud the lnmllte to an outside haspltal without notVjftng the OIGand dJdnot timely 111/orm o.fllcus oft he autlwrlzatkm to end C(Jfltl"aballd SW'V6111mlu lWicJt. O.fllcus dJd not adequately CQmpUte 1W/Ul"l8d ~ntatWn. • Did the hiring authority Identify a policy violation or luue aDd take corrective action, Including training? 171<! hiring autlwrltyp rovitkd tralntng to Ueutmants, sergeants, and ojJiars to addiVS the documentaiWn ~cJu and lack ofC Qmm1111JctdJon regarding the termtnatk>n ofo ontraband SW'V61Uana lWicJt. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-00-25 2017-03-25 I. Drop !.Drop Incident Summary 17-155111-CW On. March 25,2017, the departmem placed an inmate 011 contraband surveillance watch after officers observed the inmate retrieve an Ulllmownitemfrom his visitor and place it in his pants. The departmem removed the inmate from contraband surveillance watch the asme dsy arui =overed heroin and marijuana from the inmate. Incident Anelllllent Sufficient The dc:partmem sllff"ICienlly complied with policies and procechua govemin& contraband 1\llVdlla.nce WitCh. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 134 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-15 2017-04-15 I. Drop I. Other Incident Summary 17-15527-cw On. Apri115, 2017, the department placed an inmate on COlllraband surveillance watch after officers obterved an object concealed in the inmate's bllltocks durin& an Ullclotbed body search. The department removed the inmate from contraband surveillanee watch the same day, after recoverina a syringe from the inmate. Incident Aneltment Intuflident aovemma The department did n.ot JW!icienlly comply with policies and procedures coatraband surveillanee watch. The department did n.ot obtain proper IUtborization. for uaing hand iaolation. deYices, complete edcquatc docwnc:n.tation, or timely 1ape the inmate's jumplllit. The hiriD& aulborityproYidcd treinin.a to address the defJCienciel. Atsenment Quettiont • Did the department comply with poildesaDd procedures when the Inmate was placed OD CSW? OjJicgs dJd not tape ~ t1rmtlU ~ jumpsmt In a tbMiy mtmMI" qftu 8USJUC~tng ~ lnmllu possus" oontraband. a Did appllcatiOD ofHaDd bolatiOD Devices comply with CSW policies aud procedures? Neltlru ~ wardm 71(11' cJrJ4 dquty wardm aJ1P'"(W" the app/Jc4tWn ofh and lsolatWn tkvlcu. lMtead, ~ admlnlsi1Ylllve offlar of~ day I1J1lP"(1Wd app/Jc4tWn of~ tkvlcu. a Did the department complete appropriate documentatiOD? OjJicgs dJd not document tM tncJdent M all requiredf orms. a Overall, did the department subltantlally comply with CSW policies aDd procedures? 'l7u tkpartment did not atkquately notVY ~ OIG, o.f!lars dJd not tJmay tape ~ tlrmtlU's }umps!Ut, and ~ tkpartment fa&d to obtoln ]Pflper autlwrlzatkmfor using lwnd lsolatWn tkvlcu. a Did the hiring authority Identify a policy vloladon or laue aDd take com:cdve actiOD, IDduding training? 'l7u hiring autlwrltyp rovkhd training to an assoclate lWII"dm regarding ~ ]11fJper authorlzalkm for hand Isola tiM tkvlcu and to a sergeant and ojJiars regarding tM diMly app/Jc4tWn of tllpe and proper tlaCU1MIItatJon. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017-M-16 2017-04-18 I. Drop !.Drop Incident Summary 17-15526-CW On. Apri116, 2017, the department placed an inmate on COlllraband surveillance watch after officers obterved an inmate receive an Ullimown.item from his visitor while kissing. The department removedtheinmatefromcontrabandsurveillance watchonApri118, 2017, two days later. During that time, thedeparlmentrecovemimarijU81lafrom the inmate. Incident Aneltment SuffiCient Ovcnll, the depar!meat JW!icienlly complied with policiesll'd procedwa aovemia& COlllraband surveillance watch. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~~ 2017-05~ I. Suspicious Activity !.Drop 2. Inmate Note Incident Summary 17-15544-CWRM On. May 5, 2017, the deparlmen.tplacedaninmate on.oon.traband surveillance watch after the inmate refused to pass throlllh the low-ilose scann.erand a subsequent Ullclothed body search. revealed the inmate bad an enlarged rectum. On.May6, 2017, the department transported the inmate to an outside hospital after the inmatecomplainedofabdominalpainandn.susea. The inmatenltumed to the institution the same day, and the department removed the inmate from coatrabuldsurveillance watch on May9, 2017. During that time, the department recovemi two inmate n.otes and heroin from the inmate. Incident Aneltment Suflident Overall, the departmeatJW!icienllycomplied with policies ll'dprocedwa aovemin& coatrabuldaurveillancewatcb. