OIG
OIG Semi-Annual Report Volume II July-December 2014
Robert A. Barton Office of the Inspector General
Inspector General
SEMI-ANNUAL REPORT
July–December 2014
Volume II
March 2015
Office of the Inspector General
SEMI-ANNUAL REPORT
July–December 2014
Volume II
Robert A. Barton
Inspector General
Roy W. Wesley
Chief Deputy Inspector General
Shaun R. Spillane
Public Information Officer
March 2015
FOREWORD
This 20th Semi-Annual Report covers the time period July through December 2014. In addition
to its oversight of CDCR’s employee discipline process, 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 Reports in a two-volume format to allow
readers to more easily distinguish the various categories of oversight activity.
Volume II reports the OIG’s monitoring and assessment of the department’s handling of critical
incidents, including those involving deadly force. It also reports the monitoring of use-of-force
reviews within the department and CDCR’s adherence to its contraband surveillance watch
policy. Since each of these activities is monitored on an ongoing basis, they are now combined
into one report to be 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
Monitoring Critical Incidents .......................................................................................................... 2
In-Custody Inmate Homicides ................................................................................................... 3
Monitoring Deadly Force Incidents.......................................................................................... 4
Monitoring Use of Force ................................................................................................................. 6
Use-of-Force Meetings Attended and Incidents Reviewed ..................................................................... 7
Department Executive Review Committee (DERC) ................................................................................ 8
Types of Force ........................................................................................................................................ 8
Division of Adult Institutions ................................................................................................................ 10
Use of Force on Mental Health Inmates .............................................................................................. 12
Video-Recorded Interviews .................................................................................................................. 13
Pilot Program for Institutional Use-of-Force Reviews ........................................................................ 15
Division of Juvenile Justice .................................................................................................................. 16
Division of Adult Parole Operations .................................................................................................... 18
Office of Correctional Safety ................................................................................................................ 18
Monitoring Contraband Surveillance Watch ................................................................................ 19
Volume II Conclusion ................................................................................................................... 27
Volume II Recommendations ....................................................................................................... 29
Volume II Recommendations from Prior Reporting Periods ....................................................... 30
Table of Charts .............................................................................................................................. 35
Appendices .................................................................................................................................... 36
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, and contraband surveillance watch incidents within CDCR. The
OIG reports these monitoring activities here to reduce the overall need for separate reports, and
also to give the reader a wider view of OIG-monitored activities in one place.
The OIG maintains response capability 24 hours per day, seven days per week, for any critical
incident occurring within the prison system. OIG staff responds to the scene (when timely
notified) to assess the department’s handling of incidents that pose a high risk for the State, staff,
or inmates. The factors leading up to each incident, the department’s response to the incident,
and the outcome of the incident are all assessed and reported; then, if appropriate, the OIG makes
recommendations. To provide transparency into the incidents, these cases are reported in
Appendix E.
The highest monitoring priority among critical incidents is the use of deadly force. For this
reason, these cases are reported separately and processed by the department and the OIG with a
higher level of scrutiny. That scrutiny includes both criminal and administrative investigations
opened by CDCR’s Office of Internal Affairs’ Deadly Force Investigation Team, which are
monitored by the OIG due to the seriousness of the event, but not necessarily because
misconduct is suspected.
Historically, the OIG has also monitored and reported on use-of-force incidents and CDCR’s
subsequent review process. The OIG’s reports in this area can also be found in Volume II.
As noted above, deadly force incidents are a subset of use of force and are also categorized as
critical incidents. These are reported separately in Appendix D.
Finally, the reader will find a report of the department’s use of contraband surveillance watch for
this reporting period. These cases are contained in Appendix F.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 1
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
MONITORING 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 an immediate response by the
department, 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;
2. Any death or any serious injury that creates a substantial risk of death to an individual in
the custody or control of the department, excluding lawful executions 1;
3. Any on-duty death of a department staff member;
4. Any off-duty death of a department staff member when the death has a nexus to the
employee’s duties at the department;
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 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 watch2;
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 incident of notoriety or significant interest to the public; and
10. Any other significant incident identified by the OIG after proper notification to the
department.
The OIG maintains a 24-hour contact number in each region to receive notifications. After
notification, the OIG monitors the department’s management of the incident, either by
responding to the site of the incident or by obtaining the incident reports and following up on
scene at a later time. More specifically, the OIG evaluates what caused the incident and the
department’s immediate response to it. The OIG may make recommendations as a result of its
review regarding training, policy, or referral for further investigation of potential negligence or
misconduct. If the OIG believes the incident should be referred to the Office of Internal Affairs,
the decision regarding any referral is also monitored. If the matter is opened for an investigation,
the OIG may monitor the ensuing investigation. Critical incidents are customarily reported in the
Semi-Annual Report that follows the incident occurrence. However, if an investigation is
initiated, a report may be held at the discretion of the Inspector General until the completion of
the investigation if reporting it would potentially negatively impact the integrity of that internal
investigation.
During this reporting period, the OIG completed assessments of 131 critical incidents
(Appendices D and E). It is important to note that the number of critical incidents within any
period is dependent upon the events taking place within the department. This report does not
directly correlate to incidents that occurred within this time frame, but rather reflects the number
1 As used herein, an individual within the custody and control of the department does not include a parolee.
2 Contraband surveillance watch cases are summarized on page 28 and detailed in Appendix F.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 2
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
of incidents the OIG has assessed and closed for the time period. There were 53 insufficient
ratings overall, 15 of which were insufficient due to late notification. In order to monitor an
incident on scene, the OIG relies on the department to provide timely notification that a critical
incident has occurred. However, even when notification is untimely, the OIG still remotely
monitors the event by collection of reports and follow-up review.
The department provided timely notification for 72 percent of the critical incidents being
reported. This is a 20 percent decline in timely notification compared to the previous reporting
period. Delays in notification impact the OIG’s ability to provide real-time, on-site monitoring
and transparency for critical incidents.
IN-CUSTODY INMATE HOMICIDES
In the last Semi-Annual Report, the OIG raised the issue of increasing violence on sensitive
needs yards. It is important to note, as previously stated, that the dates of these homicides
preceded the case closure and reporting of the events. The actual dates of occurrence were
September 24, 2011, through December 7, 2013. More than half of the in-custody homicides
involved sensitive needs yard (SNY) inmates even though these yards house only 27 percent of
the inmate population and were originally created to prevent violence to those inmates requiring
protection from the rest of the population for various reasons.3 In addition to the listed
4
4 homicides, there were three in-cell great bodily injury incidents that were against inmates
classified as SNY, but that did not result in death. These incidents occurred on
February 27, 2014; May 15, 2014; and June 5, 2014.
As previously reported in the OIG’s assessments of these events, there are steps the department
can take to lessen such risks. Given the current nature of the population on sensitive needs yards,
which comprises sex offenders as well as gang dropouts and other general population inmates,
the OIG recommended the department consider some additional preventative steps. These
included re-examining its double-cell policy for sensitive needs yards, requiring completion of
compatibility forms to help ensure that inmates are properly placed with compatible cellmates,
and giving potential cellmates the opportunity to document their agreement to house together.
Inmates with prior violence toward cellmates should not be double celled, even on an SNY, until
each inmate’s propensity for violence is considered. Additionally, the OIG recommended the
department review the process for transitioning inmates from single-cell designation to
double-cell status pursuant to prior OIG recommendations.
In response to the above recommendations, the department agreed to take into consideration the
information provided by the OIG, but felt that the OIG’s data for two reporting periods, one year,
did not provide enough historical data to develop a hypothesis for the number of inmate
homicides involving SNY inmates. The department cited the overall number of homicides, which
has decreased from 20 in both 2012 and 2013 to nine in 2014. The OIG is not disputing the
decrease in the overall homicide rate and hopes it will continue in 2015; however, the overall
decrease only highlights the need to examine the disproportionate number of SNY inmate
victims. The OIG will continue to monitor and report on the department’s response to this issue.
3 Second Report on CDCR’s Progress Implementing its Future of California Corrections Blueprint, Page 74.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 3
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
MONITORING DEADLY FORCE INCIDENTS
Deadly force incidents are a type of both critical incidents and use-of-force events the OIG
monitors. These incidents automatically result in both an administrative and a criminal
investigation if the Office of Internal Affairs chooses to conduct a deadly force investigation, the
only exception being when the force occurs outside the prison and an outside law enforcement
agency conducts the criminal investigation. Appendix D contains each case involving use of
deadly force closed in this reporting period, regardless of whether the Office of Internal Affairs
was involved.
Any time CDCR staff use deadly force, the department is required to promptly notify the OIG.
When the OIG receives timely notice of a deadly force incident, a Special Assistant Inspector
General immediately responds to the incident scene to evaluate the department’s management of
the incident and the department’s subsequent deadly force investigation, if initiated.
CDCR policy mandates that deadly force investigations be conducted by the Office of Internal
Affairs’ Deadly Force Investigation Team. The OIG also monitors any use of force involving a
head strike by custody staff with any instrument on an inmate, and any warning shots.
The Office of Internal 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.
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.
Deadly Force Investigation Team incidents usually require review by the Deadly Force Review
Board. An OIG representative participates as a non-voting member of this body. The Deadly
Force Review Board reviews those cases to which the Office of Internal Affairs sends a Deadly
Force Investigation Team. The Deadly Force Review Board is an independent body consisting of
outside law enforcement experts and one CDCR executive officer. Generally, after the
administrative investigation is complete, the investigative report is presented to the Deadly Force
Review Board. The Deadly Force Review Board examines the incident to determine the extent to
which the use of force was in compliance 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 needed.
Because the use of deadly force has such serious implications, the department’s use of deadly
force has always received the highest level of scrutiny. During this reporting period, the OIG
closed 46 potentially deadly force incidents. The incidents included the intentional use 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
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 4
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
is broken into two categories: Appendix D1 contains cases where the OIG monitored an incident
involving warning shots that the Office of Internal Affairs did not respond. Appendix D2 reports
cases where the Office of Internal Affairs opened a case that the OIG monitored. There are 39
such cases being reported during this period. The number of cases being reported does not
correlate with the actual number of times the Office of Internal Affairs responded on scene
during this reporting period, as the OIG only reports a case once all activity is completed.
Of the 39 cases being reported in Appendix D2, the Office of Internal Affairs responded on
scene in 35 cases, including six cases where a full Deadly Force Investigation Team responded.
In two cases, outside law enforcement conducted the criminal investigation, while the Deadly
Force Investigation Team conducted the administrative investigation. One of the cases involved
an off-duty incident where a sergeant used his personal firearm to shoot and kill a pit bull dog
that was attacking a child, and the other was a case involving a fugitive who engaged in a gun
fight with multi-agency task force members.
In response to the OIG’s recommendation, the Office of Internal Affairs instituted a pilot project
on January 16, 2014, requiring an on-scene response for any incident involving any strike to the
head with a baton or impact munition, regardless of injury. Of the 39 cases being reported during
this period, July through December 2014, 31 cases involved incidents where a claim was made
that the use of less-lethal force resulted in head injuries. In some of these cases, inmates claimed
being struck on the head and then later recanted their claims, or the claims were unsubstantiated.
Other cases involved custody staff reporting that the baton or impact munition may have
inadvertently struck an inmate on the head.
Pursuant to the pilot project, the Office of Internal Affairs responded to all 31 cases involving
potential head injuries due to the use of force. Of the 31 total cases, six resulted in inmate
transport to an outside hospital for treatment of injuries consisting mainly of lacerations and
concussions. None of the incidents resulted in death. The remaining incidents involved injuries
such as bruising, redness, swelling, or abrasions that were treated at the institution. In many of
the cases, it could not be determined whether the injuries were the result of the use of force as
opposed to inmate assaults. In all 31 cases, the Office of Internal Affairs determined the
incidents did not meet the requirements for a full deadly force investigation and the
investigations were terminated. The OIG concurred with all of these determinations.
While none of these incidents resulted in serious injury or death or subjected the department to
major liability, the potential for this type of outcome warranted the pilot program. The Office of
Internal Affairs has terminated the pilot project, citing the major expenditure of resources. On
February 12, 2015, the Office of Internal Affairs issued a memorandum noting a return to its
prior policy. The OIG consulted with the Office of Internal Affairs regarding the pilot project
and agreed that the pilot did not produce results justifying the increased use of Office of Internal
Affairs resources involved in implementation of the pilot project. However, the OIG will
continue responding and monitoring incidents involving the use of potentially deadly force as it
has done in the past, and will recommend a Deadly Force Investigation Team be sent by the
Office of Internal Affairs on a case-by-case basis if deemed necessary.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 5
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
MONITORING USE OF FORCE
The OIG monitors the department’s evaluation of the force used by staff and reports its findings
semi-annually. The monitoring process includes attending Institutional Executive Review
Committee (IERC) meetings, where every use of force incident is reviewed and evaluated for
compliance with policy.4 The department is tasked with maintaining the safety and security of
staff members, inmates, visitors, and the public. At times, this responsibility requires the use of
reasonable force by sworn correctional officers. In doing so, officers are authorized to use
“reasonable force,” defined as “the force that an objective, trained, and competent correctional
employee, faced with similar facts and circumstances, would consider necessary and reasonable
to subdue an attacker, overcome resistance, effect custody, or gain compliance with a lawful
order.” The use of greater force than justified by this standard is deemed “excessive force,” while
using any force not required or appropriate in the circumstances is “unnecessary force.” Both
unauthorized types of force are categorized as “unreasonable.”5
Departmental policy requires that, whenever possible, verbal persuasion or orders be attempted
before resorting to the use of force. In situations where verbal persuasion fails to achieve desired
results, a variety of force options are available. The department’s policy does not require these
options be employed in any predetermined sequence. Rather, officers select the force option they
reasonably believe is necessary to stop the perceived threat or gain compliance.
Per departmental policy, use-of-force options include, but are not limited to, the following:
a) Chemical agents, such as pepper spray and tear gas;
b) Hand-held batons;
c) Physical force, such as control holds and controlled take downs;
d) Less-lethal weapons (weapons not intended to cause death when used in a prescribed
manner), including the following: 37mm or 40mm launchers used to fire rubber, foam, or
wooden projectiles, and electronic control devices; and
e) Lethal (deadly) force. This includes any use of force that is likely to result in death, and
any discharge of a firearm (other than during weapons training).
Any department 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. After the report is submitted, a multi-tiered review process begins. As part of its
oversight process, the OIG reviews each of the reports, including the entire multi-tiered process.
The OIG also provides oversight and makes recommendations to the department in the
development of new use-of-force policies and procedures.
When appropriate, the OIG recommends an incident be referred to CDCR’s Office of Internal
Affairs for investigation (or approval to take disciplinary action based on the information already
available). In the event the OIG does not concur with the decision made by the local hiring
authority, i.e., the warden or parole administrator, the OIG may confer with higher level
department managers. If the OIG recommends disciplinary action on a case, the department’s
response is monitored and reported.
4 See “Pilot Program for Institutional Use-of-Force Reviews” later in this section for the exception to this policy.
5 Department Operations Manual, Chapter 5, Article 2.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
The OIG attends as many use-of-force committee meetings that 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 that it held 518 use-of-force committee meetings. Of those, the
OIG attended 390.
Use-of-Force Meetings Attended and Incidents Reviewed
During this reporting period, the OIG monitored and evaluated 2,148 use-of-force incidents. In
addition, 188 incidents were reviewed more than once due to the cases not being fully prepared
upon first review by the IERC. The use-of-force data being reported does not correspond to all of
the incidents that occurred. This data is derived only from those incidents that were reviewed and
monitored from July through December 2014.
In preparation for a use-of-force meeting, the OIG evaluates all departmental reviews completed
prior to the meeting. At each level of review, the reviewer is tasked with evaluating reports,
requesting necessary clarifications, identifying deviations from policy, and determining whether
the use of force was within policies, regulations, and applicable laws. The levels of review are
the initial review conducted by the incident commander; the first level management review
conducted by a captain; the second level management review conducted by an associate warden;
and the final level of review where the incident is reviewed by the use-of-force review
committee, with the ultimate determination made by the institution head or designee. During the
meeting, the OIG observes the review process and engages in contemporaneous oversight by
raising concerns about the incidents when appropriate, asking for clarifications if reports are
inconsistent or incomplete, and engaging in discussions with the committee about the incidents.
Through this process the OIG draws an independent conclusion about whether the force used
was in compliance with policies, procedures, and applicable laws and whether the review process
was thorough and meaningful. Table 1 illustrates the OIG-monitored incidents by the division
within CDCR.
Table 1: Number of Separate Use-of-Force Incidents Reviewed, by Division
Number of Incidents
Division
Reviewed
Division of Adult Institutions 1,957
Division of Juvenile Justice 155
Division of Parole Operations 33
Office of Correctional Safety 3
Total 2,148
Through involvement at the use-of-force meetings, the OIG influenced the department’s decision
to prescribe additional training, pursue employee discipline, obtain additional factual
clarifications, or make policy changes in 187 individual cases. The OIG commends the
department on its willingness to consider OIG recommendations on the 187 cases to arrive at the
appropriate outcome.
In the adult institution cases monitored by the OIG, CDCR found the force used was within
policy 92 percent of the time, while the OIG found the force used was within policy 91 percent
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 7
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
of the time. In the juvenile facility cases, both CDCR and the OIG found the force used was
within policy 90 percent of the time, and for both parole and the Office of Correctional Safety
(OCS), CDCR and the OIG found the use of force to be in compliance in all of the cases
reviewed. These numbers are consistent with prior reporting periods and show that of the cases
fully prepared for review, the department is able to take meaningful and appropriate action. As
noted in previous reports, the department has struggled with timeliness, thorough evaluations,
and fact gathering by first and second-level reviewers. In this reporting period, 487 of the cases
monitored by the OIG had to be deferred because they were not ready for complete review when
they were brought to the use-of-force committee. From these reviews and prior reports, it is
apparent that the department should continue efforts to achieve timely reviews.
Department Executive Review Committee (DERC)
Pursuant to Department Operations Manual, Sections 51020.4 and 51020.19.6, and Title 15,
California Code of Regulations, Section 3268(18), the 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 also assigns a Deputy Inspector General to monitor DERC reviews.
Types of Force
A single incident requiring the use of force may involve more than one use of force and may
require use of different types of force. For example, during a riot, officers may use lethal force,
chemical agents, expandable batons, and less-lethal force to address varying threat scenarios as
the riot progresses.
The department also distinguishes between immediate and controlled use of force. Immediate
use of force is defined in departmental policy as the force used to respond without delay to
inmate behavior that constitutes an imminent threat to institution/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/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. These situations do not normally involve the immediate threat of
loss of life or immediate threat to institution security. All controlled use-of-force situations
require the authorization and the presence of a first- or second-level manager or an
Administrative Officer of the Day (AOD) during non-business hours. Staff must make every
effort to identify disabilities, to include mental health concerns, and to note any accommodations
that may need to be considered when preparing for a controlled use of force.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
The types of force used in incidents are always examined by the use-of-force review committees,
but the officer has discretion in determining the level of force required in each situation. In the
vast majority of cases, the type of force used is appropriate for the situation and does not become
an issue of discussion. The primary focus of committee review is to evaluate whether the
use-of-force policy and other policies, such as decontamination of inmates, video-recorded
interviews, escort of inmates post-incident, completion of log entries, etc., were followed.
During this reporting period, staff contributed to the need for force in 92 of the 2,148 incidents
reviewed, approximately 4 percent of the incidents. While there were varying reasons staff
contributed to the need for the use of force, four major reasons were the following:
1) Using force when no imminent threat was present (23 incidents);
2) Opening a cell door or otherwise allowing inmates access to unauthorized areas (21 incidents);
3) Restraint equipment (such as handcuffs) being inappropriately applied or not applied when
required (11 incidents); and
4) Failing to sound an alarm during an incident, which may have negated the need for force (10
incidents).
Other examples of how staff contributed to the need for force included entering the cell of an
agitated or noncompliant inmate instead of leaving the cell door closed and waiting for additional
staff; issuing unauthorized property to inmates while on property restriction (such as suicide
watch); making inappropriate or violence-inciting statements; and ignoring safety concerns of
inmates. The department made the same finding and took appropriate action in the vast majority
of these cases.
Table 2: Staff Contribution to the Need for Force, by Mission
Mission Incidents
High Security (Males) 34
Reception Centers 25
General Population (Males) 8
Female Offender/Special Housing 10
Juvenile Justice 14
Adult Parole 1
Office of Correctional Safety 0
Total 92
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 9
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Division of Adult Institutions
CDCR’s Division of Adult Institutions (DAI) comprises four mission-based disciplines: reception
centers (RC), high security (HS), general population (GP), and female offender/special housing
(FOPS/SH).6 As of December 31, 2014, the department housed 121,198 in-state inmates.7 The
following table displays a breakdown of how the inmate population is distributed throughout the
missions.
Table 3: In-State Inmate Population, by Mission
Inmate Percentage
Mission
Population of Population
High Security 35,369 29%
Reception Centers 38,986 32%
General Population 34,357 28%
Female Offenders/Special Housing 12,486 10%
Total 121,198 100%
Percentages are rounded to the nearest whole number so may not total exactly 100.
Of the 2,148 total use-of-force incidents the OIG reviewed, 1,957 (91 percent) occurred within
the DAI. The OIG found the reports adequately articulated the justification for using force and
adequately described the force used in 97 percent of the incidents. The remaining 3 percent of
incidents reviewed had inadequate justification for the use of force. For the most part, the
number of incidents of force is proportionate to the size of the missions, with the high security
mission having a slightly higher percentage of use-of-force incidents.
Table 4: Number of Incidents Reviewed by the OIG, by Mission Within DAI
Mission Incidents Percentage
High Security (Males) 762 39%
Reception Centers 604 31%
General Population (Males) 367 19%
Female Offenders/Special Housing 224 11%
Total 1,957 100%
Percentages are rounded to the nearest whole number so may not total exactly 100.
6 The full name of this mission is “female offender programs and services, special housing” (FOPS/SH). All of the
female institutions are part of this mission, as well as the California Medical Facility, the California Health Care
Facility, and Folsom Women’s Facility.
7 The department contracts to house nearly 9,000 additional inmates in out-of-state facilities. The OIG does not
monitor the use of force in out-of-state facilities unless it is deadly force. CDCR data is derived from:
http://www.cdcr.ca.gov/Reports_Research/Offender_Information_Services_Branch/Monthly/TPOP1A/TPOP1Ad14
12.pdf.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Table 5: Frequency of Force by Type in Reviews Completed, Grouped by Mission
Adult Institutions
Institution Applications Physical Chemical Expandable Less-Lethal Deadly
Institution Name Mission
Initialism of Force Force Agents Baton Force Force
Female/Special
CCWF Central California Women’s Facility 106 34% 57% 8% 0% 0%
Programs
Female/Special
CHCF California Health Care Facility 55 64% 31% 4% 0% 0%
Programs
Female/Special
CIW California Institution for Women 93 47% 42% 8% 3% 0%
Programs
Female/Special
CMF California Medical Facility 51 24% 75% 2% 0% 0%
Programs
Female/Special
FWF Folsom Women's Facility 15 7% 80% 13% 0% 0%
Programs
ASP Avenal State Prison General Population 51 6% 88% 4% 0% 0%
CAL Calipatria State Prison General Population 170 7% 67% 1% 24% 1%
CEN Centinela State Prison General Population 60 8% 67% 8% 17% 0%
CTF Correctional Training Facility General Population 40 30% 58% 13% 0% 0%
CVSP Chuckawalla Valley State Prison General Population 20 15% 70% 15% 0% 0%
FSP Folsom State Prison General Population 53 8% 79% 11% 2% 0%
ISP Ironwood State Prison General Population 96 2% 95% 2% 1% 0%
MCSP Mule Creek State Prison General Population 118 16% 51% 18% 15% 0%
PVSP Pleasant Valley State Prison General Population 69 13% 67% 6% 14% 0%
SOL California State Prison, Solano General Population 77 19% 71% 1% 8% 0%
VSP Valley State Prison General Population 19 47% 47% 5% 0% 0%
CAC California City Correctional Facility High Security 25 8% 88% 4% 0% 0%
CCI California Correctional Institution High Security 51 16% 63% 6% 10% 0%
COR California State Prison, Corcoran High Security 111 22% 68% 7% 3% 0%
HDSP High Desert State Prison High Security 96 15% 65% 5% 15% 1%
KVSP Kern Valley State Prison High Security 209 7% 70% 3% 20% 0%
California State Prison, Los Angeles
LAC High Security 331 17% 58% 8% 16% 0%
County
PBSP Pelican Bay State Prison High Security 214 7% 69% 7% 16% 0%
SAC California State Prison, Sacramento High Security 283 41% 52% 4% 3% 0%
Substance Abuse Treatment Facility &
SATF High Security 89 16% 53% 9% 17% 3%
State Prison at Corcoran
SVSP Salinas Valley State Prison High Security 157 10% 78% 0% 12% 0%
CCC California Correctional Center Reception Center 48 13% 73% 6% 8% 0%
CIM California Institution for Men Reception Center 81 32% 64% 1% 2% 0%
CMC California Men's Colony Reception Center 60 42% 45% 5% 0% 0%
CRC California Rehabilitation Center Reception Center 103 21% 77% 2% 0% 0%
DVI Deuel Vocational Institution Reception Center 110 31% 45% 24% 0% 0%
NKSP North Kern State Prison Reception Center 209 10% 59% 4% 27% 0%
Richard J. Donovan Correctional
RJD Reception Center 170 34% 51% 7% 7% 0%
Facility
SCC Sierra Conservation Center Reception Center 75 20% 75% 5% 0% 0%
SQ California State Prison, San Quentin Reception Center 67 19% 54% 12% 15% 0%
WSP Wasco State Prison Reception Center 245 13% 62% 9% 17% 0%
21% 64% 7% <1%
3,827 8% Overall
TOTAL Overall Overall Overall Overall
Applications Average
Average Average Average Average
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 11
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Use of Force on Mental Health Inmates
Nearly half of the total uses of force (48 percent) reviewed this reporting period were on inmates
participating in the department’s mental health services delivery system (MHSDS) at the
Correctional Clinical Case Management System (CCCMS) level or above.8,9 The department
reports that about 29.5 percent of its in-state inmate population was at the CCCMS level or
above during this reporting period.
Table 6: Use of Force, by Mental Health Status
MH Code Percentage
Non-Mental Health 52%
CCCMS 31%
EOP 14%
48%
MHCB 2%
DMH 1%
Percentages are rounded to the nearest whole number so may not total exactly 100.
Chart 1: Frequency of Force by Type for Mental Health Population
120%
Non Mental Health CCMS or Higher
100%
100%
92%
79%
80% 72%
58% 57%
60%
52%
48%
42% 43%
40%
28%
21%
20%
8%
0%
0%
8 Note that 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.
9 The department’s MHSDS provides mental health services to inmates with a serious mental disorder or who meet
medical necessity criteria. The MHSDS is designed to provide an appropriate level of treatment and to promote
individual functioning within the least clinically restrictive environment. Mental health care is provided by clinical
social workers, psychologists, and psychiatrists. CDCR provides four different levels of care: CCCMS, Enhanced
Outpatient Program (EOP), Mental Health Crisis Bed (MHCB), and Department of Mental Health (DMH). 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/DCHCS/index.html.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 12
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Table 7: Frequency of Force by Type, Grouped by Mental Health Status
Chemical Agents Physical Force Less-Lethal Force Baton
Number % Number % Number % Number %
Non-MH 1,390 58% 215 28% 230 57% 128 52%
CCMS 707 30% 254 33% 131 33 75 30%
EOP 246 10% 217 28% 37 9 39 16%
42% 72% 43% 48%
MHCB 22 1% 53 7% 0 0 2 1%
DMH 22 1% 30 4% 2 1 2 1%
Total 2,387 100% 769 100% 400 100% 246 100%
Other/Non-Conventional Lethal Force Taser Total # Total %
Number % Number % Number % Number %
Non-MH 5 21% 6 100% 11 92% 1,985 52%
CCMS 6 25% 0 1 8% 1174 31%
EOP 10 42% 0 0 0% 549 14%
79% 0% 8% 48%
MHCB 2 8% 0 0 0% 79 2%
DMH 1 4% 0 0 0% 57 1%
Total 24 100% 6 100% 12 100% 3,844 100%
Percentages are rounded to the nearest whole number so may not total exactly 100.
The department recently modified its use-of-force policy with regard to mental health inmates,
and the changes were implemented during this reporting period, July through December 2014.
On July 31, 2014, CDCR filed a plan with the court overseeing the Coleman lawsuit pertaining
to how the department uses force on mental health inmates. Major changes to CDCR’s
use-of-force policy include limitations on the amount of chemical agents used, increased
responsibilities for mental health clinicians to evaluate an inmate’s mental status to determine
whether the inmate is able to understand directions, and requirements that custody supervisors
oversee the use of force. If a clinician decides force should not be used, the incident must be
referred to senior custody and mental health management to resolve. The department has drafted
new procedures to address this deficiency, and statewide training has commenced and will
continue over the next few months. Staff is responsible for complying with the new policies
immediately upon receipt of training. It appears there is an effort to use physical restraint on the
mentally ill as opposed to more severe methods. The data shows that while the use of force and
chemical agents is proportionately greater (48 percent compared to 29.5 percent of the
population), there is a lower proportionate percentage of use of batons, 40mm direct-impact
rounds, and lethal force on the mentally ill. At this point, no conclusions are being drawn from
this data, but it will be a focus of future monitoring.
Video-Recorded Interviews
The department’s use-of-force policy requires video-recorded interviews if an inmate alleges
unreasonable force or has sustained serious or great bodily injury that could have been caused by
the use of force. The video recording should be conducted within 48 hours of discovery of the
injury or allegation. If the inmate refuses to be video recorded, CDCR policy requires staff to
record the inmate confirming his or her refusal to be interviewed. However, the actual process
for conducting video-recorded interviews of inmates involved in a use-of-force incident is
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 13
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
inconsistent among the adult institutions, as some institutions are not following the policy, with
the most common deviations listed below.