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 135 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~~ 2017~-11 I. Drop I. Drop Incident Summary 17-1554~~ On. May 6, 2017, the dcpartmm.t placed an imnatc on contraband surveillancc watch after officers found bindles ofs uspected drup in a bag from which the imnatc was es.ting during a visit The department removed the imnatc from contraband surveillallce watch on May 11, 2017, five days later. During that time, the department recovered marijuana from the imnatc. Incident Aneltment Suflident Overall, the dc:partmcntaW!icienllycomplied withpoliciea lftdproccchua aovemin& contrabandaurveillance watch. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~-14 2017-05-16 I. Drop I. Drop Inddent Summary 17-15554-CW On. May 14,2017, the departmentp1aced animnatc on contraband surveil1allce watch after officers oblerved a visitor pus a bindle to the imnatc during a kW. The department tran.ported the imnatc to an outside hospital the same day for oblervation. On. May 16, 2017, the department removed the inmate from contraband surveillancc watch and returned the imnatc to the institution. During that time, the department recovered heroin from the imnatc. Incident Aneltment Sufficient Overall, the dc:partmcntaW!icienlly complied with policiea lftd proccchua aovemin& contrabandaurveillance watch. Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~-20 2017-05-22 I. Drop I. Drop Incident Summary 17-15558-CW On. May 20,2017, the department placed animnatc on contraband surveil1allce watch after officers discovered the imnatc's visitor with bindles of suspected dru&s and an x-ray revesleda foreign object in the inmate's abdominal area. The department tran.ported the inmate to an outside hospital and retnmed the imnatc to the institution the same day. The imnatc remained on contraband surveillallce watch until May 22, 2017. During that time, the department recovered marijuana from the imnatc. Incident Aneltment Insufficient The department did not aW!iciently comply with policies andp roccdiua perning contraband J\ll"Yc:i.11amlc watch. The department did not notifY the oro when tralllferring the inmate to an ou!lide bolpita1, and officcn did not adequately complete required forma. The birina aathorilyprovided training to of1icera to reprdina documentation requirement~. A1senment Queltiont • Did the department complete appropriate documentation? OjJicus dJd not tlwroughJy @cument l1rmaU acJMtJu on 1M MWf orm pertaining w U7fi"Utra1Md COIIUYlband su~ watch. a Overall, did the department aubatantlally comply with CSW pollela and procedurea? 171<! thpartment did not notifY the OIG whm trtlll!lfet'rlttg 1M illmllte w an outside hospital, and o.fllcut~ did not compktely @cument the Incident 0111"61jU/nd forms. a Did the hiring authority Identify a polley vloladon or laue and take com:cdve action, lndudlng training? 171<! hlrlllg autiJorlJyp fOllltkd training w ojJicutl regaMing @cumentaJJon requbl!ments. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 136 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Date Placed oo Contraband Watch Date Taken off Contraband Watch Reaton for Placement Contraband Found 2017~-28 2017-05-30 I. Drop I. Drop Incident Summary 17-15562..CW On. May 28, 2017, the departmellt placed an inmate 011 contrabarui surveillance watch after an x-ray ahoM:d a forei111 object i11 the inmate's abdominal area and the inmate told officers be swallowt:d drup. The departme11t removed the inmate from contraband surveillance watch o11May30, 2017, two days later. During that time, the departmem rccovemi methamphetamine from the inmate. Incident Aneltment Intuflident The departmellt did 11ot JW!icienlly comply with policies and procedurea aovemi"' COt1lrlband IUrYeillancc watch. The departmellt placed the inmate in mecbanical ratrainta without proper aulboriratioo and did Dot document the jllltificltion. The hirl111 authority provided trainin& to addlaa the deficiencies. Attenment Quettiont • Did application of restraints eomp1y with CSW pollda and procedura? 'l7u tkpartmem did Mt obtain proper atdhorlz4Jkm w plaa th4 l1rmaU In rutralnts. a Did the departmmt complete appropriate doeummtatlon? 'l7u tkpartmem did Mt dccUIMIIt th4 }ustl/k~Ukm to plaC4 thalnmau In rutralnts. a Overall, did the department aubltantlally comply with CSW pollela and pmeedura? 'l7u tkpartmemp lae4d th4 l1rmaU In rutralnts without pttJJJU autllorlzaJion and did Mt document th4 justljlcaJion. • Did the hiring authority ldmtlfy a policy violation or lllue and take eoneetlve action, Including training? 'l7u hiring atdhorltyp rovkhd training wan assoaau wrll"dm, a captain, and a /Uutmant18garrllng rutl"alntp roc~. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 137 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA AppendixG 29 Field Inquiry Cases Central ContadDate OIG Can Number CateType 2016-03-29 16-0011711-Fl Field Inquiry Incident Summary On. March 29, 20 16, an inmate's mother submitted a complaint to the OIG alleging an officer sexually uaaulted her SOl1 on March 22, 2016. She abo alleged the department retaliated against the inmate when be attempted to report the alleged sexual uaault. Disposition The hiring authority conducted an inquiry and did not identify any staff misconduct. The OIG identified ~ regarding the incident reports and recommended custody and medical staff write objective reports without demeaning comments. The hiring authority agreed and provided training. The OIG abo recommended replaci"i an outdated inmate complaint form with the current form. The instillltion agreed and changed its policy to require the u.e of appropriate forms. The hiring authority also agreed that all futnre sexual uaault allegations will be timely reported to the OIG. Overall A11e11ment Rating: Intuffident The department did not su.fficiently eddraa the matter becau.e it did not timely reapond to the OIG's requat for an inquiry. ContadDate OIG Can Number CateType 2016-08-15 16-0012414-FI Field Inquiry Incident Summary On. All8lllt 15, 2016, an inmate submitted a complaint to the OIG alleging another inmate and an officer engaged in an overly familiar relationship. Disposition The hiring authority conducted an inquiry and did not identify any staff misconduct. Overall As~e~~ment Rating: Suffident The department alrlf"JCiently add!aled the OIG'a field inqWry. ContadDate OIG Can Number CateType 2016-11-03 16-0012465-Fl Field Inquiry Incident Summary On. November 3, 2016, an inmate s11bmitted a complaint to the OIG alleging that officers were overly intrlllive while condu.ctin8 random drl18 testing. Di1position The hiring authority conducted an inquiry and did not identify any staff misconduct. Overall A11e11ment Rating: Sufficient The departmentslrlf"JCiently add!aled theOIG'a field inqWry. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 138 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Number CateType 2016-11-17 16-0012593-FI Field Inqu.ity Incident Summary On November 17, 2016, an inmate submitted a complaint to the OIG alleging a lieutenant wu providing oontldential sexual assault investigation information to other inmates. Ditposition The hiring authority identified potentialst iff miacoruluct hued on the lieutenan(s alleged providing of confidential sexual assault investigation information to inmates. Therefore, the hiring authority referred the cue to the Office of Internal Affairs for investigation. The Office of Internal Affairs opened an investigation, which the OIG accepted for monitoring. Overall Attettment Rating: Suflident The department sutrJCiently eddrcNed the OIG's field inquily. Contact Date OIG Ca1e Number CateType 2016-12-14 17-0021684-FI Field Inqu.ity Incident Summary On December 14,2016, an inmate submitted a complaint to the OIG allegina an appeals coordinator failed to respond to three complaints the inmate submitted and rejected a fourth complaint the inmate submitted against the asme appeals coordinator. Ditposition The hiring authority initiated an inqu.ity and determined the inmate complaint against the appeals coordinator was previously forwarded to the hiring authority who determined there wu no misconduct. The hiring authority directed that Cllltodystsffreceive training regarding the time1ybandlina of inmate complaints against stiff. Overall Attettment Rating: SuffiCient Overall, the dc:partmentlllfficientty eddreued tbe oro's field