Three hundred four incidents that OIG monitored required video recorded interviews. In 33
cases, a video recording was not completed. Video-recorded interviews were completed in 271
incidents; however, in 186 incidents, the video recorded interview, while done, was not
completed according to policy. Combining the 33 cases where no video recording was completed
with the 186 incidents where the video recording was not completed according to policy, results
in a policy compliance rate of only 61 percent. The errors that were found included not
conducting an interview when one was required, interviewers not adequately identifying
themselves or interviewers not adequately identifying the inmate’s injuries. The OIG has
reported these concerns in prior reports. The Department has advised the OIG that it is directing
staff to follow the instructions found in CDCR Form 3013, (REV. 02/10), Inmate Interview
Guidelines. The OIG will continue to monitor this issue and report whether the Department’s
corrective action is effective.
Chart 2: Video Recordings, by Mission/Division
120
111
103
100
80
60 Video Required
47
43 Video Not Completed
38 37 or Out of Policy
40
18
20
10 9
4
1 1
0
HS RC FOPS GP DJJ PAR
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 14
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Pilot Program for Institutional Use-of-Force Reviews
At the OIG’s urging, in 2012 the department began developing a streamlined process for
reviewing use-of-force incidents in which there were no issues after review of the incident
reports. At the time, the department was having difficulty meeting its 30-day timeline for
use-of-force review in some institutions due to the volume of cases. The new process provides
the means by which certain use-of-force incident reports can be placed on a “consent calendar”
based on the decisions reached in the first three levels of review. The OIG recommended a
process whereby each stakeholder would review the incident reports, and if no issues were
found, the incident could be forwarded to the warden for final disposition without having to be
formally heard at the Institutional Executive Review Committee. The recommendation included
a provision that if any of the stakeholders, including the OIG, had questions about any of the
incidents, those incidents would be heard at committee. The original purpose of a streamlined
review process was to provide time for more thorough reviews of incidents most likely to have
issues. The initial indications in this pilot show this type of review is more appropriate at
institutions with lower security and non-mental-health designations.
In order to be considered for “consent” and to bypass a formal IERC review, the incident must
not include any of the following circumstances:
Allegations of unnecessary/excessive use of force;
Serious bodily injury or great bodily injury likely caused by staff use of force;
Controlled use of force;
Extraction;
Use of force possibly out of compliance with policy before, during, or following the
incident;
Discharge of warning shot;
Involvement of any inmate who is a participant in the Mental Health Services Delivery
System (MHSDS) at any level of care.
This change to policy required approval by the Office of Administrative Law, and late in this
reporting period the department implemented the new use-of-force review process at three
institutions (High Desert State Prison in Susanville; Kern Valley State Prison in Delano; and
California State Prison, Los Angeles County, in Lancaster) on a 24-month pilot basis.10
When this change was first recommended, the pilot institutions were chosen based only on the
number of use-of force incidents at that institution. One institution was chosen in each of the
three regions. The IERC process is defined in Title 15, California Code of Regulations,
Section 3268(a)(17), and because the process is defined in regulation, a review by the Office of
Administrative Law was required before the pilot program could be implemented. This led to a
long lead time for implementation. Immediately prior to implementation of the pilot program, it
was recognized that any use of force on a participant in the Mental Health Services Delivery
System required increased scrutiny and would be an inappropriate case for the pilot program, so
due to the high number of mental health inmates at these pilot institutions, very few incidents
met the requirements for consent review. As a result, as noted above, use of force against an
10 Details of the pilot program can be found in Title 15, California Code of Regulations, Section 3999.16 (operative
February 11, 2014, pursuant to Penal Code Section 5058.1(c)).
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 15
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
inmate who was a participant in the MHSDS would receive full review through the IERC. It was
discovered that the institutions identified early in the process that had large numbers of uses of
force and that might benefit from this program also had a large population of inmates
participating in the MHSDS. To better determine if this process will provide efficiencies worth
implementing, the department has recently added Calipatria State Prison to the pilot program, as
it has a low population of inmates receiving mental health care.
During this reporting period, the department reviewed 108 incidents as a part of the pilot
program. Of these, the OIG agreed with the conclusion of 106 of the incidents and the
determinations made on them by the department.
Table 8: Number of Pilot Incidents Reviewed
Cases OIG
Cases CDCR
Institution Concurred with Difference
Referred for Consent
Consent
Calipatria State Prison 54 53 1
High Desert State Prison 18 17 1
Kern Valley State Prison 14 14 0
California State Prison,
22 22 0
Los Angeles County
Total 108 106 2
While it is still too early in the pilot program to make a determination on its efficiency, the table
above illustrates that Calipatria State Prison, an institution with few inmates receiving mental
health care, referred twice as many cases to consent as any other prison in the pilot. If rolled out
statewide, this streamlined process might still prove beneficial, especially since the OIG
monitors 100 percent of those decisions.
Division of Juvenile Justice
During this reporting period the Division of Juvenile Justice (DJJ) consisted of three facilities
and one conservation camp and was responsible for supervising 653 juvenile offenders.11 The
OIG reviewed 155 use-of-force incidents occurring throughout the three juvenile facilities. There
were no incidents in the juvenile conservation camp this reporting period.
Among the 155 incidents reviewed, there were 457 uses of force. The OIG found the reports
adequately articulated the justification for using force and adequately described the force used in
all but 14 of the incidents. In those 14 incidents where the OIG found that the reports did not
adequately articulate the justification for the use-of-force and did not adequately describe the
force, eight resulted in staff training, three resulted in corrective action, and three were referred
for possible disciplinary action. The OIG commends the department on its willingness to identify
and appropriately resolve use-of-force issues in the DJJ.
11 Data derived from:
http://www.cdcr.ca.gov/Reports_Research/docs/research/Population_Overview/POPOVER2014.pdf.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 16
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
The following tables provide summaries of the types and frequency of force used in the juvenile
facilities from July through December 2014.
Table 9: Number of Incidents Reviewed—Division of Juvenile Justice
Facility Incidents
N.A. Chaderjian 59
O.H. Close 41
Ventura 55
Total 155
Table 10: Types of Force—Division of Juvenile Justice
Facility Types of Force Uses
Baton 2
Chemical Agent 169
N.A. Chaderjian
Less-Lethal Force12 1
Physical Force 31
N.A. Chaderjian Total 203
Chemical Agent 101
O.H. Close Less-Lethal Force 3
Physical Force 12
O.H. Close Total 116
Chemical Agent 107
Ventura Less-Lethal Force 1
Physical Force 30
Ventura Total 138
Grand Total 457
12 Less-lethal force used in DJJ consists of foam projectiles fired from a 37mm launcher.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 17
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Division of Adult Parole Operations
During this reporting period the Division of Adult Parole Operations (DAPO) consisted of two
parole regions and was responsible for supervising over 42,000 parolees.13 The OIG reviewed 33
use-of-force incidents: 17 in the north parole region and 16 in the south parole region. Among
the 33 incidents reviewed, there were 39 individual uses of force. Of those incidents where a
determination was made, the OIG found the reports adequately articulated the justification for
using force and adequately described the force used in all cases. The following tables provide
summaries of the types and frequency of force reviewed in the parole regions from July through
December 2014.
Table 11: Types of Force—Parole Regions
Parole Region Types of Force Uses
Baton 1
Chemical Agent 2
PAR-North
Physical Force 12
Taser 6
PAR-North Total 21
Physical Force 13
PAR-South
Taser 5
PAR-South Total 18
Grand Total 39
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 (OCS) is the primary departmental link with allied law
enforcement agencies and the California Emergency Management Agency. Major
responsibilities of OCS 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 reporting period, the OIG conducted reviews of three use-of-force incidents involving
three uses of force by OCS employees; there were two uses of physical force, and one use of a
Taser. Of those three incidents, the OIG found the reports adequately articulated the justification
for using force and adequately described the force used in all cases. In addition, there were two
incidents involving use of deadly force by OCS that the OIG monitored at the Deadly Force
Review Board.
13 Data derived from:
http://www.cdcr.ca.gov/Reports_Research/Offender_Information_Services_Branch/Monthly/TPOP1A/TPOP1Ad14
12.pdf
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 18
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
MONITORING CONTRABAND SURVEILLANCE
WATCH
In 2012, citing concerns by the Legislature that CDCR’s contraband surveillance watch process
was not being applied consistently, the OIG developed a contraband surveillance watch
monitoring program. Contraband surveillance watch is a significant budget driver for CDCR
because it requires additional staffing for one-on-one observations. Additionally, contraband
surveillance watch can subject the State to significant liability if abuses occur or if it is imposed
punitively. 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 notifies the OIG every time an inmate is placed on contraband surveillance
watch. The OIG collects all relevant data, including the name of the inmate, the reason the
inmate was placed on contraband surveillance watch, what contraband was actually found, if
any, and the dates and times the inmate was placed on and taken off watch. The OIG responds on
scene to formally monitor any contraband surveillance watch where a significant medical
problem occurs, regardless of the time the inmate has been on watch, and in all cases where
contraband surveillance watch extends beyond 72 hours. The monitoring includes inspection of
the condition of the inmate and all logs and records, ensuring the department follows its policy.
This on-scene response is repeated every 72 hours until the inmate is removed from contraband
surveillance watch. Any serious breaches of policy are immediately discussed with institution
managers while on scene. For the first time since beginning contraband surveillance watch
monitoring, the OIG now formally assesses the sufficiency of how the department conducts each
contraband surveillance watch extending beyond 72 hours.
During this reporting period, the OIG was notified of 206 contraband surveillance watch cases.
This report does not include contraband surveillance watch cases reported from the out-of-state
facilities. Of these 206 cases, inmates were kept on contraband surveillance watch longer than 72
hours but less than 144 hours in 46 cases; nine cases involved inmates placed on watch for 144 to
216 hours; and four cases extended beyond 216 hours. This report assesses the 59 cases that
extended beyond 72 hours, with a detailed description of the four cases that extended beyond 216
hours. There were no cases during this reporting period where the OIG went on scene as a result
of medical concerns. There were 147 cases that did not extend beyond 72 hours, and in
44 percent of these cases (64 cases), contraband was recovered.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 19
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Contraband was found in 47 percent of the contraband surveillance watch cases that extended
beyond 72 hours.
Chart 3: Duration of Contraband Surveillance Watch Cases
Total Contraband Surveillance Watch Cases = 206
Up to 72 Hours
71%
(147 Cases)
From 72 to 144 Hours
22%
(46 Cases)
From 144 to 216 Hours
Over 216 Hours
2% 5%
(4 Cases) (9 Cases)
Chart 4: Contraband Found in Cases Extending Beyond 72 Hours
Total Cases Contraband
47% 53% Found (28 Cases)
Total Cases Contraband
Not Found (31 Cases)
59 Total Cases Greater Than 72 Hours
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 20
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Chart 5: Contraband Found in Cases Lasting Less Than 72 Hours
Total Cases Contraband
44% 56% Found (64 Cases)
Total Cases Contraband
Not Found (83 Cases)
147 Total Cases
Chart 6: Contraband Found in All Contraband Surveillance Watch Cases
Total Cases Contraband
45% 55% Found (92 Cases)
Total Cases Contraband
Not Found (114 Cases)
206 Total Cases
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 21
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
As previously noted, this report only covers in detail those 59 contraband surveillance watch
cases that extended beyond 72 hours. Contraband was found in 28 cases that extended beyond 72
hours. Drugs were recovered in 61 percent of the cases where contraband was found, while the
remaining recovered contraband primarily consisted of weapons, inmate notes, and other
contraband.
Chart 7: Contraband Type and Frequency in Cases Extending Beyond 72 Hours
70%
65%
60%
55%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Drugs Weapons Inmate Notes Other Tobacco
During this reporting period, the OIG rated the department on the adequacy of its management of
contraband surveillance watch cases monitored by the OIG. Of the 59 cases that exceeded 72
hours, the OIG found that the department sufficiently managed the contraband surveillance
watch process in 31 cases (53 percent) and was insufficient in its management of 28 contraband
surveillance watch cases (47 percent). In those cases where deficiencies were noted, the
department took corrective action mainly via staff training. While the OIG concurs that the
majority of deficiencies could be appropriately addressed through additional staff training, the
same issues are being seen again and again. The OIG recommends the department review its
current contraband surveillance watch training policies and determine where improvements can
be made. The OIG suggests the department develop an on-the-job training component for
custody staff newly assigned to a contraband surveillance watch case. For staff who consistently
fail to follow contraband surveillance watch policy, the OIG recommends the department take
corrective action beyond training, up to and including disciplinary action.
In this reporting period, the department’s contraband surveillance watch placements increased
slightly over the prior reporting period (206 in this period compared to 192, 246, and 293 for the
three prior reporting periods). Also, the number of inmates on contraband surveillance watch
beyond 72 hours trended upward (59 in this period, compared to 48, 75, and 92 in the three prior
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 22
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
reporting periods). Finally, there were four contraband surveillance watch cases exceeding 216
hours in this reporting period, compared to 2, 11, and 8 in the three prior periods.
While the department’s decision for placing an inmate on contraband surveillance watch in all
but seven of the 59 cases exceeding 72 hours was within policy, 34 of those cases had
subsequent policy violations, with many cases having multiple policy violations during the time
the inmate was on contraband surveillance watch.
Chart 8: Policy Violations in Contraband Surveillance Watch Cases
The department failed to document consistent
53%
medical assessments during contraband
surveillance watch.
The department failed to document consistent
hygiene checks during contraband surveillance 49%
watch.
The department failed to timely notify the OIG
25%
when an inmate was placed on contraband
surveillance watch.
The department failed to apply restraints consistent 17%
with policy during contraband surveillance watch.
0% 15% 30% 45% 60% 75% 90%
In the 59 contraband surveillance watch cases that extended beyond 72 hours, the majority of
process violations involved failures to complete appropriate documentation, failures to provide
timely notification to the OIG, and failures to document consistent hygiene checks.
It should be noted that in 31 of the 59 contraband surveillance watch cases that extended beyond
72 hours (nearly 53 percent), medical staff failed to note required medical checks in the inmate’s
medical record, as required by policy. The OIG recommends that the department work with
California Correctional Health Care Services (CCHCS) to ensure medical staff is trained on and
familiar with CCHCS Policy 4.33, Contraband Surveillance Watch.
In 49 percent of contraband surveillance watch cases exceeding 72 hours that incurred policy
violations, the department failed to complete appropriate documentation concerning inmate
hygiene (up from 46 percent from the last reporting period). In 25 percent of cases, the
department failed to timely notify the OIG when an inmate was placed on contraband
surveillance watch (up from 23 percent from the last reporting period).
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 23
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
California Correctional Center had six cases with at least one policy violation; Centinela State
Prison had five cases with at least one policy violation; and High Desert State Prison and the
Richard J. Donovan Correctional Facility each had four cases with at least one policy violation.
Six institutions had cases extending beyond 72 hours with no policy violations: Pelican Bay State
Prison, Kern Valley State Prison, Pleasant Valley State Prison, Folsom State Prison, Avenal
State Prison, and the N.A. Chaderjian Youth Correctional Facility.
When failures to comply with policies and procedures are identified, those responsible should be
held accountable through the department’s disciplinary process if neglect or misconduct is
reasonably believed to have occurred. Without accountability, remediation is unlikely. The OIG
is committed to monitoring this process to avoid abuses and accomplish the legitimate goals of
contraband surveillance watch. With the department’s returned focus on drug interdiction, it
seems likely more contraband surveillance will occur. This makes it even more vital that the
department make better efforts at notifying the OIG in a timely manner to ensure transparency
and eliminate the repeated policy violations to achieve successful outcomes.
The following table details the total number of contraband surveillance watch cases that occurred
during this reporting period at each institution.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 24
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Table 12: Contraband Surveillance Watch Cases, by Institution, July–December 2014
Number of Number of
Number
72 to Less 144 to Less Cases Over Cases Over
of CSW Less Than 216 Hours
Institution Than 144 Than 216 72 Hours 72 Hours
Cases by 72 Hours or More
Hours Hours Rated Rated
Institution
Sufficient Insufficient
ASP 2 1 1 0 0 1 0
CAC 3 2 1 0 0 0 1
CAL 4 3 0 1 0 1 0
CCC 23 17 4 2 0 5 1
CCI 1 1 0 0 0 N/A N/A
CCWF 2 1 1 0 0 0 1
CEN 9 4 5 0 0 2 3
CIW 8 6 1 1 0 0 2
CMC 3 3 0 0 0 N/A N/A
CMF 2 1 1 0 0 0 1
COR 10 9 1 0 0 1 0
CRC 13 10 3 0 0 1 2
CVSP 2 2 0 0 0 N/A N/A
DVI 6 3 3 0 0 3 0
FSP 8 6 1 1 0 2 0
HDSP 5 1 4 0 0 1 3
ISP 5 4 0 0 1 0 1
KVSP 8 7 1 0 0 1 0
LAC 8 7 1 0 0 0 1
MCSP 4 4 0 0 0 N/A N/A
NACYCF 12 10 2 0 0 2 0
NKSP 3 2 1 0 0 0 1
OHCYCF 2 2 0 0 0 N/A N/A
PBSP 13 10 3 0 0 3 0
PVSP 4 3 1 0 0 1 0
RJD 9 5 1 2 1 0 4
SAC 5 3 1 0 1 1 1
SATF 3 3 0 0 0 N/A N/A
SCC 2 1 1 0 0 0 1
SOL 6 3 3 0 0 2 1
SQ 4 2 2 0 0 0 2
SVSP 15 10 2 2 1 3 2
WSP 2 1 1 0 0 1 0
Total
CSW 206 147 46 9 4 31 28
Cases
Contraband Contraband Contraband Contraband
Recovered: Recovered: Recovered: Recovered: Sufficient Insufficient
64 Cases 21 Cases 4 Cases 3 Cases = 52% = 48%
= 44% = 46% = 44% = 75%
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 25
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Contraband surveillance watch is not meant to be a long-term event. As time passes, risks
increase and it becomes a very costly practice. For this reason, the OIG pays close attention and
will continue to report these cases separately. Nevertheless, there are some instances that may
warrant it. A summary of the four cases of contraband surveillance watch lasting over 216 hours
(nine days) is below.
The longest duration for contraband surveillance watch this reporting period lasted 410 hours (17
days). In that case, the department placed an inmate on contraband surveillance watch after
officers observed what appeared to be a transfer of contraband during a kiss with an authorized
visitor. The inmate was removed from contraband surveillance watch 17 days later. During that
time, the department recovered drugs from the inmate. Deficiencies were noted in the
department’s management of this contraband surveillance watch. The OIG did not receive timely
notification of the inmate’s placement on contraband surveillance watch. Required medical
assessments were not consistently conducted. The department addressed these deficiencies by
implementing procedures to ensure that required medical assessments for inmates on contraband
surveillance watch are conducted timely.
The second case involved a 354-hour (14-day) contraband surveillance watch that began after an
inmate told staff that he swallowed razor blades and an x-ray confirmed the presence of a foreign
object. The inmate was removed from contraband surveillance watch 14 days later. During that
time, the department recovered nothing from the inmate. Deficiencies were noted in the
department’s management of this contraband surveillance watch. The department failed to notify
the OIG when the inmate was transported to an outside hospital while on contraband surveillance
watch. The department further failed to adequately document inmate hygiene and restraint
cleaning. The department failed to document proper securing of clothing, initial cell searches,
meals, and blanket issuance and removal in accordance with departmental policy. The
department provided training to all involved custody staff to address these deficiencies.
The third case also involved a contraband surveillance watch that lasted 14 days (348 hours). In
this case, the department placed an inmate on contraband surveillance watch after the inmate
failed to pass a metal detector during a cell search. Specifically, the cell search was conducted
after the department received information that the inmate was in possession of a weapon.
Although a weapon was not recovered, the contraband surveillance watch did yield drugs and
inmate notes. The OIG found no deficiencies in the department’s management of this case.
The fourth and final case of contraband surveillance watch lasting over 216 hours was a case
lasting 288 hours (12 days). An inmate was placed on contraband surveillance watch after an
officer observed an inmate appear to insert something into his rectum while in the visiting room.
The inmate was removed from contraband surveillance watch 12 days later. During that time, the
department recovered approximately 42 grams of heroin from the inmate. Deficiencies were
noted in the department’s management of this contraband surveillance watch. Specifically, the
department failed to timely obtain approval for the third 72-hour extension and failed to timely
notify the OIG of the extension. The department also failed to consistently document supervisory
checks and range of motion releases and failed to document any cleaning of the restraint
equipment. Training was provided to address these deficiencies.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 26
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
VOLUME II CONCLUSION
The goal of publishing the OIG’s Semi-Annual Report in two volumes is to allow the reader to
easily focus on specific areas of monitoring conducted by the OIG. All areas of monitoring
require transparent oversight in order to ensure public trust, proper adherence to policy, best
practices, safety and security of staff and inmates, and accountability to the taxpayer. In all of the
monitoring activities, the OIG alerts the department to potential risks or problem areas and
makes recommendations for improvement. It is the goal of the OIG that this monitoring will help
avoid potential abuse, costly litigation, and expensive federal oversight.
Critical incidents as described within this report have the potential for serious consequences for
staff, inmates, and the taxpayers at large. As such, OIG oversight provides independent
assessment on how the incidents occur, how they are handled, and their outcomes. A 20 percent
decline in timely notification compared to the previous reporting period prevents the
performance of this oversight role and requires attention by CDCR management.
This report repeats our recommendation that the department examine violence directed at SNY
inmates. The OIG attended 390 use-of-force meetings throughout the State and evaluated a total
of 2,148 unique incidents. In the overwhelming number of reviews, the committee took
appropriate action. The department and the OIG noted improvement is needed in following the
video policies. The OIG is also specifically monitoring the use of force on mentally ill inmates.
The OIG’s monitoring of contraband surveillance watch continues to evolve. If documentation
and observation policies are not followed, serious medical issues could occur. If the process does
not maintain policy integrity, there may also be a waste of departmental resources. Overall, the
OIG found the department to be insufficient in its management of contraband surveillance watch
in almost half (47 percent) of the cases that exceeded 72 hours, with the majority of deficiencies
being related to poor documentation. These cases will likely increase due to the new focus on
drug interdiction, making OIG oversight even more important.
Another area of concern is that while the department does have a policy related to threat
assessments for threats against parole agents and other government officials, the department
lacks consistent statewide threat assessment procedures to follow when an inmate attacks a line
staff member, such as an officer. Institutions have individual local operating procedures, but
there is no statewide policy. In one case, inmates planned and executed an attack on an officer
while on duty. The institution completed a threat assessment 30 days after the incident. However,
despite numerous requests by the OIG, the department did not provide the threat assessment to
the OIG until over six months after its completion. After reviewing the threat assessment, the
OIG found it vague, not identifying why the officer was attacked. The OIG recommended the
institution request a threat assessment by the department’s experts, the Office of Correctional
Safety, but the institution declined.
The OIG is concerned for the safety and security of all employees and recommends the
department review and enact consistent policies to minimize future occurrences and determine
the source of all threats against staff when possible.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 27
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
The department is not acting consistently in instances where an inmate swallows a razor blade.
An institution is authorized to place an inmate on contraband surveillance watch when there is
reasonable suspicion that the inmate has concealed contraband in his or her body. A question has
arisen whether a razor blade is considered contraband for purposes of the contraband
surveillance watch policy. Inmates in a general population setting are entitled to possess razors
for grooming, while inmates in segregated housing are not, making razors contraband in one
setting and not the other. Most institutions have initiated contraband surveillance watch protocols
for inmates who reported swallowing a razor blade, regardless of their assigned housing
program. Institutions placing inmates on contraband surveillance watch generally articulate that
when an inmate removes the blade from the shaving razor, it becomes contraband. However, in
November 2014, the Director of Adult Institutions stated that a general population inmate should
not be placed on contraband surveillance watch for swallowing a razor blade because it is an
item he or she is entitled to have and is, therefore, not contraband. Even if not viewed as a
security issue, the inmate still should be observed or monitored in a setting that will prevent any
health risks. An inmate is certainly not authorized to possess a razor in an altered state within his
or her body.
The practice at different institutions has remained inconsistent, with some placing the inmates on
contraband surveillance watch, some placing them in a medical setting, and a few doing neither.
Therefore, the OIG recommends that the department develop a clear policy for inmates who
swallow, or reportedly swallow, foreign objects such as razor blades. The OIG further
recommends that the department ensure its position is known to all institutions to prevent the
inconsistent application of the contraband surveillance watch policy as it relates to razor blades
and similar ingested items. Finally, the OIG recommends that the department address staffing
needs if and when an inmate is placed simultaneously on contraband surveillance watch and
suicide watch. Currently, mental health and custody staff are often assigned simultaneously to
watch the same inmate, which may be a waste of resources.
Oversight is a critical element for the transparency of the California corrections system. As this
Semi-Annual Report reflects, the OIG continues to provide recommendations to the department
with the goal of the department’s processes continuing to improve. The OIG is committed to
monitoring the vital areas of critical incidents, use of force, and contraband surveillance watch
and to providing transparency to the California correctional system.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 28
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
VOLUME II RECOMMENDATIONS
The OIG commends the department for implementing prior recommendations and
continues to encourage CDCR to implement those that remain. The OIG recommends the
department implement the following recommendations from Volume II of this
Semi-Annual Report, July–December 2014.
Recommendation 2.1 The OIG recommends the department develop a consistent statewide
policy for threat assessments when an inmate attacks a line staff member, such as an officer.
Recommendation 2.2 The OIG recommends that the department develop a clear policy for
inmates who swallow foreign objects such as razor blades. The OIG further recommends that the
department ensure its position is known to all institutions to avoid inconsistent application of
contraband surveillance watch policy.
Recommendation 2.3 The OIG recommends that the department evaluate the concurrent
monitoring when an inmate is simultaneously placed on suicide watch and contraband
surveillance watch.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 29
OFFICE OF THE 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, January–June 2014.
Recommendation 2.1 The OIG recommends the department revise CDCR Form 3013, Inmate
Interview Guidelines to clearly include the following instructions:
The video recording shall be conducted by persons uninvolved in the incident.
The interview shall be conducted in a location conducive to acquiring a clear recording of the
interview, free of outside noise or distractions.
The video recording should be made within 48 hours of discovery of the injury or allegation.
The inmate shall be told, on camera, the reason for the interview, i.e., “You made an
allegation of unnecessary or excessive use of force,” or “You sustained an injury during the
incident.”
The interviewer shall not interfere with the inmate’s ability to be interviewed.
CDCR Response: Substantially Implemented
The department has initiated a workgroup to amend its use-of-force policy, which is now in the
third phase of implementation. The modifications will encompass clarification and direction on
the interviewing process.
The department will make every effort to ensure that inmate interviews are free of outside noise
or distractions. However, in a prison environment, background noise cannot always be avoided.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 30
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Recommendation 2.2 The OIG recommends the department review and revise its current
policies regarding cellmate placement and double celling on sensitive needs yards.
Implementation steps should include the following:
Institute compatibility guidelines requiring the completion of CDCR Form 1882-A, General
Population Double Cell Review and completion of the CDCR Form 1882-B, Administrative
Segregation Unit/Security Housing Unit Double Cell Review to help ensure that inmates are
properly housed with compatible cellmates.
Require potential cellmates to document their agreement to house together.
Provide clear guidelines for transitioning single-cell-designated inmates to double-cell status
on sensitive needs yards.
Require that central files of inmates on sensitive needs yards are reviewed for propensity for
violence and prior assaultive behavior before double celling (part of the CDCR Form 1882-A
process).
CDCR Response: Not Implemented
The department is reviewing the current practice of double celling inmates on sensitive needs
yards.
The department will take into consideration the information provided by the OIG. The OIG’s
two reporting periods (one year) do not provide enough historical data to develop a hypothesis
for the increase of inmate homicides in housing on sensitive needs yards. At this time, there will
not be any modifications to the department’s current policy. However, the department will
continue to review the current practices and any developing trends that become apparent.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 31
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
The OIG recommended the department implement the following recommendation from
Volume II of the Semi-Annual Report, July–December 2013.
Recommendation 2.1 The OIG recommends the department, including the Department of
Juvenile Justice, implement a statewide policy directing the investigative services unit at each
institution to investigate the origin of narcotics whenever they are discovered during contraband
surveillance watch, cell searches, or overdose. This would include, but not be limited to,
obtaining visitor logs and surveillance video as it pertains to the inmate or ward in question. If
such a policy is in existence, additional training is necessary to ensure it is followed statewide.
CDCR Response: Fully Implemented
It is the expectation all criminal activity is thoroughly investigated in a timely manner and in
accordance with the law. DAI will direct wardens to ensure Investigative Services Unit post
orders encompass due diligence requirements for investigations, including, but not limited to,
narcotics discoveries. Wardens will be informed of the requirement at the next Wardens’ meeting
and will be required to provide proof of practice.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 32
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
The OIG recommended the department implement the following recommendations from
Volume II of the Semi-Annual Report, January–June 2013.
Recommendation 2.1 The OIG recommends refresher training for all wardens and institution
administrative officers of the day on the requirement and process for prompt notification to the
OIG on all critical incidents.
CDCR Response: Fully Implemented
On February 3, 2014, wardens and all staff members responsible for overseeing or performing
the duties of an Administrative Officer of the Day (AOD) were provided an instructional
memorandum amending the AOD Notification Matrix. The amended AOD Notification Matrix
provided additional persons and offices that shall be notified of certain incidents and provided
clarity as to what shall be reported. This amended AOD Notification Matrix has been in effect
since February 3, 2014.