inquily. Contact Date OIG Cate Number CateType 2017-m-17 17 -0021909-FI Field Inqu.ity Incident Summary On February 17, 2017, an inmate s11bmitted a complaint to the OIG raWna concerns for his safety if he were tran.ferred from the administrative segregation llnit to the general population, claimina the institution did not address his concerns dl1ring a clauification review. Ditposition The hiring authority determined the inmate's safety concerns may not have been previously con.idered and took steps to ens11re the information wu con.idered at the inmate's next clauification review. Overall Attettment Rating: Suflident The department sutrJCiently ecldrcNed the OIG's field inquily. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 139 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Number CateType 2017-m.-24 17 -0022213-FI Field Inqu.ity Incident Summary On February24, 2017, an inmate s11bmitted a complaint to the OIG alleging that inmate complaint forms were not available in the housing unit. Ditposition The OIG coruluctcd an lln&lUlOllliCCd viJit to the inmate's hO!Wng unit and found that inmate complaint forms are located on the unit However, the forms are kept in an office where inmates are not permitted. Policy reqlilita complaint forms to be readily available. In response to the complaint, the institution chan&ed its procedures to ensure all inmate complaint forms are moved to an area readily accessible to inmates in each housing unit. OveraD Attettment Rating: Sufficient The department auft"ICiently eddrcSicd the OIO's field inquiry. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 140 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA North ContadDate OIG Ca1e Number CateType 2015-03-19 15-0000597-FI Field Inquiry Inddent Summary On March 19,2015, an inmate submitted a complaint to the OIG alleging the department falsely identified him u an associate of a security tlm:atgmup. Di1position The birinJ authority corulucted an inquiry and determined the departmem never validated the inmate u an associate of a security tlm:at group. The hirinJ authority did !lOt identify any staff miscoruluct. Overall A1te11ment Rafut&: SuffiCient The department suffiCiently addressed the OIG's field inquily. Contact Date OIG Cate Number CateType 2016-07-25 16-0011869-FI Field Inquiry Incident Summary On July 25, 2016, an inmate submitted a complaint to the OIG alleging an officer used unreuotl8ble force on him. Di1position The OIG identified that the department did !lOt aclmowied&e or act upon the inmate's written request to postpone a rules violation hearin&, and the hearing officer may !lOt have properly considered the inmate's mental health status. The department provided the inmate with an additional rules violation bearing and a mental health USCS~ment. The hirinJ authority did !lOt identifyanystaff miscoruluct. Overall A11e11ment Rafut&: SuffiCient The department autrJCiently addressed the OIG's field inquiry. Contact Date OIG Cate Number CateType 2016-08-23 16.0012023-FI Field Inquiry Incident Summary On Alll!lllt 23, 2016, a lieutenants11bmitted a complaint to the OIG alleging another lieutenant was harassing him. Di1position The birinJ authority took appropriate managerial action to addrtas the lieutenant's concema. Overall A11e11ment Rafut&: Sufficient The department sutftciCIIlly addressed the OIG's field inquily. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 141 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Number CateType 2016-08-25 16-001202(}-FI Field Inqu.ity Incident Summary On Alll!lllt 25, 2016, a legblative staff member submitted a oomplaint to the OIG because a ward's mother alleged her son wu attacked three times in school, the facility wu not addressing his safety concems, and be wu being retaliated against for !lOt attending school by being forced to sit in the bathroom wbile school wu in session. Ditpolition Prior to the OIG'a inquiry, the hiring authoritycorulucted an inqu.ity into the concerns expressed by the ward's mother. The hiring authority also ended the practice oft emporarily placing wards in the bathroom. OveraD Attettment Rating: Sufficient The dcpertment suffiCiently eddrcued the OIO's field inquiry. Contact Date OIG Can Number CateType 2016-08-26 16-0012029-FI Field Inqu.ity Incident Summary On Alll!lllt 26, 2016, a foreigt1 