Recommendation 2.4 The OIG recommends the department develop a policy that defines when
the clock officially starts for contraband surveillance watch.
CDCR Response: Substantially Implemented
On March 28, 2014, a contraband surveillance watch workgroup met to discuss and clarify
CDCR’s policy as to when an inmate is officially on contraband surveillance watch. The group
concluded that the most prudent time measurement for an inmate on contraband surveillance
watch would be the day/date calculation. This time measurement is consistent with most other
departmental policy time frames and should simplify and enhance the contraband surveillance
watch tracking, extension, and notification process.
Contraband Surveillance Watch Start Clock Defined: The contraband surveillance watch time
measurement clock shall start on the day/date the inmate is initially placed on contraband
surveillance watch. An inmate is initially placed on contraband surveillance watch when staff has
identified the need for contraband surveillance watch and has implemented observation or
restraint measures, e.g., the inmate is isolated, staff begins direct and constant observation of the
inmate, the inmate is placed in waist chains or taped clothing, etc.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 33
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Recommendation 2.5 The OIG recommends the department ensure that each institution conduct
thorough training for all custody staff on all policies and procedures of contraband surveillance
watch. This should include supervisor training so those tasked with ensuring compliance are also
fully familiar with and enforcing those policies and procedures.
CDCR Response: Fully Implemented
All available institution custody managers and supervisors were provided refresher contraband
surveillance watch training. This training was completed on January 1, 2014. Any institution
custody managers and supervisors who did not receive the training due to a long term absence,
e.g., extended sick leave, military duty, etc., will be required to take the refresher training upon
their return to duty. Additionally, as new institution custody managers and supervisors are hired,
they will be provided refresher contraband surveillance watch training accordingly.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 34
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
TABLE OF CHARTS
Table 1: Number of Separate Use-of-Force Incidents Reviewed, by Division .............................. 7
Table 2: Staff Contribution to the Need for Force, by Mission ...................................................... 9
Table 3: In-State Inmate Population, by Mission ......................................................................... 10
Table 4: Number of Incidents Reviewed by the OIG, by Mission Within DAI ........................... 10
Table 5: Frequency of Force by Type in Reviews Completed, Grouped by Mission .................. 11
Table 6: Use of Force, by Mental Health Status ........................................................................... 12
Chart 1: Frequency of Force by Type for Mental Health Population ........................................... 12
Table 7: Frequency of Force by Type, Grouped by Mental Health Status ................................... 13
Chart 2: Video Recordings, by Mission/Division ......................................................................... 14
Table 8: Number of Pilot Incidents Reviewed .............................................................................. 16
Table 9: Number of Incidents Reviewed—Division of Juvenile Justice ...................................... 17
Table 10: Types of Force—Division of Juvenile Justice .............................................................. 17
Table 11: Types of Force—Parole Regions .................................................................................. 18
Chart 3: Duration of Contraband Surveillance Watch Cases ........................................................ 20
Chart 4: Contraband Found in Cases Extending Beyond 72 Hours.............................................. 20
Chart 5: Contraband Found in Cases Lasting Less Than 72 Hours .............................................. 21
Chart 6: Contraband Found in All Contraband Surveillance Watch Cases .................................. 21
Chart 7: Contraband Type and Frequency in Cases Extending Beyond 72 Hours ....................... 22
Chart 8: Policy Violations in Contraband Surveillance Watch Cases .......................................... 23
Table 12: Contraband Surveillance Watch Cases, by Institution, July–December 2014 ............. 25
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 35
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
APPENDICES
Appendix D contains the assessments for 46 deadly force incidents monitored Page 37
during the reporting period, listed by geographical region.
D1 contains the assessments for 7 deadly force incidents monitored by Page 37
the OIG during the reporting period but not investigated by the Office of
Internal Affairs, listed by geographical region.
D2 contains the assessments for 39 deadly force cases investigated by Page 41
the Office of Internal Affairs and monitored by the OIG during the
reporting period, listed by geographical region.
Appendix E contains the assessments for 85 critical incidents monitored during Page 64
this reporting period, listed by geographical region.
Appendix F contains the results and outcomes of 59 OIG-monitored Page 103
contraband surveillance watch cases during the reporting period, listed by the
date the inmate was placed on contraband surveillance watch.
SEMI-ANNUAL REPORT VOLUME II JULY–DECEMBER 2014 PAGE 36
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
APPENDIX D1 7
MONITORED DEADLY FORCE INCIDENTS
Central Region
Incident Date: 2014-04-26 Deadly Force Incident
Incident Summary OIG Case Number: 14-1055-RO
On April 26, 2014, six inmates began fighting on an exercise yard. The observation officer gave repeated orders for all inmates on the
exercise yard to get down; however, the inmates who were fighting ignored the orders. Responding custody staff deployed chemical agents
without effect. The observation officer continued to order the inmates to get down. The fighting inmates continued ignoring the orders.
Other uninvolved inmates refused to get in a seated position and began moving towards the fighting inmates. The observation officer
discharged a warning shot from a Mini-14 rifle into a safe area. This caused some of the fighting inmates to stop; however, two inmates
continued attacking a third inmate and other uninvolved inmates continued slowly moving towards the fighting inmates. The observation
officer discharged another warning shot from the Mini-14 rifle into a safe area. This ultimately caused all inmates to comply with orders to
get down. The third inmate who was being attacked sustained bleeding, swelling, and bruising to his face as a result of the attack. None of
the inmates sustained serious injury. The department adequately notified the OIG and the OIG responded to the scene.
Disposition
There did not appear to be an immediate threat to justify the observation officer's two warning shots. Therefore, potential staff misconduct
was identified and the case was referred to OIA Central Intake before going to the institution's executive review committee. An
investigation was opened, which the OIG accepted for monitoring.
Incident Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident.
Incident Date: 2014-05-27 Deadly Force Incident
Incident Summary OIG Case Number: 14-1229-RO
On May 27, 2014, three inmates attacked a fourth inmate on an exercise yard, punching and kicking the fourth inmate in the head. The
observation officer ordered the inmates to get down but the three inmates continued their attack. The observation officer then noticed one
of the aggressors attempt to stab the fourth inmate with an inmate-manufactured weapon. The observation officer aimed a less-lethal round
at that aggressor's thigh but missed and struck another aggressor in the shoulder. The three inmates ignored additional orders to get down
and continued to punch, kick, and stab at the fourth inmate. The observation officer transitioned to the Mini-14 rifle and fired a warning shot
at an open area on the ground, away from any inmates and staff. However, the three inmates continued their attack. Another officer
deployed a pepper spray grenade, causing the main aggressor with the weapon to move away from the fourth inmate, but the other two
aggressors continued to punch the fourth inmate. The observation officer then aimed a second less-lethal round at one of the remaining
aggressors, but it missed and struck the ground. The inmates then complied with orders and got down. The fourth inmate was taken to the
triage and treatment area for further treatment but was rehoused later the same day. The OIG was timely notified and responded to the
scene.
Disposition
The institution’s executive review committee determined that the use of force was in compliance with departmental policy. No staff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation. The OIG concurred.
Incident Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 37
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Incident Date: 2013-06-21 Deadly Force Incident
Incident Summary OIG Case Number: 13-0896-RO
On June 21, 2013, a riot erupted involving 21 inmates. An officer in an observation tower observed approximately five inmatesstriking an
inmate who was on the ground and unable to defend himself. The officer fired one warning shot from a Mini-14 rifle, which stopped the
attack on the defenseless inmate; however, the riot continued. Three inmates later returned to the defenseless inmate and began striking
him again. The observation officer again fired a warning shot from a Mini-14 rifle, which stopped the attack on the defenseless inmate, while
the riot continued. Responding custody staff deployed chemical agents and less-lethal rounds to try to gain control of the incident; however,
the involved inmates continued to riot. The observation officer saw an inmate knock another inmate to the ground and then continue to
strike the defenseless inmate. The observation officer fired a third warning shot from a Mini-14 rifle. This warning shot caused the inmates to
stop rioting. All injuries were minor in nature and consistent with fighting. The department adequately notified the OIG and the OIG
responded on scene.
Disposition
The institution's executive review committee determined the use of force was in compliance with departmental policy. No staffmisconduct
was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation. The OIG concurred.
Incident Assessment Rating: Insufficient
The department's response was not adequate because the institution's executive review committee did not finalize the review of the
incident until January 15, 2014, almost seven months after the date of the incident.
Assessment Questions
Did the use-of-force review committee adequately review and respond to the incident?
The incident occurred on June 21, 2013, and was not brought to the executive review committee until January 15, 2014, almost seven
months later, in violation of departmental policy.
Incident Date: 2014-06-25 Deadly Force Incident
Incident Summary OIG Case Number: 14-1516-RO
On June 25, 2014, two inmates attacked a third inmate on an exercise yard. An officer ordered all inmates to get down. All inmates complied
except the three involved inmates. The tower officer gave an additional order to get down but the involved inmates still failed to comply.
Through binoculars, the tower officer saw one inmate striking another inmate in the back of the head with a weapon and the inmate being
struck was unable to defend himself. The officer fired one warning shot from a Mini-14 rifle and the inmates immediately got on the ground.
The department adequately notified the OIG and the OIG responded on scene.
Disposition
The institution’s executive review committee determined the use of force was in compliance with the departmental policy. No staff
misconduct was identified. The OIG concurred.
Incident Assessment Rating: Insufficient
The department’s response was not adequate because the institution's executive review committee did not finalize the review of the
incident until December 15, 2014, almost six months after the date of the incident.
Assessment Questions
Did the use-of-force review committee adequately review and respond to the incident?
The institution's executive review committee did not finalize the review of the incident until December 15, 2014, almost six months
after the date of the incident.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 38
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Incident Date: 2014-07-03 Deadly Force Incident
Incident Summary OIG Case Number: 14-1582-RO
On July 3, 2014, two inmates were observed attacking another inmate on the exercise yard. The two inmates made stabbing motions and
kicked the other inmate in the head. The inmates refused orders to stop fighting. An observation officer fired a warning shotfrom a Mini-14
rifle. Two officers simultaneously deployed pepper spray. The injured inmate sustained bleeding head wounds and was transported to an
outside hospital for medical treatment. The inmate was later returned to the institution. The department adequately notified the OIG and
the OIG responded on scene.
Disposition
The institution’s executive review committee determined that the use of force was in compliance with departmental policy. No staff
misconduct was identified. The OIG concurred.
Incident Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident.
Incident Date: 2014-09-17 Deadly Force Incident
Incident Summary OIG Case Number: 14-2266-RO
On September 17, 2014, two inmates attacked a third inmate on an exercise yard, striking the inmate in the head and upper torso in a
stabbing motion. The yard observation officer gave orders for all inmates to get down, to which all inmates complied except the involved
inmates. The third inmate ran toward the observation tower while pursued by the first two inmates, as well as a fourth inmatewho got up
and ran towards the third inmate. The observation officer saw a weapon in the hands of one of the inmates and observed him striking the
third inmate with stabbing motions. The observation officer fired a single warning shot from a Mini-14 rifle which stopped the attack. The
third inmate was transported to an outside hospital for treatment of lacerations and puncture wounds. He returned to the institution two
days later. The OIG was timely notified and responded on scene.
Disposition
The institution's executive review committee determined that the use of force was in compliance with departmental policy. No staff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation. The OIG concurred.
Incident Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident.
South Region
Incident Date: 2014-08-04 Deadly Force Incident
Incident Summary OIG Case Number: 14-1861-RO
On August 4, 2014, an officer observed an inmate on the ground being beaten by two other inmates. The inmate being beaten was
unresponsive, in a fetal position, and unable to defend himself. One of the inmates was striking the victim in a manner consistent with a
stabbing assault. The officer fired one warning shot from a Mini-14 rifle into a wall adjacent to where he saw the inmate on the ground. The
department adequately notified the OIG and the OIG responded on scene.
Disposition
The institution's executive review committee determined that the use of force was in compliance with departmental policy. No staff
misconduct was identified. The OIG concurred.
Incident Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 39
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 40
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
APPENDIX D2 39
INVESTIGATED AND MONITORED
DEADLY FORCE CASES
Central Region
Incident Date: 2014-07-15 Deadly Force Incident
Incident Summary
On July 15, 2014, a suicidal inmate reported that he wanted to kill someone. The inmate then threw a milk carton and punched an officer in
the eye, causing the officer to hit the wall and fall to the ground. A second officer ordered the inmate to get down but the inmate advanced
towards the first officer. The second officer aimed his baton at the inmate's thigh but was not sure where the baton struck because the
inmate slipped. The inmate then began lunging at the second officer. The second officer held the baton with both hands to block the
inmate's advance and allegedly struck the inmate's face with the baton. Additional officers responded and ultimately subdued the inmate.
The inmate sustained bruising, redness, and swelling to his face, head, knees, and hands. He was taken to the triage and treatment area for
evaluation and returned to his cell the same day. The first two officers and a third officer were taken to an outside hospital for treatment.
The first two officers remain off work due to their injuries, but the third officer returned to work. The Office of Internal Affairs and the OIG
were timely notified and both responded to the scene.
Administrative Investigation OIG Case Number: 14-1779-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Insufficient
The department's predisciplinary process failed to sufficiently comply with policies and procedures. The Office of Internal Affairs failed to
timely respond to the incident and failed to provide a draft report to the OIG. The institution failed to obtain adequate initial reports
regarding the incident.
Assessment Questions
Did the OIA adequately respond to the incident?
The Office of Internal Affairs delayed more than six hours in responding to the scene.
Was the critical incident adequately documented?
The institution failed to properly document the incident. The institution initially obtained two different written versions of the incident,
one from the involved officer and one from a supervisor who recorded a telephone interview with the officer.
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
The special agent failed to provide a copy of the draft investigative report to the OIG.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with this determination. The institution's executive review
committee determined that the use of force was within departmental policy; however, the hiring authority issued a letter of instruction to
the incident commander for failure to submit a thorough and accurate incident report. The OIG concurred.
Incident Date: 2014-10-30 Deadly Force Incident
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 41
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Incident Summary
On October 30, 2014, six inmates began fighting in a housing unit. All inmates ignored orders to get down. A control booth officer fired six
less-lethal rounds at the buttocks and legs of the fighting inmates but the officer did not see where the rounds struck. The inmates
continued to fight. Several responding officers used pepper spray which caused most inmates to stop fighting; however, one inmate
continued attacking an inmate who was no longer fighting back. One of the responding officers gave additional orders to get down but the
inmate kept attacking the second inmate. The officer fired one less-lethal round at the first inmate's buttocks but did not know where the
round struck. Another officer used pepper spray to finally stop the attack. Nine inmates were treated for minor injuries at the institution.
One of the inmates claimed a less-lethal round struck the back of his head. The Office of Internal Affairs and the OIG were timely notified
and both responded to the scene.
Administrative Investigation OIG Case Number: 14-2583-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Insufficient
The department failed to sufficiently comply with policies and procedures governing the predisciplinary process. OIA Central Intake delayed
processing the case. In addition, the Office of Internal Affairs failed to conduct a proper investigation by not taking proper equipment to the
scene and failed to provide the draft investigative report to the OIG.
Assessment Questions
Did OIA Central Intake make a determination regarding the case within 30 calendar days?
OIA Central Intake received the request for investigation on October 31, 2014, but did not take action until December 24, 2014, 54
days after the receipt of the request.
Upon arrival at the scene, did the Deadly Force Investigation Team special agent adequately perform the required preliminary tasks?
The special agent did not take a camera to the scene. Therefore, he was unable to take adequately photograph the inmate's injuries.
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
The Office of Internal Affairs did not provide the OIG with a draft copy of the investigative report.
Was the predisciplinary/investigative phase conducted with due diligence?
OIA Central Intake failed to process the case in a timely manner.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force complied with departmental policy and the OIG concurred.
Incident Date: 2014-10-07 Deadly Force Incident
Incident Summary
On October 7, 2014, two inmates began fighting on an exercise yard. After the two inmates ignored orders to stop fighting, anofficer fired
one less-lethal round at the ground seven feet away from the inmates, causing the less-lethal round to skip. The two inmates continued to
fight. The officer then fired a less-lethal round at one of the inmate's thighs but the inmates kept fighting. The officer fired another less-
lethal round, again aiming at one of the inmate's thighs, causing both inmates to get down. At the same time, a second officer had observed
the fighting inmates and gave orders for the inmates to get down, which the inmates had ignored. The second officer fired a less-lethal
round aiming at an inmate's thigh but did not see where the round struck. The inmates began to comply with orders to get down. The
inmates were taken to the triage and treatment area where one of the inmates reported he had been struck in the head by a less-lethal
round. That inmate sustained abrasions to the back of his head. Both inmates were later rehoused the same day. Both the Office of Internal
Affairs and the OIG were notified and responded to the scene.
Administrative Investigation OIG Case Number: 14-2451-IR
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 42
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department failed to sufficiently comply with policies and procedures governing the predisciplinary process. The hiring authority failed
to timely notify the OIG and the special agent failed to provide the draft investigative report to the OIG.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified by the hiring authority until the OIG was already at the institution. The OIG was notified by the Office of
Internal Affairs and responded on scene.
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
A draft report was not provided to the OIG.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined that use of force was within departmental policy. The OIG concurred with the determination.
Incident Date: 2014-09-25 Deadly Force Incident
Incident Summary
On September 25, 2014, a control booth officer observed one inmate repeatedly strike a second inmate's head with his fists while they
were on the upper tier of a housing unit. Both inmates ignored the control booth officer's orders to get down. The control booth officer
discharged a less-lethal round, aiming at the first inmate's hip. The control booth officer did not see where the round struck; however, the
first inmate sustained abrasions, bruising, pain, redness, and swelling on his neck which appeared consistent with being struck by a less-
lethal round. The OIG and the Office of Internal Affairs were not timely notified but both responded on scene.
Administrative Investigation OIG Case Number: 14-2450-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department’s predisciplinary process failed to sufficiently comply with policies and procedures. The institution failed to timely notify the
OIG and the Office of Internal Affairs. Additionally, the institution's executive review committee made a determination regarding the
incident before OIA Central Intake completed its determination.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The Office of Internal Affairs was not notified until more than three hours after the incident.
Was the OIG promptly informed of the critical incident?
The OIG was not notified until more than three hours after the incident.
Was the HA's response to the critical incident appropriate?
The institution's executive review committee made a determination regarding the incident on October 17, 2014; however, OIA Central
Intake did not complete its determination until October 22, 2014. Since the deadly force investigation team responded to the incident
and the matter was referred to OIA Central Intake, the institution's executive review committee should have postponed its review.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 43
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined the control booth officer's use of force was within departmental policy. The OIG concurred.
Incident Date: 2014-09-08 Deadly Force Incident
Incident Summary
On September 8, 2014, an officer saw two inmates striking each other in the face with their fists. The officer activated his alarm and
ordered both inmates to get down; however, both inmates continued fighting. The officer fired a less-lethal round, aiming at one of the
inmate's thighs, but the officer did not know where the round struck. The inmates continued to fight and ignored the officer's repeated
orders to get down. Eventually, one of the inmates began choking the other inmate. The officer fired a second less-lethal round, aiming at
the lower leg of the inmate who was choking the other inmate, striking the intended target and causing both inmates to stop fighting. The
inmate who began choking the other inmate claimed that a less-lethal round ricocheted and struck him in the head. That inmate had
abrasions and redness to his head. Both inmates were medically examined and rehoused the same day as the incident. The Officeof
Internal Affairs and the OIG were notified and both responded to the scene.
Administrative Investigation OIG Case Number: 14-2281-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department's predisciplinary process failed to comply with policies and procedures because the Office of Internal Affairsfailed to
provide the OIG with a draft copy of its memorandum which assessed the possible use of deadly force.
Assessment Questions
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
The Office of Internal Affairs failed to provide the OIG with a draft copy of its memorandum wherein it was determined the incident did
not meet the Office of Internal Affairs' criteria to open a deadly force investigation.
Did the special agent cooperate with and provide continual real-time consultation with the OIG?
The special agent failed to provide a draft copy of the investigative memorandum.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined the discharge of the less-lethal round was in compliance with the department's use-of-force policy. The OIG
concurred.
Incident Date: 2014-09-04 Deadly Force Incident
Incident Summary
On September 4, 2014, an inmate porter asked for a cell door to be opened to hand an item to an inmate in the cell. As the control booth
officer began to open the cell door, the inmate porter squeezed through the opening and began striking the inmate in the cell. The inmate's
cellmate also began to attack the inmate. The control booth officer activated his alarm and gave orders for the inmates to get down. The
inmates continued fighting, moving outside of the cell. The control booth officer fired two less-lethal rounds at the aggressor inmates. A
responding officer utilized a pepper spray grenade which ultimately caused the inmates to stop fighting. All inmates were medically
evaluated and rehoused. During the medical evaluation, it was determined that one inmate was struck in the forehead with a less-lethal
round. The Office of Internal Affairs and the OIG were notified and both responded on scene.
Administrative Investigation OIG Case Number: 14-2280-IR
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 44
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department’s response was not adequate because the Office of Internal Affairs failed to provide the OIG with a draft copyof the
investigative report to allow for feedback.
Assessment Questions
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
A draft copy of the investigative report was not provided to the OIG.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined that the use of force was in compliance with departmental policy. However, potential staff misconduct related to
the control booth officer opening the cell door was identified. The OIG concurred. The hiring authority referred the case to the Office of
Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Incident Date: 2013-11-05 Deadly Force Incident
Incident Summary
On November 5, 2013, a special agent and a parole agent from the Office of Correctional Safety participated in a joint task force operation
with outside law enforcement agencies in order to apprehend a fugitive. After receiving information regarding the fugitive's whereabouts,
members of the joint task force entered a residence and encountered gunfire from the fugitive. During the entry, the fugitiveshot and
injured a parole agent and, in response, the special agent and other outside law enforcement officers discharged multiple rounds from their
firearms. The fugitive fled the residence while continuing gunfire. As the fugitive exited the residence, another parole agent and an outside
law enforcement officer shot at the suspect. The fugitive died as a result of multiple gunshot wounds. The Office of InternalAffairs and the
OIG were notified and both responded to the scene.
Administrative Investigation OIG Case Number: 13-2482-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. Exonerated No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Insufficient
The department's predisciplinary process failed to comply with the department's policies and procedures. The department attorney failed
to accurately confirm the deadline for taking disciplinary action, failed to provide the OIG with a written summary regardinghis review of
the draft investigative report, and failed to identify the appropriate allegations at the findings conference. The Office of Internal Affairs
failed to provide adequate notice regarding an interview conducted by outside law enforcement. The hiring authority failed totimely
conduct the findings conference.
Assessment Questions
Within 21 calendar days, did the department attorney make an entry into CMS accurately confirming the date of the reported
incident, the date of discovery, the deadline for taking disciplinary action, and any exceptions to the deadline known at thetime?
Although the department attorney made a timely CMS entry confirming key dates, he incorrectly noted the deadline for taking
disciplinary action as November 7, 2014, instead of November 5, 2014.
Did the department attorney provide written confirmation summarizing all critical discussions about the investigative report to the
special agent with a copy to the OIG?
The department attorney sent an e-mail message to the special agent regarding his review of the draft investigative report. However,
the department attorney failed to share the written confirmation with the OIG.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 45
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Did the special agent cooperate with and provide continual real-time consultation with the OIG?
The special agent sent e-mail notification for an interview being conducted that same day by outside law enforcement regarding the
related criminal investigation. Rather than calling the OIG to immediately notify of the interview, the special agent sent e-mail
notification three hours before the interview was scheduled to commence. The interview location was two hours away and the OIG
was unable to attend.
Did the HA timely consult with the OIG and department attorney (if applicable), regarding the sufficiency of the investigation and the
investigative findings?
On September 25, 2014, the Deadly Force Review Board forwarded its findings to the hiring authority that the uses of deadly force
complied with departmental policy; however, the hiring authority did not meet with the department attorney and the OIG regarding
investigative findings until October 27, 2014, 32 days after the Deadly Force Review Board's results memorandum.
Did the VA provide appropriate legal consultation to the HA regarding the sufficiency of the investigation and investigative findings?
The department attorney failed to identify the appropriate allegation as a use of deadly force. Instead, the department attorney
recommended the appropriate allegation to be a use-of-force policy violation.
Was the predisciplinary/investigative phase conducted with due diligence?
The hiring authority failed to timely consult with the OIG and the department attorney regarding the investigative findings.
Disposition
The Deadly Force Review Board found that the discharge of the lethal rounds complied with the department's use-of-force policy. The hiring
authority subsequently exonerated the special agent and the parole agent. The OIG concurred.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's disciplinary process sufficiently complied with policies and procedures.
Incident Date: 2014-08-20 Deadly Force Incident
Incident Summary
On August 20, 2014, an officer observed a two-on-one inmate altercation. The officer gave numerous orders for the inmates to stop with no
effect. The officer discharged a less-lethal round which struck an inmate on the head as the inmate engaged in a fight on an exercise yard.
The Office of Internal affairs and the OIG were both timely notified and both responded to the scene.
Administrative Investigation OIG Case Number: 14-2117-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined the use of force was within policy. The OIG concurred with the determination.
Incident Date: 2014-07-08 Deadly Force Incident
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 46
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Incident Summary
On July 8, 2014, a control booth officer observed two inmates fighting in the dayroom. The inmates ignored the control booth officer's
orders to get down and continued fighting. The control booth officer fired one less-lethal round, aiming at one of the inmate's right thigh.
The control booth officer was unable to see where the less-lethal round struck and the round did not stop the inmates. However, the
inmates complied with orders to stop fighting once the door opened allowing more officers to respond. Both inmates had injuries from the
fight. Additionally, one of the inmates reported being struck by the less-lethal round in the same place on his face where the second inmate
had punched him. The inmate explained that he was struck by the less-lethal round while the second inmate had him in a choke-hold. The
first inmate was taken to an outside hospital for further examination and returned to the institution three days later. The second inmate
had an injury to his left arm that could have been consistent with being struck by the less-lethal round. Neither the Office of Internal Affairs
nor the OIG were timely notified; however, both responded to the scene.
Administrative Investigation OIG Case Number: 14-1656-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department’s predisciplinary process failed to sufficiently comply with policies and procedures. The institution failed to timely notify the
OIG and the Office of Internal Affairs.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The Office of Internal Affairs was not notified until almost three hours after the incident occurred.
Was the OIG promptly informed of the critical incident?
The OIG was not notified until almost three hours after the incident occurred.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined the control booth officer's use of force was within policy; however, the video-taped interview of the inmate
following the incident was determined to be out of policy because the purpose of the video-taped interview was not adequately explained
to the inmate. Training was provided. The OIG concurred.
Incident Date: 2014-07-08 Deadly Force Incident
Incident Summary
On July 8, 2014, three inmates began attacking a fourth inmate, punching and kicking him while he was on the ground. Pepper spray
grenades were deployed, but the inmates continued their attack. Two officers each fired one less-lethal round, aiming at the hip area of two
different attackers. Neither officer could confirm where his respective round struck. However, a less-lethal round may have struck the
inmate who was being attacked. That inmate sustained a possible concussion and lacerations to the left side of his head and the bridge of
his nose. He was taken to an outside hospital for further treatment and returned to the institution on July 11, 2014. The Office of Internal
Affairs and the OIG responded to the scene.
Administrative Investigation OIG Case Number: 14-1649-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s predisciplinary process sufficiently complied with policies and procedures.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 47
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee found no violation of departmental policy. The OIG concurred.
Incident Date: 2014-06-20 Deadly Force Incident
Incident Summary
On June 20, 2014, an inmate became irate with an officer because the officer refused to return a magazine picture the inmate had been
using to block his cell window. The inmate used profanity and yelled that he would fight the officer and punched the officer on the
forehead. A second officer saw the altercation, activated his alarm, and ordered inmates to get down; however, the inmate involved in the
altercation refused to get down. The first officer attempted to control the inmate by grabbing the inmate's arms but the inmate kept
punching the first officer in the face. The first officer attempted to defend himself by punching at the inmate's face. The second officer
attempted to use his baton, aiming at the inmate's bicep; however, the inmate then punched the second officer, causing the second officer
to lose control of the baton. The second officer was unsure if the baton struck the inmate. The inmate was taken to the correctional
treatment center for medical evaluation and rehoused later the same day. The two officers were taken to outside hospitals fortreatment of
injuries, both sustaining minor injuries to the head and knees. Both officers later returned to work. On June 22, 2014, the institution
discovered the second officer may have struck the inmate in the head with his baton. The Office of Internal Affairs and the OIG were
notified later that same day and both responded to the scene.
Administrative Investigation OIG Case Number: 14-1546-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department failed to comply with the policies and procedures governing the predisciplinary process. The department failedto timely
notify the Office of Internal Affairs and the OIG of the incident and the Office of Internal Affairs failed to provide the OIG with the draft and
final investigative report.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The hiring authority failed to notify the Office of Internal Affairs until two and one-half hours after discovering that an officer may have
struck an inmate on the head with a baton.
Was the OIG promptly informed of the critical incident?
The hiring authority failed to notify the OIG until two and one-half hours after discovering that an officer may have struck an inmate on
the head with a baton.
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
A draft copy of the investigative report was not provided to the OIG.
Was the final investigative report thorough and appropriately drafted?
A final report was not provided to the OIG.
Was the predisciplinary/investigative phase conducted with due diligence?
The department failed to timely notify the Office of Internal Affairs and the OIG.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined that the use of force complied with departmental policy. The OIG concurred with the determination.