consulate submitted a oomplaint to the OIG regarding an inmate's allegation that officers assaulted him during a use-of-force incident. Ditpolition The institution's executive review committee determined the use offoroe oomplied with policy. At the OIG's recommendation, the department attempted to interview the inmate, but the inmate re:f\aed. The OIG concurred with the hiring authority's actions. OveraD Attettment Ratln&: SuffiCient oro·. The dcpertment suffiCiently eddrcued the fteld inquiry. Contact Date OIG Cate Number CateType 2016-09-21 16-0012293-FI Field Inqu.ity Incident Summary On September 21, 2016, an inmate submitted a oomplsint to the OIG alleging the hiring authority failed to investigate allegations of sexual misconduct by an officer perpetrated against him and other inmates. Ditpolition The department provided Prison Rape Elimination Act training to the lieutenant, provided locally desigt1atedinvestigation training to all investigative services unit staff; and made staffing changes. OveraD Attettment Rating: Intuftident The dcpertment fliled to sufficiently resolve the matter because the department did not initiate a Prison Rape Elimination Act inquiry and oomplcte the review in a timely manner. Contact Date OIG Can Number CateType 2016-09-28 16-0012294-FI Field Inqu.ity Incident Summary On September 28, 2016, an inmate's mother submitted a complaint to the OIG alleging an officer kicked her son several times in the head after be fell on the floor. Ditpolition The hiring authority conducted an inqu.ity and did not identify any staff misconduct. OveraD Attettment Ratln&: SuffiCient The dcpertment suffiCiently eddrcued the OIO's field inquiry. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 142 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Number CateType 2016-10-17 16-0012756-FI Field Inqu.ity Incident Summary On October 17, 2016, an inmate submitted a complaint to the OIG alleging the department failed to investigate his allegations of sexual barusment by officers. Ditposition The hiring authority corulucted an inqu.ity regarding the allegations, made a staffing change, and provided locally desigMted investigator training to the investigative services unit The hiring authority did not identifY any staff miseoruluct. Overall Attettment Rating: Intuflident The dc:partmentdidnouu.fliciell!ly eddreu the maucrbecause the inatitulioft delayed referring the maucr to the investigative services unit to implement Prison Rape FJimination Act polk:ies and procedwa. Contact Date OIG Can Number CateType 2016-12-09 17 -0012906-FI Field Inqu.ity Incident Summary On December9, 2016, an inmate's mother submitted a complaint to the OIG alleging the dt:partmentharused and racially diserimi1l8ted against the inmate and improperly placed him in the administrative segregation unit after food be threw near a trash can splattered on an officer. Disposition The OIG identified that an officer, sergeant, lieutenant, and appeals ooordinator who participated in processing the rules violation report may have failed to identifY that the inmate complained of \ll1reUOnab1e use of force and rejected the inmate's appeals for lack ofd ocumentation without clearly identifYing missing documents or actions the inmate needed to take to have the appeal processed. The OIG abo identified that the institution placed the inmate in the administrative segregation unit for a seemingly excessive term after the food splattered on the officer. In response to the OIG's field inqu.ity, the hiring authority conducted an inqu.ity and found the lieutenant had identified the inmate's \ll1reUOnab1e use-of-foree allegation and conducted a video-recorded interview of the inmate. Howcva; the interview wu Ulllimely and the documentation not appropriately processed. The hiring authority provided training to the officer, lieutell8lll, appeals coordinator, and a captain. Overall Attettment Rating: Sufficient The department suft"ICicnlly eddreued the OIG'1 field inquiry. Contact Date OIG Can Number CateType 2016-12-20 16-0012840-FI Field Inqu.ity Incident Summary On December 20, 2016, an inmate's spouse submitted a complaint to the OIG alleging an officer engaged in a sexual relationship with the inmate. Ditposition The hiring authoritycorulucted an inqu.itypursuant to the Prison Rape FJiminationActand determined the allegation wu unfounded. Overall Attettment Ratin&: SuffiCient The dc:partmentluft"ICicnlly eddreued the OIG's field inqlliry. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 143 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Number CateType 2016-12-20 17 -0012907-FI Field Inqu.ity Incident Summary On December 20, 2016, an inmate submitted a oomplaint to the OIG alleging officers were bringing contraband into the institution for inmates and allowing inmates to steal from the supply closet with the lmowledge of~ycbologists. Ditpolition The hiring authority conducted an inqu.ity and did 1lOt identify any staff miJconduct. Overall Attettment Rating: Suflident The department sutrJCien!ly addressed the oro·. fteld inquily. Contact Date OIG Ca1e Number CateType 2016-12-21 17-0013062-FI Field Inqu.ity Incident Summary On Dccember21, 2016, an inmate submitted a oomplaint to the oro allegina that inmate complaint forms wa-c 1lOt available in the administrative segreption unit. Ditpolition The OIG conductedaniiii&D110IIliQC vWtto the adlninUtrative segregation unit and found that inmate oomplaintfonm mre available on the unit. Overall Attettment Rating: Sufllcient The department sutftcieatly addressed tbe OrG't fte1d inquily. Contact Date OIG Cate Number CateType 2017.{11-18 17-0013064-FI Field Inqu.ity Incident Summary On January 18, 2017, an anonymous individual s11bmitted a oomplaint to the OIG alleging a teacher was committing fraud by taking a leave ofa bsence during the ten-month period in which his teaching credential was suspended and that both the wardenandedi1Cation supervbor approved the leave of absence even th011gh they were aware the teacher was being suspended for the same period. Furthermore, even th011gh the teacher's credential was slliPC"ded, the teacher allegedly contimled teaching at the institution. Ditpolition The OIG discovered the department hired the teacher even thol1gh a prior employer suspended him for improper contact with a student and, at the time of hire with the department, the teacher was subject to another pending investigation regarding similar alleged miJconduct. The department terminated the teacher's leave ofa bsence, following which the teacher resigned. The department abo established procedl1res to ens11re it maintains acwrate information regarding the 1tat111 of its teachers' credentials to prevent hiring individuals without valid credentials and to appropriately address those teachers whose credentials are SlliPended after hire. Overall Attettment Rating: Sufficient The department tutfJCien!ly addressed tbe OrG't fte1d inquily. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 144 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Number CateType 2017-m.-23 17 -0022217-FI Field Inqu.ity Incident Summary On February23, 2017, an attorney submitted a oomplaint to the OIG alleging the department was not pn:x>essing an inmate's1egal mail. Ditposition The hiring authority determined that the depsrtmem's mail proccdule was being followro. Overall At-ment Rating: Suflident The departmentsutriCic:nlly addrased the oro•s field inquiry. Contact Date OIG Can Number CateType 2017-03-20 17-0022339-FI Field Inqu.ity Incident Summary On March. 20, 20 17, an inmate submitted a complaint to the OIG alleging an officer denied inmates access to cleaning supplies which placed the inmates at risk for colds arui an influellZa outbreak. Disposition The department verified inmates were provided disinfectant to clean their cells and inmate porters cleaned the building. Overall At-ment Ratina: Sufl"tcient The department autriCic:nlly addrased the oro. field inquiry. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 145 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA South ContadDate OIG Ca1e Number CateType 2015-05-18 17 -0022341-FI Field Inquiry Inddent Summary On May 18,2015, an inmate submitted a QOI!lplaint to the OIG alleging two officers were using unnecessary fon>e on inmates, being diJoourteous, and violating the Prison Rape Elimination Act. Ditposition The hiring authority corulucted an inquiry and found insufficiettt evidence to support the allegations. Overall At~e~~ment Ratin&: Sufficient The departmetttsllffiCienlly addraled theOIG'a field inqujry. Contact Date OIG Cate Number CateType 2016-05-23 17.0013061-FI Field