Incident Date: 2014-06-15 Deadly Force Incident
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 48
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Incident Summary
On June 15, 2014, an officer observed two inmates in a cell injecting themselves with suspected controlled substances. The officer notified a
second officer. Both officers went to the cell, had the control booth officer open the cell, and ordered the inmates to leavethe cell for a cell
search. The inmates ignored the orders and squatted, making furtive motions towards their respective groin areas. When the inmates
ignored the orders, the control booth officer activated an alarm and additional officers responded. A third officer gave additional orders for
the inmates to get down, which were ignored and she discharged pepper spray at the inmates. One of the inmates ran out of thecell and
hit the first officer several times on the face and head with his fists. The first officer struggled with the inmate and struck the inmate in the
chest with the pepper spray canister, causing it to burst. A fourth responding officer attempted to use his body weight to force the inmate
down but was unsuccessful. The inmate then started hitting the first and fourth officers. At the same time, the second inmaterushed out of
the cell and began repeatedly hitting a fifth officer in the head. The fifth officer attempted to punch the second inmate butwas uncertain if
she was able to hit him. The second officer ordered the second inmate to get down, but the second inmate ignored the orders. The second
officer aimed and struck his baton at the second inmate's right arm but the second inmate moved and instead the baton struck the second
inmate's head. The second inmate continued to attack staff and ran at a lieutenant. A sixth officer aimed his baton at the second inmate's
shoulders but missed as the inmate continued to move, striking the inmate's head. The second inmate got down, then got back up and
resumed fighting with staff. A seventh officer then aimed his baton at the second inmate's shoulder but the inmate ducked down as the
seventh officer swung the baton, striking the inmate's head. Both inmates were medically evaluated and rehoused in the administrative
segregation unit the same day. Neither of the inmates sustained serious injuries. The officers received minor injuries and were taken to an
outside hospital. The Office of Internal Affairs and the OIG were not timely notified, but both still responded on scene.
Administrative Investigation OIG Case Number: 14-1465-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department failed to sufficiently comply with policies and procedures governing the predisciplinary process. The department failed to
timely notify the Office of Internal Affairs and the OIG of the incident. Additionally, the Office of Internal Affairs failedto provide a copy of
the investigative report assessing the possible use of deadly force.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The incident occurred on June 15, 2014; however, the Office of Internal Affairs was not notified until the following day.
Was the OIG promptly informed of the critical incident?
The incident occurred on June 15, 2014; however, the OIG was not notified until the following day by the Office of Internal Affairs soon
after they were notified.
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
A draft copy of the investigative report was not forwarded to the OIG for feedback.
Did the special agent cooperate with and provide continual real-time consultation with the OIG?
The special agent did not provide the OIG with a draft copy of the investigative report which would have allowed OIG to provide
feedback.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined the force used was in compliance with departmental policy. The OIG concurred.
Incident Date: 2014-06-14 Deadly Force Incident
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 49
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Incident Summary
On June 14, 2014, two inmates began fighting on an exercise yard. The inmates ignored repeated orders to stop fighting and were
unaffected by pepper spray grenades that custody staff deployed. One of the fighting inmates restrained the second inmate in a headlock. A
sergeant used his baton, aiming at the first inmate's arm; however, the baton struck both the first inmate's arm and the second inmate's
face. The sergeant then aimed at and struck the first inmate's shoulder blade with the baton, but the first inmate still heldthe second
inmate in a headlock. The sergeant then aimed at and struck the first inmate's wrist with the baton. This final strike causedthe inmates to
stop fighting and comply with orders. The first inmate sustained a broken wrist. The Office of Internal Affairs did not receive timely
notification, but still responded on scene.
Administrative Investigation OIG Case Number: 14-1464-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department failed to comply with the department’s policies and procedures governing the predisciplinary process. The department
failed to timely notify the Office of Internal Affairs and the OIG of the incident. In addition, the initial notification to the OIG failed to inform
the OIG of a possible baton strike to an inmate's head.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The Office of Internal Affairs was not notified until three hours after the incident.
Was the OIG promptly informed of the critical incident?
The institution notified the OIG over two hours after the incident and did not provide any information that there was a possible baton
strike to an inmate's head. As a result, the OIG did not respond to the incident.
Was the predisciplinary/investigative phase conducted with due diligence?
The institution failed to provide timely notice to both the OIG and the Office of Internal Affairs and failed to advise the OIG of a possible
baton strike to an inmate's head.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined the use of force was in compliance with departmental policies and procedures. The OIG concurred.
Incident Date: 2014-05-13 Deadly Force Incident
Incident Summary
On May 13, 2014, as a counselor was escorting an inmate on the exercise yard, the inmate became distracted by other inmates and drifted
several steps behind the counselor. Four inmates then attacked the first inmate. The counselor turned around when she heard a
commotion and saw the four inmates attacking the first inmate. The control booth officer saw the four-on-one inmate attack and gave
orders to stop fighting. The control booth officer utilized three less-lethal rounds, aiming at the thighs of the attacking inmates. One less-
lethal round struck the knee of one of the attacking inmates. Additionally, one of the attacking inmates reported a less-lethal round
ricocheted off the ground and struck him on the shoulder and cheek which resulted in redness and swelling to those areas. After being
medically evaluated, all involved inmates were rehoused later that same day. Although not timely notified, upon notification,both the
Office of Internal Affairs and the OIG responded to the scene.
Administrative Investigation OIG Case Number: 14-1187-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 50
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department's predisciplinary process failed to comply with the department's policies and procedures. The institution failed to timely
notify the Office of Internal Affairs and failed to notify the OIG. The Office of Internal Affairs failed to provide the OIG a copy of the draft and
final memorandum assessing the possible use of deadly force during this incident.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The institution failed to notify the Office of Internal Affairs until nearly two hours after the incident.
Was the OIG promptly informed of the critical incident?
The institution failed to notify the OIG. The OIG was notified by the Office of Internal Affairs nearly two hours after the incident.
Upon completion of the investigation, was a draft copy of the investigative report timely forwarded to the OIG to allow for feedback
before it was forwarded to the HA or prosecuting agency?
The Office of Internal Affairs failed to forward a draft copy of the investigative report to the OIG to allow for feedback.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force was in compliance with departmental policy. The OIG concurred.
Incident Date: 2014-04-07 Deadly Force Incident
Incident Summary
On April 7, 2014, two inmates began attacking a third inmate on an exercise yard, hitting the third inmate with their fists. Officers gave
orders for the inmates to get down, but the inmates refused to comply. An observation officer discharged four less-lethal rounds, aiming for
the legs and buttocks of the two attackers. The observation officer could not confirm where each round struck. However, the observation
officer believed a less-lethal round struck the back of one of the attacker's heads because the less-lethal round bounced in the air after an
attacker's head suddenly moved forward. Another officer discharged five less-lethal rounds, aiming at and striking the attacking inmates'
legs. After a total of nine less-lethal rounds and three pepper spray grenades were discharged by custody staff, the inmates ultimately
stopped fighting and got on the ground. The inmate who may have been struck in the head sustained a large contusion to the back of his
head, consistent with being struck by a less-lethal round. That inmate was sent to an outside hospital for observation and testing. He
returned to the institution two days later. The inmate who was attacked sustained a possible broken nose and was also taken to an outside
hospital for treatment and later returned to the institution. The Office of Internal Affairs and the OIG were notified and both responded to
the scene.
Administrative Investigation OIG Case Number: 14-0826-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined the use of force was in compliance with departmental policy. The OIG concurred.
Incident Date: 2014-08-31 Deadly Force Incident
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 51
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
Central Region
Incident Summary
On August 31, 2014, five inmates attacked a sixth inmate in a dining hall. The inmates ignored orders to stop fighting. The observation
officer fired one less-lethal round, aiming at the thigh of one of the five attacking inmates. However, the less-lethal round struck a seventh
inmate who was not involved in the altercation. The seventh inmate sustained a wound on his scalp and was taken to an outsidehospital
where he received six staples to close the head wound. The OIG and the Office of Internal Affairs were both timely notified and responded
to the scene.
Administrative Investigation OIG Case Number: 14-2119-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined the use of force was in compliance with departmental policy, but identified a policy violation followingthe incident.
Specifically, an officer failed to offer water to decontaminate an inmate exposed to pepper spray. The officer was ordered tocomplete
training. The OIG concurred with the hiring authority's determinations.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 52
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Incident Date: 2013-12-26 Deadly Force Incident
Incident Summary
On December 26, 2013, two inmates attacked a third inmate on an exercise yard. Custody staff gave numerous orders to stop andget down
but the attackers failed to comply and continued attacking the third inmate, who had fallen to the ground. Custody staff deployed two less-
lethal rounds and chemical agents and continued giving orders to stop and get down. The inmates continued their attack. The control booth
officer fired one round from the Mini-14 rifle for effect, but the round missed its intended target. After the Mini-14 rifle was fired, the
attacking inmates separated from the inmate who had been attacked and all inmates assumed prone positions. The inmate who was
attacked was transported via life flight to an outside hospital for treatment and later returned to the institution. Both attacking inmates
were remanded to administrative segregation. The Office of Internal Affairs responded to the scene and conducted a criminal investigation.
The OIG also responded. Although no criminal conduct was identified, pursuant to departmental policy, the matter was referredto the
district attorney's office for review. The department also opened an administrative investigation, which the OIG accepted formonitoring.
Criminal Investigation OIG Case Number: 14-0009-IR
Investigation Assessment Rating: Sufficient
The department sufficiently complied with all policies and procedures governing the investigative process.
Administrative Investigation OIG Case Number: 14-0010-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. Exonerated No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
Overall, the department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
The Deadly Force Review Board found that the discharge of the lethal round was in compliance with the department's use-of-force policy.
The hiring authority subsequently exonerated the officer and the OIG concurred.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's disciplinary process sufficiently complied with its policies and procedures.
Incident Date: 2013-08-13 Deadly Force Incident
Incident Summary
On August 13, 2013, an off-duty officer allegedly negligently discharged his personal weapon, with which he failed to qualify, during an
altercation with a private citizen. The Office of Internal Affairs was notified and responded on scene.
Administrative Investigation OIG Case Number: 13-1675-IR
Findings Initial Penalty Final Penalty
1. Weapons - Carrying 1. Sustained Salary Reduction Modified Salary
Unauthorized Weapon Off Duty 2. Sustained Reduction
2. Negligent Discharge of a Firearm
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s predisciplinary process sufficiently complied with policies and procedures.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 53
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Disposition
The Deadly Force Review Board found that the discharge of the round was not in compliance with the department’s use-of-force policy. The
case was referred to the hiring authority for further action. The OIG concurred. The hiring authority sustained the allegations that the officer
failed to qualify with and negligently discharged the weapon and imposed a 10 percent salary reduction for six months. The OIG concurred.
At the Skellyhearing, the officer acknowledged that his actions violated policy and he should have exercised better care and control over his
weapon. Based on these factors, the department entered into a settlement agreement with the officer wherein the penalty was reduced to
a 10 percent salary reduction for three months and the officer agreed not to file an appeal with the State Personnel Board. The OIG
concurred based on the factors learned at the Skellyhearing.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department sufficiently complied with policies and procedures.
Incident Date: 2014-08-22 Deadly Force Incident
Incident Summary
On August 22, 2014, two inmates engaged in a fight and failed to comply with orders to stop fighting. Officers fired seven less-lethal rounds
to stop the fight. One of the inmates subsequently claimed he may have been struck in the head with one of the less-lethal rounds. All
rounds left visible marks on the inmate's body. Pictures taken of the inmate following the incident depicted the impact points on his body,
none of which were on his head.
Administrative Investigation OIG Case Number: 14-2142-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined the use of force to be in compliance with the department's policy. The OIG concurred with the determination.
Incident Date: 2014-11-04 Deadly Force Incident
Incident Summary
On November 4, 2014, two inmates began to fight on an exercise yard. Officers gave multiple orders for the inmates to get down and stop
fighting, but the inmates continued to fight. In order to stop the fight, the control booth officer fired one less-lethal round at the back thigh
of one of the inmates. The round struck the inmate on the side of his chest. The second inmate alleged that the round struck him on his
head behind his ear. The Office of Internal Affairs and the OIG were timely notified and both responded on scene.
Administrative Investigation OIG Case Number: 14-2617-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 54
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force was in compliance with departmental policy. The OIG concurred with the determination.
Incident Date: 2013-11-18 Deadly Force Incident
Incident Summary
On November 18, 2013, an inmate attempted to murder an officer by repeatedly slashing him in the head and neck with an inmate-
manufactured weapon. Officers used chemical agents, physical force, and batons to stop the attack, without effect. A second inmate tried
to attack the responding officers; however, he was sprayed with pepper spray and assumed a prone position. One responding officer
allegedly intentionally struck the first inmate twice on the head with a baton to stop the attack. The officer who was attacked also allegedly
intentionally struck the first inmate on the side of his head with a baton to stop the attack. The first inmate was physically forced to the
ground and restrained. The officer who was attacked sustained several puncture wounds and lacerations to his head and neck, and was
taken to an outside hospital by ambulance for medical treatment. The officer survived the attack but missed several months from work as a
result. The department's deadly force investigation team responded to the scene and conducted a criminal investigation. The OIG also
responded. Although no criminal conduct was identified, pursuant to departmental policy, the matter was referred to the district attorney's
office for review. The department also opened and administrative investigation, which the OIG accepted for monitoring.
Criminal Investigation OIG Case Number: 13-2497-IR
Investigation Assessment Rating: Sufficient
The department's investigative process sufficiently complied with policies and procedures.
Administrative Investigation OIG Case Number: 13-2498-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. Exonerated No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
The Deadly Force Review Board determined that the officers' actions were in full compliance with the department's use-of-force policy. The
hiring authority subsequently exonerated the officers and the OIG concurred.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's disciplinary process sufficiently complied with policies and procedures.
Incident Date: 2014-09-14 Deadly Force Incident
Incident Summary
On September 14, 2014, during an inmate fight, an officer used his expandable baton to strike at an inmate’s right shoulder. The strike
glanced off the inmate’s shoulder and inadvertently struck the inmate on the back of the head. The officer delivered a secondbaton strike
to the inmate's lower back. The inmate sustained a non-life-threatening cut on the back of his head which required two staples to close. The
inmate was treated on site by medical staff and rehoused in administrative segregation. The Office of Internal Affairs and the OIG were
timely notified and both responded on scene.
Administrative Investigation OIG Case Number: 14-2348-IR
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 55
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined that the use of force complied with departmental policy. The OIG concurred with the determination.
Incident Date: 2013-10-29 Deadly Force Incident
Incident Summary
On October 29, 2013, an off-duty sergeant allegedly used his personal firearm to shoot and kill a pitbull dog that was attacking an 11-year-
old boy. The boy was hospitalized with serious injuries and sustained multiple puncture wounds to his chest and abdominal area as a result
of the pitbull dog attack.
Administrative Investigation OIG Case Number: 13-2506-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. Exonerated No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
Overall, the department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
The Deadly Force Review Board determined the use of force complied with departmental policy. The hiring authority subsequently
exonerated the sergeant. The OIG concurred with the hiring authority’s determination.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s disciplinary process sufficiently complied with policies and procedures.
Incident Date: 2014-08-11 Deadly Force Incident
Incident Summary
On August 11, 2014, a control booth officer observed two inmates fighting in the dayroom. The inmates continued fighting after officers
ordered the inmates to stop. The control booth officer fired one less-lethal round at the buttocks of one of the inmates. The inmate moved
and the round did not strike the intended target; however, the inmates stopped fighting. One inmate had blood on the side of his head, was
sent to an outside hospital for treatment, and returned to the institution that night. The control booth officer believed he may have struck
the inmate in the head with the less-lethal round. The OIG and the Office of Internal Affairs were timely notified and both responded on
scene.
Administrative Investigation OIG Case Number: 14-1975-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s predisciplinary process sufficiently complied with policies and procedures.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 56
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined that the use of force was in compliance with departmental policy and the OIG concurred.
Incident Date: 2014-08-06 Deadly Force Incident
Incident Summary
On August 6, 2014, after officers removed paper from an inmate's window, the inmate blocked officers from closing his cell door and
refused orders to remove his foot from the door. The inmate clenched his fists and made a sudden movement toward the officers. One of
the officers pushed the inmate back into the cell, but the inmate began punching the officer and grabbed his baton. A second officer struck
the inmate on the back and shoulders with a baton. A third officer and the first officer used physical force to gain control of the inmate and
the baton that the inmate had taken. The inmate eventually complied with orders to get down and was placed in handcuffs. The inmate had
a wound on his forehead requiring four staples that could have been caused by being struck in the head with the baton. The OIG and the
Office of Internal Affairs were timely notified and both responded on scene.
Administrative Investigation OIG Case Number: 14-1915-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined that all uses of force complied with departmental policy. The OIG concurred with the determinations.
Incident Date: 2014-05-24 Deadly Force Incident
Incident Summary
On May 24, 2014, two inmates were involved in a fight. Officers responded and ordered the inmates to get down but the inmatescontinued
fighting. One officer drew his baton and struck one of the inmates in the left shoulder. The inmates were again ordered to get down but
continued fighting. The officer attempted to strike the second inmate in the shoulder with his baton. However, due to the erratic
movements of the two inmates, and the first inmate pulling the second inmate toward him, the baton struck the second inmate on the top
of his head causing a two-inch laceration on the inmate’s scalp. The inmates stopped fighting and got down. The injured inmate was taken
to the infirmary and received staples to close the laceration. The Office of Internal Affairs and the OIG were timely notified and both
responded on scene.
Administrative Investigation OIG Case Number: 14-1255-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The institution's executive review committee determined that the use of force
complied with departmental policy. The OIG concurred with these determinations.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 57
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Incident Date: 2014-04-29 Deadly Force Incident
Incident Summary
On April 29, 2014, approximately 25 inmates engaged in a riot on an exercise yard. Officers fired one warning shot from a Mini-14 rifle and
six less-lethal rounds to stop the incident. One inmate was struck in the lip by a less-lethal round. The injured inmate was treated at the
institution where he received three stitches and returned to his housing unit. The Office of Internal Affairs and the OIG were timely notified
and responded on scene.
Administrative Investigation OIG Case Number: 14-1075-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution’s executive review
committee determined the use of force complied with departmental policy. The OIG concurred with the determination.
Incident Date: 2014-03-15 Deadly Force Incident
Incident Summary
On March 15, 2014, two inmates began fighting in the day room. The control booth officer ordered the inmates to get down and,when
they did not comply, the officer fired one less-lethal round at an inmate’s leg, but missed. The inmates continued fighting and the officer
ordered them down again and aimed a second less-lethal round at an inmate’s leg. The round missed the inmate's leg, hit the inmate in the
back, and ricocheted, hitting the inmate in the back of the head. The inmates separated and got down, but then resumed fighting. A third
less-lethal round was fired at an inmate’s leg, but again missed. The inmates stopped fighting and got down. The Office of Internal Affairs
and the OIG were timely notified and responded on scene.
Administrative Investigation OIG Case Number: 14-0617-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined the use of force was within departmental policy and the OIG concurred.
Incident Date: 2014-02-14 Deadly Force Incident
Incident Summary
On February 14, 2014, custody staff observed two inmates fighting. The inmates refused orders to stop and an officer deployedpepper
spray, to no avail. Another officer fired one less-lethal round that potentially struck one of the inmates on the head. The inmate sustained a
laceration to his head, was transported to an outside hospital for treatment, and returned to the institution the following day. The Office of
Internal Affairs and the OIG were timely notified and both responded on scene.
Administrative Investigation OIG Case Number: 14-0476-IR
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 58
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
North Region
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee found the inmate cut his head when he fell during the fight and that staff's use of force prior to, during, and following the
incident complied with departmental policies and procedures. The OIG concurred.
Incident Date: 2014-10-24 Deadly Force Incident
Incident Summary
On October 24, 2014, two inmates began fighting on an exercise yard. Officers gave multiple orders for the inmates to get down and stop
fighting but the inmates continued to fight. An observation officer fired one less-lethal round, aiming for the back thigh of one of the
inmates. The round had no effect. The officer fired a second less-lethal round. Both inmates complied with orders to stop fighting and got
down. Both inmates were removed from the exercise yard and were medically evaluated. One inmate suffered abrasions on the back of his
right arm and the back of his upper left thigh. These abrasions were consistent with being struck by the less-lethal rounds. The second
inmate had no injuries consistent with being struck by a less-lethal round; however, he claimed that he had been hit in the head and cheek
by one of the rounds. The Office of Internal Affairs and the OIG were timely notified and responded on scene.
Administrative Investigation OIG Case Number: 14-2533-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force was in compliance with departmental policy. The OIG concurred with the determination.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 59
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
South Region
Incident Date: 2014-09-17 Deadly Force Incident
Incident Summary
On September 17, 2014, two inmates attacked a third inmate. A control booth officer fired multiple less-lethal rounds in an attempt to stop
the fight. One inmate initially claimed he was hit on the head by one of the rounds. The inmate had no serious injuries and was treated for
wounds related to the fight. Later, the inmate said he did not know what caused his head injuries. The inmate did not requirefurther
medical care and was returned to his cell. The Office of Internal Affairs and the OIG were timely notified and responded to the scene.
Administrative Investigation OIG Case Number: 14-2237-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department sufficiently complied with policies and procedures governing the predisciplinary process.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force was in compliance with departmental policy. The OIG concurred.
Incident Date: 2013-12-23 Deadly Force Incident
Incident Summary
On December 23, 2013, an officer allegedly fired four rounds from his off-duty weapon and wounded a private citizen who had attempted
to rob him. The private citizen sustained gunshot wounds to the left side of his lower abdomen, left lower back, and left upper arm. He was
transported to a local hospital where he received life-saving treatment. The Office of Internal Affairs and the OIG were timely notified and
both responded to the scene.
Administrative Investigation OIG Case Number: 13-2724-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. Exonerated No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
The Deadly Force Review Board found that the discharge of the lethal rounds was in compliance with the department's use-of-force policy.
The hiring authority subsequently exonerated the officer and the OIG concurred.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department's disciplinary process sufficiently complied with policies and procedures.
Incident Date: 2013-12-30 Deadly Force Incident
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 60
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
South Region
Incident Summary
On December 30, 2013, two parole agents and outside law enforcement officers located a parolee-at-large who was a suspect in a recent
homicide. As the parolee attempted to flee in his vehicle, the parole agents and outside law enforcement officers fired at the vehicle,
striking the parolee twice in the shoulder. The parolee did not sustain life-threatening injures and was taken to a local hospital where he
obtained medical treatment before being placed into custody. The Office of Internal Affairs and the OIG were timely notified and responded
on scene.
Administrative Investigation OIG Case Number: 14-0002-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. Exonerated No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s predisciplinary process sufficiently complied with policies and procedures.
Disposition
The Deadly Force Review Board and the institution's executive review committee found that the discharge of the lethal rounds complied
with the department's use-of-force policy. The hiring authority subsequently exonerated the parole agents and the OIG concurred.
Disciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
The department’s disciplinary process sufficiently complied with policies and procedures.
Incident Date: 2014-01-26 Deadly Force Incident
Incident Summary
On January 26, 2014, two inmates began fighting. Officers gave multiple orders for the inmates to get down but the inmates continued to
fight. Two officers used their batons, striking the inmates on the thigh and buttocks, which stopped the fight. One of the inmates initially
alleged that an officer struck him on the head with a baton. The inmate later denied being hit on the head with a baton, stating his injuries
were the result of the fight. Both inmates were treated at the institution for non-life threatening injuries. Although the Office of Internal
Affairs was not timely notified, they responded on scene.
Administrative Investigation OIG Case Number: 14-0406-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Sufficient
Substantive Rating: Sufficient
Overall, the department's predisciplinary process sufficiently complied with policies and procedures.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force was in compliance with departmental policy. The OIG concurred with the determination.
Incident Date: 2014-04-08 Deadly Force Incident
Incident Summary
On April 8, 2014, two inmates began fighting. Orders to stop fighting were ineffective. One officer inadvertently struck one of the fighting
inmates on the head with a baton while attempting to stop the fight. The inmate who was struck with the baton was treated at an outside
hospital and returned to the institution later that day. The Office of Internal Affairs and the OIG were not timely notified but both
responded to the scene.
Administrative Investigation OIG Case Number: 14-0910-IR
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 61
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
South Region
Administrative Investigation OIG Case Number: 14-0910-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department failed to sufficiently comply with policies and procedures governing the predisciplinary process. The institution failed to
timely notify the Office of Internal Affairs and the OIG.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The institution did not notify the Office of Internal Affairs until four hours after the incident occurred.
Was the OIG promptly informed of the critical incident?
The institution did not notify the OIG until four hours after the incident occurred.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force complied with departmental policy and the OIG concurred.
Incident Date: 2014-05-29 Deadly Force Incident
Incident Summary
On May 29, 2014, an officer allegedly struck an inmate on the head with a pepper spray canister after the inmate approached the officer
with clenched fists and failed to stop his advance even though the officer deployed pepper spray in the direction of the inmate. The inmate
suffered minor injuries. The OIG and the Office of Internal Affairs were not timely notified, but responded to the scene the following day.
Administrative Investigation OIG Case Number: 14-1257-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The institution failed to timely notify the Office of Internal Affairs and the OIG. As a result, neither the Office of Internal Affairs nor the OIG
were able to timely respond to the scene.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The institution did not notify the Office of Internal Affairs until one and one-half hours after the incident.
Was the OIG promptly informed of the critical incident?
The institution did not notify the OIG until one and one-half hours after the incident.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined the use of force was within departmental policy. The OIG concurred.
Incident Date: 2014-08-09 Deadly Force Incident
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
South Region
Incident Summary
On August 9, 2014, an inmate became disruptive and failed to comply with orders to get down. After the use of pepper spray, the inmate
hit an officer in the chest. The officer inadvertently struck the inmate on the head with his baton while attempting to strike the inmate on
the shoulder. The inmate received a laceration to the back of his head and was transported to a community hospital for treatment, which
included staples. The inmate returned to the institution later the same day. The Office of Internal Affairs and the OIG were not timely
notified; however, both responded to the scene.
Administrative Investigation OIG Case Number: 14-2005-IR
Findings Initial Penalty Final Penalty
1. Use of Deadly Force 1. N/A No Penalty Imposed No Penalty Imposed
Predisciplinary Assessment Procedural Rating: Insufficient
Substantive Rating: Sufficient
The department failed to sufficiently comply with policies and procedures governing the predisciplinary process. The institution failed to
timely notify the Office of Internal Affairs and the OIG.
Assessment Questions
Did the institution timely notify the Office of Internal Affairs of the incident?
The institution failed to notify the Office of Internal Affairs until three and one-half hours after the incident.
Was the OIG promptly informed of the critical incident?
The hiring authority failed to notify the OIG until more than two hours after the incident.
Was the predisciplinary/investigative phase conducted with due diligence?
The institution failed to notify the Office of Internal Affairs and the OIG of the incident in a timely manner.
Disposition
After an initial review, the Office of Internal Affairs determined that the circumstances did not meet its criteria for a full investigation of the
use of deadly force and the investigation was terminated. The OIG concurred with the determination. The institution's executive review
committee determined that the use of force was in compliance with departmental policy. The OIG concurred with the determination.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
APPENDIX E 85
CRITICAL INCIDENT CASE SUMMARIES
CENTRAL REGION
Incident Date OIG Case Number Case Type
2014-02-02 14-0486-RO Other Significant Incident
Incident Summary
On February 2, 2014, as inmates were preparing to be released for the evening meal, an officer noticed that the inmates were moving down
the stairs without authorization. The officer asked the inmates why they were moving without permission. One of the inmates struck the
officer in the face with his fist. A second inmate told the officer “we have to do this.” Seven inmates began striking the officer in the head
and upper torso. The officer was struck on the side of his right knee, causing him to collapse. As the inmates continued punching and kicking
the officer while he was down, the control booth officer fired two less-lethal rounds to stop the attack. The injured officer stood to his feet,
called for assistance on the radio, drew his baton, and ensured that the inmates remained down until responding officers arrived.
Disposition
The institution's executive review committee found that although the use of force was within departmental policy, officers failed to
announce the alarm over the radio. Training was provided to the officers. No staff misconduct was identified; therefore, the case was not
referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response to the incident was inadequate. Although the department timely notified the OIG, it failed to attempt to identify
why the officer was assaulted and it unnecessarily delayed providing the OIG with the threat assessment. The OIG concurred with the hiring
authority’s decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Did the department adequately consult with the OIG regarding the critical incident?
Although the threat assessment was completed on March 4, 2014, the institution did not provide it to the OIG until September 22,
2014, despite numerous requests.
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
The threat assessment the institution completed was vague and did not attempt to identify why the officer was assaulted.
Was the HA's response to the critical incident appropriate?
The OIG recommended that the institution request a threat assessment by the Office of Correctional Safety. The institution conducted
its own threat assessment.
Incident Date OIG Case Number Case Type
2014-02-12 14-0487-RO In-Custody Inmate Death
Incident Summary
On February 12, 2014, an officer heard someone yell “man down” on a basketball court. The officer ran to the location of the incident and
found an inmate on the ground, unresponsive but breathing. An emergency medical response was requested. Within two minutes, medical
staff arrived and provided life-saving measures. The inmate became responsive and was transferred to the institution’s medical clinic. The
inmate appeared to have a head injury caused by blunt force trauma. The inmate was transported to an outside hospital via ambulance
where he stopped breathing and was pronounced dead after life-saving measures failed.
Disposition
The autopsy established the cause of death to be respiratory arrest due to a brain injury caused by blunt force trauma from afall. The
department’s Death Review Committee determined that although there were inconsistencies in the timeline between first responder notes,
the death was not preventable. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for
an investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to notify the OIG in a timely and sufficient manner preventing
the OIG from real-time monitoring of the case. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of
Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified until three hours after the inmate was transported to an outside hospital and two hours after he died.
Incident Date OIG Case Number Case Type
2014-02-27 14-0503-RO Inmate Serious/Great Bodily Injury
Incident Summary
On February 27, 2014, a housing unit officer heard slapping noises coming from a cell. The officer responded to the cell and saw an inmate
striking his cellmate in the head and upper torso with his fist. The cellmate was lying on the lower bunk covering his head with his arms. The
inmate attacker complied with orders to stop and laid prone on the floor. The officer activated the alarm. Responding staff arrived and
removed the attacker from the cell without incident. Due to a serious head injury, the injured inmate was transported to an outside hospital
via ambulance. The injured inmate returned to the institution from the hospital on March 3, 2014. Two days later, the inmate’s condition
deteriorated. Therefore, he was transferred back to the outside hospital for an additional five days before returning to the institution.
Disposition
The department completed an in-cell assault review and determined that the inmates were compatible at the time they were housed
together. The OIG concurred. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for
investigation.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-04-25 14-1331-RO Inmate Serious/Great Bodily Injury
Incident Summary
On April 25, 2014, an officer ordered an inmate to return to his cell after the inmate became boisterous and quarrelsome withmedical staff.
The officer reported that the inmate suddenly hit him in the head with his fist. The officer attempted to force the inmate tothe ground with
his body weight. Additional officers arrived, forced the inmate to the ground, and placed him in restraints. The inmate alleged that the
officers used unreasonable force. The inmate was transported to an outside hospital for treatment of a fractured orbit and returned after
four days.
Disposition
The institution's executive review committee determined that the use of force was in compliance with departmental policy and the OIG
concurred. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to notify the OIG that the inmate sustained a fractured orbit
due to use of force, thereby preventing the OIG from real-time monitoring of the incident. The OIG concurred with the hiring authority's
decision not to refer the matter to the Office of Internal Affairs for investigation.
Assessment Questions
Was the OIG promptly informed of the critical incident?
Although the OIG received timely notification of the incident, the OIG was not informed about the inmate's fractured orbit resulting
from the use of force. The OIG was told only that the inmate assaulted custody staff and that the inmate received a slight cut during
the incident.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Incident Date OIG Case Number Case Type
2014-05-05 14-1053-RO In-Custody Inmate Death
Incident Summary
On May 5, 2014, two officers responded to a cell and discovered an unresponsive inmate after the cellmate had yelled "man down." The
cellmate was secured and removed from the cell. Responding custody and medical staff began life-saving measures on the unresponsive
inmate. The inmate was taken to an outside hospital where he was later pronounced dead. As the cellmate was being photographed and
processed for evidence, he stated that he and the inmate were doing exercises in their cell when the inmate suddenly fell to the ground.
The cellmate had no apparent signs of injury on his body.
Disposition
The autopsy determined the inmate died of natural causes due to atherosclerotic heart disease. No staff misconduct was identified;
therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-05-07 14-1081-RO In-Custody Inmate Death
Incident Summary
On May 7, 2014, an inmate suddenly lost consciousness and hit his head in a shower. Officers responded and found the inmate
unresponsive but breathing. Officers requested an emergency medical response. As medical staff removed the inmate from the shower, he
stopped breathing and emergency life-saving measures were initiated. The inmate was transported to an outside hospital via ambulance
where he was pronounced dead after life-saving efforts failed.
Disposition
The autopsy report revealed the cause of death was cardiac arrest. The inmate had an abnormally slow heartbeat that required a
pacemaker. The department’s Death Review Committee determined that the death was not preventable, and the inmate had refused a
pacemaker. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
Overall, the department's response to the incident was sufficient. The department adequately notified and consulted with the OIG on the
incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-06-04 14-1300-RO In-Custody Inmate Death
Incident Summary
On June 4, 2014, an inmate told an officer "he hit me" during a security check. The officer noticed the cellmate was on the floor, covered
with a blanket and unresponsive. An alarm was announced over the radio. The inmate that alerted officers was removed from thecell and
an emergency extraction team entered the cell. Officers removed the blanket and discovered the unresponsive inmate had a bag and towel
covering his head with a cloth tied around his neck. Officers immediately removed the towel and bag and began life-saving measures, while
another officer obtained a cut-down tool and cut the cloth tied around the inmate's neck. Medical staff arrived and continued life-saving
measures; however, the inmate was later pronounced dead.
Disposition
The autopsy determined that the inmate died of strangulation following blunt force trauma to his head. The manner of death was homicide.
The department completed an in-cell assault review and concluded that the inmates were compatible at the time they were placed
together, and their cell assignment followed departmental policy. No staff misconduct was identified; therefore, the case wasnot referred
to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department’s response was not adequate because the department failed to notify the OIG preventing the OIG from real-time
monitoring of the case. The OIG concurred with the hiring authority’s decision not to refer the matter to the Office of Internal Affairs.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Assessment Questions
Was the critical incident adequately documented?
The institution was unable to provide documentation to show this incident was reviewed by the institution's emergency medical
response review committee as required by departmental policy.
Was the HA's response to the critical incident appropriate?
The hiring authority was informed about departmental policy requiring an emergency medical response review but did not address
the matter.
Was the OIG promptly informed of the critical incident?
The OIG was not notified. The OIG discovered the death while reviewing the department's daily briefing report.
Incident Date OIG Case Number Case Type
2014-06-05 14-1303-RO Inmate Serious/Great Bodily Injury
Incident Summary
On June 5, 2014, an inmate was moved to a new cell. The inmate occupying the cell was instructed to sit on the lower bunk. Asthe officer
was removing the handcuffs from the inmate, the other inmate jumped up from the lower bunk and began attacking the inmate with an
inmate-manufactured weapon. The officer used pepper spray to stop the attack. The injured inmate was transported to an outside hospital
via ambulance where he spent four days due to his injuries. The other inmate was placed in administrative segregation pendingan
investigation. The injured inmate alleged he was forced to move in with the other inmate after he told the sergeant that he was not
compatible and feared for his safety.
Disposition
The hiring authority completed an inquiry into the injured inmate’s allegation that he told the sergeant he feared for his safety prior to
being placed in the cell with the inmate. The inquiry concluded that the injured inmate told the sergeant he could not be housed with
specific gang associates and that the assailant was not affiliated with that gang. The institution's executive review committee determined
that the officer used pepper spray closer than the minimum distance allowed by policy. The deviation from policy was deemed acceptable
based on the immediate threat and the OIG concurred. The hiring authority’s in-cell assault review determined that both inmates had a
history of single-cell status due to in-cell assaults, but both inmates were housed appropriately at the time of the incident. The review did
not address the inadequacy of the department's policy for determining compatibility of inmates on a sensitive needs yard. No staff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response to this incident was satisfactory. The department adequately notified and consulted with the OIG regarding the
incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-06-10 14-1335-RO Inmate Serious/Great Bodily Injury
Incident Summary
On June 10, 2014, an officer responded to a cell after hearing a loud, banging sound coming from the cell. The officer observed an inmate
on the floor and his cellmate striking him in the face with his left fist. The officer saw that the attacker was holding an inmate-manufactured
stabbing weapon in his right hand. The officer activated the alarm and ordered the inmate to stop the attack. The inmate ignored the orders
and continued the attack until additional officers arrived. The inmate then submitted to restraints without incident. The injured inmate was
transported to an outside hospital via ambulance for injuries, including two punctured lungs and multiple stab wounds to the face and
upper torso. The inmate returned to the institution the following day.
Disposition
The department’s in-cell assault review concluded that custody staff did not immediately place the injured inmate on single-cell status until
three days after the incident. This delay did not result in any further incident and the involved staff received training. The OIG concurred
with this decision. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Overall Assessment Rating: Sufficient
The department's response was adequate in all critical aspects. The department adequately notified and consulted with the OIGregarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-06-15 14-1467-RO Inmate Serious/Great Bodily Injury
Incident Summary
On June 15, 2014, officers were conducting an unclothed body search of an inmate after a visit when the inmate suddenly reached for his
rectum and attempted to remove an object. Officers ordered the inmate to stop and get down on the ground. The inmate began tocomply,
but suddenly jumped to his feet. Officers forced the inmate down, causing him to hit his head on the ground, and placed a spit hood over
his head allegedly to prevent the spread of bloodborne pathogens. The inmate became unresponsive. Medical staff determined the inmate
had an open wound and bruising on his head. The inmate was transported to an outside hospital via ambulance for a life-threatening head
injury. The inmate returned to the institution after treatment the following day.
Disposition
The institution's executive review committee ordered training for custody staff because of the inappropriate use of the spit hood. Training
was also provided to custody staff regarding videotaping interviews. In addition, the OIG consulted with the hiring authorityregarding the
poor communication regarding the suspected contraband and the failure to request reports from the officers at the hospital. Since the
primary reason the inmate was transported to an outside hospital was due to a medical emergency, the suspected contraband wasa
secondary issue and the officers at the hospital did not appear to know the inmate was concealing contraband. The OIG recommended
training for the incident commander to ensure better communication and more thorough report writing. The hiring authority concurred
with the OIG. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate. The department failed to notify the OIG in a timely and sufficient manner preventing the OIG
from real-time monitoring of the incident. The OIG determined custody staff at the institution failed to advise the officers at the hospital of
the need to observe the inmate for suspected contraband, and reports were not requested from officers at the hospital. The department
failed to properly follow the use-of-force policy regarding use of the spit hood and timely completion of the videotaped interview. The OIG
concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs for investigation.
Assessment Questions
Was the critical incident adequately documented?
The incident commander failed to identify the officers on duty at the hospital or request reports from them; therefore, it isunknown
why the officers did not observe the inmate remove the contraband.
Was the HA's response to the critical incident appropriate?
Due to miscommunication, officers at the hospital were unaware that the inmate had suspected contraband. Also, officers placed a
spit hood on the inmate because he was bleeding from a laceration, which is not consistent with departmental policy. The spithood
will not prevent the transfer of blood from a head injury, because it is composed of loose netting around the head. Also, although the
video-taped interview was initially conducted within 48 hours, there was a malfunction that went undetected for nine days; therefore,
a second video-taped interview was necessary. Therefore, the video-taped interview was not completed within 48 hours.
Was the OIG promptly informed of the critical incident?
The OIG was not notified until six hours after the incident.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Incident Date OIG Case Number Case Type
2014-06-29 14-1552-RO In-Custody Inmate Death
Incident Summary
On June 29, 2014, a control booth officer asked a floor officer to check a cell after hearing a “man down” call. The floor officer found an
inmate unresponsive in the cell with visible injuries to his face and a large amount of blood on the floor. The officer announced a medical
emergency over the radio. Responding officers removed the cellmate. Medical staff called an ambulance and began life-saving measures on
the injured inmate after determining he did not have a pulse. The inmate was transported to the medical clinic while life-saving measures
continued. The ambulance arrived and transported the inmate to an outside hospital where he was later pronounced dead. The cellmate
told officers that he hit the inmate after he was sexually assaulted by him.
Disposition
The autopsy determined that the inmate died of blunt force trauma to his head, neck, and chest. The manner of death was homicide. The
department completed an in-cell assault review and concluded that the inmates were compatible at the time they were placed together
and their cell assignment followed departmental policy. The OIG concurred. No staff misconduct was identified; therefore, thecase was not
referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate. The department adequately notified and consulted with the OIGregarding
the incident. The hiring authority decided not to refer the matter to the Office of Internal Affairs and the OIG agreed.
Incident Date OIG Case Number Case Type
2014-06-30 14-1537-RO Hunger Strike
Incident Summary
On June 30, 2014, 34 inmates in administrative segregation began a hunger strike, protesting restrictions on appliances and property in the
administrative segregation unit. The inmates ended their hunger strike on July 3, 2014, after the hiring authority addressed some of the
inmate grievances which included electrical repairs and access to property and canteen.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department provided adequate notification and consultation to the
OIG regarding the incident. The OIG concurred with the decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-06 14-1645-RO Suicide
Incident Summary
On July 6, 2014, while conducting welfare checks, an officer discovered an inmate hanging by a bed sheet in his cell. Responding custody
staff cut down the inmate. Officers and medical staff began life-saving measures. The inmate was transported to an outside hospital via
ambulance where he was pronounced dead after life-saving efforts failed. The inmate was the sole occupant of the cell.
Disposition
The autopsy determined the cause of death was ligature strangulation. The inmate returned from the Department of State Hospitals for
suicidal behavior and then was placed in administrative segregation because he feared for his life. The department's ForensicPsychological
Autopsy Report determined clinical staff did not make the appropriate determination that the inmate was at risk for suicide which would
have required the implementation of a five-day follow up. The report recommended training for clinical staff. No staff misconduct was
identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Incident Date OIG Case Number Case Type
2014-07-08 14-1659-RO In-Custody Inmate Death
Incident Summary
On July 8, 2014, an officer discovered an unresponsive single-celled inmate lying on his bunk with the television and light on. Officers
announced a medical emergency, entered the cell, and secured the inmate as medical staff arrived. Medical and custody staff removed the
inmate from his cell and carried him to the emergency response vehicle where they began performing life-saving measures. Despite these
life-saving efforts, the inmate was later pronounced dead.
Disposition
The coroner determined the cause of death was heart failure. The department's Death Review Committee determined the death wasnot
preventable. The department evaluated the medical response to the emergency and determined that proper medical practices were
followed. The OIG did not concur because life-saving efforts were delayed. The OIG recommended that the institution address the physical
barriers in the housing unit which led to the delay and develop a plan for improvement. No staff misconduct was identified; therefore, the
case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because they failed to notify the OIG in a timely and sufficient manner preventingthe OIG
from real-time monitoring of the incident. The department also failed to address the delay in providing life-saving efforts to an unresponsive
inmate. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the HA's response to the critical incident appropriate?
The OIG informed the hiring authority about the delay in life-saving efforts. The hiring authority referred the matter to their chief
physician who stated that medical staff should have considered never starting life-saving measures. The OIG clinical expert disagreed,
noting that even after a significant delay in life-saving efforts, the automated external defibrillator recommended shocking the
inmate. The OIG recommended that the institution improve their emergency medical response plan so that life-saving efforts can be
initiated sooner to avoid missing the brief window to successfully restore circulation.
Was the OIG promptly informed of the critical incident?
The OIG was not notified until more than two hours after the inmate was pronounced dead.
Did the HA timely respond to the critical incident?
Life-saving measures were delayed. Life-saving efforts should have begun within ten seconds after determining the absence of a
pulse. The inmate was moved from the cell, down the hall, down a complex set of stairs, out of the building, onto a stretcher, and into
the back of the emergency vehicle before life-saving efforts were started.
Incident Date OIG Case Number Case Type
2014-07-09 14-1648-RO Suicide
Incident Summary
On July 9, 2014, medical staff discovered an unresponsive inmate hanging in a cell. The noose was made from a bed sheet tied around the
inmate's neck and attached to the upper bunk. Responding custody staff cut the noose from the inmate's neck and began life-saving
measures with the help of medical staff. Additional medical staff arrived and transported the inmate to the medical clinic where he was
pronounced dead. The inmate was the sole occupant of the cell.
Disposition
The coroner's autopsy determined the manner of death was suicide and the cause of death was hanging. The department's Forensic
Psychological Autopsy review determined that there was no record of the required suicide risk evaluation or initial mental health screening.
Based on case factors, the review determined the inmate was a high risk for suicide. The Emergency Medical Response Review Committee
identified opportunities for improvement specific to calling an ambulance and initiating the emergency response vehicle sooner. Based on
the review, mental health clinicians received training and clinical supervisors will actively monitor the completion of suicide risk evaluations.
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Overall Assessment Rating: Insufficient
The department adequately notified and consulted with the OIG regarding the incident. However, the department's actions priorto the
incident were inadequate because the institution failed to complete the required mental health evaluation and suicide risk assessment or
failed to document those encounters upon the inmate's arrival to the institution due to an inadequate mental health screeningprocess. The
OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the critical incident adequately documented?
There was no documentation to confirm the inmate received the required suicide risk screening or the initial mental health evaluation
upon arrival at the institution.
Incident Date OIG Case Number Case Type
2014-07-16 14-1702-RO Inmate Serious/Great Bodily Injury
Incident Summary
On July 16, 2014, an inmate became verbally disruptive while waiting in a holding cell with other inmates. Officers were unsuccessful at
calming the inmate down, so they asked the inmate to move out of the cell away from the other inmates. The inmate refused to move, so
officers removed all uninvolved inmates. An officer activated the alarm after the inmate began screaming obscenities. As officers responded
to the alarm, the inmate stood up and lunged toward officers with clenched fists. Two officers used physical force to take the inmate to the
ground, restrain him, and place him in a spit hood. The inmate was transported to the medical clinic via a gurney and treatedfor a head
injury.
Disposition
The institution's executive review committee determined the lieutenant should have remained at the cell front instead of placing the
incident under the control of the sergeant and stepping away to call the captain about the escalating situation. The committee determined
that door to the cell was not locked because the lieutenant was new to the reception center and unaware that the door did not
automatically lock when it closed. The lieutenant received training following the committee’s determination. In addition, thehiring
authority instructed custody supervisors to thoroughly address the inmate’s allegation of unreasonable force after the OIG expressed
concerns regarding the initial video-taped interview with the inmate. The OIG also disagreed with the hiring authority about the use of the
spit hood. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the hiring authority failed to address the misuse of the spit hood. In addition,
custody supervisors inadequately assessed the inmate's allegation of unreasonable force and the failure to secure the holdingcell door after
the uninvolved inmates were removed. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of
Internal Affairs for investigation.
Assessment Questions
Did the use-of-force review committee adequately review and respond to the incident?
A sergeant placed a spit hood on the inmate because he was bleeding from a laceration on his forehead, which is not consistent with
departmental policy. The spit hood will not prevent the transfer of blood from a head injury because it is composed of loose netting
around the head.
Was the HA's response to the critical incident appropriate?
The custody supervisor and manager failed to fully address the inmate's allegation of unreasonable use of force. The lieutenant failed
to secure the cell door after removing the other inmates from the holding cell and left the scene of the incident before it was resolved.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Incident Date OIG Case Number Case Type
2014-07-17 14-1935-RO Inmate Serious/Great Bodily Injury
Incident Summary
On July 17, 2014, officers on an exercise yard observed two inmates striking a third inmate in the upper torso and face. An alarm was
announced on the institutional radio. Officers then noticed that the third inmate was bleeding profusely from his upper torsoas the attack
continued. Two officers fired three less-lethal rounds at the attackers. Although none of the inmates were struck with the less-lethal rounds,
the attack stopped. One of the assailants threw an inmate-manufactured weapon over a concrete wall. The weapon was recovered and
placed into evidence. The injured inmate suffered multiple stab wounds, was air-lifted to an outside hospital, and returned to the institution
five days later.
Disposition
The institution’s executive review committee determined that the use of force was in compliance with departmental policy, andthe OIG
concurred. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation.
Overall Assessment Rating: Sufficient
Except for failing to timely document the assailants as enemies of the injured inmate, the department’s response to the incident was
otherwise satisfactory. The department adequately notified and consulted with the OIG regarding the incident. The OIG concurred with the
hiring authority’s decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-25 14-1761-RO In-Custody Inmate Death
Incident Summary
On July 25, 2014, an officer was escorting an unrestrained inmate, when the inmate complained of chest pain. The officer called medical
staff, and a nurse responded. The nurse assisted with placing the inmate into a wheelchair and transporting the inmate to thetriage and
treatment area for a medical evaluation. As a physician was examining the inmate, the inmate went into cardiac arrest. Medical staff began
life-saving measures and called an ambulance, which transported the inmate to an outside hospital. The inmate was pronounced dead after
life-saving efforts failed.
Disposition
The autopsy determined that the inmate died of coronary artery disease. The department's Death Review Committee concluded that the
death was not preventable, but the inmate should have been transported in an emergency response vehicle instead of a wheelchair. No
staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate. The department adequately notified and consulted with the OIGregarding
the incident. The hiring authority decided not to refer the matter to the Office of Internal Affairs, and the OIG agreed.
Incident Date OIG Case Number Case Type
2014-08-02 14-1864-RO Other Significant Incident
Incident Summary
On August 2, 2014, a suicidal inmate escaped from an institution's vehicle while being transported to another institution. While en route,
the officers heard a "thump" noise, pulled over, and discovered the inmate missing and his leg restraints left behind. Outside law
enforcement agencies were alerted and an incident command post was activated. The next day, outside law enforcement apprehended the
inmate who had a ten-inch screwdriver in his possession.
Disposition
Potential staff misconduct was identified. The vehicle's holding area had equipment issues allegedly not identified or addressed prior to the
inmate's transport. Additionally, required forms were allegedly not completed and the transportation officers allegedly made unauthorized
stops and failed to comply with departmental policy regarding who should be armed during the transport. Therefore, the hiringauthority
referred the case to the Office of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-08-19 14-2043-RO Contraband Watch
Incident Summary
On August 19, 2014, officers learned that an inmate was planning to introduce drugs into the administrative segregation unit.During
questioning, the inmate admitted to having drugs hidden in his rectum. The inmate was placed on contraband surveillance watch. On
August 22, 2014, the inmate asked medical staff if they would remove the drugs from his body because they were not coming outduring
bowel movements. The inmate was transported to an outside hospital where he remained on contraband surveillance watch. While at the
hospital, the inmate defecated a bindle of drugs which an officer recovered. A colonoscopy verified the absence of additionalcontraband.
The inmate was removed from contraband surveillance watch and returned to the institution on August 23, 2014.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The OIG determined that the department adequately responded to the incident in all critical aspects. The department’s notification and
consultation to the OIG regarding the incident was sufficient. The hiring authority decided not to refer the matter to the Office of Internal
Affairs, and the OIG agreed.
Incident Date OIG Case Number Case Type
2014-09-09 14-2221-RO Other Significant Incident
Incident Summary
On September 9, 2014, two officers observed three inmates attempting to conceal an unknown object. The officers ordered the inmates to
submit to a search. During the search, the metal detector alerted one of the officers to a potential weapon. The first officer ordered the
inmate to submit to handcuffs, but the inmate turned and hit the officer in the face with his fist. The inmate then punched the second
officer twice in the face, retrieved an inmate-manufactured weapon from his person, and attempted to stab the second officer in the neck.
The alarm was activated and additional officers arrived. Officers used pepper spray, physical force, a baton, and a head strike with a pepper
spray canister to gain control of the inmate. The second officer fractured his thumb during the incident. Two other officers received minor
injuries. The inmates did not receive serious injuries as a result of the force used.
Disposition
The institution’s executive review committee determined that the use of force deviated from departmental policy because pepper spray
was used closer than the allowable minimum distance and the pepper spray canister was used to strike the inmate in the head. However,
the committee concluded that the use of force was reasonable based on the threat presented to the officers. The committee also
determined that the camera operator should receive training because he failed to identify himself during the video-taped interview. No staff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation. The OIG concurred.
Overall Assessment Rating: Sufficient
The OIG determined that the department adequately responded to the incident in all critical aspects. The department informed and
consulted with the OIG about the incident in a timely and sufficient manner. The OIG agreed with the decision not to submit the matter to
the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-09-11 14-2190-RO PREA
Incident Summary
On September 11, 2014, an inmate alleged that a painter fondled her buttocks through her pants. The inmate also alleged that she
reciprocated in sexual contact and exposed her breasts.
Disposition
Potential staff misconduct was identified based on the inmate's allegation of a sexual assault; therefore, the case was referred to the Office
of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Overall Assessment Rating: Sufficient
Overall, the department's response to the incident was sufficient. The department adequately notified and consulted with the OIG on the
incident. The OIG concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-11-04 14-2645-RO Inmate Serious/Great Bodily Injury
Incident Summary
On November 4, 2014, during the dayroom release, several inmates told officers there was a “man down” in one of the cells. Officers found
an inmate lying on the floor of his cell in a pool of blood. Officers requested an emergency medical response after determining the inmate
was unresponsive, but breathing. Medical staff called for an ambulance and placed the injured inmate in a cervical collar andbackboard.
The inmate was transported to an outside hospital via ambulance and returned to a different institution 15 days later. The cellmate was
placed in administrative segregation pending investigation.
Disposition
The injured inmate did not implicate his cellmate as the cause of his injury. Training was provided to custody staff after the OIG expressed
concern regarding the inadequate investigation and crime scene management. No staff misconduct was identified; therefore, thecase was
not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because custody staff failed to adequately process the crime scene and document the
investigation. In addition, the investigative services unit failed to provide the cellmate with the Mirandawarning prior to questioning him.
The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the critical incident adequately documented?
The investigative services unit documented that they gathered information and determined there was no substantial facts to conclude
the cellmate committed a battery. The investigators failed to document what information was gathered and analyzed or how they
arrived at their conclusion.
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
The investigative services unit did not read the cellmate his Miranda rights prior to questioning him. They did not conduct acell search
for weapons, and did not use evidence markers or collect items with potential evidentiary value while processing the crime scene.
Was the HA's response to the critical incident appropriate?
Officers failed to immediately take custody of the cellmate and collect his clothing for potential evidence prior to the unclothed body
search. Facility staff did not notify the investigative services unit until one and a half hours later.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Incident Date OIG Case Number Case Type
2013-09-24 13-2091-RO Suicide
Incident Summary
On September 24, 2013, a single-celled inmate was found hanging in his cell by a sheet. After cutting down the sheet, custody and medical
staff initiated life-saving measures, which continued while the inmate was transported to the medical clinic. Subsequently, a physician
pronounced the inmate dead.
Disposition
An autopsy confirmed the manner of death as asphyxia due to hanging. Potential staff misconduct was identified based on the alleged
failure of custody staff to immediately perform life-saving measures upon the inmate who had committed suicide; therefore, the hiring
authority referred the case to the Office Of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for
monitoring.
Overall Assessment Rating: Insufficient
The department's response was not adequate because custody staff allegedly failed to immediately perform life-saving measures upon the
inmate. The OIG concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the HA's response to the critical incident appropriate?
Custody staff allegedly failed to immediately perform life-saving measures upon the inmate who committed suicide.
Incident Date OIG Case Number Case Type
2013-10-04 13-2183-RO In-Custody Inmate Death
Incident Summary
On October 4, 2013, custody staff responded to a "man down" call and observed an inmate standing by his cell door. Custody staff also
observed the cellmate lying on the cell floor on his back, bloodied from unknown injuries. The inmate standing by the cell door was
handcuffed and removed from the cell. Custody staff began life-saving measures on the injured inmate until medical staff arrived and
continued life-saving measures. The inmate was subsequently pronounced dead at the scene.
Disposition
An autopsy determined the cause of death was homicide. No staff misconduct was identified; therefore, the case was not referred to the
Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2013-12-11 13-2632-RO In-Custody Inmate Death
Incident Summary
On December 11, 2013, an inmate was discovered in a housing unit with a head injury that included active bleeding from the ear, nose, and
mouth. Another inmate told an officer that the inmate slipped and fell in the restroom area. The injured inmate was transported by
helicopter to an outside hospital where he was pronounced dead the next day.
Disposition
An autopsy determined that the inmate died as a result of blunt force injury to the head as the result of a fall. It was determined that he had
no injuries to the face and was intoxicated at the time of death. The department’s Death Review Committee determined there were no
medical care concerns or emergency response issues. Potential staff misconduct was identified based on the captain's alleged failure to
promptly notify the hiring authority and the OIG of the critical incident. Also, a lieutenant allegedly did not assume control of the potential
crime scene or promptly notify the investigative services unit. The hiring authority referred the case to the Office of Internal Affairs for
investigation. The case was returned to the hiring authority with approval for disciplinary action. The OIG accepted the casefor monitoring.
Training regarding evidence and crime scene preservation was provided to custody staff.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Overall Assessment Rating: Insufficient
The department’s response was not adequate becausethe department failed to notify the OIG in a timely and sufficient manner preventing
the OIG from real-time monitoring of the case. The department also failed to properly secure the crime scene and preserve evidence. The
OIG concurred with the hiring authority’s decision to refer the matter to the Office of Internal Affairs.
Assessment Questions
Did the HA make a timely decision regarding whether to refer any conduct related to the critical incident to the OIA?
The hiring authority discovered potential misconduct on December 12, 2013, but did not refer the matter to the Office of Internal
Affairs until April 15, 2014, 124 calendar days later.
Was the critical incident adequately documented?
Some of the responding officers failed to submit reports prior to the end of their shift.
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
The investigative services unit did not take control over the potential crime scene and investigation until four hours after it had been
notified of the incident.
Was the HA's response to the critical incident appropriate?
Custody staff failed to timely secure the cell as a crime scene. The cell was secured as a potential crime scene only after custody staff
were notified that the inmate was going to die from his injuries, four hours after the incident.
Was the OIG promptly informed of the critical incident?
The hiring authority notified the OIG over four hours after the department was notified that the inmate was likely going to die from
his injuries.
Incident Date OIG Case Number Case Type
2014-01-08 14-0135-RO In-Custody Inmate Death
Incident Summary
On January 8, 2014, an inmate complained of swollen legs and was transported to an outside hospital for medical tests. The inmate suffered
cardiac arrest and died at the hospital.
Disposition
The autopsy report identified the cause of death as an anaphylactic reaction to dye used during a CT scan at the hospital. Nostaff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department adequately notified and consulted
with the OIG on the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office ofInternal Affairs.
Incident Date OIG Case Number Case Type
2014-01-21 14-0240-RO Suicide
Incident Summary
On January 21, 2014, an officer observed an inmate straddling the guard rail on the fourth tier of a housing unit. The officer ordered the
inmate to get off the rail. The officer, while turning to get the attention of other custody staff, observed the inmate fall to the ground level
floor. Responding officers found the inmate lying face down and bleeding with obvious severe head trauma. Medical staff and afire captain
responded to the scene and provided emergency care. The inmate was transported to the triage and treatment area and then to an outside
hospital. On January 22, 2014, the inmate was pronounced dead at the hospital.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Disposition
The coroner did not perform an autopsy, but the coroner's report indicated the inmate died of multiple blunt force injuries by suicide. The
department's Death Review Committee concluded the death was not preventable, and the standard of care during the emergency was met.