Inquiry Inddent Summary On May 23, 2016, an inmate's mother submitted a complaint to the OIG alleging officers failed to provide the imnate a receipt for property confiscated during a cell search, officers did not iasue a rules violation report to the cellmate, and the inmate wu denied the right to call willlesses during the rules violation bearing. Ditposition In rtapOOJe to the OIG's inquiry, the hiring authority reviewed the matter and determined the inmate received a receipt for confiJcatedproperty in the form oft he rules violation report, the inmate wu allowed to call willlelaes to testify, and forensic examination of the mobile phone supported the rules violation report againat the inmate, not the cellmate. Overall At~e~~ment Ratin&: Sufficient The departmetttallffiCienlly addraled theOIG'a field inqujry. Contact Date OIG Cate Number CateType 2016-06-30 16-0011634-FI Field Inquiry Incident Summary On Juru: 30, 2016, an inmate submitted a QOI!lplaint to the OIG alleging a substance abuse cowuelor brought COlllrabarui into the institution, engaged in sexual relations with another inmate, tlm:atened to have otherimnates kill him ifh e reported the misconduct, and that the other imnates falselyaccuaed him ofmakin& threats, which resulted in his placement in the administrative segregation unit. Ditposition The hiring authority corulucted an inquiry and did not identify any staff misconduct. Overall Attellment Rating: Suflident The departmetttsllffiCienlly addraled theOIG'a field inqujry. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 146 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA Contact Date OIG Cate Numba- Cate'l'ype 2016-07-20 16-0012028-FI Field Inquity Incldmt Summary On July 20, 2016, an inmate submitted a complaint to the OIG a11egina an officer worked i11 the inmate's houai11a Ullit i11 violatiooof a staff aeparatioo alert and the mstitutioo took 110 actioo 011 the inmate's complaint apinat the officer. Dlspo~ltlon The hiring authority conducted an inquity and determined the officer bad 110 oontact with the inmate and there was 110 violatioo of the aeparatioo protocol. Overall Anetllllellt Ratlna: Sufficient The departmca\t sW!iciently addraled the OIG'a field inquity. Contact Date OIG Ca1e Numba- Case Type 2016-09-12 16-0012292-FI Field Inquity Incldmt Summary On September 12, 2016, an advocacy groupsubmittedacomplaintallegingthataninmate suffered serious bodilyinjuryaftersbe was UNultedbyanotherinmateand, therefore, the matter should have been refern:d to the district attorney's office for possible proaecution. Dlspo~ltlon The mvestiptive services Ullit mvestipted the matter and referred the cue to the district attomey's office, which dccli11ed to prosecute. Overall Anetmtent Rating: Suftlclent The departmca\t sW!iciently addraled the OIG'a field inquity. Contact Date OIG Cate Numba- Cate'l'ype 2016-11-28 17-0021903-FI Field Inquity Incldmt Summary On November 28, 2016, an inmate submitted a complaint to the OIG aile gin& personnel i11 the inmate J11PC11s office rejected his complai11ts as untimely without C01Uidcring delays cauaed by departmental mail processing and becauJe his complai11ts were ataill.st personnel i11 the inmate J11PC11s office. Dlspo~ltlon The mstitutioo changed its policy to require notificatioo to the hiring authority before rejeeti11g appeals as untimely and to require complaints abOiltappeals office personnel to be routed to the hiring authority for resol11tion. Overall Anetmtent Rattna: Sufficient The departmca\t Jl1fficiently addraled the OIG's field inquity. Contact Date OIG Ca1e Numba' Case Type 2016-12-21 16-0012848-FI Field Inquity Incldmt Summary On December 21, 2016, an anooymou.s individl1alsubmitted a complai11t to the OIG allegina an officer u i11trodl1cing mobile phones and other contraband mto an mstitutioo. Dlspo~ltlon The hiring authority conducted an inquity and was llll&ble to verity any oft he i11formation. Overall Anetllllellt Rating: Sufficient The departmca\t sW!iciently addraled the OIG'a field inquity. SEMI-ANNUAL REPORT VOLUME II JANUARY-JUNE 2017 Page 147 OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA SEMI-ANNUAL REPORT January-June 2017 Volume II OFFICE OF THE INSPECTOR GENERAL Robert A. Barton INSPECTOR GENERAL Roy W. Wesley CHIEF DEPUTY INSPECTOR GENERAL STATE OF CALIFORNIA August 2017