The department's executive summary of suicide report identified concerns with the inmate's mental health treatment and recommended
training to the primary clinician in suicide risk evaluation. In addition, the institution asked for an architectural and engineering assessment
to determine if additional fencing on the upper tiers is within design standards. No staff misconduct was identified; therefore, the case was
not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the OIG was not timely notified of the incident preventing the OIG from real-time
monitoring. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not promptly informed of the critical incident. The OIG was notified almost 30 hours after the critical incident when the
inmate was pronounced dead by a hospital physician.
Incident Date OIG Case Number Case Type
2014-02-21 14-0445-RO Other Significant Incident
Incident Summary
On February 21, 2014, an inmate failed to fully comply with orders to get down and officers deployed pepper spray. The inmatethen
attacked an officer. Two other inmates moved toward the incident and officers responded by deploying pepper spray and using physical
force. Four officers were injured in the process of stopping the assaults. One officer received lacerations to his face and another officer
struck his head on a wall and sustained injury to his hand. The third officer sustained a hand injury and an abrasion on the face, and the
fourth officer sustained a knee injury.
Disposition
The institution's executive review committee determined that the use of force was within departmental policy. The OIG concurred. No staff
misconduct was identified. Therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department’s notification and consultation to the
OIG regarding the incident was sufficient. The OIG agreed with the decision not to submit the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-02-27 14-0485-RO Suicide
Incident Summary
On February 27, 2014, a single-celled inmate was observed standing in his cell leaning forward with a ligature around his neck. Life-saving
measures were unsuccessful.
Disposition
An autopsy revealed that the cause of death was strangulation consistent with suicide. The institution’s suicide report and administrative
review determined there was potential staff misconduct by a lieutenant, a sergeant, five officers, and a registered nurse whowere all
allegedly negligent in their duties prior to the incident, or in response to the incident. Therefore, the hiring authority referred the case to the
Office of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Overall Assessment Rating: Sufficient
The OIG determined that the department adequately responded to the incident in all critical aspects. The department adequately notified
and consulted with the OIG regarding the incident. The OIG concurred with the hiring authority’s decision to refer the matterto the Office
of Internal Affairs.
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NORTH REGION
Incident Date OIG Case Number Case Type
2014-03-04 14-0518-RO In-Custody Inmate Death
Incident Summary
On March 4, 2014, a single-celled inmate was found unresponsive in his cell. Officers removed the inmate from his cell and immediately
began life-saving measures. The inmate was transported to the triage and treatment area for medical treatment. Medical staff continued
life-saving measures; however, these attempts failed and the inmate was pronounced dead by a responding paramedic.
Disposition
The autopsy determined that the cause of death was cardiac dysrhythmia. No staff misconduct was identified; therefore, the case was not
referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department adequately notified and consulted
with the OIG on the incident. The OIG agreed with the decision not to submit the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-03-06 14-0949-RO In-Custody Inmate Death
Incident Summary
On March 6, 2014, officers found an unresponsive inmate on the floor of his cell with his cellmate cradling his head. Officers removed the
cellmate from the cell, determined the inmate not to be breathing, and began life-saving measures. Life-saving measures continued as the
inmate was transported via ambulance to an outside hospital where he was later pronounced dead.
Disposition
An autopsy revealed that the cause of death was asphyxia due to strangulation and the manner of death was homicide. The department's
Death Review Committee determined that the death was not preventable. A review of the in-cell homicide conducted by the department
revealed that the inmates were appropriately housed in compliance with departmental policy. The department discovered that some
classification forms were not appropriately completed and provided training. No other staff misconduct was identified. Therefore, the case
was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Officer of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-03-10 14-0576-RO Inmate Serious/Great Bodily Injury
Incident Summary
On March 10, 2014, a yard officer observed three inmates attack a fourth inmate with inmate-manufactured weapons on the exercise yard.
One of the three inmates was holding the fourth inmate while the other two were striking the fourth inmate in the upper torsoand head
area in stabbing motions. The yard officer activated his alarm and ordered the inmates to get down. After the inmates failed to comply with
orders to get down, the control booth officer fired a less-lethal round aiming for the thigh of one of the involved inmates. The round missed
the intended target and the inmates continued their attack. The officer fired a second less-lethal round at the thigh of an involved inmate.
The officer was unable to identify where the round struck; however, all inmates stopped fighting and assumed prone positions.All four
inmates suffered injuries consistent with fighting and one inmate sustained a laceration to his knee which may have been a result of the
less-lethal round. The inmate who was attacked was taken to the triage and treatment area for multiple stab wounds. He was subsequently
air-lifted to an outside hospital for treatment of injuries consisting of numerous stab wounds and lacerations to his head, torso, and arms,
and a puncture wound to his chest. It was determined the injuries were not life threatening. The inmate returned to the institution later the
same day.
Disposition
The institution’s executive review committee determined that the use of force was in compliance with departmental policy. TheOIG
concurred. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department adequately notified and consulted
with the OIG on the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office ofInternal Affairs.
Incident Date OIG Case Number Case Type
2014-03-15 14-0619-RO In-Custody Inmate Death
Incident Summary
On March 15, 2014, an officer was conducting a count when he came to a cell occupied by two inmates. When the officer asked one inmate
to wake his cellmate, who was lying on his bunk, the inmate stated that he had killed his cellmate during the previous evening because he
kept waking him up at night. The officer attempted to get the cellmate's attention by knocking on the door and calling his name. When the
inmate did not respond, the officer initiated a medical emergency alarm. Custody and medical staff responded to the cell. Theresponsive
inmate was restrained and removed from the cell. The unresponsive inmate was subsequently transported to the triage and treatment area
where he was pronounced dead.
Disposition
The autopsy report indicated the inmate's death was due to asphyxia. Rigor mortis and lividity were present when the inmate'sbody was
discovered. An officer responsible for conducting counts during the previous shift allegedly failed to notice the inmate was lying
unresponsive on his assigned bed. As potential staff misconduct was identified, the hiring authority referred the matter to the Office of
Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department's notification and consultation to the OIGregarding the
incident was sufficient. The OIG concurred with the hiring authority's decision to refer the matter to the Office of InternalAffairs.
Incident Date OIG Case Number Case Type
2014-03-20 14-0690-RO PREA
Incident Summary
On March 20, 2014, a single-celled inmate housed in a mental health facility alleged that he was raped by an unidentified staff member
while in his cell. The inmate was interviewed and the institution's investigative services unit reviewed the housing unit video. During the
time of the alleged incident the inmate was under one-on-one observation, and the video did not show anyone entering the inmate's cell.
The inmate was not taken for a medical evaluation based on the results of the video review. In the four days prior, the inmate had made
similar allegations of sexual assaults being committed by unknown persons. In each instance, the housing unit video was reviewed, and did
not show anyone entering the inmate's cell. The inmate was interviewed and transported to a local hospital for a medical evaluation.
Disposition
Potential staff misconduct was identified based on the inmate's allegation of a sexual assault; therefore, the case was referred to the Office
of Internal Affairs for investigation. After review, OIA Central Intake determined there was not a reasonable belief that misconduct
occurred. The OIG concurred with the decision.
Overall Assessment Rating: Insufficient
The department's overall response was inadequate because the hiring authority failed to timely refer the matter to the Officeof Internal
Affairs and only referred the matter after recommendation by the OIG. The department also failed to timely notify the OIG.
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NORTH REGION
Assessment Questions
Did the HA make a timely decision regarding whether to refer any conduct related to the critical incident to the OIA?
The inmate alleged incidents occurred from March 16, 2014, through March 20, 2014. The hiring authority discovered the alleged
misconduct on March 20, 2014, but did not refer the matter to the Office of Internal Affairs until August 28, 2014, 161 days after the
date of discovery and only after the OIG recommended the referral.
Was the HA's response to the critical incident appropriate?
The hiring authority's response to the critical incident was not appropriate because the hiring authority delayed reporting the incident
to the Office of Internal Affairs.
Was the OIG promptly informed of the critical incident?
Of the five allegations over a five day period, the department only notified the OIG on two occasions.
Did the institution timely notify the Office of Internal Affairs of the incident?
The matter was not referred to the Office of Internal Affairs until 161 days after the inmate made the allegations.
Incident Date OIG Case Number Case Type
2014-03-22 14-0698-RO Inmate Serious/Great Bodily Injury
Incident Summary
On March 22, 2014, as officers released culinary workers back to their housing units, officers observed an inmate stumble from the inmate
restroom with visible injuries to his head and neck. The inmate was transported to the triage and treatment area, and then transported to
an outside hospital. The inmate was treated for multiple stab wounds and was returned to the institution on March 25, 2014. Several
inmates were placed under investigation for this assault.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to notify the OIG in a timely manner preventing the OIG from
real-time monitoring of the case. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal
Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified of the incident until the following morning.
Incident Date OIG Case Number Case Type
2014-04-08 14-0840-RO Inmate Serious/Great Bodily Injury
Incident Summary
On April 8, 2014, seven inmates attacked another inmate on an exercise yard. Officers ordered the inmates to get down but they did not
comply. The yard observation officer fired one less-lethal round aiming at the right thigh of one of the seven inmates. The round hit the
inmate's lower back and he stopped fighting while the other inmates continued fighting. Officers deployed chemical agents to stop the
fighting. Two inmates, including the inmate being attacked, used inmate-manufactured weapons. One inmate suffered a laceration to the
back of the head and neck. He was transported to an outside hospital and returned to the institution the next day. Another inmate suffered
a puncture wound to his back. He also was transported to an outside hospital and returned to the institution on May 2, 2014. A third inmate
received medical treatment at the institution for a cut and puncture wound to his left shoulder and a puncture wound to his back.
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NORTH REGION
Disposition
The institution's executive review committee found the use of force in compliance with departmental policy; however, trainingwas
provided to responding officers regarding proper report writing procedures because an officer involved with the search and escort of one
inmate was not identified in reports. The OIG concurred. No staff misconduct was identified; therefore, the case was not referred to the
Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department’s notification and consultation to the OIGregarding the
incident was sufficient. The OIG agreed with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-04-09 14-1172-RO Hunger Strike
Incident Summary
On April 9, 2014, an inmate initiated a hunger strike due to issues related to his diet, programming, and property. The inmate was
subsequently transferred to the institution's correctional treatment center where medical staff could closely monitor his condition. On July
9, 2014, an administrative law judge authorized the department to administer involuntary psychiatric medication to the inmate. On July 14,
2014, the inmate ended his hunger strike by eating while monitored by medical staff.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-04-20 14-0940-RO In-Custody Inmate Death
Incident Summary
On April 20, 2014, inmates in a dormitory unit alerted custody staff of a "man down." Officers who responded to the scene found an inmate
lying on his bunk with his head directly facing into the pillow and vomit at the head of the bed. The inmate was not breathing and did not
have a pulse. Custody and medical staff initiated life-saving measures which were continued as the inmate was transported to the triage
and treatment area. The inmate was subsequently pronounced dead.
Disposition
The department's Death Review Committee concluded that the inmate's death was unexpected and unpreventable. The autopsy attributed
the death to opiate intoxication. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for
investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-05-13 14-1158-RO Hunger Strike
Incident Summary
On May 13, 2014, an inmate missed his ninth consecutive meal. The inmate told custody staff that he was on a hunger strike because he
wanted to starve himself to death. Although the inmate was being monitored by mental health and medical staff, officers failed to timely
notify management of the hunger strike. The inmate ended his hunger strike on May 19, 2014.
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NORTH REGION
Disposition
The hiring authority determined that custody staff failed to follow hunger strike protocols by not making appropriate timely notification to
management staff. As a result, the hiring authority issued a memorandum to all staff regarding hunger strike protocols and training was
provided to the custody staff involved in this incident. The OIG concurred. No staff misconduct was identified. Therefore, the hiring
authority did not refer the matter to the Office of Internal Affairs.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to timely notify the OIG and failed to timely make other
required notifications. The department also failed to timely complete required documentation. The OIG concurred with the hiring
authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the critical incident adequately documented?
Hunger strike protocols require that custody staff generate a report and immediately notify medical staff and the facility lieutenant.
The lieutenant is then required to immediately notify the captain and associate warden. In this case, the report was not generated
until five days later.
Was the OIG promptly informed of the critical incident?
On May 13, 2014, an inmate missed his ninth consecutive meal. The OIG was not notified of the hunger strike until May 16, 2014,
three days later, and was told that administrators were just made aware of the hunger strike.
Incident Date OIG Case Number Case Type
2014-05-17 14-1169-RO Inmate Serious/Great Bodily Injury
Incident Summary
On May 17, 2014, an inmate informed a nurse that he was feeling suicidal and the inmate agreed to see a physician. Therefore,the nurse
left the cell to call a physician while a medical technical assistant remained at the cell to observe the inmate. The medicaltechnical assistant
also left the cell front. A second medical technical assistant asked the control booth officer to open the inmate’s cell doorso the inmate
could go to see the physician. The inmate ran out of the cell and began climbing the second tier railing. Medical and custodystaff ordered
the inmate to get down but the inmate jumped off the second tier, landing on his head on the floor below. The inmate was flown by
helicopter to an outside hospital for treatment and returned to the institution the same day. The nurse and the medical technical assistants
are employed by the Department of State Hospitals.
Disposition
No departmental staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation. The
Department of State Hospitals is conducting its own investigation to determine whether any of its employees engaged in misconduct.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-05-19 14-1173-RO Suicide
Incident Summary
On May 19, 2014, an inmate summoned an officer and reported that his cellmate had hung himself. The cellmate was lying on hisbed with
torn bed sheets wrapped around his neck. The first inmate was placed in hand restraints and taken to a holding cell. Officersentered the
cell, cut the sheets, and placed the second inmate on a gurney. Officers and medical staff performed life-saving measures. The inmate was
taken to an outside hospital where he died the next day. The first inmate later admitted to a sergeant that he had assisted in the suicide of
his cellmate by holding him down.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Disposition
Potential staff misconduct was identified in that custody staff allegedly failed to timely submit reports and properly gatherand preserve
evidence. The hiring authority did not refer the matter to the Office of Internal Affairs for an investigation. However, the hiring authority
provided training regarding timely submission of reports and asked the local district attorney's office to provide training to the entire
institution regarding evidence preservation. The hiring authority also changed the local procedure so that the investigative services unit
would be primarily in charge of all evidence collection and preservation in inmate deaths. The hiring authority also purchased new
equipment for the investigative services unit. The OIG concurred with the hiring authority's determinations.
Overall Assessment Rating: Insufficient
The department’s response was not adequate because the institution failed to properly process the deceased inmate's cellmate for
evidence and allowed officers to leave the institution without writing reports before their shift ended.
Assessment Questions
Was the critical incident adequately documented?
The department failed to require every employee involved in the incident to write a report before they left work at the end of their
shifts.
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
The investigative services unit failed to properly process the dead inmate's cellmate for evidence. The inmate was secured inanother
cell but was not evaluated for injuries and not properly checked for evidence of a crime. One of the investigative services unit officers
failed to timely write an incident report.
Was the HA's response to the critical incident appropriate?
The institution failed to properly process the deceased inmate's cellmate for evidence. The cellmate was secured in another cell but
was not evaluated for injuries and not properly checked for evidence of a crime. Officers were also allowed to leave the institution
without writing reports documenting their involvement in the incident before their shift ended.
Incident Date OIG Case Number Case Type
2014-05-21 14-1197-RO Suicide
Incident Summary
On May 21, 2014, while conducting welfare checks, an officer discovered a single-celled inmate hanging from a bed sheet tied to the top of
the cell door. An alarm was activated and officers entered the cell, cut the material, and initiated life-saving measures. Medical staff
responded, assumed life-saving measures, and called for an ambulance. Paramedics continued life-saving measures; however, the inmate
was pronounced dead at the institution.
Disposition
The coroner determined the cause of death was asphyxia due to hanging. No staff misconduct was identified; therefore, the case was not
referred to the Office of the Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-05-31 14-1284-RO Contraband Watch
Incident Summary
On May 31, 2014, an inmate was placed on contraband surveillance watch after drugs were found in his possession during an unclothed
body search. On June 1, 2014, medical staff transferred the inmate to an outside hospital for a higher level of care when theinmate became
unresponsive. The inmate produced four bindles of suspected drugs at the outside hospital and was returned to the institutionlater that
day.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Overall Assessment Rating: Insufficient
The department failed to provide timely notification to the OIG when the inmate was sent to the outside hospital. The hiring authority
chose not to refer the matter to the Office of Internal Affairs; the OIG concurred with this decision.
Assessment Questions
Did the department adequately consult with the OIG regarding the critical incident?
The department did not consult with the OIG regarding this critical incident. The OIG became aware of the critical incident when
reviewing the contraband surveillance watch documentation that identified the inmate's transfer to an outside hospital.
Was the OIG promptly informed of the critical incident?
The OIG was not notified when the inmate was transferred to an outside hospital.
Incident Date OIG Case Number Case Type
2014-06-03 14-1574-RO PREA
Incident Summary
On June 3, 2014, an inmate alleged he was the victim of a sexual assault and that an officer pushed his closed baton into theinmate's
buttocks area while making lewd remarks. The inmate claimed that he had his boxer shorts on and that there was no penetration.
Disposition
Potential staff misconduct was identified based on the allegations of staff sexual assault; therefore, the hiring authority referred the case to
the Office of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-06-09 14-1325-RO PREA
Incident Summary
On June 9, 2014, a nurse informed custody staff that a single-celled inmate alleged an unidentified officer entered his cell and raped him
while he was asleep sometime during the previous week. The inmate was interviewed and taken to an outside hospital but refused an
examination.
Disposition
Potential staff misconduct was identified based on the allegation of staff sexual assault; therefore, the hiring authority referred the case to
the Office of Internal Affairs for investigation. After review, OIA Central Intake determined there was not a reasonable belief misconduct
occurred. The OIG concurred.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the OIG was not timely notified and the hiring authority did not timely refer the case
to the Office of Internal Affairs.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Assessment Questions
Was the HA's response to the critical incident appropriate?
The hiring authority failed to timely notify the Office of Internal Affairs.
Was the OIG promptly informed of the critical incident?
The OIG was notified almost two hours after the inmate reported the allegation.
Did the institution timely notify the Office of Internal Affairs of the incident?
The inmate reported the allegation on June 9, 2014. The institution notified the Office of Internal Affairs on June 19, 2014.
Incident Date OIG Case Number Case Type
2014-06-13 14-1531-RO Hunger Strike
Incident Summary
On June 13, 2014, an inmate began a hunger strike due to custody, family, and legal issues. The inmate was subsequently transferred to the
correctional treatment center so he could be closely monitored by medical staff. On July 7, 2014, the inmate ended his hungerstrike and
started eating as monitored by medical staff.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-06-27 14-1573-RO PREA
Incident Summary
On July 4, 2014, an inmate alleged that on June 27, 2014, he was the victim of a sexual assault by two officers. He claimed that he was
forced to orally copulate the two officers.
Disposition
Potential staff misconduct was identified based upon allegations of staff sexual assault; therefore, the hiring authority referred the case to
the Office of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-06-28 14-1830-RO Hunger Strike
Incident Summary
On June 28, 2014, an inmate initiated a hunger strike because he wanted to be released from prison. The inmate was subsequently
transferred to the correctional treatment center where he could be monitored by medical staff. On August 12, 2014, the inmateended his
hunger strike by eating as monitored by medical staff. On August 19, 2014, the inmate was discharged from the correctional treatment
center and transferred to a housing unit.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Overall Assessment Rating: Sufficient
The OIG determined that the department adequately responded to the incident in all critical aspects. The department adequately notified
and consulted with the OIG on the incident. The OIG agreed with the decision not to submit the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-07 14-1581-RO Suicide
Incident Summary
On July 7, 2014, an officer discovered a cell window covered. The officer knocked on the door and attempted to get the single-celled inmate
to respond. After no response, the officer placed a shield in front of the food port and opened the food port. The officer pushed his alarm
after observing the inmate's motionless body in the middle of the room. Responding officers found the inmate hanging from torn bed
sheets tied to the light fixture in his cell. Officers entered the cell, cut the noose, and with the assistance of a nurse who was also present,
lowered the inmate to the floor. Medical staff initiated life-saving measures. The inmate was later pronounced dead.
Disposition
The coroner determined the cause of death was suicide by asphyxiation. The department's Death Review Committee determined thedeath
was not preventable. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for
investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department provided adequate notification and
consultation to the OIG regarding the incident. The OIG agreed with the decision not to submit the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-07 14-1627-RO Suicide
Incident Summary
On July 7, 2014, an inmate was found hanging in a bathroom with a bed sheet tied to the vent and around his neck. Medical staff observed
him, activated an alarm, and responded. The inmate was taken down and emergency life-saving measures were started. The inmate's pulse
was restored and he was taken to an outside hospital where he was placed on life support. Subsequent tests determined that the inmate
had no brain activity. On July 9, 2014, the inmate was removed from life support and subsequently pronounced dead.
Disposition
The autopsy report concluded that the cause of death was hypoxic ischemic encephalopathy due to asphyxia by hanging. Potential staff
misconduct was identified based on the officer’s alleged failure to conduct the required inmate count; therefore, the hiring authority
referred the case to the Office of Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-08 14-1654-RO Contraband Watch
Incident Summary
On July 8, 2014, an inmate was placed on contraband surveillance watch after reporting that two weeks prior he had placed a weapon in his
rectum. The following day, the inmate complained of abdominal pain and was transported to an outside hospital. The inmate returned to
the institution later the same day after receiving treatment for pain. The inmate was removed from contraband surveillance watch when
test results indicated there was no foreign object in his body.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department adequately notified and consulted
with the OIG on the incident. The OIG concurred with the decision not to submit the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-17 14-1723-RO In-Custody Inmate Death
Incident Summary
On July 17, 2014, officers observed six inmates attacking two inmates on an exercise yard. The tower officer fired two less-lethal rounds,
which missed their intended target, and two yard officers deployed pepper spray to stop the altercation. One inmate sustainedmultiple
puncture wounds and was pronounced dead by medical staff at the institution. The other inmate sustained multiple stab wounds and was
sent to an outside hospital for further treatment. He later returned to the institution. Two inmate-manufactured weapons made of metal
stock and two made of melted plastic were found at the scene.
Disposition
The institution’s executive review committee determined that the use of force was within departmental policy. The OIG concurred. No staff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-19 14-1712-RO Contraband Watch
Incident Summary
On July 19, 2014, an inmate was placed on contraband surveillance watch after custody staff observed the inmate place an unknown object
in his mouth during visiting. The following day, the inmate was transported to an outside hospital because he appeared very anxious and
had an elevated pulse and blood pressure. While at the outside hospital, the inmate became very agitated as a result of a ruptured bindle
and was placed in four-point restraints. On July 22, 2014, the inmate was removed from contraband surveillance watch after producing a
total of eight bindles of suspected narcotics. On July 25, 2014, the inmate returned to the institution after receiving treatment for a drug
overdose.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation. However, the
department addressed the lack of documentation by providing on-the-job training to involved custody and medical staff.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the medical assessment and other required documentation were not properly
completed. The hiring authority decided not to refer the matter to the Office of Internal Affairs, and the OIG agreed.
Assessment Questions
Was the critical incident adequately documented?
The documentation related to the contraband surveillance watch did not contain an initial medical assessment form, a comprehensive
medical assessment, and did not identify that a supervisory review was conducted during two shifts. Other required documentation
was also incomplete.
Incident Date OIG Case Number Case Type
2014-08-12 14-2058-RO Hunger Strike
Incident Summary
On August 12, 2014, 12 inmates initiated a hunger strike to protest that they are not permitted to have televisions in the administrative
segregation unit. After 24 days, all 12 inmates ended their hunger strike on September 5, 2014, by eating.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 87
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department’s notification and consultation to the OIGregarding the
incident was sufficient. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-08-13 14-2241-RO Hunger Strike
Incident Summary
On August 13, 2014, an inmate began a hunger strike in protest of a rules violation report he received for battery on staff. On September
19, 2014, the inmate was transferred to the outpatient housing unit to be monitored more closely by medical staff. The inmateended his
hunger strike on September 22, 2014.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's overall response to the incident was adequate in all critical aspects. The department adequately notified and consulted
with the OIG on the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office ofInternal Affairs.
Incident Date OIG Case Number Case Type
2014-08-14 14-2166-RO PREA
Incident Summary
On August 14, 2014, a nurse allegedly rubbed an inmate's buttocks while giving him a medication by injection into his buttocks. The nurse
also allegedly licked his lips while giving the injection and made a sexually suggestive comment.
Disposition
Potential staff misconduct was identified based on the allegations of staff sexual assault; therefore, the hiring authority referred the case to
the Office of Internal Affairs for investigation. After review, OIA Central Intake determined there was not a reasonable belief misconduct
occurred. The OIG concurred with this decision.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG on the
incident. The OIG concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 88
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2012-10-27 14-1379-RO Suicide
Incident Summary
On October 27, 2012, an officer discovered an unresponsive single-celled inmate in his cell and called for a medical response. Medical staff
responded to the scene but life-saving measures were not initiated because the inmate was pulseless and in full rigor mortis. The
department's Death Review Committee opined that the inmate died of an accidental overdose; however, the coroner later determined that
the inmate death was a suicide, caused by an intentional overdose of amitriptyline, a medication prescribed to the inmate.
Disposition
The coroner determined the manner of death was suicide, caused by an overdose of amitriptyline. No staff misconduct was identified;
therefore, the case was not referred to the Office of Internal Affairs. However, subsequent to this incident, the department implemented
new statewide protocols for administering amitriptyline to prevent inmates from keeping a supply of the drug on their person or in their
cell.
Overall Assessment Rating: Sufficient
Overall the department's response to the incident was adequate; however, the department failed to timely notify the OIG that the coroner
determined that the inmate's death was a suicide. The OIG concurred with the hiring authority's decision not to refer the matter to the
Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2013-11-14 13-2473-RO Suicide
Incident Summary
On November 14, 2013, an inmate notified an officer that another inmate was attempting to hang herself in the housing unit shower. The
officer responded to the location and discovered an unresponsive inmate hanging from a shower pipe by a sheet tied around herneck. The
officer activated his alarm and used scissors to cut down the inmate. Another officer immediately responded, and they began life-saving
measures. Medical staff responded to the scene and took over life-saving measures until paramedics arrived. The inmate was transported
to an outside hospital, where she was placed on a ventilator. The inmate died two days later.
Disposition
The coroner determined that the manner of death was suicide due to hanging. No staff misconduct was identified; therefore, the case was
not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the hiring authority failed to address concerns expressed by the OIG related to the
security of the shower programs. The hiring authority decided not to refer the matter to the Office of Internal Affairs, and the OIG agreed.
Assessment Questions
Was the HA's response to the critical incident appropriate?
The OIG expressed concerns to the hiring authority regarding the lack of supervision and the inability of officers to ensure the safety of
inmates in the shower areas. The hiring authority agreed with the concerns and stated that she would implement a more structured
shower program and explore the procurement of curtains or doors that would ensure inmate privacy but improve the safety and
security. Several months later, the hiring authority has yet to take any action.
Incident Date OIG Case Number Case Type
2013-11-26 13-2591-RO Suicide
Incident Summary
On November 26, 2013, custody staff discovered a single-celled inmate unresponsive on the floor of his cell with a sheet tied around his
neck. Custody staff activated an alarm, removed the inmate from his cell, and initiated life-saving measures. Medical staff responded and
the inmate was transported to the triage and treatment area where life-saving measures continued but the inmate was pronounced dead.
There was an allegation that before his death the inmate called out for help but was ignored by custody staff.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Disposition
An autopsy determined the cause of death to be suicide by hanging. The OIG met with the hiring authority and discussed the deficiencies
with the manner in which the inquiry into the inmates' allegations was conducted. No staff misconduct was identified; therefore, the case
was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to notify the OIG in a timely and sufficient manner preventing
the OIG from real-time monitoring of the case. In addition, the inquiry conducted by the investigative services unit was not thorough
because the control booth officer neither submitted a memorandum nor was he interviewed. Likewise, the inquiry failed to identify all
inmates who were interviewed about the incident and it was not clear whether all inmates who were housed near the deceased inmate
were interviewed. Based on the hiring authority's unwillingness to conduct further inquiry, the OIG concurred with the decision not to refer
the matter to the Office of Internal Affairs because there was not sufficient evidence to determine whether potential staff misconduct
occurred.
Assessment Questions
Did the department adequately consult with the OIG regarding the critical incident?
The department failed to notify the OIG of the inmate's suicide. The OIG became aware of the incident through a daily report nine
days after the inmate's death.
Was the critical incident adequately documented?
The control booth officer neither submitted a memorandum nor was he interviewed. Likewise, the inquiry by the investigative services
unit did not identify all inmates who were interviewed and it was not clear whether all inmates who were housed near the deceased
inmate were interviewed.
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
Immediately following the suicide, other inmates reported that two days prior to the suicide, the dead inmate told housing unit
officers that he was suicidal; however, the officers did not take steps to ensure the inmate received appropriate mental health
treatment. Furthermore, the inmates reported that the deceased inmate called out for help hours before the suicide, but no officers
responded. The institution's investigative services unit did not conduct an inquiry into these allegations until January 9, 2013, over a
month after the suicide. Additionally, the inquiry report was neither complete nor clear. The report did not fully indicate which
inmates were interviewed, whether the inmates housed closest to the deceased were actually interviewed, and exactly what each
inmate said.
Was the HA's response to the critical incident appropriate?
Immediately following the suicide, other inmates reported that two days prior to the suicide, the deceased inmate told housing unit
officers that he was suicidal; however, the officers did not take steps to ensure the inmate received appropriate mental health
treatment. Furthermore, the inmates reported that the deceased inmate called out for help hours before the suicide, but no officers
responded. The institution did not conduct an inquiry into these allegations until January 9, 2013, over a month after the suicide.
Additionally, the inquiry report was neither complete nor clear. The report failed to fully indicate which inmates were interviewed,
whether the inmates housed closest to the deceased were actually interviewed, and exactly what each inmate said.
Was the OIG promptly informed of the critical incident?
The institution failed to notify the OIG.
Incident Date OIG Case Number Case Type
2013-12-08 13-2651-RO Contraband Watch
Incident Summary
On December 8, 2013, an inmate was transported to an outside hospital after informing staff that he swallowed three razor blades. A
medical evaluation performed at the hospital confirmed the inmate ingested foreign objects and he was immediately admitted tothe
hospital and placed on contraband surveillance watch. On December 15, 2013, the inmate returned to the institution. A medicalassessment
noted that the inmate had swelling and a laceration above his right eye. The inmate alleged that one of the transportation officers punched
him in the eye during the transport from the hospital.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Disposition
Potential staff misconduct could not be determined due to the department's failure to adequately document the incidents. Therefore, the
matter was not referred to the Office of Internal Affairs for investigation. However, the hiring authority provided training to custody staff
regarding documentation requirements and providing constant visual observation of an inmate on contraband surveillance watch during
transport.
Overall Assessment Rating: Insufficient
The department failed to comply with contraband surveillance watch policies and procedures. Specifically, there is no documentation
verifying that the inmate was kept under constant visual observation during his transport to and from the hospital. Further, the department
failed to follow use-of-force policy concerning the allegation that the inmate had been assaulted by an officer. The OIG concurred with the
hiring authority's decision not to refer the matter to the Office of Internal Affairs because the hiring authority failed to conduct a sufficient
inquiry to determine whether potential staff misconduct occurred.
Assessment Questions
Did the department adequately consult with the OIG regarding the critical incident?
The department failed to adequately notify the OIG when the inmate was removed from contraband surveillance watch.
Did the HA make a timely decision regarding whether to refer any conduct related to the critical incident to the OIA?
The institution failed to timely conduct a video-taped interview of the inmate concerning his complaint of assault by an officer. As a
result of the delay, a timely decision was not made about whether to refer any conduct to the Office of Internal Affairs.
Was the critical incident adequately documented?
Transportation officers failed to adequately document that the inmate was taken to an outside hospital, that the inmate sustained an
injury during his return trip to the institution, or that officers maintained constant visual observation of the inmate during transport to
and from the hospital.
Incident Date OIG Case Number Case Type
2014-01-08 14-0132-RO In-Custody Inmate Death
Incident Summary
On January 8, 2014, an inmate was found unresponsive in his cell approximately two hours after being seen in the clinic complaining of
difficulty breathing. Life-saving measures were initiated and the inmate was transported to an outside hospital. However, he was
pronounced dead three days later.
Disposition
The autopsy determined the cause of death was cardiac dysfunction and that bronchial asthma contributed to the death. The department's
Death Review Committee determined the inmate was not properly assessed when complaining of difficulty breathing. Potential staff
misconduct was identified based on the alleged failure to properly perform a nursing assessment and alleged failure to provide appropriate
medical care; therefore, the hiring authority referred the case to the Office of Internal Affairs for investigation. An investigation was opened,
which the OIG accepted for monitoring.
Overall Assessment Rating: Insufficient
The department's response was not adequate. The department failed to timely notify the OIG and the hiring authority delayed six months
before referring the matter to the Office of Internal Affairs. The OIG concurred with the hiring authority's decision to refer the matter to the
Office of Internal Affairs.
Assessment Questions
Did the HA make a timely decision regarding whether to refer any conduct related to the critical incident to the OIA?
The department learned of the misconduct on April 1, 2014, but the hiring authority did not refer the matter to the Office ofInternal
Affairs until September 29, 2014, six months after the date of discovery.
Was the OIG promptly informed of the critical incident?
The OIG was not notified until approximately two hours after the incident.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-01-14 14-0209-RO PREA
Incident Summary
Between January 14, 2014, and January 22, 2014, an inmate made seven separate allegations that he was sexually assaulted by staff.
Disposition
Potential staff misconduct was identified based on the alleged failure to comply with the Prison Rape Elimination Act; therefore, after urging
by the OIG, the hiring authority referred one of the sexual assault claims to the Office of Internal Affairs for investigation. An investigation
was not opened.
Overall Assessment Rating: Insufficient
The department's response to the incidents was not satisfactory. The hiring authority failed to sufficiently inform the OIG regarding the
allegations. Additionally, the hiring authority failed to comply with the Prison Rape Elimination Act policy because it failed to timely refer the
allegations to the Office of Internal Affairs for investigation, failed to adequately document each allegation, and cannot confirm that a
sexual assault advocate was provided to the inmate for each of the claimed assaults. Further, there appeared to be a misunderstanding by
custody staff regarding the scope and requirements of the Prison Rape Elimination Act policy. The OIG concurred with the hiring authority's
decision to refer the matter to the Office of Internal Affairs.
Assessment Questions
Did the department adequately consult with the OIG regarding the critical incident?
The department failed to consult with the OIG on three of the sexual assault claims.
Did the HA appropriately determine whether to refer any conduct to the OIA related to the critical incident?
The hiring authority did not refer this case to the Office of Internal Affairs for investigation until the OIG made the recommendation.
Did the HA make a timely decision regarding whether to refer any conduct related to the critical incident to the OIA?
The hiring authority failed to notify the Office of Internal Affairs until two months after the date of discovery.
Was the critical incident adequately documented?
The institution only completed four incident packages out of the seven sexual assault allegations.
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
The investigative services unit failed to follow the Prison Rape Elimination Act protocols because they did not generate a request for
investigation of each sexual assault claim as required.
Was the HA's response to the critical incident appropriate?
The hiring authority failed to adequately document, notify, and request investigations on each sexual assault claim as required by the
Prison Rape Elimination Act policy.
Was the OIG promptly informed of the critical incident?
The institution failed to notify the OIG of three of the sexual assault claims and failed to timely notify the OIG regarding a fourth
claim.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-02-01 14-0348-RO Contraband Watch
Incident Summary
On February 1, 2014, officers observed a bindle protruding from an inmate's anal cavity during an unclothed body search. The inmate ran,
and an officer forced the inmate to the ground to effect custody. A bindle containing suspected heroin was recovered near theinmate. As a
result of the force used by officers, the inmate sustained a bump on his head. The inmate claimed he lost consciousness. The inmate was
placed on contraband surveillance watch and hours later complained of dizziness and vomiting. The inmate was transferred to an outside
hospital for a higher level of care, where he was diagnosed with a concussion. He returned to the institution the next day instable
condition. On February 4, 2014, the inmate was removed from contraband surveillance watch. No additional contraband was recovered.
The inmate alleged that officers used unreasonable force and that he was sexually assaulted by an officer during the incident.
Disposition
The institution's executive review committee determined the use of force was in compliance with policy and there was insufficient evidence
to sustain the inmate's allegation of unreasonable force. The OIG concurred. The hiring authority ordered training for custody staff assigned
to the contraband surveillance watch incident for proper hand hygiene and documentation of effective communication. The sexual assault
allegation was referred to the Office of Internal Affairs for investigation; however, the case was rejected. The OIG concurred with these
decisions.
Overall Assessment Rating: Insufficient
The department's overall response to the incident was inadequate because they failed to notify the OIG of the serious injury sustained by
the inmate during the incident. Additionally, although the OIG concurred with the hiring authority's ultimate decision to refer the inmate's
sexual assault allegation to the Office of Internal Affairs, the department failed to discover and address the allegation in a timely manner.
Assessment Questions
Did the HA make a timely decision regarding whether to refer any conduct related to the critical incident to the OIA?
On May 28, 2014, the OIG advised the hiring authority that the crossed out section of the inmate's written statement contained an
allegation of sexual assault. On June 24, 2014, the OIG again met with the hiring authority and urged the hiring authority totake
further action. The matter was ultimately referred to the Office of Internal Affairs on July 1, 2014, nearly five months after the
allegation was made.
Was the critical incident adequately documented?
The hiring authority failed to adhere to policies related to documentation for contraband surveillance watch and failed to document
the date and the identity of the staff member who accepted the inmate's written allegation of unreasonable force, which included an
allegation of sexual assault.
Was the HA's response to the critical incident appropriate?
On February 3, 2014, the department interviewed the inmate based on his injury and allegation of excessive force. The inmate also
provided a written allegation that included a crossed out statement alleging that he was sexually assaulted by an officer during the
incident. The department failed to take any action on the sexual assault allegation until the OIG inquired on May 28, 2014.
Was the OIG promptly informed of the critical incident?
The hiring authority failed to notify the OIG of the inmate's injury and the allegation of sexual assault. The OIG discoveredthe
inmate's injury while monitoring the contraband surveillance watch and the sexual assault allegation while reviewing the inmate's
allegation of unreasonable force.
Did the HA timely respond to the critical incident?
On February 3, 2014, the department interviewed the inmate based on his injury and allegation of excessive force. The inmate also
provided a written allegation that included a crossed out statement alleging that he was sexually assaulted by an officer during the
incident. The department failed to take any action on the sexual assault allegation until the OIG inquired on May 28, 2014.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 93
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-02-11 14-0444-RO Hunger Strike
Incident Summary
On February 11, 2014, an inmate refused to eat or drink because she was depressed. After the inmate refused nine consecutive meals, the
department initiated hunger strike protocols in accordance with departmental procedure. On February 17, 2014, the inmate was
transported to an outside hospital for a higher level of care due to dehydration concerns. Three days later, the inmate returned to the
institution in stable condition and consumed a meal. Subsequently, the inmate initiated three additional hunger strikes over a four month
period which resulted in hospitalization, but ended with the inmate returning to the institution with no serious medical complications.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Insufficient
The OIG found the department's overall response to the incident was inadequate because they failed to notify the OIG that theinmate was
taken to an outside hospital as a result of her hunger strike. The OIG concurred with the hiring authority's decision not to refer the matter to
the Office of Internal Affairs.
Assessment Questions
Was the critical incident adequately documented?
Medical and custody staff recorded conflicting information specific to the dates of the inmate's hunger strikes and the number of
missed meals.
Was the OIG promptly informed of the critical incident?
The institution failed to notify the OIG that the inmate had been taken to an outside hospital as a result of her hunger strike. The OIG
learned of the incident by reviewing the department's daily report.
Incident Date OIG Case Number Case Type
2014-02-22 14-0462-RO In-Custody Inmate Death
Incident Summary
On February 22, 2014, an inmate alerted custody staff that his cellmate was unconscious. Custody staff removed the inmate from the cell
and responding medical staff initiated life-saving measures. The inmate was transported to the triage and treatment area where he was
pronounced dead.
Disposition
The coroner determined the inmate died of a drug overdose. The department's Death Review Committee concluded the death was not
preventable. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department’s response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority’s decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-03-13 14-0629-RO In-Custody Inmate Death
Incident Summary
On March 13, 2014, an inmate alerted officers that her cellmate was having a medical emergency. Custody staff responded to the cell and
found an unresponsive inmate lying on the floor. Officers called for medical assistance and removed the inmate from the cell,and
responding medical staff initiated life-saving measures. The inmate was transported via ambulance to an outside hospital, where she was
pronounced dead.
Disposition
The coroner determined the inmate died from a pulmonary embolism. No staff misconduct was identified; therefore, the case wasnot
referred to the Office of Internal Affairs for investigation.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to notify the OIG in a timely and sufficient manner preventing
the OIG from real-time monitoring of the case. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of
Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified until more than three hours after the incident.
Incident Date OIG Case Number Case Type
2014-05-03 14-1100-RO In-Custody Inmate Death
Incident Summary
On May 3, 2014, an officer conducting morning security checks discovered a double-celled inmate unresponsive inside his cell. The officer
activated his alarm and responding custody staff initiated life-saving measures. Medical staff responded and continued life-saving measures
while the inmate was transported to the triage and treatment area. Paramedics arrived and took over the medical emergency, but the
inmate was pronounced dead. The cell was secured as a possible crime scene, and the cellmate of the dead inmate was placed in
administrative segregation pending further investigation. The inmate was later cleared of any involvement.
Disposition
The autopsy determined the cause of death was an accidental overdose of fentanyl. No staff misconduct was identified; therefore, the case
was not referred to the Office of Internal Affairs for investigation. The hiring authority agreed with the OIG that the investigative services
unit should have taken steps to determine the possible source of the fentanyl. The hiring authority has since modified its post orders to
require an investigation into the origin of narcotics whenever there is an inmate overdose.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the investigative services unit failed to investigate the origin of the fentanyl used by
the dead inmate. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Did the investigative services unit, or equivalent investigative personnel, adequately respond to the critical incident?
After the coroner's report concluded that the inmate died from a lethal level of fentanyl, the OIG inquired about an investigation into
its source. The investigative services unit assumed the inmate died from a heroin overdose and had not taken steps to investigate the
overdose beyond questioning the dead inmate's cellmate.
Was the HA's response to the critical incident appropriate?
The toxicology report from the coroner found that the inmate died from a lethal level of fentanyl, an analgesic prescription drug that
is also known to be used for illicit purposes. After the coroner's report was released, the institution failed to investigatehow the
inmate obtained the fentanyl.
Incident Date OIG Case Number Case Type
2014-05-05 14-1135-RO In-Custody Inmate Death
Incident Summary
On May 5, 2014, an inmate returning from his work assignment alerted custody staff of a "man down" in his cell. Officers responded to the
cell and found an unresponsive inmate lying on the floor. Officers removed the inmate from the cell and initiated life-saving measures until
medical staff relieved them. Paramedics responded to the institution and took over the medical emergency but the inmate was pronounced
dead.
Disposition
An autopsy determined the cause of death was heroin intoxication. The department's Death Review Committee determined the death was
not preventable. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for Investigation.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 95
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to notify the OIG in a timely and sufficient manner preventing
the OIG from real-time monitoring of the case. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of
Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified until nearly 90 minutes after the inmate died. By the time the OIG responded, the coroner's investigator had
already responded to the scene, removed the inmate's body, and completed their inspection.
Incident Date OIG Case Number Case Type
2014-05-10 14-1168-RO PREA
Incident Summary
On May 10, 2014, an inmate alleged that he had been sexually assaulted by two officers who had been involved in an earlier use-of-force
incident involving the inmate.
Disposition
Potential staff misconduct was identified based on the inmate's allegation of sexual assault; therefore, the hiring authorityreferred the case
to the Office of Internal Affairs for investigation. The Office of Internal Affairs determined there was insufficient evidence to open an
investigation.
Overall Assessment Rating: Insufficient
The department's overall response to the incident was inadequate because they failed to timely notify the OIG of the incident. The OIG
concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The institution did not notify the OIG for over 24 hours after the allegation was made.
Incident Date OIG Case Number Case Type
2014-05-20 14-1506-RO Hunger Strike
Incident Summary
On May 20, 2014, an inmate began a hunger strike and weighed 190 pounds. Over 30 days later, the inmate remained on a hunger strike
and had lost 41 pounds. The inmate's stated reason for his hunger strike was a lack of programming available at the institution and he
wanted to be included in the early release program for non-violent inmates. The OIG began monitoring the hunger strike, the inmate's
medical condition, and legal proceedings the department initiated when notified of the inmate's weight loss. The inmate was transferred to
an outside hospital on July 16, 2014, and returned to the institution after ending his hunger strike on July 30, 2014.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate. The department failed to adequately document the inmate's ability to understand advice
provided by medical staff when the inmate refused care, and the department's daily report failed to accurately document the inmate's
weight. The department also failed to provide the OIG accurate information regarding the inmate's weight and failed to timelynotify the
OIG when the inmate was transferred to an outside hospital on July 15, 2014. The OIG concurred with the hiring authority's decision not to
refer the matter to the Office of Internal Affairs.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Assessment Questions
Was the critical incident adequately documented?
The department failed to document the inmate's ability to understand medical staff's advice when the inmate was refusing care. In
addition, the department failed to document the inmate's weight in the daily report.
Was the OIG promptly informed of the critical incident?
The OIG was not informed that the inmate was transferred to an outside hospital until the day following his transfer.
Incident Date OIG Case Number Case Type
2014-06-23 14-1493-RO Other Significant Incident
Incident Summary
On June 23, 2014, an officer was returning a loaded revolver and holster to the armory. Upon entering the armory, the officerremoved the
revolver from the holster at which time he noticed the hammer was pulled back in a ready-to-fire position. The officer attempted to reset
the hammer and, while doing so, discharged the weapon, causing one round to enter a cinder block wall. There were no injuries.
Disposition
The institution's executive review committee determined the conduct was outside of departmental policy. The OIG concurred. Potential
staff misconduct was identified due to the alleged careless handling of the firearm; therefore, the hiring authority referredthe case to the
Office of Internal 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.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-01 14-1533-RO Other Significant Incident
Incident Summary
On July 1, 2014, an inmate attempted suicide by wetting the top of his head and inserting an object into an electrical outletin his cell. The
inmate was housed in administrative segregation on single-cell status at the time of the incident and is the suspect in the murder of a
correctional officer. After initial evaluation, the inmate was sent to an outside hospital for further evaluation and when returned to the
institution, was placed on suicide watch for a week, following which he was returned to administrative segregation.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-07-30 14-1820-RO Suicide
Incident Summary
On July 30, 2014, an officer discovered a single-celled inmate in her cell hanging by a bed sheet that was tied to a bookcase and tied around
the inmate's neck. Custody staff entered the inmate’s cell, cut the noose from around the inmate's neck, and began life-saving measures.
The inmate was transported to an outside hospital and shortly after her arrival, was pronounced dead by a hospital physician.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 97
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Disposition
Autopsy results revealed that the death was caused by asphyxiation. The suicide review committee examined the case and provided
recommendations to the institution concerning training for mental health staff in identifying inmates who meet the criteria for referral to
the psychiatric in-patient unit, state-wide training concerning prevention of prescription drug abuse and the controlled circulation of
syringes in institutions, as well as state-wide training to reduce the introduction and distribution of drugs in institutions. No staff misconduct
was identified; therefore, the case was not referred to the Office of Internal Affairs for an investigation.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to timely notify the OIG of the critical incident preventing the
OIG from real-time monitoring of the case. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of
Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified until three hours after the incident.
Incident Date OIG Case Number Case Type
2014-08-06 14-1916-RO Contraband Watch
Incident Summary
On August 6, 2014, an inmate notified custody staff that he swallowed razor blades. The inmate was evaluated by medical staffand placed
on mental health crisis status. Later that evening, the department transported the inmate to an outside hospital and initiated contraband
surveillance watch protocols after an x-ray confirmed the presence of an object that appeared to be a toothbrush handle with a razor blade.
The hospital recommended a medical procedure to remove the items, but the inmate refused. The department removed the inmate from
contraband surveillance watch on August 13, 2014, after it was determined by medical staff that the objects would not pass without the
recommended procedure. On August 15, 2014, the inmate returned to the institution in stable condition and was returned to mental health
crisis status.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.However, training
was provided to involved custody staff to address the documentation deficiencies that occurred during the contraband surveillance watch.
Overall Assessment Rating: Insufficient
The department's overall response to the incident was inadequate because it failed to timely notify the OIG of the incident. Also, the
department failed to adequately document inmate and restraint hygiene and failed to consistently document supervisory checks.The OIG
concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the critical incident adequately documented?
The department failed to adequately document inmate and restraint hygiene and supervisory checks.
Was the OIG promptly informed of the critical incident?
The OIG was not notified until more than four hours after the inmate was placed on contraband surveillance watch.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-08-07 14-1914-RO Contraband Watch
Incident Summary
On August 7, 2014, two inmates attacked a third inmate on an exercise yard directly in front of officers, requiring the use of pepper spray to
stop the attack. The three involved inmates were placed on contraband surveillance watch because it was believed the inmates staged the
incident as part of a plan to introduce contraband into the administrative segregation unit. Additionally, drug paraphernaliawas found
during a subsequent search of one of the inmate's property. The department released the inmates from contraband surveillance watch on
August 10, 2014, after one of the inmates produced a bowel movement containing four separate packages of suspected narcotics and
inmate notes related to narcotic trafficking.
Disposition
The institution's executive review committee determined the use of force was within departmental policy and training. The hiring authority
ordered training for all involved custody staff related to the contraband surveillance watch documentation policy. The OIG agreed with the
hiring authority's decisions. No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for
investigation.
Overall Assessment Rating: Sufficient
Although the department did not clearly articulate the justification for placing the inmates on contraband surveillance watch, the OIG's
review of the circumstances and discussion with the department revealed that the placement was justified. The department's response was
satisfactory in all other critical aspects. The department adequately notified and consulted with the OIG regarding the incident. The hiring
authority decided not to refer the matter to the Office of Internal Affairs, and the OIG agreed.
Incident Date OIG Case Number Case Type
2014-08-11 14-1933-RO Suicide
Incident Summary
On August 11, 2014, while conducting a security check on an inmate who did not report for his meal, an officer discovered a single-celled
inmate in his cell hanging by a sheet tied around his neck. Officers cut the sheet and initiated life-saving measures until medical staff
responded and took over. The inmate was transported to an outside hospital for a higher level of care but was pronounced deadby the
emergency room physician.
Disposition
The examiner opined during the autopsy that the inmate's injuries were consistent with hanging. The department's preliminary Death
Review Committee summary and the department's Statewide Mental Health Program suicide report noted the cause of death was
asphyxiation due to hanging, and the death was not preventable. No staff misconduct was identified; therefore, the case was not referred
to the Office of Internal Affairs. However, as a result of this incident and the department's quality improvement plan, the institution
completed training for mental health care staff to achieve better coordination with county correctional institutions for mental health care
screenings and services provided to inmates.
Overall Assessment Rating: Insufficient
The department’s response was not adequate because the department failed to notify the OIG in a timely manner preventing the OIG from
real-time monitoring of the case. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal
Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified until nearly three hours after the inmate died.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-08-11 14-2169-RO Hunger Strike
Incident Summary
On August 11, 2014, an inmate began a hunger strike to protest his placement in administrative segregation pending a transferto a
different institution. The inmate ended the hunger strike approximately 30 days later by consuming a nutritional drink. The inmate lost 20
pounds, 13 percent of his body weight, during the strike but suffered no medical complications and was transferred to a different
institution.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-08-19 14-2021-RO Suicide
Incident Summary
On August 19, 2014, an officer conducting an inmate count discovered an inmate holding his cellmate from behind in the back of their cell.
The inmate told the officer he woke up, found his cellmate hanging and had just cut him down. The officer activated his alarmand
responding medical and custody staff initiated life-saving measures. The inmate was transported to the triage and treatment area where he
was pronounced dead. The cellmate of the dead inmate was placed in administrative segregation pending further investigation, but was
later cleared of any involvement.
Disposition
The medical examiner concluded the cause of death was suicide by hanging. The department's suicide review noted that the mental health
documentation for the inmate did not provide a clear understanding of the inmate's symptoms or formulation of treatment interventions
and recommended further inquiry of the mental health records to determine appropriate training for mental health staff. No staff
misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-08-23 14-2032-RO In-Custody Inmate Death
Incident Summary
On August 23, 2014, an inmate alerted custody staff that his cellmate was having a medical emergency. Responding custody staff lowered
the inmate from his bunk and initiated life-saving measures. The inmate was transported to the triage and treatment area where he was
pronounced dead by a physician.
Disposition
The coroner determined the cause of death was heart disease with methamphetamine intoxication as a contributing factor. The
department's Death Review Committee determined the death was not preventable. No staff misconduct was identified; therefore, the case
was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG agreed with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 100
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-08-23 14-2033-RO In-Custody Inmate Death
Incident Summary
On August 23, 2014, an officer discovered an unresponsive, single-celled inmate slumped over his in-cell toilet. An officer pressed his alarm
and responding custody staff initiated life-saving measures until medical staff arrived. The inmate was transported to the triage and
treatment area where he was pronounced dead by a physician.
Disposition
The coroner determined that the manner of death was natural, caused by cardiovascular disease. Potential staff misconduct wasidentified
based on an officer's alleged failure to conduct the required inmate count; therefore, the hiring authority referred the caseto the Office of
Internal Affairs for investigation. An investigation was opened, which the OIG accepted for monitoring.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-08-30 14-2268-RO PREA
Incident Summary
On August 30, 2014, officers used physical force to gain control of an inmate after the inmate struck an officer in the face with his head. The
inmate sustained a small cut on his cheek and alleged that officers used unreasonable force during the incident. The inmate also alleged
that he was sexually assaulted by an officer during a subsequent search. Prison Rape Elimination Act protocols were initiated.
Disposition
The institution's executive review committee determined the use of force was in compliance with departmental policy but ordered training
for custody staff regarding timely completion of incident reports. The OIG concurred. The sexual assault and unreasonable force allegations
were referred to the Office of Internal Affairs for investigation; however, the case was rejected.
Overall Assessment Rating: Insufficient
The department's response was not adequate because the department failed to timely notify the OIG. The OIG agreed with the hiring
authority's decision to refer the matter to the Office of Internal Affairs.
Assessment Questions
Was the OIG promptly informed of the critical incident?
The OIG was not notified until nearly three hours after the incident.
Incident Date OIG Case Number Case Type
2014-09-23 14-2245-RO In-Custody Inmate Death
Incident Summary
On September 23, 2014, an officer conducting security checks discovered a single-celled inmate unresponsive in his cell. The officer
summoned custody and medical staff who responded to the cell and found the inmate with an inmate-manufactured syringe protruding
from his abdomen. No life-saving measures were taken because the on-scene nurse determined that lividity and rigor mortis had set in.
Disposition
The department's Death Review Committee concluded that the inmate's death was an accidental heroin overdose and was not preventable.
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.
Overall Assessment Rating: Sufficient
The department's response to the incident was satisfactory in all critical aspects. The department adequately notified and consulted with
the OIG regarding the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal
Affairs.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 101
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Incident Date OIG Case Number Case Type
2014-10-12 14-2504-RO Contraband Watch
Incident Summary
On October 12, 2014, an inmate informed custody staff that he swallowed 25 razor blades. The inmate was escorted to the triage and
treatment area where an x-ray confirmed the presence of a foreign object resembling a razor blade. The inmate was transported to an
outside hospital for observation. Four days later, the inmate returned to the institution. The following morning, the inmate was evaluated
by medical staff and again transported to an outside hospital due to medical complications from swallowing the razors. The inmate returned
to the institution on October 21, 2014, and was placed on contraband surveillance watch. He was removed from contraband surveillance
watch on October 23, 2014, after an x-ray showed negative results for foreign objects.
Disposition
Potential staff misconduct was identified based on the inmate being attired in a security smock, rather than the taped jumpsuit required by
the contraband surveillance watch protocol. The hiring authority issued a letter of instruction to a captain and a lieutenant. The OIG agreed
with the hiring authority's decision.
Overall Assessment Rating: Sufficient
The department's response was satisfactory in all critical aspects. The department adequately notified and consulted with theOIG regarding
the incident. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of Internal Affairs.
Incident Date OIG Case Number Case Type
2014-10-23 14-2522-RO Contraband Watch
Incident Summary
On October 23, 2014, an inmate in administrative segregation informed custody staff that he swallowed razor blades. The inmate was
placed on contraband surveillance watch after an x-ray confirmed the presence of metal objects. On October 26, 2014, the inmate
complained of abdominal pain and was transported to a local hospital for evaluation and returned to the institution the same day. The
inmate was removed from contraband surveillance watch on October 28, 2014, after an x-ray confirmed the lack of foreign objects. While
the inmate was on contraband surveillance watch, the department recovered one piece of a metal object.
Disposition
No staff misconduct was identified; therefore, the case was not referred to the Office of Internal Affairs for investigation.However, the
hiring authority provided training to staff related to proper documentation of contraband surveillance watch incidents.
Overall Assessment Rating: Insufficient
The department's response to the incident was not adequate because it failed to comply with contraband surveillance watch protocols after
it was determined that the inmate had ingested contraband and failed to adequately complete documentation related to the contraband
surveillance watch. The OIG concurred with the hiring authority's decision not to refer the matter to the Office of the Internal Affairs.
Assessment Questions
Was the critical incident adequately documented?
The department failed to adequately document the inmate's activities for the duration of the contraband surveillance watch, as
required by departmental policy. Specifically, the department failed to consistently complete documentation regarding range of
motion, supervisory checks, and access to proper hygiene.
Was the HA's response to the critical incident appropriate?
When the inmate was placed on contraband surveillance watch, the department failed to properly tape the waist of the inmate's
paper shorts.
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OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
APPENDIX F 59
CONTRABAND SURVEILLANCE WATCH
CASE SUMMARIES
CENTRAL REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-18 2014-08-21 Suspected Drugs Nothing
Incident Summary 14-12791-CWRM
On August 18, 2014, the department placed an inmate on contraband surveillance watch after an officer observed him swallow a small
plastic bag as his door was opening for a cell search. The inmate was removed from contraband surveillance watch on August 21, 2014,
three days later. During that time, the department did not recover anything from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department did not timely
notify the OIG of the inmate's placement on contraband surveillance watch; documentation was not provided after the inmate exceeded
the initial 72 hours on contraband watch; hygiene checks were not consistently documented; medical staff did not evaluate theinmate on a
regular basis. These problems were addressed by providing training to the officers after the OIG discussed the insufficiencies with the hiring
authority.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-19 2014-08-23 Suspected Drugs Drugs
Incident Summary 14-12801-CWRM
On August 19, 2014, officers learned that an inmate was planning to introduce drugs into the administrative segregation unit.During
questioning, the inmate admitted to having drugs hidden in his rectum. The inmate was placed on contraband surveillance watch. On
August 22, 2014, the inmate asked medical staff if they would remove the drugs from his body because they were not coming outduring
bowel movements. The inmate was transported to an outside hospital where he remained on contraband surveillance watch. The inmate
defecated a bindle of drugs while at the hospital, which was recovered by an officer. A colonoscopy was completed and it verified the
absence of additional contraband. The inmate was removed from contraband surveillance watch and returned to the institution on August
23, 2014.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-05 2014-10-09 Suspected Drugs Drugs
Incident Summary 14-13421-CWRM
On October 05, 2014, the department placed an inmate on contraband surveillance watch after officers observed him placing a bindle of
suspected drugs into his mouth and swallowing it. The inmate was removed from contraband surveillance watch on October 09, 2014, four
days later. During that time, the department recovered drugs from the inmate.
Incident Assessment Sufficient
Overall, the department sufficiently complied with policies and procedures governing contraband surveillance watch. Although the hiring
authority verbally approved the use of hand isolation devices, the signature to support the authorization was not obtained until the OIG
brought this to the hiring authority's attention. Training was provided to all involved custody staff.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 103
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
CENTRAL REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-08 2014-10-12 Suspected Weapons 1. Other
2. Weapons
Incident Summary 14-13431-CWRM
On October 08, 2014, the department placed an inmate on contraband surveillance watch after he failed to clear a metal detector. The
inmate was removed from contraband surveillance watch on October 12, 2014, four days later. During that time, the department recovered
drug paraphernalia and metal sharpened to a point from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch because it failed to provide timely
notification to the OIG and failed to obtain proper authorization to place the inmate on contraband surveillance watch. The department
identified these discrepancies during a self-audit and provided training to the involved custody staff.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-12 2014-10-17 Suspected Drugs Drugs
Incident Summary 14-13481-CWRM
On October 12, 2014, the department placed an inmate on contraband surveillance watch after he appeared to swallow contrabandduring
a visit. The inmate was removed from contraband surveillance watch on October 17, 2014, five days later. During that time, the department
recovered five bindles of drugs from the inmate.
Incident Assessment Sufficient
Overall, the department sufficiently complied with policies and procedures governing contraband surveillance watch. Minor discrepancies
were noted related to consistency of documentation specific to supervisory checks and cell searches. These minor discrepancies were
identified by the department, and training was provided to all involved.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-27 2014-12-01 Suspected Weapons Nothing
Incident Summary 14-14111-CWRM
On November 27, 2014, the department placed an inmate on contraband surveillance watch after the inmate informed staff he had
swallowed a razor blade and it was confirmed by an x-ray. The inmate produced four bowel movements that were negative for contraband,
and an x-ray determined the inmate was clear of any foreign body. The inmate was removed from contraband surveillance watch on
December 01, 2014, four days later. During that time, and the department recovered nothing from the inmate.
Incident Assessment Sufficient
Overall, the department sufficiently complied with policies and procedures governing contraband surveillance watch. Although the
department had minor discrepancies documenting range of motion and hygiene, the hiring authority addressed these discrepancies with
training.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 104
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-06-25 2014-07-01 Suspicious Activity Nothing
Incident Summary 14-12191-CWRM
On June 25, 2014, the department placed an inmate on contraband surveillance watch. Specifically, during an unclothed body search
subsequent to a cell search, staff observed suspected contraband protruding from the inmate's anal cavity. The inmate was removed from
contraband surveillance watch on July 01, 2014, six days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch because it failed to provide timely
notification to the OIG when the inmate was placed on contraband surveillance watch and failed to complete a medical assessment prior to
the inmate's placement on contraband surveillance watch. Documentation related to daily activity and other required forms were not
provided to the OIG. The department acknowledged these problems and agreed to provide training to custody staff.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-06-25 2014-07-01 Suspicious Activity Nothing
Incident Summary 14-12201-CWRM
On June 25, 2014, the department placed an inmate on contraband surveillance watch, after custody staff observed the inmate placing
suspected contraband into his mouth as they approached his cell to conduct a cell search. The inmate was removed from contraband
surveillance watch on July 01, 2014, six days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to provide
timely notification to the OIG when the inmate was placed on contraband surveillance watch and failed to timely remove the inmate from
contraband surveillance watch status at the appropriate time. Documentation specific to medical assessments and inmate hygiene was
inadequate. The department agreed to provide training to custody and nursing staff regarding documentation and other policy
requirements after consulting with the OIG.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-06-27 2014-07-11 Suspected Weapons 1. Drugs
2. Inmate Note
Incident Summary 14-12241-CWRM
On June 27, 2014, the department placed an inmate on contraband surveillance watch after the inmate failed to pass a metal detector
during a cell search. Specifically, the cell search was conducted after the department received information that the inmate was in
possession of a weapon. The inmate was removed from contraband surveillance watch on July 11, 2014, 15 days later. During that time, the
department recovered drugs and inmate notes from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 105
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-06-30 2014-07-05 Suspected Drugs Nothing
Incident Summary 14-12321-CWRM
On June 30, 2014, the department placed an inmate on contraband surveillance watch after he assaulted an officer and was suspected of
concealing drugs. During the course of placing the inmate on contraband surveillance watch, the inmate surrendered drugs. Theinmate was
removed from contraband surveillance watch on July 05, 2014, five days later. During that time, the department recovered nothing from
the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. Documentation specific to hand
washing and range of motion was insufficient. The department agreed to provide training to custody staff regarding documentation.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-07-05 2014-07-09 Suspected Drugs Drugs
Incident Summary 14-12331-CWRM
On July 05, 2014, the department placed an inmate on contraband surveillance watch after custody staff observed a clear object protruding
from his anal cavity during an unclothed body search. Custody staff also discovered a bindle in the inmate's work area whichthe inmate
admitted was his. The inmate was removed from contraband watch on July 9, 2014, four days later. During that time, the department
recovered drugs from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-07-13 2014-07-18 Suspicious Activity Drugs
Incident Summary 14-12391-CWRM
On July 13, 2014, the department placed an inmate on contraband surveillance watch after he was observed placing an unknown object
into his rectum during visiting. The inmate was removed from contraband surveillance watch on July 18, 2014, five days later.During that
time, the department recovered drugs from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-07-18 2014-07-22 Suspected Weapons Nothing
Incident Summary 14-12481-CWRM
On July 18, 2014, the department placed a ward on contraband surveillance watch. Specifically, the ward told custody staff that he was
going to harm himself and he failed to clear a metal detector. The ward was removed from contraband surveillance watch on July 22, 2014,
four days later. During that time, the department recovered nothing from the ward.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 106
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-07-19 2014-07-22 Suspicious Activity Drugs
Incident Summary 14-12491-CWRM
On July 19, 2014, an inmate was placed on contraband surveillance watch after he was observed during visiting placing an unknown object
into his mouth. The inmate was removed from contraband surveillance watch on July 22, 2014, three days later. During that time, the
department recovered drugs from the inmate.
Incident Assessment Insufficient
The department did not sufficiently comply with contraband surveillance watch policies and procedures. The department failed to conduct a
medical assessment of the inmate prior to placement on contraband surveillance watch. Additionally, the department failed to document
that consistent supervisory checks were conducted and did not complete self-audit documents. The department addressed the lack of
documentation and health and safety requirements by providing training to custody and medical staff.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-07-26 2014-08-01 Suspicious Activity Drugs
Incident Summary 14-12551-CWRM
On July 26, 2014, the department placed an inmate on contraband surveillance watch. Specifically, during an unclothed body search after
visiting, an officer observed a clear plastic object drop to the ground and further observed clear plastic material protruding from the
inmate's rectum. The inmate was removed from contraband surveillance watch on August 01, 2014, six days later. During that time, the
department recovered drugs from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-05 2014-08-11 Suspected Weapons Nothing
Incident Summary 14-12621-CWRM
On August 05, 2014, the department placed an inmate on contraband surveillance watch after informing custody staff he ingested a razor
blade. The inmate was removed from contraband surveillance watch on August 11, 2014, six days later. During that time, the department
recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-06 2014-08-11 Suspected Drugs Drugs
Incident Summary 14-12631-CWRM
On August 06, 2014, the department placed an inmate on contraband surveillance watch after staff observed the inmate swallowing
bindles. The inmate was removed from contraband surveillance watch on August 11, 2014, five days later. During that time, thedepartment
recovered drugs from the inmate.
Incident Assessment Insufficient
The department did not sufficiently comply with policies and procedures governing contraband surveillance watch. Documentation specific
to inmate hygiene, supervisory checks, and cell searches was inadequate. The department identified the deficiencies and agreed to provide
training to ensure that the required documentation is completed.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 107
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-06 2014-08-09 Suspicious Activity Other
Incident Summary 14-12641-CWRM
On August 06, 2014, the department placed a ward on contraband surveillance watch. Specifically, officers observed cloth protruding from
the ward's buttocks, and he refused to be searched. The inmate was removed from contraband surveillance watch on August 09, 2014,
three days later. During that time, the department recovered money from the ward.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-07 2014-08-10 Suspicious Activity Nothing
Incident Summary 14-12651-CWRM
On August 07, 2014, the department placed an inmate on contraband surveillance watch. Specifically, during an unclothed body search the
inmate removed a small bindle from her bra and swallowed it. The inmate was removed from contraband surveillance watch on August 10,
2014, three days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to
document that supervisory checks were consistently conducted and failed to timely complete internal audit documentation. The
department provided training to the involved custody staff.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-11 2014-08-15 Suspicious Activity Nothing
Incident Summary 14-12751-CWRM
On August 11, 2014, the department placed an inmate on contraband surveillance watch. Officers observed the inmate acting suspiciously
while on the exercise yard. After officers requested the inmate submit to a search, the inmate ran towards a fence and started to climb the
fence while placing items in his mouth. The inmate was removed from contraband surveillance watch on August 15, 2014, four days later.
During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-14 2014-08-18 Suspicious Activity Nothing
Incident Summary 14-12761-CWRM
On August 14, 2014, the department placed an inmate on contraband surveillance watch when he failed to clear a metal detectorupon
arrival at the institution. The inmate was removed from contraband surveillance watch on August 18, 2014, four days later. During that
time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 108
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-29 2014-09-03 Suspected Weapons Nothing
Incident Summary 14-12881-CWRM
On August 29, 2014, the department placed an inmate on contraband surveillance watch. Specifically, the inmate informed staffthat he
ingested one or more razor blades. The inmate was removed from contraband surveillance watch on September 03, 2014, five dayslater.
During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-04 2014-09-09 Suspicious Activity Nothing
Incident Summary 14-12991-CWRM
On September 04, 2014, the department placed an inmate on contraband surveillance watch after custody staff observed a clear lubricant
in and around his anal cavity during an unclothed body search. The inmate was removed from contraband surveillance watch on September
09, 2014, five days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department did not
consistently document the application, removal, and sanitizing of hand isolation devices, and the presence or absence of contraband in
inmate-produced bowel movements. The department also retained the inmate on contraband surveillance watch a day longer than
necessary and failed to document a medical assessment. The department agreed to provide corrective action and training to involved
custody staff.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-09 2014-09-12 Suspicious Activity 1. Inmate Note
2. Weapons
Incident Summary 14-13001-CWRM
On September 9, 2014, an inmate was placed on contraband surveillance watch after the inmate swallowed a large white bindle during a
clothed body search. The inmate was removed from contraband surveillance watch on September 12, 2014, three days later. During that
time, the department recovered a weapon and inmate notes.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-07 2014-09-15 Suspicious Activity Drugs
Incident Summary 14-13031-CWRM
On September 07, 2014, the department placed an inmate on contraband surveillance watch. Specifically, while the inmate was being
monitored in the visiting area, an authorized visitor passed him an open popcorn bag. Officers believed the bag contained contraband and
retrieved the bag. Suspected drugs were found in the bag and the visitor was arrested for introducing drugs into the prison. The inmate was
removed from contraband surveillance watch on September 15, 2014, eight days later. During that time, the department recovered drugs
from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 109
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-21 2014-09-25 Suspected Weapons Inmate Note
Incident Summary 14-13201-CWRM
On September 21, 2014, the department placed an inmate on contraband surveillance watch after receiving information the inmate was
one of several inmates suspected of being in possession of weapons and inmate notes. The inmate was removed from contraband
surveillance watch on September 25, 2014, four days later. During that time, the department recovered inmate notes from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-21 2014-09-25 Suspected Weapons Nothing
Incident Summary 14-13211-CWRM
On September 21, 2014, an inmate was placed on contraband surveillance watch. Specifically, the department received information that
the inmate was one of several inmates in possession of weapons or inmate notes. On September 25, 2014, the inmate was removedfrom
contraband surveillance watch, four days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-19 2014-09-25 Suspected Inmate Note Inmate Note
Incident Summary 14-13241-CWRM
On September 19, 2014, the department placed an inmate on contraband surveillance watch after an officer observed the inmate swallow
an inmate note. The inmate was removed from contraband surveillance watch on September 25, 2014, six days later. During that time, the
department recovered inmate notes from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to
document that the inmate received a medical assessment prior to being placed on contraband surveillance watch and did not document
that hand isolation devices were consistently removed during meals or that proper hygiene opportunities were provided. The department
agreed to provide training to custody and nursing employees regarding documentation and other policy requirements.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-12 2014-10-17 Suspected Drugs Nothing
Incident Summary 14-13461-CWRM
On October 12, 2014, the department placed an inmate on contraband surveillance watch. Specifically, the inmate's visitor wasobserved
acting nervously as she handed an opened candy bag to the inmate. An officer approached the inmate and discovered a bindle ofsuspected
contraband in the candy bag. The inmate was removed from contraband surveillance watch on October 17, 2014, five days later. During
that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to timely
document the approval to place the inmate on contraband surveillance watch and failed to complete the appropriate documentation for
the application and removal of hand isolation devices. The documentation specific to inmate hygiene was also inadequate. Thedepartment
provided training to custody staff regarding these documentation requirements.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 110
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-22 2014-10-26 Suspected Weapons Drugs
Incident Summary 14-13611-CWRM
On October 22, 2014, the department placed an inmate on contraband surveillance watch when a metal detector indicated the presence of
metal in his groin area. The inmate was removed from contraband surveillance watch on October 26, 2014, four days later. During that
time, the department recovered drugs from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-24 2014-10-28 Suspected Drugs Drugs
Incident Summary 14-13651-CWRM
On October 24, 2014, the department placed an inmate on contraband surveillance watch after custody staff observed lubricant around the
inmate's anus during an unclothed body search. The inmate was removed from contraband surveillance watch on October 28, 2014,four
days later. During that time, the department recovered drugs from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-24 2014-10-27 Suspected Drugs 1. Drugs
2. Inmate Note
Incident Summary 14-13681-CWRM
On October 24, 2014, the department placed an inmate on contraband surveillance watch after receiving information that the inmate was
in possession of contraband and custody staff observed lubricant around the inmate's anal cavity. The inmate was removed from
contraband surveillance watch on October 27, 2014, three days later. During that time, the department recovered drugs and inmate notes
from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-25 2014-10-28 Suspicious Activity Weapons
Incident Summary 14-13701-CWRM
On October 25, 2014, the department placed an inmate on contraband surveillance watch after informing staff he ingested razorblades.
The inmate was removed from contraband surveillance watch on October 28, 2014, three days later. During that time, the department
recovered a razor blade from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 111
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-02 2014-11-05 Suspicious Activity Nothing
Incident Summary 14-13801-CWRM
On November 2, 2014, the department placed an inmate on contraband surveillance watch after custody staff observed the inmate
secreting suspected contraband during visiting. The inmate was removed from contraband surveillance watch on November 5, 2014, three
days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to timely
notify the OIG of the inmate's placement on contraband surveillance watch. Additionally, documentation specific to daily activity regarding
range of motion, supervisory checks, access to proper hygiene, and cell searches was inconsistent. The department identified these
problems and providing training. The department also agreed to train administrative custody staff regarding timely notification.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-26 2014-11-12 Suspicious Activity Drugs
Incident Summary 14-13811-CWRM
On October 26, 2014, the department placed an inmate on contraband surveillance watch after officers observed what appeared to be a
transfer of contraband during a kiss with an authorized visitor. The inmate was removed from contraband surveillance watch onNovember
12, 2014, 17 days later. During that time, the department recovered drugs from the inmate.
Incident Assessment Insufficient
Overall, the department failed to comply with policies and procedures governing contraband surveillance watch. The OIG did not receive
timely notification of the inmate's placement on contraband surveillance watch. Required medical assessments were not consistently
conducted. The department addressed this problem by implementing procedures to ensure that required medical assessments for inmates
on contraband surveillance watch are conducted timely.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-13 2014-11-17 Suspicious Activity Nothing
Incident Summary 14-13961-CWRM
On November 13, 2014, the department placed an inmate on contraband surveillance watch when custody staff observed the inmatewith a
clear lubricant around his anal cavity during an unclothed body search. The inmate was removed from contraband surveillance watch on
November 17, 2014, four days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-16 2014-11-21 Suspected Drugs Nothing
Incident Summary 14-14021-CWRM
On November 16, 2014, the department placed an inmate on contraband surveillance watch after officers observed him swallowingan
unidentified object passed to him by a visitor. The inmate was removed from contraband surveillance watch on November 21, 2014, five
days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
Overall, the department sufficiently complied with policies and procedures governing contraband surveillance watch. The hiring authority
identified inconsistencies in the documentation in regards to cell searches. Training was provided to all involved custody staff.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 112
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-15 2014-11-18 Suspicious Activity Nothing
Incident Summary 14-14031-CWRM
On November 15, 2014, the department placed an inmate on contraband surveillance watch. Specifically, the inmate was observedholding
steel wool and a battery in his right hand and an unidentified object in his left hand. The inmate swallowed the unidentifieditem after an
officer ordered him to show what was in his left hand during a clothed body search. The inmate was removed from contraband surveillance
watch on November 18, 2014, three days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-20 2014-11-24 Suspected Weapons Weapons
Incident Summary 14-14081-CWRM
On November 20, 2014, the department placed an inmate on contraband surveillance watch after an X-ray confirmed that the inmate had
swallowed a razor blade and the inmate was threatening self harm. The inmate was removed from contraband surveillance watch on
November 24, 2014, four days later. During that time, the department recovered weapons from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch by not documenting whether hand
isolation devices were removed during meals, and the presence or absence of contraband in bowel movements. Additionally, a medical
evaluation prior to the inmate being placed on contraband surveillance watch was not documented. The department agreed to provide
training to custody and medical staff regarding these deficiencies.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-12-10 2014-12-17 Suspicious Activity Tobacco
Incident Summary 14-14181-CWRM
On December 10, 2014, the department placed an inmate on contraband surveillance watch after custody staff received information that
the inmate would attempt to transport controlled substances into the institution in his anal cavity. The inmate was removed from
contraband surveillance watch on December 17, 2014, seven days later. During that time, the department recovered tobacco fromthe
inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-12-14 2014-12-22 Suspicious Activity Inmate Note
Incident Summary 14-14211-CWRM
On December 14, 2014, the department placed an inmate on contraband surveillance watch after custody staff observed the inmate place a
plastic bag in his mouth. The inmate was removed from contraband surveillance watch on December 22, 2014, eight days later. During that
time, the department recovered inmate notes from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 113
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
NORTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-12-22 2014-12-26 Suspicious Activity Nothing
Incident Summary 14-14281-CWRM
On December 22, 2014, the department placed an inmate on contraband surveillance watch after he was observed swallowing razorblades.
The inmate was removed from contraband surveillance watch on December 26, 2014, four days later. During that time, the department
recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to timely
notify the OIG of the inmate's placement on contraband surveillance watch and documentation specific to hand washing and nurse
assessments were insufficient. The department agreed to provide training to custody and nursing staff regarding documentation
requirements.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 114
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-07 2014-08-13 Suspected Weapons Nothing
Incident Summary 14-12661-CWRM
On August 7, 2014, the department placed an inmate on contraband surveillance after a medical procedure confirmed the presence of an
object consistent with a razor blade, which the inmate indicated he had swallowed. The inmate was removed from contraband surveillance
watch on August 13, 2014, six days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to timely
notify the OIG when the inmate was placed on contraband surveillance watch and failed to consistently and accurately documentinmate
and restraint hygiene and supervisor checks. The department provided training to address the deficiencies.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-10 2014-08-18 Suspected Drugs Drugs
Incident Summary 14-12711-CWRM
On August 10, 2014, the department placed an inmate on contraband surveillance watch after he was observed swallowing a bindle in the
visiting area. The inmate was removed from contraband surveillance watch on August 18, 2014, eight days later. During that time, the
department recovered drugs from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-21 2014-08-24 Suspicious Activity Nothing
Incident Summary 14-12831-CWRM
On August 21, 2014, the department placed an inmate on contraband surveillance watch after the inmate reached for an unknown item in
his sock during a search, then moved his hand toward his mouth as if to swallow something. The inmate was removed from contraband
surveillance watch on August 24, 2014, three days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-26 2014-08-29 Suspected Weapons Nothing
Incident Summary 14-12901-CWRM
On August 26, 2014, the department placed an inmate on contraband surveillance watch after he informed staff that he was suicidal and
had swallowed a razor blade. The inmate was removed from contraband surveillance watch on August 29, 2014, three days later. During
that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to
adequately document inmate and restraint hygiene. The department further failed to maintain proper restraints on the inmate when he
returned from an outside hospital, thereby allowing the inmate to be unrestrained for an extended period of time in violationof
departmental policy. The department provided training to involved custody staff.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 115
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-08-31 2014-09-15 Suspected Weapons Nothing
Incident Summary 14-12921-CWRM
On August 31, 2014, the department placed an inmate on contraband surveillance watch after an inmate told staff that he swallowed razor
blades and an x-ray confirmed the presence of a foreign object. The inmate was removed from contraband surveillance watch on
September 15, 2014, 15 days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to notify
the OIG when the inmate was transported to an outside hospital while on contraband surveillance watch. The department furtherfailed to
adequately document inmate hygiene and restraint cleaning. The department did not document proper securing of clothing, initial cell
searches, meals, and blanket issuance and removal in accordance with departmental policy. The department provided training toall
involved custody staff.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-16 2014-09-19 Suspicious Activity Nothing
Incident Summary 14-13091-CWRM
On September 16, 2014, the department placed an inmate on contraband surveillance watch after he was observed with lubricant around
his anal cavity. The inmate was removed from contraband surveillance watch on September 19, 2014, three days later. During that time, the
department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to conduct
the appropriate medical assessments. Additionally, the department failed to properly document the initial cell search and unclothed body
search, as well as range of motion, hygiene, restraint hygiene, trash, and blanket issuance and removal. The department provided training
to custody staff to address the deficiencies related to documentation.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-09-23 2014-09-26 Suspected Drugs Nothing
Incident Summary 14-13251-CWRM
On September 23, 2014, the department placed an inmate on contraband surveillance watch after custody staff observed him swallow a
white bindle. The inmate was removed from contraband surveillance watch on September 26, 2014, three days later. During that time, the
department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to conduct
the appropriate medical assessment of the inmate prior to placement on contraband surveillance watch. Additionally, the department failed
to complete daily activity documentation regarding medical assessments, range of motion, supervisory checks, mattress and blanket
issuance and removals, and access to proper hygiene. The department provided corrective action and training to custody and nursing staff
regarding documentation requirements.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 116
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-04 2014-10-08 Suspicious Activity Nothing
Incident Summary 14-13411-CWRM
On October 04, 2014, the department placed an inmate on contraband surveillance watch after the inmate appeared to remove a bindle
from a bag of chips and place it in his mouth during visiting. The inmate was removed from contraband surveillance watch on October 08,
2014, four days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The institution failed to notify the
OIG of the inmate's placement on contraband surveillance watch in a timely and sufficient manner. In addition, the departmentfailed to
document the authorization of leg restraints and failed to document the initial cell search. Documentation related to supervisor checks,
range of motion, and cell inspections was inadequate. The department provided training to address the deficiencies.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-15 2014-10-20 Suspicious Activity Nothing
Incident Summary 14-13541-CWRM
On October 15, 2014, the department placed an inmate on contraband surveillance watch after the inmate fought another inmate in plain
view of officers. The fight appeared to be staged for the sole purpose of introducing contraband to the administrative segregation unit. The
inmate was removed from contraband surveillance watch on October 20, 2014, five days later. During that time, the department recovered
nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to conduct
a medical assessment of the inmate prior to placement on contraband surveillance watch. In addition, the department failed toconsistently
document that the inmate was afforded access to proper hygiene and failed to obtain proper authorization for the use of leg restraints. The
department provided training for involved custody staff to ensure proper use of leg restraints.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-23 2014-10-28 Suspected Weapons Other
Incident Summary 14-13631-CWRM
On October 23, 2014, the department placed an administrative segregation inmate on contraband surveillance watch after he admitted
swallowing razor blades. The inmate was removed from contraband surveillance watch on October 28, 2014, five days later. During that
time, the department recovered a metal foreign object.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The institution failed to adequately
tape the waist of the inmate's clothing. In addition, not all inmate activities were documented as required. The department addressed these
deficiencies by providing training to the officers.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 117
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-26 2014-10-30 Suspected Drugs Drugs
Incident Summary 14-13661-CWRM
On October 26, 2014, the department placed an inmate on contraband surveillance watch after he was observed swallowing a bindle during
a search. The inmate was removed from contraband surveillance watch on October 30, 2014, four days later. During that time, the
department recovered four small bindles of suspected heroin from the inmate.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-27 2014-11-05 Suspected Weapons Nothing
Incident Summary 14-13711-CWRM
On October 27, 2014, the department placed an inmate on contraband surveillance watch after an inmate reported to staff that she
swallowed a bolt that had been removed from her bed. An x-ray confirmed the presence of a metal object in the shape of a bolt. The inmate
was removed from contraband surveillance watch on November 05, 2014, nine days later, but remained on one-on-one observation by
mental health staff. During the time on contraband surveillance watch, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to
adequately document supervisor checks, inmate and restraint hygiene, restraint checks, and range of motion releases. Furthermore, the
department failed to provide constant visual observation by custody staff on at least two occasions. The department provided training to
supervisory custody staff to address the deficiencies.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-10-31 2014-11-04 Suspected Drugs Nothing
Incident Summary 14-13751-CWRM
On October 31, 2014, the department placed an inmate on contraband surveillance watch after the inmate surrendered two razor blades
and an inmate manufactured syringe from his anal cavity during an unclothed body search. The inmate was removed from contraband
surveillance watch on November 04, 2014, four days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. There is no documentation that
custody staff provided constant visual observation during first watch shifts. In addition, documentation specific to inmate hygiene,
unclothed body searches, mattress searches, blanket issuance and removal, and request for additional custody staff coverage was
inadequate. The department provided written counseling to the employees to address the deficiencies.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 118
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-01 2014-11-05 Suspicious Activity Nothing
Incident Summary 14-13761-CWRM
On November 01, 2014, the department placed an inmate on contraband surveillance watch after she was observed cutting her armwith a
razor and then telling an officer that she swallowed the blade. The inmate was removed from contraband surveillance watch on November
05, 2014, four days later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department failed to
adequately document supervisor checks, inmate and restraint hygiene, restraint checks, range of motion releases, and the results of an
inmate bowel movement. The department provided training to custody staff to address the inadequate documentation.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-11-07 2014-11-13 Suspected Weapons Nothing
Incident Summary 14-13871-CWRM
On November 07, 2014, the department placed an administrative segregation inmate on contraband surveillance watch after the inmate
informed staff he swallowed a razor blade. The inmate was removed from contraband surveillance watch on November 13, 2014, six days
later. During that time, the department recovered nothing from the inmate.
Incident Assessment Insufficient
The department failed to comply with policies and procedures governing contraband surveillance watch. The department's self-audit
identified that custody staff failed to document blanket issuance and removal, but provided no corrective action. The OIG's review found
that documentation specific to range of motion, hygiene, supervisory checks, and blanket issuance and removal were inadequate. The
department agreed to provide training to custody staff to address these deficiencies.
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-12-07 2014-12-19 Suspicious Activity Drugs
Incident Summary 14-14151-CWRM
On December 07, 2014, the department placed an inmate on contraband surveillance watch after an officer observed an inmate appear to
insert something into his rectum while in the visiting room. The inmate was removed from contraband surveillance watch on December 19,
2014, 12 days later. During that time, the department recovered approximately 42 grams of heroin from the inmate.
Incident Assessment Insufficient
The department failed to substantially comply with policies and procedures governing contraband surveillance watch. Specifically, the
department failed to timely obtain approval for the third 72-hour extension and failed to timely notify the OIG of the extension. The
department also failed to consistently document supervisory checks and range of motion releases and failed to document any cleaning of
the restraint equipment. Training was provided to address the deficiencies.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 119
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SOUTH REGION
Date Placed on Date Taken off Reason for Contraband
Contraband Watch Contraband Watch Placement Found
2014-12-17 2014-12-22 Suspected Mobile Phone Other
Incident Summary 14-14241-CWRM
On December 17, 2014, the department placed an inmate on contraband surveillance watch after he failed to clear a metal detector upon
admission to the administrative segregation unit. The inmate was removed from contraband surveillance watch on December 22, 2014, five
days later. During that time, the department recovered string, paper, and pieces of a latex glove.
Incident Assessment Sufficient
The department sufficiently complied with policies and procedures governing contraband surveillance watch.
SEMI-ANNUAL REPORT JULY-DECEMBER 2014 PAGE 120
OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA
SEMI-ANNUAL REPORT
July–December 2014
Volume II
OFFICE OF THE INSPECTOR GENERAL
Robert A. Barton
INSPECTOR GENERAL
Roy W. Wesley
CHIEF DEPUTY INSPECTOR GENERAL
STATE OF CALIFORNIA
March 2015